Partners in health [full issue]

WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • MARCH 1985 partners in health Untapped potential by Mechai Viravaidya The dimensions of the problem of bringing about Health for all by the year 2000 are stag- gering. If we add to that problem the short amount of time and the limited funds available, we might well be inclined to throw in the towel. Yet achieving this goal is possible. In matters of health, even minimal funds—provided they are creatively spent—can lead to positive changes in behaviour with major long-term be- nefits. Look at breastfeeding—it is free, while oral rehydration therapy to save children with acute diarrhoea and contraceptives to help parents space their families are very low in cost. Mr Mechai Viravaidya is Secret- ary-General of the Population and Community Development Association and Governor, Pro- vincial Waterworks Authority, Bangkok, Thailand. He will also be General Chairman of the Technical Discussions during the Thirty-eighth World Health Assembly this May, in Geneva. The discussions have as their theme: "Collaboration with nongovernmental organizations in implementing the Global Strategy of Health for All" Creative solutions to thousands of problems are needed if we are to achieve our goal. Can governments find these solutions alone ? I doubt it, if the past is any indications. Political, bureaucratic, financial and other con- straints restrict the ability of govern- ments to design and implement new, innovative projects. It is precisely be- cause of these limitations on govern- ment that nongovernmental organiza- tions exist. Now is the time for govern- ment bodies—both national and inter- national—to acknowledge the role of NGOs in bringing health services to hundreds of millions of poor people, and to follow up that acknowledge- ment with concrete backing and support. 2 WORLD HEALTH, March 1985 WORLD HEALTH, March 1985 It could be argued, especially in the case of developed countries, that the NGO sector has been responsible for nurturing every significant social re- form of this century. In the developing countries, NGOs have also played a vital role in bringing health and other development services to the people. Yet the NGO sector has the potential to be a much greater force than it is at present. A concerted effort is needed to identify indigenous, national NGOs and provide them with funds to up- grade their technical and managerial skills, expand their existing activities and conduct new pilot projects. In the past, a disproportionately small share of international develop- ment assistance funds has been chan- neled through local NGOs. Funds have almost exclusively gone to government agencies, with mixed results at best. • Nongovernmental organizations are in- valuable partners to national and internation- al government bodies in bringing health services to millions of the world's poor people. Photo WHO/C. Viedma ♦ Closeness to the target audience and strong motivation are essential qualities of nongovernmental health workers. Photo WHO/P. Merchez Currently, most NGOs in developing countries can only obtain foreign as- sistance through other NGOs based in developed countries. Bilateral and in- ternational aid agencies claim to be strongly supporting NGOs, but that sup- port seems to be 99 per cent .verbal and only one per cent financial. It is time to modify those figures ; to allow actions to speak louder than words. By their very nature, NGOs are more able to design and implement creative solutions to pressing health problems than can government entities. This is because they tend to be closer to their target " audiences " and more moti- vated in their specific fields of opera- tion. They are less bureaucratic, and more able to be flexible and to experi- ment even when only small amounts of money are available. And they are held accountable ; they must demons- trate success or cease to operate— a condition that ministries of public health are not required to meet. Countless examples can be cited whereby funds going into the NGO sector in developing countries have had an extremely high " leveraged " impact, as the NGOs success has led to changes in government action, either through the government directly adapting and expanding the NGO ap- Cover: This year's Technical Discussions will reflect the increased partner- ship for Health for all between WHO and nongovernmental organizations. Designed by Peter Davies. IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization. Editor : John Bland Deputy Editor and This Month's Theme Editor : Christiane Viedma Art Editor: Peter Davies News Page Editor : Peter Ozorio World Health appears ten times a year in English, French, German, Portuguese, Rus- sian and Spanish, and four times a year in Arabic and Farsi. Articles and photographs not copyrighted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Av. Appia, 1211 Geneva 27, Switzerland. Contents Untapped potential by Mechai Viravaidya 2 Partners in health by Gururaj S. Mutalik 5 The NGO Group on Primary Health Care 8 A short story 11 A forum for high-level debate 12 Friends of children by Habiba H. Wassef 13 Red Cross—one partnership among many 16-17 Women's councils by Pnina Herzog 18 Preventing blindness by Alan W. Johns 20 An aging world by David Hobman 21 Consortium against rubella by Jean Wilson 22 Sharing resources in the Caribbean by J. Kenneth Thompson 24 The daily struggle in Mali by Anne-Marie Gaudras 25 Financing primary health care by Hakan Hellberg and Edward P. Mach 26 News Page 30-31 proach or by changing laws and regu- lations so as to facilitate the natural expansion of that approach. With a working partnership between govern- ment agencies and NGOs, founded on mutual respect and shared objectives, tremendous progress can be achieved in the next 15 years. In Thailand, the Ministry of Public Health has a strong record of en- couraging participation of NGOs, with immensely satisfactory results. Collab- oration exists on many levels, from mutual representation on governing boards that shape policies and pro- grammes, down to the grass-roots level where activities of the two sec- tors are coordinated. Such coopera- tion began, and has had its biggest success, in family planning, where at least four NGOs have actively and con- tinuously played a major role in the national family planning programme. In just 15 years, this partnership has helped Thailand to reduce its popula- tion growth rate from 3.30 per cent per year to only 1.60, the most cost- effective development effort ever undertaken in that country. The Public Health Ministry is now encouraging the NGOs to expand their services into actually attempt to disrupt the work of the nongovernmental bodies. Some- what naturally, governments show a strong tendency to protect their own turf, but this is a shortsighted view- point. Tax laws discourage donations to NGOs and make it difficult for them to obtain duty-free privileges for much-needed imports. At the same time, governments attempt to channel international assistance through gov- ernment agencies rather than through the private sector. Bilateral and inter- national aid agencies shouldn't go along with these attempts—but they generally do. Although the NGO sector in de- veloping countries is only just emerg- ing, there are already thousands of such bodies in existence. Given a chance, these bodies could take mean- ingful strides. But assistance is needed, firstly, to identify NGOs with growth potential, secondly, to improve their management and technical skills and, thirdly, to provide funds to implement projects. Some indigenous NGOs are already large, highly professional or- ganizations requiring only increased funds for programme expansion. At the other extreme are small, nascent NGOs which have potential for growth but need to be built up, almost from scratch. The time has come for the interna- tional community to make a major commitment of funds towards institu- tion building and programme expan- sion of NGOs in the developing world. It should be regarded as venture capi- tal for health. A difficult task lies ahead, but the potential in terms of health benefits to billions of people makes it well worthwhile. ■ "The NGO sector has the potential to be a much greater force than it is at present.... A working part- nership between government agencies and NGOs can make tre- mendous progress in the next fifteen years" other areas of public health, so as to complement and support the govern- ment's own work, but at no direct cost to the government. Unfortunately, in Thailand and elsewhere, the fact remains that many government agencies view NGOs with distrust, as competitors rather than as partners. Sometimes these agencies ♦ The success of family planning pro- grammes in Thailand is due to a great extent to close collaboration between Ncos and the Ministry of Health. Photo WHO/C. Chit 4 WORLD HEALTH, March 1985 5 Partners in health A ealth for all by the year 2000 has been aptly termed a social con-tract between the governments, people and wHo. Inherent in this part- nership concept is the recognition of the principle that health is a commodi- ty which cannot just be delivered from the outside, nor procured merely for a price even in a welfare state. Appropriate health technology in growth monitoring and creative teamwork will help Nicaragua to protect the health of the new generation. Photo WHO/P. Merchez Health development pre-supposes a creative teamwork involving self-help and self-care by the people them- selves, supplemented by adequate health care services based on an ap- propriate health technology. It de- mands fulfilment of conditions beyond the narrow confines of medical con- cerns of disease, its diagnosis, cure or even prevention, and embraces the very quality of life of the people and their essential needs. The primary health care concept which is the key to the achievement of Health for all by the year 2000 objectives, engenders all this and more. In its quintessence it is an interface between the extension of essential services, including health as an integral part of the role and WORLD HEALTH, March 1985 by Gururaj S. Mutalik responsibility of the government, and the vibrant, dynamic, upward struggle of the people in the community for the betterment of their own quality of life. Dr G. Mutalik is in charge of WHO's office for Collaboration with the United Nations System, Nongovernmental and other Organizations Actions at this vital interface where both these development streams meet is crucial for the well-being of the community. It is here that the volun- tary groups, societies and organiza- tions called by the unsatisfactory term " nongovernmental organization " — NGOs for short—have their greatest strength. They are the bridges be- tween people and the government. They are the pace-setters, innovators and reformers. Their contribution to the Health for all movement could make all the difference ! While coordinated, complementary and mutually planned actions between governments and NGOs are still a long way off, there are exciting trends and developments all over the world, which augur well for the HFA/2000 movement. In one country in Asia an NGO is collaborating with the government's malaria control programme, bringing to its implementation much-needed popular acceptance of and involve- ment in the programme at the village level. The results have been dramatic. In another Asian country, an NGO has succeeded in motivating thousands of villagers in a family planning pro- gramme that combines health care with income generation, employment with community-based family plan- ning. What is remarkable about this achievement is its cost-effectiveness and replicability. In a short time this organization has been able to provide services for a third of the country, thanks to exemplary collaboration with official governmental services. Noos are collaborating with governments in all health fields, as here in the Indian malaria control programme. Photo WHO/A. S. Kochar • Local nongovernmental groups working in the field of primary health care are break- ing through the remotest regions of Africa. Photo WHO/C. Stauffer In a third large country, hundreds of nongovernmental organizations have taken up the Health for all message and are working in numerous villages to translate primary health care into real actions with peoples' involve- ment. It is here that one can see a dramatic decline in maternal mor- tality, the virtual disappearance of neonatal tetanus and a sizeable fall in infant mortality. Governmental pro- grammes by comparison have still to make a lot of headway in fulfilling their objectives. In Africa there are several countries where health conditions are critically unsatisfactory, particularly in the re- mote villages. The health services hardly reach such places. It is here that NGOs traditionally have borne the brunt of health care and have striven hard to bring to the people a measure of primary health care. Many of them are expatriate NGOs run by foreigners, but the local groups are gradually coming to play their role. In recent years a group of international NGOs (NGO Group for Primary Health Care), with some support from wHo, have launched a major initiative in six countries to promote and facilitate a lively partnership between national governments and NGOs for implement- ing primary health care. In some Latin American countries and the Caribbean, NGOs have for years been the real allies of people in assist- ing them to grapple with their first level health problems. In several coun- tries, such NGOs have taken steps to relate to each other as well as to the governments, so as to reach a better understanding of the perspective of national health problems as well as to mobilise resources to support their grassroots work in the community. In the more developed countries including Europe and the North American continent, NGO work—while assuming a different dimension—is just as relevant and effective. Often the NGOs here, being better organized and with more resources, are in a position to work out cost-effective and trend- setting social projects for larger appli- cation. They also effectively play the role of advocates for various social causes. Another facet of the NGO move- ment, whether in developing countries or developed countries, relates to pro- fessional health work. Members of health professions and health workers devote themselves to community health work, launching such specific programmes as prevention of blind- ness and other disabilities, oral health, prevention and treatment of leprosy, tuberculosis and other specific dis- eases, early detection and treatment of such diseases as cancer, diabetes and cardiovascular diseases, and care of the aged. These professional associa- tions and societies, often supported by their international links or parent bodies are a source of tremendous potential and support for dealing with many of these priority health pro- grammes. At the international level, interna- tional NGOs follow the national pat- tern, in that they either belong to the general health and development group or to a specific professional or techni- cal group. Many of them carry out national projects or activities either directly or through their national affiliates. Besides providing a broad platform for exchanges of experiences and expertise, they represent a for- midable global social development force to mobilise resources, spearhead development education, carry out 6 WORLD HEALTH, March 1985 public education, and act as advocates for various worthwhile social causes. wHo has a long tradition of close collaboration with nongovernmental organizations (NGOs). The foundation for this collaboration—encompassing today every major area of health—was laid down by the Member States at the First World Health Assembly in 1948. Ever since the historic Declaration of Alma-Ata in 1978, and the subse- quent commitment of Member States to achieve the goal of Health for all by the year 2000, this collaboration has acquired a new meaning. The recent monitoring of the degree to which the Global Strategy has been im- plemented by Member States has underscored the formidable challenges of Health for all, and the need to marshal all available resources at all levels in order to meet them. There is widespread recognition of the role that NGOs already play as dynamic allies in this struggle. Their expertise and ex- perience and their innovative ap- proaches could be a much greater asset if they were properly mobilised. A real partnership between people and government is inherent in the primary health care concept itself. NGOs, as representatives of groups of people, could do much to promote and strengthen such a partnership. While worldwide voluntary action for health is considerable in volume and magnitude, it is mostly ad hoc, often unrelated to national health strategies, plans or programmes, and invariably uncoordinated. Few NGOs relate to each other or to the govern- ments' programmes, and this results in a lack of concerted action which could produce a real impact on health prob- lems. There is an urgent need for governments to share responsibilities with NGOs so as to benefit from their experience and expertise, to draw les- sons from their innovative ventures and to support them in their work. There is a similar need for NGOs to show better understanding of national plans and priorities, to be willing part- ners in the larger task of implementing Health for all strategies and to use their natural strength of closeness to the community to help stimulate the development movement amongst the people. The partnership approach de- mands that governments be willing to support NGOs through allocation of resources and to consult them in for- mulating plans and programmes. Some countries have initiated a dia- In some parts of Latin America, Ncos are the best allies of people in providing essential preventive health services, such as immuniza- tion of children. Photo WHO/P. Merchez logue in this direction. In a few coun- tries in Asia, Africa and the Americas, using modest resources from WHO, the systematic collection and analysis of information about NGO work has shown that interaction between NGOs and the ministries of health is opening new vistas of cooperation in national health work. There are some real issues in NGO/ government collaboration which need to be addressed before a lasting and effective partnership can be built up. Are governments willing and ready to share responsibility and resources to enable NGOs to play their role in implementating HFA strategies ? Are NGOs willing and ready to reci- procate the implications of the part- nership approach by showing a better understanding of national policies, programmes and priorities ? Are they willing to relate to each other and contribute to concerted action ? By whom and how should voluntary work be coordinated? What kind of national mechanisms need to be adopted to preserve and promote the innovativeness and initiative of NGO work, while bringing it into the main- stream of health development? There are many more such ques- tions. The Technical Discussions at this year's World Health Assembly in Geneva in May will focus on some of the issues outlined in the foregoing pages in order to promote and foster the partnership concept. At the Alma-Ata International Conference in 1978, the Member States, NGOs and wHo in an historic partnership worked together to crys- tallise the precepts and practice of primary health care. The Thirty-second World Health Assembly, held in May 1979, by launching the Health for all move- ment, set its seal on this social contract. It is a tryst with destiny, with only 15 years left to redeem the pledge. This partnership could make all the difference ! ■ WORLD HEALTH, March 1985 7 The NGO Group on Primary Health Care Working together since 1976, a number of European-based international bodies now meet regularly as "the NGO Group on Primary Health Care," to find the best ways of relating NGO efforts in PHC to those of WHO he first practical ventures in primary health care were to be found in the projects and pro- grammes of non-governmental organi- zations some ten, twenty or thirty years ago. This should surprise no- one. NGOs by their nature have the opportunity to be flexible, responsive to local needs, and certainly more free to experiment with creative new approaches than governments. A group of nongovernmental or- ganizations in official relations with WHO, which form the NGO Group on Primary Health Care, have in this article focused on a few issues relating to the Tech- nical Discussions in May 1985 Indeed in many countries, organized health services can trace their history back to a start in the private or volun- tary sector. Today those NGOs which are involved in health care represent an important and perhaps crucial re- source as global cooperation steps up its drive towards Health for all by the year 2000. NGOs have grown in number and spread widely until they now account for a substantial proportion of the health care given in many countries. They are able to provide both human and material resources, and to mobil- ise the financing of programmes. Their diversity makes it difficult to assess ► The NGO Group, WHO and UNICEF, are partners in implementing primary health care strategies in five small countries of Eastern and Southern Africa. Photo WHO/C. Stauffer 8 just how much they contribute to health care provision nationally and internationally. One recent attempt to put a financial figure on the size of their contribution to international de- velopment aid suggested that NGOs accounted for at least US $700 million in 1978. For comparison, the same study showed that international devel- opment aid from major bilateral donor countries was about US $1,200 million in that year ; the World Bank and other development banks accounted for US $600 million, and the UN sys- tem provided US $550 million. As important as the magnitude of this contribution are the characteris- tics of the work done by NGOs. The relative independence of NGOs allows them to focus their activities and limit their scope to specific areas and pro- grammes (where government health care is obliged to be comprehensive and countrywide). Their flexibility has encouraged them to experiment and to embark on trials of new approaches, which have served as pilot efforts in health care research and have pro- vided many lessons for the health planners. They have often taken on aspects of health care which govern- ments have not been able to tackle, including programmes to remote rural areas, or special programmes for lep- rosy, tuberculosis, rehabilitation and the like. Because of their smaller or- ganizational structures, they can often respond more easily and quickly to emerging needs. NGOs have taken jus- tifiable pride in being close to the communities they serve and thus can more surely match their resources to needs, taking into account local cus- toms and value systems and encourag- ing community participation. With the passage of time, NGOs have come to work more closely with the governments of their host countries. They are now more regularly co- operating consciously with the de- velopment and implementation of government policy and guidelines. They often assume responsibility for certain programmes, acting on behalf of the government. As a result of this closer collaboration, they are playing a more active role in health policy, de- bates and discussions. Among themselves, the NGOs have not always been able to coordinate their work to collaborate meaning- fully. But here too, progress is being made. In some 30 countries, coor- dinating associations now exist which facilitate closer working ties among the NGOs and—through a single rep- resentative, a group or a bureau— closer working relations with the gov- ernment. This has been an important mechanism, and more countries are now looking at the positive features of this approach. Collaboration among NGOs is also a feature now at the level of the interna- tional NGO offices. Since 1976, Euro- pean-based international bodies have been meeting as the NGO Group on Primary Health Care. Formed initially to see how best to relate NGO efforts in PHC to those of wHo, this Group has more recently embarked on an NGO/ WHO/UNICEF collaborative programme with governments to carry out PHC strategies in five of the smaller coun- tries of Eastern and Southern Africa. The stress has been on fostering col- laboration among the NGOs themselves and encouraging the integration of NGO efforts into the national pro- gramme. This Collaborative Pro- gramme has already seen the forma- tion of a new coordinating association in Swaziland, and a broadened coor- ♦ Ncos are everywhere adopting the primary health care approach. Here in India, a nutri- tion monitoring programme will help prevent blindness by detecting vitamin A deficiency. Photo WHO/Helen Keller International/N. Cohen dinating effort where such associations already existed in Botswana, Lesotho, Zambia and Zimbabwe. Collaboration is vital if the global effort to achieve Health for all by the year 2000 is to succeed. Coming along a bit more slowly, but surely growing, is the mutual growth of confidence and partnership between the NGO com- munity and governments. This has also put added emphasis on community participation which will be essential for the global strategy to succeed. In sup- port of this, improved methods of communication must be employed, and joint planning must be made a reality however much it may vary from situation to situation. The develop- ment of health care programmes has shown that logistic support and the supervision of health personnel must be of prime consideration. Moreover, research is urgently needed on the mechanisms required to bring about those fundamental changes in atti- tudes that are required to implement the primary health care approach. NGOs have responded to health care needs and created programmes to meet them in both industrialised and developing countries around the globe. More and more, PHC is being accepted as a fundamental approach for NGOs in the health care field. The experience of NGOs in PHC is, how- ever, perhaps more extensive and more studied in developing countries. That experience has highlighted cer- tain problem areas, particularly in the financing of health care, and has sug- gested some guiding principles for dealing with the problems. Problem areas In many countries, tax receipts cover less than half of the national expenditure for health care. It is un- likely that the public sector will raise significantly more funds in the coming years. Moreover, foreign currency to purchase even the most essential pro- ducts for these activities is often scarce, and external aid through loans has in many countries further reduced the availability of foreign currency. Governments as well as NGOs have tended to use their resources for financing sophisticated buildings and equipment. Such investments are of- ten seen as more tangible proof of progress and therefore more easily WORLD HEALTH, March 1985 9 ♦ It is essential that NGO projects initiated and managed by outside personnel prepare for the time when activities will be handed over to national qualified staff. Photo WHO/P. Merchez conducive to fund-raising. The ear- marking of financial resources of NGOs has further contributed to this tenden- cy. Yet this policy results in an excess- ively costly health care service by absorbing considerable resources for running costs and withdrawing finan- cial and human resources from pri- mary health care. In some countries with limited trained human resources and a lack of a structured career pattern, some NGOs have attracted personnel by providing supplementary benefits. This has crea- ted an imbalance in the manpower distribution in health care services. In other cases NGO projects are initiated and managed by outside personnel ; when the time for a handover to national qualified personnel has come, it is realised that not enough provision has been made for their training in management and fund-raising. In the past, projects have been plan- ned without sufficient consultation of and participation by the community, thus violating one of the principles of PHC and weakening the potential for problem-solving in the community itself. These projects have not been maintained by the community once outside funding and personnel are withdrawn. The priorities of the country of the local community have not always been considered. This results in the provi- sion of special services to particular groups, instead of building a truly accessible health care team able to respond to the health care needs of the community as a whole. In some in- stances, the direct financing of com- munity health workers has fostered the development of parallel health services outside the government health care system. Apart from the duplication of services, there may also be a breakdown in the referral system, the basis for a well-functioning PHC programme. The introduction of high technology sometimes hampers the community's capability for problem- solving and thus reduces its self- reliance. There may be little or no coopera- tion between NGOs working in the same country, and little coordination with governmental organizations. As a result NGO services tend to overlap or even be in competition with other services. This in turn leads to poor utilisation of resources. Increasingly, there is, among NGOs committed to PHC, a strong desire to coordinate their efforts with other NGOs and with the government. In those countries where there already exists a coordinating agency, there is more opportunity for dialogue be- tween government and NGOs, leading to a more unified national health care system. Evaluation and research have too often been neglected in first-level health programmes. So the results— whether positive or negative—have not been available to improve existing programmes or to be considered when new projects are planned. Guiding Principles Certain guiding principles can be laid down to help resolve the kind of problems already mentioned : A country's health care strategy should be consistent with its socio- economic development plans. NGOs, when planning PHC programmes with the community, must likewise take into account the socio-economic de- velopment plans for the area and the cultural characteristics as well as the existing health care facilities, so as to provide for coordination of services as well as allowing for expansion. NGO-supported and organized health care services must be an inte- gral part of the total health care sys- tem of a country, including the referral system. NGOs should coordinate their health care activities among them- selves and with the governmental health plan, and their PHC projects, including supportive services, should not be financed in isolation from the overall development of health and related activities. The mobilisation and allocation of both national and external re- sources for the development of NGO- supported or NGO-organized PHC programmes must be in harmony with the national health care strategy, and must be run in such a way as to ensure continuity of financing. In addition, external resources are a contribution to international solidarity. The training of health personnel should be in appropriate numbers and should use appropriate methods. The training should be task-oriented and practical ; it should include technical as well as managerial tasks. There should be provision for supervision and con- tinuing education. For more effective participation in policy formulation and planning with the government, NGOs should actively pursue the monitoring and evaluation of their own work as well as carrying out or supporting relevant operational research. ■ 10 WORLD HEALTH, March 1985 A short story r Bahun, from the Ministry of Health of Xenobia, was ap- pointed to prepare his country's contribution to the technical discus- sions to take place at the same time as the 1985 World Health Assembly. "It's a challenging task," he pon- dered. "The partnership concept is not new, but to make it work will take a lot of doing. But it is true there is no other way to achieve Health for All. The time has come for our official programmes to build bridges with nongovernmental organizations." Clasping his head with his hands and closing his eyes, Dr Bahun could see so many places, so many roads. And so many faces. NGO people of all kinds, from those with a bureaucratic " touch " to those who have the feel of the soil. And all of a sudden, an image flooded through his mind : he saw a huge sphere made of hundreds of thousands of these faces, as lively and active as the cells in a living organism, transmitting information and inter- acting one with another. He had visited six NGOs, and each one was different in every way—in their operation patterns, and in their resources. But all had a common, essential feature. All of them provided services and all of them involved peo- ple. And yet he noted that their pro- jects were carried out in a kind of vacuum, in isolation from one another and from the government services. "This is the all-important ques- tion", thought Dr Bahun : "HOW TO RELATE." NGOs work on tight and unsure budgets. They very often de- pend on resources coming from abroad or simply from people of good will. But they have been able to teach everyone a simple lesson : that the quality of work does not depend only on resources. Very often indeed, they have stretched their meagre resources to an incredible extent. And their variety of forms and ac- tivities ! First and foremost there are those local groups at the village level. They are far from organized but they are closest to the people. They have meagre resources but have the great- est potential for action. Then there are national organizations including all the medical and professional associations whose programmes can have a power- ful influence on the progress of prim- ary health care. And there are the large international NGOs and their af- filiates here, who have many resources and a lot of expertise if only we can make effective use of them. There is plenty we can do from the government side to facilitate their work. But the great need is to coordinate yet to avoid any sense of control. ♦ "Only from the alliance of the one, work- ing with and through the other, are great things born." Photo Zafar Dr Bahun looked at his fingers cros- sed before him on the table, and he realised that community participation and intersectoral collaboration were like his two hands... two hands weav- ing together to represent the Primary Health Care approach, incorporating it into the social tissue. "If we succeed in collaborating truly with NGOs, we will create a real synergetic develop- ment," He thought. He liked this word " synergy " borrowed from science : it meant different qualities that, when they are merged, make a complete- ly new one. Agricultural extension, health activities, teaching villagers how to maintain their water pumps and sanitation systems— all these things can combine to produce a total rebirth of the village ! Dr Bahun began to think that it was particularly rewarding for the next technical discussions to be devoted to collaboration with NGOs. He had been agreeably surprised to learn that W110 collaborated with over 130 of them. The emerging focus on national level collaboration, where the real problems are : that was a real breakthrough ! And this international rosary had the same thread—individual and collective involvement—and the same beads— prevention of blindness, care of the elderly, leprosy control, diarrhoeal diseases control, oral health, reha- bilitation, family planning, mother and child care and so on. Now he could see a light at the end of the tunnel. To have a meaning, development not only had to involve people but also had to be people- centred. Whatever the political sys- tem, any national development must be based on the fundamental, vibrant energy of the people. This energy is the unceasing tide that will make it possible to improve the quality of life, to make people's potential blossom into happier societies, into socially productive life ! And this could be made possible because, where altru- istic ideals had proved insufficient in the past, now living dialogue and true partnership could be brought into play. "It is for us," thought Dr Bahun, "to provide opportunities for NGOs to understand the national strategies and to work along with these strategies. But first we have to win their trust, allay their misgivings and demonstrate that they are our precious assets. Then they will truly become what they should be : vital pathways to develop- ment." In his mind, Dr Bahun was rolling up his sleeves. The task to be per- formed before these ideas could be converted into action was immense. So many people to be convinced. So many odds to fight. But it was worth- while ! This was real work, that could herald a new era in health partnership. A new bold step for the fulfilment of Health for All. He remembered a sentence from a book he had read : " Only from the alliance of the one, working with and through the other, are great things born." ■ WORLD HEALTH, March 1985 11 A forum for high-level debate very year, in the month of May, Technical Discussions on a careful- ly chosen theme take place during WHO's annual World Health Assembly. Although not an integral part of the Assembly proceedings, these Technical Discussions provide a valuable forum for participants from nearly all countries of the world to engage in an informal high-level in-depth debate. The conclu- sions reached in such a debate can offer pointers and guidelines for future ac- tions, and help to influence policies which the Member States collectively decide to adopt in the Assembly and other organs of WHO. The Executive Board for the Techni- cal Discussions in May 1985 has selected the theme of : " Collaboration with nongovernmental organizations in implementing the Global Strategy for Health for All." All Member States and nongovern- mental organizations (NGOs) in official relations with WHO, as well as a large number of international, regional and national NGOs in contact with the Or- ganization were invited to provide com- ments and suggestions. These have been taken into account in preparing the background paper for the Techni- cal Discussions, which will serve as the main working document. Mr Mechai Viravaidya, who contributes to this issue of World Health, will be the Chairman of this year's talks. The Discussions themselves will stimulate governments and NGOs to re- view critically the current status of mutual collaboration within the context of the Global Strategy. They will clarify the role of NGOs at all levels—national, regional and global—in implementing the Health for All objectives, especially as regards promoting community in- volvement. And they will help to set priorities and identify ways and means by which vaio can foster greater in- volvement of NGOs in the Health for all strategies. These are the issues that will be addressed during this year's Technical Discussions : How willing are governments to re- cognise nongovernmental bodies as essential partners in national health programmes? What are the impediments to such recognition? How willing are voluntary societies to ♦ Mr Mechai Viravaidya, General Chair- man of WHO's Technical Discussions being held this May, in conversation with Dr Gururaj Mutalik, who coordinates WHO's relations with NGOs. Photo WHO/J. Germain regard themselves as a part of a national and global effort to implement the policy of Health for all? What are the impedi- ments to this process? What are the extents and limits of governmental/nongovernmental partner- ship in carrying out health policies? Where government and Ncos have suc- ceeded in working together, how were the impediments overcome? Can their ex- perience be used by countries that have not yet fully tried out such a partnership? To what extent do mechanisms exist for Nco-to-NCO and Nco-to-government coordination? How effective are they and what form do they best take? What are the most effective means of identifying and encouraging relevant self-help groups, particularly in under- served communities? What are the guidelines for governmental support of these groups in the interests of Health for all without destroying their spontaneity and their indigenous nature? In the implementing of Health for all at the national level, what is the value and strength of the link between national NGOs and their international affiliates? What should be the role of WHO at the global, regional and national levels in promoting, supporting and strengthening effective partnership between govern- ments and NGOs in order to accelerate the implementation of Health for All strategies? The success of the Discussions de- pends finally on the participants them- selves and therefore it is important that adequate representation is assured not only from governments, but also from the NGOs themselves. Government dele- gations have already been urged to in- clude representatives of national NGOs in their delegations. And international NGOs having official relations with wHo have also been urged to include national affiliates or other national or local NGOs in their delegations. One and a half days is a very short time in which to discuss such a multi- faceted issue, particularly when we take into account the inevitable constraints of space and cost of attendance, which may limit the numbers of representatives who are finally able to attend in person. But the Technical Discussions offer a forum where the chosen subject can be debated in a frank and open way, where many differing individual points of view are expressed and debated, and where an audience from vastly different social and cultural backgrounds but often fac- ing similar problems can come to grips with an important issue. And of course the action will not stop there. The ideas and perceptions that have been melted and shaped in the crucible of these talks will be followed through in countries, in regions and at the international level. The process of dialogue, the exchange of views and the fresh understanding of others' view- points will help to forge new and crucial links between the government and the voluntary world. The attainment of Health for All by the year 2000 will at least in part depend on a massive build- up of this critical partnership in health. ■ 12 WORLD HEALTH, March 1985 Friends of children by Habiba H. Wassef With the blessing of the Ministry of Health, a benevolent voluntary organization in Egypt carried out a campaign to reduce severe rheumatic heart disease in children ji etween 1960 and 1980, the over-all incidence of severe rheumatic heart disease in Egypt fell from 478 for every one thousand rheumatic heart children to only 56 per thou- sand. In those governorates (pro- vinces) where measures to combat the disease were particularly intensive, there were even more dramatic im- provements in the incidence and death rates. One of the key factors in this improvement was a non-governmental voluntary organization called the As- sociation of the Friends of Children with Rheumatic Heart Disease. Working in close collaboration with the country's health services, this body undertook a joint nationwide cam- paign against rheumatic heart disease. The campaign enjoyed the blessing of the Ministry of Health and involved school health services and university children's hospitals all over the country. Ever since the late 1940s, the large numbers of severe cases coming to the outpatients department of the Cairo University Children's Hospital re- ceived little special attention. In view of the overcrowded clinics and the chronic shortage of hospital beds, the death rate was high. Only in the mid- 1950s did one member of the hospital staff take the initiative of seeking permission to start a special rheumatic heart clinic, on her return from specialisation abroad. Working on a quasi-voluntary basis and helped by one or two of the young interns, she ► The Rheumatic Heart Centre, established at the foot of the Great Pyramids at Giza, came into being thanks to the initiative of a voluntary association in Cairo. Photo WHO/D. Henrioud ran the clinic after finishing regular duties. This clinic established the correct diagnosis and managed the cases ac- cordingly, but also offered health edu- cation sessions for mothers and older Dr H. Wassef is Public Infor- mation Officer for WHO's Re- gional Office for the Eastern Mediterranean in Alexandria children. The children themselves re- ceived cards to ensure that their cases were followed up, and this helped a special registry to be started. When eventually several beds were allocated to heart patients, this created a special ward in the hospital. Gaps and deficiencies soon became apparent in the system of managing rheumatic heart disease solely through a clinic and a ward. The need was pressing for a "home, " where children with active rheumatic disease could stay for longer periods until the dis- ease was controlled. As the number of cases attending the newly established Rheumatic Heart Clinic grew, the need became more urgent. This same staff member then de- cided to create such a " home " with the help of some friends, mostly non- medical women. The result was the formation of this benevolent voluntary association. With some small capital collected from its members, plus a government subsidy from the Ministry of Social Affairs, a Rheumatic Heart Centre was established at the foot of WORLD HEALTH, March 1985 13 ♦ All the children who stay in the Centre's wards are under medical supervision and care. Photo WHO/D. Henrioud the Great Pyramids at Giza, a suburb of Cairo. It had 28 beds, and almost all services to the children were per- formed by members on a voluntary basis. Charitable contributions came pouring in, both from local people and foreigners, and made it possible to build six wings of 40 beds each, an outpatient clinic, handicraft and weav- ing workshops, and a school. The design of the complex was the con- tribution of a famous architect/con- tractor, and the building was com- pleted in 1962. All the children who stay in the wards or " dormitories " are under medical supervision and care. They spend their time learning different handicrafts in the form of occupational therapy and/or apprenticeship. As the years went by, the picture of rheuma- tic heart disease changed. Cases were less severe, and more children were fit enough to attend school. Higher clas- ses were therefore added to the prim- ary school so that the children at the Centre have guaranteed access to pre- paratory and secondary education. The outpatient clinic attached to the Centre receives new cases referred from other clinics, health centres and even from private practitioners. At the same time, the Centre, wards and clinic also serve as a training school for all physicians participating in the case- finding campaigns. The limited capacity and coverage of the clinic and the Centre at the Pyramids in the face of a health prob- lem like rheumatic heart disease, which afflicts children all over the country, led to the setting up of other Rheumatic Heart Clinics in Cairo and in several other Governorates. Mostly affiliated to university children's hos- pitals, these clinics were supplied with the necessary equipment by the As- sociation and their physicians received special training, in turns, at the Py- ramids Centre. The activities of these new clinics replicated those of the first Rheumatic Heart Clinic, namely diag- nosis, management and follow-up, in- cluding the prevention of recurrences. Health education and motivation of the public continued to be an impor- tant component of their activities. Nation-wide campaign During the 1970s, the encourage- ment and support extended to the Association by two consecutive Minis- ters of Health, together with the active collaboration of the school health ser- vices, inspired a nation-wide joint pro- gramme to combat rheumatic heart disease among children aged between six and twelve. Based on case-finding and a long-term preventive scheme, health education and the motivation of parents and older children were again important elements. School health physicians from all the governorates, a total of 130 doc- tors, underwent training for a period of one week at the Pyramids Rheuma- tic Heart Centre. Their training stres- sed the detection and diagnosis of early rheumatic heart disease. Detected cases were rechecked by specialists, and proven cases were started on long-term treatment. Dur- ing this campaign about three-quarters of the school children in this age group, totalling about four million, were screened. The results of the campaign soon became apparent. Follow-up studies conducted every ten years, each taking a sample of 1,000 rheumatic heart children, revealed a steady decline in severe disabling heart disease from 47 per cent recorded in 1960, to less than 15 per cent in 1970, and then to less than six per cent in 1980. The fall in the death rate caused by rheumatic heart disease was no less dramatic, especially in those Governorates where combat measures were most active ; it dropped from 15 per thou- sand in 1960 to eight per thousand in 1970, and only two per thousand in 1980. The main factor behind the positive results obtained over the last two de- cades, in the opinion of the founder of the Association, is the understanding and support of the mothers and of the older patients themselves. Health edu- cation and motivation of the public are considered to be a cornerstone in this success story, by helping to prevent recurrences of the streptococcal throat infection causing the disease and by seeking appropriate treatment and ensuring follow-up of the infection or of the rheumatic heart disease once it occurs. The awareness of the general public and the orientation of the physicians themselves, together with the spread of preventive measures and follow-up centres all over the country, enabled the patients (and physicians) to know more about the disease, and to know where to go for appropriate care. The dedication and generosity of its members has equally contributed to the success of all the endeavours of the Association. Government sectors, whether health or social, were prompt with their support whenever they were approached. Staff of the health ser- vices at field level were inspired to match the enthusiasm and dedication of these members. This is especially WORLD HEALTH, March 1985 14 ► These children in the streets of Cairo will be in good health provided their parents are well-informed and motivated to benefit from concerted medical and socio-economic measures. Photo WHO/C. Viedma the case for those who received their pre-campaign training at the Pyramids Centre. Plans for the future Today the Association enjoys a much higher status, and has initiated a Child Health Centre on the outskirts of Cairo on the west bank of the Nile. Not yet operating to its full capacity, this Centre will provide a wide range of medico-social services to the in- habitants of Dokki neighbourhood. Apart from out-patient and in-patient care, it currently provides social wel- fare services, in collaboration with local social workers, to needy mothers and fatherless children. A Well-Baby Clinic, the services of a Day Care Centre and a Creche will soon be available, as well as a chil- dren's club for the children aged from six to thirteen. A kindergarten and school for retarded children will follow. All the necessary funds are provided by contributions from members and from external benevolent sources. The members themselves help in running and supervising the various activities. While a nominal cost is charged for the services of this Centre, a number of services are free, such as those of the diarrhoea and oral rehydration clinic and of the malnutrition clinic. The idea underlying this Centre is to achieve the goal of improving child health in the community through com- prehensive medico-social services. " Most childhood diseases are pre- ventable, " says Dr Zahira Abdin, the dynamic personality behind all these activities. "Improvement of child health can only be the result of con- certed medical and socio-economic measures applied to a well-informed, motivated public. Our aim is to sup- plement those measures and to fill the gaps that are present in the existing health services. This is done by making available to all sectors of the popula- tion, especially the needy and the under-served poor, those health ser- vices and social care that answer to their identified needs. " ■ WORLD HEALTH, March 1985 15 First aid practice for two young mem- bers of the Red Cross in the People's Republic of China. Photo WHO/League of Red Cross Societies The League of Red Cross Societies and WHO launched their world-wide children's poster competition nearly two years ago, to promote pro- grammes of community-based re- habilitation (CBR) for disabled people. National Red Cross groups in 49 countries around the world made a first selection. A 15-member jury in Geneva, chaired by actor Peter Us- tinov, had the difficult task of select- ing a world winner and four regional winners from some 500 designs. Here we illustrate some of the win- ners and some of the also-rans. Others have already appeared in the last issue of World Health. c~C2vn ny Si ni&u na. ue3a14,;,, 4 /id ahct ,l,„cla 16 Red Cross• The Red Cross move- ment was founded in 1863 by the Swiss pacif- ist Henry Dunant. Today the League of Red Cross Societies, with national societies in 135 coun- tries, is always in the forefront when natural and man-made disasters strike ; it epitomises the international NGO which is greater than the sum of its parts. It derives its strength from all those na- tional societies, with their thousands of keen volunteers who represent a quiet army of health-oriented individuals, trained to act in emergencies great or small, as well as in times of peace. Our joint poster competition sym- bolises a much wider collaboration between the two global organizations, whose work together is making a notable contribution towards the goal of Health for all by the year 2000. Rehabilitation depends on what dis- abled people themselves, their families, neighbours and the community at large are able to do. The vast efforts now under way to start rehabilitation pro- grammes in communities, supported by the League of Red Cross Societies and by WHO, are based on this approach. The Red Cross/WHO collaboration thus illustrates the creative partnership that WHO has been able to forge with over 130 international NGOs for the attainment of Health for all by the year 2000. World-winning poster—"All of us are happy little birds"—by eight-year-old He Ning, of Tianjin, China. Winner, African Region, by Elida Rija Mahefa- son, 13, of Antananarivo, Madagascar. Also from Madagascar, a variation on the WHO emblem by Joanne Robine Rafidiarivolaninosy, 14. Winner of the jury's selection by seven- year-old Margarita Rosales Salazar, of Saltillo, Coahuila State, Mexico. Winner, European Region, by Timea Laczi, of Budapest, Hungary. Winner, Region of the Americas, by Karina Maki Mishinoya, 11, of San Luis Potosi, Mexico. Another European entry, by Csilla Dobrotka, of Tatabanya, Hungary. An entry from the Asia and Pacific Region, by Krisana Tantiwat, 12, of Bangkok, Thailand. WORLD HEALTH, March 1985 -one partnership among m any Women's councils by Pnina Herzog Our goal is to motivate people to help themselves and thus improve their conditions. May we succeed in making the world to some extent a better place for our children and grandchildren D isease knows no boundaries ; it can be carried very rapidly from one country to the other. In or- der to survive and to combat ill health we, the women of the International Council of Women (icw), and indeed all women, must practise sisterhood and responsibility to each other. Mrs Pnina Herzog is the Perma- nent Representative to WHO of the International Council of Women, and also the Convener of icw's Standing Committee on Health Our problems are interrelated and cannot be solved in isolation, and it is the accumulated and shared know- ledge, wisdom and understanding of all of us — from wherever we are — and the process by which we increase that knowledge and understanding that may eventually benefit us all. Founded in 1888, the International Council of Women unites together under one large " umbrella " women's voluntary organizations from 76 coun- tries. The icw offers a platform where the members can exchange ideas, lis- ten to each other, try to understand each other and together encourage women to recognise their responsi- bilities as individuals within the family, the community and society at large. As early as 1909 Lady Aberdeen, the first Convener of icw's Health Standing Committee, appealed to wo- men of all nations " to awake to a sense of their manifest duty in regard to the health of their children and their homes ". Among its numerous other func- tions, icw has placed special emphasis on its role as an informative and educational organ. In recent years the Council took steps to raise the aware- ness of its members to the relationship between health, the status of woman and development. This has been done primarily through a series of international and regional seminars in which Alio has collaborated and participated. In turn, these meetings triggered off numerous national seminars and pro- jects as well as Education for Health programmes initiated by icw's national affiliates. Botswana, for example, held a series of seminars on enrichment of family life, education for family health, child care, prevention of accidents at home and in the community, and nutrition. Besides holding seminars, the mem- bers of the National Council of Wom- en in Botswana have been active in setting up nursery schools, typing schools, club houses, vegetable gar- dens, mobile clinics and so forth. These women are working hard to ♦ Improvements in the education of women (above), and in such services as water supply and sanitation, are essential to raising the level of health and promoting development in the Third World. Photo Helvetas secure a better future for themselves and their children. The Kenya National Council of Wo- men held workshops on horticultural models for rural communities. In col- laboration with Kwandoya primary school, they put on show a model of how to grow the best tomatoes, carrots and cabbages. Water is available from both a tank and a local dam, and in some places also from water pipes. This project has an important educa- tional value, not only for the women and the school pupils but also for the other villages in the surrounding area. 18 WORLD HEALTH, March 1985 When the icw held its triennial meeting in Kenya in 1979, the partici- pants visited the Centre for Appropri- ate Rural Technology outside Nairobi. Two participants from Cameroon were impressed by the cooking oven, the carbon refrigerator, devices for drying vegetables, the hand-made water pumps and so on. On returning home, the two women organized a seminar on the appropriate technology they saw in Nairobi, and how to transfer it to the conditions of life in Cameroon. The National Council of Women in India has undertaken an ambitious plan to provide clean drinking water to 25 villages. They fought their way through the jungle of bureaucracy and finally succeeded. Now the govern- ment digs the wells, lays the pipelines, builds the pumphouses and runs the day-to-day expenses. Thirteen villages now get clean drinking water through the cooperative scheme. The National Council is also planning mobile units for welfare and family planning pro- grammes. The National Council of Women in the United Kingdom has a permanent working party which studies and makes recommendations to the gov- ernment on all matters concerned with alcohol abuse. It prepared a paper, which was well received and publi- cised, drawing attention to the "foetal alcohol syndrome" and highlighting the possible hazards to the baby of alcohol consumption during preg- nancy. The Health Committee has an important role in educating and in- forming members through lectures and discussions, so that individuals may use the National Health Service to their own best advantage. Members participate in the running of the Na- tional Health Service through mem- berships of health authorities and community health councils. In short, all icw's affiliates are in- volved in projects which are attempt- ing to turn dreams into reality. In 1909, the few women who formed icw's Health Committee joined in the battle against tuber- culosis. Since then the scope of its work has covered such areas as al- coholism, narcotics, drug addiction and venereal diseases. The Committee is also active in child health, maternal care and the protection of the health of the industrial worker. Following the Technical Discussions on nutrition during the World Health Assembly in Geneva in 1977, icw's The National Council of Women in the United Kingdom is drawing attention to the danger of alcohol consumption during preg- nancy. Photo L. Sirman Women and women's organizations are best placed to stimulate proper nutrition in the family. Photo WHO/P. Almasy. Health Committee undertook a study on the role of women and women's organizations in guiding the family in proper dietary patterns. A leaflet pre- pared for this purpose was sent to all affiliates, who used it in their pro- grammes for health education. It is worth noting that as long ago as 1930 there had been efforts by the icw to persuade the League of Nations to set up an International Institute for Public Nutrition. Later it supported the breastfeeding of infants and the use, after weaning, of locally available and acceptable foods. Community participation in health development has always been advocated by the International Council, and so has the establishment of people's health courses for both men and women. In their health education pro- grammes, our affiliates take into con- sideration WHO's plans of action as outlined by icw's Health Committee. National Councils of Women translate into their own languages, and circulate to their members, information on nut- rition, correct use of medicines, tradi- tional practices, breastfeeding, family planning, oral rehydration therapy and the code on breastmilk substitutes. Besides its official relations with Wm, icw is a member of the NGO Groups on Primary Health Care and on the Elderly, as well as of other NGO groups within the framework of specific WHO programmes. As an NGO primarily concerned with the interests of women, icw sees im- portance in all activities within the area of women in health and develop- ment. Our members from different parts of the globe work together in a cooperative spirit to fight our common enemies, which are hunger, disease, ignorance. Our goal is to motivate people to help themselves and thus improve their conditions. May our concerted efforts make the world, even to some small extent, a better place for our children and grandchildren. ■ WORLD HEALTH, March 1985 19 Preventing blindness s long as wHo itself has existed, there have been efforts on the part of international NGOs for the pre- vention and cure of blindness in de- veloping countries which have run par- allel with, if not in actual collaboration ♦ The Royal Commonwealth Society for the Blind pioneered an eye camp programme in India for the mass extraction of cataracts under field conditions. Photo WHO/Royal Commonwealth Society for the Blind with, the efforts of wiIo and Ministries of Health. The isolated mission station, the mobile eye unit, the temporary eye camp and the Flying Doctor—these are all familiar features now in many iso- lated corners of the world. The launch- ing of the International Agency for the Prevention of Blindness (IAPB) finally gave recognition to the work of these enterprises and accelerated their inte- gration with national eye care pro- grammes. This event was at the same time the culmination of a quarter of a century of effort by international NGOs dealing with eye care and also the starting point for accelerated deve- lopment. In less than ten years, 54 national committees or commissions for the pre- by Alan W. Johns vention of blindness have been formed in developing countries ; and the crea- tion of national eye care plans and their integration into national health care have now become the rule rather than the exception. While Ministries of Health set objectives and determine policy, they recognise the important role that international NGOs and national societies of and for the blind have to play. The current situation in Kenya offers an excellent example of collaboration Mr Alan W. Johns is Director of the Royal Commonwealth So- ciety for the Blind, Haywards Heath, Sussex, U.K. between international NGOs, the nation- al agency for the blind and the Ministry of Health. In 1982, the national Preven- tion of Blindness Committee was recon- stituted, to which the Ministry of Health provided an influential Chairman and half of the membership. The Kenya Society for the Blind provided the Secretary of the Committee, as well as secretariat services, and the remain- ing places were filled by international NGOs involved in eye care services in Kenya. Rural eye care The International Eye Foundation had been working for some years on its Kenya Rural Blindness Prevention Pro- ject, the Christoffel Blindenmission had for many decades been associated with eye care provided in mission hospitals and through Sight By Wings, and the Royal Commonwealth Society for the Blind in partnership with Operation Eyesight Universal had, over the years, built up a fleet of mobile eye units providing treatment and referral ser- vices throughout rural Kenya. Within a year of its reconstitution, the Prevention of Blindness Committee had produced a Five Year Eye Care Plan which received the consent of the Minis- ter of Health and promises of support from all the participating agencies. Although the main thrust of the international NGOs has been in setting up and carrying out national eye care plans, a parallel tradition has been the attack on single causes of blindness. This is best typified by the efforts of Helen Keller International in the field of pre- venting blindness from Vitamin A defi- ciency, and by the eye camp programme pioneered by the Royal Commonwealth Society for the Blind for the mass ex- traction of cataracts under field condi- tions. An earlier and much more com- plex project was aimed at control of onchocerciasis—" river blindness " —in West Africa; this was pioneered by NGOs but was later adopted by wHo in collaboration with the World Bank, FAO, and the UN Development Pro- gramme. While it continues to be the responsi- bility of Ministries of Health to deter- mine national objectives and policy, it has rightly been the task of the interna- tional and national NGOs to provide the risk capital for development, experi- menting and improvising until solutions to problems in the field have been found which can be replicated within countries or regions. Subsequent developments at national level have followed on from developments at the international level. Three years after the IAPB was launched, wHo established its Pro- gramme for the Prevention of Blindness. The international NGOs currently spend more than US $20 million per annum on blindness prevention in collaboration with this Programme—but it is not only the financial grant total which counts. The particular role of international and national NGOs, because of their variety of approach and flexibility of operations can bring about real success in the provision of rural eye care. ■ 20 WORLD HEALTH, March 1985 An aging world lthough the warning signs of a rapidly aging world have been evident for some time, it was not until quite recently that serious re- sponses to this universal phenomenon began to emerge in the public arena. They in turn led to the World Assem- bly on Aging held in Vienna in 1982. At the same time, the creation of the International Federation on Aging (IFA) a decade ago gave a new means of expression to organizations repre- senting the world's older citizens, and to those who serve them on a global basis within the voluntary sector. It now collects and provides information on self health care of the elderly. The International Federation, which is now officially recognised by wHo, believes that, if the goal of Health for all by the year 2000 is to be achieved, it will need to mobilise all the human resources it can muster. In the case of older people, this will mean extending WHO's existing networks of relation- ships beyond those traditionally as- sociated with prevention, primary health care, and treatment : it will need to establish coalitions with a wide range of organizations reflecting wide- ly differing characteristics. In this process representative groups working at both national and international levels in a combination of advocacy, service delivery and self- help will emerge as valuable partners. If longevity is to be seen as a bonus to be enjoyed rather than as a burden to be endured, social and economic conditions, as well as cultural factors, will have as much influence on the process of decent human survival as the practice of medicine. In other words, good health, or a personal sense of well-being, depends upon a multiplicity of factors : the degree to which old people command respect and feel they have a continuing role in their community will have a powerful influence on their lives, and so too will their income, living conditions, diet by David Hobman ♦ Several Naos are collaborating on behalf of the elderly to make longevity a bonus to be enjoyed and to achieve Health for all. Photo WHO/J.-F. Chretien and the skills of their physicians and nurses. After all, by the very fact of their long lives, they have already demonstrated the effectiveness of their personal survival kits. Mr David Hobman is President of the International Federation on Aging, and Director, Age Concern, based in the United Kingdom From this it follows that the working relationships now being established between the WHO and the IFA may prove to be one of the vital links in bridging global strategies with local solutions. The International Feder- ation's growing membership—now based on 84 organizations in 42 coun- tries—involves a powerful combina- tion of older people who have the widest possible range of life-skills, ranging from professionals in such dis- ciplines as social administration and community organizations to experts in gerontology and geriatric medicine. But its strength lies in the fact that it is, in essence, a lay organization con- cerned with the normality of the aging process. Among its current activities of specific interest to the readers of World Health are a skills exchange programme teaching day-care techni- ques to be carried out initially in three continents ; the collection of material on self health care, health promotion and family support ; the exploration of health problems in rural areas ; and regular health-related features in IFA's International Bulletin which provides valuable resource material on an inter- country comparative basis. A number of WA members within the European Economic Community are also work- ing together through Eurolink-Age, an informal coalition, on the pre- scription, packaging and marketing of drugs, and on the role of "well elderly" clinics where healthy old people are regularly checked up and screened. Undoubtedly, as time goes on, the possibilities for collaboration between IFA and wHo will develop further as the world's population contains an ever-greater percentage of aging indi- viduals. Several NGOs are collaborating on behalf of the elderly to achieve Health for All. The International Centre of Social Gerontology (IcsG), which to- gether with the IFA was one of the first NGOs dealing with the elderly, is de- veloping a documentation centre on social gerontology to serve WHO's Member States, particularly develop- ing countries. Joint icso/wHo activities have frequently been carried out, for example on accident prevention in the elderly. Activities co-sponsored with other NGOs have involved the International Association of Gerontology in 1980, 1981, 1983, and 1984; the Interna- tional Epidemiological Association in 1984 ; the International Council of Nurses in 1985, and the World Confed- eration of Physical Therapy, 1987. ■ WORLD HEALTH, March 1985 21 NAME DATE OF IMMUNISATI SITIvE esriNG Consortium against rubella by Jean Wilson Eleven national NGOs in the United Kingdom joined forces last year to launch a campaign to immunize all young girls against rubella. If this disease should occur during early pregnancy, it can put the baby at grave risk of mental or physical handicap ntil 1941, when Dr Norman Gregg in Australia linked rubella with congenital cataract, the disease first described by German scientists in the mid-eighteenth century was re- garded as a harmless childhood infec- tion. We now know that a woman who contracts rubella during the first sixteen weeks of pregnancy faces a grave risk that the baby may be born deaf, blind, mentally or physically handicapped, or sometimes bearing throughout child- hood a distressing combination of these impairments. A vaccine against rubella became available in the late 1960s. Use of this vaccine, one of the safest of all immuni- zations, has, in some countries, reduced the prevalence of congenital rubella to the point where elimination of the dis- ease (though probably not total eradica- tion) is a practical possibility. Different control strategies are followed. In the United States, all children— both boys and girls—are offered im- munization in infancy ; in some States, a child has difficulty entering school and a woman may not get a marriage licence without evidence of rubella immuniza- tion. In Sweden, both girls and boys are immunized in infancy, and girls a second time, in early adolescence. In the United Kingdom, the policy is to offer immunization to all girls be- tween the 10th and 14th birthdays and to urge adult women to have a blood test followed, if necessary, by vaccination. It was against this background that, in 1983, the Department of Health and Social Security and the Health Educa- tion Council joined with eleven national nongovernmental organizations to pro- mote, throughout England, Wales and Northern Ireland, a concerted three- year campaign aimed at increasing the take-up of rubella vaccination to the point where permanent control might be achieved. A National Rubella Council was established and the government provided a sum of £1.8 million to ensure that supplies of the vaccine would every- where be available through the National Lady Wilson is Chairman of the British National Rubella Council Health Service. The nongovernmental organizations set up a national office to coordinate, through their combined na- tional networks, the resources of the community, and they sought collabora- tion from all relevant medical and edu- The Princess of Wales, Patron of the National Rubella Council, launching a cam- paign to urge girls in the United Kingdom to be vaccinated against rubella. Photo UK Press Association 0 cational bodies and from organizations of women and youth. The campaign was launched in November 1983 by the national Rubella Council's Patron, the Princess of Wales, at a national event in Lancaster House, London, the scene of many governmen- tal and diplomatic occasions. From the outset, we saw our task in terms of public motivation and delivery ; to con- vey to every school and home in the Don't be in the RED wini Rubella 1 Vaccination of young girls against rubel- la; a "credit card" that will protect their future children against grave mental or physi- cal handicaps. country the simple message that congen- ital rubella is a disabling scourge against which any woman can protect her baby in advance. A record card, designed in the style of commercial credit cards, is given to every vaccinated schoolgirl and to every woman who has had a positive blood test. A "Birth Day" card reminds a new, unprotected mother of her need for immunization before her next pregnancy. The media are collaborating magnifi- cently in regional and national publicity. Through her patronage, the Princess of Wales—wife of Prince Charles, the heir 22 WORLD HEALTH, March 1985 to the British throne—has brought to this campaign a warmth of personal interest and an invaluable contemporary style with which girls and young mothers readily identify. Photographs of the Princess meeting children handicapped by rubella, listening to the problems of parents or talking to health workers are regularly featured in films, television and newspapers. As the campaign de- veloped, the effectiveness has become apparent of the partnership between strategy and voluntary organizations. To the comprehensive coverage which only government can provide, we in the pri- vate sector were able to add an aggres- sive form of publicity, a relationship with the media which was perhaps more convincing because of its informality, and an ability to mobilise voluntary service and motivation within the com- munity. We are convinced that what has been described as " a characteristic Brit- ish mix of statutory and voluntary ac- tion" has enabled us to achieve results not possible for one partner alone. The eleven national nongovernmental organizations in the " Consortium" are each concerned in their daily work with the individual impairments resulting from congenital rubella : deafness, blindness, mental handicap, and heart impairment. The fact that their mem- bership includes many people who are themselves handicapped or are parents of handicapped children has added strength, immediacy and conviction to the campaign. This involvement of the disabled themselves also influenced the style of our publicity. Without minimis- ing the tragedy of giving birth to a needlessly handicapped child, we are determined to do all we can to encour- age the integration of disabled people into society and to foster the demand for effective rehabilitation. During the first year, we have concen- trated on the task of increasing the up- take of the rubella vaccine amongst girls aged 10-14 years. At the outset of the campaign, in November 1983, the Minister for Health estimated that 83 per cent of such girls were protected by immunization. The figures for 1984 have not yet been compiled nationally but school returns from many parts of the country show a striking increase. The most recent figures from some re- gions showing the percentage of fifteen- year-old girls immunized against rubella include Oxford 92 per cent, Wessex 96 per cent, Trent 94 per cent and, from Wales, an astonishing 99 per cent. How- ever, there remain considerable varia- tion between different regions and dif- ferent schools, and a recent sample survey has revealed a lack of awareness and motivation amongst young women aged 16-24 years. In reaching schoolgirls, there has again been an effective partnership be- tween the education authorities, the professional associations of teachers, the school health services and the non- governmental organizations concerned with youth. It has been suggested that each school should appoint a junior staff member or senior student as the focal point to stimulate immunization. The Girl Guides Association, the largest or- ganization for young females in the country, is actively promoting the cam- paign amongst its members. Television " shorts " aimed particu- larly at schoolgirls have been regularly shown on various television channels. A film is being produced with language Cartoon by Tony Hart which we hope will reflect the rapidly changing mood and vocabulary of young schoolgirls. Poster competitions in schools and art colleges are producing a flow of ingenious, contemporary public- ity. Of the various slogans proposed, perhaps "Rebel against rubella" catches the mood of a non-conforming generation. During the second year of the cam- paign, our emphasis will increasingly be on women of childbearing age. A car- toon by Tony Hart, which we reproduce above, illustrates the mixture of serious message and whimsical presentation which we shall be trying to generate. Members of the Women's Royal Vol- untary Service, Inner Wheel and Sorop- timists, amongst many others, are vigor- ously collaborating in this campaign. The Chairman of the National Federa- tion of Women's Institutes, with its membership of 355,000 women scat- tered throughout the villages of England and Wales said : " We are encouraging all our members, not only to ensure their families' protection but also to alert their communities to the needless risk of babies damaged by rubella." The Council is urging that, wherever possible, a "rubella representative" should be nominated by these organiza- tions to stimulate interest amongst their members. The partnership established nationally between Government and voluntary organizations has been repro- duced regionally. We are collaborating with the Regional Health Authorities in conferences which bring together key people to examine the facts about ru- bella and to establish regional action groups. General medical practitioners, community medical and health educa- tion officers, school nurses, health vis- itors and midwives are working with the voluntary organizations of youth and of women in their regions. In a typical project in one area, the community health services took to the streets for one week with a rubella screening project. The team of medical, nursing and administrative staff offered blood testing to women of child-bearing age. Publicity—including posters and door-to-door handouts—were distri- buted by staff, boy scouts and, in one neighbourhood, by the local milkman A staffing rota was compiled using volun- teers from all departments, and the clinic was manned from 9 a.m. to 4 p.m. daily. Between November 1984 and May 1985, the U.K. Post Office is post- marking 30 million letters with the slogan "Don't risk rubella. Be wise, immunize !" The ethnic groups living in the U.K. will be a particular target of our cam- paign in 1985. The rubella literature is being printed in Punjabi, Gujarati, Hin- di, Urdu, Bengali and Chinese. Through the nongovernmental organizations con- cerned, we are in touch with the re- presentatives of the ethnic groups in the major cities. A rubella calypso, first composed in the Caribbean island state of Antigua, will be used in our campaign amongst West Indian communities in the U.K. It goes as follows : "What is all dis mystification About dis thing called immun- ization ? It means—if you're going out with a fella— Make sure you've had your rubella." ■ WORLD HEALTH, March 1985 23 Sharing resources in the Caribbean by J. Kenneth Thompson he spirit of voluntarism is strong in the Caribbean region. This is just as well, as many of the governments of the smaller islands cannot afford to finance all the health services that are needed in their com- munities, however much they would wish to do so. There are instances where govern- ments have been able to assume finan- cial responsibility for some of the pioneer work of benevolent societies. For example, the salaries of staff at ♦ This mentally retarded boy is one of the "children with special needs" who receive appropriate therapy and care from several voluntary NGOs in the Caribbean region. Photo WHO/M. N. J. Marie some of the schools for the blind are paid from national resources. Since the breakdown of the Federa- tion of the British West Indies, which sought to band together the many small island governments, it has been Mr J. K. Thompson is Consultant in Disabilities to the Common- wealth Secretariat, which is based in London difficult to maintain any regional ap- proach to health and welfare needs. Consequently, heavy responsibility has fallen on each individual country's nongovernmental organizations to do what they can, especially for " children with special needs ", whether physical or mental. To maintain their work, they have necessarily to resort to im- aginative methods of fundraising and the soliciting of external aid. Today there are several examples of effective working together, although travel between the islands is too costly for the degree of experience-sharing and joint planning that they would wish. For mentally retarded children, the Caribbean Association for Mental Retardation and other Developmental Difficulties is resorting to video casset- tes for the sharing of its training mate- rials. The Caribbean Council for the Blind has developed in the last five years into an 18-country organization with an effective ten-year plan. It was significant to observe at their five-year review that the Chairman, the Execu- tive Director and almost half of the delegates were themselves blind peo- ple ; and that nine of the participants were representing governments, along- side their NGO colleagues. The growth of the concept of appro- priate therapy for disabled people is also important, since the smaller is- lands cannot each hope to maintain fully trained professionals in phy- siotherapy, speech training and occu- pational therapy, to mention only three disciplines. Through a Carib- bean Association of Rehabilitation Therapists, the islands are learning to share their professional resources. Partial financing of consultations of this kind by the Commonwealth Foundation has been indispensable. Government employees as well as organizers and fundraisers from the general community join in all these activities. And as the members seek to come together as far as possible on a regional basis, they strengthen their own position as the organization through which external assistance —bilaterally from governments as well as from international NGos— can most rationally reach the people who most need help. ■ WORLD HEALTH, March 1985 The daily struggle in Mali by Anne-Marie Gaudras V he narrow sandy track arrives ab-ruptly at the village of Kebila in southern Mali, near the frontier with Ivory Coast. About 20 people alight from the four-wheel-drive vehicles which left Bamako that same morning in November 1983. They are experts, tech- nicians, planners and managers who have only known each other for a week and are attending a workshop on primary health care. This field visit will give them a better understanding of the everyday realities of primary health care. The chief medical officer of the health centre for Kolondieba, a district of 127,000 inhabitants and 212 villages divided into five administrative areas, tells them about some of the problems. For example, while some effort has been made to provide equipment for rural maternity units, he complains of the small number and lack of punctuali- ty of the staff. There needs to be a definite system for vaccinations : DPT + polio immunization, for example, is performed only on demand. Tetanus and BCG vaccinations are available only at the maternity units, and the latter only on the 25th of each month. The supply of drugs and vaccines is inade- quate and irregular, and there is no cold chain to ensure that vaccines are refrig- erated to the right temperature. More funds are needed to buy petrol so that the health workers can make their rounds. The women have long waits at the well, which practically dries up in the dry season, and there are queues from four in the afternoon till midnight. Pre- mature babies, who are common be- cause of malaria and anaemia in pre- gnant women, are fed on cow's milk mixed with water. A few nurses offer oral rehydration salts, but do not as yet teach the village women to make the rehydration fluid themselves. The birth attendants and the staff of the ma- ternity units do not use growth charts, and few couples receive advice about the spacing of births. Nevertheless, efforts are being made to tackle most of the problems. The school parents' association provides funds to pay the birth attendant who runs the little rural maternity unit. There is a pharmaceutical store where essen- tial drugs can be bought at a 15 per cent government discount. Of course, it is the same store where the villagers buy cloth, spirit for their lamps, cooking oil and soap. Anne-Marie Gaudras is an infor- mation assistant with UNICEF. She works in Abidjan, Ivory Coast The water supply has become more accessible and regular since the instal- lation of a foot pump, which the village blacksmith can repair if it breaks down. Now about 20 women can fill their containers every hour. In the village of Mafele, the installation of a water pump has also proved a boon, for the sur- rounds of the well have been levelled and even cultivated. Moreover, as the spokesman-interpreter points out, in- testinal diseases have become less common and the most common reason for seeking health care today is injury or hernia caused by the heavy "daba ", the peasant's traditional hoe ! The chief medical officer at Bou- gouni, another district visited, spoke of the same problems as his counterpart at Kolondieba. But he could also point happily to a village where, in the 1960s, a programme for training rural birth attendants was developed at the insti- gation of a midwife who moved into this rural area with her husband. She began to give advice on obstetrics and hygiene to the traditional birth atten- dants, who after a while were delighted to see a fall in the number of perinatal deaths. On their return to Bamako the work- shop participants, with the everyday realities of Mali fresh in their minds, made their analysis of the situation in Africa as a whole. Their conclusions were not optimis- tic : they found that progress generally has been slow and unsatisfactory be- cause, even though the political will to advance is loudly proclaimed, there are so many unhelpful attitudes and finan- cial constraints to circumvent. As one member put it, "things don't get done by themselves". An official expression of political will is not enough ; the readi- ness to struggle for health and develop- ment must be all-pervading, and it is essential to harness the necessary tools and adapt them to the develop- ment process if, by the year 2000—only 15 years away—the worldwide target of Health for All is to be achieved. These tools are community participa- tion, the multisectoral approach, inte- gration of programmes in a compre- hensive effort, and redistribution of resources. The workshop produced suggestions and proposals that can be applied to specific cases. How can we hope to bring primary health care to everyone unless we remember that, to be effective, we sometimes need compasses, camels, guides, and a timetable of the movements of nomadic populations ? Another meeting was suggested for 1985, since the global objective is no- where near being achieved in the conti- nent of Africa, and the establishment of a new health order there is urgently needed. The participants agreed that all countries must see to it that the Health Development Charter for Africa is ratified—and that from now on its terms are scrupulously carried out ! ■ WORLD HEALTH, March 1985 25 Health Economics Financing primary health care by Hakan Hellberg and Edward P. Mach In many countries, the costs of PHC have not been fully worked out and sources of finance for health programmes in the future are left vague. Far more work needs to be done to ensure a realistic and sound estimation of costs ne of the more essential re- quirements of primary health care is that it should be at a cost that people can afford right now. At the same time, it is vital to investigate and use all possible resources to sup- port and finance PHC, since relying only on traditional sources of financ- ing will not be enough. The very concept of PHC calls for changes in the traditional approaches to basic health services. People's involve- ment, intersectoral action for health and the need for appropriate technol- ogy all require new forms of financing. Each of the different elements of PHC has potentially a whole set of different sources for support and financing, and these sources will vary from one situation to another. This becomes evident if we consider the different ways there are of supporting health education, food, water and sanitation, maternal and child care with family planning and immuniza- tion, disease control, essential drugs and treatment of common diseases and injuries. The studies which led to the evolu- tion of the PHC concept identified a number of ways to finance expanded and improved health care coverage of the population. They considered that the most important alternative to financing from government, foreign aid, employers and charities would be the participation of communities in their own local health programmes. In the early 1970s, many examples were found around the world. In China, low- Dr Hakan Hellberg is Director of Health for all Strategy Coordina- tion at WHO headquarters in Ge- neva, and Dr Edward P. Mach is a consultant with that division cost health facilities, the use of tradi- tional techniques and medicines, modest salary levels for health work- ers, and voluntary workers were financed mostly by contributions from production brigades, communes or factories as well as regular family payments under cooperative schemes. In Cuba, more than 50 per cent of the government budget was allocated to health and education. In Bangladesh, a health project providing immunization against communicable diseases and limited curative services relied on insurance subscriptions from the populations. A rural health project in India provided maternal and child health services, health education and diagnosis and treatment of simple common diseases from collected loc- al fees and a modest government grant; these amounted to 70 per cent of the total budget while the other 30 per cent came from donations. In addition, labour and local material were donated by villagers for building health facilities. In Venezuela, the cost of the "sim- plified medicine" programmes— health care provided by auxiliary health workers, covering about 10 per cent of the rural population—was borne by the national and state gov- ernments, but the community also participated by contributing towards the cost of maintaining and running buildings, and building or equipping dispensaries. In Niger, village health workers, trained traditional birth attendants, and village pharmacies were taken in charge by rural communities. Each village had a health management team that dealt with all financial mat- ters, while a treasurer kept the stocks of the pharmacy, purchased new drugs and recorded all financial trans- actions. The village health worker was a volunteer, and his only reward was that the villagers provided his day-to-day subsistence, mainly in the form of food. In Senegal, groups of villagers worked together to build maternity centres from local material, and tradi- tional birth attendants were briefly 26 WORLD HEALTH, March 1985 ♦ The most important alternative to financ- ing primary health care from government or other sources would be the participation of communities in their own health care programmes. Photo WHO/P. Almasy trained by the government health ser- vices, then served as midwives, col- lecting a very small fee for assisting the deliveries. Many other examples could be quoted from various countries at dif- ferent levels of development ; the alternatives were usually a combina- tion of the methods of financing described here. More equitable Further evolution of the PHC con- cept of financing laid emphasis on more equitable distribution of funds between urban and rural areas ; be- tween the wealthier layer of the popu- lation and the poor ; between hospi- tals and the rest of health services. The potential effect on health of some of the resources of other sectors, such as agriculture, industry or min- ing, was recognised and promoted. The efforts to obtain more funds for expansion of the health care system have to be seen in the context of the worldwide economic crisis that has affected both developed and develop- ing countries since the mid-1970s. The developing world, with the possi- ble exception of oil-producing coun- tries, was affected in many ways : higher prices for imported fuel, de- creasing agricultural production in areas hit by drought, decreasing de- mand for and prices of their export goods, and a reduced flow of tourists all had a negative influence on the economies of many countries. For these reasons neither the govern- ment nor the industrial and agricultur- al employees could augment their expenditures on health, and substan- tial groups of the population with shrinking employment opportunities could not pay more for health. Conse- quently for many developing coun- tries to achieve the goal suggested by WHO of spending around five per cent of the gross national product on health still remains an intention, de- pendent on a considerable improve- ment in the national economy. Another very difficult alternative would be to rearrange the scale of priorities within the limits of existing resources. To replicate any of the model financing schemes often proved to be a serious problem for the promoters of PHC. The Chinese and Cuban experiences were often declared non-applicable, because the social, economic, political and cultural cir- 27 WORLD HEALTH, March 1985 ♦ When the population are willing to par- ticipate, they must be able to count on the support of a national infrastructure and on the capability of the public sector to re- spond to community initiatives. Photo WHO/P. Merchez cumstances of these countries differ so markedly from other developing countries. Participation of com- munities in bearing the cost of local health programmes was in some countries declared contrary to the traditions and culture of the people, and therefore not feasible. In other situations, the population seemed to be quite willing to participate, but there was an absence of organizing effort, national framework, and capa- bility of the public sector to respond to community initiatives. Even the redistribution of govern- ment funds proved to be a slow process. Ministries of Health have to keep the existing health services run- ning, and they absorb the bulk of their budget. To change the priorities of health policy, for example by provid- ing more health care to rural people or allocating more funds for peripheral health services, is difficult to imple- ment financially. Such radical solu- tions as closing some hospitals or dismissing health personnel from ur- ban services were usually deemed politically impracticable in most de- veloping countries. So all that was left for reallocation was the additional finance received by the Ministry of Health from the Treasury (if any). Fortunately, many countries now have a declared policy of using all additional funds that become avail- able, including foreign aid, for primary health care. In spite of all these constraints, PHC programmes have been de- veloped and to a lesser or greater degree also financed in most coun- tries. Progress can be seen, even though both the amount and the regu- larity of resources often leave much to be desired. While the efforts to organize health programmes with the involvement of the communities at the local level continue in most countries, the issue of whether to levy charges for various health care services often arises. Cost-sharing ideas proposed in the public health sector include : charges for drugs (the full or partial cost of drugs) ; charging the real cost of beds in the case of pay-beds in hospitals ; charging some fees for ambulatory and hospital care ; charging PHC by-passing fees for " improper" use of health services ; that is to say, services at the peri- phery would remain free of charge, but individuals seeking medical care directly in hospitals (without being referred there) would pay a fee ; establishing various voluntary health insurance schemes, for exam- ple a unified system of private em- ployers-employees' health insurance schemes with uniform contributions and agreed fees for providers of medi- cal care ; in some countries such 28 WORLD HEALTH, March 1985 providers could be from both the public and private sector ; — charging insurers of vehicles with the cost of treatment in hospitals of victims of road accidents. Governments are understandably cautious about tackling the issue of fees where health care was previous- ly free of charge, and particularly in countries where at the time of obtain- ing independence the health of the population was declared the govern- ment's responsibility. Many countries would need preliminary studies to estimate the expected revenues from fees, taking into account the addition- al costs of administration, procedures for making exemptions for the very poor, allowances for emergencies and so on. An important aspect is that the revenues from charges should remain with the health institutions that collect them, and should not be channelled directly to the Treasury. This practice at present is frequently a disincentive for health personnel. Other technical difficulties arose when political leaders, senior civil ser- vants and donor agencies wanted to know how much it would cost to Financing of priority programmes, such as water supply, has a direct bearing on health policies. Photo WHO/P. Merchez provide PHC for the whole population of the country. Even estimating the existing level of the cost of PHC proved difficult. In order to work out the answer to such questions, plan- ners and statisticians demanded a clear definition of PHC. Besides medi- cal care in the public and private sector, should the cost of nutrition, water supply and housing pro- grammes also be calculated ? Equity, social justice and local decision-mak- ing all form part of the PHC concepts but their cost can hardly be estimated. The use of earlier cost data as a basis for future estimates was found to be another problem. PHC means using available and affordable tech- nologies for health care, food produc- tion, provision of safe drinking water, and education, but there have hitherto been no data for such new ap- proaches. Arithmetic calculations may be misleading when it comes to es- timating the cost of coverage of addi- tional groups of the population. Pro- viding health care to scattered families is usually more expensive than the per capita cost in a densely inhabited area. WHO has already published a manual for developing countries under the title " Planning the finances of the health sector" (by E. P. Mach and B. Abel-Smith). This manual explains the relationship between health policies Among the cost-sharing ideas proposed in the public health sector is charging vehi- cle insurers with the costs incurred in treating victims of road accidents. Photo WHO/C. Viedma and the financing of priority pro- grammes. It reviews definitions and techniques of data collection on health costs. And it suggests ways of preparing a master plan for the future use of all financial and material re- sources. A recent progress report on imple- menting strategies for Health for all by the year 2000, prepared on the basis of information submitted to WHO from more than 100 countries, has re- vealed that in a number of countries the cost and financing part of plans was not worked out ; expenditure data were incomplete or non-exis- tent; sources of financing of future health programmes were left vague or not identified. It is clear that far more work should be done to ensure a realistic and technically sound esti- mation of costs. And this will entail realistic planning of all sources of funding ; a constant search for new sources of financing, with a parallel effort to reduce waste of resources in all areas of the health sector ; and the development of competent man- power to undertake all these tasks. ■ WORLD HEALTH, March 1985 29 000 •• 0 • 0 • 000 000 000 •• * 00* 000 0•0 000 00000• •• 0 00000 0 •• 00•• 00 *00 0 •• ••• 000000 000 •••00• 00000* *00000 000 00 000 0• 000 000 00* 0 •• 000 ••• •O•••• 0•• 0• 0• ••• 0000 • 0 ••• *•0 00• ••* •0• ••0 000 ••• 00000• 0•0 00 0•0 00* ••• 000 0•• 000 New drugs to fight Parasitic Diseases Molluscicides and larvicides have always been—and still are—among the major weapons against the blackfly and water snail vectors, respectively, of onchocerciasis and schistoso- miasis. But now reports show that drugs are proving effective against these two parasitic diseases. Details : Ivermectin, a new, anti-para- sitic drug, has been tested suc- cessfully in four African coun- tries on 133 victims of oncho- cerciasis, a disease transmitted by the bite of the blackfly. Some 40 million people, mainly in parts of tropical Africa but also in Latin America, are estimated to be suffering from onchocerciasis— river blindness. Clinical trials show that a single dose of the drug, taken by mouth, reduced to near zero the microfilariae in the skin, according to reports presented during a recent meeting on tropical medicine in Calgary, Canada. The drug has been tested in Liberia, Mali, Senegal and Ghana, in the last country for Photo WHO/Merck & Co Dr. Aziz examining a 14-year-old blinded by onchocerciasis. Worldwide Statistical Report from WHO Sixteen developing countries of the Western Pacific reported altogether more deaths in 1980 from diseases that normally strike affluent nations than from infectious and parasitic diseases. An estimated 32 per cent—or 2.9 million — of the deaths in these countries were caused by diseases of the circulatory system, and other degenerative diseases, such as diabetes, stomach ulcers, and cirrhosis of the liver, all major problems of the industrialised world. Infectious and parasitic diseases, the number one killers in the Third World, are estimated to account for 25 per cent—or 2.6 million—of all deaths reported by the 16 countries, the lowest proportion of all developing regions. This is attributed mainly to reduced mortality from such diseases in the largest developing country of the Western Pacific region—China. WHO says in its 1984 World Health Statistical Annual that the difference in mortality "warns against uncritically viewing the health problems of all developing regions together, and should stress the need for a more careful scrutiny of regional health problems". The annual gives mortality for 150 causes of death, plus estimated infant mortality rates, as well as life expectancy rates for Africa, the Americas, the Eastern Mediterranean, Europe, South-East Asia and the Western Pacific. It also gives morbidity, for the first time, for the world's leading childhood diseases. Among the highlights : All Causes of Death : In developing countries, the majority of deaths occurred in the under 15 age group, namely 60 per cent in the African and Eastern Mediterranean regions ; over 50 per cent in South-East Asia ; and 40 per cent in Latin America and the Caribbean. For the Western Pacific, the figure is under 20 per cent, again largely attributable to China's progress in reducing mortality from the diseases that tend to claim young lives. In developed countries the majority of deaths—from 65 to 70 per cent—occurred among people aged over 65, as compared to 25 to 40 per cent for Third World countries. Infant Mortality: The infant mortality rate (deaths under one) ranged from 6 to 8 deaths per 1,000 live births for Japan, the Netherlands, and the Nordic countries to over 100 for most African and many Asian nations. Life Expectancy: Japan leads in life expectancy for both males and females, respectively 74.5 and 80.2 years. While general mortality figures are shown for developing and developed countries alike, specific causes of death, adjusted for age, are given for 30, mainly industrialized, countries reporting. Among them are : Ischaemic Heart Disease: The death rate from heart attack for both men and women ranged from a high of 300 per 100,000 population, in Scotland, to a low of 49, in Japan. Lung Cancer : The death rate from lung cancer ranged from a high of 70 per 100,000 population, in Scotland, to a low of 22, in Sweden. Figures for Canadian women show a steadily increasing death rate, from 18.1 in 1979, to 22 per 100,000 in 1982, representing a 20 per cent increase in deaths in four years, twice the figure for Canadian men. Alcoholism : The death rates from cirrhosis of the liver for both sexes ranged from a high of 33 per 100,000 population, in Italy, to a low of 4, in England and Wales. Accidents: The death rates from road accidents for both sexes ranged from 23.4 per 100,000 population in Yugoslavia, to a low of 8.8, in Sweden. over a year on 19 patients at the WHO-supported Onchocerciasis Chemotherapy Research Centre in Tamale. "As encouraging as our re- sults so far have been", says Dr Mohammed Aziz, senior direc- tor of clinical research for Merck Sharp & Dohme, the developer of the drug, "we don't know as much as we need to know until we have studied it in many more patients." As plans pro- ceed for a new two-year trial on 1,000 patients, hopes are high. Oxamniquine, praziquantel, and metrifonate have proved ef- fective against schistosomiasis, a water-borne disease caused by a parasitic flatworm. The first, manufactured by Pfizer, is used against the intestinal form of the disease ; the second, manufactured by Bayer and de- veloped with WHO, is effective against all forms ; and the third, also a Bayer product, is used against urinary schistosomiasis. All are taken by mouth. Experts were told recently that, after drug treatment, the infection rate dropped from 90 to 13 per cent among school children in the Nile Delta, and from 50 to 11 per cent overall in Sudan's Gezira area. ■ 30 WORLD HEALTH, March 1985 If you would like to obtain a complete catalogue of all wHo publications, or receive sample copies of other WHO periodicals which you want to evaluate before placing a sub- scription, please con- tact: World Health Or- ganization, Distribution and Sales, 1211 Geneva 27, Switzerland. DOMINICAN REP. - • • IL Asra4u0AI LRaLreA:AeR cF JAMAICA VIRGIN IS. St CHa'.13NISETVOIPSHERI-- 1 ANTIGUA 9R 6 MONTSERRAT ° GUADELOUPE sF DOMINICA C-.) MARTINIQUE St LUCIA 0 St VINCENT & BARBADOS THE GRENADINES .•.; GRENADA t) St CHRISTOPHER & NEVIS 'Pain-Killing Ladder' Reported successful Eighty-seven per cent of cancer patients in a Japanese test of guidelines for pain therapy –136 out of 156–received "complete relief" from a three- step treatment for the manage- ment of pain developed by WHO. The tests were carried out in 1983-84 by Dr Fumikazu Takeda at the Saitama Cancer Center, north of Tokyo. Central to the guidelines is the administration of analgesics –pain-killers–regularly by the clock, rather than only "as re- quired" at times of pain, which is generally the practice. The drugs increase in strength, from non- narcotic to mild and then to strong narcotic pain-killers until the patient is pain-free–hence the concept of an "analgesic lad- der". If a drug proves ineffective, a stronger drug is prescribed. Additional drugs, technically called "adjuvants", are also used under special conditions. Psychotropic drugs are pre- scribed, for instance, to calm fears and anxieties. As part of a new initiative, WHO is attempting to raise conscious- ness to a largely neglected prob- lem in cancer care–the manage- ment of pain. The guidelines were developed essentially to teach non-pain specialists how to control most cancer pain. The ages of the patients treated at the Saitama centre ranged from 8 to 83. Before cancer therapy commenced, pain was severe in about two-thirds of cases. Aspirin or paracetamol was gi- ven by mouth every four to six hours to patients with mild or moderate–and at times even severe–pain. Where these non- narcotics were ineffective, codeine, a mild narcotic, was ad- ministered at fixed intervals. Where pain was not relieved by non-narcotics or mild narcotics, and when pain was severe and chronic, morphine was given every four hours, in some cases with adjuvant drugs. " Psycholog- ical dependence was not re- ported at all," says Dr Takeda. Overall, through the application of the "ladder" principle for cancer pain relief, 87 per cent of patients received "complete relief ", 9 per cent "acceptable relief ", and the remaining 4 per cent "partial relief ". Similar tests are also being carried out in India, Italy and the USA. ■ Newsbriefs Acute Respiratory Infections. At least six million children die yearly from acute respiratory infections. Yet, "enough is already known how to systematically introduce control measures" against the diseases, delegates from 18 nations in South-East Asia and the Western Pacific say. They call for a stepped-up drive against the infections in a final commu- nique following a meeting in Sydney, Australia, sponsored by the Aus- tralian Development Assistance Bureau, WHO, and UNICEF. Dear Member of Parliament: "I wish to inform you that one of your constituents who was a patient of mine, has died. The death was due to the following disease : ❑ Lung cancer, ❑ Coronary heart disease, ❑ Chronic obstructive lung disease, ❑ Other tobacco-related cancer or vascular disease. "This person smoked. Tobacco smoking is the major avoidable cause of this disease. " This text, printed on a black-edged card, is being sent to MPs by local doctors as part of a new British Medical Association drive against smoking- related disease. The aim is to build parliamentary support for a total ban on advertising of cigarettes, and in particular the sponsorship of sporting events by tobacco companies. "Voluntary controls" by the industry itself just aren't working, says Dr John Havard, the association's secretary. 'Freedom from Cancer Pain': Experts in pain therapy from 22 countries have called for education and information programmes, aimed at the public at large, to promote the concept of "Freedom from Cancer Pain", as a right for cancer patients. Patients, and their families, should be made aware that pain is not inevitable, and is almost always controllable. These facts are little known, the experts state following a meeting in December in Geneva. And they add : "Drugs are the mainstay of pain management. If used correctly–the right drug in the right dose at the right time intervals–drugs are effective in a high percentage of patients." (See adjoining story). Crisis in Africa : An assessment by the UN Secretary-General describes the situation in Africa today as "grave", with 27 countries facing "abnormal food shortages and nine countries also affected by drought". Among countries hardest hit: Burkina Faso, Chad, Ethiopia, Mali, Mozam- bique, and Sudan. In a plea for renewed commitment to Africa by developed countries, the UN warns that development is "virtually at a standstill", and that prospects for economic recovery are "not encouraging". The concern is shared by the International Labour Organization. "Output in industry, mining, and agriculture has been falling in recent years, while Africa's overall annual GNP has dropped below zero. Left to its own devices Africa cannot overcome its deepening crisis," the ILO says. WHO's Member 165. Just two months after independence from the United Kingdom, St. Christ- opher (known as St. Kitts) and Nevis became WHO's 165th full member on 3 De- cember 1984, by depositing its instrument of acceptance of WHO's Constitution with the United Nations, New York. The two-island, new Eastern Caribbean nation is 269 square kilometers (104 sq. miles) in size. The capital is Basseterre. In the next issue The UN Decade for Women, launched in 1976, was a bid to attract worldwide attention to the inferior status unfairly conferred on one half of humanity, and to spotlight the huge contribution–all too grudgingly recognised–that women make towards development. What has the Decade achieved ? The April issue of World Health sums up the outlook for women in health and development. WORLD HEALTH For readers everywhere 1985 Subscription Rates One year Two years Three years US$ 12.50 22.50 30.— Sw. fr. 25.- 45.- 60.— ORDER FORM Please enter my subscription to "World Health" as follows: One year Two years Three years I enclose cheque/international postal order in the amount of Name - Street City • Country • World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national cur- rencies, please contact your usual bookseller. WORLD HEALTH, March 1985 31 -11V- RIF Partnership starts here. Photo WHO/UNICEF