Health education [full issue]

THE MAGAZINE OF THE WORLD HEALTH ORGANIZAT'ON • APRIL 1977 • USA $ 1 . 12 New Schools for Old . . 30 News Page Cover: This health worker's training must fit her to meet the real needs of the world we live in. (Photo WHO/J. Mohr) Contents Who will care for Health? by T. FOlop 3 The Brain Drain by A. Mejia & H. Pizurki . . 6 Vital Team Work by D. Flahault 16 A Mongolian Feldsher speaks 20 Manpower Planning by D. K. Ray 24 World Health appears in Arabic, English, French, German, Persian, Por- tuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. 2 • WORLD 1-EA131-1 THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • APRIL 1977 USA 91 HEALTH EDUCATION Who will care for Health ? TRAINING VORE PHYSICIANS AND VORE NURSES WILL NOT SOLVE THE HEALTH PROBLEVS OF VANY DEVELOP- ING COUNTRIES: THERE VUST BE NEW EVPHASIS ON TRAINING BROADER CATEGORIES OF HEALTH PERSONNEL by Tamas FOlop CT he Constitution of WHO states that "the health of all peoples is fundamental to the attainment of peace and security" but it does not of course say who will care for health. For many centuries this question has not even been raised, the answer having been taken for granted: to care for health or rather for sick people has been the almost unique responsibility of physicians, later helped by nurses. However, in those centuries medical care was the privilege of the few. Has the situation in the world radically changed since then? The number of medical doctors for ev- ery 10,000 inhabitants of the world in 1970 was only 7.9, according to World Health Statistics Report (Vol. 27, No. 2, 1974). While in developed countries this ratio was 14.7, in Africa (South Africa ex- cluded) it was only 0.7. If in these days there are about 14,900 inhab- itants for every one physician in Africa and 5,030 in East Asia (not including China and Japan), it seems quite ob- vious that in these latter areas the physi- cians are not the ones who care for the health of the majority. We can state this with even more certainty if we add that in most of these countries 80 per cent or more of the population live in rural areas, while 80 per cent or more of the <Health care in the years to come will demand a radical change in the training of health pro- fessionals, whose skills in future will be more relevant to the needs of the community and to the tasks to be performed. (Photo WHO/M. Jacot) doctors live in the big cities, and the sit- uation is hardly different as regards the other health professionals (nurses, den- tists, pharmacists, and so on). This means that 80 per cent of the qualified health manpower are serving 20 per cent of the population, while the other 80 per cent of the population remain largely uncovered or have access virtual- ly only to practitioners of traditional medicine. It is well known that within the big cities, too, the distribution is far from even : the districts where the well- to-do live are over-served, while the slum areas are under-served or not served at all. Another factor that contributes to these quantitative problems is the migration of qualified health manpower. WHO has studied the international migration of physicians and nurses and in 1972 identified some 140,000 physi- cians, about six per cent of the world total, who were working or studying abroad. This problem is discussed in some detail elsewhere in this issue. So far we have been speaking about the lack, the maldistribution and the migration of trained health personnel. What has been the reaction of individ- ual countries to all these phenomena? They have stepped up the training of qualified health personnel. The past two decades were characterized from this point of view by enormous efforts to produce more doctors and to a lesser degree nurses, because of the wide- spread belief that simply training more of the same will automatically solve all health problems in the world. We are, in spite of this, no nearer to solving the health manpower problems today than we were 20 years ago. It is obvious that besides the quantitative problems there are other, qualitative ones as well. The main problem here, among many others, is that often it has not been planned what kind of and how many health workers are needed to meet the health needs and demands of the whole population of a country. Then, if such plans exist, the schools for health per- sonnel do not take into account what is needed and thus their "product" may be, and very often is, irrelevant to those health needs and demands. This means that the health workers emerging from the schools may be theoretically well or even very well prepared, but they do not know the health situation of their own country and are not well prepared to cope with such a situation. Finally, the trained health workers are freqently not properly managed, their work is not monitored, therefore there are no data concerning the quality of their work to be fed back into the planning and "pro- duction" process in order to readjust these processes. In short, the health manpower development process, which consists of the planning, "production" and management of health manpower, is largely fragmented, its components are hardly connected with each other— still less with the development of health services—and it is frequently irrelevant to the health needs and demands of the people. It is relatively easy to define the prob- lems but then the question arises : what can be done about their solution? WHO has recently elaborated a comprehen- sive, long-term programme which aims at the promotion and development of 3 Who will care for health? <Village health workers attending a course on primary health care in Torodi, Niger. The teacher is a qualified male nurse. The new emphasis on training primary health workers stems from the realization that simply provid- ing more physicians and more nurses will not solve the health problems of developing countries. (Photo WHO/ R. da Silva) A class of student nurses in Peru. Training> new categories of health workers at the vil- lage and community level does not mean that more nurses will not be required. But their instruction too will need to be properly geared to the progress of science and to the needs of society. (Photo WHO/T. Feynes) the types and numbers of health man- power needed to provide health services which are adequate for, and appropriate to, the needs of the whole population of a country. The programme suggests that the over-all aim and principle of the health manpower policy in each member state should be : to concentrate all national efforts so as to satisfy the health needs of the entire population through health ser- vices composed of balanced teams of health personnel; that is, to ensure that all health activities are undertaken at the most peripheral level of the health services as is practicable, by workers most suitably trained to carry out these activities. Here emphasis should be put on the most "suitably" trained as op- posed to the most "highly" trained, since the latter term might entail confus- ing the most sophisticated and most costly with the optimal. The main aim in the coming years should therefore be to effect a radical change in health manpower development that will make it relevant to present and foreseeable future community health needs and tasks to be performed. The changes should result in a sound health manpower system which will plan, develop and manage/utilize effi- ciently the right "mix" of health person- nel within well-conceived health and other services, which will continuously monitor whether they are functioning properly, and which will adjust the plan- ning and "production" systems on the basis of such monitoring, so as to achieve a full health coverage for the en- tire population in the coming decades. This clearly means that, besides the emphasis placed on the training of "classical" categories of health workers (such as doctors or nurses), a fresh em- phasis should be laid on the training and utilization of auxiliary and primary health workers and their supervisors. This new emphasis stems from the real- ization that the provision of training— generally hospital- and disease-oriented training—for more physicians and nurses will not solve the health problems of many countries, particularly develop- ing ones, in the foreseeable future. Hence, there is a need for non-tradi- tional solutions. The number of physi- cians, nurses and other "classical" categories of health workers will, however, also have to be increased. As their role becomes more important, their education will need to be properly geared to the progress of science and to 4 the needs of society. It must be made relevant to community health needs and demands without reducing its basic quality; it must, in addition, prepare health professionals for their leadership role both in the health team and in com- munity development. This means that health professionals must prepare them- selves for their future along lines quite different from the present ones. The answer to the question in title has thus been answered : health teams will look after the health of the world, with health workers properly trained for their jobs and properly utilized in jobs for which they were trained. Health teams with many different categories of health workers will ensure the health of all peoples as stipulated in the Constitution of WHO. The Organization's health manpower development programme en- visages activities both at the national level and by the Organization itself in the form of collaboration with member states all aiming at this goal. On the following pages, different as- pects of this programme will be dis- cussed : the effect on health services of personnel migrating abroad; the rele- vance of educational processes to the health needs and demands of the popula- tion; the role of health teams with special regard to primary health care; one example of a versatile health worker —the Mongolian feldsher ; and health manpower planning. It has to be stressed that the main aim of the integrated health manpower development process should be to con- tribute to the strengthening of health services. There is only one yardstick to measure the effectiveness and efficiency of this process: how far and with what results has it contributed to the develop- ment of health services and, through that development, to the improvement of the health status and quality of life of the population? Relevance is the key word; relevance of the integrated development of health services and health manpower, relevance of the health manpower development process to the health needs and demands of the population. Radical changes are needed in this direction. All health manpower development efforts, including the work of schools for health personnel, should bring us closer to WHO's constitutional objective : the attainment by all peoples of the highest possible level of health, which includes their physical, mental and social wellbeing. ■ 5 The Brain Drain THE MIGRATION ABROAD OF PHYSICIANS AND NURSES HINDERS THE EFFORTS OF HEALTH SERVICE PLANNERS, PARTICULARLY AT A TIME WHEN HEALTH SERVICES ARE TRYING TO INCREASE THEIR COVERAGE by Alfonso Mejia and Helena Pizurki rom time immemorial, migration has been a fact of life. Legend suggests that even mythical men and demigods, among them Adam, Prometheus, and Daedalus, were compelled to migrate because of dis- agreements with the equally mythical ruling powers of the time. Thus Jeho- vah, Zeus, and Minos can be considered the first in a long line of power holders who, unwittingly perhaps, fostered the migration of those in search of indepen- dence, knowledge and self-fulfilment. At the terrestrial level, it is well known that Plato attracted talented islanders to ancient Athens, that the Ptolomies en- ticed scholars and scientists from Greece to Alexandria, that many learned Gauls and Spaniards wandered to Rome. It is also said that for at least the past 2,200 years people in power have imple- mented policies either to prevent or to promote migration. In the past as in the present, measures taken to promote migration appear to have been more successful than measures to prevent it. A specific form of promotional migration policy manifested itself in Italy during the early days of university develop- ment—in the form of the theft, by one city state from another, of all the teach- ing staff and students of a university. With the founding of the New World and the intensification of the industrial revolution, the volume of migration in- creased, with the migrants deriving from all social strata—barons and beggars, adventurers and outcasts, gold diggers and breadwinners—and the movement being primarily from both Eastern and Western Europe (the developed areas of the world) to North America (a deve- loping area of the world at the time). From all appearances, this migration, which was accompanied by huge capital flows, was acceptable and beneficial to both donor and recipient countries alike, since it not only represented a transfer of labour from surplus to deficit areas, but also helped to create, in the latter, an economic infrastructure which had important feedback effects in the donor countries and tended gradually to narrow the economic gap between coun- tries at different levels of development. The current wave of migration, however, is different in several ways from that occurring in the 19th and early 20th centuries. The main differ- ence is that it is no longer a mass move- ment of the poor, the wretched, and the homeless, but primarily a movement of the elite from less prosperous countries to a few of the richest countries of the world, the alleged effect being a widen- ing gap between the rich and the poor nations. This particular form of migra- tion, popularly referred to as "brain drain", or conversely "brain gain", has involved professional groups of all sorts—scientists, engineers, lawyers, teachers, physicians and nurses. In more recent years, the numbers of migrant physicians have been increasing while those of other professional groups have been decreasing. It is largely this ano- maly that has caused governments and international bodies to press for more information and action relative to health manpower migration. In the health "industry", health work- ers, particularly physicians, are the most expensive commodity in terms of both educational and utilization costs. Data from various sources indicate that the payroll for health personnel in many countries ranges between 60-70 per cent of the costs of delivering health services. A large proportion of the payroll is con- sumed by physicians and nurses. The cost of educating a physician ranges be- tween US$5,000 and US$80,000 depend- ing on the economic status of the coun- try and the level of specialization of the physician. These factors alone account for much of the concern that govern- ments manifest with respect to health manpower migration—the main ques- tions being whether a country should in- vest scarce resources in the costly educa- tion of manpower who eventually migrate, and whether, migration not- withstanding, a country can afford to produce costly manpower for work that could be performed by health personnel who cost less to society in terms of edu- cation and utilization. To interpret, in realistic terms, the phenomenon of health manpower migration is by no means easy, and ef- forts to do so have led to vehement debate in national and international forums. The line of the debate is clearly drawn between two opposing forces. On the one hand are the internationalists, who claim that the donor countries are producing more physicians and nurses than they can economically absorb, that the surplus migrates, and that through Selman A. Waksman, awarded a Nobel Prize> in 1952 for his work in the discovery of strep- tomycin and its value in treating tuberculosis. His work was carried out in the United States—but his discovery has subsequently proved of no less value to his native Russia and to the rest of the world. (Photo WHO/USIA) 6 Wow WOW rows .1stwo The Brain Drain their migration the total world output is raised and mankind as a whole benefits. On the other hand are the nationalists, often unfairly accused of having a chau- vinistic and myopic perspective, who feel that those countries most in need are losing manpower to those in much less dire circumstances. In more practi- cal terms, the internationalist would ar- gue, for example, that the discoverer of streptomycin, Waksman, did a great deal for the people of his native Russia, as well as for the rest of the world, by his work in the USA. The nationalist, on the other hand, would argue that, while this type of assumption might be valid with respect to a very few of the world's top-notch "brains", the argu- ment cannot be extended to cover the majority of highly-educated and skilled migrants, most of whom do not achieve world-wide renown for their contribu- tions to mankind. Within the last few years, the debate between the two factions has become al- most meaningless, given that new ele- ments have entered the picture. One of these is the almost obsessive fear in some of the major recipient countries that a heavy dependence on foreign health manpower may lead to a lower standard of health care. A second is the growing realization that health man- power migration, like most migration, is an index not only of structural mal- adjustments and faulty manpower planning in both donor and recipient countries alike, but of insufficient, in- compatible, and/or wrongly administered foreign aid and technical assistance. In view of this realization, the major recipient countries have begun to re- examine their policies towards health manpower migration and some have al- ready taken measures that will result in a modification of inflows. The United Kingdom and the USA have started to increase the production rate of national physicians and Canada has revised its licensing requirements regarding foreign physicians. The USA is also trying to supplement its health labour force with other types of health personnel, particu- larly physicians' assistants. Such mea- sures, as well as those being taken by members of the European Economic Community, are bound to modify dras- tically the patterns of health manpower migration in terms of both volume and direction. One possible result of such measures is that countries where the supply of health manpower, particularly physicians, is far greater than can be economically supported, may have to deal with a situation of discontent among those who cannot find employ- ment at home and will not be needed abroad, at least not in those countries to which their colleagues have traditionally migrated. In view of the diverse interpretations of the phenomenon of health manpower migration and the various calls for ac- tion, the World Health Organization, at the request of its member states and with financial and other support from national and international bodies, em- barked on a study of the international migration of physicians and nurses. As originally designed, the study was to consist of three phases, the first focused primarily on the societal factors under- lying the migration, the second primari- ly on the health system factors and the third primarily on the personal motives, perceptions and characteristics of indi- vidual physicians and nurses. Valuable clues The first phase of the study was based on existing published and unpublished information retrieved with the assistance of WHO's regional offices and member states. This information, while incom- plete and/or unreliable in some in- stances, nevertheless provided valuable clues as to the dimensions, directions, determinants, and consequences of health manpower migration. About the year 1971 there were at least 140,000 physicians in countries other than those of which they were nationals or in which they had been born or trained. This number represents six per cent. of the world's total of physicians at that time (excluding the People's Republic of China). The num- ber of physicians who migrated in 1970 alone (over 13,000) is equal to one- eighth of the output from the world's medical schools that year (again exclud- ing China). Some 77 per cent of all physicians abroad were found in only five countries : the USA (with about 68,000 in 1972), the United Kingdom 21,000 in 1970), Canada (9,000 in 1971), the Federal Republic of Germany (6,000 in 1971), and Australia (4,000 in 1972). Of the 140,000 migrant physicians, only about nine per cent were found to be in developing countries in Africa, Asia and Latin America. Of the five major recipient countries, three were also heavy donors of physi- cians, namely Canada, the Federal Republic of Germany, and the United Kingdom. However, the heaviest donors were two developing countries, namely India and the Philippines, each with over 10,000 physicians abroad. Other countries suffering heavy losses were Ireland, Iran, Pakistan and Bangladesh, and the Republic of Korea, all with over 3,000 physicians abroad. A number of other countries lost a considerable pro- portion of their complement of physi- cians, e.g. Jamaica, Paraguay, Syrian Arab Republic and Trinidad and Toba- go (40-50 per cent loss); Barbados, Dominican Republic, Guyana, Leba- non, Sri Lanka and Thailand (25-39 per cent loss). The situation is not lacking in ironies : as one source indicates, fewer French physicians and professors were sent to newly-independent Togo than there were Togolese physicians and professors sent to France, a country which takes pride in her aid to former colonies; there are more specialists of all kinds from other Commonwealth countries working in Britain than there are British specialists working elsewhere in the Commonwealth; Haiti and Ireland have more of their physicians outside the country than inside. As regards nurses, an estimated 135,000 or about four per cent of the world's supply of nurses (excluding those in China) may be outside their country of birth, citizenship, or training. Of these, about 92 per cent are in Eu- rope, North America, and the developed areas of the Western Pacific. Over 9,000 are in developing countries : about 4,600 in Asia (nearly a half of these in Saudi Arabia) and about 3,500 in Africa. The major donor countries of nurses (i.e. those countries from which the estimat- ed average number of nurses going abroad annually is over 500) ar the Phil- ippines, the United Kingdom, Canada, Australia, New Zealand, and Egypt. The estimates are based primarily, An emigrant family boards ship bound for a> foreign country where its members' collective skills might find new outlets. The current wave of migration consists largely of a mass movement of the elite from less prosperous countries to a few of the richest countries of the world—the alleged effect being a widening of the gap between rich and poor nations. (Photo WHO/P. Almasy) 8

The Brain Drain A "brain drain" for one country is another country's "brain gain". In North America and in many countries of Europe, it is taken for granted that a sizeable proportion of the health staff will be of African, Asian or Middle Eastern origin. Many of these skilled immigrants may decide to stay in their country of adoption. In 1971, at least 140,000 physi- cians were at work in countries other than those of which they were nationals or in which they had been born or trained. (Photos Jean Mohr © and WHO/M. Jaco though not exclusively, on the numbers registering abroad each year. What pro- portion of these nurses actually remains abroad is unknown. Many hypotheses have been put for- ward to explain the migration of health manpower. From the perspective of the individuals who migrate, the main rea- son is the desire to improve their profes- sional and financial situations. How- ever, this desire must find its roots in certain features in the home country that appear less favourable when compared with those found abroad. In the case of physicians, the study has found that the basic "push" factor in the donor countries is that they pro- duce more physicians than they have the economic capacity to employ and there- fore risk the emigration of physicians. This "push" factor in the donor coun- tries is strengthened by a "pull" factor in the recipient countries, which pro- duce fewer physicians than they need and therefore become lands of opportu- nity for physicians from abroad. This relationship seems to hold for both developing and developed countries alike. The study also found that : There was no discernible relation- ship between physician loss and either the ratio of government to private ex- penditure on health or the percentage of total government expenditure allocated to health. The uneven distribution of physi- cians and nurses respectively between urban and rural areas appears to have no discernible relationship with migra- tion, despite numerous assertions to the effect that international migration is merely an extension of internal migra- tion from rural to urban areas. Countries that do not have the eco- nomic capacity to absorb more physi- cians and that nevertheless have rela- tively high production rates generally lose physicians, and vice versa. The income of physicians in the donor countries is, on average, about 18 times higher than the per capita in- come of the population (the range being from three to 42 times higher), while in the receiving countries it is about eight times higher on average (the range being five to 11 times higher). There is a con- siderable difference, however, between the income of physicians in the major donor countries and those in the major recipient countries, the latter receiving at least six times as much. In countries that have either a low or medium gross domestic product (GDP) per capita, there appears to be a relationship between the loss of physi- cians through migration and a low ratio of nursing personnel to physicians. The same does not hold for countries having a high GDP per capita. There is a highly-significant and pos- itive relationship between the migration of physicians to the USA and the pro- 10 portion of specialists among physicians in the donor countries. (g) Perhaps the most widespread com- mon factor to explain why physicians and nurses migrate is that the education and training they receive has scant rele- vance to the health needs of the majori- ty of people in the countries from which they emigrate. In many donor countries, medical and nursing education is focused on disease patterns that are more typical of affluent than of poor societies. This is evident in curricula at undergraduate levels as well as in the large numbers of specialists and the dis- proportionate amount of research, equipment, and facilities devoted to areas of medicine that are relevant to only small segments of the local popula- tion. In addition, many physicians from these countries go to affluent countries for postgraduate training—a training that is unlikely to be geared to the needs of the less affluent societies. Much has been said about the loss to the donor countries and the gain to the recipient countries of the cost incurred in educating those physicians and nurses who migrated. Statistics in this regard are contradictory. While it is evident that there is a loss or gain in the above context, the extent of this is not clear, given the diversity of variables (some of them unquantifiable) that need to be considered. Furthermore, there is insuf- ficient information about the extent to which donor countries are compensated for their losses through foreign aid and the remittances sent home to relatives by the migrants. Much has also been said about the impact of migration on the health status in both donor and recipient countries alike. However, the methods used to measure this are so indirect as to be al- most useless. Certainly the migration of health manpower cannot help the efforts of those responsible for planning health services and health manpower. Where attempts are being made to increase the coverage of health services, then a con- tinuous drain of skilled personnel is a very serious problem. In the recipient countries, the inflow of foreign health manpower obviates the need to bring about structural changes in the health system, and this too can have serious implications in the long run. The policy implications, for both donor and recipient countries alike, are quite clear : reform the professional edu- cation system so that the right skills in the right proportions are produced; create the right local institutions to train the needed secondary and tertiary levels of health manpower; send abroad only those students for whom specialized training at home cannot be provided and whose specialities will be directly applicable on their return. Such reforms can be effected only on the basis of well- calculated policies and plans for produc- ing and utilizing health manpower with- in the context of the health services' requirements. ■ 11 New Schools for Old THREE SPECIALISTS FROV THE HEALTH VAN POWER DEVELOPVENT DIVISION AT WHO HEAD- QUARTERS IN GENEVA-DR V.A.C. DOWLING, DR J.-J. GUILBERT AND DR F.M.KATZ-TALKED TO WORLD HEALTH ABOUT THE TRAINING OF HEALTH PERSONNEL TO MEET WORLD NEEDS WORLD HEALTH: Would you like to start by defining "health manpower develop- ment" and "health education" for our readers? DOWLING: These terms for us mean two widely differing concepts. Health man- power development is the education and training of the health worker at all levels, from the specialist physician to the village health worker. Health educa- tion on the other hand means the educa- tion of the public—all kinds of promo- tion work in the field of health. At present, WHO's drive to train the village health worker to undertake the basic tasks of health care means that we must consider these two concepts together, rather than keeping them, as it were, in separate compartments. KATZ: There is also a certain degree of overlapping in these two concepts, in the sense that the function of every trained health worker is to provide an educational function for the public. Every health worker should be an educator. WH : The Director-General of WHO, Dr Halfdan Mahler, has roundly criticized most of today's medical schools, which he sees as "ivory towers", out of contact with the real and urgent needs of today's society and designed to prepare doctors to see only this or that disease and the tech- niques that are deployed to counter it. How can we ensure that medical studies and training are made relevant to people's needs? KATZ: What is needed is a new ap- proach. In the past, medical education has trained medical doctors to treat eso- teric diseases rather than to improve health by not only curing illness but by promoting health and preventing dis- ease. There has been too much hospital- oriented training and insufficient stress on health care within the community. GUILBERT: Today we have a different notion of what constitutes the minimum of relevant competence for the student health personnel, and how to plan a flexible, student-oriented curriculum. A training school's curriculum should en- able the student to discover for himself or herself what are the population's needs in terms of health in order to set his or her educational goals. DOWLING: At the same time we some- times run into a barrier. WHO preaches that the curriculum must be made rele- vant to the needs of the population to be served. So when we are invited to advise on the setting-up of a new school in a developing country, we urge the or- ganizers to prune down and adapt the curriculum to the needs of the popula- tion; that curriculum will be very dif- ferent from those which apply in a weal- thy industrialized country. But it is easy for those responsible for health services in a developing country to assume that such different education and training will produce a second-class doctor. We on the contrary believe that it will pro- duce a first-class doctor. GuiLBERT : Now how can one construct such a programme? Data has to be gathered from various sources to deter- mine the aims of a training school and the tasks the graduate is to perform. Any member of the health team should have the competence and motivation to respond to the needs of a given popula- tion. We can enumerate these sources like this: epidemiological surveys of the inci- dence and prevalence of certain health problems in a given area; task analysis of each health worker; a prospective study of future tasks; the health policy at national or regional levels; the relevant educational policies; expectations of the population as regards its health needs; 12 (7) expectations of the student in rela- tion to his or her social function : each student should be in a position to know what the population actual- ly wants and what it is not receiving. Only then would he or she be moti- vated to find ways of meeting the needs of a society. KATZ: There is no question about the difficulty of getting to know the needs of a community. But we are making deter- mined attempts to involve the communi- ty, for instance in what we call primary health care. The idea is not to impose some kind of outside technology but to let each community work out for itself its own health requirements. DOWLING: The accent today is very much on community development, and WHO is working hard to ensure that health is always an integral part of development. It is often said that health has only a low priority in government thinking; what is really meant is that the health services have a low priority. Everybody wants health. But in the past, what the people actually needed did not filter through into development planning. Sir John Wilson, the President of the International Agency for the Prevention of Blindness, once recalled that on a visit to West Africa he asked an old man what were the main illnesses in his village. Sir John was surprised to find that—although 20 per cent of the inhab- itants were blind through onchocerciasis (river blindness)—this fact was not men- tioned. The villagers had not found it worth mentioning. They have to be en- couraged to notice such everyday facts about their own health. WH: What you are saying is that hither- to we have all too often overtrained doc- tors? GUILBERT: It could be said so, but usually for irrelevant tasks while priori- ty ones are neglected. The competence of the health worker is the important thing, not the length of time that it takes to be trained. The period of training ought to be allowed to vary. Take the case of ten nurses : perhaps some cannot manage the training course in three years, but could do it in four years or five. They should be given the opportu- nity to take the course over four years, or over five years. On the other hand, a few could achieve an acceptable level of performance after only two years of training. What is vital is that, once qual- ified, they should at least be non-toxic to the populations they serve. Dr F. M. Katz (left) consults his fellow- experts from WHO's Health Manpower De- velopment Division, Dr J.-J. Guilbert and Dr M.A.C. Dowling (in glasses) during a question-and-answer session at the Geneva headquarters. (Photo WHO/D. Henrioud) Of course, the consumer's needs are of the utmost importance. In this sense, the patient is the most important mem- ber of the health team—he or she ought not to be considered merely as a "case". KATZ: Yes, there are many examples of professional elitism. In the past there has been a high degree of over-profes- sionalism—using education to achieve status. It is like some highly exclusive golf club, where the entry qualifications are deliberately made very difficult so as to maintain an elite. This is all too typi- cal of many professional fields, but is more for the defence of the profession than to respond to the consumers' needs. DOWLING: The fact is that the older school of doctors today finds it more difficult to change radically its whole approach to community health. In this sense, the answer to your question is that in many aspects the doctor is under- trained. 13 New Schools for Old Students of anatomy in serried ranks at a tra- ditional medical school. Training methods have in the past been class-oriented and hospital-oriented, working on the assumption that all students will undertake the training course in exactly the same number of years. (Photo WHO) New approaches to the training of health workers make use of more relevant material and are more in tune with the local situation. These village health assistants are undergoing a basic training course in West Africa. (Photo WHO/R. da Silva) WH : How can a big international agency like WHO ensure that training fits local needs, and how may we evaluate whether that training is successful and effective? KATZ : What WHO is trying to do is to work with the national planners to draw up a programme that takes into account all the factors listed, to ensure that its objectives are indeed the right ones, to help them to implement the programme, and finally—to complete the cycle—to see that the people actually carrying out the programme also evaluate the degree to which they are achieving those objec- tives. Programmes like this must have rele- vance both to the characteristics of the students and to the total culture. We are now carrying out a series of case studies which attempt to indicate different ap- proaches to the education of health workers—approaches that are more in tune with the local situation and make use of a more relevant and more effec- tive educational process while at the same time aiming at producing high quality personnel. I must emphasize that we are not looking for models of what can be done in any given situation. On the contrary, these studies—in the Netherlands, Canada, Israel and Mexico—are show- ing us how quite different approaches may be needed to overcome the present misuse of available "models"; for in- stance, attempts to adopt western university standards in quite inappro- priate circumstances. Different ap- proaches are needed for different requirements, even if situations have certain basic conditions in common. GUILBERT : Yes, each programme has to be country- or population-specific. But of course one can think of countries which have certain specific problems in common regionally. WHo's role is to help the decision-makers (teachers, ad- ministrators, ministry of health officials) to use the right educational techniques to construct relevant training pro- grammes. It requires a different ap- proach too depending on the level; one can picture somebody trying to create a "new" curriculum only to have it turned down by a decision-maker at a higher level in the hierarchy who might say : "Why have you not included more hours of anatomy ?" Such a person needs himself to be trained to help him take the risk of bringing about a change DOWLING : There are several examples of schools which have tackled a new kind of approach. The crucial question is why so many have not gone on being as radical as we had hoped. A school for health personnel is to open next October near Shiraz in Iran, which will have no "departments" and will be community- oriented. Although it will no doubt meet with opposition, if those responsible can push through with it, it stands a good chance of producing doctors really in tune with the needs of the community. KATZ : You asked how we evaluate a programme's effectiveness. Well, cer- tainly we have the tools to evaluate the effect of a given programme on a student. We might say a programme is effective if it produces a graduate (or course-ender) who has the kind of com- petence required by or specified by the programme. But effectiveness is not enough. We also need to know that the process by which this has come about has been efficient in the sense of making the best use of such "input variables" as 14 the student when he first arrives, the teachers, the learning materials and so forth. And of course we need to be sure that ill producing the end-product—the graduate—we have not also produced some undesirable characteristics or un- anticipated outcomes, for example a cynical physician who is off-hand about his patients. WH : Do you consider that formal exami- nations are really necessary in the con- text of health worker training? GUILBERT : Yes, as a seal of approval that these people are not dangerous for your kids! Anyone responsible for train- ing health workers has a social responsi- bility to ensure that they are more help- ful than harmful. KATZ : I agree that there is a need for some kind of assessment to guarantee competence. But in the past all too much attention has been focused on the need for a certificate or a diploma. One of the functions of an examination is to certify that a person has achieved some level of competence, yet at present they don't provide such evidence, and such examinations may be harmful to the educational process. There has been progress in the last decades, and it seems that educational programmes are now much more oriented towards prac- tical activities and continuing evalua- tion. DOWLING : Certainly the modern ap- proach to teaching is based very much on appreciation of the fact that the lear- ner is the vital element : all students are different individuals—we are not just concerned with an anonymous class. Today there is more recognition of the interaction of individuals in a small group. On the other hand we have a long way to go and a lot to learn as WHO steps up its thrust towards community involvement and primary health care. We have various programmes under way which are looking into methods of getting the health message across to the lower educational levels—say, the rural or community health worker. Starting next year in Southern Sudan, for exam- ple, with the help of Danish Interna- tional Development Agency (DANIDA) funds, we shall be exploring ways of giv- ing village health workers continuing and basic education which will in turn enable them to promote health and health messages among village commun- ities. The objective will be to come up with a method and perhaps with materials—for instance radio broadcasts accompanied by printed or visual material—that may be specifically tai- lored to local constraints but yet can be adapted to other circumstances. In the future, we are likely to see much more concentration on self-in- structional methods—while at the same time improving the teacher-student rela- tionship. I am thinking of self-learning mechanisms that will supplement and complement that relationship. GUILBERT : Inevitably we have to be cost-conscious : learning aids can save time and help students to attain their objectives more quickly. But the teacher will still play a vital part. Above all we have found that teaching methods which place the student in an active role— where he or she has to take decisions on what to do next—are far more useful than those which entail only a passive acceptance of instructions. ■ 15 Vital Team Work A TRUE SPIRIT OF COOPERATION DOES NOT GROW OF ITS OWN ACCORD AVONG HEALTH WORKERS WHOSE TRAINING HAS PREPARED THEM FOR WORK- ING INDEPENDENTLY RATHER THAN AS A TEAM by Daniel Flahault [II0 ore than 4,000 million people live on our planet today. Of these, 3,000 million live in the developing countries; and out of this number only about 20 per cent— perhaps 600 million—have any sort of access to official health services. What this means is that about 2,500 million persons have no possibility of obtaining the health care they need. Such figures enable us to measure the scale of the problem. Finding an urgent remedy to this state of affairs is one of the most burning problems of our times. There is no miracle solution that can improve the situation radically in a mat- ter of weeks. But, in our view, in the developing countries where the econom- ic infrastructure is frail and there is an acute shortage of health personnel, only team work in the rural health services can show the road to progress. In this context let us try to answer three questions : why do we recommend team work? why seek to organize it? and why try to make it official? Why do we emphasize the value of team work? The answer is both simple and convincing: this method of working represents the best possible way of bringing more and better services to all. Working alone and in isolation, the doctor—like the nurse, the medical as- sistant, the midwife, the sanitary en- gineer, the dentist and the pharmacist each in their own sphere—will undoub- tedly develop certain useful activities which will be appreciated both by the community and by the local authorities. Human lives will be saved, the compli- cations of certain diseases will be avoided, men and women who have been cured will be able to return to work. But at the village and hamlet level, whatever the intrinsic value of the health personnel, these isolated and in- dependent activities are not enough; they merely represent the misuse and waste of available resources. Coverage of the population will be limited to those who live close to the health centre where the doctor, the nurse or the medical assistant work. In other words it will be incomplete. This recurring situation explains why, in many rural areas of the developing countries today, only 20 per cent of the inhabitants have access to official health services. Elsewhere, the doctor and the nurse may respond to emergency cases, travelling wherever there is need but neglecting those activities that relate to preventive medicine and community development. Health services of this kind will en- sure punctual delivery of care for the benefit of a few. Comprehensive activi- ties for the benefit of all the people will not be provided. That is not to say that on the spot care should be replaced by comprehensive activities, but it is impor- tant to ensure a balance between these different types of activity so that indi- vidual cases of sickness do not blind us to more general disorders of the com- munity—in fact so that we can no longer see the wood for the trees. Clear- ly several doctors, medical assistants, nurses, midwives or other health person- nel, or any association or combination of these, will result in a better organiza- tion of the work-load, and a better dis- tribution of the tasks which will ensure that at least a minimum of health care reaches all the population of any one sector. More services can be made available if some of the health workers, trained for certain simple routine tasks, can release the professional personnel and enable them to concentrate on activities which require a higher level of compe- tence. At the village level, the training of health agents to give emergency first aid, to spread the good word about hygiene, to switch more complex or serious cases to an upper level of treatment, and to participate in community development will also increase the potential activities of the health services, and extend them to the fields of curative and preventive medicine and to health promotion. Obviously these health agents should not be left to themselves but should form part of a system, and in that sys- tem they should work as a team of which each member is a vital cog. At the level of the rural health centre, the ap- pointment of an auxiliary worker will permit the person in charge to leave the centre and do his or her rounds among the local people and try to resolve their problems. This health team discussing the day's pro-l> gramme of work in a West Bengal village, India, includes a research aide, a sanitary en- gineer, a research analyst, a health educator and an officer in charge of training. Together they will find the best ways of solving the villagers' most serious health problems. (Photo WHO) 16 7.1 1,7 f , 114% .• - • -2•*- • :S• 1"11.• 4* - 6 ,4 ,rt • t • • 'WA( 41'4i 10 • ' • : • Ab,tot 4.. . k. 17.jorperfe.ttest, ' , - V ‘161' • fe 41. • " st: 1•*".„' V ./1s . ,c k 1;1 ,.. - 4/. • (1. ,10 . • . • ‘,* ec y 6i/i; s ;* . 14, • • 6. .? iel.144 41, rig - 160 , ; • P' 44.11.v. '11" ';t" 11/..• • ,100q .4! " - Vit 4E0, t . • Pia *•"‘" `' ;4611r: *et .• I Vital Team Work The same will be true at the rural hos- pital level, where several physicians ought to be able to share out the jobs, taking turns in being on duty at the hos- pital and in visiting the centres associat- ed with their hospital, so as to keep an eye on the whole organization, the way the duties are apportioned, how the work is carried out and the quality of the work. Better health services can in this way be put at the disposal of all the people; team work will guarantee regular super- vision of the health staff in charge of vil- lage dispensaries, rural health centres and rural hospitals. Freed by their aux- iliary colleagues from simple routine tasks, the chief medical assistants and head nurses at the centres will be able to advise and help the village health agents, rectify any errors they might make and supplement some of their functions. Similarly the personnel of the rural health centres will be observed, assisted and regularly checked by the staff of the rural hospitals, who will themselves work in close collaboration with the dis- trict and provincial levels of the health services. These different levels of health services form a complete integrated sys- tem, and the same inter-locking machin- ery which ensures their inter-dependence and their interaction naturally creates ties between the different levels of ac- tion, fosters the team spirit and the feel- ing of belonging to a single body, and results in team work where each mem- ber has his role to play and each role is complementary. Within the team one finds exchanges, shared efforts and common practices developing which stimulate individual action and constitute an important ele- ment in continuous training. Permanent recycling is an additional guarantee of the quality of the services provided and increases the competence of each mem- ber of the team. Backed up by health service officials working at a higher level, conscious of belonging to a group and not being in isolation, the local health team will find its prestige and its credibility strengthened. It will find it easier to win the confidence of the local population, and that confidence in turn will facilitate the development of ser- vices that are better adapted to the needs. If it is true that team work ought to enable the number of available services and the quality of the health care to be improved, the people also have a right to expect that this work is organized for their benefit. But that organization does not occur by itself. All team work demands a certain degree of coordination; everyone agrees that it is needed, but agreement between one person and the next often stops there. It is when it proves necessary to put this coordination into practice—thus imposing certain limitations on privi- leges, autonomy and freedom in order to arrive at a rational and coherent plan of activities—that difficulties and differ- ences of opinion arise. Stumbling -blocks Such difficulties have to be recognized if they are eventually to be overcome. Certain stumbling-blocks appear because of the structure of the health serv- ices, which in many countries have been traditionally geared towards health care of the individual rather than that of whole communities, thus favouring the individual approach. As a result, train- ing programmes, services offered and the administration itself have most often been centred on those types of staff and activity that operate best in isolation. To these structural stumbling-blocks we may add those stemming from the fact that curative activities took precedence over preventive ones, and the medical aspect over the health aspect, thus unde- niably favouring the medical staff. If we think that in the health team the medi- cal staff still ought to have pride of place, at least we also think that this place should be shared. This sharing of responsibility among the members of the health team is un- doubtedly a source of discord. All too often people take up positions for motives from which neither politics nor passions are lacking. Nevertheless what is needed is to re-examine the needs of the people and of the health services, to class these needs in order of priority, to determine what tasks have to be done and who should carry them out—that is, which team is involved—and then to train the personnel needed for these tasks. Next it has to be ensured that the personnel carry out their duties effec- tively; this in turn poses problems of management, responsibility, supervision and evaluation; these are the functions of the team leader. Who will be this team leader at the different levels of action? What will the relationships be between these various levels? Finally, other stumbling-blocks and divergences stem from the individuality of the personnel who are invited to be members of the health teams. The nurse, often harassed, tries to escape from the tutelage of the doctors. The sanitary en- gineer, long under-estimated and even ignored, hesitates about integrating him- self in a team where he fears to lose his identity. The physician, bathed in the glory of his therapeutic triumphs, too often tends to impose his views on those who should be quite separate associates, and to order them about. Present-day tendencies towards corporatism only serve to reinforce the individualism of one person or another; advantages gained and the self-interest of each pro- fession come to override all other con- siderations, including the exigencies of the health services and the good of the people. Planning health activities so as to make rational use of the always limited resources of personnel and services, while reconciling the legitimate aspira- tions of each member of the health teams—these are foremost among the tasks to be carried out and the obstacles to be overcome by those who are trying to foster the team spirit among health personnel. It is not enough merely to recognize the value of team work, particularly in rural areas and in developing countries. In order to organize this work, as we have seen, a number of difficulties have to be surmounted. In our view, these can only be ironed out if there is a will to make progress and if the necessary means of involvement exist. For this will and these means to become reality, the involvement and support of each coun- try's health authorities are essential. In- volvement and support may take on dif- ferent forms according to local condi- tions and circumstances; but in any event it is necessary to explain what is meant by "team work" and why it should be developed or encouraged. It will also be necessary to spell out what modifications those in charge of the health services envisage in the or- ganization of tasks at the rural level, or in the training and administration of per- sonnel at the different levels of action and what repercussions they expect within the health services. In this way, informing the interested parties—that is, the people served and the health person- nel—about the measures which directly concern them ought to provoke the kind 18 At an open-air "clinic" set up in an Iranian village, members of the health team under- take a variety of activities—routine medical check-ups, first aid for minor injuries, vacci- nations, and health education for mothers of small children. Each member is a vital cog in the team, and the team itself forms part of a planned health system, ensuring that at least a minimum of health care reaches all the pop- ulation. (Photo WHO/D. Deriaz) of reactions which will enable the origi- nal proposals to be adapted and im- proved. A climate of confidence should thus be created which will facilitate the kind of steps needed to bring about any desired changes. Once the information has been con- veyed and the reactions to it have been received, a genuine policy for team work in the rural health services will be estab- lished. After the declarations of intent, administrative measures will be required to systematize the team work and deve- lop it progressively. These measures will vary from one country to the next : designation of national and regional officers, the drawing up and approving of rules and instructions spelling out the responsibilities of different members of the health teams at different levels, or- ganization of work schedules, initial training and subsequent recycling of those personnel who prove suitable for redeployment in a multi-disciplinary framework, which will include supervi- sion and evaluation. Working as a team does not signify working alongside one another. Team work should permit health activities to be rationalized, developed and im- proved. A true spirit of cooperation does not grow of its own accord among health workers with different traditions, whose training has prepared them for working independently rather than as a team, and who find themselves in situa- tions to which they find it hard to adapt. The health service officers have to keep an eye on things, while at the same time showing a readiness to act and to make available the means needed for working out and implementing a genuine team work policy—not least in those rural health services which are still not ade- quately developed. ■ 19 Cif he public health system of Mon-golia, which started 50 years ago with no more than a 15-bed hos-pital, is today a comprehensive network of preventive and curative ser- vices covering the vast country, with its own medical and research institutions, and 1 doctor and 3.6 auxiliary health workers for every 500 people. A key role in this remarkable achievement has been played by the feldsher, a versatile health auxiliary, one of whose basic functions is health education of the public. The earliest batches of feldshers were sent out on pioneering missions to remote rural areas to bring basic medical care to the people and to fight the prejudices and superstitious beliefs of pre-revolu- tionary Mongolia. As Mongolia celebrated the 55th an- niversary last year of the founding of its health services, World Health decided to interview a rural feldsher about his daily life and work. The questions were an- swered by Feldsher Lhamsurengijn Sag- dar, who has been working for eight years in one of the brigades (work areas) of the somon (district) of Hutag in the aimak (province) of Bulgan in the north of the country. The people he serves are herdsmen living in their unique portable tents, and moving with their cattle from pasture to pasture. There are 700 people in Mr Sagdar's work brigade. He claims to know each one of them. WORLD HEALTH: Tell us something about your work and life at this station. SAGDAR : I came to this medical post on transfer from another somon, and have been working and living here for the last eight years. It is important that I live at the brigade centre, because in a rural medical post you have to be familiar with everybody's daily life and state of health. There are in all some 700 people in the brigade, spread over an area of about the same number of square kilometres. I can say that over these years I have managed to get acquainted with all of them. I often visit the members of my bri- gade in their tents. We do not wait for the patients to come to us : we go to them so that timely help can be given. These visits often mean several days' journey, since vast distances separate one herds- man's camp from another. WH : What facilities does your station provide, and how is it staffed? With what kind of health problems are you mostly concerned? §AGDAR : Our medical post has almost all the necessary facilities for curative and preventive care. It does not yet have a laboratory. When necessary, we send patients or specimens to the somon, inter-somon or aimak hospital for labor- atory tests. Sometimes we make use of the mobile laboratory sent to our post from the aimak headquarters town. Besides me, the staff includes two nurses and Focus on Health Education A MONGOLIAN FELDSHER SPEAKS "CONDUCTING CONTINUOUS HEALTH EDUCA- TION IS VY FIRST DUTY. PREVENTION IS OUR BASIC PRINCIPLE. EVERY EFFORT IS VADE TO RAISE THE HEALTH KNOWLEDGE OF THE PEOPLE. CHILD CARE, CORRECT FEEDING AND VACCINATIONS ARE AMONG THE VOST IV PORTA\T TOPICS FOR HEALTH EDUCATION." 20 two health assistants, the latter more versed in sanitary work. We keep under permanent observa- tion all pregnant women and all chil- dren up to the age of three, as well as patients with a history of cardiovascular disorders. WH : Can you describe a typical day in your working life ? §AGDAR : My working day begins with my morning round of indoor patients' wards. Then I hold a surgery for patients brought to the centre. Next, in response to any calls that may have been received, I visit patients in their homes and give them the necessary treatment and care. On my house calls, I must take the necessary medicines with me, since herdsmen living far from the brigade centre cannot be expected to come back to the medical post to obtain the medication prescribed. One of my important duties is to check the sanitary Working as a feldsher in a northern province of Mongolia, Lhamsurengijn Sagdar says he has learnt to know all 700 inhabitants of his district even though they are scattered over an area of about as many square kilometres. Ill- ness in the family while he was a schoolboy impelled him to choose "this noble and humane profession". (Photo WHOIMinistry ofHealth,Ulan Bator) state of public buildings and other es- tablishments, and conduct discussions on environmental sanitation as a means of preventing disease. WH: If you have a patient you cannot treat at your own station, what action do you take? AGDAR : If a patient needs specialized medical care we send him to the inter- somon hospital. From our post, the inter- somon hospital is 45 km away, and the aimak hospital about 100 km. There is a permanent telephone link with the inter-somon and aimak hospitals. WH: What part do you take in the health education of the people ? Are any special measures taken to ensure community par- ticipation? Are you concerned with school health activities? AGDAR : Conducting continuous health education is my first duty. Prevention is our basic principle. Every effort is made to raise the health knowledge of the people. My talks are often accompa- nied by visual aids, filmstrips, slides and posters. The subjects for health educa- tion are many and varied, but the most important are child care, correct feeding of children, and vaccinations. The people participate actively in our programmes. I should like to mention that vaccina- tion campaigns in our country have resulted in the virtual elimination of such diseases as measles, poliomyelitis, whooping cough and diphtheria. 21 A Mongolian feldsher speaks 4Under the canvas wall of a circular tent traditional home of the largely nomadic Mon- golian herdsmen and their families—a woman feldsher checks that the latest addition to the family is thriving. Home visits have a particular meaning for the> feldshers; they involve driving far from paved roads in order to catch up with the herdsmen as they move their cattle—and their tents— from pasture to pasture. (Photos WHO/D. Henrioud) We are helped in our health education work by health promoters. These are members of the public who take a short training course, and are awarded the health promoter's certificate after an examination. The brigade council has a four- member health protection committee, which helps promote community partici- pation in measures aimed at prevention of disease and implementation of the health programme. Every week the com- mittee discusses the results of the work done and plans measures for the future. Our brigade has a primary school, and health of the schoolchildren is a major concern of our medical post. Every three months, I carry out a routine health examination of the children, and every week a sanitary inspection of the grounds and premises of the school. The medical post staff maintains close con- tact with the teachers and joins them in applying health measures and teaching the pupils healthful ways of living. WH : What education did you have in order to become a feldsher? Were other categories of health workers also studying at your school? gAGDAR : Following a basic school train- ing of at least eight years, feldshers are required to do a four-year course at medical college. They receive, in addi- tion to general education, training in more than 20 specialized subjects. In our country, medical colleges also provide training facilities for mid- wives, nurses, and pharmacists with intermediate-level training. WH : Is there any special reason why you chose the career of feldsher? How do you keep in touch with the new knowledge that has become available since you left school? Can a feldsher become a full physician if he wants to? SAGDAR : When I was at school my mother fell seriously ill. I saw how she suffered, and also how she was cured by our somon feldsher, Dadendev. From that time on I began to dream of becoming a feldsher, and when the time came, I chose this noble and humane profession. Since I finished medical college I have been working on my own to improve my qualifications and knowledge. I read a lot and subscribe to medical periodi- cals. I also try to read up-to-date books in my field. In 1974, I completed a short course of advanced feldsher training. In our country all the necessary con- ditions exist for improving one's qualifi- cations. Every feldsher for example, has the right to enter the Medical Institute to become a physician. All you have to do is prepare yourself to sit the competi- tive examinations. Many of my class- mates have already done it. And I am trying to keep up with them. 22 WH: Can you describe in general terms where the area of responsibility of the feldsher ends and that of the doctor begins? In your view, what is the doctor's attitude to the feldsher—does he or she see the feldsher only as a helper or also as a substitute doctor for many occasions? SAGDAR : You have asked me a compli- cated question. To speak frankly I have never thought about it. First of all, I should like to point out that both ex- perts, feldsher and physician, have equal responsibility vis-a-vis the people. But their range of duties is different. Our physicians consider the feldshers as their closest collaborators. WH: Who supervises your work? How often does a doctor or a health team from the somon or aimak hospital make calls at your station? How do they supervise your work? SAGDAR : In our system the feldsher's post comes administratively and organ- izationally under the somon or inter- somon hospital, and also under the bri- gade authorities. Physicians from the inter-somon hospital visit us once a month. They inquire abotit our work and give the necessary instructions and advice. They examine the patients, and supervise all the preventive and curative work of our post from the professional point of view. The somon and brigade authorities take an active interest in the administration of our medical post, pro- viding us with every form of coopera- tion, including transport. WH: What part do you take in the social life of your somon? SAGDAR : Like my colleagues, I take an active part in social work. I am a mem- ber of the somon directorate of the Red Cross and the people's supervisory group. At the brigade level, I personally direct the work of the primary organiza- tion of the Red Cross. All the adult members of our brigade are members of the Red Cross Society. The medical or- ganizations and the Red Cross Society work in close cooperation. WH: Can you say something about your family life? What do you do in your free time? SAGDAR : I have a large family with growing-up children. In our country much attention is paid to maternal and child welfare. Mothers of large families get cash allowances, and this applies to my wife also. She works as cook at the boarding school. Our brigade also has a kindergarten and a day nursery. I am an amateur photographer. I also enjoy playing chess in my spare time. I like hunting, too. ■ 23 Manpower Planning THE TASK OF HEALTH PLANNERS IN FUTURE WILL BE TO PROVIDE A BLUEPRINT FOR THE KIND OF ACTION THAT WILL USHER IN A NEW ORDER OF HEALTH CARE FOR THE BENEFIT OF ALL MANKIND by Dev Ray ilo ealth services are particularly "labour intensive", that is to say, much of the money required to run them is allocated to sal- aries and wages of the health personnel. The proportion of total expenses for health services that is spent on wages can be as high as 60 or 70 per cent. This is understandable since in health care, whether in a hospital or in an outlying dispensary, trained people have to take care of the sick and those who are sus- ceptible to illness. These trained people, whether they are professionals or not, are described as manpower. In the health services, therefore, it is necessary to use manpower wisely, especially since there is often a lack of such personnel in developing countries. Recently, more and more emphasis is being placed on planning so as to make a judicious use of resources. But what is a plan? A plan is a set of instructions to undertake certain actions. For example, the plan of a building provides a blue- print not only of how the building is designed but also, implicitly, of how it is to be constructed. A health plan is, similarly, a set of instructions for build- ing up the health services in a specified period of time. As its first step it usually lays down what type of health services are needed to prevent and treat most common diseases and illnesses; how many clinics, hospitals and other health facilities are to be built and when; what will be their resource requirements in money, equipment, supplies or trained people in order to keep a defined popula- tion as healthy as possible. The plan enables the health authorities to achieve some of the health goals or objectives they have set themselves. For example, one objective might be to extend coverage of rural populations by dispensaries and clinics from 20 per cent to 40 per cent in five years time. As has been mentioned earlier, man- power is one of the resources—in fact the most important—that is needed for health services. A health manpower plan is meant to ensure that the right num- bers and quality of manpower are avail- able to staff the health facilities as the needs expand, so as to keep up with current and future demands of services from the people. It is like planning the production and supply of bricks to be used in buildings. For an individual building, the builder has to plan and phase the ordering of bricks, taking into account supply time and the schedule of construction. The situation gets more complicated in planning the production of bricks, since the brick producers have to consider all likely construction work in the area, their schedule and the prices that builders may be willing to pay. The analogy between manpower plan- ning and planning for production of bricks stops there. Manpower planning is considerably more intricate because of the human factors involved. For example, the behaviour pattern and skills of in- dividuals are different; individuals with differing skills may not be easily substituted for one an- other; manpower cannot be stored; individuals may leave the services when they wish; trained manpower cannot be pro- duced at short notice; performances of individuals depend a great deal on motivation, conditions of service, career opportunities and so forth. In addition, all these characteristics are interrelated, and a manpower plan must take into account all the interactions. Planning is not a new activity and or- ganizations have always devoted part of their efforts towards preparing for the future. However, there is good planning and bad planning. A bad plan is drawn up when previous experience has not been adequately taken into account, no explicit goals have been considered, and sufficient attention has not been paid to the pre- vailing country situation in terms of distribution of illnesses in the community, geography, social and economic con- ditions, the political system, and the feelings and preferences of the people regarding health care. Health planners at work. Just as an architect> has to take into account the special require- ments of his building and the future avail- ability of building materials, so a health planner must lay down a set of instructions for build- ing up a country's health services over a cer- tain period of time. The planners must also decide what will be the resource requirements in terms of money, equipment, supplies and trained personnel. (Photo WHO/D. Henrioud) 24

s • a . A lack of proper planning also amounts to bad planning. Experience up to now indicates that health man- power development has often been done without a plan. Examples of this are numerous : a newly expanded hospital, completed at great cost by obtaining foreign loans, stands unused because of a lack of nursing personnel; the gift by a developed country of a modern university hospital soon becomes a double liability—a major drain on the health budget and a sophisticated teaching facility which is inappropriate to local needs; in order to pay the wages of the staff of a health system, the budgets for drugs, equipment and facility main- tenance are cut to the point where effectiveness of service is severely compromised; three nursing schools are opened in a single region where there are already sufficient nurses, including one hospi- tal with an average of two nurses for every three beds; 1 because of some administrative bar- rier to the promotion of health work- ers, the morale of the personnel falls to a critically low point. There are many more such examples where various resources have not been kept in balance, or where trained people have been improperly utilized. How did these examples come about, with their consequences of wasted resources, low morale or unnecessary human suffering? They are not the result of stupidity or malevolence. Health is one of the few fields where everyone takes the same side—against disease and suffering—and there are plenty of well-meaning, talented people. These examples rather stem from a degree of disregard of the complexities of health services, from actions based on a piecemeal approach, from a certain resistance to change and from a high Left, teaching the teachers. When this class of students in Burma eventually graduate, they will in turn become instructors for dif- ferent categories of health personnel. Right, a trainee health worker in Brazil tends a newborn baby under the supervision of a qualified nurse. The health services of the future will require careful manpower planning to ensure the right mix of trained personnel with different skills and the best possible util- ization of those skills. (Photos WHO/J. Mohr and WHO)

degree of institutional professionalism which make providers of health care dis- trust planned changes. The underlying causes of the lack of proper manpower planning are mani- fold, but they include : failure to consider the political frame- work; lack of coordination between the ser- vices and training institutions; fragmentation of health services among multiple administrations and agencies; uncoordinated use of resources— manpower, materials and money; organizational rigidity; lack of appreciation of planning and what it entails; lack of involvement of the planners in the implementation of their plans. How can one tell if a plan has been suc- cessful? The success of a building plan is seen when the building is complete, functionally useful and aesthetically pleasing. The success of manpower planning is seen when health services are functioning properly and where a balance has been reached between the quality and quantity of manpower requir- ed and that which will be available. But many conditions have to be fulfilled for this. Past experience has to be ex- amined to determine what levels of skills are necessary to perform jobs, ex- periments have to be conducted to detect how trained people are utilized, the proper mix of manpower, money, drugs and equipment has to be found, and all these factors have to be con- solidated. More than this, a manpower plan must be seen in its proper context. A health manpower plan has no meaning unless it is related to a health plan. But it is the practice rather than the exception to see health plans with very little mention of manpower plans. The health plans often deal with manpower require- ments but leave out how the required manpower is to be developed and how to make training more relevant to the health services. It is time to put a stop to this and develop manpower plans which are appropriate to the national health plans and take explicit account of the country's manpower policies. Finally, health planning and health manpower planning must be relevant to the existing disease patterns and should be suited to the overall socio-economic plan of the country. The aim of manpower planning is to ensure that the required number of ap- propriate personnel are available at the proper time to staff the health services. In other words, it gives guidance as to what should be the present actions so that a balance exists in the future. The planning horizon, or the number of years in the future to be considered, has to be sufficiently long. A present deci- sion to establish a nursing school will not affect the future availability of nurses for four or five years, when the school graduates its first class. This long-term view is another special characteristic of manpower planning. 28 Manpower Planning <Good planning entails paying meticulous at- tention to details, as these trainee draughts- men are learning. Health planners too must acquire special skills, not only through ex- perience but also by learning the principles and theories. (Photo ILO) Dental assistants in training at a European> dental hospital. The aim of manpower plan- ning is to ensure that the required number of skilled personnel are available at the proper time to staff the health services; and such forward planning needs a long-term view over the next four, five or six years. (Photo WHO/T. Farkas) In addition, people being what they are, adequate attention must be given to their motivation. This is probably one of the most difficult tasks that planners and managers face, since without a motivated group of people all plans are likely to fail. Motivation can be affected by many things—incentives for good performance, job satisfaction, improve- ments in working conditions. Most im- portant, however, is for health workers to feel part of teams where not only do they value their work but they also feel that they are indispensable. Manpower planning, like health plan- ning, is a continuous cyclical process, with constant reviews and adjustments. being made to ensure that the health service goals and the manpower demands are matched by an appropriate supply of staff. It is ultimately the nature of the services which will dictate the demand for manpower, and any change in these services, or even in the socio-political conditions of a country, will lead to changes in manpower plans. It is assumed that architects and building designers must have special skills—both through special education and experience. It is often forgotten that manpower planners, as well as health planners, must acquire special skills, not only through experience but also by learning the principles and theories. They must have special aptitudes and motivations if they are to be effective, and it is not enough to designate a plan- ner arbitrarily in the hope that he will do the job as well as anyone else. Simi- larly, the planners must be involved in implementing their plans, just as archi- tects often coordinate the construction of their buildings. The separation be- tween planning and implementation must be broken down if plans are to be successfully converted into reality. Two main factors, the social aware- ness of health and the scientific and technological explosion, have shaken the foundations of health care during recent decades. The steady advance of knowledge and the increased availability of funds for medical research have not provided the solutions to health prob- lems. Rather, the gaps have widened in developing countries between the best which medicine can offer and what is available to vast numbers of people. The health establishment is on trial for its failure to serve the needs of society, for choosing wrong priorities in determin- ing relevance in health manpower edu- cation, and for wrongly allocating finan- cial and manpower resources. In the future, the health services will undergo a change towards increased team work, and towards primary care and community medicine. These changes will in turn bring about far- reaching alterations in the education and training of health manpower. Health planning, and particularly health manpower planning, when undertaken in an appropriate manner, will provide the blueprint for the kind of action which will usher in a new order of health care to the benefit of society at large. ■ 29 ANpNNCNNN KOHTP0Ab cONTR 0 I. CANCER- NEW WHO FIGURES STILL NEED FOR VACCINATION CARDS? With smallpox confined to two foci in Somalia and Kenya, in the world, the question is often asked whether inter- national travellers still need to carry smallpox vaccination certificates. For a great many destinations, the an- swer still is 'yes", because—despite the success of the smallpox eradication programme—health administrations do not wish to drop their guard too soon. The World Health Assembly in a resolu- tion last year recommended that evi- dence of vaccination should be required only from travellers who may have vis- ited a smallpox-infected country within the preceding 14 days. A number of countries have accordingly amended their health regulations. There are, (Photo WHOIAlovosti) however, about 80 health administra- tions who want smallpox vaccination certificates from travellers from all countries. Travellers should verify from travel agents and other sources the regula- tions in force in the countries they in- tend to visit. This information is also available in the publication, Vaccination Certificate Requirements for Interna- tional Travel, which is published by WHO and updated periodically. "MYSTERY" DISEASE ABATES The epidemic of viral haemorrhagic fev- er that struck Southern Sudan and Zaire in the last quarter of 1976 appears to have abated as mysteriously as it ap- peared. First reported in Southern Sudan in September, the disease, with- in the brief span of ten weeks, affected How the electron-microscope saw the Zaire virus. (Photo Center for Disease Control, Atlanta, USA) 161 people, 77 of whom died. In North- ern Zaire, 358 cases were reported with 325 deaths. In Zaire, the zone of Bumba, to which the outbreak was confined, has been freed from travel and other restrictions even though active surveillance mea- sures are being maintained throughout the country. The causative organism identified by three laboratories collaborating with WHO—in Belgium, the UK and the USA—was found to be similar to the virus of the Marburg or "green monkey" disease. The disease got this name from an outbreak in 1967 in Marburg, Feder- al Republic of Germany, and two other centres, when 30 cases of virus disease, seven of them fatal, occurred among laboratory workers handling the infect- ed tissues of imported African green mon keys. When the governments of Sudan and Zaire reported the outbreak, WHO re- sponded by sending virologists and epi- demiologists to help identify the causa- tive organism. A WHO-organized team of epidemiological investigators is now in Sudan examining various aspects of the outbreak to determine the cause of the disease, its mode of spread and methods of prevention. The team in Zaire, organized by the Government, is multinational and includes WHO repre- sentation. One of the puzzles for the researchers is the origin of the virus. It has been sug- gested that it could be a rodent virus that by mutational change has adapted itself to humans and to transmission between them. Experts are searching among rodents and bats to determine if they played a role in the latest outbreak. Four and a half million people die of cancer throughout the world each year and six million develop the disease, ac- cording to recent WHO estimates. The figures are based on extrapolation of the existing information, since WHO has access to cancer data only from a small number of countries, representing 27 per cent of the world population. In developed countries—where more reliable figures are available—cancer strikes two out of three families. An estimated 14 million people will die of cancer in Europe during the present decade. In Europe and North America, cancer is the principal cause of death among women in the age group 30- 54 years, and the second most impor- tant cause of death among children (1- 15 years). In the developing countries, as communicable diseases decline, can- cer is expected to move to the forefront as a cause of death and sickness. The outlook in cancer is not, however, as grim as the figures might suggest. Hundreds of thousands of cancer suf- ferers have been completely cured, and the incidence of the disease in some forms has been drastically reduced through preventive methods. For in- stance, deaths and illness caused by cervical cancer have been reduced by 40-60 per cent in the last 20 years in Canada, the USA and the USSR. Film for World Health Day • "Immunize and Protect your Child" is the slogan for World Health Day, 7 April 1977, and "Protect Them Now" is the title of a new film jointly produced for the occasion by WHO and UNICEF. The film, which lasts 15 minutes and is in 16 mm colour, was made in Ghana and shows something of the unnecessary suffering caused to chil- dren through lack of immunization. Their susceptibility to infection by such diseases as tuberculosis, measles, poliomyelitis, diphtheria, tetanus and whooping cough is of- ten heightened by advanced stages of malnutrition. Local populations are now accepting the idea of im- munization, particularly when it is endorsed by their own tribal healers and by village health workers. Con- vincing everybody of the need to protect their children in this way is a vital part of WHO's Expanded Pro- gramme on Immunization. For further information about this and other films please contact the Film Officer, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• ••••• ••••••• ••••••• ••••••• ••• ••• ••• ••••••• ••••••• ••••••• ••••••• ••••••• ••••••• ••••••• ••• ••• ••• ••••••• •• • ••• • ••••••• • • ••••• • •••••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• ••••••• ••• ••• ••••••• ••• ••• ••• ••••••• ••••••• ••• ••• ••••••• ••••••• ••• ••• ••••••• ••• ••• ••• •••••• •••••• ••••••• ••••••• ••••••• ••• ••• ••• ••• ••• ••• ••• ••• ••••••• ••• ••• ••• ••• ••• ••••••• ••••••••••• ••••••• ••• ••••••• ••••••• ••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• ••• ••• ••••••• ••••••• ••• ••• ••••••• •••••••••• •••••• ••• ••• ••• ••••• ••••••• 30 WHO's Resources and Display Centre. (Photo WHO) teaching aids on show One of the most eye-catching cor- ners of WHO's Geneva headquarters is the Resources and Display Centre which forms part of the Health Man- power Development Division. The exhibits, models and teaching aids which are put on show are of particu- lar interest for WHO officials who are setting off to work in often remote corners of the globe. It is vitally important for them to see the kind of technological aids that may be of use in health education "in the field". Thus there would be no practical value in carrying a mains-operated slide projector to some rural village of South-East Asia where there is no electricity supply. Instead the public health educator might take along a lightweight battery-operated projec- tor with its own folding screen— which in turn rules out the need for a heavy roll-up screen. The Display Centre includes many anatomical models, including several specially designed for family planning instruction, and even a human skele- ton—in plastic. There is a wide variety of audiovisual material, including full- scale videotape recorders which re- cord sight and sound simultaneously. The technical gadgetry naturally appeals to members of the public who visit WHO headquarters, but this is not the full story. Much of the Dis- play Centre's work involves offering specialized advice on how teaching aids may be used in training pro- grammes, explaining the cataloguing, storage and retrieval techniques of audiovisual material, and answering inquiries about the availability of courses or programmes for training the different members of the health team. educational handbook The 1976 edition of WHO's Educa- tional Handbook effectively sums up a whole educational system in just over 300 pages. It consists of a selec- tion of items from the recent litera- ture on the theory of adult education, and its practical application in solv- ing problems in the training of health personnel. In addition, it contains a set of exercises which the serious reader may like to tackle in order to evaluate his or her own knowledge of the subject. It is couched in a relative- ly simple form, and invites the reader to solve the most intransigent teach- ing problems by selecting the most appropriate of the various theoretical models available. Prepared by Dr J. -J. Guilbert, it is produced in Spanish and Italian as well as English and French : further translations may follow. Copies are available on request from the Divi- sion of Health Manpower Develop- ment, World Health Organization, 1211 Geneva 27, Switzerland. schools for medical assistants The global shortage of health pro- fessionals, particularly in the develop- ing countries, has increased the need for new types of health workers to fill the gap. The World Directory of Schools for Medical Assistants has been compiled by WHO to provide health administrators, educators and students with a compendium of infor- mation about this type of training centre throughout the world. The Directory is a bilingual (English/ French) publication, and contains data up to 1973 about schools for medical assistants in those coun- tries or areas whose governments have responded to WHO's request for details. Each country or area is dealt with in a separate entry, giving the names and addresses of the schools, their conditions of admission, the dura- tion of training, language of instruc- tion, and other relevant information. The Directory has 112 pages and may be ordered from : Distribution and Sales Service, World Health Or- ganization, 1211 Geneva 27, Switzer- land, price Sw. fr. 24.— or US$9.60. Authors of the month All the authors of signed articles in this month's issue are staff members of the Division of Health Manpower Development (HMD) at wilii) head- quarters in Geneva. Dr T. FOLoP is the Director of the Health Manpower Development Di- vision. Dr A. MEDIA heads the Health Man- power Systems unit in HMD and Mrs H. PIZURKI is a member of the Nursing unit. Dr M.A.C. DOWLING is responsible for Educational Communication Sys- tems, Dr J.-J. GUILBERT for Educa- tional Planning, and Dr F.M. KATZ for Education Evaluation. Dr D. FLAHAULT heads the Health Team Development unit. Dr D.K. RAY is in charge of the Health Manpower Planning unit. WORLD HEALTH for readers everywhere ORDER FORM Please enter my subscription to "World Health" as follows: US$* Sw.fr.* One year 10.— 25. Two years 18.— 45. Three years 24.— 60.— One year : Two years: Three years: I enclose cheque/postal order in the amount of Name • Street City: Country • or equivalent in local currency . World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland The kiss of life: practical instruction for a village health worker in Samoa (Photo WHOIR. J. Gobius)