First Regional Seminar on Medical Assistants, Manila, Philippines, 1-7 October 1974 : final report

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Icp/HMD/l8 ORIGINAL: EOOLISH

FIRST REGIONAL SEMINAR ON MEDICAL ASSISTANl'S

Sponsored by tile

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WORLD IIEALTH OROANIZATION REOIONAL OFFICE . PCII. THE WESTERN PACIFIC

Manila. Philippines 1-7 Ootober 1974

FINAL REPCll.T

• WHOfWPRO Ll13RAk'.Y (\'iani!a. Philiupiner

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CONmlll'S

IN'l!\OIlJcrION ••••••••••••••••••••••••••••••••••••••••••••••••••

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4. 5. 6. CC»«:WSI OMS

EVAWATICIf ANlEX 1 -

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ANNEX 2 - LIST OF PARTICIPANTS. CONSULTAN1'S AND .sECRE'rARIAT •••••• ~ • • • • • • • • • ,. • • • • • • • • • • • • • • • • ,. • • • • • •

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• ANNEX 4 C~

......................................... TO SMALL GROUPS •••..••••••••.•••••.••.•.••• ANNEX 5 - 'mE USE CP MEDICAL ASSISTANTS IN <7l'IIER PQ'rS fJP 'BiB ·W<JlID ••••••••••••••••••••••••••••••••• ANNEX 6 - HEALTH CARE IBLIVERY IN 'mE PEOPIE'S

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RBPUBtrC ANt&)(

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CHINA - DR V. SIDEL ..••••.•.•....•..•••

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EVAWATION CP 'mE SBMINAR /

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ANl£X 8 - SUllARY OF EVAWATI ON REPLIES ••••••••••••••••••••••

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1.

lNTROOOCTION

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From its inception, the World Health Organization has been dedicated to the goal of improving the quantity and quality of health services rendered to the people of the world. The Organization realizes that to achieve this goal countries must have an adequate supply of competent and motivated health personnel. The utilization of medical assistants has been demonstrated as a practical and economical way by which the supply of health manpower can be increased. During the Past several years the World Health Organization has devoted considerable attention to encouraging the training and use of medical assistants, but at the same time the Organization, fUlly realizes that the ultimate decision as to what health personnel are to be trained and utilized is an individual country matter, for the appropriateness of the use of medical assistants depends on the health care system of each country. The Western Pacific Regional Office of the World Health Organization is in a unique position to promote better understanding of the contributions that medical assistants can make in the delivery of health services. Western PacifiC, with its divergent cultures, political systems and health systems, is an area where medical assistants might make a significant contribution 1n the delivery of health care. The Regional Office, therefore, decided to convene a seminar which would address itself to the topio of the training and utilization of medical assistants. In deoiding to convene the seminar, no preconceived notions that the use of medical assistants was the ultimate answer for every nation or territory of the Region was held. Indeed, it was felt that only through an uninhibited exchange of ideas and experiences by representatives of Member nations and territories could a better understanding of the training and utilization of medical assistants emerge. 2. PLANNING

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The Seminar Director spent time in the Regional Office some months before the seminar to assist the Secretariat in the planning of the meeting. Development of objectives was a priority activity; and in the end, two goals and e1ght specific objectives were agreed upon. Once the objectives had been set, a seminar programme was developed (Annex 1). The seminar partiCipants (Annex 2) were selected on the basis of numerous crt teria. The most important were whether they had experience in the training and utilization of medical assistants or whether they would benefit by learning about how medical assistants can effect the delivery of health services. Once the partiCipants had been selected, information on the seminar, including references and the like, were distributed (Annex 3). As the term "medical assistant" has many definitions it was decided not to formulate a single definition. However, to ensure that the participants would come to the seminar with some understanding of what is included in the title "medical asSistant", a

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frame of ref.Nnce 1f8IJ prorlded. The.eminar partioipant. _re informed that the term lfoulcl be used in a senerio .lIIae md it enoompas.e. a wide range of h.alth pel'll -1 pert01'ldna tlmoUCIDa . . desoribed in WHO Teohn1oal Report No.

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" ••• the term 'medical ..si.tant' i. u.ed to mem a health work.r 11110 hu reoelftd appropriate tralninS and. 11110, in the fl.ld of promotion. proteotion and re.toration of health (inoludins diasno.i. and treatment of di ..... ) hu oertain clearly defined duti •• and re.ponaibil1ti ••••• "

"The term 'lMd1cal phyBician. The medical direot .upervi.ion of a in an oIitqiq po.t; or only re.ote supern.ion

...latant' ref.rs to an auxiliary to a ...i.tant may work in an institution under the ~ioim; he (ahe) may perform his (her) duties be (ab.) may be a ~r of a health teu with by a ptQwioian ••• "

Partioipant. . .re cI1reeted to the magazine World Health of June 1972, 1Iilere the Technioal Report det1D1Uon i. supported in m introdllotory artiole desoribinS m.d1oal ... i.tant. .. : "H.alth pera_l wboa. du.U_ ..,. rmg. tl'OIII .1IIple ourati11'8 prooedures forc~ di...... to wid.r oare. inolucl1ns a vari.ty of diasno.t1o, ourative and pre.-ntive practice. "

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Finally it WIUI brousbt to the attention ot the partioipant. that the "medioal ... i.tant" may be m ... latant medioal officer, a paediatriC ... ooiate. a maternal and child h.alth .peciali.t. a hospital ... latant. ~ health extension offioer, • _4IIx, • medioal .aislat1ant or whatever. It f t . decided thet the seminar .hould not get bogged down in tl71II& to define the t.rm. "medical ...i.tant", but be conoem.d with the tlmotiClllll performed by a wide rmge of health personnel oovered under thi. rubrio. Because the variety of health peraonn.l used in the oountries repre.ented in the We.tem Paoific Resion was .0 sreat, it was decided not to obtain definitive inf_tion t'rom euh ot tbe partiCipant. en the type. md oategories of health peraODllel Qed in their oountri •• i iP terri torie.. It w . . obvious that such a li.t, if obtainable, would under the be.t oiroumetanoe. not be definitive md it. ult1a1loe value to the .... n.r 1IOIIlcl be que.tionabl.. Therefore. the partioipants . .re requ••ted to beoome .. flllll1liar . . pos.iblewith the type. of health penonnel in their o_try who .aU.fied the de.oription of medioal ...i.tant prorlded. II\u'therwore, the partioipant. were ..ked to be familiar with the health oare .1ISte.(.) of their oouiltrie. and with how _dioal uai.tant. operate within that .ystem; they are inrlted to br1ns along any information which they misht oonaider pertinent to tho obJ.otives of the seminar. The participants _re enoourag.d to share information md ide. . durinS the seminar .0 that an appreoiation of how .ed1oal . .Bl.tant. om be inatZ'Wllental in improvlns the cr-litJ' ot health .erno". oould be developed.

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3.

OJ3JECI'IVFS

The task of developing a detailed set of seminar objectives was accomplished by first stating two goals. which might best be defined as the general aspirations of the seminar. The goals were then defined as specific objectives and stated in terms such that their accomplishment could be assessed on the conclusion of the seminar. The goals and objectives Which guided the seminar were the following:

1. To demonstrate the value of "medical assistants" in improving the delivery of health services.

2. To explore ways in which the utilization of medical assistants in the deli very of health services can further be improved. Objectives 1. in use. To develop an awareness of the variety of medical assistants currently

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2. To develop an understanding of how the use of medical assistants evolved. 3. To develop an understanding of how medical assistants are trained and utilized. 4. To develop an appreciation of the impact medical assistants can have on the delivery of health services. 5. To develop an 'awareness of some of the problems encountered in the training and utilization of medical assistants. 6. To consider approaches in determining the type (level) of medical assistants required.

7. To consider ways in Which the training of medical assistants can be improved •. 8. To consider ways in Which the utilization of medical assistants can be improved. Accomplishing the objectives during a one-week period appeared as a most ambitious goal, but it is evident from the summary of the seminar evaluation (included in this report) that the objectives were achieved •

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• 4. Sinoe thi. was designated as a "seminar" it was decided that the greater portion ot the progrume be devoted to small group discussions. Beoause of the small nUilber at participants it waa determined that three groups would be ideal. In each group, partiCipants would haYe an opportunity to exchange ideas, experienoes, problelllll and aocompliahlleDts in the tra1n1ng and utiUzation of medical assistants. It was anticipated that from this sharing would emerge some conclWlions on how the training and utllization of medical assistants evolved, and how future tra1n1ng and utillzation i CIOI.Ild be strengthened and improved. Briet' plenary Sessions _1'8 held but 1Ielelr t'or the pnopoae ot "tying together" small group discussions. . .

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In keeping with the nature and. purpose

at a seminar, no group leaders or

rapporteurs were Wled. Since each participant and coneul tant represented a unique talent, asking one to be a leader and still another to be a rapporteur would deIl7 the groups the benefit ot' those individuals' experienoes; under that arrangement, in each group one partiOipant would be preoocupied with "leading" the group and another partiCipant involved in taking definitive notes. During the first group session, the consultant in each group was requested to begin the discussion but in no way serve as the group "leader". As it turned out, eaoh group disoussed the topios without the benet'it of an assigned leader. To ensure that the groupe would focus on the topios related to the objectives, a set of "charges to the IIIIIILll groups" were developed (Annex 4). As seen in the Annex, tor each topio listed in the proglWlllll!. a set of questions to be discussed wers fol'llllllated; the intention was l..re17 to provide the group with suggestions as to what issues, related to each topio, might be appropriate for discussion. In fact, each group discussed those questions and many others. Although it was decided that no rapporteur would be selected or assigned to a group, each group was requested to select one individual to present a brief - lasting less than fift minutes - ~ ot' the major points discussed. The individuals who were to g1 Ye a IIUIIIIII&I7' at' the groups' deliberations at the plenary session (which followed the group disoussions) were clearly informed they were n.t to keep elaborate notes, bI.lt merely a brief record. that they could use t'or reference when they made their presentation at the plenary session. The plen&r7 sessions were under tha chairmanship of the seminar director. Each group representative reported 1ihe sallent points discussed. After the three briet reports, all at' the partioipants had an opportunity for add1 tional comments, observations or questions. The priM&r7 purpose of the plenary sessions waa to give each group a s _ of what the other groups were diSCUSBi~. At the end of each day the sem'nar direotor summarized the conclusions reached by the gro\3P8. The oanolusions were drafted and presented to the oonsultante for 1iheir review sinoe they had part1oipa~ in eaeh ot' 1ihe group se..1ona and were able 1;0 judge tha aoouraay and v&Udit7 of the oonolusions drafted by the seminar director. A list of all of the oonolusions was prepared in draft form and distribu.ted to the parUoipan_ GIl the final day of 1ihe They then

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• • had an opportunity to review the oonolusions in their groups; and in a plenary session eaoh group reoommended any ohanges, additions or deletions that they felt were appropriate. The partioipants did not see the the draft of the conclusions drawn up by the seminar direotor until the last day of the seminar. This was deliberately arranged for there was the danger that if the eonclusions were distributed on a daily basis an inordinate amount of time would be spent discussing worda, phrases and the like in the conclusions. It was not the purpose of the seminar to develop a set of definitive, well-polished conclusions that would be binding. The seminar was essentially divided into three parts although this was not stated on the programme. Part I was concerned with "what is going on in the training and utilization of medical assistants", Part II with "what are the problems in the training and utilization of medical assistants" and Part III wi th "What needa to be done to improve the training and utilization of medical assistants." One of the oonsultants, Dr Ernest J. Watson, presented information and material as an introduction to Part III of the programme. Dr Watson discussed the need and importanoe of identifying the health needa of society before detsrmining the task to be performed by mediCal assistants. He also discussed how training programmes might be developed and how medioal assistants might be effioiently and effeotively used.

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During an afternoon session, oonsideration was given to the use of medical assistants in other parts of the world (Annex 5). This was not meant to be a comprehensive presentation but a review of a sample of programmes, past and present, in the training and utilization of medical assistants. Beoause of the signifioanoe of health oare delivery in the People's Republio of China, a one and a half hour session was devoted to that topic on the final day of the seminar, under Dr Sidel who had been able to visit the People's Republio of China on two ocoasions (Annex 6).

5.

RliSULTS

The relevanoe and significanoe of the seminar was immediately defined in the introduotory remarks by the Regional Direotor, Dr Franoisoo J. Dy. In his intrOductory remarks he said: " .•• When this regional aotivity was proposed to the Member oountries and territories of the WHO Western Paoific Region and endorsed by them it was felt that the topic was of particular relevance to this part of the world and that it was timely to seek an opportunity to consider the multitude of problems associated with the use of medical assistants and to discuss possible solutions.

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"We all are aware of the fact that the ultimate goal of making health oare available to every community, family and indiVidual is far from being reached in many of our countries, where 70 to 80% of the population live in rural and often remota areas. Yet it is Just this part of the population on which national eoonomies are often mainly

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based; so impaired produotivity due to ill health of the rural worker has every severe effects on the nation as a whole. Much thousht has been given to and much effort is being put into schemes to develop basio health eervices and programmes which could cover the entire population; but numerous cOll8traints hamper the suocessful implementation of such plans. Next to finanCial constraints the non-ayailabi11ty of health manpower in suf"ficient quantity represents the major problem. The establishment of new medical and other health professional schools has proved not to contribute a great deal to the" solution of the manpower problem. "Nobody will deny that i t would be ultimately desirable that full-fledged professional services be made available even in the most outlying parts of a oountry, but at the present stage of development and no doubt for quite some time to oome this is neither feaaiblenor economioally Justifiable. Education of the top echelons of health workers is a long and expensive undertek1ng, and at the end of this training such health workers have reached a level of knowledge and skills which requires for its optimal deployment sophisticated support in terms of technical facilities and of assisting personnel •••

" ••• On the other hand, it is not so much sophisticated medical care that is needed by the rural oOlllllUllity. The majority of health probl_ enoountered there are of a oomparatively simple nature not requiring a refined diagnostic and therapeutic armament. Moreover, the maJori~ of health probl_ facing today's rural oOlllDUllities in developing oountries are preventable diseases whioh oan sucoessfUlly be tackled by methods whose application does not require the highest degree of soientifio knowledge and skill. "In reoognizing these briefly outlined facts many countries around the world inoluding some oountries and territories in the Westem Pacifio Region are now produoing and employing health personnel whcse training is shorter, less elaborate, less expensive and - hopefully - more task oriented than that of the top-echelon health professionals. Also beoause of their sooial and educational background, they are better suited to 11ve and work in a rural environment. Good results as well as some failures and pitfalls have been reoorded in these experiments. No doubt there is a need to look for possible 1Jpprovement in the training and utilization of such "front_line" health workers where they are alread;y oOlllllissioned. Those oountries not ;yet utilizing this type of personnel but oonsidering their introduction soaner or later will surely be interested to learn from the experienoe of others. It is much regretted that the largest Member country in the Region, the People's Republio of China, with her considerable experience in the utilization of health auxiliary cOlllllOnly known as the "barefoot doctor" was unable to take up DIY invitation to partiOipate in the seminar. We had looked forward to invaluable contributions which doubtless could have been made. But even so I am sure that the expertise gathered around this table will make it possible for this sBllinar to reach

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conclusions of general validity, and that every one of you will gain some new inaigb.t and take away with you ideas worthy of further consideration ••• " It was neyer intended that this seminar deyelop a set of recommendations or guidelines on the training and use of medical assistants. The purpose was to consider as many aspects of the training and' utilization of medical assistants in a seminar environment as time pel'lll1 tted. There were no group leaders, no rapporteura, no position papers and no restrictions on What could be said. The seminar provided an opportw:li t7 to share ideas and experiences and produced a set of cOlloluaiOl18 •. '!'be oOllolusions presentsd in this report are not to be OOIlstrued in my way as reoOlllMndationa or guidelines. The conclusions represent the oollective wisdom and experiences of a unique group of individuals interested and inyolved in the training and utilization of medioal assistants, and hope~ will provide the reader with some new insights an tha training and utilization of medieal assistants which might not be obtained elsewhere.

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CONCLUSICtlS

1. The evolUtion ot the training and utilization of medical assistants in the Westem Pacifio Region is influenced by a number ot factors. The most prominent factors, however, moe I

(a) the historical development of each country and territory, (b) the health needs ot the population, (c) the gecsr811b7 ot the OCNlltry or terri tory , (d) national independence, (e> the availability ot health manpower resources, and (f) eoonomic oonsiderations.

PerhsjlSthe·!!I"st_impc)r~nt'iDilue~C:~-f~c:.t~,-~1i the. health 'rin.d8,of ~j,eopie and because these vary :rr- CCNlltryto country, no s1ngle pattem of training or ut:l.lization of medical assiatants baa emerged. The pattems are divergent as are the people, geography, history, ,and goyemments ot the Westem Pacific Region. 2. There should ~ nC! s1nale set or !!a~gory of medical assistants; these questions and that ot whether auch personnel should be utilized, are for the individual Gountry to deoide.

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3. With. a variety of "1;ypes" of medioal ..sistants, it is ineviteble that their functions shoul4 l1kew1se vary. Simple ,inOoulatiO!lS. cOllllllllity medioine, and lllatemal. oh1ld health care are but samples of the wide range of their duties. Indeed, these mwst vary if they are to be detennined by the

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• society's health needs, implied or expressed, which also vary. Furthermore, the title and name ascribed to a medical assistant is of lesser importance than the function he/she performs. Initiating a programme in the training and use of medical assistants provides countries with an opportunity to tailor the arrangements to their particular needs, something that cannot be done so readily in respect of the other existing health personnel. 4. Since training programmes are determined by functions to be perfonned, the types of programmes are also numerous. They vary in length, but this again is a matter for the individual country to decide on the basis of its needs, resources, and constraints. There is a danger, however, that progranrues can become too IonS and too detailed, imitating the education of physicians. At present local resources are being used for training but more resources are required. It is also evident that more qualified teachers of medical assistants are needed. Developing training programmes for medical assistants can also provide a career for those who might not otherwise have an opportunity to work in a health occupation.

5. Medical assistants can play a significant role in improving the health of a country or territory. Remote and rural areas can make excellent use of medical assistants. Admittedly each nation must determine how best to provide health services to these areas, but the use of medical assistants represents one approach which appears practical and economical. Physicians, especially, should appreciate the role of medical assistants and make every effort to utilize them to the maximum. 6. Uke other "key" health personnel, the medical assistant can be an "instrument of change" for the health of a nation, provided he is given appropriate training and resources. In performing his/her functiOns and being sensitive to the attitudes, mores, cultural patterns and religions of the people served, and by working together with others in "leadership" roles in the community, significant improvements can be brought about.

7. The services performed by medical assistants include the administration of health programmes, diagnOSis, treatment, dispensing, and community medicine; the role must be determined by local health needs. 8. Medical assistants have a role to play in urban hospitals but continuous review is necessary to ensure that a disproportionate number are not employed in such settings. If this does occur, it may be advisable to encourage, with additional incentives, some medical assistants to seek appointments in rural areas where they can have even a greater impact on improving health. However, this must be based on local needs and circumstances. Assessing the impact medical assistant have had on health services admittedly is a difficult matter. This is so not only because of the vsriety of tasks performed but also because, more often than not, the medical assistant is a part of a health team and is difficult to isolate those duties performed only by medical assistants or, indeed, by physicians, nurses and other health personnel. Nevertheless, much greater efforts must be made in this direction.

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10. For further improvement in training and utilization of medical assistants. it is important to be aware of potential problems. including the difficulty at times of attracting them to and retaining them in remote areas, their ill-defined legal status in oertain oountries. the possibility of reducing the health oare produotivity of,physioians who devote their full time to training programmes, the demands of some oommunities in selecting their own medical assistant, their reJeotion by some physiCians and nurses. and occasional politioal pressure to eliminate them from a country's health services for "prestige" reasons. Nevertheless, these are problems that can be dealt with if the programmes for training and utilization are well conceived and developed. 11. RecrUiting appropriately qualified and highly motivated candidates for admission to medical assistant training programmes must continue to be a priority goal. In admitting students, a balance appears appropriate ••• an appropriate distribution of the sexes, adequate cultural representation, representation of rural and urban baokgrounds. and other individual factors ensuring that students will be able to funotion effectively when they are posted. Individual oountry and Oommunity oircumstanoes should, in the final analysis, determine who is selectsd for training. 12. Training progr_ _ for medical assistants. as indeed all training progralllDSs, need continuous improvement. Teachers must be of outstanding quality and skilful in pedae;oQ;textbooks and other teaching/learning materials must be in an appropriate and relevant language; and examinations should reflect the subject matter learned and ahould critioally assess students' competence. There is a need to relate training programmes for medical assistants to the training of other health personnel so that the health team can evolve with each member of the team developing an appreciation and understanding of the other members' contribution to providing health care services. Progr8lllDes should be continuously evaluated so that they renect changes in health needs. health manpower supply, and other cirollllStances. 13. The matter of supervision of medioal assistants is a major but not an insurmountable problem. Beoause of the geographio looation of medical assistants' posts, frequently supervision is minimal. On the other hand. supervision should be minimal where the quality ot the medical assistant is known to be outstanding. But supervision is also a matter of quality. that is, individuals responsible for supervising medical assistants at times lack the ability to supervise adequately. FUrthermore. some professionals are reluotant to assume responsibility for supervision. It is obvious that more efficient and more effective ways to supervise medical assistants must be developed. A promising possible approach may be the ooncept of "cOlllllllll1ty accountability," that is, the community in which the medical assistant funotions oould develop standarda of performance and, on the basis of those standards. Judge the. work of the medical assistant. This approach. however. is extremely difficult and fraught with problems; so it must be critically examined before it is tried. Regardless of the approach to supervision decided upon. both the medical assistants' technical skills and their "output" should be supervised. 14. In addition to being adequately trained. for a medical assistant to function effeotively in a oommunity a number of other factors are important. Hel she should haft lin UIlCMntand1ng of oOlllllUllity health needs. be aware of

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community customs, be familiar with the eXisting health care system have access to referral "backup", have adequate facilities, be given rew~rds for outstanding performance, have periodic opportunities to take continuing education courses and be given incentive to remain in the community. The single, most important factor, however, is that medical assistants be satisfied with their job ••• knowing that they are appreciated for the contributions being made to improVing the health of a community.

15. Determining the types of medical assistants to be trained depends on a number of factors, including: (a) The health needs and demands of society. These can be determined from morbidity and mortality data, disease patterns, stated needs of communities and individuals, and data on accessibility to· health services. The needs of the profession. The needs of the profession can be determined from health manpower data, data on the distribution of manpower by type and geographic area, information on duties performed by physicians and other health personnel and the way the profession perceives the role of the medical assistant. Availability of resources. This determining factor includes financial resources to support the medical assistant, physical facilities to enable him/her to function as a health worker, and opportunities for continuing e<Jcat~on and car~er mobility.

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(c)

16. In determining the types of medical assistants to be trained a distinction between physicians, nurses and other health workers must be made. While there might be some variation wi thin the category, roles must be clearly defined to avoid professional conflicts, overlapping of responsibilities and gaps in the delivery health services.

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17. Each country or territory must take into consideration a number of factors in determini.ng where medical assistants are to be trained. Wi thout a doubt the objectives of the training programme are important and must relate to the tasks to be performed, but it is not always possible or practical or desirable for training to take place where the medical assistant will work. On the other hand, it is not essential and at times is impractical to train medical assistants with medical students at a medical school.

18. The curriculum for training medical assistants must be flexible. The training objectives must be responsive to the changes in the health needs of society and other conditions. CUrricula, to some extent, should reflect the cultural and social values of the populations which the medical assistants will serve. It is of the the greatest importance that all students be thoroughly and continuously evaluated in order to attest to their competence to perform as medical assistants before they graduate. 19. Medical assistants should be trained so that they may assume a wide range of responsibilities such as operating and administering rural health centres and becoming leaders or coordinators of the health team.

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20. The utilization of medical assistants can be improved in a number of ways. Without question, however, the most significant way is having his/her role clearly defined and understood. Once the role i~ defined - by training or statute or both - medical assistants will be in a better position ~ to assume responsibilities beyond their capability. By the same token, if medioal assistants are given the opportunity to delegate some of their less "professional" responsibilities, as well as referring more complicated and involved tasks to more highly qualified professionals they will be better able to offer the health service for which they were trained. 21. Far greater efforts are needed to make medical assistants an integral part of, and acceptable to, the community they are assigned. If a community has never had a medical assistant, it should be informed beforehand about what the medical assistant will do, how he/she will relate to the total community, and what his/her responsibility to the communi ty will be. At thll ssme time, medical assistants must be adequately prepared to assume their community role. They should not be socially superior or inferior, should understand and appreciate local community customs, should be familiar with the community dialect and be willing to p~rticipate in a wide range of community activities directed toward community development. 22. The quality of services offered can be improved if the medical assistant is a personally and professionally contented individual. This can be done in a number of ways including: (a) (b) providing adequate housing, salaries. continuing education courses, journals and equipment; encouraging medical assistants to upgrade themselves to become teachers of other or similar auxiliaries, to teach community volunteers in health and other subjects, to meet other health personnel and to adapt new health technology to the community; ensuring that paper work is at a minilDlllD and, for those who desire it, providing an opportunity for job rotation to other areas.

(c)

In the final analysis, medical assistants will be contented personally and professionaly if they are appreciated and their contribution appropriately rewarded. Some medical assistants may wish to become physicians and should not be denied this opportunity. However, it must be made clear to them that the route to this goal will be arduous, with all university requirements having to be satisfied.

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The seminar was most suooessfUl in achieving its obJeotives, as pointed out by the seminar direotor in his olosing address n

• •• the use of medioal aesistants appears to be an approaoh of oonsiderable potential; that, potential has already been demonstrated. It is up to all of us to oapitslize on that potential in mrder to make the availability of quality health servioes to all peGple a reality. "

7.

EVALUATION

At the oonolusion of the seminar the partioipants were requested to oomplete an evaluation form (Annex 7). They were requested not to sign their ~ to the form and to be espeoially oritioal and oons~ot1ve on question 8 which dealt with how the seminar oould be improved. The replies oonoerning the degree to which the seminar obJectives had been IIIEIt and the value of the topics discussed are summarized and tabulated in Annex 8. The reaction to the consultants, as might be expected, varied. The oonsultants were perceived to be espeoially helpful in clarifying isaues, offering suggestions, asking pertinent questions, providing insight, but most of all in giving the participants the benefit of their experienoes. Similarly, the partioipants almost unanimously agreed that they would have liked to hear more about the experience of other countries in the training and utilization of medical assistants. The partioipants' peroeption of their ability to influenoe the development or improvement of programmes to train and to utilize medioal assistants in their countries was espeoially interesting. Only two could not say whether they "ould have any' effeots the re_inder felt that they would be able to influenoe their programmes. As a _tter of faot, thirteen peroeiyed themselves as having "oonsiderable" influence in their countries.

The suggestions as to how the Western Paoifio Regionsl Offioe oould encourage greater utilization of medical assistants were as varied as the partioipants themselves and are not inoluded in this report. However. the suggestions can be ~ized as follows: (1) (2) (3) (4) hold more seminars on thiis SUbJect, assist oountries in assessing their need for medioal assistants. study the roles of different medical assistants in different oountries. oonduot operational and evaluative researoh on medioal assistants.

(5) (6)

provide consultant and other technical help to assist countries 1n developing pro~s. and ..sist in developing short-tel'll teeober training ~s.

All to ways of improving the seminar. OIll,. tour suggestions were ottered. calling for: (1)

more time to review oonclusions.

(2) (,)

110" IIQre

detailed /Il'aup reporte. _terial on currioula and teeohiJls _terials. and

(_)

&

written ~ ot .ediAl assistant prosr-s in the oountries represented.

tlat

".ftI71;h1Dg was

'!be oOllSeneus. however. perhape was in the _orela ot one partioipantot the h1pst order."

- 15 -

ANNEX 1

PROGRAMME

Tuesday, 1 October 0830 - 0930 '

•

(1) (2) (3) (4)

Opening remarks by the Regional Director Introduction of participants, consultants am secretariat Administrative announcements Seminar format

1000 - 1200.

Small groups - Session I Topic A - Evolution of medical assistanta Topic B - Training of medical assistants Continuation of small groups

1500 - 1600

Plenary session

Wednesday, 2 October 0830 - 1045

Small groups - Se88ion II Topic C - Utilization of medical aS8istants Topic D - Impact of medical assistants on health services Plenary session Small groups - Session III Topic E - Probleas in training medical a8si8tanta Plenary 888Sion

1100 - 1200 1245 - 1400

am utilization of

1415 - 1515

Thursday, 3 October 01330 - 0900 0900 - 1200

Plenary se88ion:

Improving the training and util1zatior, of medical assistans (J. Watson)

I

Small groups - Session IV Topic F - Determining types of medical assistants Topic G - Developing effioient training programmes Continuation of small grOUp8 Plenary session

• 1245 - 1400 1415 - 1515

- 16 -

Annex

1

Friday, 4 October 0830 - 1045'

Small groups - Session V Topic H - Improving the utilization of medical assistants Plenary session Plenary session: The training and utilization of medical assistants in other parts of the world

1100 - 1200

1245 - 1515

Monday, 7 October 0830 1000

Plenary session:

Discussion of health care deUvery in the Peoples' RepubUc of China

1015'

-ino

Small groups - Review seminar conclusions Plenary session and conclusiona Closing session and evaluation

1130 - 1200 1200

- 17 -

ANNEX 2 LIST OF PARTICIPANl'S, CONSULTANTS AND SECRETARIAT 1.

PARTICIPANl'S

AUSTRALIA AUSTRALIE

Dr Br1an Re1d

Ass1stant D1reotor Child. and Rural Health Department of Health Northern Terr1tary Dr Bhupendra Path1k Aot1ng Pr1no1pal F1J1 School ot Medioine SUva Dr Pen1 Vu1yale

FIJI FIDJI

Direotor of Preventive Medical Servioes Health Department SUva FRENCH POLYNESIA Dr Lou1s Carloz POLYNESIE FRANCAISE Medeoln-aJoint au Direoteur de la Sante publique B.P. 611 Papeete GILBERT AND ELLICE ISIANDS lLES GILBERT-ETELLICE KHMER REPUBLIC REPUBLIQ,UE KHMERE

S1ster Rotia Tito Medioal Department P. '0. Box 268

Bikenibeu, Tarawa Dr H1ng Kunthuon

Bureau oentral de Statistiques et de Plan1f1o&tion Minist~re de 1& Sante publique Phnon Penh Mr

MAlAYSIA MAIAISIE

William Greenall Prinoipal Hoapital Assistants Training Sohool Serellban, Nageri Sellbllan bin Baba AhIIIed

Mr Mohanmed Mesh

•

Senior Tutor Sohool of Nursing General Hospital Penang

- 18 -

Armex 2 Dr S.K. Mukherjee

Director of Medical Services Medical and Health Department Kuohing Barawalt

NEW HEBRIlES

Dr A.J. Sinclair

NOUVEUES-HEBRIDES

Senior Medical Offioer Medioal Department British Residenoy Port-Vila

PAPUA NEW GUINEA Mr Mathew Hapoto PAPUA-NOUVEUE-GUlNEE Health Extension Offioer Public Health Department P. O. Box 1034 Boroko

PHILIPPINES

Dr Trinidad A. Gomez Chief. Offioe of Health and Eduoation Persormel Training De~nt of Health Manila Dr Franoisco Aguilar

Chief. Office of Planning Service Department of Health Manila REPUBLIC OF KOREA REPUBLIQUE lE CCJlREE Dr Choo Hwan Kim

Section Chief Public Health Seotion Bureau of Publio Health Ministry of Health and Sooial Affairs Seoul Dr Arobati Hioking Senior Medical Offioer/ Deputy Director of Health Servioes Department of Health Services Saipan

TRUST 'l'ERR1:TCRY

OF THE PACIFIC ISIANDS TERRITOlRE BOOS TUTEUE DEB lIES DU PACIFIQUE REPUBLIC OF VIET-NAM REPUBLIQUE DU VIET-NAM

Dr Nguyen-Xuan .Trinh Chef du Service de Formation Minist8re de la Sante 59. Ed. Hong-Thap-TIl Saigon

- 19 -

Annex 2 Dr Van Van Cua

Directeur interieur de l' InstUut Institut national de Sante publique 135 Tran-Hoang-Quan Saigon Dr Nguyen-Kim-Son Directeur <.'e l'Ecole de infirm1llres de Banm@thuet (Dsrlac) Darlac

WESTERN SAMOA SAMOA-OCCIDENTAL

Ms. Leti Tufuga-Fatu Hospital Nursing Supervisor Health Department Apia 2.

CONSULTANTS

Dr Edwin F. Rosinski (Seminar Director) Vice.Ch&noellor University of California San Franoisco, California 94122

U. S. A. Dr Viotor W. Sidel Chief, Departaent of Sooial Medioine Montefiore Hospital and Medical Center 1-11 East 2l0th Street Bronx, New York 10467

U. S. A. Dr E.J. Watson

Principal Para-Medical Training Centre Department of PUblic Health Madang, Box 2033 Papua· New Guinea 3. SECRETARIAT

Dr Deniel Flahault

Chief Medical otfioer Health Teu DeveloJallnt Division of Health Manpower Development WHO Headquarters Geneva

- 20 -

Annex 2 Dr Ewald G. Kapal (Operational Offioer) Health Manpower Development WHO Regional Offioer for the Western Pacific Manila

Ms Mary O. Abbott Regional Adviser in Nursing Eduoation WHO Regional Offioe for the Western Pacific Manila

Dr George Emery Regional Adviser on Community Health Servioes WHO Regional Office for the Western Paoifio Manila Mr J. Aboede

PUblio Information Offioer WHO Regional Offioe for the Western Paoific Manila Dr R. Coppedge

Senior Medical Offioer ProJAot VNR/HMD/a2 (6b.OJ) Saigon Republic of Viet-Nam

Dr R. Leclercq Medical Officer ?,roJeot LAO/HMO/Ol (6201) Vientiane Laos Ms. O. Manning WHO Nurse Educator ProJeot ICP/HMD/CY;) (4401) ~

FiJi

4.

OBSERVERS

Mr Peter Bailey Programme Officer UNICEF P. O. Box 883

Manila

- 21/22 -

JIfa COIl8tanoe SIf1ntoll

MnlberCIDA .lI'1eld Trainina De_tration ProJeot National Jnati tute ot Publio Health Saie Republio ot Viet-NaIll

- 23/24 • ANNEX 3

BrJ'U1t, John (1969) Health and the developing world, New York, Cornell Uni verai ty Press Pendall, N.R.E. (1972) Auxiliar1es in health oarel Progrll/lllll8S 1n d.velopin.e; oountries, Saltillore, Johns Hopk1na University Preas (tor Josiah Maoy, Jr. Foundation) RoalnU1, B.P. " Spencer, P.J. (1965) 'DIe Asa1atant III8dloal ottioer - the tn1n1n.e; ot the HCUoal auxiliary in d.velopin.e; oountries, Chapel Hill, University ot North Carolina Press Sadler, Altred et. al. (1972) 'DIe phfBioian asa1stant- tody and ~rrow, New Haven, Yale Univera1ty Press World HIIaltb, June 1972 Pan AMrioan Health Organization (1973) Medioal auxiliaries (So1ent1fio ~blioation

No. 278).

Store,. Patriok(l972) 'DIe soviet teldllhllr as a a1oian's asa1stantBethesda John E. Poprt,. International Center Department ot Health, Bd.uoation and Weltare PUblioation No. (NIH) 72-58). Sanaoal, J. (1968) The training ot paruedioal personnel 1n the develop1ng oountries, Iarael J. Med. So1. 4, pp. 665-70.

- 25/26 -

ANNEX 4

CHARGES TO SMALL GROOPS

Tuellday, 1 October Topic A: Why

Disouss the evolution of the development of medical asllistants. was it decided to use them? Who decided? Types being used; wb7 this particular types? In what settings?

Topic B:

Dis11'Oas

how medical aSllistants are trained. B.Y whom? CUrricula? Evaluation?

Wednesday, 2 October Topic C: Topic D: Discuss how medical assistants are utilized. B.Y whom? What do they do? Where are they used?

Topic E:

Disoussthe impact that medical assistants have had on the delivery of health lIervices. Is there any evidence to support the improvement in health? Improved accessibility to services? , Discuss the problems encountered in the traininf and utilization of medical assistants. Acceptance; supervision, promotion; legal status.

Thursday, 3 October Topic F: Discuss the ways to determine what types (if any) of medical assistants are needed. Needs of society? Needs of the medical profession? Can existing health personnel fill the roles? Discuss how medical assistants can be trained efficiently for most effective utilization? In new settings? With other health personnel?

Topic G:

Friday, 4 October Topic H: Discuss ways in whioh the utilization of medical assistants can be improved. As part of health team; better supervision; greater independence.

Monday, 7 October Review the conclusions. Any

corrections, additions etc.?

- 27 -

ANNEX 5

THE USE OF MEDICAL ASSISTANTS IN CYl'HER PARTS OF THE WORID INTRODUCTION - DR D. FIAHAULT Between the 15th and 16th oentury in Europe, barbers were used in armies as surgeons and were known as feldshers. In the year 1840 Jamaioa established a school for "dispensers" while in 19th oentury Franoe, health offioers, comparable to medioal assistants, were trained. In India, there were assistant surgeons, and at the end of the 19th oentury vaccinators were trained in Fiji. In Indo-China, prior to World War I, IndoChinese dootors were introduoed. In Afrioa, a number of experiments were undertaken by the English and French speaking Afrioan oolonies. In Nigeria medioal auxiliariea were trained for the English oolonies of Western Africa. At the beginning of the 20th century, beoause of the shortage of medical staff in the armed foroes and the need to extend health ooverage, the "Dakar Sohool" was developed and beoame the most important sources of medioal assistants for all French speaking territories. Around the 1930s, in the former Belgian Congo, Leopoldville was the site of the first "Medioal school." In Algeria, after independence, a oategory of worker called medical public health assistant developed, while in Indonesia the Dutch trained a type of "doctors" which they called medical assistants. In the years 1955 to 1965 - the end of the colonial era - serious problems occurred in connexion with medioal auxiliaries. Medical assistants had been closely related with the develo~nt of health services, but they were perceived as secondary types of health personnel. With independenoe there wae resen~nt in the training of medical assistants. In 1964 in the United States of ~rioa. the first lMdical &asistants programme was developed at Duke University. It was the first time that in a highly developed oountry this oategory of medical assistants was introduoed. The Amerioas were late in acoepting the concept of lMdical assistants; the United states of America made a start in 1964. and Guatemala is now developing a progranne. USSR - r:R V. SIIEL Medical assistants in the Soviet Union are known as fledshers. They were introduced in the Russian armies by Petar the Great in 1700 as a variety of the German army "field barbers".

- 28 -

Annex 5 In 1861. there developed in Russia local units which were responsible for providing medical care for the areas under their administration. These uni ts had no IIIOney with which to hire doctors so instead they hired retired army fel<iShers. In 1864. the demand for feldshers was so great that the first training school for civilian feldshers was opened. In 1900. there were some thirty-two feldsher training sohools. there were some 30 000 feldshers, more than the number of doctors. In 1913.

In 1918, following the Revolution, it was decided to phase out the feldshers and to replace them with regularly trained doctors. However, the difficulty of getting doctors to move to rural areas made it impossible to provide adequate health services without feldshers. In the period from 1913 to 1965 there was a vast increase in the number of physioians, feldshers and other health workers in the Soviet Union. At present, there is one health workers for every 100 men and women. Feldshers play an important role in the health oare system. Health workers are salaried whethev they are physioians or any other kind of health worker. In Soviet Union, particularly at the end of World War II, maternal and ohild health and ocoupational health gained importance. Also oooupatior.al safety and therapeutic medicine for the faotory workers evolved. The most reoent data indioate that of the feldshers, 5<J:' are women and 5<J:' are men. Feldshers have different roles in urban and rural areas. In urban areas they work with plIysioians and the physioians provide direo,t supervision over them. In rural areas the feldshers are stationed with midwives and a close relationship with the physician exists. Feldshers have full secondary sohool education follOWed by feldsher training which lasts two and a half years. If the period of secondary and primary eduoation is shorter, feldsher training lasts for three and a half years. Auxiliaries have shorter training periods and work under the direct supervision of the feldsher.

AFRICA - rB! D. FIAHAULT

In Dakar, after World War I, when the military doctors decided to extand coverage of health services to the rural regions, they undertook a radical reorgenization of the health services. To acoomplish this reorganization they needed additional personnel and this need for more health personnel was the major reason for establishing the sohool in Dakar. The medical assistants were trained for four years and reoruited at the level of 8 or 9 years of primary and seoondary education. Training was followed by one year's intarnship

- 29 -

Annex 5

supervised by dootors in various ho.pitals. The training espeoially suited the medioal assistant. to the oontrol of endeBdo di...... of the region and they provided great servioe. for the African population between the two world wars and even after World War II. In 195~ the sohool in DaII:ar,'J:)eoame a faculty of medioine. Political pressure led to an ending of medioal a.ststant training and exi.ting medioal assistants. who were not too,old. were given an opportunity to suppl...nt their studies to beoome MIla. At pre.eRt. there are no medioal a.sistants a. suoh. rather MDs who reoeived additional .tudy. In Zaire. a .1milar medioal a.ai.tant was trained. but the orientation of the training was more preventive. Medical as.lstants were workers in rural hospitals throu8bout the oGUntry and ~ aotually .peoialized in minor surgery. As in other C01U1tr1.S of Afrioa. the oonoept of medioal assistanta r1U1 into psychologioal and politioal diffioulties. The medioal aSSistant was the only one to baok up the European dootors. At the time of independenoe there was not one Congolese dootor and the need to produoe more doctors beoame a most urgent priority for World Health Orsantzation. TO upgrade the medical a.sistants to MD level. they were sent for three years training to a European medical school to supplement their medioal uai.tant training. This prosrs- was most sucoe.sful and a number of Mdioal assistanta returned to Africa as MDB. ~t that did not solve the health manpower problem of rural areas. Rural hospitals. where medical assistanta used to work before independenoe. often have no skilled personnel other than the public health nurse. Zaire is aware at ita problems and is trying to find .0lutiCIIIB 1:0 thi. by s . .ing whether they oan return to training of medical assistants. In Engliah speaking African aOlU1trie. like Kenya. Malawi. Zambia and Nigeria, medical . . .i.tant. under went a three-year oour.e atter eight to nine years of basio eduoation. They worked at rural oentre. in curative and preventive oare. After World War II lI8d1oal as.i.tanta beo_ part of health teams. and their training was extended. The evaluation of the prognu.es and curricula was done on a regular basi.. in such a way that medical assistant were fundamental in improvement of the health of the population. In Higeria. _inly in the Northern states. there are few plt;ysiciansl therefore community nur •••• di.pensary attendants and dres.ers assume medical assistants' funotions. The need for medical assistants is reoognized. but opposition to them i. still strong. The Nigerian Medical A.sociation favours the training of nur.e. rather than medical assistants. In Uganda and particularlY in SUdan. prosra-Bs for MOe and medical aUXiliaries r1U1 parallel to each other. There i. excellent tsam work in the rural health oentre•• In Uganda. the medical assistant is responsible for the health of an area with a bmalth centres. and suboentres and dispenaarie ••

- }O -

Annex

5

In Tanzania, which is influenced b:y the Chinese model, the level of medical assistants can be oompared with that of the barefoot dcctors. 'Tanzania has several levels of medioal workers other than physioians who aot as primary oare health personnel and include rural medical aides, medioal assistants, assistant medical officers and licensed l18dioal practitioners. Health centres are manned b:y Assistant medical officers and med1cal ass1stants only do simple ourat1ve work 1n the hosp1tals.

ETHIOPIA - DR J. WATSON

In Ethip1a, the Gondar PUblic Health School trained health off1cers(four years), d1spensary attendants (one year), sanitariana (three years) laboratory workers (three years) and nurses (three years). '!be nurses were trained 1n basic commun1t:y health, obstetrios and general nursing. All students were trained as a team doing their praotical work together in a nUmber of ways. Assooiated with the School were five training health centres with a number of villages near each health centres. At the training health centres the tra1ne,e health officer, sanitarian and nurse work together, particularl:y 1n the1r final :year of training. '!be health offioer is the auxi11ary to the doctor and may be considered equivalent to a medical assistant. They are the tsam leaders ar.d are in charge of health centres. Ethiopian health teams follow a wellplanned concept and are still considered an efficient part of the health services. The training was done aga1nst a background of great poverty. The population of Ethiopia is ten times that of Papua New Guinea, yet the budget is the same. When the Addis Ababa Medical School opened in 1962, the Gondar School became part of it. The training of health officers became more academic and they began avoiding work in remote areas. Also, health officers were given opportunity to become medical doctors after speoial training.

IRAN AND SRI IANKA - DR E.F. ROSINSKI

For a number of years Sri Lanka tra1ned and uti11zed a middle level heal th worker known as an Apothecary. Ths training was of two years duration and students were requ1red to have 10 to 12 years' preparatory education prior to admission. The training took place at the Medical College in Colombo with the first year devoted to phannacy, elementary anatomy and physiology. The second year cons1sted of course work in medicine, hygiene, public health, surgery, materia medica, antenatal and postnatal care, child welfare and dispensing. '!be Apothecaries funct10ned as II generali.a~s" dealing with ourative and preventive medicine. '!be intent10n was to "phase out" the training of Apothecaries as aoon as there was an adequate suppl:y of physioians and the physioians were equitably distributed geographioall:y.

- ,1 Annex 5 In 1950 Iran disoontinued its prosr- of training Behdars. their equivalent to a middle level health worker. The Behdari programme was of four years' duration with the first two years deYoted to the premedioal and basio medioal soienoes and the last two years to -.dioine. sursery. parasitology. pharmaoology aM a number of speoialty olerkships. The Behdar was assigned to small Tillage. am rural areas and fUnotioned as a "general" practitioner." He was required to work as a Behdar for eight years after which he could seek ~i •• ion to a -.dioal sohool. The Behdari training programme was of such a type that tho.. selected for medical sohool were required to oomplete only the last three years of the seven-year medical school currioulum. Almo.t every Behdar eleoted to return to medioal sohool. To fl11 the gap in health serTice. left by the di.oontinuance of the Behdar progr_. Iran has reoently initiated a prosra- to use village health workers trained in less than ona year.

MALAYSIA - III KJKHERJEE

•

"Medical assistant" training started in Malaysia around 1890. with a category of health workers known as dres. .ra. Training of male nurses and then hospital assistants followed. The hospital . .sistants eventually beaa.e the backbone of health services including the smaller hospitals in the districts. The goal of health services in Malaysia i. to provide a continuity of service. that is. the same range ot .erT10e. at all levels and to integrate preventive and ourative .ervice. tor the promot1on of health.

Medical .ervloes in Malaysia and Sarawalt inolude the general hosp1 tala under which there are district ho.pital.. Main health centres are for a population of 50 000 While health suboantres are for a population of 10 000. Eaoh main health centre has fClUr auboentres. At the suboentre there 18 a mldwife and a ocmnun1 ty nurse for every 2000 population. COIIIIIIUn1 ty nur.e. are midwives who have had six months' additional training in oOlllll\UIllty health.

The organization in Sarawalt is quite different lleoause of different problems. " It includes the general ho.pital. provinoial hospitals and district hospItals. In Malaysia. there are n\llllerou. oategories of medical auxiliaries who have primary. subs1diary and supportive role ••

VIET-HAM - III VAN VAN CUA

• In VIet-NaIll. the first ...o.io&l tuul ty w.. established in Hanoi with teaohers frOlll France and the trainee. in a category of "Indo-Chinese

doctors."

- 32 -

Anrex 5

In 19JOa there were two types of dootors, "French" dootors and Indo-Chinese dootors. Frenoh doctors were looated at Saigon and Hanoi. ~ oategory of Indo-Chinese dootor. was later abandoned and the Hanoi Medical Sohool started training Frenoh medioal dootor.. Around 1945, a second univer.ity faoulty of medioine was opened in Saigon. After independenoe, a number of army phy.ioians and Frenoh dootors returned to Franoe and there was a shortage of dootors in Viet-Nam. The Ministry of Health turned to the training of medioal a •• istants, in. a three-year oour•• oentred around olinical problema and preval.nt di.ea.... This programme oontinued for four year. and was eventually turned over to the army which oontinued it. The oivilian school no longer operate.. At pre.ent, nurses, midwives and publio health a.si.tants are trained. Medioal assistants make medioal diagnoses, treat widespread diseases including infeotious diseases, provide maternal and ohild health care, and deal with sanitation proble... Efforts are being lllade to streamline the ourriculum and to take publio health assistants out of hospitals and send them to olinios in the distriots. FIJI - DR VUIYAIE In 1818 young people were reoruited as vaooinators against smallpox. Over the years the programme expanded and eventually led to a three-year medical assistant oourse in 1886. Practitioners were sent to rural areas, while some worked in hospitals. In 19JOa the Rookefeller Foundation oreated the Central Medioal School for the South Paoifio and took studenta from various neighbouring islands (Tonga am Western Samoa) for training. The graduates were known as Assistant Medioal Offioers. Gradually, the course was upgraded and with speoialization, some Assistant medical officers became registrars and developed into much more specialized practitioners. In 1952 the length of the oourse increased to five years and correspondingly higher eduoation for interns was required. Graduates of the five-year oourse were awarded a diploma in medicine and pursued university level work in specialized hospitals. However, Fiji is at the stage where it is obvious that the professional school graduates are underutilized at the health centres in rural areas. For this reason in 1971 the International Medical Education Mis.ion, at the invitation of the University of the South Pacific and the Government of Fiji, oame to advise on the future of medical, dental and health auxiliary eduoation. The mission noted that IDUch work carried on by small health teams requires the serviaes of less than fully qualified professionals. The Fiji Government therefore asked the World Health Organization to make a study to assist i t in defining its needs for health s.rvices and detemining its requirement of personnel to provide the servioes.

- 33 -

Annex

5

LAOS - M R. IECIERCQ.

Since its establishment in 1957. the Royal School of Medicine of Laos has produced 168 medical asaistants. at the rate of 14 per annum; 80% are civilians and 6~ are male. ']he duration of training wu four years until 1972. one year of publio health studies was added.

After that date.

Data ooncerning graduate medioal assistants As of 1 February 1974. out of the total of 168 graduates: lout of 10 became a physician (4 additional years of study in France) lout of 10 was going to beoome a physioian

- 17

19 - 132 - 8

8 out of 10 remained medical . .s!stants •

1.e. 0.5 out of 10 was lost (dead. expatriate. without medical oocupation)

2 out of 10 are following refrellher courses (2/3 abroad)

32 -

5.5 out of 10 praotise in Laos (2/3 in the Provinoe of . V1ent..1Jirie,. 1.e. 1 medical assistant for 8000 1nhab1tants and 1/3 in the other provinoe.. 1. e. 1 medical assistant for 45 000 inhabitants Opinion poll that: ,85~

92 58

- 34

among

the .tudents following medical assistant courses

The replies given to a questionnaire

b7 99 students (out of 117) show

wish to carry on with MO studiss after obtaining their me4ioal assistant degree; wish to work in a hospital;

~

27'1> wish to work in a rural health oentre. but half of these in the Province of .Vientiane only; thus. outside this province and for the next five years •. there will be no more than one rural medical assistant for each province • •

The more the students advance in their studies. the less they appreciate the differenoe between the medioal assistant and a medical offioer.

- 34 •

Annex 5 Data oonoerniIII the IAotian medioal body In the area oontrolled by the Vientiane Government, out of a total of 2 000 000 inhabitants, there were, as of 1 February 1974:

. 55 .dootors 1}0 medioal assistants Amons the medical dootors: 7 out of 10 graduated from French universities

8 out of 10 work in Vientiane hospitals none praotise in rural zones Among the medioal assistants: 7 out of 10 are graduates of the Sohool of Medioine in IAos

8 out of 10 work in hospitals 6 out of 10 work in Vientiane hospitala 6 out of 100 work in rural areas

For a total of 200 000 inhabitants, Vientiane has: 1 medioal doctor for 5000 inhabitants 1 mediaal assistant for }ooo inhabitants

For the rest of the governmental zone (1 500 000 inhabitants), there are: 1 medioal dootor for 120 000 inhabitants 1 medioal assistant for 27 000 inhabitants The two main problems faoing IAos (1) (2) How to oope with a gap in rural health whioh widens with a yearly population inorease of ~1 Is it advisable for this oountry to oontinue the simultaneous trainins of two·aategories of medical personnel whioh are not easy to differentiate? This is useless in rural areas, and its value remains to be demonstrated in oities. •

- 35,06 -

Annex 5

USA -

m v.

SIDEL

In the 78ar 1900, the leading causes of death in the USA were - pneu.onia and influenza - tuberoulosis - diarrhoea, gastroenteritis - diseases of the heart Seven1;J' 78are later, the leading oauses of death were - Mart disease - cardiovascular disease - oanoer and malignant tumour - stroke - accidents - infeotious oauses of death In the USA there is one doctor for every 700 people. The problem in the USA lies in the distribution of health personnel. In 1969. 500 000 people in the United States were living in counties with no praotising phYsician. A number of approaches have been attempted to deal with the ma!distribution problem. TO develop a new form of medical personnel, in 1964 Duke University began training personnel called phySician assistants, equivalent to the medical assistants. In 1960 the phYsiCian assistants were unhappy about being called "assistants" so they were given the title of phYsician associates. Dr Richerd 8mi th developed a p~ for medical extender or Madex, relying heavily on former corpsmen. At Duke Univer81ty the prog~ is largaly acade.nc with graduates taking assignments in hospitals and other medical centres. The Madex, after some didaotio training, is placed with a praotitioner to whom he becomes an apprentice. During the pest twenty years phYsioians and other health workers have moved away from the poorer seotions of cities. TO fill the gaps, under some kind of government sponsorship, different types of health workers are being trained such as casunity health aides, fuily haalth workers and school aides. These workers generally are tmined for three to six months.

•

Muoh of ths medioal praotice in the United State. is in the private sector. I t is l,argely on Unooordinated, unoontrolled type of praotioe and in that situation medical assistant. -u.t work with an individual physioian or individual sraup at physiciana.

- 37 -

ANNEX 6

HEALTH CARE JELIVERY IN THE PEOPU'S REPUBLIC OF CHINA - m V. SIlEL

The health of the Chines. people hall ohanged greatly over the past few decades. The change is apparent in IIIIUIY .ome reflected in the 8Jlecdotes that returning visitors tell, and others in the few available statistics. The most dramatic change is in the prinoipal' oauses of death.

_Y.,

In China, during the 19,08 and 1940s, the leading oauses of death were infectious and parasitio diseases and oomplioationa of malnutrition. Today it appears that the leading oauses of death, at least in a large city such as Shanghai, are the same as those in the de~loped nations of the West: canoer, stroke and heart diseases. In 1949, the population of China was .stimated to be 540 million, some 85 per oent rural. ~ith respeot to the praotioe of what the ,Chinese oall "Western medioine, n there were at III08t 40 000 Western-style physioians and perhaps 90 000 beds in Western-style hospitals. If these medioal resouroes had been evenly distributed, the ratio of physioians to potential patients would have been one to 1, 000 and of beds to patients, one to 6 000. Instead, of oourse, most of the resouroes were oonoentrated in a few oities, and even there most of the population depended on p!'actitionera of traditional Chinese medioine for suoh oare as they reoeived. Beginning in 1949, China's new goftl'!Bl!lnt oonfronted this defioienoy in health resources by initiating a dual prosr-. Some of the strategies adopted by the New Ministry of Health were unique to China; others were the same strategies as those adopted by many other teohnologically underdeveloped nations. In the first oategory were innovative efforts to involve the bulk of the population in "mass lIO_nts" • nteee w.re aimed pr1lliarily at improving publio health and sanitation. A fUrther innovation was an attempt to enlist the praoti tioners of tract 1 tlonal,lIII<l1oines in, 'o~rall heai th Prosra_s,' In the seoond oategory Were pro~s that empha.ized the training of large numbers of new health workers. nte prinoipal efforts to increase the numbers of·health personnel were direoted on one hand toward the trainIng of m!ddle level health worker., and on the other toward the e.tablishment of oentres of exoellenoe. These oentre.· . .re urban training faoI1Ities that were expected to pioneer new medioal techniques and also to provide a flow of skilled personnel to areas of speoial need. In 1950, at a national health oonferenoe in Peking, four prinoiples of health were emphasized:

•

•

(1) Medioine must serve the workers; (2) TraditIonal Chinseee medioine must be integrated with Western medioine; (3) Prevention must be put fir.t; (4) Health workers IIIlSt be part of the health movement in the rural areas.

- 38 -

Annex 6 By 1965, in roughly 15 years. China had trained 150 000 doctors in courses of five to six years; but the population rose to 725 060 000 so that there was a total of one dootor for every 500 000 people. There was courses of only three years for an "assistant doctor" similar to the USSR feldsher. ']here was one aasistant dootor for every 400 000 people.

The brigade health station is served by barefoot doctors. who generally receive three to. six months' initial training. followed by continuing on-the-Job education. Barefoot dootors think of themselves not as expert health workers. but as peasant who do SOBle medical work. They have been responsible for' treating the "light diseases" of .fellow brigade members: minor injuries; gastrointestinal illness, oolds and bronohitis. ']hey alao administer immunization against diptheria. tetanus, whooping cough. l18asles, smallpox, _poliom,relitis. Japanese encephalitis and meningococcal meningitis. Another of their publio health duties is to supervise the oolleotion, treatment and storage of huaan exoreta for utilization as fertilizer. They reoeive no extra inoome tor their work as barefoot dootors. but their health-station servioe earna them work points. so they lose no inoome either.

•

Following the Russian modele. the Ministry of Health set up a number of middle medical schools. Students who had reached the intermediate level of the secondary sohool system were sent to middle medioal school for a threeyear course that prepared them to work as "assistant dootors". This is a category oa.parable to the Russian feldsher. a physioian's assistant who is expeoted to act as a physioian when neoessary. At the same time the middle medical sohools trained other personnel suoh as nurses. midwives. teohnicians and pharmaoists. Medical care in urban China follOWS the same portion of deoentralization as in the rural areas. 'In Peking proper, for example. the nine urban distriots have an average population of about 400 000. The city's munioipal medioal services inolude tour speoialized research hospitals and twenty-three general hospitals; ten of the general hospitals have more than 500 beds. Eaoh of the nine distriots is subdivided into "neighbourhoods". The publio Health Department is responsible for supervising the urban equivalent of the rural produotion-team aid stations: a total of 25 health stations operated by "lane o~ittees." The Fenaheng neighbourhood has 1}2 lanes in all, so that each of the 25 lane oommittees represents the residents of five or six lanes, or some 400 familles. Each lane oCIIIIDittee health station is staffed morning and afternoon by looal housewives who have title "red medial worker." The hours of servioe are from 8 to 11 in the morning and from 1 to 5.)0 in the afternoon.

- 39 -

Annex 6 At thel1ealth station much of the emphasis is on preventive medicine, in particular t.mun1zation against infeotious diseases. Most immunization of local ohildren is done at the station. If necesB&I'Y, one of the medical workers will call for a child at home or even adm1nister an inoculation there. Factory workers seldom use the lane committee health stations because their own factory medical facility is more convenient. China has by no means solved its med1cal problems. What we have seen of the delivery of medioal care in both rural and urban areas, however, convinces us that pUblio l1ealth and medical care in China are better than in other nations handicapped to a similar degree by technological underdevelopment. One striking instance of this is the sucoess of the Chinese campaign for birth o o n t r o l . ' Birth oontrol statistics from rural areas are substantially different. For example, one rural oommune outside Peking, with a total population of 46 000, has oompiled contraception stat1stics for 5 777 married couples where the wife is of ohildbearing age. Only 8 per cent of the wives and 2 per cent of the husbands have been permanently sterilized. Another 41 percent of the wives use contracept1ves, the "pill" being favored over intrauterine devices by per cent to 18 per cent. Among the husbands 9 per cent use the condom, bringing the total of contraceptive users to 50 per cent.

2'

One still unresolved medical issue is how to achieve an effective union of Western and traditional medical practices. It will probably never be known exactly how many practitioners of traditional medicine there were in 1949, but they were estimated to number hundreds of thousands, and they provided at least sorne degree of tiealth care to a large and faithful clientele, particularly ~n the rural areas. Nonetheless, then as now, certain difficulties stand in the way of integrating the traditional and the Western-style praot1tioners. Tradit10nal Chinese medicine is much more than a collection empirical remedies. Traditional Chinese pharmacology emphasizes herbal remedies, usually in the form of a broth or tea that the patient drinks. Moreover, the medioine oabinets in rural and urban health stations are stocked with herba~ remedies as well as with Western ones. Some herbal remedies are even available as a sterile preparation for injection. A summary of China's achievements in transforming the delivery of medical oare since 1949 shows an interweaving of three main threads: decentralization, demystification and continuity with the past. Following a pattern that many students of community medioine would be happy to see more widely emulated in Western countries, the delivery of medical care in China begins at the lowest possible level in both the city and the oountryside • Initial medical attention is in the hands of health aides who are part of the community they serve. From this initial point of contact a clearly organized system of referral leads, level by level, up to a plateau of sophisticated medical specialization. The patient with a problem that cannot be handled at

•

- 40 -

• Annex 6 one level of this decentralized structure moves on to the level above. The system is an efficient, low-cost one. Moreover, it has the advantage of building social cohesion and local self-relianoe by emphasizing neighbourliness and service to others trOll the lowest level up. From the Chinese point of view demystification runs parallel to decentralization. The front-line medical workers are men and women with little in the way of formal education. They ~rk on a part-time basis and receive their inatrllction in health care througn brief programmes that emphasize the practical aspect. They urge participation on the part of the people they look after. For example, each individual is expected. as a patient. to look out for his own health and. as a citizen. to look out for the health of the cCllllllUlli ty. Under these circumstances it is no wonder that much of the IIIYstery medicine SO often holds for the layman has been effectively dispelled. DalllYstiflcatlon has alao been f'urthered by ahortening the term of formal medical education and by assigning urban physioians to periodic tours of duty in the oountryside. The two ~eps express with respeot to medicine the determination of Mao and others to eliminate "elitism" in general.

•

It seems that the Chinese have managed to overcome severe problems, to improve their system of medical oare and to enhance the health of their population by making medioal change an integral part of chenge in Chinese society as a whole.

- 41 -

ANNEX 1

EVAWATION OF THE SEMINAR

1.

For you as an 1ndivWual. to what extent do you feel the following seminar objectives were met? (Circle one for each objective). (a) To develop an awareness of the variaty of meciical assistants

currently in use. Not at all (b)

Somewhat

Almost coaplately

Complately

To dev.lop an UJlderst&lld.1ng of how the un of meciical assistants

evolved. Not at all (c) Salllewhat Almost coapletely Completely

To develop an understanding of how meciieal assi.tants are trained and. utilized. Not at all ao-what Almost cOlllPl.a te ly Complately

(d)

To develop an appreciation of the impact medical assistants can have on the delivery of haalth .ervice•• Not at all ao-what Almost completely Completely

(a) To develop an awareness of sa. of the problema encountered in the training and utilization of . .dieal assistants. Not at all (f) Somewhat Almost ooapletely Completely

To oonsider approaches in deterla1n1ng the t7Jl8 (lavel) of medical assistants required. Not at all

S___ t

Almost oOllpletely

Completely

, (S)

'1'0 aonsider ways in which the training of medical assistants oan be iIIproved Not at all

Somewhat

Almost completely

Completely

(h)

To aonsWer ways in which the utilization of medioal assistants can be improved.

•

Not at all

Almost oompletely

Complately

- 42 -

, Annex 7

2.

Rate the topics discussed in the small groups according to the value they were to you. (Circle one for each topic). The evolution of the development of medical assistents. No value Some vallie Considerable value

Topic A.

Topic B.

The ways in which medical assistants are trained.

No value Topic C.

Some value

Considerable value

How medical assistants are utilized. No value Some value Considerable value

Topic D.

The impact that medical assistants have had on the delivery of health services. No value Some value Considerable value

•

Topic E.

The problems encountered in the training and utilization of medical assistants. No value Some value Considerable value

Topic F.

The ways to determine what types (if any) of medical assistants are needed. No value Some value Considerable value

Topic G.

How medical assistants can be trained efficiently for most effective utilization No value Some value Considerable value

Topic H.

The ways in which the utilization of medical assistants can be improved. No value Some value Considerable value

In what ways did the consultants contribute to your group. (Check all those that apply). Asked pertinent questions. Gave us the benefit of his experiences. Provided additional insights into problems Offered suggestions Helped clarify issues Kept the discussion on the topic

•

-

~,/44

-

•

Annex 7 Resolved confliots. Proposed rec~ndations SUss-sted references. others (Please list).

4.

Would fou 11ke to ha'fe t.U'd

IIOre alxlut the experienoes of o'tMr oountries on the train1na: and. u.. of _d1eal. assistants suoh as presented b1 Drs Flahault and. S1del?

(C1role one)

NO

5. •

Did you enoounter &n1 d1ffioulties during 1I1e seminar? . (Language, little opportunit)< to speak, eto.) Pleaae list •

6.

To what extent w1ll you be able to 1nfluenoe the development or illlProve_nt of prosra-s to train and. to Itt111ze medioal assistants

1n your oountry? Not at all 7.

(C1role one) Sc.MWhat Cona1derably Cannot sa;r

What would you aussest that WFRO do to enoourap greater utllizat10n of med10al .ssistants? (Plea.. desoribe).

8.

How oould this seminar have been illproved? (Please desoribe)

- 45 -

• •

ANNEX

8

SUMMARY OF EV'AWATION REPLIES

1.

For you . . an ind1v1d.ual. to what extent do you feel the following nlll1nar obJeotina _re met?

Complete- AlJIoat CompletelY' 1y (a) To d.".lop an awarenaaa of the varietY' of medioal ..aiatant. currant17 in un. To develop an underatanding of how the u.. or medical aaaiatanta eyolnd. To develop an underatand1ng of how medical . .aiatant. are trained and utilized. To develop an appreoiation or the iapaot medi ...l . .aiatanta oan have on the del1ver;v of health aerYicea. To develop an awareneaa or ao.e of t.be proble. enoOWlteNd in the tr&1n1Jlg and util1_tlon of medioal . .alatanta,. To oonsider approUbla in detel'll1n1ng the tnJe (lenl) of JIIed10al . .a1atanta required. the

Somewhat

Not at All

10

8

, 1

(b)

• • ( 0)

11

9

4

B

9

(d)

.

8

7

6

(e)

10

10

1

(f)

4

8

9

(8) To oClllaider wqa in wblch f

training or ...:1.1081 .aaiatant. o an be illlProved. (h) To oonsider w&;va in which the utilization or mediaal . .aiatant. oan be 1IIIProved. Total Peroent

4

12

5

4 55 }2.7

8 70

9

•

168 100.0

41.7

4, 25.6

0

• - 46 • j

Annex 8

•

2. Rate thetopios disoussed in the small groups aooording to the value they were to you.

TOP.I C S

Considerable value

·SOIlle

value

. No· value

No anawer

A. B. C. D.

The evolut1on of the development

of medioal assistants The ways in whioh medioal aas1stants are tra1JIed. How medical aasistants are utilized The 1mpact that med10al assistants have bad on the delivery of health serv10es. The problems enoountered 1n the

13 16 17

5 4 4

1

2 1

13

8

• •

E.

tra1ning and utilization of medioal assistants. F. The ways to determine what types ~if any) of medical ass1stants are needed. How medical assistants oan be trained effiaiently for most effeative ut1lization. The ways in whio~

20

1

13

8

G.

13 ..

7

1

H.

the

utilization of mediaal ass1~tants can be illlProved '0 Total Peraent

12

9 46

168 100

117 69.6

27.4

.2 1.2

3 1.8

•