W 0 R L D H I AL T H ORGANIZATION
RIGION~L O,FICE FOl THE WESTERN I'ACIFIC
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ORGANISATION MONDIALE DE LA SANT~
BUlEAU ReGIONAL DU I'ACIFIQUE OCCIDENTAL
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REGIONAL COMMITTEE Twenty-seventh session Manila 6-11 September 1976
'WP RI KC2. 71 T£j 1
5 August 1976
OlUGlNAL:
l!;NGLl~ti
TECHNICAL PRESENTATION
by
Kenneth W. Newell, M.D. D.P.H. 1
1 Director, Division of Strengthening of Health Services, WHO, Geneva
WPt!./ KCL7/TPj 1. t'Ci6t::: 1
l"ly first nealtn service experience as a younl:!, pny<>ic~all in l~jOs
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was to nave the sole nealth restl0nsioility for a very uiO.Latt:::u laq,ely Polynesian rural area wllere the nearest ulaJor l.losl!~tal. was more than a nundrea lIules away over secondary roads. 1 Wai:> "resl!u U;' .lol.e" in as far as I was the salaried employee of tue boVern!il~mt m;al.tu services out I was not tola what my responsioilit~es were; 1 wa::; unselected oy tne people with wnOlll 1 would live, ana I o.~u llOt eVt:!ll speak tne commonly used language. 1 naa come from a meuical scnool wnich had taught me !lOW to treat people in a l.lospital anu WIUCH uau briefly explained some of tne public nealtn responsibilities tor tut::: registration of births and aeatns, for clean fOOQ alla water, aWl tor cnilahood l.Illlllunization in urban situations, out WhiCH olllittea to lUa~e clear to me what my role snould be as a nealth worKer. In al.l. illy innocence 1 was meant to be the govel;nment's response to tue prilUary Healtn needs of the people and it appeared tHat illy ~resence was sufticient to fulfil the government I s legal ana ll~ral re::;pullsibilities. My experience was extreme but not unique out What nappened has influenced my whole life and is relevant to this techni.cal presentat~ou. On lilY arrival at my assigned area I set up a clinic with pride and pleasure and preened myself for professional action. Tnree montns passed and while 1 came quickly to know the families of the po1.iceman, tne schoolmaster, the hotel keeper, tne owner of the villal:!,e store and some of the large scale farmers, hardly another person KnocKed at my door. Health service "demand" did not appear to exist. 1 asKed myselt whether the absence of tne people requesting treatment was beCaUl:>e tne people were leading a healthy life in an idyllic situation, and tne major health nazards nad been removed. Possibly illness was now a matter of accident or unexpected disaster. Another possibil~ty was tnat the need was tnere but that I was unacLeptable. Tnere was a wide range of explanations and in my restlessness I started to lOOK around and asK. questions. Babies were oeing born unassisted by me and some of tnem died. Cnildren and adults were dying too but none ot them were my ~at~ents or ]'('ople I had ever seen. It was said that there was a nion rate 01 pulmonary disease whiCh was thought to be tl,1berculosisj Llyaatid disease t,r~lS prevalent, in some valleys many adults showed Signs of rheUmatic heart disease, the diet was Changing as fish and crayfiSh became uara t.o ca ten due to commercial over-exploitation: and many Children at sctlOol 01 walking down the road had pigmented impetiginous-liKe lesions on tueir legs of a kind 1 had never seen before. Things were CLearly not "rignt" III tne nealth sense and yet health service demands were negligible. I found myself, therefore, in a situation where my training was on.Ly partially relevant, where my role was to respond to a demand wnicn di.d not fim.l its expression in visits to a person suCh as me, and wnere there was clearly a complete disjunction between the serv~ces on the one l~nd and bOth perceived ana unperceived health related neeas of tue peolJle 011 the other.
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WPR/RC27/TP/I page '2.
That experience was from a far off corner of a ricn developed country but it does not seem to be very dissimilar from wnat I later came to learn exists in much of the wider Pacific area. If one puts to one side the populations of the industrial cities of Australai:>ia, Japan, Singapore and Hong Kong the remaining majority of people are largely in small discrete communities very similar to my own. for we most part they are small, numble, nomOgeneous groups witn a heritage of local organization and independence plus an almost unique sense of dignity and pride. For many years I thougnt that tnis was because they were in the past seafaring groups who often lived on islands and were, therefore, forced oy geography to be small and close-knit. !lUS is clearly incorrect as later I nave found similar qualities in rural Malaysia, in the Philippines and also in tne colDlnunes and l.Il tne cities of the People's Republic of China. This intimacy and sense of social responsibility appears to be different from the usual European pattern and yet in llealth we assume that they SHOUl-a be tne same and appear to be puzzled When European healtn service solutions do not appear to fit. At present in much of our Region nealtn se:cvices are sometning which are presented often as a rignt to the peop:Le oy a benign government. Yet some countries are poor and navl~ not tne resources to reach all the people using "conventional" means; some areas are so isolated that they can rarely be reached; and some of tJ..e healtn services provide standard production professionals suet. as myself not so much as nealth workers but as health service Jresponses to medicopolitical needs rather than to the health needs of the people themselves. Something is certainly wrong and while we must b(~ conscious of tne past and the present our major concentration of I~fort must be to try and think about what we can do to correct it. Once more I must return for my inspiration to my own past. In New ~ealand Maori areas and elseWhere in Polynesia there useCl to be no clearly specified health workers. A bil:th was assisted oy the nusband and certain female relatives. The rE~sident multi-purpose professional was the II to hunga" who was health wOl:ker, adviser upon the planting of crops or the catching of fiSh, and even the arbiter of wnat was anti~social oehaviour. There were community concerns about nealtn out there was no nealth service. H.ealtn and ill-·nealth was tnougnt of in a wide way and included many aspects of living, including wnat you ate and how you behaved as well as the inexpJ.icable disasters of infection, accident or acute or cnronic illness. I postulate that maybe we are turning a full-circle and are beginning tel understand that our present views are fully compatible witn such thir~ing from our past. I may even gO further and say that the linkages "micn nave now been described oetween the multiple primary causes of illness and their ultimate expression, plus the knowledge we nave ~~ined upon hOW to prevent and treat nealth failures, reinforce the idea that unless we adopt such a wiele philosophy of health our OULer efforts will surely fail. We must be careful not blindly to accept the criticism that such a change is a step backwards rather than fOl:wards as it J.S prooable that some of the fundamental truths springing frelm our own societies nave evolved over time with good cause anel we can only ignore them at our peril.
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If ~UCll ideas nave a general relevance it :moulu ue iJ0ti::d.ul.e to t:xtract the essence wniCh way nelp us to lJleet tne neeUl:> anu uelUall.(U' ot Qur popula tions and. to iJropose a cour se of action for bovenllllt!ll tl:l. '.lnere alJpear to be tnree main general iJrl.nciiJles: .l. "healtn" ratner tnan nealtn l:lervice orientation uirectt!u towards primary causes
8. major empnasis must De l'!,iven to tlle prilllary <;.ause:;; v1. ill-hea.Lth ana lIlisery wnether tnis is ba!:>ea upon SUCu CHJ..Ill'!,l:> as poverty, insufficient or impro~er food, tne .lac~ of watt:r or its contamination, numan and otner pollution, lacK of eaucat1.on, or pnysical or social iso.lation. 1'ni::; eII1lJuasi!:> aue!:> nut naVe tJJ be justified only for nealtn reason!:> as eliIDinatiou 01 cae causeti of ill-healtn may as well be inaepenaent national l'!,oa.l.s or tue hign-ranking demanas of tne people tlwll~selves for their own ::HiKe. In tne same way tnat the motivation tur actiou IUay CUlllt~ frOllt uifferent sources tne steps .Leauing to cnanoe amI. iUlI!.Lt:!Ult:!utatiulL are also multi-sectoral. lne accepted respousibl.litiel:l 01 tUt:! nealtn sector appear to have been contracting in tue pal:lt uecadt!s ana now we must start expanding tuem again. ::>ucn all expallSl.OU meanl:l involvement and tne use of tne orl'!,anizatiollS anu stills that we nave, to assist in countering these general evils in conjunction witll others, plus a retraining anu retoOll.llb ot our health resources wnich have to be more effective in tnt:!l:>t: area!:l too. It should no longer be acceptable for us to wait for tnel:lt: cnanges to nappen rather tnan ta~e active steps to curre(;t tneul.
2.
Community Organization and participation
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Few of the above actions can be done to people, et:>pecially in the rural areas. Even if there were enough ret:>ources, ano tnere are not, they do not arrive and blossom as presents from a central auttlOrity. It nas been said that: 1 "It is easy to say that food is what is needed by a malnourished child and that connnunity ueveloplAent is a mecnanism that can be used to supply it. It is hard to say that community development is a goal and that conullunities in tne ,Process ot developing find a way of seeing that chilaren get food. Inese concepts are not the same. Tne way in whic~ cnange is assisted and results are obtained may del?ena to a crucial. extent UP0l,l wnicH approaCh is adopted." A viable local community organization witn fu.ll individua.L participation appears to be a major sec:ret to success in nea.J,.th. If this is true then there are national implications. It must mean that a national decision is required to return health
1 World Health Organization. (English text), Geneva, 1975.
Health by the People, p. 192
WPl\/RC27/TP/l page 4
responsibilities to the people themselves. This is a irightening and major political decision for any country oecause with SUCH a decision must come the reversal of many national pO.licies wniCli were designed, or had their unwitting expression, Lo uestroy ) ('.,3 J organizations and to discount local resources and initl_ativE!. Goupled with this is the overt statement that nealtn decipions are to be made by society as a whole and not only by interestt:d professional groups. Such a reversal of national policy rey'uirec; more than a resolution from a national assembly. Years 01 mistrust and health dependence have made people sllspiciout>; Illi.lIly local organizations may nave already been destroyed and wiLL neea to De rebuilt. Such damage cannot be undone without encouragement and action in addition to national acceptance. Even where tnio has been started or been done there are thorny problems. To DI;;! effective local responsibility for action must be Joined to lOG;:. responsibility for a lot of decision making and mechap,isms llaVe to be found to resolve issues where a local priority or form ot action differs significantly from national policy or the views c~ the experts in the capital city. Such a proposal is very different from proposals for " reg ionalization" or other sometimes lip-service proposals whicL may be still centrally bureaucratic even though the site of the bureaucrats may have changed. ::,ucn a building up at the periphery not only re4.uires different sorts of .l:-'eople but different criteria to assist .1.11 aeciding what is required. It coulu oe tuat continuous resiuence and presence in ttle community and personal acceptance lll<iy De of greater importance to the primary nealth care worKer t:.nan academic acnievement or tne level of competence in ueC;11tn tectUlology. If local individual ana community loouey or retiources need to be used rattler tnan taxation resou;cces comine, troill aiar, tnen some of the waste ana stupidities wnJ.l::n are present.l.y tolerated may become unacceptable. People will nave tu De trdiu~u for what they tlave to dO, to properly function and not t,u fo1.1uw arbitrary professional establisnment stanaards wniCtl may pe of the greatest importance to the J:!roiet>::>iona.ls tnemst:!lves. 3. Aperopriate nealth technology
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The village nealth structure is required not just as a pre~ence but because it nas sometning to 6ive. Pasi!;. wo;S;1.d researcn achievements nave shown us that there ~ lNays of [~lpin6 people to improve their nealth, decrease their ill-neal t1l. , treat tLle sick and prevent and assist the disabled. ~ut wnile tne principles are general for man as a wnole tne wanner of expression of tnese principles of interven't.ion is almost l.uiillJ.te. The choice of options must be made as an e.xpre.ssion of tnat ::>ociety I s needs and structure but once this nas oeen made tne KUowledge eillU tools mustoe wade available to all tnose :in need. luis caullot oe done with only a .l:'eripneral form ot serviCla. Tne viJ..la6e worKer SOOll
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fails unless there is a supportinb structure of training and referral points, whether these be cliuics, ho>;pitals, titJecialist teams, production and distribution mechanisms lor drugs, ec..ll.lpmenl, knowledge and skills, or a more knowledgeable coll edbue to teacll and assist and act as the link. Too often this need nas been inverted and what was designed as a support has DeCOlue tne inward looking monster with no direct populatioLl based contact and an insatiable appetite for money and manpower too often expendt'u upon the favoured few selected by geography, wealth, social class or technological arrogance. tlalauce is incredibly difficul.t and must oe as much a poli tical as a techIl1cal decit:>ion. What I have been describing is not a model for a nealtn serviCe wniCH could reach all people. It is not an agreed or approved form 01 organization in a newer edition to be slavishly fol.lowed J.l a country js to oe modern or up-to-date. Rather it lS a list~ng 01 SOllIe qualit les which would appear to be linked to ::;uccess and \.Jhich could have a wide spectrum of expressions in different sorts of countries illla in many political systems. The emphasis upon central. authority decisiou making which encourages a firm base of peripneral diver~ity is liKel.y ~o mean the reverse and no two countriel>, or even two regiolls withiu a country, may make the same decision cnoices. The qualities I have summarized are not a UtoiJian dream conjured by theoreticians or worKed out in aostract by lJlanners. Tney nave come from endeavours already taKing place in countriet:> in different regions of the world and many of them nave been in existence long enougn for us to be confident that they work and decrease il.l.-healtn at low cost and in an acceptable manner. The qualities themselves were brougnt together in 1975 by the Director-General of WHO and presented to tne World Health Assembly as a response to an organizational study of tne ~xecutive Board in 1973. The group of qualities were tiiven tne Lode Word "Primary Health Care" and are clearly different in their nature fJ:<.HI1 oLher complexes whether they were ca.lled .Basic Heal th ~ervices or SOIn8 other name. The ideas presented were debated by the Worla HE'D i th Assembly in 1975 and in 1976 and were endorsed by appropriate res01utions and all the background papers and tne conclusious are freely available. IIp
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What is proposed is that within the wider world objective of nea.l.t.n for all by the year LUaU, there should be a series of national endeavours. Tnese would include a reconsideration of the present and prOjected nealtn service proposals within countries and an informed and in-aepth nationa.l. debate upon the problems in the health sector if it is to based upon social equity, and of possible solutions. Such a debate would properly include a consideration of the relevance, applicability, advantages ana disadvantages of a direct expression of some of the qualities whicn 1 have summarized. I emphasize "informed" debate because some of tnese qualities imply a major change in direction and action from what is at present being practised and affect everyone. ~ucn changes can never be thOUg,tlt of lightly or superficially. hopefull.y, sucn a aebate would be followed by appropriate action with the support of wHO and friend.l.Y countries, where this is required.
WPR/RC2 7/TP 11
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Up until this point I have been speaKing as elJl mdividual and colleague from this Region. however, 1 cannot ignc)re that in my I?resent WliO role I am employed to assist all Member ::ltates.. From this standpoint I am acutely conscious that in the WestE:~rn l'ac~fic t<.t:!gion you have many advantages and the potential to be allong tne worl.a leaders in the social and health evolution which will be necessary to bring neal th to all people. In this t<.egion the social and political. objectives of such ideas as I have mentioned are al.ready acceptt:!d by all governments. Local social and heal th organizations al ready exis t in mst countries as part of their neritage. During the past uecade some of your countries or areas are already among t.ne world leaders in developing and applying innovations based upon lJ,ualities silnilar to those endorsed by the World health Assembly, and have amassed. an. enormous amount of practical experience in the difficulties and the useful steps which could be taken to implement them. In most countries or areas there are already sufficient resources and trained manpower to move along this path. The extreme diversity which you nave must result in similar diversity of expression and if you encourage and fostt:!r it, record your successes and failures, and open your doors witn numility, others wi.ll be able to observe and learn and decide upon their own appropriate path. This could be of immense benefit not only to your own people but to others who are less fortunate than yourselves in this and in other Regions. It is my opinion that there are few choices open to you as countries or areas or as a region. Tne direction is clear and tne main questions are directed to the speed of change and ~lether the ricner and leading countries are willing to nelp their less fOll:'tunate neignbours. In such assistance size is of less-significance. Tile world l1.aS not yet got a good working example of how an island or a SWill group of )U,UUU or 100, 000 people can organize itself upon primary n.eal th care principles. Such a leader could well come from the Western Pacific. What is being discussed here today in this Technical Presentation is not a new statement of objectives - they are alrE~ady agreea upon it is instead a debate upon how to proceed, in what manner and tne ways in which we can help ourselves and each other. I ~l quite contident that with goodwill and understanding we can reach agreement and proceed rapidly together.
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