Priority research for health for all

2'~to~tt, ~e4eet~e, (M

, .~ae~ ate

Priority research for health for all Copenhagen: WHO. Regional Office for Europe. 1988 European health for all series ; No.3 ISBN 92-890-1054-1

Health For All - Research - Europe

The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health . Through this Organization, which was created in 1948, the health professions of some 160 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.

The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region has 32 active Member States.a and is unique in that a large proportion of them are industrialized countries with highly advanced medical services. The European programme therefore differs from those of other regions in concentrating on the problems associated with industrial society. In its strategy for attaining the goal of"health for all by the year2000" the Regional Office is arranging its activities in three main areas: promotion of lifestyles conducive to health; reduction of preventable conditions; and provision of care that is adequate. accessible and acceptable to all.

The Region is also characterized by the large number of languages spoken by its peoples, and the resulting difficulties in disseminating information to all who may need it. The Regional Office publishes in four languages- English, French, German and Russian - and applications for rights of translation into other languages are most welcome.

a Albania, Austria, Belgium, Bulgaria, Czechoslov;1kia, Denmark, Finland, France, German Democratic Republic, Federal Republic of Germany, Gree,e, Hungary, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Ponupl. Romania. San Marino. Spain. Sweden. S-..ll­ zerland, Turkey, USSR, United Kingdom and Yugoslavia .

Priority research for

health for all

World Health Organization 18-~ Regional Office for Europe ~ · · 1

Copenhagen ~

Priority research for

health for all

European Health for All Series, No. 3

ICl'/ RPD 11 0 Tot editing by: M.S. 13 urghcr

ISBN 92 890 1054 I

© Wo rld Hea lth Orga ni za tio n 1988

Pu bli ca ti o ns o f th e Wo rld Hea lth O rga ni za ti o n enjoy copyri ght protec tio n in acco rdance with the prov isions of Protoco l 2 o f the Uni ve rsa l Copyri ght Co nve ntio n . Fo r right s o f reproducti o n or transla ti o n, in pa rt o r in ro to, of publi ca tio ns iss ued by the WHO Regio na l Offi ce fo r Eu ro pe a p pli ca tio n sho uld be made to th e Regio nal O ffice for Euro pe. Scherfigsvej 8, DK-2100 Copenhage n 0, Denma rk . The Regio na l Office we lco mes such a pplica tions.

Th e designa tio ns employed a nd the prese nt a ti o n o f the ma teri a l in thi s publicatio n do no t impl y the ex press io n o f a ny o pini o n wha tsoever o n the pa rt o f th e Secreta ri a t o f the Wo rld Hea lth Organi zatio n co nce rning t he lega l sta tus o f a ny co untry, territ o ry, city o r a rea o r o f it s a uth o riti es, o r co nce rning the delimita ti o n o f it s fro ntiers or bounda ri es.

T he mentio n o f spec i fi e co mpa nies o r of ce rt a in ma nu fac turers' p rodu cts does no t imply tha t they a re endorsed o r n::co mmended by the World Hea lth Organi za ti o n in preference to o thers o f a simila r na ture tha t a re not me nti o ned . Erro rs a nd o miss io ns excepted , the na mes o f p ro prieta ry products are di stingui shed by initia l ca pita l let ters.

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CONTENTS

Page

Preface IX

Introduction ....................................... .

Health for all through research

What health for all means

The 38 regional targets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

T he answer: research strategies . . . . . . . . . . . . . . . . . . . . . . . 5

Target 32. Research and health for all . . . . . . . . . . . . . . . . . 5

What research is needed? . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Research strategies for Member States 8

I. The regional analysis: a framework

2.

for setting priorities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Choosing priority areas for research

Common themes

Priority research

Support for health development

11

12

19

27

Ti me frame . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Close links to other targets . . . . . . . . . . . . . . . . . . . . . . . . . . 28

V

- I

How and who to act on research recommendations . . . . . . . 28

Target 33. Policies for health for a ll . . . . . . . . . . . . . . . . . . . 29

Target 34. Planning and resource a llocation . . . . . . . . . . . . 32

Target 35. Health information systems 38

Target 36. Planning, education and use of hea lth personnel . . . . . . . . . . . . . . . . . . . . . . . 43

Target 37. Education of personnel in other sectors . . . . . . . 46

Target 38. Health technology assessment 47

3. Appropriate care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

The challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Changing the structure of health care

The task for health services research

General recommendations for research

Target 26. A health care system based on

59

60

61

primary health care . . . . . . . . . . . . . . . . . . . . . . . 66

Target 27. Rational and preferential distribution of resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Target 28. Content of primary health care . . . . . . . . . . . . . . 74

Targe t 29. Providers of primary health care . . . . . . . . . . . . . 79

Target 30. Coordinating community resources for primary health care . . . . . . . . . . . . . . . . . . . . . . . 82

Target 3 1. Ensuring the quality of services 84

4. A healthy environment . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Knowledge: the key to action . . . . . . . . . . . . . . . . . . . . . . . . 90

The chain of causes and effects . . . . . . . . . . . . . . . . . . . . . . . 90

VI

Two ways to define environmental health hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Using the results of research . . . . . . . . . . . . . . . . . . . . . . . . . 92

Managing environmental risks to health 93

Target 18. Policies for a healthy environment . . . . . . . . . . . 94

Target 19. Monitoring, assessment and control of risks in the environment . . . . . . . . . . . . . . . . . 95

Target 20. Control of water pollution

Target 21. Protection against air pollution

100

102

Target 22. Food safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Target 23. Protection from hazardous wastes . . . . . . . . . . . I 05

Target 24. Healthy homes . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Target 25. Healthy working conditions . . . . . . . . . . . . . . . . 108

5. Healthy lifestyles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Three caveats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

The linchpin: interdisciplinary research . . . . . . . . . . . . . . . . 113

Themes in lifestyles research . . . . . . . . . . . . . . . . . . . . . . . . . 114

Target 13. Healthy public policy

Target 14. Social support systems

Target 15. Knowledge and motivation for

119

122

healthy behaviour . . . . . . . . . . . . . . . . . . . . . . . . 126

Target 16. Promoting positive health behaviour . . . . . . . . . 129

Target 17. Decreasing health-damaging behaviour . . . . . . . 130

Vil

6. Health for all in Europe by the year 2000 . . . . . . . . . . . . 137

Five requirements for research . . . . . . . . . . . . . . . . . . . . . . . 137

vm

Target I. Equity in health 140

Target 2. Adding life to years . . . . . . . . . . . . . . . . . . . . . . . 144

Target 3. Better opportunities for the disabled . . . . . . . . . . 146

Target 4. Reducing disease and disability . . . . . . . . . . . . . . 148

Target 5. Eliminating seven specific diseases . . . . . . . . . . . 152

Target 6. Life expectancy at birth

Target 7. Reducing infant mortality rates

Target 8. Reducing rates of maternal mortality

Target 9. Combating diseases of the

152

153

153

circulatory system . . . . . . . . . . . . . . . . . . . . . . . . 155

Target 10. Combating cancer . . . . . . . . . . . . . . . . . . . . . . . . 157

Target 11. Reducing accidents . . . . . . . . . . . . . . . . . . . . . . . 160

Target 12. Stopping the increase in suicides . . . . . . . . . . . . . 162

Preface

This book is the third in the new European Health for All Series. The firs ta set out the European policy on health for all. The secondb dealt with research policy; this companion publication moves from policy to practice, pointing out the topics and methods of research needed to help achieve health for all in the European Region.

History shows an impressive record of contributions by research to the improvement of health. The knowledge supplied by the research community has been one of the most valuable tools in the struggle against disease, disability and death. Researchers feel justifiable pride in their past and present work. With its remarkable track record, vast resources and sense of responsibility to society, the European research community will want to grasp the exciting new opportunity detailed in this book: the chance to contribute to health for all and thereby to expand and develop the field of research.

The Member States of the WHO European Region have pledged to reach the goal of health for all by achieving the 38 regional targets. Action, however, requires knowledge, both existing information and that yet to be discovered. Research can generate the knowledge

a Targets for health for all. Copenhagen , WHO Regional Office for Europe, 1985 (European Health for All Series, No. I) .

b Research policies for health for all. Copenhagen, WHO Regional Office for Europe, 1988 (European Health for All Series, No. 2) .

IX

required; the role of the research community in the health for all movement is thus a vital one. The targets call for specific improve­ ments in health. What, specifically, are the implications of the targets for research?

The European Advisory Committee on Health Research carefully analysed each of the targets. This book is the result of the regional analysis: a framework that countries can use to set their own pri­ orities for research for health for all. The publication sets out five overriding themes of priority research in the Region. It discusses in practical terms the topics and methods of research needed to achieve each target, and the resulting opportunities for the research com­ munity.

Within these pages is an array of fascinating topics for research that is highly likely to contribute to the attainment of health for all. By choosing the topics that meet their needs, countries and scientists can discover vital new knowledge and determine how to use existing knowledge more effectively. The priority research described here builds on the scientific successes of the past and the endeavours of the present; it offers the European scientific community the chance to work in new areas and with new colleagues, using research to build health for all.

X

J.E. Asvall WHO Regional Director for Europe

Introduction

Knowledge is essential to transform a policy into a reality and research is the most powerful tool for generating this knowledge. Research - most often basic biomedical work on topics chosen by the investigators themselves - has supplied the knowledge behind the greatest victories in the fight against disease, disability and death. Such research is still undeniably valuable.

Nevertheless, the WHO Regional Office for Europe and the Member States of the Region are asking for a fundamental change in research. They ask that this tool be used more effectively than ever before, to reach a specific goal: health for all. They ask that policy-makers and the research community of each country work together to provide the knowledge needed to reach this goal, by building and using research strategies suited to their special needs.

Policy-makers and the research community in each Member State of the Region should cooperate to determine what research is most important, according to their own priorities, perform the studies and use the results to improve health. By taking up this challenge both groups will not just work more effectively; they will also make a better future for themselves and for society by helping to achieve health for all.

Health for all - global, regional and in countries - is the most ambitious health policy ever set. The Member States of WHO have chosen a far-reaching goal: health for all people by the year 2000.

1

Health for all through research

What health for all means

The 38 regional targets

At the heart of the health for all movement is a new look at health with a broader perspective. Health remains the goal of health policies and health care systems, but it has a wider definition. The Member States have pledged to attain for their people more than a reduction in disease and disability. They are working for a positive kind of health: a state of complete physical, mental and social wellbeing. Reaching such a goal requires a wider view of the factors that affect health, encompassing something more than the physical problems of individual people. This view must examine the ways in which factors in society and in the environment affect people's health. A policy for health for all thus requires positive health to be built in new ways and new settings, by new combinations of people, in addition to the methods and means used successfully in the past.

The European Member States have taken the first steps to­ wards their revolutionary goal. Through their representatives in the Regional Committee for Europe, the parliament of the Regional Office, they adopted 38 regional targets as concrete goals to work towards, and 65 regional indicators by which to measure their progress.a Briefly put, the targets describe how present conditions must be changed to reach health for all.

The regional targets are not legal bonds on any Member State. They form a flexible framework that the political authorities, professional groups and general public of each nation can use to build their own targets, policies and programmes for health for all.

The targets have been carefully designed, and they fit as closely together as the blocks of stone that compose a pyramid. Each rests on the support of others and dovetails neatly with its neighbours. The apex of the pyramid is equity (target I), to be attained by re­ ducing present inequalities in health between and within countries.

The targets can be divided into three closely related groups, according to their purposes and their dates of completion. Fig. 1 illustrates this relationship.

a Targets for health for all. Copenhagen , WHO Regional Office for Europe, 1985 (European Health for All Series, No. I).

2

Fig . 1. How the regional targets fit together

requirements for health

(targets 1 -12)

Necessary changes

Healthy lifestyles

(targets 13-17)

Healthy environment

(targets 18-25)

Appropriate care

(targets 26-31)

Support for health development (targets 32-38)

Targets 1-12 (to be achieved by the year 2000) are the funda­ mental requirements for health. These include equity, a longer and better life for all, and reductions in deaths from certain causes. Thei r achievement will mean that health for all is a reality.

3

Targets 13-31 (to be reached by 1995 or 1990) detail th e three kinds of change needed to reach the first group of targets:

• making healthy lifestyles eas ier for people to choose;

• eliminating risks to health in the environment a nd improv ing people's homes and workplaces; and

• redirecting the focus of health care away fr<;>m the hospital and towards primary health care in the community.

Targets 32-38 form the third group and must be achieved before 1990. Each specifies o ne kind of support needed to reach the other ta rgets. Research , in target 32, takes pride of place. The o ther targets concern country policies for health for all, the management of health development, hea lth information systems, training for manpower in health and ot her sectors, anc;i technology assessment. These targets form the foundation for the others. Their achieve­ ment is the vital first step in the achievement of health for al l.

Common themes unite the targets . These themes include equity, the methods to be used to build health for all (the preventio n of disease, the promotion of positive health , and primary health ca re) and how people can contribute to the work (through community participation , and intersectoral and international cooperation).

Included with the targets are prerequisites for health. They can be described as the ground on which the pyramid of targets must be built. Without peace, social justice, enough food and safe wa ter, adequate education, decent housing, and a useful role in society and an adequate income for every person, the goa l cannot be reached.

Clearly the Member States have set themselves a huge task . Its completion requires change and commitment from people in all sectors of society in every Member State. People must discover how their work affects health and work actively with others for health for all. Five groups of people have rights to and responsib il ities in health for all; health authorities at all levels (including policy­ makers and administrators), health professionals of all kinds (in­ cluding the research community), the people, sectors other than health, and international organizations.

4

This book sets out topics for research for hea lth for all that should appeal to members of the second group . A related publi­ cationa discusses the responsibilities of and opportunities that both the research community and policy-makers can find in working together for health for all.

The targets are to be achieved within a very short time (2-12 years). Action for health for all, based on knowledge, is plainly needed. Part of this knowledge already exists, and health for a ll would not be so fa r away if it were used. New knowledge is also needed. How to acquire and apply knowlege for health for all is a question that demands a response.

The Regional Committee's answer is target 32.

Before 1990, all Member States should have formulated research strategies to stimulate investigations which improve the appli­ cation and expansion of knowledge needed to support their health for all developments.

This target can be achieved if Member States establish machinery to ensure the effective application of new knowledge in the development of health policies and programmes; determine what gaps there are in the knowledge needed to support the strategy of health for all and set research priorities accordingly; ensure a balanced representation of all academic disciplines relevant to health and of providers and users of health services as well as health policy-makers, in the planning and coordinating of research for health for all and make the research community an active contributor to the development of health for all; stimulate relevant multidisciplinary research; and allocate sufficient resources to conduct the research needed, giving prefer­ ence to aspects that have not received the support they deserve.

a Research policies for health for all. Copenhagen, WHO Regional Office for Europe, 1988 (European Health for All Series, No. 2).

5

The answer: research strategies

Target 32. Research and health for all

In other wo rds , the Member States of the Region have agreed that research strategies, resulting in guided research directed at specific goals, will ensure that the knowledge needed to attain health for all is provided and used well.

The targets cover fields of activity that are fundamental to public health but new subjects for country policies and health research. The structure of the targets suggests six broad tasks:

• describing every aspect of the health of the population so that progress towards the targets can be monitored (target 32);

• finding out what biological factors determine health (tar­ gets 1-12);

• assessing the part that lifestyles play in maintaining or en­ dangering health (targets I 3-17);

• studying the ways in which the physical, biological and social environment (including the basic prerequisites for health) deter­ mine the health of individuals and populations (targets I 3-25);

• developing effective and efficient methods of providing people with appropriate care (targets 26-31); and

• improving policy-making, planning and management in pro­ grammes for health for all (targets 32-38).

To provide the necessary knowledge, health research must venture for the first time into fields that lie outside its traditional domain , the health and related sciences. To succeed, heal th re­ sea rchers must seek cooperation with people in all the disciplines that can contribute the expert knowledge necessary. This will mainly involve the biomedical, behavioural and social sciences, although questions will also arise that will require answers fro m, for example, engineers, architects and other specialists.

Researchers working for health for all will take their expertise into new, unfamiliar areas and work with new colleagues in new

6

ways . The research community has the chance not only to con­ tinue basic research for health but also, through goal-directed research, to take part directly in making and carrying out health and research policies. The research community can thus help to decide the future of its own profession by contributing to health for all.

When adopting thehrgets in 1984, the Regional Committee asked the European Advisory Committee on Health Research (EACHR) to help create a regional strategy for research for health for all. The EACHR (16 experts on different kinds of research, health admin­ istration, and research policies and administration) had two tasks: to advise the Regional Office for Europe on its regional policy on research for health for all, and to analyse each of the regional targets, to discover what kinds of research were most needed. In both tasks, the EACHR worked to meet three needs.

The first was flexibility . Strategies for health for all must be carried out in all 32 Member States of the European Region, an area bo unded by Norway in the north, Israel and Turkey in the south-east, the USSR in the east, Iceland in the north-west and Portuga l in the south-west. All these countries have widely dif­ ferent patterns of mortality and morbidity, health care systems and research capacities. All must determine their own priorities and the regional research strategy must provide them with a framework and a guide for their own strategies.

The time frame for completing priority research had to be equally flexible. The completion dates set for the regional targets - some as early as 1990 - are far too restrictive to be applied to research. The regional strategy must point out areas of research that wi ll contribute to achieving the targets, even if applicable resu lts cannot be produced within such narrow time limits. A flexible time frame is particularly necessary to the opening of new areas of investigation .

Second, the regional strategy, and the analysis of the targets in particu lar, had to make specific recommendations for priority

7

What research is needed?

Research strategies for Member States

research to attain the targets. The EACHR therefore analysed the targets one by one, along with the Regional Committee's dis­ cussion of and suggestions for attaining them.

The third requirement was participation. Individual scientists, the scientific community, and national and international research bodies were all needed to take part in developing the regional strategy from the outset. They were to point out gaps in knowledge and the resulting needs for research. They were also to suggest, discuss and agree on both the research projects required and the timing of their implementation.

The work of the EACHR :-vas considered by the Regional Com­ mittee, the Regional Health Development Advisory Council, the Consultative Group on Programme Development ( 15 senior health administrators who advise the WHO Regional Director for Europe on the regional programme), ministries of health, ministries re­ sponsible for science and technology, medical research councils, and by members of the research community, before it gained final approval from the Regional Committee at its thirty-seventh session in 1987. This book is one of the results.

Target 32 requests Member States to make research strategies to support their progress towards health for all. Like the regional targets, the regional research strategy outlined here is an oppor­ tunity, not a prescription that all countries must follow to the letter. It should inspire European countries to develop research strategies that meet thei r priorities and needs by offering a frame­ work on which they can construct their own research policies and projects. It is also designed to help countries to attain regional and country targets by translating them into concrete research recommendations, by enlisting the support of the research com­ munity for health for all, by guiding the allocation of research resources in Member States, and by stimulating all sectors to include health for all in their research policies . Finally , the re­ gional strategy will guide the research activities of the Regional Office.

8

The regional strategy for research for health for all has three parts :

• an analysis of the most important research needs arising from the targets;

• a resea rch policy that sets criteria for choosing research topics of high priority, and spells out the material and human re­ sou rces needed and ways to ensure that they are provided; and

• a plan to promote and carry out the strategy.

Country strategies could have the same components. This book contains the first part of the regional strategy. Here

the regional targets are analysed, singly and in groups, for their research implications. Although specific research needs will vary from co untry to country, the targets themselves hint strongly at the kinds of research most useful in their achievement. Resea rch policies and a plan for promoting them are discussed in the related publica tion, Research policies for health for all.

The roles of the scientific community and health authorities, policy-makers and administrators cannot be separated for dis­ cussion as easily as the parts of a resea rch strategy. While the scientific community is likely to be most interested in this book and health authorities and the people who make health policy will be most concerned with the companion publication, their roles are closely intertwined. As proof of the close relationship between both the subjects of and the audiences for the two books, the publications have an introduction and first chapter in common.

Just as community participation is a cornerstone of health for all, so cooperation between and within both groups is essential to the success of strategies for research for health for all. An effective strategy demands that policy-makers and researchers help each other to fulfil their complementary roles. Policy-makers should point out important topics for research. Researchers should not only study these, but advise policy-makers on their choices and help

9

to make both research policy and plans for using the knowledge gained. Policy-makers should then use these findings to plan and run health care systems and services. Finally, researchers should evaluate the success of the whole strategy.

By working together within the regional and country research strategies, policy-makers and the research community can produce not only vital knowledge for health for all but also the kind of intersectoral collaboration that will help to make it a reality .

10

1

The regional analysis: a framework for setting priorities

This regional analysis of the targets for health for all identifies.the areas o f research needed to attain them. Just as health for all calls upon the scientific community to take part in research policy, so policy-makers can profit from the discussion of priority areas of resea rc h. While the regional analysis displays an inventory of tempti ng opportunities to the scientific community, it also carries implica tions for research policy by suggesting priorities among the differen t topics. These priorities will be particularly interesting to the people in charge of policy on health research at country level. The regional analysis is a starting point from which researchers and makers of country policies on resea rch for health for all can take their fi rst step: choosing their own priorities.

In analysing each of the 38 regional targets, the European Advisory Committee on Health Research worked to sti mulate research of priority in the struggle to achieve regional and country targets, not all possible research related to health. The members of the Com­ mittee tried to choose research topics that are:

• highly likely to contribute to the attainment of the regional targets (preferably but not exclusively within the time frame suggested by the Regional Committee);

11

Choosing priority areas for research

Common themes

• closely linked to the Regional Committee's suggested solutions for attainment,a although other options will be pursued;

• likely to yield results that can be translated into health policy and action; and

• unfortunately, likely to be neglected otherwise, despite their importance.

The Member States themselves pinpointed gaps in knowledge and problems in achieving the targets in the first of their triennial evaluations of their progress towards health for all.b

The regional targets share common themes, vital elements of their success: equity, disease prevention, health promotion, primary health care, community participation, and intersectoral and inter­ national cooperation. Similar themes run through research for health for all. They include three areas of research:

health policy and organizational behaviour

inequities

community participation and intersectoral collaboration

and two essential tools:

better information systems and indicators for the targets

international comparative studies.

a Solutions for attaining the targets are thoroughly discussed in Targets for health for all (Copenhagen, WHO Regional Office for Europe, 1985 (European Health for All Series, No. I)).

b Evaluation of the strategy for health for all by the year 2000. Seventh report on the world health situation. Vol. 5: European Region. Copenhagen, WHO Regional Office for Europe, 1986.

12

Naturally, many concrete research questions can touch several themes . The importance of the themes will, of course, vary from country to country.

Research on health policy and organizational behaviour is an overriding priority for four main reasons.

First, although enough information is already available to take firm act ion on many targets, nothing is being done. Research on implementation is therefore needed. Most of the problems of, obstacles to and constraints on implementation can be understood by applying .the concepts and methods of such disciplines as pol­ itical science, sociology, soc ial policy and management science. In addition, policy formulation should be systematically scrutinized as a social process. This is a difficult area of study. In implement­ ation analysis in particular, the researcher must deal with vested interests and the inevitable problems arising from the definitions used. Researchers must also have the courage not only to recognize that no further information is needed but to tell policy-makers that the time has come for action.

Second, current health care systems do not function as well as they should. In many important areas, current services are based on conventional wisdom rather than hard scientific evidence. Health systems research and evaluative research can help to show the best way to deliver services. Technology assessment will allow people to choose technology of proven safety, efficiency, effective­ ness an d acceptability. Finally , quality assurance will see that high standa rds of care are met.

Th ird, the regional targets detail changes in the organization of health care systems, and emphasize community participation in and consumer satisfaction with health services as keys to health for all. The targets call for several far-reaching structural changes. These include: a shift of emphasis from the hospital to primary health care as the focus of health care, more teamwork among health personnel , more systematic mechanisms for quality assurance and technology assessment, the promotion of more effective com­ muni ty participation, the encouragement of mutual-aid groups,

13

Research on health policy and organizational behaviour

Research on inequities

and the introduction of systematic planning for research. Such changes must be founded on knowledge of the conditions, con­ straints and consequences of organizational development.

Fourth, the direction of health research needs to be scrutinized. Researchers are usually more interested in providing better means to reach the goals of social and health policies than in questioning these goals. Now may be the time to make a critical analysis of the goals of research, particularly research on health systems. Such work often focuses more on the quality , accessibility and cost­ efficiency of services and systems than on their effects on health, acceptability, and ethical and political desirability.

Priority research on health policy and organizational behaviour should address:

• the relationship between overall social policy goals, health policy and people's health;

• influences on the design and implementation of health policy;

• the means of carrying out health policy and the priority ranking of health policy goals;

• the role of other sectors in health care;

• the relationship between official and unofficial (professional and lay) care systems and between public and private care sectors;

• the organizational and administrative structures of central, regional and local health care;

• the cost-benefit ratio, cost-efficiency and cost-effectiveness of new and established health services; and

• the quality of care.

Target I deals with equity in health. This is no accident; raising the overall level of health and increasing equity are the two basic goals of health care. People may suffer from inequities because of their social status or class, sex, ethnic group or geographic location. Despite the

14

position of equity as the pinnacle of the targets , establishing a reliable pictu re of equity within and between countries will be very difficult until they improve their information base on this critical issue.

Research on equity should include:

• defining concepts and creating indicators to measure inequities in health;

• gaining a better understanding of the factors and mechanisms that create and maintain inequities; and

• studying policies and evaluating programmes to reduce health inequities.

Community participation and intersectoral collaboration, themes of the regional targets, are two of the cornerstones of all work for health for all. Relatively little is known, however, about how they have been organized. Less is known about their effects on the cost, effectiveness, quality and acceptability of health policies and ser­ vices. Even the idea of community participation is poorly defined. Studies on such questions are urgently needed. Determining the role of community participation in primary health care is particu­ larly important.

Better information is so urgently needed that one of the targets is devoted to it. Today's information systems do not provide the kinds of information necessary to achieve the targets or to measure progress towards achieving them. Weaknesses can be found in: the definition of concepts of and boundaries between sectors of health care, and the availability, reliability and interpretation of data. It is also difficult to disaggregate data in a way that makes them relevant to various population , administrative and geographical groups. Finally, the length, techniques and coverage of reporting vary among countries.

Current data also say very little about such problems in health care as the quality of life, overtreatment, iatrogenic disease, the feelings of alienation in patients and their families, the unwanted extension of life, or the emotional and financial costs of illness to

15

Research on community participation and intersectoral collaboration

Need/or better information

the family. Further, present information systems are not well suited to assessing equity.

This problem calls for two remedies: the development of better information systems, and, within these, the development of better indicators for evaluating progress.

Research is needed to standardize procedures for data collection and to assess the cost-effectiveness of collecting new data. A balance must also be struck between the legitimate needs of policy-makers and researchers for information and the protection of patients' rights to privacy and confidentiality.

Health information systems. Most health information systems have been designed to collect administrative data. They are often simple "head counts" showing, for example, how much money has been spent or how many surgical operations have been performed.

The usefulness of the information collected can be increased in two ways. First, the value of a single item of data can be enhanced by making it more detailed and precise or by adding modifiers to derive secondary data. For example, the severity of conditions could be recorded along with diagnoses or a price tag or estimate could be attached to the record of each service used. Cost-analysis or time-and-motion studies may be needed to obtain such modi­ fiers. Second, several items of data can be combined in various ways to provide more meaningful information.

Looking at the relationships between data will produce useful information for health planning, evaluation and health service research . More must be known than the total number of services produced; research must reveal the impact of care on people's health - not just the number of patients discharged but their satisfaction with their care. Other neglected areas are the safety and acceptability of procedures to patients and the cost-effectiveness of services. Information systems should also allow researchers to identify and analyse differences in health care practices.

Indicators. Developing a standard system of collecting infor­ mation is one of the most pressing needs in research for health for

16

all. This system should be applied to all the kinds of data that are relevant to achieving the targets but either unavailable at present or interpreted differently from country to country. Research must focus on the types of data that should be collected; how to define, store, retrieve and evaluate them; and what kinds of feedback mechanism must be established to monitor specific programmes.

New indicators of health need to be developed or existing ones must be improved in several areas.a Equity is perhaps the most impo rtant, but problems that cross national boundaries also de­ serve special attention. Most indicators on these issues are quali­ tati ve; quantitative indicators should complement them whenever possib le. The possibilities for disaggregating data in a meaningful way should be increased. The variables used in the disaggregation should have clear, standard definitions.

New or better indicators are also needed to assess:

• the consumer's view of health care needs;

• early changes in biological systems caused by long-term, low­ dose exposure to environmental agents;

• the effectiveness of health care services (results, quality of care, client satisfaction);

• the costs and efficiency of services;

• commun ity participation in health care;

• health behaviour and positive health; and

• the eva luation of health systems development (through the use of "tracers").

The targets call for many profound changes. Such reforms can be risky and costly ventures. The political risks may be great because

a A revision of the regional indicators has been endorsed by the Regi onal Committee for Europe: Revised list of indicators and procedure for monitoring progress towards health for all in the European Region (198 7- 1988) (Copen­ hagen, WHO Regional Office for Europe, 1987 (unpublished docum ent EUR/RC37/8 Rev. I)).

17

International comparative studies

the outcome cannot always be guaranteed. Policy-makers may want to know about the experience of other countries, particularly if the countries are engaged in similar activities. Such information is often difficult to obtain. It may not be be collected systematically; many variables of interest to other countries may be overlooked. Finally, the information may be unavailable simply because of language barriers or because it is scattered throughout the system.

International comparative studies can help to solve these problems . They can give better insights into many aspects of progress towards health for all than studies conducted within a single country. They are particularly useful in working for ap­ propriate care. Traditions in care and the organization of health services can often be better evaluated when contrasted with those of other countries, where their development has taken a different direction.

Much can be learned from an analysis of the strengths and weaknesses of different countries' approaches to organizing health care. Studies based on rigorous sc ientific research designs, how­ ever, not only are very expensive but also yield results that may be difficult to use. Fortunately, relatively simple and inexpensive descriptive studies may be wholly sufficient for decision-making.

Regular international health surveys might be another solution to the problems of method and expense. The surveys could be carried out in connection with or as a complement to the triennial regional evaluations of progress towards health for all, to avoid duplication of work. To minimize costs and lighten the burden on countries of collecting data, health surveys could cover a sample of Member States and their populations. Although each survey should include certain basic measurements, to enable trends to be as­ sessed, it should also have its own specific focus. Each country should use similar definitions and standardized measurements, to produce comparable results.

International collaborative studies are needed:

• to collate, compare and disseminate the information available in different countries on the strengths and weaknesses of

18

various approaches to providing health services and on many other variables related to the regional targets;

• to carry out truly comparative research according to a common protocol, to study most of the areas related to achieving the regiona l targets, particularly the area of health policy; and

• to provide models for developing health services.

At the beginning of this book, the 38 regional targets were com­ pared to a pyramid (Fig. 1) because the attainment of each will result from or lead to the attainment of others. Further, the structure they form will lead to a peak of achievement: equity in health. Like architects explaining a design, people explaining the targets begin at the top. They start by discussing the great goal and the other targets that form the 12 fundamental requirements for health for a ll in Europe. Then they talk about how to get there: through the three groups of necessary changes (healthy lifestyles, a healthy environment and appropriate care). They finish by exam­ ining the foundation of the structure, the seven kinds of support needed to make the necessary changes.

This is the right way to describe a plan or a completed project. The European Member States, however, are moving from the first to the second position. They have begun the work to achieve the targets, but it is far from over. To build this monument, the countries of Europe are working from the ground up.

For this reason, the regional analysis of the targets begins with the foundation for health for all, the last group of targets, which are to be attained first. This group starts, appropriately enough, with research. The discussion then moves through appropriate care, a healthy environment and healthy lifestyles and ends with the fun­ damental requirements for health. A chapter is devoted to each group of targets. In each chapter, the targets are analysed first collectively and then one by one, in numerical order.

This order has some interesting features. For example, research grows in importance as the reader moves from group to group. In addition, the reader parallels the journey that researchers and

19

Priority research

Support for health development

(targets 32-38)

policy-makers will take as they expand their familiar responsibilities to include the new opportunities in health for all.

Some of the landmarks on this journey are familiar. For ex­ ample, the bulk of health research is already proceeding, most often successfully , towards many of the sa me goals as the firs t 12 targets. Why, then, should the Member States and the resea rch community take on the arduous job of working through the targets? The answer lies in the nature of the health for all movement. It is designed not to reject but to build on the successes of the past and present, to reach a more complete kind of health in the future. This means that research will be sharpened and refined and therefore a more effective tool in the work for positive health.

Although research priorities will vary from one country to another, on the basis of the target-by-target analysis, the following summary of overall priorities for each of the five groups of targets may be suggested for Europe as a whole.

The last seven targets detail a number of prerequisites for all work to improve health, including research. These requirements must be met to change attitudes and working practices among politicians, health authorities, health personnel , people in other sector and, above all, the general public. One prerequisite - research strategies (target 32)- is so important that a publicationa is devoted to it, in addition to the discussion in this book. Another - the need for more detailed , reliable and standardized data for every target (target 34) - is an overriding theme of resea rch for health for all. The other necessary kinds of support are: country health policies committed to the principles of health for all, well trained and motivated health personnel, support from professions outside the health sector, and health care technology that meets people's needs in an effective and an acceptable way.

Increased research is needed for:

- making health policy

a Research policies for health for all. Copenhagen, WHO Regional Office for Europe, 1988 (European Health for All Series, No. 2) .

20

educating health personnel

assessing health technology.

Health policies based on the principles of health for all can probably best be promoted by a clear demonstration of their advantages: greater effectiveness, efficiency and equity. Therefore, comparative studies, policy research, scenarios and simulation models are needed to determine which health care systems can best meet the goal of improving people's health at minimal cost and in an equitable way.

Ironically, the success of modern health care has created the need to change the education of health personnel. Acute conditions are losing ground to chronic and disabling health problems. The aging of the population will reinforce this trend. The central question here is how to adapt the education of health personnel to the new health needs of the chronically ill , the elderly, the mentally ill and long-term patients. Cultural and recreational needs should be included with needs for medical care. Evaluative research on existing training programmes should compare their objectives (and resul ts) with the new objectives, skills and attitudes required to meet actual health care needs. Different models of education for health personnel should be compared, to point out the curricula and teaching methods most likely to improve health workers' abil ities and motivation to provide competent, comprehensive care in the community.

The tendency towards an unchecked expansion of health tech­ nology brings a number of evils in its train. The costs of care skyrocket, the providers and users of services are alienated from one another, and patients are treated like objects and lose their responsibility for their own health. The assessment of health tech­ nology can control the tendency and fight its unfortunate side effects . Multidisciplinary research is urgently needed at all levels to improve the assessment of health technology.

The work should begin with deciding what technology most needs assessment and setting criteria to make such decisions. Next, the technology selected must be evaluated for its efficacy, efficiency

21

- - 1

Appropriate care (targets 26-31)

and impact on society. Finally, the study results must be built into coherent recommendations for health policy, and these recommen­ dations must be used to change the practice of health care and health care planning.

These six targets outline the design and structure of a system for the delivery of appropriate health care, based on well developed, integrated primary health care. The quality of care should be assured through the systematic assessment of technology and evaluations of health workers' performance. Appropriate care is so important in achieving health for all that it is a basic theme of the targets and a priority in research that has already been dis­ cussed in part.

Successfully redirecting a health care system primarily depends on political will and decision-making. Research on health y terns can be an important source of advice for policy-makers. It can also help to ease the transition from the hospital to primary health care as the centre of health care systems. Researchers can draw policy­ makers' attention to considerable amounts of existing data.

The central research questions are:

• how to develop a system of primary health care adapted to countries' central and local circumstances;

• how to allocate resources according to people's needs;

• how to achieve a proper balance of resources between primary health care and hospital and specialized care;

• how to mobilize community participation;

• how to educate health care personnel in teamwork and the management of services;

• how to make primary health care more acceptable to patients and how to use it to support lay care and self-help; and

• how to assess the quality of care and how to use the results to improve the acceptability of health services to patients and the feedback to health personnel.

22

These eight targets have two aims, as closely related as the two sides of a co in. The first is to safeguard human health from potential harm resulting from biological, chemical and physical age nts, in­ cluding hazardous waste. The second is to enhance the quality of life by providing people with clean water and air, safe food, and pleasant living and working conditions.

Increased research is needed to:

study specific agents and their effects

provide information on risks and their management

develop integrated monitoring systems

promote community participation in work for environ­ mental health.

More basic research is needed on health hazards in the environ­ ment , their causes and possible means of preventing them. This work should include studies on genetic variability, ecogenetics and environmental genotoxicology. The interaction of different agents has to be investigated at the level of the intact animal , the organ and the cellular and subcellular systems. Other important topics are the interaction of low-dose and long-term exposure to agents and co mbined exposure to various risks.

A comprehensive and internationally comparable inventory is needed of the available data on both environmental agents and their effects on the environment and hea lth . Such an inventory shou ld also review the data for their usefulness in preventing enviro nmental risks and protecting health . The data collected shou ld include facts that will help political decision-makers to manage risks and to improve regulations and laws to protect the environment.

Sometimes the best way of protecting human health may be to moni to r the environment. At other times, it may be better to moni to r adverse effects in the population , preferably before symp­ toms a re recognized. Monitoring must cover all aspects of environ­ mental health in which risk management is called for. Research

23

Healthy environment (targets 18-25)

Lifestyles conducive to health

(targets 13-17)

must show what is to be monitored and how this should be done to ensure that the information is valuable in decision-making.

Finally, the public must be encouraged to take a greater part in presenting, discussing and handling environmental health issues. Studies based on the behavioural and social sciences must identify ways to provide people with better information on health concerns and risk factors. They must also show how to establish community participation in environmental risk management. This will result in a greater desire for safety; and decision-makers will take greater care to ensure that they consider environmental health when plan­ ning and assessing new developments.

Lifestyles (which are largely determined by the individual, societal and environmental factors that prevail in a society and the different groups composing it) strongly influence health or illness. The five targets on lifestyles recognize these facts. The social and be­ havioural sciences have two important roles in research on life­ styles. They should assess the effects of various lifestyles on health and promote the concept of healthy lifestyles as the normal way of life in a society.

Increased research is needed on:

indicators of lifestyles

lifestyles that damage health (risk behaviour)

lifestyles that improve health (positive health behaviour)

induced changes in lifestyle (health promotion).

Valid, reliable and sensitive indicators of health-related be­ haviour are needed to discover exactly how lifestyles affect health. In particular, completely new measures should be developed to assess such factors as positive health behaviour, social support and social integration, and chronic stress arising from work and from roles imposed on people according to their sex.

Intervention programmes must be based on a thorough under­ standing of what health-damaging behaviour does to the person who engages in it, and the purpose it serves for the individual and

24

society. Research can provide the knowledge needed. In addition, all intervention programmes should be scientifically evaluated.

The emphasis on positive health is a promising new approach to improving people's health. It implies a fundamental change of direction for health research: a shift from the study of disease and treatment to the study of health and factors that promote it. A clearer concept of positive health is urgently needed. Descriptive and analytical studies of how certain lifestyles can benefit health are equally important.

The deepest motive for studying current lifestyles is the in­ tention to change them, to promote lifestyles that enhance health and to reduce those that damage it. Large-scale attempts to modify widespread behaviour will , however, cause ethical and practical problems. These can be solved only if new forms of community participation are developed for planning and running intervention programmes and the research projects that will accompany them.

Targets 1-12 aim at reducing health inequities, morbidity and mortality from specific causes, and at improving the quality oflife.

Increased research is needed:

to improve the data base

to redirect research towards public health needs

in the forms of longitudinal studies and small area data.

Setting up a reliable data base on inequities, morbidity, mor­ tality and the quality oflif e is of primary importance. It is needed to provide information for the monitoring of progress towards the targets.

Priority should be given to research projects aimed at pre­ vention of, treatment of or rehabilitation for common diseases. Research that offers chances of improving the quality of life is equally important. Research objectives should not therefore be limited to issues affecting only selected target populations, such as hospital patients, but should extend to problems of morbidity in

25

Fundamental requirements for health for all (targets 1-12)

primary care and the community. While better, broader assess­ ments of high-powered modern technology are urgently needed, more attention should also be paid to diagnostic and therapeutic strategies and evaluative research in primary health care.

Chronic, disabling disease causes many major public health problems in the European Region, which will be augmented by the aging of the population. Research is urgently needed on the course and outcome of different forms of illness over periods of years, the relevant risk factors, and the effectiveness of different forms of intervention, even though the results of such studies may not be available by the target date.

To give a wider focus to health policy, health surveys should include people's perceptions of their health and that of their families. Both retrospective and, in most cases, prospective longi­ tudinal studies will also be necessary. Small area data on the need for health services, and their provision and results, are required to plan and evaluate intervention programmes. These data should be collated with relevant community or regional data.

26

2

Support for health development

The targets in this chapter detail the requirements for changes in the thinking and working practices of everyone whose contribution is needed to achieve health for all. The first requirement, of course, is research strategies, but they are thoroughly discussed elsewhere. The others are: a health policy committed to the principles of health for all (target 33), effective management (target 34), a reliable information base (target 35), well trained and motivated health personnel (target 36), support from professions outside the health services (target 37), and health care technology that effectively and acceptably meets people's needs (target 38).

These targets must be reached first. Their date for completion - before 1990 - confirms this fact. The support measures they call for are needed to create the necessary conditions for health develop­ ment. All the research proposals in this chapter will not, however, be equally important in all countries. Depending on national and local circumstances, research should be directed towards removing the most serious obstacles and filling in the most serious gaps in knowledge. The methods that promise to yield results most rapidly should be selected, even at the expense of detail and compre­ hensiveness.

27

Time frame

Close links to other targets

How and who to act on research recommendations

Nevertheless, the deadline set for these targets does not mean that research not finished or perhaps not even started by 1990 should be abandoned. Many of the studies proposed wil l, in fact, have to be continued or followed up long after this date . The deadline actually reflect the urgency of studies that will provide the necessary basis for healthy policy and research into other fie lds.

The regional targets are so closely related that recommendations for research on them overlap. Much of what is recommended for the s ix targets in this chapter will be further discussed in other chapters. This is particularly true of Chapter 3, on appropriate care , which out lines the necessary steps for developing a health care system based on primary health care. The present chapter takes a more genera l view of the health care system as a whole, as a part of society. It thus gives a systematic putline of research needs, which are later developed into detailed research proposals.

Naturally, many of the research recommendations out lined in this a nalysis will have to be adapted to meet national priorities and local circumstances. This is particularly true for research into measures to support health development. Perhaps more than anywhere else, each Member State is on its own in this area. The research rec­ ommendations in this chapter are thus rather general. Some quite conspicuously lack the specificity required before actua l research can be started. The most demanding part of designing research on support measures is left to the policy-makers and health researchers in each Member State.

A glance at the topics dealt with in this chapter shows that the main disciplines involved will be the socia l, behavioural, peda­ gogical and organizational sciences. In most Member States, however, these disciplines have not yet been drawn sufficient ly into health research. The existing health research infrastructure must be changed or expanded. This will attract more contri­ butions from disciplines without a traditional link to health re­ search and foster wide interdisciplinary cooperation to support health for all.

28

Before 1990, all Member States should ensure that their health policies and strategies are in line with health for all principles and that their legislation and regulations make their implementation effective in all sectors of society.

This could be achieved if all countries were to make a systematic review of their health policies and health legislation in the light of the regional health for all strategy and targets, and to develop health for all strategies and targets and amend or extend their health legislation accordingly, taking due account of the specific legal, political and structural conditions in each Member State.

Many targets echo this call for Member States to make policies in line with the principles of health for all. In fact , policy is a central concern of each group of targets. Eight targets suggest that govern­ ments make policies for:

making primary health care the hub of the health care system (target 26)

monitoring and controlling pollution (targets 20-23)

helping people to choose healthy lifestyles (target 13)

developing people's health potential (target 2)

equity in health (target 1).

Target 33 envisages four types of action: an official and explicit commitment of government to the objective of health for all; legislation that adapts the health for all strategy to national, re­ gional and local circumstances; work to enlist the support of influential political and social organizations; and the establish­ ment of health councils whose members represent a wide range of interests in health care and in political, economic and social affairs.

What can scientific research do to stimulate and support these policies?

29

Target 33. Policies for health for all

The task

Priority topics

It can contribute in two main areas: monitoring and evaluating the development of health policy, and showing the value of policies for health for all.

Monitoring and evaluating policy development. In deciding on health policy, government officials and health authorities have to reconcile many different (and possibly conflicting) interests and demands in health and other sectors of society. As a result, the original intentions of the strategy for health for all may be watered down or the aims reinterpreted, to make them less challenging and more easily compatible with other, conflicting interests. Health researchers can play an important role as advocates of the original intentions and principles of the strategy. As advisers to govern­ ments or to funding organizations, scientific experts from all disci­ plines could use their personal and professional prestige to buttress the strategy, especially its less easily accepted parts.

More specifically, policy analyses and health systems research could influence the making of health policy. They should aim first at clearly describing health policy as outlined by the targets. In principle, at least, every government in the European Region has endorsed policies for health for all. Continuous monitoring of national health policy should be used to point out shortcomings and gaps in the implementation of such policies. Policy analyses could heighten the awareness of discrepancies between an officially proclaimed policy and its translation into action. Analyses could also define areas in which action is still needed.

The methods of process evaluation should also be applied to the making of health policy, to analyse the obstacles to changing national health policy and to seek ways of overcoming them. Successes and failures in health policy development should also be assessed. The reasons for failure, the parts played in the process by different groups and the influences of other sectors of society should be analysed. This should make the process of health policy formulation clearer to the people involved, to professionals and to the general public. An assessment of the influence of scientific research on the process of developing health policy should be

30

included in these studies. Such analyses could have useful side effects. Public awareness of health policy issues could be increased and, in turn, could help to mobilize public and professional sup­ port for policies in line with health for all.

Showing that policies work. Probably the best way to promote pol icy decisions in favour of a health care system guided by the princi ples of health for all is to prove the value of such a system. All health care systems share three overall objectives: effectiveness, cost-efficiency and equity. Policy-makers and the various interest groups involved in decision-making would be convinced of the worth of a health care system based on primary health care if they had clear proof that it is the best way to reach those objectives. Ways must be found to analyse health policies found successful in Member States and to determine the extent to which they would be usefu l in other countries.

Different health policies can be compared in several ways . Research can determine how close an existing health care system comes to meeting its own objectives, or compare trends in health policy development in various countries over a period of time. The third alternative is to analyse different ways of organizing a health care system. This would allow for projections of both the resources needed and the results expected, and demonstrate the consequences of decisions for different types of health policy.

All analyses must cover six main sets of variables:

• cultural, social, economic and environmental conditions known to affect health (such as minimum income, poverty and un­ employment , sanitation and water supply, and air pollution);

• factors in the health sys tem that reflect the characteristics of different health policy alternatives (such as the presence of com ponents of primary health care, the distribution of resources between hospitals and primary health care, and the provision of support and rehabilitative se rvices in the community);

• ind icators of positive health and of patterns of mortality, mor­ bidity and disability;

31

Target 34. Planning and

resource allocation

• indices of effectiveness, allowing an assessment of the degree to which services meet health care needs;

• input variables (including cost-assessment); and

• indicators of equity in the provision of se rvices (their avai l­ ability according to need, and the extent to which vari"o us groups in the population find them accessib le, affordable and accepta ble).

As this incomplete list clearly shows , a detailed and compre­ hensive comparison would take years to complete. An appropriate analytical model for eva luating a lternatives for health systems must therefo re be developed if the powerful tools of evaluative research are to be used in making decisions on hea lth policy in the foreseeable future. The first a nd most important task for resea rch is thus to single out major variab les . These can serve as provisional or proxy indicators of a who le set of related variables. It must be possible to obtain reliable data o n them without too much ad­ ditional effort.

Once a set of essent ia l variables has been es ta blished and de­ fined in practical terms, the conseq uences of different health po licy decisions can be identified. This cou ld prove the worth of hea lth policies guided by the principles of health for a ll. It would certa inly be the greatest support research could give to such policies and to the health care system that should grow out of them.

Before 1990, Member States should have managerial processes for health development geared to the attainment of health for all, actively involving communities and all sectors relevant to health and, accordingly, ensuring preferential allocation of resources to health development priorities.

Such a process should cover the systematic planning, monitoring and evaluation of health for all activities, with due regard to the specific legal, political and structural characteristics of each country.

32

The Me mber Sta tes a re as ked to crea te hea lth po li cies a imed a t es tabl is hin g a hea lth ca re sys tem guided by the principles of hea lth fo r all. Wh en they have d o ne so, how are they to t ra nsla te po li cy deci sio ns into a n orga ni za ti o na l structu re t ha t wo rks? Ta rge t 34 answers thi s questi o n.

Me mber Sta tes a re to d eve lop o r st re ngt hen the ways in which t hey ma nage hea lth deve lo pment , in order to ma ke, ca rry o ut a nd evalua te stra tegies fo r hea lth fo r a ll. Beca use lega l a nd admin­ ist rative structures differ a mo ng Member Sta tes, these stra tegies co ul d ta ke th e fo rm o f eith er a sys tema ti c hea lth pl a n o r a less fo rma l, ye t coherent , set o f rul es, regula ti o ns a nd incenti ves . The o rgan iza ti o na l st ra tegy sho uld ta ke as its leading o bject ives the p rinci ples of hea lth fo r a ll (p ro mo ting hea lth ; reduc ing ineq ui ty; increas ing the effecti ve ness, efficiency a nd q ua lity of the hea lt h system; a nd strengthening co mmunit y pa rti cipa ti o n a nd iote r­ sectora l coopera ti o n in hea lth affa irs).

An ad equa te o rgani za ti o na l stra tegy shou ld :

• aim a t reducing hea lth haza rds a nd imp rov in g people's hea lth ;

• be capa bl e of se lectin g lo ng-term so lutio ns tha t favo u r hea lth pro mo tion a nd the preventio n of ill hea lth ;

• be a mena ble to cost-effectiveness a na lys is; a nd

• ensure tha t the people who use a nd p rov ide se rvices a lso ta ke part in pla nni ng, implementing a nd eva lua ting them.

Such a n o rga ni za ti o na l stra tegy gives ri se to severa l ma in ma n­ ageme nt tas ks. First , prio rit y o bjecti ves a nd ta rge ts must be d e­ fin ed to so lve the most urgent hea lth a nd hea lth se rvice p ro blems in eac h co untry. Nex t , the ma in types of ac ti vity to be unde rta ken in the hea lth sector a nd in o the r relevant secto rs must be in d ica ted, a long with the a uth o riti es to be respo nsi ble for carry ing them o ut. Special a ttentio n must be g ive n ,to o rga ni za ti o na l meas ures to develop o r strengthen prima ry hea lth ca re a nd to ensure its in­ tegratio n with hospita l a nd specia li zed ca re. (Th is to pic is mo re full y d iscussed in C ha pter 3.) F ina ll y, a nd perha ps most impo rta nt ,

33

The task

Priority topics

priont1es in the allocation of resources must be set; effective machinery must be established for continuously monitoring and assessing resource allocation.

Member States should be encouraged to use a network of experts and institutions to ensure that management practices are effective. This network could help to: develop and apply appropriate man­ agement processes; give adequate training to all the people who will be actively involved in organizational change; involve com­ munities in decision-making; allocate resources preferentially to local communities to develop or strengthen primary health care; and ensure the continuous evaluation of processes and results of organizational change and make further changes if necessary.

WHO is prepared to help European Member States build better management processes. The Regional Office for Europe will sup­ port individual countries, if requested, and use its network of national institutions for developmental and educational activities aimed at improving management processes. In addition, WHO will encourage countries to share information on and expert knowledge of management problems and will coordinate corresponding re­ search at the regional level.

The research work needed to facilitate and support effective man­ agement will be detailed in the discussion of several other targets. The main organizational task is to establish or strengthen a fully developed primary health care sector and to integrate it with hospital and specialized care. Chapter 3, on appropriate care, contains a number of specific research proposals for various aspects of this task.

Chapter 3 outlines the structural changes needed in the health care system and the general contributions to be sought from organ­ ization, management and health services research. The contri­ bution of research to solving specific problems in managing health systems is detailed under targets 26-31 . The present chapter dis­ cusses more general recommendations.

Using expertise from other sectors in health management. Health management should make full use of theories and practices

34

developed outside the health sector, especially those of industry and commerce. Although these sectors have different objectives, they share similar problems of managing complex organizations. In industry and commerce, successful solutions have been found to such problems as:

• how best to allocate scarce resources to attain well defined objectives;

• how to structure authority and decision-making so that people at all levels become committed to their work and use their creative potential;

• how to channel the flow of information so that essential infor­ mation is readily available to management at different levels;

• how to set up programmes of basic and continuing education adapted to an organization's objectives and needs; and

• last, and perhaps most important, how to establish machinery for continuously evaluating an organization's performance and for ensuring rapid feedback to be used in management decisions.

Briefly, at present management theory has three broad prin- ciples: management by objectives, delegation and decentralization, and a systemic approach (continuous evaluation and feedback).

If the experience gained in the business world from these man­ agement problems were made available to the health care system, the co mplex and demanding task of restructuring the system in accordance with the principles of health for all could be solved. The cooperation of successful industrial managers would be a desirable aid to the long-term health services research groups that should be established in Member States (see Chapter 3). Management experts from ou tside the health sector should be included in the network of experts and institutions that Member States should use to develop and apply appropriate management processes. Care must be taken , howeve r, to safeguard the specific character of health services research and its emphasis on people.

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Studying health services and organization. Adequate health man­ agement should follow a clear strategy with well defined objectives. It should aim at getting results and should involve other sectors of society and the users of services. Finally, responsibilities and func­ tions at different levels should be clearly defined . Detailed descrip­ tive analyses should be made of management processes at various levels of the health care system. They could determine whether current practice meets standards for adequate management, and where improvements are most urgently needed. Such descriptive case studies might conclude, for example, that health care has no single, clearly defined objective but rather multiple goals in its different components and levels. The studies might also show that the explicit and implicit aims in health care conflict, or that the aims of certain interest groups dominate the whole system. Case studies could also point out the adverse effects of management practices, reveal where normative regulations raise obstacles to a dynamic approach, and suggest the changes necessary. It would be wise to draw extensively on the expertise of professional managers and management consultants for clear assessments of current man­ agement practices in the health system.

In addition, comparative case studies of particularly effective management processes could be useful. They could determine and describe the essential dimensions of effective management in practical terms. They could also be used to develop a standard set of incentives to the adoption of more effective management practices.

Pilot studies using tracers could test alternative models of management processes, determine where innovative impulses get bogged down in the system, and explore the impact of new in­ centives and regulations . These could help solve certain manage­ ment problems (such as defining objectives and goals, structuring the flow of information for management, and establishing means for rapid feedback of information on performance so that organ­ izational changes can be made). Besides providing criteria for more effective management practices, the results of such pilot studies could be used to develop and test models of health management

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problems. These in turn would facilitate future decisions on man­ agement issues. The models could also be used in the training of administrators and health personnel for management.

The question of training various kinds of health professional for management deserves particular attention. Studies should assess the content, processes and results of existing training pro­ grammes for management at the different levels of the health care system. They should also point out essential elements for change in new developments in curricula.

Studies are also needed to analyse the effects on management of heal th legislation and the administrative regulations that follow. Many well intended laws and regulations lose their original impact. When introduced into administrative and management practice , they meet with unforeseen obstacles or produce unintended side effects that impede their implementation. Regulations for cost­ containment may serve, in some countries at least , as an example of this type of problem. Process analyses of the implementation of selected health laws and regulations could pinpoint any obstacles and harmful side effects.

Health insurance systems and remuneration schemes are parti­ cularly important topics. Studies should assess their effect on the provision and use of services, on the preferences given to certain patterns of care, on unmet health care needs , on the attractiveness of different health professions, on equality of access to health services and, as a result, on health . Although many probably conflicting interests have to be taken into account, changes in these schemes could provide effective incentives for a widespread change in the provision and use of health services.

Intersectoral research. Establishing health services based on the principles of health for all will affect other sectors of society than health . These will include: social legislation and social services; education; health insurance; housing and town planning; environ­ mental protection in industry and agriculture , in the home , on the roads and in vehicles; and the production and marketing of food­ stuffs. It is therefore highly important that intersectoral research be

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Target 35. Health information

systems

The task

Priority topics

promoted and researchers in other sectors mobilized to study the effects on health of their own fields of work.

Before 1990, Member States should have health information systems capable of supporting their national strategies for health for all.

Such information systems should provide support for the planning, monitoring and evaluation of health development and services, the assessment of national, regional and global progress towards health for all and the dissemination of relevant scien tific information; and steps should be taken to make health information easily accessible to the public.

More detailed, reliable indicators are needed to achieve a lmost every target. Because adequate information is a prerequisite for making decisions on health policy and for eva luating the exist ing hea lth care system and any structural changes in it , studies are urgently needed to determine the gaps in the information needed. Research shou ld then concentrate on filling these gaps, to provide health policy-makers and managers with the facts they need to start health for a ll development. The next task for research is to build up more detailed and comprehensive information systems.

Specific research requirements for the various indicators are discussed in later chapters. A framework for pointing out the research needed to yie ld health information is given here.

Current health information systems. The processes and results of actua l health inform atio n systems should be carefully eva luated at national, regional and local leve ls for:

• the va lidit y of the kinds of data contained (morbidity, disability and positive hea lth ; the quality, access ibility and acceptability of services; indicators of needs for hea lth services);

• their adeq uacy for monitoring health for all development;

• their reliability and accuracy;

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• t he ir usefuln ess for de c is io n-m a king in hea lth po li cy, hea lth ma nage ment , dia g nos is a nd trea tment ;

• the pe rtin ence o r th e da ta o n hea lth se rvices;

• the fl o w o f informatio n within a nd betwee n leve ls o f hea lth ca re (pri m a ry, hos pita l a nd spec ia li zed ca re); a nd

• the fee dbac k o f in fo rm a ti o n to a nd it s int e rpre ta ti o n by th e pub li c .

T he a na lyses sho uld pick o ut th e strengths a nd wea knesses o f to d ay's hea lth informati o n sys tems . They sho uld indica te th e im­ p roveme nt s need ed , such as new in fo rm a ti o n a nd bette r p rocedures fo r the co ll ec ti o n , retri eva l a nd inte rpreta ti o n o f d a ta, o r fo r th e fl ow of in fo rm a ti o n . S pec ia l a tt enti o n sho uld be g ive n to th e eco nom ics o f hea lth in fo rm a ti o n . Th e cos t-effec ti ve ness a nd cos t­ effi ciency o r current informa ti o n sys tems sho uld be assessed .

In a dd iti o n , mo re must be kn o wn abo ut th e in fo rm a ti o n th a t heal t h po licy-m a kers and lea din g a dmini stra to rs ac tu a ll y use to make d ec is io ns . D escriptive studi es, us ing inte rviews a nd parti ci­ pan t obse rva ti o n , sho u ld assess th e so urces a nd co ntent of s uch in fo rma ti o n . These studi es co uld suppo rt hea lth po li c ies based o n th e princ iples of hea lth fo r a ll.

Adequate informati o n for th e peo ple is a n o bvio us prerequis it e for t he ir pa rti c ipa ti o n in wo rk fo r hea lth fo r a ll. Resea rch ca n co n trib ut e to imp roved public in fo rm a ti o n by di scover ing how muc h va ri o us gro ups kn ow a bo ut hea lth . Studies sho uld eva lua te hea lt h inform a ti o n ca mpai g ns ai med a t th e ge ne ra l public and de te r m ine ho w much o f th e co nt ent o f th e po pul a r medi a pert a in s to hea lth. Research sho u ld a lso prese nt impo rtant findin gs to th e publ ic fo r d isc uss io n .

Nc11 · information needs. T he wide a rray o r new indica to rs needed ca ll s fo r co ns idera ble resea rch by all sc ie ntifi c di sc iplines re la ted to hea lt h . Th e mos t impo rt a nt new indica to rs w ill d esc ribe: hea lth s ta tus, hea lth be havi o ur , need s for health se rvices, th e hea lth se rvices provided, the va riati o n o r services acco rding to soc ial

39

characteristics (such as poverty, unemployment and social dis­ advantages), and the effectiveness and efficiency of care.

Studies are needed to determine the content of all the rec­ ommended new indicators ; to test their validity and reliabil ity; to set up procedures for the collection, retrieval and analysis of the resulting data; and to devise channels for an effective flow of information to the appropriate recipients . The general public, patients, communities, health care personnel, health researche rs, managers and health policy-makers all need information if they are to play their parts in achieving health for all.

Ways of collecting data. Collecting data is expensive. Compara­ tive studies on the advantages and disadvantages of the various methods of data collection should point out the most suitable and efficient ways of obtaining reliable information on specific indi­ cators. For example, indicators of poverty and unemployment may call for a population-based survey or a micro-census. Indicators of health behaviour , nutritional patterns and health status could be assessed by interviews in sample surveys in communities. The same methods could be used where health care is provided, to measure client sa tisfaction and the quality of se rvices.

The links between different information systems and the com­ patibility of data from different sources are particularly important issues. The designers of new indicators or data collection systems must take care to ensure that they are compatible with existing data and with the systems of other institutions or sectors.

The possibilities for econdary analysis of data stored by hospi­ tals , insurance companies, and sickness funds should receive special emphasis. These data could reveal much about trends in health development, the results of treatment, the accessibility of services, health inequities , and the effects of unemployment. Once the insti­ tutions agree to cooperate and effective methods for data analysis are developed, secondary analysis can be a rapidly accessible and relatively inexpensive source of information. Such analysis must not proceed, however, until the right of patients and care providers to privacy is ensured.

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Information for primary health care. Since hospital information systems are well developed in most countries, research should concentrate on the needs for information in primary care. Criteria for se rvices needed by special population groups (such as the elderly, the chronically ill, the disabled, the disadvantaged or socially vulnerable groups) must be established and the corre­ sponding data kept up to date. Screening methods must be de­ veloped to find people whose needs are neglected.

Resea rch projects employing the techniques of action research and participant observation are probably best for determining the information needed for primary health care. They could also find the best way of obtaining the required data. "User-friendly" com­ puterized methods of collecting, analysing and using clinical and administrative data should be developed; they would be particu­ larly useful in primary health care.

Cost-effective information. A huge amount of information is needed at all levels of the health system and great resources are necessa ry for the development of new indicators and the collection of new data. The cost-effectiveness of gathering and using health information is thus an important issue. Criteria must be devised for weighing the advantages gained through the availability of specific data against the cost of collecting and analysing them.

Again, the possibility of secondary analysis of existing data should be carefully explored whenever the introduction of new indica tors is considered. Methods should be developed to balance eventual losses of information against savings of resources in time, money and personnel.

The ethics of information. Because of the rapid development of electronic information technology, the protection of personal data has become a highly sensitive issue, particularly in matters relating to hea lth. Ways must be found 'o f ensuring citizens' rights to have access to data on their own health , and to protect their privacy by having a say in decisions on the use of such data.

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At the same time, researchers obviously need to be able to get statistical data on health for planning and evaluation. Some way of linking different sets of data on the same person must be found. This is especially important for long-term studies and those re­ lating health to sociodemographic characteristics. This resea rch requirement can easily conflict with people's right to the protection of personal data. This conflict often handicaps health-related re­ search, and resea rchers, as well as health administrators and the public , see m to feel growing insecurity and confusion about this issue.

National and international regulations for the use of health data in scientific investigations should therefore be created. They should strike a balance between the protection of personal data and research requirements. Techniques should be developed to prevent the mis-use of data storage and linkage systems.

This issue can be settled satisfactorily only if the general public and groups with a particular interest in the protection of personal data have ample opportunities to help establish such regulations.

International comparisons of health information. International comparisons are a powerful tool of investigation in many different areas of health research. By indicating, for instance, successful policy decisions in favour of a health system based on primary care, such comparisons could support the making of such policies in other countries. Comparisons could also reveal the special short­ comings of policy decisions. In addition, experience gained from new developments in one country could be used in others.

Relevant information (on such subjects as the structure of health services, population characteristics, economic and environ­ mental conditions, health status, health behaviour, the allocation of resources, and the outcomes of the services delivered) must be comparable within and among countries. This is the most im­ portant prerequisite for comparative studies. WHO should make full use of its international connections and its network of collab­ orating centres to promote an internationally compatible classifi­ cation and coding of information on health and health services.

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Before 1990, in all Member States, the planning, training and use of health personnel should he in accordance with health for all policies, with emphasis on the primary health care approach.

This can be achieved if all countries analyse their needs for the different categories of health manpower required to implement their policies of health for all, adopt suitable health manpower policies, and decide on the numbers and educational qualifications required for each category of personnel.

The pla nning , education and use of hea lth care personnel in most countries depend greatly on the ap proach taken to health. Any discussion of health personnel should begin by examining the ap­ proach that has shaped the hea lth care system in which they work.

In recent years, people have tended to take a technological approach to the problems of hea lth. In hospitals, in particular, advances in genetic resea rch , organ transplantation, health tech­ nology and clinical pharmaco logy are held to promise furt her progress in fighting disease and increasing li fe expectancy. This approach inevitably demands that a ll health care (and thus the training of hea lth perso nnel) become more and more spec ia li zed a nd co mpartmenta lized. In many countries the technological ap­ proach has led to a relative glut of high ly specia li zed personnel, especia ll y ph ysicia ns, a nd a lack of paramedical and care personnel (such as nurses, physiotherapists, ergotherapists, home helps and social workers).

Today, hea lth policy-makers, hea lth professionals and the genera l public are increasingly co ncerned about the widening dis­ tance between providers and patients and the loss of patients' ind ivid ua lity that have resulted from too great a dependence on technology. In many countries, a ,new health movement favours what may be called an ecologica l approach to the problems of health a nd hea lth care. This approach gives priority to people's capacities for prese rving and strengthening their own health, for

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Target 36. Planning, education and use of health personnel

The task

Priority topics

creating a healthy physical and social environment, and for caring for and supporting each other.

From this point of view emerge new needs for health, including more services that promote health, and preventive, supportive and rehabilitative services in the community. Such services will cope better with the changes in patterns of morbidity and meet the new health care needs that result. Consequently, health care personnel should centre their activities on their caring, supportive and coun­ selling functions. The ecological approach is the core of the regional strategy for health for all.

The planning and education of health personnel thus take place in a social context marked by conflicts and contradictions. On the one hand, modern clinical health care calls for highly specialized health personnel and technology-intensive methods of treatment and care. On the other, new health care needs, arising from changes in the morbidity patterns in industrial societies and from a different understanding of the patient's role, demand broadly qualified health personnel and personnel-intensive methods of care. In addi­ tion, the need for cost-containment seems to close the door on any attempt to meet people's new health care needs by increasing the total number of health personnel.

The solution to these problems, according to targets 26-31, is to shift the focus of health care systems to primary care. Of course, this will require that personnel be shifted to that sector, along with other resources. Personnel requirements in such a health care system, and research to support them, are detailed in Chapter 3.

The strategy for health for all calls for the use of the ecological approach to health, not only in primary health care, but also in the other areas of health care and other sectors of society. Equity, health promotion and the prevention of disease, citizen participation and multisectoral cooperation are objectives for the planning and edu­ cation of personnel in all sectors of the health care system. Re­ search on health personnel is an important part of this task.

New needs and work for the health professions. Research into epidemiology and demography should determine the health care

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needs of the population. This will allow an estimate of the number and qualifications of various kinds of personnel required to meet health care needs. Questions to be considered include the balance between medical and paramedical personnel, the effect on health of various physician/population ratios, and health care needs that are inadequately met at present.

Pilot studies of well run primary care units could define the activities and duties of the various health professionals working there and determine the knowledge, skills and attitudes they reqmre.

The research methods employed should include participant observation, expert panels and group discussions between primary health care teams and the people who use their services. The results of these studies could be used to make a clearer description of job profiles in primary care services. They could also be fed into educational programmes for health personnel.

Presen t and future education. The goals of the academic training of health personnel may differ widely from service requirements, consumer expectations and general socioeconomic conditions. Evaluative studies should be used to determine where serious divergences occur and thus where improvements are most urgently needed. Such studies should compare the objectives, curricula and results (in knowledge, skills, attitudes and motivation) of edu­ cational programmes for the various health professions with the objectives and service requirements of new health care needs.

Many existing educational programmes will have to be adapted to the emerging requirements of new health services. Students acquire not only knowledge and skills in their professional edu­ cation but also secondary socialization. In this process they imbibe specific attitudes, motivation and values for their future work. Educational programmes should therefore strive to impart atti­ tudes, motivation and values that attract students to primary health care and enable them to work as partners wit