Regional Seminar on Urban Primary Health Care, Manila, Philippines, 30 November - 4 December 1981 : report

lCP PHC 001

ENGLISH ONLY Deceniler 1981

ACEGIONAL SEMINAR ON URBAN (-- PRIMARY HEALTH CARE Convened by the WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 30 November - 4 December 1981

REPORT

•

Not for Sale Printed and diatributed by the WHO Regional Office for the Western Pacific Manila, Philippines

NOTE

The views expressed in this report are those of the participants in the Seminar and do not necessarily reflect the policy of the World Health Organization.

This report was prppared hy the World Health Organization Regional Office for the Western Pacific for Governments of Memher States in thp Region and for participants in th" Regional S"minar on Urban Primary Health Care, held in Manila, Philippines, from 30 November to 4 December 1981.

CONTENTS

I.

SUMMARY

.. " .. " . " .. " ................................................................................ .

7.

1 N'f'RODUCTlON

........................................................................................

2 3

3. 4.

OBJECTIVES ORGANIZATION REPORT 5.1 5.2 5.3

............................................................................................ .... ,. ........................ ,. ........................ ,. .............. " .......... ,. .

3

5.

. . . . . . . . . . . . . . . . ,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e, . . . . . . . . . . . . . . ..

4 4

Genera 1 ...................................................................................... .. Urban health problems •.••..•••.•••••••.••••••••••••

Health services in urban communities Health and urban development Funding of services The planning process Follow-up activities

••••••••••••••• ••••••••••••

5 7 9

5.4 5.5 5.6 5.7 5.8

.••••••••.•••.••.••••.•

Community involvement and participation

•.••••••.•••.•••...••••••••.•.•• ••.•••.•••.••••••••••••.•.••••• ••...•••.•••••.•••••••••.•.••..

Problem identification (research and development)

5.9 6.

10 12 13 15 18 19 21 29 33/34 35 37 41 67 67

POSTSCRIPT ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6

................................................................... LIST OF PARTICIPANTS ................................... WELCOME SPEECH BY THE REGIONAL DIRECTOR CHAIRMEN AND RAPPORTEURS

....... .......

........ " ....... , ........... .

CLOSING SPEECH BY THE REGIONAL DIRECTOR

GUIDELINES FOR THE PREPARATION OF CITY REPORTS SUMMARY OF CITY REPORTS

.................................. .........................................

ANNEX 7 - SUMMARY OF CASE STUDIES 7.1

7.2

HONG KONG MANILA

ANNEX 8 - WORKING 8.1 8.2 8.3 8.4 8.5

................................................. PAPER AND OTHER DOCUMENTS ..................

..................................................

88

103 103 107 110

Declaration of Alma-Ata ...................... . Problem Identification .•••••.•••••••••••••.••

Evolution of Health Care Delivery Systems and Intersectora1 Relationships •••••••••••••• Guidelines for Group Discussion ••••..••.•..••

113 117

WPR/PHC/8l.2 Health and Urban Development Some Environment and Pollution Aspect ••••••••

ANNEX 9 - SEMINAR AGENDA

.................................. ................................

123 125

ANNEX 10 - LIST OF WORKING DOCUMENTS

1.

SUMMARY

The Seminar examined the current health problems in urhan communltles in th~ Region in the light of city reports, a fi~ld visit to observe specisl health problems within Metro Manila and the City of Manila, a paper on health and urban development, and two city case studies. It was generally recognized that there are a number of problems Common to all cities: these arise from the nature of the ecology of cities and from uncontrolled urbanization, which has led to an impairment of the health status of many urban dwellers through deterioration of existing basic health services and facilities, an inadequate infrastructure, the re-emergence of communicable diseases, and the appearance and increase of new diseases associated with urbanization and consequential lifestyle changes. These problems have been compounded by a rapid growth of the urban population. Natural population increase is high in many cities but, even where the natural rate of population growth has been reduced, the overall increase remains high because of inward migration. Inward migration into urban centres is a common problem and has proved extremely difficult to control; in most cities, it is now uncontrolled and uncontrollable. Contributory factors to health problems which are to a certain extent common to all cities are: age-distribution of the citY.population, quality of housing, availability and distribution of potable water, systems of refuse and solid waste disposal, availability and distribution of food, and the extent of air pollution and noise. For new, mainly rural migrants, the social uprooting, high-rise living and exposure to high-speed factory technology and dense motorized traffic create disruptions which lead to additional hazards, resulting in mental health problems and a high incidence of accidents. The present health care system fails to satisfy all the basic health needs of the people. A reorientation of existing health care systems is necessary in addition to the allocation of a greater volume of resources. The Seminar recognized that the allocation of additional resources presents considerable difficulties in view of the current world economic situation, and that substantial increases will be possible only within the context of socioeconomic development. However, the realignment of the health system providing for appropriate and efficient reallocation of resources, including facilities and manpower as well as finance, towards a more rational and suitable approach to the current health needs of urban communities could effect a considerable improvement in the health status of those communities. The coordination of services within the health sector is a matter of urgency. Many sections of the health services operate without reference to other sections; there is a notable separation of preventive and curative medicine, while health promotion and the encouragement of self-care attract little support and receive a minute portion of the health budget. The private health sector operates as a completely separate section of heslth care in most countries and, although it consumes considerable resources, it serVes a minority of the population; there is thus a need to integrate this sector in the total h~alth care system.

- 2 -

Many health problems of the urban connnunities have their root cause thE" health Rector. There is thus a need for the helllth sector to as.ist in the identification of those hpRlth problems which require action by other sectors; there is also a need for an effective intersectoral approach to urban development and urban renewal so that the advantages of urbanization can be achieved without the disadvantages. Uncontrolled urbanization has produced severe health problems and the health of many urban communities is deteriorating to such an extent that urgent remedial action is required. In order to be effective, this action should follow three main directions, which, although considered separately in their details, should constitute a coordinated and holistic approach. These are, first, the strengthening of the health services so that they become more relevant to current health problems; the development of primary health Care is an important part of this strengthening process. Second, the development of the intersectoral approach to current health problems and the prevention of new problems associated with increasing urbanization; environmental protection is one of the important components of this approach. Third, the urgent need for research and development directed at existing problems and within the context of current and developing services. Problems need to be identified with more clarity; programmes directed towards the solution of those problems need careful monitoring to ensure more efficient management and greater responsiveness to changing needs. Information systems should be simple and effective, and have a strong base in the community. out~idp

An essential part of all the above activities is the development of community participation and involvement, which is the key to the effective implementation of programmes at the connnunity level. Just as problems are experienced at the level of individuals, families and communities, so their solution must be effective at that same level: if it is not, then the health of the people will not be improved, and on the contrary is likely to deteriorate still further. Th~ primary health care spproach provides the means whereby the problema r"Jating to the h .. "lth of urban connnunitieR can he identified snd

lo]vfI'd.

2.

INTRODUCTION

. The Seminar was organized by the World Health Organization Regional Offlce for the Western Pacific for senior health officials who work at the urban level or senior officials from city governments who work on urban development. The working language of the Seminar was English.

- 3 -

3.

OBJECTIVES

1. The general objective of the Seminar was to draw the attention of city Or local governments to primary health care in urban areas as part of urban development. addres.ing present and future health nepds. particularly those in depressed areas. 2. In addition to the general objective. the Seminar had three specific objectives: (1) To provide for an exchange of information and city experiences in urban health development. particularly those directed towards depressed or under~erviced

areas.

(2) To stimulate city authorities to adopt and implement the primary hpalth care approach in the 801ution of urban health problems within the national health system. (3) To identify strategies for the primary health care. approach which can be developed to respond to the health needs of the urban poor.

4.

ORGANIZATION

The Seminar first met in plenary session for the welcome speech by the Director. Following the election of the Chairman. Vice-Chairman and Rapporteur. the Seminar met in plenary session where country report. On the henlth .tatus were presented hy participants. Re~ional

The second day of the Seminar was devoted to a field visit within Metro Mani la. On the third day. the Seminar met in plenary session to consider a paper on heRlth and urban development and to hear and discuss the two city case studies of Manila and Hong Kong. The Seminar went on to meet in groups for discussion. reporting in plenary session on the fourth and fifth days. At the final plenary session. the Seminar considered and adopted the report. The Steering Committee met throughout the seminar to advise the secretariat on progress. This enabled group discussions to be oriented towards the seminar objectives in a progressive and sequential manner. The Steering Committee consisted of the Chairman. the Vice-Chairman, the Rapporteur. the chairman and rapporteur of each discussion group, the two temporary advisers, the consultant and members of the Secretariat.

- 4 -

A list of the city reports, case studies, working papers and other background documents considered by the seminar is attached as Annex 10.

5.

REPORT

5.1

General

The Seminar had before it the Report of the International Conference on Primary Health Care, held at Alma Ata in 1978. Particular note was taken of the Declaration of Alma-Ata. The Seminar re-affirmed the immediate relevance of this Declaration to the current and increasing health problems of urban life. It saw the Declaration as a statement of a political commitment to the goal of health for all by the year 2000 and also as constituting the approach to the achievement of that goal. Within the health sector, and between the health sector and the other health-related sectors, the Seminar considered primary health care to be an essential component of the response to the unacceptably low health status of urban dwellers. The technical details and strategies should be developed according to the broad basic approach laid down in the Declaration but in a manner relevant to the particular needs of different urban communities. Because the details of the nature and extent of health problems in different urban communities vary within the context of different social, community, behavioural and administrative structures, so also the approaches and solutions must vary in order to be relevant to the needs of different urban centres and to the differing requirements of communities within each urban centre. The Seminar noted that the report of the Western Pacific Regional Conference on Primary Health Care, held in Hanila in 1977, contains a working definition of primary health care which was accepted by that conferencp, and which is still relevant: "A primary health care programme is an intimately linked group of activities, closely and effectively coordinated with the social, economic and related health services, to help individuals, families and communities deal with the many-sided problems of living, in particular with health problems. The programme is part of a responsible and accountable health service system. It recognizes and gives form to the dynamic and reciprocal interaction necessary between health and socLoeconomic factors; between the provider and the consumer, promoting personal and community responsibility and involvement in their o~ health care. Primary Health Care stresses the importance of health promotion and development, increasing the capability of individuals, families and communities to live a healthy life without overemphasizing treatment of disease". The Seminar noted that the Regional Conference inCludes in its recommendations the followin~: "Primary health care progrllmmes are a8 relevant to urban problems rUTal onps and mURt bft prp8f'nted as such". 8S

to

- 5 -

It was considered that this statement remains a valid expression of urban health problems at the preRPnt time. The Seminar considered that the majority of urban h... 81 th proh1('m. hRve their origin in two primary caU8es. ~pnerally

The process of urhanizllt ion 1S

uncontrolled and proceeds at a pace exceeding the rate at which PRsential servicps are provided. Urbanization OCcurs in response to developmental processes which are uncoordinated and frequently produce environmental pollution and degradation. This gives rise to effects which lead to a general deterioration of the health status and also a production of specific diseases through toxic contamination of the air, food or water supply. These effects are compounded by the rapid growth of urban pnpulRtionR, which, in spite of a decrease in the rate of natursl·population growth, continues to increase through inward migration. The degree of inward migration produces new health problems and compounds existing problems in all cities of the Region. Efforts to control inward migration have in general not been successful except where control can be exercised across well demarcated boundaries. Control of inward migration in larger countries with rural populations of considerable size presents a virtually insoluble problem. The Seminar considered that these are the two prime root causes of urban ill health. They present a very great problem and there is an urgent need for studies directed at obtaining a clearer understanding of the factors involved; without such an understanding no solution can hope to succeed. Following a general review of common problems, the Seminar went on to consider some of the latter in more detail. In doing so the Seminar realized the very specific nature of health problems and their social context in different urban centres. The very nature of the problems calls for specific approaches with regard to the operational details of programmes aimed at problem solution; nonetheless the Seminar recognized the benefit of being able to consider common problems together. To facilitate its study, health and health-related problems were examined within the context of different subject headings. In presenting the consensus of its deliberations, the Seminar did not assign any priority to thp order of presentation of the subjects, recognizing that there is an pssential and close relationship between them. 5.2 Urban health problems

The Seminar went on to discuss some of the specific health problems of urban communities. In affirming health to be one of the fundamental rights of all people, the Seminar noted that the complex interrelationship of factors poses particular difficulties in identifying the causation of urban health problems. The maintenance of healthy people and families within healthy communities presents special problems in an urban environment. The Seminar took note of the gross inequalities in the health of urban communities and in the provision of health and health-related services. These inequalities are not in general, being reduced; and in many urban areas are even becoming more pronounced. The Seminar urged that the principle of equity should be more clearly observed in the provision of all

- 6 -

services designed to meet urban health problems and that equity should be spen in the context of needs rather than of mere geographical equality in RPrvice provision. This principle should he brought to the attention of thOR" TPRponRible for the plonning and provision of services for urban cOrTRnunitif!". including those outside the health sector.

There are problems in the provision of 24-hour care in the cities and in aome areas the availability of emergency care is not good. There is frequently a high ratio of hospital beds to the population but this is associated with mal-utilization of services with the substitution of secondary and tertiary care for primary care. This calls for attention for two reasons: first, secondary and tertiary care are expensive and constitute a considerable waste of resources if used inappropriately, and, second, the results attainable in a good primary health care service are at least clinically equal to those achieved when the same patients are inappropriately treated in the tertiary sector. The growth of industry in urban areas gives rise to specific health problems among workers as well as more general problems of pollution, and the establishment of new industries may produce new and hitherto unidentified toxic substances. In addition, the development of industry attracts inward migration into the city, which in turn exacerbates environmental health problems and housing shortages. Increasing industrialization is associated with an increase in work-related accidents, which poses a particular problem as it not only adds to the number of disabled persons but also decreases economic growth. In the absence of social security provision for those disabled by such accidents, the loss of family income imposes a severe burden on the family. The Seminar noted the growing problem of social breakdown in urban communities and the social isolation of individuals. This is a potent factor in the production of ill health and of the many facets of social malaise. The )08S of traditional patterns of living without their replacement by new patterns more appropriate to an urban environment, and the haphazard inward migrntion of people into the cities require remedial action. However. the remedy is not clear and the problem itself not well quantified. The Seminar considered that this matter should receive more attention and that exchanges of information on the problem and on attempts at its solution should be facilitated. The urban lifestyle change produces changes in disease patterns, which become increasingly apparent as communicable diseases are controlled. In addition, the health problems of the urban dweller are exacerbated by air and water pollution, housing shortages, lack of adequate sanitation and environmental degradation. The rapid rise in the cost of living in urban centres, often compounded by increased costs of travel to work, was also noted. Highly mobile groups of the population were identified as being potentially at increased risk. The health and health-related services do not adequately meet the needs of this group. Because the health problems of urban communities are deficiencies in other sectors and because the root causes health-related problems are complex and interrelated with intersectoral coordination is considered to be absolutely compounded by of health and other sectors, necessary.

- 7 -

5.3

Health services in urban communities The nld problemA of urban health have to a consid .. rable extent be .. n However, there are now new problems and

aOfiw{>recl hy traditional methods.

the traditional methods which provided health services to passive recipients are now inadequate. Urban primary health care is therefore seen not as an alternative solution but as an evolutionary response to the newer problems of urban ill-bealth. Primary health care is not entirely new; what is new 18 the development of primary bealth care within an intersectoral approach in the context of the urban environment. The Seminar recognized the health bias of its constituent members. This is not considered to be entirely a disadvantage as health is being viewed in the context not only of medical care, but in terms of the progressive development of bealthy individuals and families within healthy communities.

The Seminar fully accepted that the health sector cannot offer a solution to such problems from within itself; many current health sector activities can only offer some amelioration of health problems for individuals without affecting the root causes. Within many urban communities there are factors which are unaffected by the provision of medical services, and treatment of the sick offers only a temporary respite in problems of ill health. It is however incumbent on the health sector to make appropriate health services available to all in accordance with their needs. Thus, during the deliberations of the Seminar, attention was paid to the specific health solutions which are required at the present time. The Seminar looked to the future, however, to provide more effective and lasting solutions to the health problems of urban communities. Such solutions are dependent upon adequate and relevant intersectoral cooperation and coordination at all levels, upon community involvement in problem identi fication and th .. init iation of solution. within the context of overall df~ve lopment.

In con.idering 80me of the problems specific to health service provision in cities, the Seminar noted that, although there is generally a higher ratio of health personnel to population in urban area. than in rural areas, there are problems of maldistribution. In some city areas medical services are gravely deficient. The Seminar also noted the undue emphasis placed on curative treatment and the separation between curative and preventive services. Staff in one branch of the services are quite often unfamiliar with the situation in the other branches, and this needs to be overcome if urban health services are to be improved and become more relevant to current health problems. There is competition between various parts of the health sectors for available resources, which are not alwaya allocated rationally on the basis of relative need. Such competition is an active impediment to the development of health servi~es that are relevant to the needs of the urban communities. In many cities, the involvement of th .. private sector in urban primary health care is almost non-existent. The private sector, however, is often of considerable and consumes considerable health resources. It must be

coordinated and integrated with urban health and attention should be paid to this specific matter.

- 8 -

The participants notpd with interest the integration of modern and trRdition:t1 medicnl prn(:tjcp' in some countries. 1n~ role of the hospital in primary health care has not hpen well investigated and needs attention. In many countries the hospital system exist. in both private and public sectors and both must playa role in the overRll improvement of the h.-alth of the community through the provision of appropriate services. Just as health problems have changed, so the role of the hospital has to change. In effecting this change it is important that the hospital sector should participate in the identification of the health problems and provides its own expertise in problem solution - they must be partners in the attainment of overall health improvement. The Seminar con.idered that this subject should be closely investigated and the results of such studies publicized. Associations of hospitals at national and international levels could be approached to initiate these studies.

The Seminar identified social security systems as contributing to primary health care development. The Seminar recognized that each country needs to base its social security programme within the context of local circumstances and national development. There are a number of countries with social security systems in operation, each of which has its special strengths and weaknesses, and much could be learnt from a review of such systems. The Seminar requested that a comprehensive review be undertaken and widely publicized. The Seminar noted the effects of popUlation growth on the health of urban communities and the need to extend family planning services as part of primary health care so as to reach the component of population in greatest need. In addition, there are problems of maternal and child ill health due to a lack of proper spacing of pregnanciesl family planning services could do much to relieve this and improve infant, child and maternal health. Health promotion and health education directed at problems as perceived by thE' community should be strengthened. This strengthening process should tak" place within an adequate framework of problem identification, inCluding the .. stabl iahment of priorities. SUCh health education and promotion activities should be carefully monitored to assess their impact upon health problems and to ensure wise use of resourcE'S in this field. The cant inuing educat ion of health workers and of workers in the health-related sectors i. an essential element in health service provision. Continuing education is part of the normal work activity and thus does not consume additional resources except time. Time spent in continuing education is not 'wasted time' as one of the effects of continuing education is an enhancement of health productivity through a more rational use of time directed at more relevant problems and the use of more appropriate teChniques. The Seminar noted that many health workers are occupied in tasks that are well below the level of their expertise. A more rational use of health staff aimed at fully utilizing their various skills would achieve a more productive health service without consuming increased resources. In this context the Seminar noted the effect on staff morale of employment in tasks at a level far below the capability of the individual staff member.

- 9 -

Many of the problems of the health services, whether in terms of effpctive delivery or their appropriateness, have their roots in a flexibility of response. In the health sector, services continue to be <teliverf'd in a mAnner appropriate to past problems rather than the health prohlem. of the present. This is particularly true of institutional car!'. and while there are institutions noted for their responsiveness to change,

they are in the minority. The solution to this lies in the appropriate re-education of health professionals at all levels, health administrators and the public. A great responsibility falls upon leaders of the health professions, institutes of health managers and administrators, community leaders at all levels and educational institutions, universities and colleges. The Seminar strongly recommended that appropriate international agencies and federations should undertake the initiation, encouragement and support aimed at the re-education and orientation necessary for the understanding and implementation of primary health care. In this context, there is a need to educate those at both ends of the planning and administrative network. Sectors such as the health sector could act as a bridge between those involved in the large-scale approach and those at the local community level. However, this presupposes that such a link is evident within the health sector; this is not always the case and there is a need to develop communication which is real and effective, and seen to be relevant, between the two levels within the health sector. The training of community leaders is an essential aspect of orientation towards implementaton of the primary health care approach. There could be considerable advantage if such training could be included in the training of health professionals. Learning together will enhance working together. Professional organizations at the national and international level Ahoulcl he encouraged to include the suhjPct of primary health care in the agenda 01 their meetings and, in particular, the specific problems of urban primary health care. 5.4 Heslth and urban development

The Seminar noted the historical separation of environmental health matters from the responsibility of departments or ministries of health. This is justified by the importance of environmental protection, which now covers many matters outside the health sector. However, this administrative separation gives rise to problems of coordination and cooperation between those responsible for the broad field of environmental protection and those responsible for health and health-related matters. The evolution of urban primary health care demands a very close relationship between these two sectors and the Seminar urged that such a close relationship be facilitated and emphasized by appropriate legislative and administrative procedures. In considering health urban development in general, and environmental and pollution aspects in particular, the Seminar stressed the importance of sociocultural factors, which need to be taken into account in the

formulation of measures designed to improve the quality of the environment. The Seminar appreciated the importance of environmental impact studies with the aim of anticipating problems in urban development and urban renewal before they occurred. In such studies, it is important to secure the full involvement of the health sector.

- 10 -

Th,' Seminar noted the current activities of the United Nations Environment Programme and emphasized the need for environmental protection in the cnntext of increasing urbani7.ation. Health improvement iR not solely ~nn.ern~d with the provision of health services but with the entirp process of 80cio.. conollljc developm.. nt within thl! context of a suitahl .. living environment and the maintenance of environmental protection. In this all factora must be taken into account. The Seminar noted that the use of certain toxic substances, such as pesticides, is banned in developed countries but that the importation of these substanc .. s is not uncommon in developing countries. It considered that this problem should be brought to the attention of governments, perhaps through the agency of WHO, so that problems of environmental pollution are not aggravated by the continuing use of these toxic and persistent chemicals. The Seminar noted that non-point source (non-localized) environmental pollution is a comparatively recently recognized problem but is gaining in importance. The Seminar urged that suitable research be undertaken and information exchanged so that these problems could be more clearly and accurately defined. A considerable problem exists, and in some countries is deteriorating in relation to ground water contamination by toxic contaminants, either from non-point source pollution or from contamination of the soil by indiscriminate land filling involving toxic chemicals. This matter needs attention as legislative measures to prevent such contamination are frequently inadequate or even completely lacking. People are the greatest resource of any country and community. In aocioeconomic development, the ultimate goal is the development of people as individuals, families and communities, so that they can realize their full potential in leading happy, contented and productive lives. Health is One of the components promoting achievement of this goal. However, the n('velopmental approach to this muat start with the problems that are seen to he important hy the local communities. There accordingly needs to he a synthesis between problems as conceived locally and problems evident at the national or major urban level •

5.5

Communlty lnvolvement and participation

•

i

•

The Seminar considered the special problems of community participation in urban primary health care. Particular difficulties are experienced in urban centres due to the fact that social structures are generally weaker in urban than in rural areas. The Seminar considered that no universal strategy for community involvement could be developed as strategies are dependent on the social and cultural aspects of the community in general and on the cultural modifications imposed by the urban environment in particular. The establishment and maintenance of community involvement needs to be evolutionary and, while the pace of such evolution should be as great as possible, too rapid a development might result in the lessening of the effective involvement of the community.

- 11 -

An evolutionary approach was considered the most effective because it is a splf-generating and self-supporting process. However, there is 8 need for suitable structures to maintain the effectiveness of community participation_ If inRdpqll8tP. social cohesion is 8 problem, then conununity

participation will bn dillicult and

coaanunity iH Rsked La parlicipate and

dpfectiv~. th~n BeeR

In addition, if the th/lt

ilK participation ill

ineffective, community participation will come to an end. Community participation in urban primary health care is often fragile and requires appropriate support; if support is not provided such participation may eventually dry up and if this occurs, the re-establishment of community involvement in urban primary health care will be extremely difficult. Community participation in the initiation of services is not sufficiently utilized, and is generally much less evident in urban areas than in rural areas. The literacy rate in the cities is often higher than in the country and there is a reservoir of people capable of involvement in primary health care. However, the opportunity and stimulus for this are often lacking. The Seminar noted that community participation is necessary in all sectors, not just the health sectors. It should be an integral part of the system. Community participation is not to be seen as a substitute for adequate provision of services by governmental and other agencies. Health staff and particularly primary health care workers should be encouraged to participate in the aspects of community development, whether as participants or initiators. Community participation can occur at many levels in the social and administrative structure of urban society and this should be actively encouraged. Community participation will grow when it is seen to be effective in the local community problems and needs. While the health or other Sf'ctors may need to initiate community development projects, those outside the community should gradually withdraw as the community becomes able to Assume progres~ively increasing responsibility. It is vital thAt health sector staff see themselves as initiators with a temporary roll'. Community participation can be .. ffectively killed by an over-prolongation of outside control just 8S it Can be by failure to provide it with essential support. Although knowledge and skills Are being developed within the health sector with regard to the initiation and support of community-based programmes, the enhancement of such skills is considered to be important, and continuing educational programmes should pay sttention to this matter. m~eting

The initiation of community programmes is not difficult. The difficulty lies in sustaining them. There is a need for appropriate support and health sector workers need to see the provision of appropriate support as one of their functions. In providing this support, local cooperation with staff in other sectors is vital; no precise guidelines for this can be laid down in advance as the nature of the support, the type of intersectoral cooperation required, and the speed of the hand-over of responsibility to the local community depend upon local problem and on the community and hehavioural structures. However, the Seminar identified the educational sector as 4 vital but little used resource. Teachers at all levels are trained in the skill of progressive learning through the imparting of knowledge and the develop~nt of learning skills. Modern educational techniques has developed considerable expertise in the cooperative learning process and teachers at all levels have very valuable and appropriate skills to offer.

- 12 -

5.6

Funding of services

The Seminar recognized that adequate funding of urban primary health core presents particular problems in view of the need for Rub"tantial input. from a n"mb~r of cloH~ly related sectors. There is an imbslance in funding and poor coordination within the health sector. There is competition for available resources and the increasing use of sophisticated high technology medical care has produced a considerable increase in health expenditure. A rising expectation of health care hy the community also increases costs. Attention needs to be given to th" mpthods of funding, particularly methods to combat the imbalance between thp variou. pArts of the health sector. The Seminar saw a danger in measures to achieve general overall economies, as these measures tend to affect adversely the community and primary health care more than institutional care. The Seminar discussed the issue of separate budgeting for primary health care development. There are many aspects to this and there are a number of factors favourable and unfavourable to such an approach. The Seminar considered that whether or not separate and specific budgetary provision for primary health care development is made would depend upon the financial and other mechanisms of the country or administration concerned; what is essential is that funds should be made available and used and that they should be adequate for properly identified programmes. Financial control is not solely a matter of allocation of additional funds. Mechanisms should be developed as matter of urgency to permit the consumption of resources to be identified and 'debited' to the various parts of the health sector. Although the outcome in the health sector is not ~a.ily quantifiable, a" thp relief of pain and suffering and enhancement of tht' qualify of I if .. cannot hI' expressed solely in monetary terms, it is nevertheless important to he able to identify resource consumption within the component parts of the health service. Such mechanisms are not generally effective with the current methods of budgetary control and effective means of such control applicable to the health sector are lacking. Attention should be paid to this. The problems of urban health cannot be overcome purely by intrasectoral reallocation and coordinated reallocation of reSOurces between sectors, as a flexible response to urban health problem is required. The developmental aspect should be emphasized and the existence of serious urban health problems constitutes a considerable impediment to overall socioeconomic development, just as socioeconomic development provides some solution to the health problems. The two aspects are closely interrelated and need to be considered together. However, intersectoral budgeting presents grave problems. Unless planning becomes a truly intersectoral process, based on an adequate and appropriate intersectoral information system, coordinated budgeting will not OCCur. The solution to imbalance in funding between the sectors therefore lies in a coordinated intersectoral approach to problem identificatio.n and solution and the formulation of appropriate plans and strategies. This requires a strong and sustained political commitment by governments; unless this occurs, a

coordinated intersectoral approach is not likely. The Seminar strongly reiterated that the nature of the problems of urban primary health care demands an intersectoral approach for their effective solution. The problem cannot be solved by a single sector working in isolation.

- 13 -

The Seminar recommended that the matter of intersectoral budgeting, on the basis of the above paragraph, should receive poecial and urgent consideration.

5.7

Problem identification (research and development)

Research and development is not a well understood term and to many health officials and administrators, it does not appear to be relevant to their problems. However, research and development is essentially concerned with problem identification and this is a necessary prelude to the establishment of p~ans to improve the health of urban communities. The Seminar drew attention to the geographical component of basic information in problem identification. It is important not only to know ~ is happening to how many of the community, but also where the particular health events are taking place. This geographical specification is vital 80 that the numerical details of urban health can be properly understood. In addition, the location of events relevant to health need to be known 80 that the remedial measures can be made specific to the problem and to the area concerned. The Seminar also noted the importance of the demographic component' and considered that information on the nature and location of the population is a most necessary component of problem identification and in the preparation of plans aimed at the solutions of specific problems. Problem identificstion must necessarily include delineation of the various sectors involved. This is particularly true with regard to administrative systems operating in most urban environments, as administative separation increases the lack of communication and coordination between the sectors. The Seminar conRidered that there is a considerable need for the establishment of good simple health information systems, able to function adequately in terms of primary health care. Information collected must be useful to the primary health care worker, who is generally responsible for the collection of much of the data. If information in a uReful and usable form i8 to be fed back to the primary health care worker, this will enhance the quality of information collected as well as helping to improve the service of the health staff. It was emphasized that the time element in the collection of information is important. The ·,'ublication of out-of-date information is of minimal use in the developmpnt of urban primary health care. Health information sytems also need to be integrated with information systems in other sectors. The Seminar recommended the undertaking of collaborative st'3dies on the establishment of information systems appropriate to urban primary health care and the early and wide dissemination of the information gained from the studies. The Seminar noted the disparity between the health professionals' view of npeds and the community's view of needs. It also noted that professionals other than health professionals have their own view of nepds and priorities. None of these viewpoints necessarily contains the whole and complete truth and it is necessary to ensure that problem identification op~rates on the basis of a synthesis of views. Such a synthesis requires an

- 14 -

understanding which must be based on good relationships between different professionals and between professionals and the community. Such rrlationships need developing and such development is a necessary part of primary health care development. The Seminar commended the case study approach to the delineation of health problems of urban communities and identification of causative factors. Such studies should pay due attention to the multisectoral nature of urban health problems and should include social and behavioural aspects relevant to the health of the community being studied. WHO could do much to encourage this in contact with ministries and departments of health through the appropriate national governments. The drawing up of a regional urban h~alth inventory would provide valuable baseline information for the urban community concerned and for those occupied with similar problems in other countries. The regular updating of such an inventory would also meet the twin goals of information and stimulation. The Seminar saw this as an effective and desirable approach in terms of cost effectiveness. In defining problems and establishing priorities, the needs of groups of the urban community at increased risk should be clearly identified. Such groups should be actively sought out as their low health status itself constitutes a barrier to their receiving adequate and appropriate care. The Seminar saw problem identification as part of the whole process, continuing with identification of causative factors and leading on to the selection of options. The planning process should include an ongoing monitoring system to provide appropriate information to enable managers to manage services efficiently and also to ensure that the services themselves are effective in terms of outcome. Research should hr encouraged into the methods of implementation of primary health care, taking into account technical and operational feasihility within the context of social and behavioural factors. The Seminar considered that redistribution of resources, manpower, facilities and finance must be done on the basis of adequate identification of the problem within the context of the intersectoral nature of primary health care. Such redistribution requires an adequate data base and the m~chanisms for using that data to clarify problems, options and programmes. This re-emphasizes the requirement for more clearly establishing practical and appropriate information systems. The Seminar strongly supported the setting up of collaborative mechanisms for research and development projects aimed at the establishment of effective health information systems for primary health care. These should establish the necessary methodology for the collection and analysis of data and the presentation of useful and usabJe information which is relevant to the needs of urban primary health care workers at all levels. In addition the information system must be geared to an effective intersectoral approach from the stage of data collection through the presentation of information. The constraints and opportunities of a primary health care system of which community initiation and pArticipation are an integral part are important factors which must be taken into account in the structuring of primary health care information services.

- 15 -

In considering the difficulties of initiating urban primary health care projects, the Seminar considered that more info~ation

is required to

identify the prerequisites for success. Some proJects have been successful while others have not. An analysis of the reasons for success and failure. and the wide dissemination of this information. are urgently required. The Seminar noted that some countries have well-established projects on: integration of the hospital in primary health care; generation of local income through development of small industries; special programmes for the urban poor; rehousing; and intersectoral coordination. The Seminar recommended that the details of these projects should be written up and the reports made widely available. In requesting this. the Seminar was aware of the constraints imposed on those responsible for such projects in terms of work load and time. International agencies could playa useful part in this matter by providing temporary staff and/or funds to enable good reports to be prepared without compromising the work of the projects. In discussing future research activities. the Seminar identified the following as additional subjects for specific research: Occupational diseases. especially those related to new industrial processes.

Efficacy of health promotion and health education measures. Sociocultural studies in health and health-related matters. 5.8 The planning process

The adequate development of urban primary health care cannot be achievp.d without the political will to proceed with such development. The mR~nitude of the proh!PffiR. both h~Dlth and health-related. in urban centres cOOHitit'rut ion al thc..>

is dRunting nnd many in government llnd administration avoid any proper IIIlttt~r. Uowpver, it is only through the dpvelopmf'lnt of

urban primary health care that such problems can be faced anci ultimately oVt-rcmne. ThE> Seminnr considered that there is a need to communicate the nature of urban primary health care to the decision makers in government 80

that its potentials can be fully realized. A national impetus is essential in providing the appropriate political direction and legislative and administrative support; the implementation of the primary health care approach must. however. be local and specific. The Seminar identified the need for an intensive campaign to inform governments of the urgency of the problem of urban health. and of the primary health care approach as a feasible and affordable solution; and felt that WHO and 0ther international agencies could assist in this. The Alma-Ata Declaration ,s evidence of a general political commitment to primary health care. What is now required is a more specific commitment directed towards the early solution of current urban health problems. Because the nature of the urban health problems requires an intersectoral approach. all the processes of problem identification. problem solution and planning n~ed to be intersectoral. The information systems of tht! different sectors have, therefore, to be in close relationship a8 their

sepRrate and isolated operation would enhance the dangers of planning in isolation. Isolated unisectoral planning has produced major health and

- 16 -

h~nlth-related

lesH

~a9y

problems in many cities. The intersectoral to achipvp in urban nrenR thon in rural ones and Rtrllcture of many urban conununitie~

~pproach th~

is much

lJdmini8trativ~

is an Hclive jlllppdilll£'nt

to intersectoral coordination. Howpver, the Seminar not~d with illterest thp d~velopment of administrative structures in B number of cities, which are designed to facilitate intersectoral coordination. Seminar participants

considered that more information should be made available on these newly developed systems for the benefit of countries facing similar problems. There is a need to identify problems in terms of a priority structure as well as of need and feasibility. It is not possible to deal with all the problems at once; resources are insufficient and proper administrative control of the complex interrelationships is generally not possible. The planning system must therefore be flexible enough to operate within a priority system without losing sight of items of lower priority which would be affected by changes in other fields. The formulation of solutions to particular problems has to take into account the overall resources available. The best solution is not the most appropriate if it consumes an undue proportion of available sources. Just as the development of primary health care needs to be seen as an evolutionary process, so also do the formulation and management of appropriate solutions. Planning should be seen as a continuing process and evaluation and monitoring require that the objectives are always clearly stated, including the details of sequencing and the establishment of suitable norms by which progress can be evaluated. The formulation of specific goals for national, city and community health programmes should be encouraged. These goals should be reviewed regularly to ascertain progress and to facilitate an evolutionary and flexible approach to changing needs. The establishment of goals must be specific and related to the needs of identified communities. Although there are COmmon problems referable to all urban communities, each urban area has its own specific health and

health-related problems; in addition, there is a variation wHhin each urban area. This makes an accurate and real identification of problems an

essential prelude to the formulation of solutions which must be relevant to the identified needs of specific communitiesa

Thus it is essential to

obtain the participation of the local community in the identification of problems as well as in their SOlution; the 'small group approach' offers great potential and the Seminar considered that the development of this approach would translate the general concept of primary health care into specific local implementation. This would achieve two important goals: first, the specific problems of the local community would begin to attract a solution and, second, it would be possible to demonstrate the effectiveness of primary health care. Such a demonstration is essential. Primary health care appears to many at all levels of society, from the high level politicians and administrators through the middle managers down to the individual members of the community, as just one theory among other theories. As long as primary health care remains merely a concept, it will not be translated into actiona

- 17 -

The

Seminar saw development in terms of social and economic growth

85

the key to the real izat ion of many of the goals of primary heal th care. Health planning needs to be con8idered within the context of coordinated urban planning. Th .. "('nlth sl'ctor has its part to play in two main areas: £irat, it must provide nppropriate health services to all members of the community in accordancp with their needs. and second, it must participate in concerted and combined action with other sectors in the solution of health and health-related problems. In this latter goal, the health sector should not appear to desire a take-over of matters properly within the sphere of other sectors of government or of urban community administration. The health sector should recognize the competence and expertise of other sectors just as those sectors recognize the expertise of the health sector within its own field. The leadership in any particular project or programme will depE'nd on the nature of the problem. Who is leader of the team is not important. What is vital was that there should be effective intersectoral cooperation and coordination of activities to achieve a successful outcome. This principle should operate whether action is necessary at a high government level or at local community level. Within the planning process, both in terms of the health and health-related sectors, the Seminar noted that, of necessity, plans involving additional staff or facilities often require a considerable time to implement. The development of community participation may also take time to achieve in certain areas. Because of this lag phase, both in the provision of staff and facilities and in the initiation of community participation, the health sector is not infrequently called upon to meet an urgent need when optimal solutions are not at that moment possible. This empha">izes the need for an evolutionary approach to problem solution. As facilities and services develop and aR community participation becomes more effective, so the optimal solution to particular problems will be likely to change. The ability of the planning system to anticipate and to effect theRe changes is crucial and such changes can not· occur in an evolutionary fllshion if there is no adequate information system.

Th"re often apP"llrs to be

8

dichotomy between planning and projPct

implementation at the macro and micro levels. Many problem~ of urban comanuniti~s are not soluble st the micro or community level B8 their

solulion requires high level political direction and inters~ctoral planning, budgeting and imlementation. Problems such as massive inward migration, location and development of industry, environmental protection, and provision of social amenities - to mention only a few of the many urban problems - cannot be solved by locally initiated projects as the solution demands large-scale planning, a massive input of resources and high-level coordination and control. Primary health care may be seen as irrelevant in such a context. However, part of the solution of such large-scale pc·ogrammes lies in the successful implementation of the local components of such plans in accordance with specific local circumstances. Primary health care must therefore be seen by the macro-planners as being able to input useful information to facilitate problem identification, to provide local specificity to overall programme development, and to provide the means of local implementation which will make large-scale planning programmes <clevant to the needs 0f the local communities and provide a firm basis for 8

successful outcome.

- 18 -

The Seminar noted that relocation of industry in order to lessen the pollution of the environment by unplanned and uncontrolled industrialization and to reduce the distance workers have to travel has achieved considerable succe8S in Borne countrip.s. The Seminar also noted that SOUle countries have introduc~d the development of secondary, smaller urbnl) centr~R and have

'.

increased rural development in an effort to reduce the growth of large cities by inward migration. The Seminar considered that the relationship between rural and urban development and between urban development in different centres should be kept in mind as there is a profound relationship between these areas. Isolated development can produce far-reaching problems. The two basic primary health care questions are: (1) What do I do when I am sick?

(2) What do I do to improve my health, my family's health and the health of the community? A third question must be added, with particular reference to the health planner and administrator. (3) How do I know that the services provided meet the real need and operate in terms of the appropriate intersectoral and intrasectoral context? This third question should also be asked of planners in other sectors and of those whose task it is to prepare coordinated plans. It constitutes the basis of evaluation and as such is a question which should be posed to planners and providers of services in all sectors and at all levels. ~.9 ~ollow-up

activilie"

The Seminar considered it absolutely essential that the momentum generated by the Seminar should be maintained. To this end a number of spec ific proposals were formulated. The Seminar recommended the holding of city, inter-city and national workshops on urban primary health care. In these, adequate time should be given for the communication of the basic philosophy of primary health care and for the identification and study of problems specific to those taking part in such workshops. The Seminar requested the collaboration of WHO and other international organizations in facilitating such workshops. The Seminar noted the health sector bias of its constituant membership, which is unavoidable at this early stage. However, in recommending the holding of local and national workshops on urban primary health care, the Seminar considered it essential that these should be appropriately intersectoral and that decision makers and policy makers appropriate to the level which the workshop is directed should be present and active. While it may be necessary for the health sector to initiate such workshops, it is vital that other sectors are involved and that political leaders and top executive are not only present but actively involved. Initiation might be a health ~ector responsibility, but not necessarily the leadership of these workshops.

- 19 -

The holding of workshops on similar functions at the conDlIunity leve I should nlso bE' considered. I t is vital that these be vi .. wed as initiating projects for continuing activity, otherwise commun~ty

participation will bp

Sp",cific and realizable goals should be estnblish .. J f,n stich conununity-bssed activities. The Seminar considered it essential that those who understand the nature of primary health care and see it as an eminently practical and feasible approach to the health problems of urban communities should initiate projects aimed at the twin goals of problem solution and demonstration. This is the only way to convince those who do not appreciate the potential and immediate utility of primary health care. Seminar participants agreed to initiate projects along the above lines in accordance with their own situation and resources. They requested that a follow-up of this seminar be arranged after an appropriate period so that there could be an exchange of information with regard to the successes and difficulties encountered in the course of translating the primary health care concept into action. A follow-up seminar should also enable one or two special subjects to be studied in depth. While general identification of urban problems is necessary, it is also essential to study specific problems in depth. Local and national expert working groups have a great deal to offer, provided that they are directed to real problems with some prospect of solution in terms of resource, political will and overall feasibility. Such expert groups must include community participation at the appropriate level and must be specific; this specificity demands that local bodies, governmental and voluntary agencies, the private sector and the community be the major participants, supplemented if necessary by resource persons from outside whose expertise in particular fields would be helpful. Tlw Seminar recommended Lhnt primary health care should be included in

diac()uraged.

th .. stlbject mattpr with rf'gnrd to fellowships granted by WHO and othl'r inlt~rnationBl Hgcncies. Such fellowRhips should pay due attention to the interSf"ctOl"lll approach. It is importnnt that those returning hom€' after theRe lellowships should lit· given adequate opportunity by their governments to pass on the results of their studies to others in their own country.

The Seminar recommended that a complete issue of World Health be devoted to urban primary health care.

6.

POSTSCRIPT

In the closing session, the Seminar considered its overall achievements in terms of the stated objectives (see section 3).

With regard to the specific objectives, the Seminar participants considered that objecti'JPs (1) and (3) had been well met within the time available and in view of the fact that the development of urban primary health care is at 8 comparatively early stage. Objective (2) was much more of a future activity; city authorities had, in the main, not been

- 20 -

represented among the participants and thus the encouragement of these authorities to adopt and implement the primary health care approach could not, apart from a few notable exceptions, be undertaken directly by the Sf>minar. However, jn i.t~ deliberations the Seminar quitf" clC'ariy identified t.he nW-'d for such Nt imullltion and mnny of the particip:tnts diRCUSsf'd in (·onsiderahl~ det;jj 1 the mechanism for achieving this within the context of"

,

their own situation and opportunities.

Stimulation cannot, however, be lett

solely to the participants and observers present at this seminar. International organizations and in particular WHO, will need to facilitate such stimulation through dissemination of information, through preparation of basic primary health care inventories applicable to the urban setting, nnd through meeting of the World Health Assembly. The participants included 8 number of specific suggestions to this end in their seminar report. The above comments with regard to specific objective (2) also apply to the single general objective of the Seminar. The Seminar participants and observers wish to express to WHO and the other international organizations associated with the Seminar their appreciation of this opportunity to meet together to consider the problems associated with the development of urban primary health care. They are confident that, in spite of the magnitude of the problems, a good beginning has been made in the development of urban primary health care and that the momentum towards improving the health of urban communities will be maintained through the coordinated efforts of national and urban governments and administrations.

,

- 21 ANN~:X

1

LIST OF PARTICIPANTS 1.

PARTICIPANTS Dr Christopher George Scarf Regional Director, Western Metropolitan Health Region Health Commission of New South Wales P.O. Box 9 Parramatta, N.S.W. 2150 Australia Dr Cai Bao Xisn Chief, Surgical Department Deputy Director, Shanghai First People's Hospital Shanghai People's Republic of China Mr Chow Chin Vice Chief Engineer, Institute of Shanghai City Planning 333 Tong-sen Road Shanghai People's Republic of China

AUSTRALIA

CHINA

HONG KONG

Dr (Mrs) Rita Khoo Lo Medical and Health Officer Medical and Health Department Medical Headquarters Lee Gardens, Hysan Avenue

Causeway Bay Hong Kong JAPAN Dr Kiyotaka Segarni Medical Officer, Health Administration Division Kanagawa Prefectural Health Department c/o International Affairs Division Ministry of Health and Welfare 1-2-2, Kasumigaseki, Chiyoda-ku Tokyo Japan Dr Jessie George Assistant Director, Health Department Ci ty Counci 1 Kuala Lumpur Malaysia

MALAYSIA

- 22 -

Annex 1 MALAYSIA (cont'd)

Mr Sulaiman bin Samat Senior Assistant Director, Developmpnt

Co-ordination Unit City Council Kua la Lumpu r Malaysia NEW ZEALAND Dr D.W. Feeney Assistant Director, Division of Clinical Services Department of Health P.O. Box 5013 Wellington New Zealand Hr Patrick Puri Gaiyer Secretary, Department of Urban Development P.O. Box 5245 Boroko Papua New Guinea Dr Evangeline Suva City Health Officer Manila Health Department City Hall Manila Phi lippines Dr Francisco casanova

PAPUA NEW GUINEA

PHILIPPINES

Prl!sidpntial Staff on Medical Affair. Office of the President Manil" Philippines REPUBLIC OF KOREA Dr Bo-Hoon Park Director, Gurogo Health Centre Seoul Republic of Korea Dr Young·-Ja Sung Deputy Director, Dobungku Health Centre Seoul Republic of Korea SINGAPORE Dr Ng Yook Kim Director, Outpatient Service and Head, Department of Tuberculosis Control Ministry of Health Cuppage Centre, 55 Cuppage Road Singapore 0922 Republic of Singapore

- 23 Annex 1 SINGAPORE (cont'd) Ms Tan Poh Lee MCH S.,nrices Nursing Officer Ministry of Health Cuppage Centre, 55 Cuppage Road Singapore 0922 Republic of Singapore Dr Bui Qui Xiem Deputy Director, Hanoi City Health Service No. 86 Tho Nhuon Str. Hanoi Socialist Republic of Viet Nam 2. REPRESENTATIVES OF THE UNITED NATIONS AND RELATED ORGANIZATIONS Dr Lay Maung Senior Regional Planning Officer UNICEF East Asia and Pakistan Regional Office P.O. Box 2-154 Bangkok Thailand Ms Victoria Rialp Project Officer (Urban Services) P.O. Box 7429 Manila Philippines Mr Michael M. Park Programme Officer, UNICEF Korea Office 17-1 Changsung-dong Chongno-ku 1. P.O. Box 1930 Seoul Republic of Korea UNITED NATIONS DEVELOPMENT PROGRAMME Ms Johanna Langenkamp Programme Officer P.O. Box 1864 Manila Philippines

VIET NAM

UNITED NATIONS CHILDREN'S EMERGENCY FUND

"

- 24 -

Annex 1 UNITED NATIONS FUND FOR POPULATION ACTIVITIES

Mr Stirling D. Scruggs Deputy Representative and Senior Advisor on Population c/o,The Resident Representative of the United Nations Development Programme in the Philippines P.O. Box 1864 Manila Philippines Mr R.M. Lesaca Deputy Regional Representative Regional Office of the United Nations Environment Programme for Asia and the Pacific The United Nations Building Rajadamnern Avenue Ban,kok 2 Thu1and

UNITED NATIONS ENVIRONMENT PROGRAMME

3. INDONESIA

OBSERVERS Dr Suyono Yaha Chief, East Java Provincial Health Services Surabayu Indones ia Dr Sudano Chief, Jakarta Metropolitan Hea 1th Service s Jakarta Indonesia Dr Abdul Rachman Surono Director, Family Planning Kedical services Jakarta Indonesia

REPUBLIC OF KOREA

Dr Sung-Kyu Ahn Chief, Health Services Research Division Korea Institute for Population and Health Seoul Republic of Korea Professor Yang-Chin Chi Department of Social Work Choongang University Seoul Republic of Korea

- 25 Annex 1 CHRISTIAN MEDICAL COMMISSION Ms Mona B.N. Lo Administrator, Kwun Tong Community Health Project of the United Christian Medical Service 130 Hip Wo Street, Kwun Tong, Kowloon Hong Kong Mr Miles Hardie Director-General, International Hospital Federation 126 Albert Street London, NWl 7NX England Dr Rufino Macagba 1352 Briarcroft Road Claremont, California 91711 United States of America METRO MANILA COMMISSION Mr Nathaniel Von Einsedel* Commissioner for Planning Metro Manila Commission

INTERNATIONAL HOSPITAL FEDERATION

Manila Philippines PHILIPPINE HOSPITAL ASSOCIATION Dr Benjamin Roa

President, Philippine Hospital Association

Second Floor, G&D Bldg. Corner D. Tuazon - Quezon Avenue

Quezon City Philippines 4• CONSULTANT Dr J.S. Dodg~

Specialist in Community Medicine

Warwickshire Area Health Authori! \';estg.1te House

y

\, ,1rket Str ...'et

W·,rwick, CV34 DE England

*Unable

to attend.

- 26 -

Annex 1

5.

TEMPORARY ADVISERS Dr J.W.L. Kleevens Head, Department of Community Medicine University of Hong Kong Li Shu Fan Building Sassoon Road

Hong Kong Professor P. Bennagen Chairman, Department of Anthropology College of Arts and Sciences University of the Philippines Diliman, quezon City Philippines 6.

SECRETARIAT Dr R.D. Mercado Director, Health Services Development and Planning WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines Dr G. Nugroho Medical Officer, Primary Health Care WHO Regional Office for the Western Pacific

P.O. Box 2932 Manila Philippines Dr L. Wasserman Technical Officer, Heal til Service s }{esea rch

WHO Regional Office for the Western Pacific

P.o. Box 2932 ~!<mil

a

Philippines l'~·

.1\.

Ros.si-Espar.nt~t

Chief, Health Service Information System Division of Strengthening of Health Services

WHO Geneva Switzerland

- 27/28Annex 1 SECRETARIAT (cont'd) Dr R.A. Noordin Medical Officer, HEALTH FOR ALL WHO Regional Office for the Western Pacific P.O. Box 2932 Manils Philippines Dr K.S. Lee Scientist, Primary Heal th Care WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines Dr V.K. Sharma Medical Officer, Primary Health Care WHO Regional Office for South-East Asia World Health House Indraprastha Estate Mahatma Gandhi Road New Delhi - 110002 India

- 29 ANNEX 2 WELCOME SPEECH BY DR H. NAKAJIMA, REGIONAL DIRfTTOR WHO RECIONAL OFFICE FOR THE WESTERN PACIFIC AT THE REGIONAl. SEMINAR ON URBAN PRIMARY HEALTH CARE Manila, 30 November 1981 The Declaration of Alma-Ata, adopted by the International Conference on Primary Health Care in 1978, was a major event in the history of mankind's search for health. Some progress has been made since that date toward achieving the goal of health for all by the year 2000 but, as you are all aware, much remains to be done. At the Conference on Primary Health Care, held in this Region in 1977, delegates were unanimous on two important matters. First, that primary health care is a fundamental right of all people in urban and rural communities alike, and, second, that urban communities have special problems and special needs. Events have confirmed the wisdom of these two statements. Four years later, we meet together to consider the status of urban health. We shall review the present position of primary health care in our cities, go on to define the problems, and then suggest the options available to improve the health of those who, by necessity or by choice, dwell in the cities. For many centuries towns have been unhealthy places. The aggregation of people has enhanced the spread of communicable diseases. n'e environmental and public health sPTvices came into being as a result of attf'mpts to df'al wi til th(,R(, problems and have done much to mitigate the ('ffectA of ppidemic disf'I1St'w

HowevE'r, cnmmunicBble diseases are still 8

major CnUSe· of death in SOniC' citip-s and, even where these have been brought

under control, new scourges are evident and incres.:;ing.

The stress of urban living has given rise to new health problems. Cigarette smoking is increasing and commercial advertising has proved more effective than health education. Of particular concern is the increase in the proportion of women cigarette smokers, especially in urban communities, and this will undoubtedly produce a dramatic rise in the incidence of lung cancer in women in the years to come. Alcohol abuse is growing in all social groups and the effects on family health and economic development are considerable. Alcohol abuse, overcrowding and increasipg traffic density have resulted in a dramatic increase in motor traffic accidents, which not only constitute a major source of family misfortune and economic loss, but also consume a substantial part of the health service resources. Drug abuse is generally on the increase. The institution of severe legal penalties does not appear to have been a very effective deterrent and it seems evident that prevention must include determined efforts at cODmlunity level to remove some of the predisposing social factors.

- 30 -

Annex 2 Cities gf'nprllily hove a high population density but it i:; mi51(',i'loing to PXPTPBA

this in tPrntS of an average number of persons per hectare, which often conceals the existence of gross overcrowding in relatively small areas of the cities. Migration into cities, whether from rural areas or from other countri~s may prespnt grave problems. The creation of squatter areas aggravates the general housing shortage and may reintroduce problems of epidemic diseases which had formerly been brought under control.

Associated with overcrowding is unemployment, exacerbated by a sudden influx of people, economic recession or a combination of both. Lack of basic education and job training worsen the situation snd the vicious circle of poverty and unemployment with their attendant social consequences is set in motion. Unemployment is often most severe among the poorly educated young and tends to increase alcohol and drug abuse. These processes are still continuing and inner city decay or outer city squatter areas are now a world-wide problem. Many of our cities are old. Drainage, sanitation and water supply may

have been adequate in the beginning but have not kept pace with city growth. In addition, these facilities are nearing the end of their useful life and need replacement. In all instances, the cost involved is enormous and few civic authorities or even governments are in a position to contemplate the outlay. Postponement of replacement work is an easy option 1n times of financial constraint but this does not solve the problem. Although the number of physicians per unit of the population is generally greater in urban than in rural areas, access to care may still be a problem. Usually, it is in the poorer parts of the cities that access to medical care is worst. Different needs among diverse population groups and differences in social custom also give rise to problems. Health services must be provided in acceptal>le (onn and at a convenient place and time. Financial barriers still exist in many health services and even with nominally free service~, transport costs and the cost of time taken off work cnn act as a detterent to utilization of services.

For some groups in our city population, excellent services have been developed which meet current needs and are responsive to new situations. However, there is a danger in the development of such special services. Coordination of services presents greater problems in cities than in rural areas where the number of health workers working in a single area is comparatively small, making coordination and cooperation potentially easiera In the city the much larger number of workers, their administrative separation and work pressures tend to isolate the components in the health care service, which should normally work together. In mentioning just a few of the health problems of c1t1es, it is obvious that for many of these, the solution does not fall primarily on the health sector. The importance of the intersectoral approach was emphasized in our Primary Health Care Conference here in 1977. The importance has not diminished but neither have the difficulties in achieving intersectoral c~)rdination. The administrative structure of most communities tends to produce intersectoral rivalry rather than cooperation. The development of

- 31 -

Annex

services in cities has tended towards specialism and competing for resources. In times of economic difficulties, competition increases and as economic difficulties are certain to be with us for many years, the intersectoral approach presents us with considerable problems. There is a parallel problem within the health sector itself. There is competition between the various health care sectors and, in spite of attempts to reduce the imbalance, institution1l care still attracts most <'f the available funds. Some countries have devised ways of combating this and those of you who have achieved some success here will have information of great value to give the rest of us. Primary health care can only be made universally accessible to individuals and families in the community through their full participation. In rural areas, community integration is generally more evident and, although traditional customs are changing, there is generally a basic community structure on which community participation can be built. This is not so evident in the cities and it is often in areas of greatest need that social disintegration is greatest. There are thus some very basic problems to be identified here. How can one improve health through community participation when one of the major factors producing ill health is the lack of community structure combined with social alienation. Although it may be true that a sense of belonging to a community cannot be induced simply by planning, it is sadly apparent that some aspects of urban development actively impede the development of community awareness. Not too long ago, public health planning was opposed by those who believed it was against the natural order of things and was doomed to be ineffective. We may be at a similar stage in relation to disease and social ill-health associated with unsatisfactory urban life styles. If this is so we need to be well armed with the facts. This is the age information and communication of information. We may not convince

:)f

everyone, but we will certainly not convince anyone with a badly presented case. There is already a mass of data for us to draw on, but it needs to be interpreted and converted to useful and usable information. However, much of the data collected about our health services, and particularly about primary health care, is not very informative. We need to develop simple,

'>asic health information systems basecl on data collected by and useful to the front-line health worker. Many people in high administrative positions in health and related sectors remain unaware of the essential nature of primary health care or of

its specitic problems and capabilities. Primary health care continues to be confused with basic medical care and is still regarded as an optional extra, to be introduced if additional funds become available. We know that there never are any additional funds.

I have said enough to indicate the nature of some of the problems. spite of the many difficulties, there is a growing realization that the matter is of great importance. There has been great interest in this Seminar, both within this Region and outside it.

In

- 32 Annex 2 Perhaps one of the most important tasks before you is to identify the problems we face in the achievement of an adequate level of primary health care in c1t1es. If this is done, we can proceed to the implementation of better primary health care. You have a demanding task in front of you but I am sure that in pooling your knowledge and experience, we shall together achieve our goal.

- 33/34 ANNEX 3

Confen~nc(~

Cha j rUlnn

Dr EVllngc 1 i ne Sl1va

Conference Vice-Chairman Conference Rapporteur Discussion Group A

Dr D.W. Feeney Dr Ng Yook Kim

Chairman Rapporteur Discu8sion Group B

Dr C.G. Scarf Dr Rufino Hacagba

Chairman Rapporteur Discussion Group C Chairman Rapporteur

Dr Abdul Rachman Surono Hs Victoria Rialp

Dr Ng Yook Kim Hs Hona Lo

- 35 -

ANNEX 4 CLOSING SPEECH BY DR H. NAKAJIMA, R~';IONAL DIRECTOR WHO REGIONAL OFFICE FOJ{ THE WESTERN PACTFTC AT 'J'HF. REGIONAL SEMINAR ON URBAN PR TMARY HEALTII CARE Manila, 4 December 1981 If "HEALTH FOR ALL" is to be achieved, it has to be achieved in terms of the full development of healthy people in healthy communities. At least half of the world's population live in cities and that proportion is p;rowin~;

in some countries in the Western Pac ific Region the proportion of

people living in cities is even greater. While urbanization provides opportunities for economic growth, it also provides opportunities for the growth of some serious health and health-related problems. When development and urbanization contribute to human happiness and welfare, they can be counted as benefits, but too often they contribute to human misery and give rise to health problems of increasing severity and complexity. Many participants in this seminar have noted the rapid growth of urban communities, especially as a result of inward migration, in which the rate of growth exceeds the growth of the necessary health and health-related services. The existence of areas occupied by the urban poor, areas of slums

and s~uatter type housing, with high mortality and morbidity and a low enjoyment of life, is becoming a too common feature of large cities. In these areas, survival takes priority and the development of healthy communities is 80 n"rnule that it seems impossible. In Illy opcnil\~

Hpef"ch,

r mentioned some of the problem", related

to urbnn

devt!iopment and to life in urban communities. You have id~ntified many morp. problems hut, in doing 80, have identified them in a very significant way. You have travelled some way down the road of problem identification and while the magnitude of the problem remains, the existence of possible soilitions has been recognized.

In this, the seminar has been greatly assisted by the pooling of experience and knowledge. All of those taking part: part1c1pants, observers, the representatives of international organizations, the secretariat and unofficial observers and visitors, have actively contributed. Discussions have been held in informal as well as in formal sessions and have been most productive. I would like to refer particularly to the field visit on the second day of the seminar, which proved most valuable and gave a considerable stimulus to the following sessions of the seminar. We are all most grateful to the Vice-Governor of Metro Manila, the Mayor of the City of Manila and to their staff, in particular the staff of the Health Operations Centre, Metro Manila, .and the City of Manila Health llt'partment tor their help in making this most memorable and valuable experience.

- 36 -

Annex 4 W(' are just at thE' beginning of th ... study of urban primary health care,

but we have made a good be~inning. Some of the problems and priorities have been identified and that is the start to the whole process. 11,., extent of the problems within the health sector and th'> magnitude of the factors relating to urban health but remaining outside the health sector could give us cause for dismay and discouragement. However, the intersectoral nature of the problem presents us with the hope of a solution. It is heartening that, in the midst of identification and definition of problem after problem, all participants have emphasized the necessity of such an intersectoral approach. It is not just desirable, it is absolutely necessary. Intersectoral coordination and cooperation are difficult enough to achieve anywhere, but especially so in urban areas, and you have identified many of the details of the difficulties. However, it is in a proper appreciation of these difficulties that the solution lies. The contributions from many participants have been most valuable in providing insights as to how good intersectoral coordination can be achieved. The evolutionary nature of urban primary health care and the necessity to build on and develop existing structures in both the government and private sectors and also with regard to community participation have been re-emphasized in your proceedings. This is a sound emphasis but an evolutionary approach calls for constant efforts to sustain the momentum, otherwise the fragile plant that is urban primary health care will wither lind die. A number of participants have expressed the desire to arrange city or country-wide workshops and seminars in their own countries and I have no """I>t thut this will 1> .. II most useful and productive proposal. countries with simi lllr probl~ms might I ike to consider Some problems jnintly and to llrrange for exchange of information, and might even lend each other staff wiLh particular and appropriate skills. All these activities are to be c01nmpnl'led and the World Health Organization is willing to collaborate with governments in assisting them, particularly with the development of urban primary health care, through the stimulus of city and intercountry workshops and seminars. On behalf olf the World Health Organization, I thank you all for your contribution to what you have created together - a most worthwhile and productive seminar.

- 37 -

ANNEX 5 GUIDELINES FOR THE PREPARATION OF CITY REPORTS FOR THE SEMINAR ON URBAN PRIMARY HEALTII CARE The term "Primary Health Care" evokes a variety of concepts and definitions between practitioners and administrators and between different countries and cities. A document is therefore prepared to assist those writing the city reports to do situational analysis and identify the major issues. This format is particularly important for comparison of urban primary health care activities and summarizing the common and specific problems. It is suggested that the report should include: (a) General information about: geography and location of the city; city government administration, planning procedures, financing and budgeting; demography, population growth, profile of concentrated urban areas, location of urban poor, family composition/income; social services, education, manpower;

health statistics, health services, health manpower, health legislation/regulation, health budget/expenditures, health status, disease pattern, environmental sanitation, including housing. (b) Special attention should be placed on three problem areas as follows:

Problem area 1: Health problems At the community level, health problems are an integral part of community problems as a whole. To some extent, community problems manifest themselves in health problems. (a) What factors are involved in the proliferation of diseases and health problems? For instance: economic condition, housing, environmental sanitation, air and water pollution, unemployment, etc. (b) What criteria do the health services use to define health problems at the community level? For instance: incidence and prevalence, disease patterns, mortality and morbidity rates. (c) What methods or approaches are the health services developing or currently using to define health status of the community? For instance: growth rate, life expectancy, health indicators.

- 38 -

Annex 5 (d) Assuming that there is a difference in perception of health problems by community and health personnel, what practical methods or approaches are the health services developing or currently usin!l to bridge the gap? How do they see the role of the community in bridging the gap? For instance: through research and community survey understand the health problems in its totality, the community perception of sickness and well being. Problem area 2 Development of a community health programme 2.1 Content and delivery of health care (a) What approaches are the health services developing or currently using to existing health problems in the community? For instance: a holistic approach to diarrhoeal diseases (cause and effect) vis-a-vis a single approach to eliminate the causal agent. (b) What appropriate technologies are the health services developing or currently using to prevent, treat and resolve the health problems in the community? For instance: in the case of infant diarrhoea, oral rehydration, drugs, medical care, health education, environmental sanitation, water supplYJ income generating activities.

(c) What systems are the health services developing or currently using to deliver the appropriate technologies cited above? Describe the system in terms of personnel t supervision, referral system, etc.

(d) Assuming that the health services are inadequate or under/over-utilized at the community level, what action are the health services taking to improve the services? For instance: through

operational research to improve the efficiency of the service. action are communities taking to support the services.

What

(e) What approaches are the health services developing or currently using to solicit community participation and intervention in the delivery of health care and the development of appropriate teChnologies. For instance: in environmental sanitation programmes,

MeH and family planning. 2.2 Health related factors

The health status of a community is affected by its level of development, which can simply characterized by three interrelated components: health care, socioeconomic factors, and the environment. When

coordinated actions are taken simultaneously in these three areas, the impact of the actions on the health of the community will be much greater than if the actions are taken in isolation. (a) What methods are the health services developing or currently using to collaborate and coordinate with other sectors in the integration of health development in the overall development of the city.

- 39/40 Annex 5 (b) AS8uming that th .. h.. 81 th needs and problems will chRnp,e 8R the community develops, what methods or approaches are the h.-lIlth servic ... developing or currently using to monitor relevant changes in the community ao as to enable a periodic modification and adaptation of the content and delivery of health care? For instance: development of a lay reporting system, family folders, or comprehensive health information system. (c) With regard to point (b) above, what methods or approaches are the health services developing or currently using to exchange information obtained with those in other related development sectors and to plan coordinated activities at the community level? For instance: participation in the planning meeting of the city development committee. Problem area 3 Programme implementation Assuming that the success of community health programmes depends upon the effective collaboration and the ability of relevant sectors and the community in contributing to and supporting the planning, implementation and evaluation of community health programmes: (a) What methods or approaches are the health services developing or currently using: to plan, implement, and evaluate community health programme? to finance and manage the programme using various sourees? for instance: government and community resources.

•

to establish referral systems, supervision and support between community health programmes and existing health services? (b) What methods or approaches are the health services developing or currently using in the development of health manpower? For instance: community health worker, public health nurses. The ultimate goal of a community health programme is the improvement of the health status of the community, Assuming that the community health programme has been developed and implemented as described above: (a) What methods or approaches are the health services developing or currently using to measure the improvement of the health status of the community? (b) What criteria do they use to select indicators?

- 41 ANNEX 6 CITY REPORT - SYDNEY Sydney is the largest of the Australian cities covering an area of 12 400 square kilometres with a population of 3.3 million which represents 22% of the national population. The Government of Australia exists in three tiers: commonwealth, state and local. The commonwealth or federal government operates from the national capital in Canberra. With regard to health care, it is involved in finance matters such a8 health insurance, grants to the state for hospital and community health, school dental services, subsidies for nursing homes and private hospital patients. State governments are responsible for public hospital and community health services, registration of health profesaionals and public health services. In New South Wales, these responsibilities are administered by the Health Commission of New South Wales which covers the 13 regions of the State of New South Wales. The state government is responsible for urban development, planning, provision of most public transport, water and sewerage (together with local governments) and electricity. It also has responsibilities in social welfare through pensions and sickness and unemployment benefit which are financed by the commonwealth government. Local governments cover geographically small areas and are responsible for local planning and building inspection, common provision of amenities such as parks, street lighting, roads, etc. They have responsibility for the provision of facilities for maternal and child health services (staffed by Health Commission personnel), immunization campaigns, collection of refuse, storm water drainage, safe building codes and building inspection and public health inspection. The Australian population structure ia typical of the developed Weatern world with an aging population and a low natural growth rate. Immigration into Australia amounts to approximately 120 000 persons each year. Within Sydnay, the population growth is small but there is a redistribution of population toward. the West where major urban development is occurring: in this area new communities are being established at a rapid rate and the population in Western Sydney increased by 35 000 in 1980. Poverty in Australia is a significant problem for health and welfare services. With a very high housing rental costs and food costs in Sydney, the poor tend to concentrate in inner city areas and in lower-cost housing far distant from the city centre. The cost of maintaining a family now requires both parents to work in a high proportion of families. Unemployment stands at 6% of the work force. The Commonwealth government makes payment to the majority of unemployed persons and consequently, while poverty is a significant problem for the caring services and those defined as poor, its consequences are less dramatic than in countries without such unemployment benefits. Approximately two-thirds of health expenditure is by the government. Australia hal I high ratio of medical practitioners to the population (1 to 528 persons), and thua there are no parts of the city or rural area without adequate or superfluous general practitioner service •• The health of the Australian community reflects that of the affluent Western world. Heart disease, malignant neoplasm and cerebrovascular disease are the top three in the list of causes of deaths and account for almost 70% of all deaths. Motor vehicle accidents account for 3.5% of all

•

- 42 -

Annex 6 deaths and come fourth in order of rank. Parameters of health status ar~ determined through national statistics on mortality and in some States on morbidity in terms of hospital admissions. In addition, health surveys are conducted by the Australian Bureau of Statistics from time to time to give an indication of health problems. The greatest investment in health care delivery in Australia is in curative services: hospitals consume 70% of all expenditure with a very high proportion being dedicated to the care of very ill in the last year of life. Infectious diseases have been successfully combated by civil engineering and an adequate public health surveillance service. Undernutrition ie almost non-existent. Preventive services are oriented towards redirecting community attitudes to reorientation of life style, and achievements in this regard have been the compulsory wearing of seat belts in cars and banning of cigarette advertising on radio and television. There have also been health promotional campaigns on issues such as obesity, smoking, reduction of alcohol consumption, increasing physical exercise, effective parenting, management of stress, etc. However, the proportion of the health budget spent on prevention of disease and promotion of health is very small. The community health programme in Sydney is a government funded free service designed to complement services supplied by general practitioners. The programme varies according to region but in developing areas it is based on a general community nurse who is related to an area health centre which is a major resource centre and which may have a staff of 70 professional health workers. Services provided by such centres are many but essentially relate to maternal and child health, mental health, geriatric care, reh.bi! itat ion, heal th promotion and public hpalth. The latter is organiEed at the relliunal raLh"r than at th .. health centr .. level. There i. a movement toward. the intesration of community health services with the hospital .ervices to expand the hospital role beyond purely curative services and to enable resource. to be diverted from curative to community health services. A second aim ia to reorientate both the community and the providers of curative health lervices to the life style causes of so much of ill health. There is at the local level close working relationships between local government welfare agencies, educational authorities, aervice clubS, community groupa and community health services. An active voice for the community in the design, management and operation of the community health services has not so far been developed in Sydney. The Australian community health programme was enhanced in 1973 by a newly elected Federal government allocating substantial capital and maintenance funds to set-up integrated programmes in the States. This injection of funds led to the development of a variety of community-based caring services, concentrating on preventive services and people with chronic illnes8e.. Subsequently, the community health programme has become a financial re.ponlibility of the State but the services have continued and have become the re.pon.ibility of the Health Commission. In the planning and implementation of programmes, local government, community group., church groups and other state governmental departments are all consulted and involved but the prime responsibility remains that of the Health Commission.

,

- 43 -

Annex 6 Because of the high level of professional staff available in the Austrslian health services, lay community health workers are not used except in special aboriginal and ethnic health programmes where the health workers are able to be a bridge between the particular community and the health service by interpreting the needs and availability of the service between the two. There are still considerable inequalities in health status between different groups in the community and these differences apply in cities as well as in rural areas.

,

- 44 -

Annex 6 I

CITY REPORT - SHANGHAI 8efore the liberation on 1949, Shanghai was separated into a number of different areas, each with different systems of public utilities and public works. Development occurred unevenly and living conditions varied greatly. A number of slum areas were dispersed around the industrial areas and urban primary health care was neglected. The multitude of small factories and workshops caused serious pollution and many were located in the residential districts. Following the readjustment of land use, the factories were moved to the outskirts of the town and this reduced the pollution in the residential areas. The water supply and sanitary services were improved and the slum areas replaced by more modern housing. A number of green belts were planned between the residential areas and the industrial regions: schools, hospitals and clinics and cultural and community centres were provided in the residential areas on sites originally occupied by the factories. The old city has been gradually and comprehensively replanned and the living environment has been greatly improved. Shanghai is now one of the three municipalities directly under the central government and has jurisdiction over 12 urban districts and 10 rural communities. It covers an area of 6100 sq. km. and has a population of 11.46 million. The urban centre covers an area of 150 sq. km. and is inhabited by 6.1 million people. Health services are provided by 399 hospitals with a total of 49 000 beds. In addition there are over 5300 clinics at factories and 1400 health stations in the urban areas. There are 2960 cooperative health ststions of the production brigades in the rural areas. The health staff now amount to 94 000 and both Chinese traditional medicinr nod we8t~rn

medicine is practiced.

In the city, hospital services are provided in a three tiered system; first level i. the sub-district hospital, then the district hospital and finally the municipal hospital. At th~ third level, the municipal hospital rec~ i ves re.ferrals. consul t 8 t ions t and a 1 so gi Ves t.echn ica 1 advice and traina staff. There are a number of specialized hospitals and the municipal general hospitals also have their predominant specialty. Of the 104 sub-district h09pilals, 31 have beds,33 are without beds and could be regarded as clinics: they are, however, known as 'hospitals' because this is the traditional term used by the people. The sub-district hospitals deliver medical and health services at the basic level including prevention of infectious diseases, immunization, maternal and child health care as well as the medical care of factory workers. About 20% of the professional staff are involved in preventive work. Thirteen of the sub-district hospitals are state-owned and financially supported by the state: the other 91 are subsidized by the state in addition to the income taken from charges for medical care. Out of the 7000 factories, 3000 have set up clinics to provide health care for the workers. A factory with more than 300 workers is obliged to set up a health station and a factory with over 3000 workers must establish a fully staffed clinic. Factory clinics are involved in health education and food hygiene in the factory and the treatment and prevention of

- 45 -

Annex 6 \

infectious and occupational diseases. They also provide general medical care and periodic physical examinations for all the workers. Maternity and child health welfare services and family planning services are also provided. The majority of the population are covered by health insurance regulations and receive free medical and health care. In addition, their lineal descendants are reimbursed for half the medical fees paid. Following the implementation of the 'Health Policy' plan and the establishment of the health and medical network at three levels, infectious diseases have been controlled and the people's health has been greatly improved. The city death rate has dropped markedly and the life expectancy has risen. Infant mortality has been greatly reduced. Following the institution of the family planning programme, the total birth rate has been reduced to 11 per thousand overall and 8.9 in the urban districts. Shanghai is still a developing city and there remaina a number of difficulties in the medical and health work. "Cities that are too big are not good". If the scale of urban population is too large, there are many complicated problems. In the planning of the city therefore, there have been measures to restrict the growth of the city so that it will not become too large. The physical planning has been integrated with the urban primary health care. This is essential so that problems of poor environment and poor housing do not rise as the city grows. Past experience gives us cause to believe that our problems will be gradually overcome through good integrated health and health-related planning.

- 46 Annex 6 CITY R~PORT

• J

- HONG KONG

Hong Kong is a city state under British rule with a Governor assisted by an Executive and a Legislative Council. The total area of Hong Kong is 1056 square kilometres with an overall population density of 4852 square kilometres. According to the 1976 census the population density of the metropolitan areas of Hong Kong Island, Kowloon, New Kowloon and Tsuen Wan was 25 400 people per square kilometre and 554 per square kilometre for the New Territories. In 1980, about 37% of the population were below the age of 20. The life expectancy is high, being about 70 years for males and 77 for females. About 98% of the population can be described as Chinese on the basis of language and place of origin. In Hong Kong, the Urban Council has jurisdiction over environmental and public health, recreation and amenities and cultural services. This is the only government body with elected representatives. The financial policy of Hong Kong is one of low taxes with attraction of foreign investment and capital inflow. Fortythree per cent of Hong Kong's people live in government provided or government assisted accommodation with controlled rents. Education is free in primary schools and up to Form 3. Formerly, tuberculosis was a major health problem in Hong Kong affecting about 1% of the population: this is now on the decline. The infant mortality rate is lower than many European and American countries and this is partly attributable to the development of maternal and child health services and partly to improvements in social and environmental conditions. The influx of refugees recently produced a rise in the overall infant mortality rate. The most common single cause of death is malignant neoplasm followed by heart disease, cerehro-vascular disease, and pneumonia. All the major communicable diseases have declined considerably. BCG vaccination coverage of newborn babies is Ilbout 99% and tuberculosis among young people is rare. A rubellll immunization programme was introduced in 1978 directed at girls aged 11 to 14 year. old and to women of child-bearing age. There are three types of hospitals in Hong Kong: government, government-assisted and priVAte. Overall, there are 4.1 beds per thousand of the population. Outpatient services are provided by the Government subsidized organizations and by private agencies. The demand is high at government operated clinics. Family planning is an important component of the Family Health Service and ante-natal and post-natal health consultation sessions are conducted for mothers: immunization programmes are provided for the children. A Comprehensive Observation Scheme was introduced in 1978 to detect and assess early developmental abnormalities and where necessary, to provide follow-up treatment. School Medical Services are operated by the School Medical Board, which is an independent body: participation is voluntary. A multi-disciplinary mental health service, an industrial health service and a dental service have recently been instituted.

.

- 47 -

Annex 6 In 1980, the continuing influx of Vietnamese refugees gave rise to concern in the medical and health departments. Emphasis was placed on the prevention of the importation of communicable disease and thp spread of these among the refugees and to the general population. Special immunization and health screening campaigns were conducted. Environmental hygiene is provided by the Urban Services Department and includes street cleaning, the collection and removal of refuse and nightsoil, food hygiene and the disposal of the dead.

- 48 -

Annex 6 CITY REPORT - KANAGAWA PREFECTURE, JAPAN The Kanaga"a Prefecture is on the border of the Ci ty of Tokyo and is located in the central part of Japanese archipelago. Kanagawa has a population of about 7 million people and includes the citiPH of Yokohama and Kawasaki from which industrial development has spread out to other parts of the prefecture. The prefecture is composed of 18 cities, 17 towns and 1 village which function as a dormitory town in relation to the Tokyo-Kawasaki-Yokohama Industrial Belt Zone. The administrative structure of Japan is organized in three levels: the national, prefectural and municipal. The 37 municipalities of Kanagawa Prefecture conduct administrative affairs in close relationship with the residents' daily lives, dealing with such matters as sanitation, fire-fighting, sewerage, education and community welfare. The prefectural governments administer regional works of broader scope, including the improvement of the environment, public housing construction, pollution control, the promotion of education and cultural activities, medical services and social welfare, industrial development and the maintenance of pub lie peace. The population density in Kanagawa Prefecture is high. In the last 25 years, more than 2 million people have migrated into the prefecture as a result of the high growth of the economy and industrialized society. The popUlation density is now 2889 per square kilometre and has produced problems of pollution, destruction of the natural environment and a considerable increase ill traffic accidents. As the population increased, so thpre were problem. of shortage of housing, schools, health and medical facilities, wtt'lfarc.~

•

fnci) itica, etc.

To meet theBe proh1emB, a new Kanagawa

pllln has been developed and a Council on the Overall Development of Kanagawa Prefecture has been formed. This is the primary channel for community participation. The life expectancy of the popUlation of the Kanagawa Prefecture is high, being slightly higher than the national average for Japan. The three main causes of death are malignant neoplasm, cerebro-vascular disease, and ischemic heart disease. These three causes account for 63% of all deaths in the Prefecture and this proportion is on the increase. Accidents t poisoning and violence account for 3.8% of deaths and suicide 3.0%, coming fifth and seventh in the ten leading causes respectively. Infectious diseases are of low incidence. As the reproduction rate decreases, so the relative value of foetal and infant life increases. The most COmmon concern regarding the latter is whether measures for emergency care are established or not. It has been necessary to organize a new-born emergency medical care system in the Prefecture. l~ere are 14 networks each with a central hospital, with four highly speciali2ed hospitals for complicated cases. An integrated maternal and child health system has been introduced starting with health education classes before marriage and going on to provide services in health education, continue with health care and medical care up to and including school age.

- 49 Annex 6

A major mi.understanding in the community is that health CRn be achieved through medication. One of the msin measures to be instituted for adult health are a health promotion movement with a strategy of distributing accurate health knowledge. Health planning has been made problem oriented and health budgeting follows the same system. But, in the implementation of all this, difficulties occur particularly with intersectora! issues. There are inadequate staff to integrate all the programmes which will be required to meet our problems. The solution was found in organizing community participation. As the leasers of the community groups come to know the population needs well, the programmes initiated by the different sectors could be integrated. For the promotion of health, the target of this plan focused on the housewives. In the beginning appropriate information was provided about health and the human body to motivate each citizen to be re.ponsible for their own health. Training sessions were held and gave the housewives minimal nursing skills to be able to care for the household members and to know the importance of the early detection of diseases. The integration of health care services and welfare services remains a major problem but will hopefully be solved through the local liaison committees and the establishment of a community approach to our problems.

.. Annex 6

- 50 -

CITY REPORT - KUALA LUMPUR The city of Kuala Lumpur is situated in central of the west coast of the Malaysian Peninsula and is the capital city of Malaysia. It has a hot and wet climate with an average rainfall of 100 inches per year. It has a population of one million and covers 94 square miles. The population density ranges from 42.6 per hectare in the central area to 24.8 per hectare in the peripheral area. The Chinese form the majority of the population at 56%, with Malays at 28% and Indians 15%. 44.4% of the population are under 20 years of age. Due to migration, the annual growth rate is 4% compared to the national rate of 2.7%. Some of the migrants into the city find themselves unable to keep up with the high cost of living and as a result, the immediate problem they face is housing. This has given rise to a squatter population which has grown at a tremendous rate and at present the squatters form 25% of the city's one million population. The urban poor are mainly formed by the squatters and are concentrated outside the original central urban area. Eighty-two percent of the working population is employed in the service sector, 15% in manufacturing and construction and only three percent in the agricultural and mining. The Kuala Lumpur City Government Administration is divided into three sectors: The Administrative and Service Sector; the Common User sector and the development sector. The City Hall's main source of revenue includes assessment rates, trade license fees, planning and building development fees and other revenue from miscellaneous sources. Financial assistance is also

received from central government by way of large loans for specific projects Bnd direct grants for projects of national interest.

The city's main problem i. caused by the rural-urban migration and the large squatter population. Other problems are massive traffic congestion and air pollution. Perennial flooding is frequent, being caused by rapid housing developments. There are many health problems in the squatter areas. A major part of the development budget is allocated for construction of low-cost housing to alleviate the housing shortages. Medical and health services are provided by the Ministry of Health and by City Hall. The Ministry of Health is responsible for all the curative services in the city and the City Hall provides the preventive aspects of health. There are four government hospitals in the City serving the city population and also acting as national referral centres. There are also 21 private hospitals, 20 government clinics and 200 private clinics in Kuala Lumpur. Dental clinics are also provided by the Ministry of Health and 27 are located in the city schools. Curative services ara also provided by private practitioners. The doctor to population ratio is 1:970 compared to the national figure of 1:3915. There are 4177 beds in the city, 80% of which are in government hospitals. In addition to the preventive health services provided by the City Hall, some maternity and child health services are provided by the Ministry of Health in the new city areas.

- 51 Annex 6 Tuberculosis is the most common of the serious communicable diseases. Due to the c1 imate and terrain, there are many potential mosquito breeding grounds. The Vector Control Unit is responsible for the control of the breeding grounds of all mosquitoes and special emphasis is laid on the control of malaria and dengue vectors. Malaria is no longer disease problem in the city but dengue fever and dengue haemorrhagic fever still pose a problem. The Environmental Sanitation Unit in the Health Department of the City Hall is responsible for general sanitation: building inspection and anti-litter control; food quality control; water supply sanitation and the control of infectious diseases. The Health Department also provides immunization services. The School Health Services involves health examinations of every school child in Standard I and VI, aimed at the detection and treatment of any deviation from normal health. The School Health Service alao provides a health education service to the children. The Maternal and Child Health Unit offers preventive health services to all pregnant mothers and to children below six years: simple curative treatment are given to the mothers and children who attend these clinics. A special project, the Sang Kancil Project, was started in 1979 to meet the numerous health problems caused by the large squatter population. After the consultation with the local community, three centres were erected within the squatter communities. The community headman is an important means of communication with the local community as he voices the requirements and the problems of the community and obtains participation from community members. The health component of the Sang Kancil project is designed for the most vulnerable in the community namely, pregnant mothers and children. Doctors supervise the work and se" some of the problems cases, but the main work i. Uonp. by nurse practilioner. was realillad that l1Iany mambers of the community lacked the essential basic.knowledge of economic development and a number of basic courses have been organized, for example in simple accounting. Most of the men in the community are fully employed but the income obtained is only just sufficient for a hand to mouth existence for a fal1lily. The majority of women are housewives who are busy in the morning but idle in the afternoon and it was decided to Btart training courses for them. A small factory with 9 donated sewing machines was started in one of the centres and an intensive tailoring course of six months duration was conducted for interested women. This has proved to be able to provide an important income supplement. It

Another programme, NADl, is a special project by the Ministry of Federal Territory to coordinate services of agencies within the city to raise the quality of life of the urban poor. The priorities in this programme are firstly, comprehensive health services for the urban poor; secondly, basic services to improve the environment particularly with regard to water supply, refuse disposal, sanitation snd provision of electricity and playgrounds and thirdly, community and family development through community education snd fSl1lily counsplling.

- 52 -

Annex 6 CITY REPORT- AUCKLAND New Zealand i. a sovereign state lying within the temperate latitudes of the South West pacific, consisting of two major and several smaller islands. The population is 3 124 000 and 83% of the population live in urban areas. Central government is responsible for a national health and welfare system, most national transportation systems, energy production, education, fire service, forestry development and low income housing development. There are also about 240 territorial local authorities, 60% serving communities of less than 5000. In addition to this structure of highly centralised national government and fragmented local government are a number of special purpose bodies ranging from harbour boards, animal pest boards to hospital boards. Hospital boards are elected bodies, centrally funded and charged with the provision of hospital and related care for their area. In 1939, a social security act provided for national superannuation and security against sickness and other forms of social disability, aiming to make hospital and other health services universally available in a publicly funded health care programme. Economic problems over the years have given riae to a dual system of public provision and subsidized private provision of health care. General prsctitioner and other primary care services and specialist services are state-subsidized; the public hospitals, which provide 80% of the hospital beds, are funded directly from the State but are operated by the locally elected hospital boards. Private hospitals, residential homes for the elderly etc. qualify for a state subsidy. A large number of voluntary agencies are active, particularly in primary health care: many receive Some subsidy from the State. In 1974, the Accident Compensation Corporation came into existence, being funded by a levy on employera and the self employed. It compensates all persons injured as a result of sn accident, whether this accident is work related or not., Rehabilitation and safety education are also actively undertaken by the Accident Compensation Corporation. The rise of technology in medical care has resulted in the consumption of 70% of public funds by the hospital sector as opposed to 20% for community care. The annual growth rate in public hospital spending has been restrained to less than one per cent, while in other sectors the subsidy has been allowocl to fall behind inflation to an increasing degree. It is now apparent that there is a financial bsrrier between the health services and the economically under privileged. The effect of this has not yet been clearly defined. New Zealand is a multi-racial society. The race native to the country, the Maoris, comprise some 9% of the popUlation and Pacific Islands Polynesians 2%. There are smaller but significant numbers of the Chinese and Indians. Communicable disease is controlled, life expectancy is relatively high and mortality rates are relstively low. There are few really rich and few really poor. A relatively small population, a stable political system, good housing, sufficient food, good education and public hygiene and a health care system of generally high standard are present.

- 53 Annex 6 The problems facing primary health care relate more to the access to and utilization of the services available and theAe problems art' compounded by some ethnic and cultural differences and the current socioeconomic

difficulties. New Zealand lacks adequate data on which to b".e a systeo. of national health planning. Difficulties are compounded by the profusion of local authorities and available health services and by the general uncertainty about the results of intervention in a health care system. Metropolitan Auckland is comprised of Takapuna, Auckland and South Auckland, which together make up one conurbation. The population of 825 000 occupies an area of 7700 hectares and represents 26% of the national population, 37% of the national work force and 20% of the national retail turnover. Auckland is governed by 30 territorial local authorities, but in 1963 the Auckland Regional Authority was formed and was given both planning and executive functions. Although the natural popUlation growth rate is now only 0.9% per annum, there is a considerable internal migration into the Auckland area. The average popUlation density in Auckland is 7.3 persons per hectare, but in Central and South Auckland densities rise to 30-45 persons per hectare. These areas correspond with the highest percentage of those who have not had secondary education, the highest number of people per dwelling and the lowest main income. Environmental health services such as water supply, sanitation and refuse collection are available to virtually all dwellings. A major current problem is unemployment and a survey carried out in 1980 by the Auckland city council found an average of 12% unemployed. This unemployment was disproportionately high amongst the young females, Maori and Pacific Islanders and the foreign-born. This unemployment is demoralizing for the individual and creates secondary social and health problems. Homelessness in Auckland is a steadily growing problem. Accommodation available for rental is becoming progressively less and the cost of rent is increasing as a proportion of total income. In the main, the disease problems are those of an affluent society showing the typical morbidity and mortality and picture of such a society. Recent studies have suggested that New Zealand has one of the highest obesity rates in the world, especially in women. Cigarette smoking is increasing in spite of a health education programme and the 1976 census showed that 38% of males and 30% of females at the age of 15 smoked regularly. A study of Maori smoking habits showed that Maori women have the highest rate of smoking (70%) and the highest rate of ischemic heart disease and lung cancer of women in any country. Alcohol consumption is rising and the association of alcohol with road accidents, crime and other social disorders is not disputed. Heavy drinking is evenly spread across all groups of the community. Drug addiction is an increasing problem. In 1979 motor vehicle accidents alone were the most frequent cause of admission to hospital. There is a well-developed system of services supporting community health. Community nursing services are provided by the Auckland hospital board. Government hospitals in Auckland provide 2815 general bed a and private hospitals. further 2000 general beds. At present 37% of Auckland citizens are covered by private medical insurance. Primary medical care in

- 54 Annex 6 Auckland is provided by some 475 general practitioners, who arc free to practice where they wish. Population per practitioner in Northern and Central Auckland is 1~12, while in South Auckland il is 2522. About 60% of the doctors are in solo practices and the remainder are in groups, usually in purpose-built premises: emergency care is increasingly being handed over to deputising services. All medicines are available free, or nearly so, to patients, and there is no levy by way of a prescription charge. A wide range of diagnostic facilities are available to the doctor and no fee is payable for these by patients. Two hundred registered nurses in Auckland are employed on a subsidy basis by general practitioners and many factories maintain an occupational health service staffed by a registered nurse with a doctor attending part-time. A recent study showed that 50% of the services provided in accident and emergency departments were for primary health care. By the year 2000, 10% of the population will be aged over 65 and what is more important for planning purposes is that the number over 75 appears to be increasingly sharp. Current opinions amongst the agencies in Auckland appears to favour the fostering of independence and quality of life for the elderly with more flexible provision of sheltered housing rather than residential homes. Planning in this area is made more difficult by the number and overlap of the agencies involved. Dental practitioners work in the private sector, and their services attract no subsidy for the patient. Children, however, are well provided for by the School Dental Service and the school child may attend a private dental practitioner under a dental benefit scheme until he or she leaves secondary school. The city's water supply is fluoridated and this has reduced the rate of dental decay by 60%. AN •••• ment of the health status of the community is hampered by the lack of an .dequate data base. Problems are produced by a number of agenciea through lack of coordination and competition for resources. Because of the numerous health authorities, special bodies and voluntary agencies involved, there is considerable diversity in the health service and problems of coordination have arisen. There is increasing recognition of the need to rationalise primary care and to devote proportionately more resources to it. Because of the complexity of the organization of the New Zealand Health Service; planning to achieve this has not proved easy. The catalyst for change in Auckland seems likely to be the Auckland Regional Authority, where, in spite of many difficulties, the process of planning, coordination and community involvement.

- 55 Annex 6 CITY REPORT - PORT MORESBY Port Moresby has a population of 130 000 which is increasing at a rate of 7.5 to 10% a year due mainly to inward migration and it is anticipated that the population will reach 250 000 by 1989. This rapid expansion of population has already put a considerable strain on both the health services and the health-related services such as water supply, electricity supply, and sewerage disposal. Health services are provided by 9 urban clinics, the Port Moresby General Hospital, six aid posts and a university clinic primarily serving the university community. There are also 8 private practitioners. The 9 urban clinics are staffed by nurses and nurse aides. They provide maternal and child health services, ante-natal services, family planning and general outpatient treatment. A large percentage of the patients coming to the clinics are children: very few adult males attend for treatment. The urban clinics cater for 75% of all outpatient attendances in Port Moresby. Although there is good access to urban clinics and the hospital, the level of health of the population is not particularly good. A recent study showed that over one quarter of the children seen in the clinics were malnourished and this is a higher figure than that found in many rural areas. The common complaints seen at the clinics are respiratory infections, skin diseases, fevers and gastro-intestinal complaints. There was formerly a system whereby doctors from the General Hospital visited the clinics on a weekly basis. However, with increasing commitments in the hospital, the doctors found it increasingly inconvenient to visit clinics and now only a few clinics are visited at all by doctors. This illustrates the pressures of a ho.pital based system producing a low priority for community based medical services. This has produced one of the biggeat shortcominga of the clinics in that there is virtuslly no in-service training provided for the nurses who are responsible for providing care at the clinica and in the community by domiciliary visiting. Care is also provided in the outpatient department of the General Hospital in the casualty and primary care department, in specialist clinics and in the paediatrics clinics. The major difference between the general hoapital clinics and the urban clinics is that medical staff are always available at the hospital. There are .ix aid posts run by the Provincial Health Office in the National Capital District. Three of these serve schools in the area, one serves government office complex, and two serve local communities. They are staffed by aid post orderlies or medical orderlies. The dental services at present include one dental clinic with a dentist and several therapists; two clinics with one dental therarist each and a m"l,j Ie c1 inic with on<' or more dpntal therapists. 'lliere is also a dental clinic operated by the dental faculty of the medical school and another clini" at the school for dental therapists.

- 56 Annex 6 There are at present 8 private practitioners most of whom are in general practice but a few specialize in paediatrics and obstetrics and gyneocology. The charges for private consultations are high and this limits theee services to a small part of the population. There is however, increasing use of private services as utilization of the public services

involves a long waiting time. In addition, the health expectation of the population haa increased the wish to see a doctor rather than a health worker.

Improvements to the urban health service are being planned. This involves the addition of a medical officer, a nurse educator and a social service coordinator to the staff of each urban clinic. A standard treatment system will be introduced to all clinics and there will be a differential fee between clinics and hospitals as an incentive to encourage use of urban clinics. Antenatal care will be provided at all urban clinics instead of only some of them, as at present. Health and welfare services will be combined in one building so that there is more cooperation between the two sectors and more community involvement in the clinics. Four additional

clinics will be built in the less affluent areas of the city and one clinic will be upgraded to a polyclinic with expanded services and staff.

- 57 Annex 6 CITY REPORT - METRO MANILA Before the creation of Metropolitan Manila as a separate unit of government, the metropolis shared the problems of the developing country in terms of increasing population, income disparity, a high incidence of communicable disease, a high infant and neonatal mortality and the emergence of the chronic conditions including drug abuse, physically and mental disabling diseases and a high rate of accidents. Existing resources and facilities were not utilized to respond to the priority needs of the people and there was poor communication between health staff and the population, leading to ineffective utilization of existing health facilities. The Metro Manila Commission was created by Presidential Decree 824 and part of this decree provided for the Commissions' power with regard to health and healthrelated matters. The organization of several city and municipal hospitals was changed so that they formed the nucleus of hospital districts, linking the work of the hospitals to that of the health centres and barangays. The Metro Manila area was divided into six zones, each zone headed by an Action Team Leader who was in charge of implementation of policies, programmes and projects emanating from the Health Operation Centre. Remarkable improvements have been noted in the organization, delivery and impact of health services. Medical health care has become available to anybody, at any time, and has produced a marked improvement in health status. A significant approach which brought about this dynamic change was the establishment of district catchment areas where barangays were allocated to primary care centres, 10 to 12 primary care centres to a secondary hospital and 3 to 5 secondary hospitals to a specialized hospital. All levels w~re link~d by a strong inter-referral system. The Metro Manila H .. alth Plan follows the concept of the 3-tiered levels of health care and involves a comprehensive programme called the "Womb to Tomb" programme. It begins with parents to be, continues to include mothers, infants, children, adolescents and young people, and goes on to people at work, at home, at leisure, the sick, the injured, the aged, and the handicapped. Environmental services maintain standards for fOOd, water, physical facilities, waste disposal, commercial and industrial establishments, and housing. The health plan includes supportive services such as information and education, manpower training and development, infrastructure development and special programmes. Health facilities have been improved at all levels. A number of special impact projects have been initiated. These include a family care nursing programme which aims at integrating family care nursing in health centre activities. Health services are being provided in aras where there are no established health centres to serve the local community and these augment the existing health facilities within Metro Manila during calamities. There are also a special project aimed at demonstration of progra~es and projects of the government through the dissemination of information; the establishment of a Drug Abuse Rehabilitation Centre and a Tetanus Toxoid Immunization project for Metro Manila aides aimed against the specific occupational hazards of tetanus.

- 58 -

Annex 6 During the five years of the existence of the programme, health indices have markedly improved. Infant and child mortality has decreased and communicable diseases, especially tuberculosis have also decreased in incidence. Chronic diseases such as bronchitis have increased as a result

of air pollution and an increase in cigarette smoking. Respiratory diseases continue to be an important cause of morbidity and mortality with pneumonia and related diseases the most important single cause of deaths. The second i. heart disease, third is tuberculnsis, fourth, cancer and fifth, cerebro-vascular disease. Major causes of death in the infants are communicable diseases, led by pneumonia and gastro enteritis. Prematurity is the leading cause of neonatal death. The major achievements in the health service had been the strengthening of the primary health care through the provision of buildings and other facilities and the redistribution of resources in terms of personnel and equipment. There are now 324 health centres in Metro Manila and many of the older ones have been upgraded. In order to maximize the use of personnel and space, some centres deliver three main services within the one centre,

providing routine medical, nursing and dental care; the treatment of mild to moderate dehydration and attendance to normal delivery cases. Nine of these three-in-one centres are currently in existence. Twenty five lying in clinics for normal delivery cases have been established and there are 120 infant and family planning clinics to give an integrated primary care service. The barangay health posts are extensions of the health centres at the community level and are manned by auxilliaries called the Barangay Health Workers. These are residents of the area and are thua always available for first aid, referral and information. They also serve as important agents ill

tIle expression of the needs of the people.

Utilization of all service. is incresying and community involvement is very important. The dental health progrAmme has been redirected more to preventive dentistry and dental. care for children has been increased. The expanded programme on immunization iA gradually improving in its coverage although the 37% fully immunized population falls well short of the desired target; the coverage, however, is improving. Work of the sanitary services continue to be implemented although enforcement creates problems. The insect, vermin and pest abatement programme was chosen 8S

one of the initial

projects to be implemented. A number of special programmes have been instituted to provide care for special groups of the popUlation and in areas of special needs. The organization of secondary and tertiary care facilities has been improved and the referral system now operate more effectively. The need for a unifying body to oversee the health service, delivery was effectively met by the creation of the Metro Manila Commission Health Operation Centre and this has resulted in significant improvement and integration of all health services.

- 59 -

Annex 6 MANILA CTTY REPORT The City of Manila is part of Metro Manila. Its cl.ief executive is the Mayor who is elected by popular mandate together with the Vice-Mayor. The office of the Mayor represents the executive power and under the Metro Manila government the Mayor is the manager, assisted by various hureaus,.

departments and offices. Planning usually emanates from the department level: a programme plan is submitted by the respective departmental heads to the city planning and development board and subsequently reviewed and discussed at a meeting of all departmental heads. If programmes are established, they are included in the next annual budget and implementation COmmences upon approval of the budget by the Metro Manila Commission. Like other parts of the country, Manila is subdivided into smaller political units called barangay and a group of barangays comprise a zone. In 1980, the estimated population of Manila was 1 743 500 and the average annual rate of increase of the previous five years was 2.8%. 52.3% of the population were in the 0 to 20 year age group. Population density was 42 461 per square kilometre. There has been a heavy inward migration from the rural areas and this has resulted in considerable parts of the city being occupied by the urban poor, dwelling and living under submarginal conditions; these are the so called "depressed areas". An area is

considered depressed when 30% of the 0 to 6 year old population are mal-nourished; where there are low income levels; high unemployment; poor housing conditions; limited educational facilities; a high population growth rate; a high rate of delinquency and crime, and a large proportion of the youth are not in school. The depressed areas are scattered allover the four ~ongre88ional

di8tricts and are not concentrated in one place alone.

Of the city's 905 barangays, a total of 292 are classified as depressed. The Manila Department of Social Welfare is the City's implementing agency in extending services to less privileged areas and aims at their upgrading from a state of social and economic deprivation. Because of the multi-sectoral nature of the problems, coordination and collaboration between the activities of different sectors is essential. Manila is a major educational centre with a large number of colleges and universities, both government and private. City streets are congested and pollution is a major problem. In spite of a decreased fertility and birth rate, the city's annual population growth is 2.S;;. A considerable proportion of this growth is due to continued migration into the city. Of the main communicable diseases, the most important are pneumonia and tuberculosis and these account for majority of death due to communicable diseases.

Infant mortality has declined but communicable diseases continue to dominate the main causes of death among infants under one year. Nine out of ten of the leading causes of mortality among infants are communicable diseases with pneumonia, gastro-enteritis, bronchitis, tuberculosis and influenza as the five major causes, in rank order. Diphtheria and tetanus are now comparatively unimportant due to the effectiveness of the expanded programme on immunization.

- 60 -

Annex 6 Responsibility for health services falls on the Manila Health Department. Programmes and services include matprn"l Rnd child health serviceH (including obstetric services) and cotmnlillicabip di~P1lge

prevention

and control: tuberculosis is still considered to be a major public heal th problem in Manila. The school health service delivers a comprehensive public health service to almost 300 000 school children, but insufficient manpower gives rise to problems in the delivery of service. The Health Education Programme is integrated into all public health programmes in the Department. Family planning and nutritional services are also important aspect. of the total health service offered. Special projects and programmes providp service. for groups of the population with particular npeds. Patients requiring secondary and tertiary care are referred from health centres to the government or private hospitals. There is one hospital bed for every 200 of the population. Population growth, which is higher than the national level, has led to considerable problems of over-crowding, a low level of sanitation, a severe housing shortage and other associated problems. The water supply is inadequate in a number of areas and, with the increasing pollution and establishment of new industries, the urban water requirement continues to

grow rapidly. At present, only 46% of Manila is served by the sewerage system and the collection and disposal of refuse gives rise to considerable problems. Environmental pollution is considered to be a health hazard. Considerable air pollution results from industry and high traffic density and the noise level is above the acceptable level of 50 decibels. Flooding is still a major problem although there has been some improvement in recent years. Housing shortages have given rise to overcrowding, particularly in areas of slum housing, and this in turn exacerbates the problems of water

supply, sewerage and waste disposal. MAnila has a relatively higll number of primary care centres compared to other cities, but their ratio to the population still falls short of the 1 to 10 OOU desired standard. Although the number of government and private hospitals is high, there is considerable mal-utilization. The high number of beds available affects the admission rate and there is a tendency to admit primary care cases to secondary hospitals. Hospitals also have problems of lack of equipment for improved diagnosis and suffer from staff shortages. The implementation of a number of health programmes is held back by lack of finance. Three broad strategies have been adopted to obtain the ultimate objective of health for all about the year 2000. These strategies involve three component parts. Firstly, strengthening the health services through health manpower development, improving coordination between the levels of health care and strengthening the supportive systems. Secondly, intersectoral coordination is being developed and City of Manila has been a pioneer in implementation of a holistic approach to health, taking into consideration the ultimate goal of socioeconomic development. Thirdly, research and development has the aim of providing health information to enable a better identification of problems and the monitoring of change. The indicators used measure health statuB and relate to the quality of life particularly in the field of primary health care intervention.

- 61 -

Annex 6 CITY REPORT SlilJlIL

Seoul is the capital city of the Republic of Korea and covers an area of 627 sq. km. The city is divided into 17 district offices and 417 Dong offices. Each Dong is subdivided into several Tongs and each Tong into several Bahns. A Bahn consists of about 20 to 30 households. In 1980 the population of Seoul was 8 336 000 giving a population density of 1330 per sq. km. 30.5% of the population in Seoul are in the 0 to l4-year age group and 2.7% in the over 65 year old age group. People classified as poor inhabit a number of slum areas in the vicinity of Seoul to which they migrated from rural areas because of the increasing industrialization in the City. They comprise about 5.6% of the total population of Seoul. A number of measures such as medicare programmes, self-help project and other measures have been developed to improve the living conditions of these urban poor. By 1980, 62.8% of city population benefited from the medical insurance programme and 5.6% from the medicare programme of the city. The rest (31.6%) are selt-supporting in medical care. The government is planning to cover the whole nation in the medical insurance programme by 1989. There are 17 District Health Centres in Seoul which take care of the inhabitants of the district with regards to public health, family planning, mother and child care and treatment of acute, chronic and communicable diseases. The Centre also provides primary medical care for the poor in the district. Each Centre maintains a close tie with the private clinics in the districts which act as primary medical care clinics. Additional family planning services are provided by other private clinics. Nurses from the District Health Centres visit each household and give advice on health care individually as well 88 collectively to commmunity groups. Several special committees in each medical field are organized under the direction of thp. Centre with the active participation of con~unity organizations. Medical care starts with primary medical care in the district health centre proceeding to the city hospital, public hospital, national and university hospital in ascending order in the medical care system. In other cases, medical care begins in private clinics and proceeds to private hospitals • • Through the successful implementation of four 5-year economic development plans, the Korean government has achieved a remarkable economic growth in the past two decades. The average annual growth rate has been approximately 10%. This has improved the standard of living of all people but has also been accompanied by a widening of the gap between the rich and poor. Industrialization has accelersted the process of urbanization and this has given rise to areas of poor housing and poor environmental conditions with a lowering of the health status of the inhabitants of those areas. Health problems in the urban slums involve particularly enteric infection, tuberculosis and nutritional deficiency. In these areas, a gap exists between need and accessibility in health care. The prevailing health problems in Seoul City relate particularly to these areas with poor environmentsl conditions. There is a lack of pre-natal care services: the nutrition of many pregnant women is poor and home delivery is common. There is a shortage of health workers, including health educators, and deficient environmental sanitary services in the poorer areas. Communicable diseases such 8S tuberculosis, parasitic diseases, typhoid and venereal disease are the priorities for control measures in Korea.

- 62 Annex 6 The Korean health car~

system is largely dependent on the private

sector through a free maTk~t system. A concentration of doctors and medical facilities occurs in the more affluent urban areas. SophiRticat~d medical

technolngy has resulted in greatly increased costs and this type of medical care is accesaible for a minority of the population, leaving the average citizens and low-income groups behind. The government is therefore adopting a medical insurance scheme and medical assistance or medical aid programmes to make medical care more widely available. Medical insurance programmes for businesses with more than 500 employees started in 1977 and was expanded to firms with 100 or more employees in 1979. There have been problems of excessive demands made on this service. The medicare programme caters for the urban poor and was introduced in 1977. A medical assistance programme covers 5.6% of the total population of Seoul. In order to effectively provide primary health care services, a number of various approaches relating health services to communities are being utilized. This include education of the consumers, home visiting and regular use of monthly neighborhood meetings. In order to achieve maximum efficiency of the primary health care service, it will be necessary to obtain the full coordination of the various sectors concerned with health and social development.

- 63 Annex b CITY REPORT - SINGAPORE Singapore i. an island republic situated in the centre of the MalAyan Archipelago and is a focal point of the trade routes of the area. It i. a modern metropolis with a population of 2.4 million. In 1978, it had 2.47 million visitors, 40% of whom were from the Asean region. The Republic has a land area of approximately 6.18 sq. km. 45% of the land areas has been developed for residential, commercial and industrial use, and 13% for agriculture. The population density is nearly 4000 persons per square kilometre and the population is mainly cen~red in the southern city area. The population conaists of 3 main ethnic groups with the Chinese forming 76%. the Malays 15% and the Indians 7%. In 1980, 39% of the popuiation were below 20 years old and about 7% were 60 years old and above. The annual population growth declined from 4.4% in 1950 to 1.2% in 1979. It is anticipated that Singapore will reach zero population growth in the year 2030 with a population of 3.5 million. About 60% of the population aged 10 years and above are economically active: for males, the rate is 72% and for females 39%. The unemployment rate among the economically active in 1980 was 3.5% and this is considered as full employment. In 1980, 68% of the population lived in public housing and by 1985 it is expected that this percentage will increase to 75%. In 1948, the three most common causes of death were tuberculosis, pneumonia, and gastro-enteritis. In 1980 these have been largely replaced by the diseases of modern living: hypertension and heart disease, neoplasm and cardiovascular disease. Tuberculosis had dropped from first place to tenth place between 1948 to 1980. As far as morbidity is concerned, re.piratory di8~8.es

are

th(~

most numerous ..

Personal health services are provided by the Government through the Ministry of Health. Environmental health comes under the purview of the Ministry of the Environment. Government personal health expenditure takes up about 1.17% of the gross nationsl product. Personal health services in Singapore are also provided through private medical practice which concentrates mainly on curative services. The Ministry of Health in Singapore is organizationally divided into two divisions: the hospital division and primary health care and health education division. In the primary health care and health education division, there are five functional units. (a) (b) (c) (d) (e) Outpatient medical service Maternal and child health service School health service Tuberculosis control Training and health education service

Working in close association with the primary health care services are the Home Nursing Foundation and the Singapore Family Planning and Population Board.

- 64 -

Annex 6 The outpatient medical service is the curative sect ion of the primary

health Cllre services and provides general medic,,1 outpatient car .. for th., publ i<:, m~dical outpatient services and pre-employment mt'dical scre~ninR for ~mpl()yee8

of

Gov~rnment

Ministriea and tuberculosis and venerpsl disease

control. Services are channelled through 12 polyclinics and 19 dispensaries. The maternal and child services provide services to mothers and to children up to 6 years old, domiciliary services concerned with the domiciliary after-care of newly delivered mothers and their babies and also home nursing care of the aged sick. The school health service provides routine medical screening of children in school and immunization of school children. Tuberculosis treatment is largely ambulatory and the venereal disease control programme is performed in conjunction with the hospital for skin and venereal diseases. In 1973, a joint coordinating commmittee on epidemic diseases was formed. The standard of living and literacy in good and transport and media communications the outside world are excellent. Community centres and there are residents' committees estates.

Singapore is high. Housing is both within the country and with centres exist in all popUlation in all large public housing

TIlese facilitate the dissemination of information to the

community. Community centres and schools are used to channel the promotion of good health habits through a series of health campaigns. Community participation takes the form of voluntary organizations to supplement government health programmes. Among these are the heart association, the anti-narcotic association, the association for the blind and for spastic and retarded children and the anti-tuberculosis association. In the future, primary health care services will be developed to take on an pven greatpr proportion of the health service needs of the community and to minimize expensive hospital care. It is anticipated that increasing participation will come from private medical practice. Efforts will be made to forestall the increasing demand for curative medicine and more attention will be paid to preventive health measures. In the context of Singapore, this will include efforts to change harmful lifestyles. Health programmes will be geared to meet the demands resulting from increasing industrialization and urbanization in an increasingly aging population.

- 65 Annex 6

CITY REPORT - HANOI n,.forf> 195/1, Hlilloi waR n Hlnall city with nn Bn~n

of 1')2 sql1nrt'

kiJomf!trPB lind "HO ()O() inhahitant.. Now the city has f"xp"lld"d to cover 2l'!(l square kilometreH with 2 450 600 illhabitants. The inner city ind\ldes 4 precints with 750 000 inhabitants and a population density of IB 600 per square kilometre. The suburbs include 11 outlying districts with 280 villages inhabited by 1 850 000 people, with a population density of 800 per square kilometre. Wards and villages are the local administrative units respectively in the inner city and outlying suburbs and provide basic health services for the people. Some differences exist between the inner city and the outlying districts. People living in the inner city usually have better education and fewer children than those in the suburbs. In the inner city each married couple has between one to three children and the population growth is between 1.5 to 1.6 percent. The population density is high. In the suburbs, people live mainly by farming and animal breeding. Their level of education seems lower and the population growth rate is higher, being between 2.2 to 2.4 percent. Housing conditions, however, are better than in the industrial quarters inside the city. Thirty years of war has left its mark on the health of the people. The housing is not sufficient to meet the needs of an expanded population and the water carried disposal system and the water supply system are old and need replacement. Industrial development has increased the problem of waste disposal and pOllution. The main disease problems are gastro-intestinal and respiratory tract infections, parasitic diseases, malnutrition, problems of

family health caused by poor family planning and disabilities resulting from war wounds.

The primary health care services are based very firmly on community participation. Preventive medicine is a vital element. In the two five-year plans, the health services will have five objectives: (a) Provision of adequate sanitation and washing facilities and a potable water supply to all families. (b) Improvement of first-aid and medical treatment, superViSion of the health of the people and control of communicable diseases. (c) (d) Improvement of the family planning programme. Improvement of the production of local medicines.

(e) Strengthening the health organizations at district and local levels. Much has already been achieved. The health surveillance of the people in many areas has been put on a firm basis and a health record system has been instituted. In some areas, up to 75% of family members have their health regulsrly check .. d on the basis of individual health records.

- 66 Annex 6 The health organization is being improved and with the aim of providing a health station for every village or ward. Efforts will be made to expand the Red CrOBB organization citizens. 80

that there is a Red Cross member for every ten

Community participation is recognized as essential and covers a wide range of work. The state and the community frequently combine in the supply of materials for health projects. Asistance from the World Health Organization and individual countries is still needed. Aid already given has bepn put to good use.

- 67 ANNEX 7 A CASE STUDY OF HONG KONG (A SUMMARY) by Dr J.W.L. Kleevens MD, DSocMed, MFCM, DPH, DTM&H, FRSH Department of COmmunity Medicine University of Hong Kong Section A. General remarks Hong Kong is a British Colony, situated on the S.E. Coast of China at the mouth of the Pearl River, a mere 130 km. S.E. of Ganton and with a total area of not more than 1037 square kilometres consists of a densely populated urban area (Victoria, Kowloon) and an increasingly urbanizing hinterland, known as the New Territories. On January 20, 1841, Hong Kong Island was ceded to Britain under the convention of Chuanbi (Chuenpi). On January 26, 1841, Hong Kong was proclaimed a British Colony. Neither of the parties was satisfied with this treaty and the British threatened to assault Nanjing (Nanking) from the sea which led to the Treaty of Nanking in August 1842. In addition to a definite cessation of Hong Kong to the British, five Chinese ports including Guangshou were opened for trade with foreigners, while the Chinese were allowed free access to Hong Kong for trading. After China' 8 defeat by Japan in 1895 snd as a result of the growing demands of Get"lllany, France and Ruuia that assisted China, the British felt the need to defend its territory more efficiently and demanded to control the land around it. By a Second Convention of Peking (1898) the COlony of Hong Kong was extended to include the so-called New Territories - comprising an area North of Kowloon up to the Shum Chun River and 235 islands, on lease for 99 years. Initially the Chinese authority was accepted to continue in these areas, but in March 1899 the British declared that New Territories a part of the Colony but under separate administration from the urban area. Hong Kong - translated in Chinese as "Fragrant Harbour" - is situated on the south-east coast of China at the mouth of the Pearl River about 130 kilometres S.E. of Ganton; 1200 kilometres S.W of Shanghai; 1100 kilometres N.W. of Manila; 2400 kilometres N.N.E. of Singapore and 2800 kilometres S.W. of Tokyo.

- 68 Annex 7 Area The tota 1 land area of about 1040 S'1. ki lomet rps compTl ses the fa 1 lowing :

Sq. Kilometres

Hong Kong Island plus adjacent small islands Kowloon and New Kowloon Stonecutters Island New Territories - mainland New Territories - island I 036.75 Total land area Climate

77.48 36.53 0.74 703.14 218.86

Sub-tropical monsoonal wi th cool, dry winters and hot, humid

summ~rs.

The average rainfall is 2127 mm, 75% of which normally falls between May and September. The mean monthly temperature ranges from 150 C in February to Z80 C in July. Population When the Colony of Hong Kong was established it was not expected to attract Chinese from the mainland. However, in those early days the population rose from 32 983 (95% Chinese) in 1851 to 878 947 (98% Chinese) in 1931. Because of the Japanese occupation of Guangshou in 1937 a total of approximately 800 000 Chinese refugees entered the Colony bringing the total number of inhabi tants up to 1. I> mi 11 ion just before the the outbreak of World W.r n. By the end of the war, du.' t·o rc-migration to China, lIonl! Kong population has reduc"d to bOO DOD, by 1947 it increased again to 8n estimated 1.6 million. An unprecedented increase came after the take-over of the Communist Government from the Nationalist's in 1949. About 750 000 refugees, mainly from Guangtong province, Shanghai and other centres of trade imigrated to the Colony and by the end of 1950 the papulation r~ached a total of approximately 2.3 million. The total estimated population at the end of 1980 was 5 147 900 (52% males). Compared to 1970 this means an increase of 29%. Large scale imigration in the last 3 years and an unexpected inflow of Vietnamese refugees since the beginning of 1979 increased the annual growth rate dramatically from an average of 1.9% for the period 1971-77 to 3.4%, 6.3% for the years 1978, 1979 and 1980 respectively. However the rate of natural increase dropped from 14.9 per 1000 to 12.0 between 1970-80. With a steady (crude) death rate of around 5 per 1000, this decrease was mainly due to a declining (crude) birth rate: 20 per 1000 in 1970 to 16.9 per 1000 in 1980. An analysis of the declining birth rate during the 70's showed two responsible trends: fewer women in the prime.child-bearing age groups (25-34 years) and fewer births.

- 69 Annex 7 However, the 1950'" and early 1960's showpd "baby I-lOom" and this will rellult in a 8ubataritial incrtl!88e of thl" nmuher of women

in the most ft.'rtile

age group: from an estimated 387 1100 in 1980 to 538 400 in 1'190. Family planning activities by the Government Family Health Service and the Hong Kong Family Planning Association will try to minimize the expected increase in the number of births by encouraging small families. Hong Kong has a land area of a mere 1060 square kilometres. The overall density was 4852 per square kilometre at the end of 1981, but there is a wide range between the metropolitan areas (25 400 per sq. km.) and the rural areas of the New Territories (554 per sq. km.) Six new towns are being developed and this will eventually result in a more even spread of the population. However Victoria and Kowloon will remain among the most heavily populated areas in the world per square unit of area. Comparing some demographic data for 1970 and 1980 the following table can be constructed

1970 (I) Po~ulation

1980 25.3% 6.1% 68.6% 458 per 1000 25.1 years

( 2) (3)

65-6~+ lears

15 lears of age ~o~ulation

Workini aie De~endencl

(4) ( 5)

Median aie ~o~ulation

ratio

37.1% 4.3% 58.6% 708 per 1000 21.2 years

The drop in dependency ratio means that there is (potentially) a larger economically prOductive group to care for the young and the retired. Life expectancy at birth in 1980 was calculated as 70.1 years for males and 76.8 years for females. As has been described earlier the greatest majority of Hong Kong resident. are Chinese (98%). The Cantonese group forms the greater part of the Chinese followed by Sze Yap, Chiu chow and Shanghai with a minority originated or immigrated in other coastal areas of China. For 1980 only 57% of the Chinese were estimated born in Hong Kong. About 65 000 persons (excluding the Armed Forces) residing in Hong Kong were from Commonwealth countries. Non-Commonwealth (66 800) residents came from the U.S.A. (17%), the Philippines (17%), Pakistan (11%), Japan (10%), Thailand (11%), Portugal (10%), Indonesia (5%), Germany (3%), Korea (3%), France (2%) and the Netherlands (2%). Economl In 1980 the Gross Domestic Product growth rate was 9%. This economic growth was export-led, the growth rate of tot.al exports in real terms was 18% and that of domestic exports 11%. There is a trend shown however for the growth rate of domestic products to decrease. The entreport trade remained vivid with a real growth rate of 37%. Hong Kong's role an entreport in particular for China in continuing to gain importance. Also the activity in the financial and related business services sector (stock market) was considered strong for 1980.

- 70 -

Annex 7 As far as the labour market was concerned, the unE"rnpLoymf>nt rate rOfi~ .1

from 2.3 to 4.3%. Ther" was a sudden increase in the supply of labour as result of immigration while the demand for labour remained r .. )ativt")y cons lant.

The new i.mmigrants were predominantly unski lIed labourers and

this had an adverse effect on the productivity particularly in the labour absorbing industry of building and construction. The Consumer Price Index averaged 16% higher in 1980 as compared to 1979. This inflation was mainly due to the depreciation of the HK-Dollar and of the rapid rate of increase in prices of import goods since the first part of 1979. Hong Kong's economy is externally oriented (as has been shown) and follow the inflation in the rest of the world. Inflation in Hong Kong there is mainly externally generated. EmplOyment and labour There is no statutory minimum wage set in Hong Kong. to an interplay of supply and demand •. Wages are subject

Wages are usually paid on a time-base (hour, day, week, month) or on the volume of work performed. Semi-skilled and unskilled workers in the manufacturing industries are usually piece-rate or paid by the day. Skilled workers and those in supervisory jobs are paid monthly. On a time basis women are usually paid less, not so when they are employed on a piece rate. Trade unions have Ipg .. l status of corporate bodies under the Trade Uniona Ordinancp and they enjoy immunity from certain civil suits. There are three major groups of unions: The Hong Kong Federation of Trade Unions,

a left-wing oriented organization with 66 unions and s membership of more than 200 000. Not affiliated but sympathizing with this Federation are 29 unions with more than 64 000 members. Right-wing oriented is the Hong Kong and Kowloon TradesUnion Council which is affiliated with the International Confederation of Free Trade Unions. It unites 71 unions with a membership of 37 000 and a further 11 associated unions with 14 000 members. Another 180 employees' unions, mostly for civil servants and teachers, have a combined membership of 96 000. Being dependent on the United Kingdom, Hong Kong is included in all declarations by representatives of the U.K. in matters of International Labour Conventions. Industrial Safety is the responsibility of the Factory Inspectorate of the Labour Department under the Factories and Industrial Undertakings Ordinance. This inspectorate, together with the Government Information Services organise programmes to promote industrial safety and the Industrial Safety Training Centre provides courses for students and workers.

- 71 -

Annex 7 The Industrial Health Division of the Labour Jepartment comprises two units. The Industrial Health Unit and the Industrial Hygiene Unit. The Health Unit examines working conditions for evidence of occupational health hazards, undertakes medical and pathological examinations for those exposed to lead, fluoride and ionising radiation and government employers exposed to conditions of work under compressed air and diving. Medical examination and assessment of degree of injUry (disability is in hands of medically qualified industrial health officers). Home visits and visits to work places are done by health visitors and nurses. The Hygiene Unit checks on environmental conditions of the worker either at its own iniative or on complaints of adverse working conditions from the workers. Of the total labour force 42% are in the manufacturing industry, 20% in wholesale and retail trade, hotel and restaurants and 16% sre engaged in community, social and personal services, while 140 000 persons are employed by Central and Local Government. Education Education is compulsory up to the age of 15 years in Hong Kong. In 1980 there were 2694 registered schools in Hong Kong of which 64% were private schools, 30% subsidized, 3% government schools and 2% were schools for special education. A total of 10 764 students left Hong Kong for oversess studies in 1979-80, 4% went to U.K., 26% to the U.S.A., 33% to canada Rnd 1% to Aust ,." I i8. Housing Demand for housing seems never satisfied in Hong Kong. At the end of 1979 a total of 32 000 flats were built under the Housing Authority Programme and another 28 600 flats by private building organisations. This were record achievements and could have resulted in improvements of the housing situation for thousands of families. However the influx of immigrants, legal and illegal from China continued and a large proportion of them became squatters. This increased the danger of fires in the severely congested temporary housing areas and create sudden demands for housing. The waiting list for those who were to be rehoused from old resettlement areas to new housing estates remained long. In 1980 the waiting list consisted of 150 000 families. A very strict priority procedure is now in operation allowing a more fair chance for residents of long standing to be allocated new flata. It is hoped that with the development of the New Towns and the curbing of the influx of immigrants from China, Hong Kong may rid itself from the squatter areas by the end of the 1980's.

-

72 -

Annex 7 Social Welfare (excluding health) The Government is advised on its pol icy in Social Welfan' by two committees: the Social Welfare Advisory Conunittec and the Rehabilitatoll Development Coordinating Committee. Voluntary agencies playa very important role in the provision and development of social welfare in Hong Kong and most are connected with the Hong Kong Council for Social Welfare and assisted by Annual Subventions from the Government, which amounted to HK$159 million for the financial year 1980-81. The "Community Chest" is an affiliation of some 77 welfare bodies to coordinate their local fund-raising activities. This resulted in a fund raised for 1978-79 of HK$17.7 million and for 1979-80 of HK$19 million. (approximately HK$5 per head of population). The Family Welfare Service comes at preserving and strengthening the family unit. Individuals and members of families are assisted in avoiding problems or deal with them. This service provides a wide range of activities: cousel1ing; care and protection and residential and foster care

for persons under the age of 21 years; day-care for children under 6 years; referrals for schooling, housing, employment, financial assistance, legal advise, medical attention, home assistance and placements in institutions

for vulnerable groups. Medical Social Workers are assigned to Government hospitals and clinics. They work closely together with the medical and nursing staff. The Adoption Unit plays an important part in handling adoption requests locally as well as overseas. wi th a greying population the Care of the Elderly begins to play an important part in the activities of the Social Welfare Department albeit still mainly through Governmental aasistance of voluntary organisations. There are two colony-wide progranunes for young people: The Summer Youth Programme and the Chinese New Year PrograDDlle, both organised by the Central Coordinating Committee for Youth recreation. During the Bummer of 1980, 2 million youth were entertained in 8000 projects while at Chinese New Year 1980 281 events were organised for an estimated 60 000 participants. The School Social Work Service helps pupils with academic, social or emotional problems. In the competitive atmosphere of the Hong Kong Schools this service i8 greatly demanded for. Rehabilitation services aim at the full physical, mental and social rehabilitation of the disabled. There are coordinated programmes with the Education Department and voluntary organisations. social workers are trained in five institutions: University of liang Kong, the Chinese University of Hong Kong, the Baptist College, Shu Yan Colleg@ and th .. 1I0ng Kong Polytechnic - around 200 social workers were trained in 1980. The Social Welfare Department provides in-service training in "ocin! work, refresher couraes and staff development programmes.

- 73 -

Annex 7 Social aspects of Hong Kong's population (an overview) From 8

small commercial entreport to a major industrial metropolis in a

period of 140 years is certainly a r<,markahle rlev"lopment. But with the realization that the transition took place mainly in the period after the Second World War it could be classified as spectacular. The odds were all against such a course of history: British Victorian colonialism thrived in an area of increasing awakening nationalism and socialism and the situation remained stable. Desperate immigrants running from political upheaval in China generated, almost without restrictions because of a "laisser faire" policy, so much energy that persistent an acceleration industrial revolution became possible. Hong Kong shows appalling density data. The neighborhood of Mongkok, for example, has a density of 160 000 per square kilometre and other (older) areas o[ the city do have comparable figures. Remarkably however there is only some evidence that this crowdiness poses a problem to the mental health of the people and family life. There seems to be an indication of a deletrious influence of overcrowding to parent-children relationship patterns and this may affect a healthy social development of a whole generation no doubt the crowded situation does affect physical health as it is conducive to direct contract and close range indirect transmission of commerciable disease (e.g. tuberculosis streptococcal upper respiratory tract and skin infections, etc.). Some of the inconclusiveness of the evidence may be explained by a limited sensitivity and specificity of biophysical indicators. However, there is speculation, that because of the long history of exposure to overcrowded situations of Chinese migrants to Hong Knn~ there might be a tolerance to the bad effects of high density of ljvin~, contrihutin~ to an ahility to remain relotivply stable under, othf'rwi ••• vt-ry flItreHHful Cirl'Um8tanCf"s. ALl this mny he lrue but could

only apply in part to the new generat ions of Hong Kong. They have not experienced the long hardship of the primary migrants and they may react more "normally" to the situation. Most of the Chinese migrants come without capital and without advanced technical experience. What they had plentiful was dedication to survive and succeed and ingenuity. Many started small shops and businesses, others became peddlers and sidewalk shopkeepers. Still, walking through the older districts of Hong Kong it is a delight to experience the all day open, small household factories, carpenter shops, printing businesses and household good shops; where you can find almost anything for the daily needs and can huy the services of skilled artisans non-existent any more in Western Europe and Northern America. However here also with the incresing influence of modern technology combined with cheap labour the availability of the good quality products from mainland China pose a serious threat to all small businesses. However, for the eager, disciplined artisan there are opportunities, giving by Government assistance and banking finance, to remain independent and successfu 1.

- 74 -

Annex 7 The institutional characteristics of Hong Kong's Chinese society contain unique aspects, unlike the ahove descrihprl strllctural pcolo~ic81 characteristic whic.:h has ;j much more universal pllttll!rn.

While it can be generalised that the Hong Kong population before 1950 consisted predominantly of local born Chinese, the new population influx changed that picture completely. The migrants brought with them attitudes and values developed under communist philosophies which later were influenced in past by the Cultural Revolution. One of the unique forces in Hong Kong's development is the success of

British Colonial rule in spite of the fact that the British suffered many blows to their status of powerful colonial masters. A colony wide s.trike of all workers in 1926 paralysed Hong Kong for months and the defeat from the Japanese invaders in 1942 are noticeable examples. From the declaration of a localization policy in 1946 an increasing number of Chinese became employed by the government which may have a stabilizing effect on the population. There seems to be a growing feeling of participation in matters of government albeit on a usually subordinate level. The division of the urban area into City Districts and the recent development of further regionalisation by District Boards and District Management Committees may foster this sense of participation. Earlier the British rulers cooperated wealthy and otherwise influential members of the Chinese population into the decision-making structure of government. fp"lin~ that R remarkahle

However, until the recent developments there was a general

the common man has no real say in matters of government. I t is observation that this general feeling of political alienation

WBS not diminished by th~ incr~lIRt"d prosplority of thp. Territory.

Social scientists have wondered what factora could be consid .. red instrumental in this "submissive" attitude of acceptance of colonial rule.

One of the important factors seems to be "familism" a force which put family and fsmily interests foremost in all important aspects of life. This is the same force against which Dr Sun Vat-sen and the Chinese Communist leaders have complained against. With a strong sense of familism prevailing it seems difficult to unite people in nation building or against an undesirable political development. The Chinese family system in Hong Kong, however, has changed considerably in itself. The most important forces in these changes were the industrialization and the fragmented immigration families, usually in small groups of siblings without parents. Now the Hong Kong family is predominantly nuclear in which the husband-wife relationship is based on equal responsibility. The wife and mother is usually also gainfully employed and contributes substantislly to the family income. The size of the typical Hong Kong Chinese family is now declining from sn average of six members to four. It is thought that this trend in limitation of family size resulted from forces generated by the increased industrialization and urbanization and not from population policy.

- 75 -

Annex 7 . . Chinese a~d "We8te~n': medicine are practised side by side in the 1e:rltory: ~lne8e medl~Jne however has never been officially developed

ne1ther d1d 1t eVer rece1ve official recognition. A morp dptailed account of the role of Chinese medicines is given in chapter on health. Environmental hygiene Water is very precious in Guangdong (Kwangtung) Province Hong Kong receives 168 million 182 million in 1982 increasing 1980, 172 million was piped to Hong Kong. Most of it comes from in China. Under the present agreement cubic metres annually. This will increase to annually to 620 million by the year 1994. In Hong Kong.

A sea-water desalter plant, operated in times of serious shortage can provide 181 850 cubic metre per day. The second important Source is rainwater. At the beginning of 1980, 403 million cubic metres were stored in reservoirs in Hong Kong. Environmental hygiene is the responsibility of the Urban Council through the Urban Services Department. One medical officer is seconded from the Medical and Health Department. A team of health inspectors work in close cooperation with the Medical and Health Department. A New Territories Services Department is part of the Urban Services Department. Hong Kong has a noticeable noise problem, particularly in connexion with the building industry and road as well as air traffic. The city is denAely packed and very square metre of ussble area is being taken for the COIIHlnlction of buildings. a number of schools have been built in areas of much noise, e.g. along a busy road or near the irternntional airport. Most

of the effluents are merely discharged into Victoria Harbour and severe pollution problems were avoided mainly because of strong coastal currents. However, with the rapid growth of the population in the last five years a ne~d is felt for the construction of sewage treatment plants particularly in area with restricted water circulation.

About 3000 tonnes of household refuse is collected every day by a team of 5000 workers. Air pollution is existent but not a serious public health problem yet. The highest reading for S02 (sulphur dioxide) during the year 1980 was 494 ug/m 3 which is well below the recommended value of 1310 ug/m3. Environmental Control is aChieved by enforcing a large number of ordinances. In addition each developer must submit a detailed environmental impace assessment to the government Environmental Protection Unit and the Environmental Protection Advisory Committee.

- 76 -

Annex 7 Section B. Health

Vital statistics and mortality The population, now over 5 million has undergone rapid growth mainly through massive immigration in the last decade. Demographically, Hong Kong's population is "gre~ing" but at the same because of the influx of people in the product1ve age groups; the medi~n age remains relatively low and an increased number of births are expected in the decades ahead. time For 1979 almost 60% of Hong Kong's population is under the age of 30 years and 27% is younger than 15 years. Nearly 10% is 60 years older. Of the women 47% were between the age of 15-44 years. Hong Kong'. health is in an advanced state of transition from that of a poor nation with tropical scourges like malaria, diarrhoeal disease and tuberculosis to that of an economically well-off country. In the two decades after the Second World War the fight against communicable and largely preventable diseases (through immunizations and vaccination) was conducted with great success so that now Hong Kong shows a mortality pattern of degenerative and chronic disease combined with accidents, a low natural increase, an infant, toddler and maternal mortality at levels comparable to advanced countries in Europe and Northern America. T~King

The reduction in all portions of the infant mortality are impressive. the figures for 1951 as 100 the following reductions can be cnlcuht .. d. foetal mortality reduced by 72% Peri natal mortality reduced by 66% Early neonatal mortality reduced by bl~ Late neonatal mortality reduced by 89% Neo-natal mortality reduced by 73% Post neo-natal mortality reduced by 92% Infant mortality reduced by 86% Lut ..

0979: 4.7 per thousand) ( 1979: 11.6 per thousand) (1979: 6.9 per thousand) ( 1979: 1.5 per thousand) (1979: 8.4 per thousand) (1979: 4.9 per thousand) (1979: 13.0 per thousand)

A comparison in time (1965-79) of the Standardized Death Rate and Age-Specific Death rates shows reductions of 30-50% in the age groups, 0, 1-4, 5-9, 10-14, 15-19, 20-24, the whole range of children and young adults. Reductions for the other age groups were less with the age-groups 65-65+ remaining almost stationary. Since the 1960's the non-communicable diseases have dominated the pattern of mortality. Neoplasms, circulatory system and injury and poisoning constituted 36% of all causes of death in 1961 and 61% in 1979. Striking is the relatively high figure for respiratory system throughout the ppriod (14-16%).

- 77 -

Annex 7 The analysis of age and cause specific death rates in broad age groups .how. the following prE'dominant causes: (ratps per 100 000).

o

years:

Anoxic and hypoxic condition, not classified elsewhere

Congenital anomalies Pneumonia, all forms 1-4 years: Pneumonia, all forms Injury and poisoning Measles Injury and poisoning Malignant neoplasms Pneumonia, all forms Injury and poisoning Malignant neoplasms Heart disease including hypertensive disease Malignant neoplasms Heart disease including hypertensive disease Cerebrovascular disease

(375) (329) ( 163) ( 34) ( 21)

(

9)

5-14 years:

( 13)

( (

6) 4)

15-44 years:

( 39)

( 28) ( 7)

45-64 years:

(329) (43) (107) (969) (869) (747)

65-65+ years:

Heart diseases including

hypertensive disease Malignant neoplssmR Cf:'.rehrovcscular d lseasf" "'or comparison:

The five most important causes of death for Hong Kong

in tho> year 1948 were: PneulDonia (175 per 100 000), tuberculosis (109), ""teritis and diarrhoea (98), premature births, congenital malformations and diseases of early infancy (67) and ill-defined causes (45). Morbidity Infectious (communicable) diseases play an insignificant role in mortality in Hong Kong. In terms of morbidity however some communicable diseases remain important. The important notifiable communicable diseases were tuberculosis, viral hepatitis, enteric fever and bacillary dysentery. Salmonellosis including enteric fever (typhoid and paratyphoid) may be used as an indicator of environmental hygiene related to food. Enteric fever is notifiable but the other salmonelloses are not. Salmonella surveillance is carried out in Hong Kong by the Tung Wah Group of hospitals, the Department of Microbiology of the University of Hong Kong and the (Government) Institute of Pathology. For 1980 they report .. cl a total number of 18~1 isolations with an average of 40 serotypes l..'lassified. This seems only the tip of 811

iceberg,

8S

the isolations are

only p.. rformed for hospital patients and not for the popUlation at large.

- 78 -

Annex 7 Inpatients There wer" 601'> 879 in-patients trentpd and diRcharg .. <I in all hospitals in Hong Kong during the ypnr 197'1. Of theMP 20% couLd be classified as accidents or resulting from accidents, normal delivery 10%, malignant neoplasms 9%, complications of pregnancy and pregnancy 8%. Heart disease including hypertensive disease was only diagnosed in 3% of the patients treated. With a total of more than 17 000 staff the Medical and Health Department is the largest government department in Hong Kong. For budget-year 1979-80 all expenditure on government medical and health provisions amounted to HK$1 038 624 769 which is 7.5% of the total expenditure for Hong Kong and is equivalent to more than HK$200 per hand of population. On December 31, 1979 there were 20 606 hospital beds available in Hong Kong of which 88% were in government or government-assisted institutions. This amounted to 4.2 beds per 1000 population. Divided according to specially 21% were classified under internal medicine, 16% under surgery, 12% for the mentally-ill and 10% for obstetrics and maternity (maternity homes are excluded). Out-patients Important indications of the need for primary care may be obtained from out-patient attendances Rnd casualties of government and government-assisted

instit\ltions. 1n the Hong Kong situation it may he useful to give the attendances of specialty clinics as well because there i. no clear-cut referral system between the levels of care. Out-patient attendances, casualties and specialist clinics All Government and Government-Assisted Tnstitutions, Hong Kong,1979 Genera 1 Clin ic Governlnent Institutions

Casualties

Specialist Clinics 8 189 976

4 463 641

670 804 278 847 949 651 225 768 491 777 49 651

Government-Assisted Institutions Total Hong Kong - Is1and* Kowloon* New Territories*

648 116 5 111 757 1 320 546 2 197 407 1 593 804

827 995 9 017 971 2 422 667 4 534 345 2 060 959

Estimated popUlation distribution in the Territory for 1979 was Hong Kong Island I 045 923, Kowloon 2 548 000 and the New Territories 1 306 077.

- 79 -

Annex 7 Although there iff no 3H8urance thnt plitients would not havfI crossed thp.

administrative border., it can bE' as""m('d that they would <In,,nd those institutions nearest to their homes nnd work (which is Il"c,'~"nrily in th .. same area). Attendance rate (per 1000 population) for the three main administrative divisions, Hong Kong, 1979 Hong Kong Island General clinic Casualties Specialist clinics 1262 216 2316 Kowloon 862 193 1779 New Territories 1220 38 1578

Attendances at out-patients departments of psychiatric centres, opthalmic service, ear-nose-throat service, dental service, 3nd

dermatological clinics may give an impression about the primary care need of some categories of patients. However, there is no clear division between "real" primary cases or referrals from the secondary level. Attendances out-patients, selected specializations, Hong Kong, 1979 Rate per 1000 population all Hong Kong Psychiatry Ophthalmic servIce (;NT Dental Dermatology (excluding VD) Dermatnlogy (VD) 162 196 65 345 17 121 176 934 352 878 565 399 33 40 13 71 4 25

The Family Health Service (FHS) is a very rplevant service if primary care is considered. The following table gives a fair indication of the demand for the various services provided by the FRS.

- 80 -

Annex 7 Family health services, attendancps, hong Kong, 1979 Number 1. 2. 3. 4. Ante-natal Post-natal Infant welfare (0-2 years) Toddler welfare (0-4 years) 205 395 21 717 981 434 101 075 Rate per 1000 children 0-4 years Total 5. Home visits

Rate per women 15-44 years 184 19

1 082 509 79 105

2649

Rate Eer 1000 women 15-44 6. Family planning 312 173 280

~ears

Another category of clients/patients to be considered for primary care are the workers. There are a certain number of occupational diseases notifiable in Hong Kong, but it is suspected that there is gross under reporting. The two main occupationally related diseases reported for 1979 were Decompression .ickness (42& cases) due to work for the underground railway and Silicosis 077 en"".). Occllpational (innutllrinl) injllriP" were reported 95 932 times with lo6 835 cases (70%) requiring at l"ast 3 dny • • ick leave. 'r~e schooling population is yet 811otllt'r ~roup of potential clients for primary care. The service does noL cover all schools hut is organised

on the baai. of voluntary participation. At March 31, 1980, a total of 7&3 schools participated with an enrollment of 170 574 pupils under the care of 204 doctors. (There were approximately 1 280 000 children between the age of 6-19 years in Hong Kong, mid-year 1979). Tn 1979 the Government operated 52 general out-patient clinics and polyclinics with a total of 242 clinical consulting rooms. In 1980, 115 consulting rooms were added. In addition, 402 clinics were in operations outside the government service. Low-cost housing estates are

all provided with clinics rented to doctors who agree on reasonable fees. All these clinics are registered under the Medical Clinic Ordinance and these have boosted the opportunities for primary care in Hong Kong.

- 81 Annex 7

Thf're iH no typical gpnprnl practice ;n Hong Kong. practitioners may twve thpir clinics in housing eNtnlf's

WE'Rtern tra;n"d catt*ring for thf>

lower income groups or in offices in the business areas. Many pr3cticE' in more than one location. The usual practice opens some hours in the morning, afternoon and at night, up to 9 p.m. There is no published information about the age and disease pattern usually observed in general practices in Hong Kong. A students' project (under the guidance of the Department of Community Medicine, Universi.ty Hong Kong into the age-pattern and disease pattern in general practice revealed the following: Age pattern patients seen in a selected group of general practice in Hong Kong ASe-Sroue Pecentalle M/F ratio 2.1 1.6 1.1

0 - 4 5 - 14 15 - 44 45 - 64 65 - 65+ Total

8 14 55 19 4 100%

0.9 0.1 1.1

This is quite a different picture from what is usually seen in Western guropean countries whpre more young children, older Age groups and women COOl" lip to the G.P. 's for help. Disease pattern according to broad diagnostic groups Percentase Morbidit~

Groue

distribudon

Predominant alle-sroue s

Respiratory Castro-intestinal Dermatological Urinary Cardiovascular Musculoskeletal Obstetric and Gynecology Neurosis Trauma

48 17 7

5 3 2 2 3

1 1

Metabolic and Endocrinology Medical check-up Miscellaneous

8 6

0 15 15 15 45 15 15 15 15 15 15 15

- 44 years - 44 44 - 44 - 45+ - 64 - 44 - 44 44 15+ - 44 - 44

- 82 Annex 7 The firat three morbidity groups are the same as seen in Wpstern European practices but the others are not rt'ally comparable. I t should be realized that the above figures are only indicative at the most. It is claimed that the government services cater for 80% of the demand for primary care but this is a figure not easily proved or disproved. The main reasons for this is that there is no patient-record systems in the Government OPD I S and that Hong Kong clients use "to shop" for doctors I advise. The means that in one illness spell more doctors are usually consulted. The "shopping" not only involves Government doctors but private practitioners and traditional healers as well. From the next table it can be calculated that 2952 'qualified Western trained doctors are not in Government Service, an odd 500 of these are in the service of the univetsity of Hong Kong and the remaining are considered (private) general practitioners. Professional medical personnel, Hong Kong,l980 In Govt. Service 1980 Medical doctors Provisionally registered medical doctors (house officers) Dentists Pharmac ists 1 040

Total Registered 1980 3 632

130 104 35 322 3 687

204 763 335 981 10 729 5 929

MidwivE"9 (without nursing qua li ficat ions) NUl'ses (general, male And female, (excluding student nurses) with midwifery qualifications without midwifery qualifications Nurses (psychiatric, male and female, excluding student nurses) Nurses (mentally sub-normal, excluding, student nurses)

1 621

2 066 310

4 800 397 2

It is estimated that there various kinds operating in Hong Medical Ordinance in Hong Kong, local populations and thus meet

are around 5000 traditional practitioners of Kong. These are not controlled under the but they are frequently consulted by the a demand for primary care.

- 83 -

Annex 7 Western and ChineHe medical faeilitips CAn h~ obsprvrd in thE' Slimp there is no separatjon. Wp.slp.Tn l raillPu doctors rf"lpT pill ientM to doctoTH I)f the HBRlt> I rainillg lInd not tv lhf";r Chinpsf> t nJinf"c1 collf"Bgu£,fI whi le til(> latter do ref~r to "Western" physicians. There are thrt'e types ISnASH.

(It

Chint's" physicians: 0) herbalists, for internal medical care; (2) acupuncturists and pressurists and (3) bonesetters who treat sprains, contusions and fractures. The percentage distribution is roughly' 70%, 10%, 20% r"spectively. It is claimed that the most CODlllon pattern of i.llness-behaviour in Chinese patients in Hong Kong would be: self-medication and self-restraint~ Western trained doctor (usually Government OPD in the lower income groups and private GP's in the middle and higher income brackets)~ traditional Chinese doctor.

Th"re is a general belief among the population that Western medicine act faster on symptoms hut have more side-effects, while Chinese medicines act slower with negligible side-effects. There is a tendency to use the two systems for separate groups of diseases and illnesses. There are a number of "practitioners" who claim to have undergone

training in Western medicine in other countries, but who are not legally allowed to practice, unless they have satisfied an official examination authority that they are competent to practice. Medical social service The work of a medical social service nnd physiotherapy service may be found on Btl levf'19 of care: primary, ~econrlnry and tertiary. Although a (tivi:ilnl1 into th,. services rendered for flD.ch level is not possible, it is u8t'"ful to pn-'sent some data for these lH'rvicea in Hong Kong 8S a who1e. Thi" wi II indicatf' the width, magnitude and d.,mand of the services provided.

Medical social

R.. rvicp,

1I0ng Kong, 1979

Nature of work

Case handled Interviews conducted Home visits made Referrals arranged Enquiries conducted Services rendered The 10 most important: counselling Waiving of medical/ hospital charges Financial assistance

71 309 160 285 1 701

25 334 68 890

55 676 22 399 17 342

occafiion::o

" "

- 84 -

Annex 7 Medical social service, Hong Kong 1979 Render~d

Services

(cont'd) 6 690

Tracing of relatives Contact with relatives (Re-) arrangement of acconunodation Job-placement Surgical appliance arranged Home care (coDllllunity nursing

occasions

4271 2 971 1 727 1 720 1 50S 1 233

.. .. .. ..

and home he lp) Handicap regiatration

..

..

In 1979, 134 869 patients were referred for physiotherapy and the total attendance was 1 202 214 (9 attendances per patient). A community health project in Kwun Tong There are many voluntary organizations engaged in alternative medical and health approaches and preventive work (e.g. Caritas, Po Leung Kuk etc.) This project is described as an example because the author of this case-study is a member of the management committee and has intimate knowledge of it. 1n the following description of, what is generally known in Hong Kong, a8 the Kwun Tong Community Health Project of the IInitf'd Christian Medical Servic(', many of the abovt" described iHS\U'H clIn

be recognizerl.

In lJec>'! •• bpr 1961l, til" (Jnited Christian Hospital (IICH) Committee (Hong Kong) becsm" interested in the industri.al area of Kwun Tong, which at thRt time containf'd some 325 000 people. ThP area i. about 12 sq. km. and has now over 3000 factories while the total population h... doubled to 650 000. Primarily no hospital was being planned for that area and th,· govprnmf'nt readily acc"pted the UCH-Committee's offer to build a 545 beds hospital. Through provision of land and subvention the government contributed to a large extent to this development and its further growth. Members of the UCH. Planning team were aware of the world-wide criticism of hospitals which only were concerned with treating disease. It was the view of the J.C. MicGilvray, Director of the Christian Medical Commission (World Council of Churches) that convinced the planning team to allow the hospital to take an active role in preventive community health in a wide sense. From the start it was made clear that what was thoul';ht necE'ssary for KwUII Tong was a hospital-based urban conununity health project. The hoopita\ WH" to be a community hospital, a teachinl'; hospital, a learning hospital, a serving hOHpital and an out-going hospital.

- 8S -

Annex 7 Two projects were right from the beginninl!; intpgraten with the hospital Rervir:e: (CHI'J. a. community lIurRing project (CNP) .1nd ':1

community hpalth projPct

1~p CNP was to bring hospital quality nursing into the high-rise housing estates, but also to squatter huts and fishing boats while the was aimed at assisting the people to improve their own health: curing-caring, prevention of disease and promotion of health.

~~P

Phvs i ca lly the CliP consists of S centres: 4 health centres and 1 occupational health centre. The health centres contain a clinic and a denIal clinic and functions as the base for CNP, health education (HE), community development (CD) and health maintenance (HH) programmes. The facilities for clinical service are demanded by the public, the other are the needs as seen by the professionals. The CNP's main aim is to follow-up patients who are discharged early from hospital but it is equally important in the long-term care and support of patients with chronic illness. Home visiting by doctors is seldom practised in Hong Kong and so the CNS play an important role in case-finding and case-holding. A third function is the general and health education the community nurses are able to give respect to nutrition, environmental health, home safety and the education and training of volunteer-helpers among family members and neighbours. The Government saw the value of this service and assists the CNP financially since 1977, while a governmental extension of the service for other areas in Hong Kong is in operation since 1979. 1~is ShOWN the potential of the CHP a8 8n alternative experimental serviCE" capahl" of introducing new elements into the medical and health provisions for the population of 1I0ng Kong.

The h .. alth education programme aims mainly at educating those who educate (teachers and volunteers). The health education team produces teaching materials and a monthly new paper that is freely distributed among people and organizations. Every three months there is another theme related to health is discussed. The community development programme is directed towards assisting the community to recognize its own responsibility for its own health. Peoples committees and good-neighbour programmes for housewives responsibility and a sense of awareness for each other's health needs. Many volunteers are enrolled in this programme. 'll,e health maintenance programmes is divided into an infant health maintenance progral11l11<" and a participation of the community health project doctors into the gov.ornmcnt "chool health programme. Basic elements of the ht.·nllh lIudnt{'Il'lI1t'(' iH dist."lse ,mel risk upgrHC..lill~ scn~eninp,

;lnd

~(hl('ntionc11

ill

n,'llIl"inll (0 h('nlth mlliul('ll<lI1C(! ,Ind promotion.

- 86 -

Annex 7

'I'11f' Ion", I ('rm pJun 01 the Guvprnlilent Mpdical cOlltnlnt'ci in " "Whi tf' P1Jppr".

And 1I('nlth St'rvicf"!4 an'

The White Paper: "The Further DeJelopment of Medical and Health Servic". in Hong Kong", July 1974. (printed and published by J.R. Lee, Governm~nt Printer at the Government Press,

Java Road, Hong Kong) contains

the ten-year as advised by the Director of Medical and Health Services and the Medical Development Advisory Committee (see paragraph on Hong Kong Govf'rnmPllt).

The summary of the proposals is: (1) (2) (3) medical and health services will be organized on a regional basis; the aim will be to serve each region with an appropriate general and specialist facilities; Government, and some government-assisted, hospitals will be brought in an integrated (regionally based) structure with uniform charges for third class beds; the accident and emergency services will be reorganized within the regional structure;

(4) () (h)

the ratio of 5.S hospital beds per 1000 population should be regarded as a dpsirabl" AtandRrn for long term planning process; )',pnPTal hOHpitnJs wi 11 be hui 11 ~:ust

fll Sh<l Tin ad Tuell Mun and then in

Kowloon; further psychiutdc faei litiE's will be provided in Princ{~ss Margarpt

the psychiatric wing of th(·

Hospital at Lai Chi

Kok and later a hospital at Shau Kei Wan; (7) "day" beds wi 11 be introduced on an experimental basis in selected

clinics;

(8)

polyclinics, beside the Tang Chi Ngong Specialist Clinic on lIong Kong Island, will be opened in East Kowloon, South Kwai chung, Sha Tin, Tuen Mun Bnd Kwun Tong:

(9) (10) (11)

clinics will be provided at Ngau Tall Kok, Lam Tin, To Kwa Wan, Ha Kwai Chung; Lei Muk Shue and Sha Tin; the Violet Peel Clinic, Central Dispensary and the clinics at Sham Shui Po and Sai Kung will be reprovisioned; provision for medical rehabilitation will be expanded and further requirements will be reviewed in the context of services to the

di.ables;

, - 87 • Annex 7

(11) (13) (14) (15) (16) (17) (III) (19) (20)

n s .. cond medical school will be established at tllf' Chinf'Rf'

University

()f

Hong Kong;

a third nurses training school will he built; a health education unit will be established; action will be taken to increase public awareness of the need to reduce accidents of all kinds; family planning services will bp expanded; the Government will play the leading role in the medical treatment of drug addiction; further considl'ration will be given to the development of community nursing;

a school dental service will be introduced; and Il dental school will be established at the University of Hong Kong.

These proposals involve the following modifications of the recommendations made by the MDAC: a revised distribution of the 1000 psychiatric beds, originally planned for the proposed hospital at Shau Kei Wan; priority being given to the hospitals at Sha Tin and Tuen Mun; the hospitn) propoRed for TuC'n Mun to hl' planned f')f" 1200 beds; and the ratio of 5.5 beds per 1000 population to be achieved over a ) onge r pe riod. EV~'I'y

yt'Hr

tht~

81 Lust ion i 8 rpv iewpd and ndjusted when' needed.

with the change in mortality and morbidity pattern the demand on secondary and tertiary services has increased tremendously. A ten-year

development plan, well designed to cope with the increased and different demands was brought in difficulty mainly because of the unexpected population pressure. Consequently major constraints became apparent: financial, space (land is scarce in Hong Kong) and even more seriously: manpower development and training.

•

Acknowledgments:

The author is greatly indebted to the Director of Medical lind Health S.. rvices, the Honourahle Ilr K.I .. Thong, of lIong Kong for his permission to ust' hi1t annual r(>porl~

liberally.

Or S.M. Lee,

Dy Director (Ilea1th) read and conunented on thl' finn) version of this case study.

- 88 -

•. Annex 7 PRIMARY HEALTH CARE IN THE CITY OF MANILA A CASE STUDY (SlIMMARY) Professor P.L. Bennagen Chairman, Department of Anthropology University of the Philippines Introduction The 41st Anniversary Souvenir Programme of the Manila Health Department, 1981 points out that "The health centre provides primary health care thru a multidisciplinary approach which includes medical, dental, nuraing and midwifery services. Emphasis is given on prevention, health education, early diagnosis and intervention." Moreover, "the health centres and clinics form the base of primary health care and serves as the entry point into the (inter-referral) system". How this concept of primary health care (PHC) is being carried out in three health centres in the Fourth Health District of Manila will be described. Typical of the 45 health centres found allover Manila are administered by the Manila Health Department, these three health centres were studied to enable us to see more clearly and concretely the structure and process of PHC in the City of Manila. For this purpose, a health survey of the areas served by the three health centres was made. In addition, one of the barangays (Barangays 844) already surveyed was further studied for a clearer understanding of the interrelationship of health and some selected environmental factors. Health personnel were interviewed for more data. Time constraint prevented us from

gathering more data from more staff members AS well from those of the cODDllunity. Tn particular, data gathering by participant-observation which is very important in cross-checking data from surveys, questionnaire and interviews was not possible. lb .. picture that emerges from this case study, therefore must be seen with these 1irnitations in mind.

I.

Pandacan, Manila

One of the fourteen municipal districts of the City of Manila, Pandacan is circumscribed by the pasig River on the north and the Estero de Pandacan (a canal) which flows from the upper portion of the Pasig RiVer joining it later at the lower portion. A national highway bisects it at the northwestern-southeastern axis and a railroad tract runs through the northwestern-southeastern axis. Relatively good roads connect various portions of the district with one another. The district is accessible from other parts of the city through a number of entry points. _.

Pandscan has four public elementary schools, a Roman Catholic Church with its psrochial school, a few small chapels, a public market and a small town park. And being on the bank of the navigable Pasig River, three oil companies have set up oil depots in the area. There are terminals for small

- 89 Annex 7 trucking and taxi firms, an assembly plant of a motorcycle company and s concrete plant. An occasional horse-drawn rig, a means of puhlic transport that has survived since pre-war days, is seen alongside dwelling unit8, together with the horse whose manure contributes to the waste and sanitation problems. Also found in the area are two banking offices, a construction firm, the Pandacan Pumping Station of the Metropolitan Waterworks and Sewerage System and the office of the Caritas International, a Catholic aid organization which has supported feeding programmes of the health centres. Gas stations, food stalls and variety stores are found allover the area. Food stalls which sell food aero •• the counter .s well as take-home dishes are increasingly becoming popular in many parts of the city. Ragong Rarangay Housing Project, the first government tenement project for urban low-income families, is in Pandacan. Set up in 1953 on a 4.3 hectare land, the project has 17 three-storey buildings with a total of 480 apartments. Originally intended for city policemen, the tenement now houses some 2400 persons with most of those working age as laborers, officeworkers and policemen. According to the Manila Department of Social Welfare, 16 of the 37 barangays in Pandacan are classified as depressed areas. Two of these are found along the railroad track and four are found along the canal. The low-lying areas are flooded during the rainy season (July to September) and are frequently marshy thus providing breeding places for mosquitoes. Makeshift dwellings are elevated above the marshy ground which often serve as garbage disposal areas. Catwalks are built to connect separated dwellinp,s. S.. rving as sourcl.' of water are three p.ublic faucets which are open most of the! time to fill up seemingly endless queues of pails and drums. In this urban setting of about 1.203 sq. km. are 14 1435 households with a population of 79 135. The population density is about 65 781/sq. km., which is considerably more than the population density of Manila itself, 45 522/sq. km. It is a little.more than 400 times the national population density of l60/sq. km. About 37% of the households have five to six members and 34% have one to four (Table 1). The rest (about 29%) have 7 or more members. As to family structure, 73% are nuclear and 27% are extended (Table 2). About 78% have some kind of schooling from grades up to college (Table 3). Some 32% of the population go to the school which 19% are unemployed, 16% are laborers and the rest are office-workers, professionals, traders, etc. (Table 4). About 38% of the families have annual incomes of PlO 000 to P14999; 25%, PS 000 toP9 999 and 12% earn Pl5 000 to Pl9 000 (Table 9). Annual incomes are generally below the so-called 1981 poverty line of P1720 (about US$2lS) per month, an amount estimated to meet the basic requirements for food, clothing, shelter, health and education of a six member family in Metro Manils. The annual incomes indicate the generally difficult economic conditions obtaining in the area, which have serious implications for PHC.

II

II

I

- 90 Annex 7 Fifty-one percent of the houses are of wooden materials, 31% ar .. of concrete-wood combination and the rest are either concr .. te (loX) or make.hift (8%) (Table 5). Pipe water is generally available hut because not all have their own faucets and water pressure is often a problem, 80me 62% have to store their water (Table 6). Only 69% have toilet facilities and only 66% have containers for their garbage. To meet the PHC needs of Pandacan are three health centres with their respective barangays: Bagong Barangay Health Centre with 21 barangays and a poulation of 42 015; Kapitan Isidro Mendoza Health Centre with 12 barangays and a population of 25 726; and Bagong Lipunan Health Centre with four barangays and a population of 11 394. II. Health problems in relation to social and environmental condition

It is generally accepted that health problems do reflect social and environmental, and therefore,community problems. No more is this clearly seen than in the detailed study of Barangay 844. The low income of most of the population is reflected in the generally poor to fair quality of housing, water and human waste and garbage disposal. Conditions in the other barangays vary and a few have better conditions than Barangay 844. For Pandacan as a whole, 68% have toilets and 66% have garbage containers. It is interesting to note, however, that the National Environment Protection council, in its annual report for 1980, observed that of the 68% of all 7 million households in the Philippines which have toilet facilities, only about one-half may be considered sanitary. Horeover, the seemingly high percentage of house. with toilets snd containen may b" deceptive from the .tandpoint of the general community. Those without toilet. (32%) dispose off their excreta by a number of ways: us .. of public toilets, "wrap-and-throw", use of vacant surroundings including streets. With the garbage that come from some 35% of the households having no garbage containers as well as the overall congestion, the general environmental condition becomes highly attractive to flies, cockroaches and other insect pests and rodents. This situation is particularly evident in the depressed areas aggravated somehow by the surrounding canal which s .. rves as a general dumping place. ~arbage

The water supply also needs a closer look. While practically all have access to piped water, some 65% store their water in various containers such as pails, bottles, plastic and metal drums all of which could easily be contaminated. Storage has to be restored to because of poor water pressure and the fact that not all have their own faucets. Under these conditions, therefore, it is not surprising to find out that during the health survey, about 27% of48477 examined indicated specific cases of illness or symptoms or specified complaints ranging from malnutrition to PTB to gastro-enteritis and bronchitis.

- 91 -

Annex 7 It might be noted that in urban settings, there sre evidences air pollution to bronchitis, pneumonia, PTS, and influenza. 1inkin~

At this point, it is important to ask how the three health centres have been responding to these health, social and environmental problems. To be able to respond to the health needs of any community, it is important to define its health problems and status. At Pandacan, the health centres gather the following data: (l) (2) (3) (4) (5) (6) Total population, age and sex distribution Total births and crude birth rate Incidence and prevalence rates Disease patterns or trends Measurement of type of coverage of activities like consultation rates, immunization rates. Nutritional status of pre-schoolers in the community to include percentages of normal, first degree, second degree, and thi~ degree malnourished children. Leading causes of morbidity and mortality Mortality rates: (n)

(7) (8)

crude

d~.th

rate, and total deaths

(b)

total and percentage of deaths with complete medical attendance, with incomplete medical attendance, and without medical attendance fetal death rate premature death rate neonatal mortality rate infant mortality rate maternal mortality rate mortality rate of 1-4 years old.

(c)

(d) (e) ( f) (g)

(h)

Data are collated at appropriate intervals before they are submitted to the District Office. For example, data on communicable diseases are reported weekly while morbidity and mortality causes are reported monthly. Nutritional status of pre-school children are determined from daily activities.

- 92 -

Annex 7 In addition to the various vital health statistics, the health centres make use of data such as annual growth rate, married couples in the reproductive age group, Environmental Sanitation Indices and Socioeconomio indic~8. For Environmental lndicea, the sanitarians and the workers of thp Office of Insect and Vermin Control, which are integrated into the health centres conduct activities to determine rat density, mosquito and fly densities. Percentages of population with or without facilities for diaposal of human excreta and garbage are also estimated. Socioeconomic indices are obtained in cooperation with the Manila Department of Social Welfare and sometimes by medical and nursing student affiliates doing practicum at the health centres. However, ocular inspections done during· home visits often provide the basis for classifying whether an area belongs to the depressed category or not. In spite of theae criteria and methods used in defining the health problems and health status of the community, the community may perceive these conditions differently. In the health centres, observations have been made by the staff of patients coming in too late for preventive measures such that the centres have to resort to curative treatment. Indeed, as one

physician pointed out, it seems that the prevailing concept of health care among the people is that it is curative. In other cases, because the patients fsil to grasp their own health problems snd the appropriate treatment, the services are inappropriately used. This happens, for example, when scheduled immunization and follow-up consultations are not followed. It is at this point that the home-visits and health education activities are very useful. However, more systematic and sustained eforts at involving the population in the process of defining the health problems and status of the community have to be exerted. Ill. Developing a community Proaramme: structure and process

The content and delivery of health care in the various health centres may be best understood by examining the staffing pattern and services rendered by each. While there is a general format for both staffing pattern and services to be rendered by the 45 health centres of the City of Manila, variations do occur according to the classification of the centres. Some of these variations are noted in the following discussions. In general, the health centres are expected to offer the following services: I. Medical services: A. B. Daily consultation and treatment Pre-natal and post-natal check-up

- 93 -

Annex 7 c. Family planning prp.-marital counselling and use of contraceptives such as pills, IUD and condom referrals to other health centres for tubal ligation PAP's smear for cancer detection D. E. Immunization: BCG, OPT, oral polio, tetanus toxoid for pregnant mothers Nutrition. Operation Timbang: weighing-in of pre-schoolers for detection of malnutrition supplementary feeding F. G. Well-baby clinic National TUberculosis Programme sputum microscopy referrals for chest X-rays free anti-tuberculosis drugs II. Health Education: A. 8. II I. Lecture-demonstration on a variety of topics related to health Mother's classea on cooking low-coat nutritious foods, etc.

Dental Serv iceB:

Periodic targets for preventive dentistry are the pre-schoolero and pre-natal patients. Services include periodic dental examinations, prophylaxis, fillings, extractions, dental health education, local application of sodium fluoride solution on pupils of play-centres in pilot areas. IV. Referrals to other institutions like Philippine General Hospital and Ospital ng Maynila (Manila Hospital) and other cooperating agencies.

V. A. B. C. D. E. F.

Others Epidemiological investigation Environmental sanitation Insect and Vermin control Playcentre for pre-schoolers Barangay linkage Training of student affiliates from midwifery, nursing and medical schools.

- 94 -

Annex, 7 G. Coordination of other private agencies such as: Senior Ladies Association civic organizations Parent-Teachers Associations Citizen Health Council To render these services, according to health centre clasiiifications are: (a) Bagong Barangay Health Centre (CIsss A): Two physicians, three nurses, one dentist, six midwives, one barangay health worker, 3 nurse-aides, one playleadf!r.

(b)

Kapitan Isidro Mendoza (Class B): Two physicians, 3 nurses, one dentist, one barangay health worker, one play leader.

(c)

Barangay Lipunan Health Centre (Class C): One physician, one dentist, one nurse, one barangay worker, one

playleader. Each of the health centres has its complement of janitor-helpers. Integrated into the three health centres are sanitarians from the Division of Sanitation. The Office of Insect and Vermin Control has a team for the four Health Districts. The teams are sssigned barangays to visit each day. AlAo complementing the health centre staff are the so-called flying squads, on., per hl'alth diatrict. The flying squad of Health Di.atrict TV is based at the M. ICBsiano Health and Lying-in Centre located in near-by Sta. Ana. The squads are compos.,d of physician-nurse team. with an ambulance and are availabl .. 24 hours a day to answer delivery calla from lying-ill clinics. It is through this structure that the individual first enters into the network of the health care system. In a very real sense, it is the individual in need of health care and seeks it who sets the health care system in motion. But also, it is the individual and the health personnel aware of every man's right to good health who activate the system and keep it going.

Efforts are therefore being done to situate health problems in the broader context of the community. Individual cases of communicable diseases are traced up to the community level. Morbid cases referred from hospitals to health centres are followed up in their homes by using.a team of medical professionals from the health centre. Each team is assigned to its own barangays. For example, the determination of malnutrition among pre-schoolers may require a team made up of a physician, a nurse, a dentist and a barangay health worker. The physician assesses the nutritional status, conducts physical examination and prescribes needed medication. The nurse records the patient's history, administers injections or immunizations and

conducts health education. The dentist assesses the dental health status an the barangay health worker conducts the weighing of children.

- 95 -

Annex 7 It may be noted that health education is undertaken not only in the clinicR but also in th .. homeR of patients durinl'. hom" visits lind oth"r outreach progralllllles. Heal th pducntion is seen 88 "8 componput of evprv

ongoing programme of the health department enabling members of the teaDI to analyze their educational techniques and methods of educating public." For this reason, health education has become a component of services such as: Family planning, Nutrition, Prevention of Drug Abuse, Prevention of Communicable Diseases and MCH. Through these activities, it is hoped that the population will gain a deeper understanding of their health condition as well as the interconnection between health and other social and environmental factors. They are also aimed at contributing to the "development of a c01lBl\unity that accepts responsibility for its health, knows its health status and resources, participates in coordinated planning and cooperative effort for further health improvement." As the point of first contact with the health system, however, the health centres are not fully equipped and able to handle cases that are brought to them. A system of referral, therefore, is established with other secondary hospitals such as the Ospital ng Maynila and the Phlippine General Hospital. Mental cases within the primary level are referred to any of the health centres of Health District III, or the pilot centre per district, which has an extended mental health programme. Drug abuse cases are either referred to Health District I or to rehabilitation centres or agency catering to drug cases. Other organizations and agencies are tapped for their support of health programmes and services. Prominent among these supporting organizations is the Senior Ladies Association (SLA). The members are usually civic-minded women in the area. They pay a monthly fee of P5.00 and meet at least once a month with the centre pereonnel to a8seS8 health nl,eds and find out how they could support the centre. They raise funds by conducting raffle contests, popularity contests,holding social dance and bingo sessions or by SOLiciting from charitable persons and orgnizations. Proceeds are utilized to improve health centre structure, facilities and equipment. In Bagong Barangay Health Centre the SLA has helped set up a play centre and a day-care centre. In the other health centres, their respective SLAs support the playcentres. civic organizations like the Lions Club, in the case of Kapitan Isidro Mendoza Health Centre, sponsor special clinics in depressed areas, provide operation expenses for indigent patients with deformities (e.g. harelip and cleft palate) and provide free medicine. These are done in consultation with the health centre. Also at the same centre, the Roman Catholic Church organization, Caritas International has been supporting feeding programmes for malnourished children. community participation takes a number of forms and is not limited to the SLA. At the District Level, there is a Citizen Health Council composed of volunteers from the health centres' area of responsibility. They coordinate with the health centres in terms of selected projects such as dissemination of information through the mass media, fund-raising for the purchase of equipment and improvement of centre facilities.

- 96 -

Annex 7 The Barangay council, through its j,ead, is also mobilized during weigh-in. in the determination of malnutrition. A few barangay heads, as in the case of Barangay 844, mobilize their constituents in cOllll11unity projects 8uch a8 the paving of alleys in the depressed areas. Discussions with the harangay councils often include detection of drug abuse in the n"ighborhood, maintenance of sanitary conditions, community beautification, and income-generating activities such as home-gardening and handicraft-making. Bagong Barangay Health Centre even has a demonstration plot for vegetable gardening. Unfortunately, as observed by the physician-in-charge of the centre, only a few have the space to grow vegetables much less to raise poultry and pigs (see Table 8). IV. Programme implementation: Translating policies into practice In the Philippines, much ha. been said of the fact that plans are honored more in the breach than in proper implementation. It is important, therefore, to pay particular attention to the whole interconnected process of planning, implementation and evaluation of the health care programme. Overall planning, implementation and evaluation of the health care programme of the City of Manila is done by the Manila Health Department. Still, it is important to see how inputs are derived at health centre level. The quantity and quality of information are an important consideration in planning. At the Manila Health Department is a Management Information System that oversee8 the systemstic gathering and processing of health and hpalth-related information. It sees to it that dats are properly gathered and rp."ordad for analysis anel .. valuation purposes. Data-gathering Itarts at the health cp.ntre level. Each family has a folder kept at the centre. This contain,' the records of all services that hove been extended to members, vital health statistics and other relevant information. Reports are then prepar"d by the health centre personnel and are submitted to the Health District office then to the Mell Division. The MHO Planning Office collates all the district reports which are then submitted to the Mayor's Office. At the district level, district meetings are held monthly and are attended by disciplinal representatives from the health centres. Follow-up of programmes are made, problems are discussed and 8olutions are sugge8ted. Similar meetings are held at the Departmental level presided over by the City Health Officer. Unresolved problems during staff meetings are discussed by ad hoc committees created during staff meetings. When the needs arise, in discussion of TB phase-out programme, resource persons from the Philippine Tuberculosis society, are invited.

as

The results of these meetings are taken into consideration in the planning process.

- 97 -

Annex 7 As in planning, so too in evaluation. At the Departmental leve I, evaluations are usually done quarterly, semi-annually and annually depending on what ik evalustpd. Fur example, nutrition programmes arp evaluated quartprly. Medical services accomplishments including activities are evaluated semi-annually. In family planning the frequency of new acceptors, defaulters and continuing users is evaluated. Morbidity, mortality and annual growth rates are the uBual objects of annual evaluation, in addition, of course, to the evaluation of the other services. It must be pointed out, however, that evaluation of the community health programme haa largely been in terms of numerical outputs. The impact of the service. on the overall social and environmental conditions has not been systematically evaluated. Based on these evaluations, plans are made to further strengthen the health care system. Health personnel are sent to seminars, seminar-workshops, scientific meetings, management workshops, training courses and study programmes here and abroad. Qualified personnel are sent to pursue graduate studies in public health as well as to in-service and pre-service training. At the health centre level, the barangay councils are tapped for barangay health workers who are then taught to help in various health centre activities, such as Operation-Timbang and health workers serve not only as a medical aide but also as a link to the community. They receive a nominal monthly allowance. Each health centre has at least one barangay health worker. Cuncl ud ing Remarks What emerge. from the abovp. discussion. is e picture o£ urban primary health care that i. trying its best to function according to its concept of primary health care and under the general social and environmental limitations characteristic of urban centres in under-developed societies. In general, it still partakes of the features of traditional basic health services dominant up to now. Among these are:hospital or clinic-orientation, health-professional-centered, predominantly curative and largely occuring within a provider-recipient relationship. To be sure there are changes taking place. The health care system as an aspect of society haa not escaped unscathed from the developmental changes that in the larger society brought about by the structural and value changes taking place world-wide. Consequently, these changes, particularly those of the development decades of the 60's and the 70's have made their impact on the various aspects of society, including health care. Specifically germane to health care is the realization that health problems cannot be isolated from social (to include economic and political) problems and environmental problems. Health problems are ultimately the result of social and environmental problems which in turn may not be resolved satisfactorily with an unhealthy citizenry. This is true not only

- 98 -

Annex 7 at the level of the community but at the country level as well. Such a total and totalizing concept of health has been expressed most hopefully in th" 1978 Alma-Ata Conference and in the slogan: "Health for All by th .. Year 2000". This is more than a slogan; it is a V181on. And a8 a potent vision, it has wrought some changes in the way primary health care has been conceptualized and operationalized allover the world. In Manila, there are signs in the health centres pointing towards that V1S10n. Mention may be made of the efforts to view health as an aspect of national development, the efforts to see health problems in the broader context of community problems, the efforts to extend health services beyond the clinic into the community, and the efforts to get citizens involved. All these are developmental changes from the older tradition of basic health services and must therefore be supported and encouraged. Still some basic changes have to be made and community-based approaches strengthened. For example, use of traditional medicine and involvement of traditional healers with additional scientific training should be promoted. Use of traditional medicine can wean people away from very expensive drugs particularly those from the inordinately profit-making transnational corporations. Use of traditional healers is a form of partnership and se 1 f-re liance. Of fundamental significance, to my mind, however, is the component of community participation. This needs a more serious conceptualization and operationalization in the Philippines particularly after eight years of martial law, not to mention the psychologically debilitating effects of our colonial heritage, which have made most of the residents acquiescent rather than decisive partners in the planning, implementation and evaluation of PIIC. Thus fAr, basically only lip service has been paid to the concept of community/people's participation. Defining community health problems and status has been essentially frODI the top to the bottom. But there are a number of ways by which the community could actively participate in the VSriOUR phases. A simple but meaningful form of cODDDunity involvement would be harnessing more fully the residents in disease surveillance and epidemiological investigations, a truly educational activity when undertaken as a cooperative effort by the staff and the community. For the health personnel, it could provide opportunities for working with other professionals not only in health but also in the social sciences as well as with the community members themselves. For the community residents, these investigations will afford them opportunities to broaden and deepen their understanding of disease causation and the relationship between health problems and community problems. Another area would be in evaluation itself. Evaluation by merely counting the numerical outputs is not enough. Towards participatory p.valuation. the experiences of other programmes can be instructive. thes~

One of

i. the Community-Based Evaluation System tried out in a con",u"i ty-based health programme in Tacloban, I.eyte. The basic feature of this method of evaluation is that it is a dialogical and evocative process dirpctly involving the programme staff and programme pRrticipants.

- 99 -

Annex 7 As more education~l activities along these Illes are consciously undertaken, (and certainly, there are II lot more) the community would undergo attitudinal and behavioural changes. These changes , however , would . not be sustained unless there are accon'panying changes in the social, and specially economic and political structures, that would allow participatory partnership between staff and community. Moreover partnership should not only be participatory but also anticip"to!),. By this is meant that both staff and community should be able to anticipate the long-term structural and value changes concomitant with urbanization in the context of Philippine national development so that these will be considered in the overall short-term and long-term community health programme. For example, long-term national goals of sustainable economic growth, equity and social justice could provide the controlling guide for the various aspects of planning, implementing and evaluating the community programme. It is argued that a community that understands these national goals and the various factors that impede or accelerate their attainment would be in a much better position to exert pressure on government for it to mobilize its resources towards the solution of health and health-related problems. The barangay as a local structure may be inadequate for this purpose being essentially the local arm of central government. Non-government organizations able to aSsume more independent positions may be more appropriate. Areas of cooperation supportive of the goals of PRC should, of course, be explored and maximized. In this regard, there is a debate as to whether community organization could succeed in depressed urban areas because of the marginalizing and alienating preuures of urban life. On the other hand, an understanding by the community of the historical and structural causes of its marginalized nnd alienated existence could provide the impetus for coming together to ... ek short-t .. rm and long-term solutions. If we agree on this, professional health workers and especially health

educators msy have to consider assuming another role - that of being community organizers. Health workers, because of their service roles, have the credibility to assume this added role. This may sound unorthodox and professional health workers may resist the idea, particularly if they are already overloaded by their health functions. Moreover, a government unsure of itself may regard non-governmental community organizations performing advocacy roles as a threat. In the long-run, however, these may simply be one of the stumbling blocks that have to be surmounted before the attainment of a strong community-based PHC able to survive political vicissitudes even at the national level. Of course, community organizing should not be seen as "anncea to all the health problems. It is only one of a variety of means by which human resources could be mobilized. Certainly, the experiences here in the Philippines by various groups involved in community-based health programmes, in addition to those of other countries, deserve to be seriously studied for the lessons they could teach us.

- 100 -

Annex 7 In any case, the particular structure and function of PHC in Manila will have to take into lerious consideration the comment of a Filipina physician in her country report on PHC in the Philippines in 1979: "in whatever form the PHC may aa8ume, the cardinal features crucial to its success are: that it should be community-based and community supported (underscoring: PLB), fot in essence PHC is a health service "of the people, for the people and by the people". TABLE 1. HOUSEHOLD SIZE, PANDACAN, MANILA SEPTEMBER 16 - 21, 1981 (nc 1443)

1 - 4 No. 489 %

5 - 6 No. 530 %

7 - 8 No. 267 %

9 - 10 No. 105 %

11- 12

13& above

No. 41

%

No. 11

%

33.8

36.7

18.5

7.3

2.8

.9

TABLE 2.

FAMILY STRUCTURE, PANDACAN, MANILA SEPTEMBER 16 - 21, 1981 (nc l443)

N uclear No. 1058 %

E xtende d No. 385 %

73

27

TABLE 3.

EDUCATIONAL PROFILE, PANDACAN, MANILA SEPTEMBER 16 - 21, 1981 (n-8389)

College No. 1685 %

Hillh School No. 2936 %

Elementarv No. 1966 %

Pre-school No. 1088 %

None No. 714 % 9

20

35

23

13

-101 -

TABLE 4.

OCCUPATIONAL PROFILE, PANOAC.\N, MANILA Sf:PTEMBER 16 - 21, 1981 (n:8389)

Laborer

Trad./ BU.lne •• No.

P1"ofeRdonal

Office Work Pension Hilitsrv Jobless ~tudent

Prj'-

School

o. ln7

% If).2

%

No. 202

%

No.

I

No.

%

No.

%

No. 1604

%

No. 2683

%

No. 1129

% 13.6

484

,."

2.4

73_

8.'

,-

1.2

28

0.3

19.3

32.3

TULE 5.

TYPE OF HOUSING, PANDACAN DISTRICT SEPTEHBEiI 16 - 21, 1981 (n-8389)

Concrete

S. . i-Concrete

Wooden

Makeshift

No.

%

No.

%

No.

, "

No.

%

143

10

4"

31. 2

73_

113

7.8

TABLE 6.

SO"'~S

OF WATER SUPPLY AND STORAGE MANILA, SEPTEMBER 16 - 11, 1981 (n-1443)

PANDAr~N,

I

ecn.unitv Well Stonpd Not - Stoned

Tapwater (NAWASA) Stoned Not - Stoned

l_. __

No.

%

No.

% ,OO'i

No. 89l

% 61. 7

No. '41

,

'.

.003

7

37.'i

- 102 Annex 7

TAlIU7.' ZXC1llTI. AlIn GAlUIAGE DISPOSAL, PANDACAN, MANILA

SEPTEMBER 16 - 21, 19B1 (n'1443)

I I

I

'''creta With Toilet No.

Garn!jie

-No.

Without No.

TOU., % 31

With Container No.

Without Container

i l

%

%

%

990

69

453

954

66

489

34

TABLE 8.

GAilDEN AND PLACE FOR ANIMALS, PANDACAN, MANILA

SEPTEMBER 16 - 21, 1981 (n-1443)

Garden

Witbout

Place for Animah Wi th An ima is With

\.'evetable I

With Garden

Without COOD

An i1ll11 la

Ornamental No.

With No.

I

:

No.

B4

% 5.B

%

%

No.

%

177

26.1

61

4.2

922

63.9

.N°'1 51

Pi2 en Without

Chicken

% 3.5

N°1 2

With No.

% 1.3

51

% 3.5

Without No. %

NO.

%

14

0.8

1325

91.8

,

I I

i

TABLE MO. 9

ANNf1AL INCOIll! IN PESOS, PANDAC4II, MANILA SEPTEMBER 16 - 21, 1981 (n-I443) (CURRENT EXCHANGE RATE IS AKOUT PB.OO to uS$l)

,

r-

Up to

4 999 No.

5 000 9 999 % No.

115

7.9

363

125~2 12T

10 000 14 999 N••

%

S43

37.6 (1)

15 000 19.999 110. % 17912.4 ( 3)

20 000 24 999 No.

25 000 % above No.

121

I

8.4

91

6~3

No resDonae No.

31

2.2

•

- 103 -

ANNEX 8 THE DECLARATION OF ALMA ~TA

The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following Declaration;

I

The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, i. a fundamental human right and that the attainment of the highest possible level of health i. a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.

II

The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of COmmon concern to all countries. III

Economic and social development, based on a New Tnternational Economic Ord .. r, is of basic importancl' [(, the fullest attainment of health for all and Lo the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace.

IV The people having the right and duty to participate individually and collectively in the planning and implementation of their health care.

- 104 Annex 8

v Covprnml'nttl hllv,' II

n'HI'III1!;ihility for IIH-' tWI111h 01" llwir pf'0l'l~ whirh

can be fulfilled only lJy the provision of adequate health alld social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of devplopment in the spirit of social justice.

VI Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where ppople live and work, and constitutes the first element of a continuing henlt}1 (:nr~

process.

VTT Primary hE'alth car .. : 1. reflects and evo}vps from the f~conomic conditions and socia-cultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and

public health experience; 2. addresses th .. main health problems in the community providing promotive, preventive, curative and rehabilitative services accordingly; includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and prop(~r nutrition; an adequate supply of Nnfe water Bnd 1)~Ric sanjtatioll; maternal and child health care; including family planning; immunization against the major inf~ctious disPRses; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;

3.

- 105 Annex 8 4. involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors; requires and promotes maximum commun.ty and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through apropriate education the ability of communities to participate; should be sustained by integrated, functional and mutually-supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need; relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's resources and to use available external resources rationally.

5.

6.

7.

IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in anyone country directly concerns and benefits every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world.

- 106 Annex 8

x An IIt'cpptablp leVld of Ilf'alth for all the p<'ople of th" world by the year 2000 can be attained through a fuller and better usP of thp world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, d~tente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and pconomic development of which primary health care, as an essential part,

should bl' "Iloted its proper share.

*** The International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, non-governmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and financial support to it, particularly in developing countries. The Conferrnce calls on all the aforementioned to collaborate in introducing, developing an,t maintaining primary health care in accordance with the spirit and content of this Dt'claration.

- 107 -

Annex 8

PROBLEM TDENTH'ICATTON

Geographical location When presented as average rates for a city, the commonly used mortality and morbidity indices frequently do not reveal the true extent of health p:oblems. There is always variation between different areas in the same CIty and although such variation maybe due to a variety of factors ' th ese . . f actors cannot be IdentIfied until the variation has been both quantified and geographically located. In the health sector the main concern of the clinician is with questions of ~ and~. In the identification of health problems of communities,. the additional question WHERE must be asked. In answering the latter questIon, a standard system of geographical location must be used, equIvalent to, that ,;,s~d,by other departments of government. By using the same geograph1cal d1v1s1ons as the census. a population base, subdivided as necessary by age and sex, enables quantitative data to be converted into rates. In order for any valid comparison to be made, rates must be used rather than total numbers. It is well known that inequalities in health follow socioeconomic differences. These socioeconomic differences are often concentrated in well-defined geographical areas of cities and, in addition, specific environmental factors may operate to a greater degree in some localities than in others. The importance of geographical location of health events hos been overlook~d by many tl~alth workers hut it is an esspntial factor in Rtudy of community health in citilPs. Som~ Huilllbl(~ t(~chni(IUf>H

The effects of lifestyle difference" may also be illuminated by area comparison. Techniques of soc.ial aTea analysis have been used now for a numher of years by economists and those in the markf'ting llnd advertising industry. Such tf'chniqllt'. have largely been ignored hy th .. health professional but there are now some well documented pieces of research which point to their usefulness. Having identified, defined, located and quantified the health problem, there remains a further definition in terms of sectorial responsibility. Because of multi-factorial nature of most health problems, this further definition involves a precise description of the inter-relationship of the various sectors with reference to the particular problem. Here a simple systems analysis may serve to illustrate a problem and provide a useful means of visual illustration.

- 108 -

Annex 8 Identification of options Although the precise description of a problem ia an absolutely esaential prelude to remedial action, there is an operational stage between description and the required action by the decision-makers. The formulation of options to set before deciaion-makers, particularly with regard to problems involving an intersectoral approach, is a complicated and time-consuming busineaa and can rarely be made by the decision-makers themselves. If, for each identified problem, an ad hoc inter-disciplinary, intereectoral working group ia aet up, the whole queation of inter-aectoral cooperation ia compromised by the amount of time required. It would seem therefore to be necessary to create some suitable administrative structure to meet this problem. It may be useful to create a small standing working group composed of as small a number as possible but involving all the appropriate sectors. Such a working group would meet regularly to examine the intersectoral problema as they were identified and would formulate options for consideration by the decision-makers. In such a system, each sector would have a suitable information system to identify problems and the existence of problema identified in one sector would be communi~ated to other sectora early rather than late. Problems which fall mainly within the province of a single department attract a priority rating in accordance with departmental policy. However, problems which involve many departments tend to attract a much lower priority ranking within each single department than the problem would warrant when viewed in its entirety. The existence of some acceptable intersectoral administrative structure may help to correct this tendency. lIealth intellil.nce or health information units The identification of health problem. i. an important matter, whichever the aector primarily involved. The less the delay involved in the identification and description, the eaaier it may be to institute remedial action. Identification of problems, however, requires that there be some peraons or group of persons responsible for this. The group neede to be large enough to be viable and must not be distracted by other responsibilities. A good health intelligence or information unit does no~ need to be large but it needs to have adequate staff, proper data process1ng facilities and the responsibility and authority to obtain information it needs. It should be allowed to form good working relationships with other sectors and this is more effective if it is not complicated by administrative structures. Informal contacts between information staff and various sectors are often more fruitful than a formalized structural relationship.

- 109 -

Annex 8 •

The structuring of health information In moat health sectors. data exists in abundance although not necessarily of the type required. It is only too easy to produce excessive amounts of data which obscures rather than illuminates. Just as the principle of management by exception is a good one in the field of management so the communication of health information should follow the same principle. Decision-makers and administrators in the health service do not wish to receive an abundance of information confirming minimal change. The function of a health information system is to identify significant change and the existence of important problems •. Feasibility as an information component In the formulation of possible solutions. questions of financial. administrative and technical feasibility will alwaya be important. In primary health care. matter of Bocial and community feasibility will also be important. In general. financial. administrative and technical feasibility is well recognized and comparatively easy to quantify and describe. Questions of social and community feasibility however are mu~h newer in concept and their quantification and description is not so well developed. The institution of urban primary health care measures. however. requires the active initiation of the identification of problems by the community as well as their active participation in the solution. This does not exclude the activities of the health professional and the expert but it does require that they should be able to work with the community and develop a proper working relationship. This is a new concept in most health services and has in general been dev"lopecl better in rural areas than in urban ones. Neverthrleas. it is a matter which is of vital importance to develop in consicl"ration of the prohlems or urban hpal.th and their solution by the application of the prillcipl"6 of primary health care. Health information units and community involvement In the delineation of community and social feasibility and with the necessity of community involvement at all stages. information gathering at the community level is essential and also the supply of processed information back to the community to facilitate their decision-making process. This has some interesting implications for the organization and

structure of health informatio, units if they are to be effective in their involvement with urban primary health care.

- 110 -

Annex 8 EVOLUTION OF HEALTH CARE DELIVERY SYSTEMS AND INTERSECTORAL RELATIONSHIPS At the Regional Conference on primary Health Care held in Manila in 1977 and the South Pacific Conference on Primary Health Care including Diarrhoeal Diaease Control hald in Suva in 1979 the concept of the development of Primary Health Care in an evolutionary manner received univer.al support. In order to a •• i.t the participants of this Seminar, the attached two document. are being circulated: • (a) (b) The Evolution of Health Care Delivery Systems Towards Health for All by the Year 2000: A Systems Perspective Re-aliening Health Care 8ystem. for Primary Health Care Implementation

The first document illustrate. the evolutionary approach in" terms of a "Past-Present-Future" sequence under seven headings. The evolutionary approach to Primary Health Care helps to emphasize that it is a development of existing health care systems towards a more rational, feasible and effective achievement of healthy people in healthy communities. It is hoped that it will assist participants to put their own country health problems into perspective as well as enabline them to appreciate the problems and progress demonstrated in other countries. The second document simplifies the translation from "Present" to "Future" and illustrates how this can be put into effect in an integrated manner. It i. hoped that these two documents will facilitate group discu.siob, especially with regard to those questions dealing with the methods to be adopted to improve the health of urban communities.

- 111 ~e-aligning

Annex 8

Health Care System for Health Hannower development

Primary Health Care Implementation

Training/reorientation to PHC and community wo Continuing education

Strengthening health services

(' 1

I Intra~ect~ral coordlnatlon

Joint planning exercise technical nroprammes

Strengthening supportive system

Management and technical series Improvement planning process Improvement logistic/referral

H F

Basic neec1s development Food/water/shelte Intersectoral coordination Environment

Income-generating activities Improvement of food/water/housing

A

o o

2

o

Human and solid waste disposal Improvement of living condition

Health informatio Monitoring change Research and deve lopment Generation of information ConmlUni ty organization/ participation

Development of lay reporting system on health and development. Interrelationship of health/disease and other factors: social, cultural, economic and seasonal.

1("

1health-related

Development of cOMmunity network, community diafnosis. Understanding community dynamics.

.z !

. ! t

!~ • • t: ,. • ~

, c

·

.• • • ·E : ~ ~

~.

! •

o

~

~

· , ·· · · , · I :.

.~

,

~

o ;~

l

~

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- 113 -

Annex 8

GUIDELINES FOR GROUP DISGUSSION The attainment of "health for all" must be seen in terms of the full development of healthy people in healthy comaunities. Physical, social and mental well-being goes hand-in-hand with social, economic and community development. Because the determinants of health problems are multifactorial and the factors themselves are intersectoral, so must be the identification of the problems and their solution. The problems and related sdministrative, economic and social backaround of the countries of the various participants will vary areatly. However, there is much in common. If participants share their experiences. problems and ideas in a Ipirit of cooperation this Seminar will achieve success measurable in terms of the improvement of the health of the communities we seek to serve. The guidelines are intended as a stimulus to discuseion, the identification of problems and to the formulation of euitablestrategie8 to the benefit of all of us. 1. Current problems and current 80lution8 In the urban centres in your country, 1.1 1.2 What health problems have been identified? How far are these prohlems met by (a) (h) (c) 1.3 primary health care services secondary) medical care services tertiary )

What improvements are necessary in these services to deal with the known problems more effectively? Are the following important factors? (s) (b) (c) (d) (e) (f)

health manpower shortages manpower distribution relource shortages resource distribution poor communication and liaison within the health sector a poor health planning system

1.4

Are there significant problems of special groups or in particular areas? If so, do these require special services? (Examples: the urban poor traffic or industrial accidents drugs alcohol mental health the frail elderly)

- 114 -

Annex 8 Do theae special services present their own problems in terms of coordination and control? 1.5 How much are poor environmental conditions important factors in the production of health problems? (air pollution) water pollution noise pollution sanitstion refuse disposal insect and animal pests inadequate housing) What is required in order to coordinate environmental action with the solution of current health problems? Does separate budgeting and administration cause any difficulty? 1.6 How effective is community involvement in the identification and solution of health problems? Is it relevant? If so, how can it become more effective?

1.7

Do current methods of financing health services impede the delivery of care or the utilization of services? Whst improvements are possible?

R('s"arch and development: monitoring of prolreas 2. 2.1

problem identification, problem solution and

Problem definition How havl' the present problems been identified? Are you satisfied that you are aware of all the problems and all the factors involved? If not, what is lacking in terms of (a) (b) (c) (d) additional information new indices communication of information to the decision-makers identification of options I

2.2

2.3

Do you have an adequate information service to produce information that is (a) (b) (c) (d) (e) (t)

useful usable timely relevant comprehensive comprehenssble

- 115 -

Annex 8 If not, how do you propose to achieve 8n adE'quateo service?

3.

Problem solution Assuming an adequate identification of the problems:

3.1 3.2 3.3 3.4

How are options identified within the health service? How are inter"cctoral problems identified and how are the options in relation to these established? How (ar does the present planning system meet the demands of problems which fall mainly within the province of a single sector? How far i8 the intersectoral (a) (b) (c)

approach adequate in terms of

(d)

problem identification establishment of options formulation of plans and programmes aimed at ',roblem solution allocation and resources

If it is not adequate in some respects, what is needed to improve the intersectoral approach? (General answers will be easy here. Please attempt to identify specific ways of improving this approach). 4. 4.1

Monitoring of progress ~ff,.c:t'iv,.ne8"

How is progrp's8 manit ora and evaluated in terms of efficiency, and CO"t-bf'nefit?

4.2

If the monitoring process can be improved, what is required in terms of (a) (b) improving the collection of data making the data more relevant to the problems (new indices, etc.) abolition of the collection of data which is not now relevant better data processing production and communication of information which and usable 1S

• (c) (d) (e)

useful

- 116 -

Annex 8 5. 5.1 5.2 6. 6.1 Response to change How far are the planning, administrative and management systems r~.pon8iv~

•

to ctlallg~?

Can they be improved?

If so, how?

Achieving an integrated system How can the changes suggested in the above 5 sections be put into effect to achieve an integrated urban primary health care system?

- 117 -

Annex 8 HEALTH AND URBAN DEVELOPMENT SOME ENVIRONMENT AND POLLUTION ASPECTS An article in a recent issue of the "World Health Forum" stated: "The reason why there are so many people in hospitals is simply that the environment in which communities live is of such poor quality that it encourages the spread of preventable medical conditions". Another author recently stated that "People often live literally surrounded by has tile rats, fleas, mosqui tos, lice, and pathogenic parasites, in surroundings highly propitious for these agents' existence and proliferation. II

•

Environmental problems of urban areas are, however, of even wider scope than those of a medical and sanitary nature. The spectrum of danger involves air, water, food, liquid and solid wastes, shelter, insects and rodents, work places, noise, transportation, accidents, nuclear energy, and more. Recognition of this is exemplified by the fact that responsibility for solving or alleviating problems associated with the environment now extends well beyond the confines of the Departments of Health. As recently as 20 years ago in the United States, the Federal Public Health Service still handled drinking water safety, water pollution, air pollution, food and shellfish sanitation, occupational health, and radiological health matters for the nation. It was eventually found necessary, though, to create an entirely independent Environmental Protection Agency, with much broader powers of investigation and control, and with vastly greater funds available for its operation. Similarly, the Member States of the United Nations saw fit to go beyond the World Health Orl\anization, UNICEF, and other specialized agencies to form the United Nat ions ..:nvironment Programme. or UNEP, to encompass Bnd coordinate work on

•

the many non-health as well as health-related problems of the environment. In 1980, the Republic of Korea established an Office of the Environment to supersede the former Environmental Pollution Control Bureau of the Ministry of Health and Social Affairs. Singapore created a Ministry of the Environment. Similar steps have been taken over the years by most of the developed and more advanced developing countries of the world. NOW, however, we are experiencing an upsurge of interest in primary health care, or PHC as it is known. One of the keystones of PHC is safe drinking water and adequate sanitation, which brings the health agencies squarely back into the environmental picture. The health department role has been reinforced eVen more by the adoption of the International Drinking Water Supply and Sanitation Decade, which most countries are heavily supporting and for which the World Health Organization is the lead agency with regard to promotion and coordination. How to effectively integrate water and sanitation activities into the primary health carp effort and to coordinate them with the work of other concerned agencies, ministries, and departments at national, provincial and local levels is now the task at hand. This is especially true now that "sanitation" comprises 8

wide range

of en-vironmental clean-up, abatement, and control activitips.

- 118 -

Annex 8 To better understand ho\< to cope with these probl .. m~, it may b" w"ll to review the kinde of environmental hazards W~ are beinl( 8uh.i~cted to, particularly in urban Ilrp8S and even mor .. particulllrly in congested and depre.sed urLan aress. nle hazards appear to fall into two main categories,

•

(1) the traditional problems of lack of adequate and safe watpr supply and of poor sanitation, including inadequate human excreta removal methods and solid waste disposal; and (2) the newer chemical, physical, and biological agents associated with modernization and industrialization, which often aversely affect health by generating or spreading diseases, inducing accident., adulterating or contaminating foods, and affecting mental health. Baaic water and sanitation problems In urban slum areas and squatter communities, much of the communicable disease arises from poor or non-existent levels of personal hygiene and the failure to comprehend or practice elementary sanitation procedures. At fault is often lack of sufficient water and the means of removing wastes from the premises and from the community. Provision of safe water in minimally adequate amounts by means of a piped system at least up to a public standpost is, however, not an insurmountable problem, certainly not from an engineering standpoint, and most developing countries will be making a concerted effort as part of their Decade approach to furnish water to all of their urban dwellers. The sanitation side is the one that is liable to be neglected and deserves our best efforts to effect an improvement. With squatter settlements comprising some 25% of Kuala Lumpur, 29% of Seoul, 35% of Manila, 45% of Bombay, etc., basic sanitation measures really have to receive higher priority in the developing countries. Faecal contamination of drinking water may introduce a variety of intestinal

pathogens - bacterial, viral, and parasitic - their presencE' being related to disfI!asea and carriers present in the community. These organisms may cause diseases which vary in severity from mild gastro-enteritis to severe

and sometimes fatal dysentery, cholera, and typhoid. Viruses of major concern are essentially those which multiply in the intestine and are excreted in the faeces of infected individuals in large numbers. Enteric viruses have considerable ability to survive in the aquatic environment and

may remain viable for days or months. Consequently, viruses are likely to be present in any sewage-polluted water, and explosive outbreaks of viral hepatitis and gastro-enteritis may occur. As with other microbial infections, enteric viruses may also be transmitted by contaminated food and aerosols. Without adequate disposal of sewage and nightsoil, and with poor food handling and preservation practices, it is small wonder that epidemics do erupt from time to time in these slum areas. Another important aspect of sanitation that is often relegated to the background is solid waste disposal. In many slum areas, garbage and trash collection is inefficient and infrequent. Unsalvageable tin cans, broken bottles, vegetable matter, old tires, plastic wastes get thrown into the nearest natural or man-made drainage ditch, canal, or dry stream bed. When heavy rains occur, flooding results because of blocked channels. Even if and when trucks can get in and haul off solid wastes, most ultimate disposal areas are simply open dumps populated by human scavengers, where rats and flies breed by the millions. Few developing countries have had much success 80 far in 80lving their solid waste problems, in spite of numerous studies

conducted.

- 119 -

Annex 8

•

Newer type health hazards As a result of industrialization, modernization of local transport, and the influx of millions from rural area. into already crowded metropolitan .'1reas, a number of newer and more insidious environmental hazards have

to plsgue residents. In many instances, specific identification of pollutants has never been made, let alone concerted efforts to monitor and control pollution. These newer hazards include air pollution from industrial poinL sources and power plants; air pollution and excessive noise from an ever-increasing number of vehicles jamming city streets; toxic component. of liquid industrial wastes entering drainsge canals, .treams, and estuarine and coastal waters; toxic chemical dumps on land; emission, storage, transportation, Bnd processing of wastes from nuclear power

nris~n

stations; and surface run-off resulting from precipitation and carrying pesticides, organic wastes, silt, heavy metals, and microbial pollutants. Air pollution is one of the most serious emerging problems in many developing countries as well as an established one in the developed countries of the Asia and Pacific region. Tokyo, Seoul, Singapore, Bangkok, Calcutta, and Manila are Asian cities with severe problems due to industrial activities and millions of private automobiles, taxis, buses, motorcycles, and trucks. In addition the burning, often incompletely, of fuels such as coal, heavy oil, and wood contributes a significant amount of air pollutants. The effects of air pollution are not only adverse to living organisms but even to inanimate objects in the form of staining and corrosion. Air pollution can also directly cause water pollution, especially at or near coastal areas. The high concentration of lead in rivers and coastal waters i~ mninly caused by emiRsiona from automobile exhausts. "Acid Tain" from powerplsnt stacks contaminates lakes and affects ecologicsl balanc ... Other toxic materials which enter the ambient air from vehicles and from industrial emissions are sulfur oxides, carbon monoxide, nitrogen

oxid ... and nitrates, and photochemical oxidants such as ozone. With more and more vehicles being equipped with diesel engines, and because of lack of mAintenance, engine wear, and poor quality of fuel, clouds of particulate

matter are constantly being spewed out along streets and main business arteries.

A whole host of poisonous materials are being found in both fresh and sea water, including carcinogens. Fortunately, they are usually in only trace amounts. Even chlorine, which is universally used as a reliable and economical disinfectant, may form dangerous compounds such as chloroform when it reacts with some types of organic substances which may be in the water. Great care needs to be taken to avoid contamination of groundwater supplies, which are widely used as drinking sources. Noise pollution in the cOllUJlunity is another complex and important problem, which interferes with communication between people, annoys and disturbs, and may produce hearing damage. Major sources of noise are road and rail traffic, jet aircraft, especially near airports and in flight paths, road and building construction, demolition, and industrial operations.

- 120 -

Annex 8 Many hospital beds are occupied by traffic accident victims. While accidents are usually regarded as matters for the police and insurance companie. to take care of, or for highway engineers to try to prevent hy safer road design, there is more perhaps that can be done through health education, behavioural studies, and mental health approaches. There is no shortage of other health hazards and environmental abuses that might be discussed. However, as far as PHC and Decade efforts are concerned, our primary interest at this time is the provision on safe drinking water and adequate sanitary waste control. Therefore, let us look at some possible ways to satisfy these specific needs. Approaches and solutions to problems By and large the technology for environmental pollution control is available. However, many of the existing methods are costly, and more economical techniques must constantly be sought. The standard, almost doctrinaire, thinking along conventional lines in the design of water distribution networks and sanitary waste collection and disposal must be transformed into a more unconventional approach, except, of course, in more highly developed and affluent situations. sociocultural aspects must be given a far more prominent place in future schemes, and the technical consultant must join forces not only with economists but also with sociologists and behavioural scientists. Feasibility planning should be conducted locally with strong emphasis on community demand for appropriate technology. To increase the number of b.meficiaries a. rapidly as possihle with regard to drinking water 'supply, Rtpp-by-at~p upgrading of 8 wAter rlistribution system may hp desirable, starting with public standposts and laler proceeding into a basic pattern of delivery hy tap in the yard of each household, furnishing about 40 Htres per capita per day. This amount seems to be about the minimum needed for protection against water-borne diseases.

In the field of sanitation, particularly in slum and squatter areas, the picture is more complicated. Local investigation is needed and conclusions drawn as to whether it is possible to arrange some organized sanitation immediately or only after a long-term change in social behaviour. Whichever the case, step-by-step build-up of sanitary schemes tends to lead to final solutions in which standard sewerage systems have no place. Such lower-cost approaches usually involve such things as latrines, septic tanks, and nightsoil bucket hauling or vacuum emptying. In the case of high-rise, densely populated areas, there is usually little choice except to opt for more standard water-carriage sewer systems. With regard to solid waste collection, small, light, and narrow vehicles able to negotiate narrow alleyways and manoeuvre around crowded market stalls might be used to transfer wastes to more accessible collection points. Sanitary land fills should replace open dumps with their air-polluting fires.

- 121/122 -

Annex 8

•

Apart from technological control, planning of cities, neighbourhoods, homes, recrelltional and work places holds p,reat potentilll to deal most satisfactorily with a cf!rtain degree of environmental pollution. conaideration8 should include: Some basic

environmental impact analysis for projects inVOlving industrial, street or road, and building construction zoning regulations governing airports, highways, power plants, industrial and commercial establishments; analysis of meteorological and topographical factors in site planning; transportation planning, including mass transit systems. staggered work hours, and vehicle emission control. Specifically, with regard to health sector and Decade efforts, it has been recommended by Gilbert and Anne White, authors of "Drawers of Water". that emphasis be placed on: "Understanding that water supply and sanitation measures in many areas can only be effective when developed in conjunction with other community improvements, and public health measures will have to be cultivated. The level of service accepted by a community must be related to other choices of community improvements. and to the community's understanding of health needs and goals, Many water supply, sanitation, health education and development experts need conviction that thiR is practicllble".

T trust we hen- are eonvinef'u LI"'l it is.

- 123 ANNEX 9

• Monday, 30 November 8:00 8:30 - 10:00

SEMINAR AGENDA

Registration Opening Welcome Speech by the Regional Director Election of Chairman and Rapporteur

10:00 - 10:30 10:30 - 12:00

Coffee break Remarks and Explanation of Procedures Plenary session - Presentation of city reports by the participants

12:00 1:30 3:00 3:15 -

1:30 3:00 3:15 4:00

Lunch Plennary ses8ion (continued) Coffee break Summing up of city reports Introduction to field visit

TUesdsy, 1 December 8:00 12:00 1:30 ~·i.dd

vi.it

l:JO 4:00

Lunch break Field visit (continued)

•

Wednesday, 2 December 8:00 9:00 Presentation: Health and Urban Development - Some Environment and Pollution Aspects (paper) Hong Kong case study Coffee break Manila case

9:00 - 10:00 10:00 - 10:30 10: 30 - 11; 30 11: 30 - 12;00 •

study Introduction to

SUlllllary of case studies. group work

- 124 Annex 9 Wednesday, 2 December (continued) 12:00 1:30 3:00 3:15 1:30 3:00 3:15 4:00 Lunch break Group work Coffee break Group work (continued)

-

Thursday, 3 December 8:00 9:00 10:00 10:30 9:00 Plenary - Report by the Group Rapporteurs Group work Coffee break Group work (continued) Lunch break Plenary session Group work Coffee break Croup W('I

- 10:00 10:30 12:00 1:30 2:15 3:00 3:15 4:00

-

12:00 1:30 2: 15

-

3:00 :I: 1 ~

rk

(cont inupd)

Friday, 4 8:00 9:00

Dec~mb~r

9:00

Plenary - Presentation of Group work Group work Coffee break Group work (continued) Lunch break Plenary - Presentation of group work Presentation of seminar draft report Open forum on impression/suggestions, etc. Evaluation of seminar

-

10:00 10:30 12:00 1:30 3:00

10:00 10:30 12:00 1:30 -

3:00 -

4:00

Closing Closing Speech by the Regional Director

- 125 ANNEX 10 I.IST OF WORKING DOCUMENTS

• IIH/PHC/Annex UR/PIlC/Annex UR/pa;/Annex UR/PIlC/Annex UR/PHC/Annex UR/PHC/Annex UR/PHC/Annex UR/PHC/Annex UR/PHC/Annex UR/PllC/ Annex UR/PHC/Annex UR/PHC/Annex I

2.1 2.2

3 4 5.1 5.2 6 7 8.1 8.2 8.3

UR/PHC/Annex 9 UR/Plle/Annex 10 UR/PHC/ Annex 11

Sydney, Australia Shanghai, People's Republic of China Shanghai, Peop!~'sRepublic of China Hong Kong Kanagawa Prefecture, Japan Kuala Lumpur, Malaysia Kuala Lumpur, Malaysia Auckland, New Zealand Port Moresby, Papua New Guinea Metro Manila ) Philippines City of Manila) Statistical Supplement to the City of Manila Seoul, Republic of Korea Singapore Hanoi, Socialist Republic of Viet Nam

•

Case studies UR/PHC/Annex 12 UR/PHC/ Annex 13 Working papers UR/PHC/4 UK/PflC/5 IIR/I'IIC/! (WPR/PIIC/81. 2)

Hong Kong Manila

Problem identification Evolution of health care delivery systemA and interse~tor81 relationships

Health and urban d"velopment - some environment and pollution aspectR

Reprints of previous publications

(a) • (b)

The Planning of Metropolitan Manila, Nathaniel Von Rinsedel, Comntission£':r for Planning, Metropolitan Manila Commission

Po ulation in Urban and Rural Life, Populi, Vol. 7, No.3, 1980 Ilalf the World Cities, J.B.D.'Souza: The Big Smoke, Ian Steele: ibid, 9-12

(cl (d) (e) (f) .'

ibid, 23-35. ibid, 35-49

People on the Move, Aprodicio A. Laquian: Cities in Crisis, Valerio Giacomini:

UNESCO Courier, April 1981, 23.

(g)

The Econology of Megalopolis, Stephen Boyden and John Celecia: ibid, 24-27

•

- 126 -

Annex 10

, the Lae Project, Papua New Guinea, ibid, 27

(h) (i)

Change without tears:

•

Rome Declaration on population and the Urban Factor, issued by the Tntf'rnational Conf"rencp on Population and the Urban Future, held in Rome, Italy, 1-1. Septembpr 1980. Group discussion was facilitated by a further document: UR/PHC/6 Guidelines for Croup discussion

,

•