First Regional Conference on National Health Planning, Manila, Philippines, 2-9 November 1972 : final report

WPRO 4103

FIRST REGIONAL CONFERENCE ON NATIONAL HEALTH PIANNING

Sponsored by the

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines 2 to 9 November 1972

FINAL REPORT

Not for sale Printed and Distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines September 1973

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NOTE The views expressed in this report are those of the consultants and participants at the Conference and do not necessarily reflect tiE policy of the World Health Organization

rhis report has been prepared by the Western Pacific Regional Office of the World Health Organization for Governments of Member $tates in the Region and for those who participated in the First Regional Conference on National Health Planning which was held in Manila, Philippines from 2 to 9 November 1972.

CONTENTS

1.

INTRODUCTION

••••••••••••••••••••••••••••••••••••••••••

1

2. 3.

HEALTH AND DEVELOPMENT

••••••••••••••••••••••••••••••••

4 8 14

REVIEW OF CURRENT SITUATION ON NATIONAL HEALTH PLANNING IN THE WESTERN PACIFIC REGION •••••••••••••••• TECHNIQUES AND PROBLEMS OF HFALTH PlANNING ••••••••••••

4.

4.1 4.2

Pre-planning Considerations (docLUnent WPR;NHP/6 ••• Health Planning Methodologies: Concepts and

14

Problems (document WPR/NHP)8) Plan (document WPR/NHp/4) 5.

••••••••••••••••••••

15 22

Co-ordinating the Health Plan with the Development

••••••••••••••••••••••••

COLLABORATION OF EXTERNAL AGENCIES IN NATIONAL HEAL'IH prANNING

6.

.....•.•.................•.........•....••..•. CONFERENCE RECOMMEN])II.TIONS ..........•.................

24 27

ANNEX 1 - LIST OF PARTICIPANTS, SECRETARIAT AND O:BSERVERS .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ANNEX 2 - PROVISIONAL RULES OF PROCEDURE • • • • ••••• •• • •• ANNEX 3 LIST OF WORKING PAPERS •••••••••••••••••••••• ANNEX 4 - SUMMARY OF THE HEALTH PLANNING METHODOLOGY AS TAUGHT IN THE WHO COURSE ON NATIONAL HEALTH PLANNING ORGANIZED IN COLLABORATION WITH THE INSTITUTE OF PUBLIC HEALTH, UNIVERSITY OF THE

29 35 43

PHILI PPINES

........................................ ,. .. .. .. .. .. .. .. .. .. .. .. ..

45

II II

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1.

IHTRODUCTION

Interest in national health planning has been shown by countries in the WHO Western Pacific Region over the past ten years. One of the first s8llinars on this subject under WHO auspices was held in Manila in 1964. Sinoe then, two aspects of planning have been. the topics of the technical discussions held in conJuction with session of the WHO Regional COIIIIIIi ttee for the Westem Pacific. In 1968. the subject was "Health Planning as an Administrative Tool" and in 19'71. "Health Manpower Problems and Needs in the Developing Countries". Since 1968, the Regional Office has conducted annually courses on national health planning in collaboration with the Institute of Public Health, university of the Philippines. This course has now trained fifty-three national and WHO staff in the Region. Other assistance requested by governments has included consultant services in health and manpower planning and the provision of fellowships for national staff. Member states, acting through the Regional COIIIIIittee, have sought the promotion of national health planning in the context of their national socio-economic development plana. Thus, under resolution WPR/RC19.R6, the Regional Co_ittee recOlllliended that "Health Authorities of M_ber States in the Region (Should) urgently take steps when appropriate to formulate a national health plan to determine their health priorities and goals within the tramework of national socio-eoonOllic develolB8Dt planning". Resolution WPR/RC20.Rl urged Metlber States in preparing their lon«-teI'll plans, to consider "(1) the integration of national health plana with socio-econOllic plana. (2) the . .chinery for planning in the health field, (3) the definition of the responsibilities of the health sector in areas of multi-responsibility, (4) the establishment of priority tara.ts, manpower requir_en ta and training and budget and other financial provisions, and (5) procedures for the continuous evaluation and.. if necessary, mod.1fication of the plan It. Finally, resolutions WPRjJ\C22.R13 and WPR/RC23.Rll expressed the hope that governments in the Resion "will prepare viable national health developJIent'plans where they do not exist and will improve and update such plans where they do exist". Most countries in the Region have policies on accelerated national development. Although a number have health plans as part of their national development plans, the progress made in health planning has been somewhat slow. Faotors contributing to this may be (1) the weak linkage of health to overall developJIent, (2) the need for a better understanding by national authorities of the role of health in national development, and (3) the need to establish or strengthen the health planning structure. In sponsoring the First Regional Conference on National Health Planning, it was the Organization's view that representatives of Member States would be provided a forum for the oonsideration of ways and means of developing the health planning process in their countries, not only to enable the advanc_ent of health on its own merits but to oontribute to developJIent.

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The First Regional Conference on National Health Planning met between 2-9 November in the Conference Hall of the WHO Regional Office in Manila, Philippines. At the opening ceremony, the Regional Director declared the objectives of the Conference as follows: (1) (2) To review the current situation in national health planning in countries and territories of the Western Pacific Region; To discuss, in the context of national health planning as part of development planning, alternative ways of undertaking national health planning within differing socio-economic milieus; To outline the assistance which WHO and external sources might provide to promote, develop and implement national health planning; the Region in the organization, preparation and implementation of national health plans where they do not yet exist and improving and updating regularly such plans where they do exist. In enjoining the Conference to identify and arrive at a consensus on the important issues of planning, the Regional Director expressed his view that the issues should include (1) the allocation of resources for dealing with the hazards of development as part of the investment and operating costs of development projects, (2) the training of personnel at all levels in the aspects of health planning relating to their duties, (3) taking measures to strengthen the health services and better prepare them for health planning functions, (4) the introduction of systems for the flow of information and ideas for decision-making and action purposes and, finally, (5) obtaining appropriate recognition and status for health officials at the highest levels of national development. The Conference was attended by 16 partiCipants from 12 countries and territories. There was also one observer from UNICEF, in the person of its Regional Director for East Asia and Pakistan, and another observer from a Member country. The names and designations of the Conference participants and observers appear in the Annexes of this report. The officers elected by the Conference were: Dr Andrew Chew Guan Khuan of Singapore

(3)

(4) To formulate recommendations which may assist countries in

Dr Phouy Phoutthasak of Laos Dr Gurmukh Singh of Malaysia Dr Pruoch Vann of Khmer Republic

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Chairman Vice Chairman Rapporteur in English Rapporteur in French

On assuming the chairmanship, Dr Chew said: "We are here to represent our governments. Our views will be expressed within the frame of our

- 3 respective government's policy. Recommendations coming out of this Conference should be realistic in order that they can serve as guidelines for future action by governments of the Region. Apart from this, the recommendations can help WHO in formulating its assistance to countries and territories in the field of national health planning. You will therefore appreciate that ours is a great responsibility". Assisting the Conference was a panel of consultants and a number of resource staff (see Annex 1). Prior to the main bUSiness, the Conference adopted its Rules of Procedures, approved the conference agenda, and established two committees, viz., a Steering Committee conSisting of officers of the Conference Committee and a Resolution Drafting Committee made up of the following members: Dr J .B. Almonte (Philippines), Dr Tapen1 Fa '&1'uaso (Western Samoa), Dr M. Hashimoto (Japan), Dr Jong Huh (Korea) and Mr Tran Van Khieu (Viet-Nam). The following topics were discussed: (1) (2) Health and Development Review of the Current Situation on National Health Planning in the Western Pacific Region Techniques and Problems of Health Planning: pre-planning conSiderations, health planning methodologies -- concepts and problems, co-ordinating the health plan with the development plan Collaboration of External Agencies in National Health Planning

(3)

(4)

The health and developaent topic was introduced by a panel representing the views of the health economist, the public health administrator, the development planner and the social planner. The topic was then taken up by the Conference in plenary meeting. The other subjects were introduced by the corresponding consultant or resource person and again discussed by the Conference in plenary meetings. The draft report, together with the recommendations of the Conference, was reviewed and adopted in a plenary session on the last day. In the closing session, all partiCipants expressed their appreciation of the preparatory work and the arrangements made for the Conference. They thanked the Regional Director, the conference secretariat. the consultants and resource persons for their valuable help and contributions. The individual statements conveyed appreciation ot new knowledge gained, the expectation that the Conference recommendations would stimulate countries to plan if they had not already done so, or to develop suitable

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approaches in their planning for so;vinw: their own health problems. They hoped that similar Conference!> would be convened by IVHO in the not too distant future. In his concluding statement, the ~egional Director stated: " ••••• You have, as a result, formulated a number of recommendations on the subject of national health planning. ~ should like to assure all of you that these recommendations will h~ sympathetically studied in the Regional Office and communicated to the governments in the Region. I have, of course, no doubt that t.h", c:Jllaboration with l'.lHO of countries and territories in the Region will not. end with this Conference. I am sure that this collaboration will continue with even more dynamism in the coming years. At this stage, I should like to stress that a periodic review of the national health planning efforts by individual countries will ensure its orderly progress ••••• " He noted the attendance of the Regional Director of UNICEF/EAPRO as evidence of UNICEF's interest in the field of health planning and its willingness to help in the promotion of health planning in the Region.

2.

HEALTH

AN~)

flEV!':LOPMENT

The first working session of the Conference was devoted to the relationship between health and development, with special reference to the experiences of countries in the WHO Western Pacific Region. The first point explored was whether there were circumstances when the health planner should practise his art without necessarily tying health to the vicissitudes of the general development plans of a country. The development plans of countries in Asia (as well as elsewhere) had not produced in the 1960's the kind of results expected. Their implementation was attended by unexpected consequences of growing disparity of personal income between the rich and poor, and growing unemployment. In addition, the growing trend of striking a balance between economic and social goals meant that some health expenditure could be Justified per ~ rather than in terms of its contribution to economic development. Under these circumstances, there were occasions when the health planner would be well advised to avoid being dragged down by the declining fortunes of the development planner. Certainly, the health sector might go on its own until the techniques of planning in these countries had reached a stage of realism and relevance at which the problem of development could be tackled in a more cohesive manner. While the Conference noted that the successes and failures of development planning had implications for, and might even call for a change in the strategy of health planning, it recognized that it was neither possible nor desirable to separate the health plan totally from the overall development plan. Two reasons were advanced: firstly, health was an integral part of social action, and secondly, the techniques of health planning could be no better than those of development planning

- 5 in general. Snapping the link between the two might make the health planning techniques lag behind those of development pLanning. 'nJ.e second point brought out concerning the relationship between health and development was in regard to the "independent" and the "instrumental" value of health. 'nJ.e "independent" value of health was defined as the desirability of health for its own sake and the human welfare implications of the health services. The "inatI'Ullental" value was defined as the contribution of health to the developlent of SOCiety as a whole. Reference was made to the fact that health investments were not intended to produoe revenue. Since health is the f'undalllental right of the individual, it should not matter if the provision of health services incurred expenditures without obtaining a direct return in terms of measurable economiC benefits. On the other hand, it was felt that as a country went through the development process, it would become progressively more possible for it to find ways and means of using health in the service of development. In other wordS, as the development process gathered momentUIII, the institutional infrastructure that was built up, almost as a by-product of development, would lead to the transformation of health services from an autonomous to a causal factor of development. Regarding "independent" and "instrumental" values of health, the Conference was in general agreement that count.ries in the Region should endeavour to provide health services to fulfil a well-deserved need of the community but that they should at the same time organize them so that the provision of health services might lead to accelerated development. Health as an organio element of the development process was discussed. This view held that development was a forward movement of the sooial system, the dimenaions of whioh happened to be output and incomea, methoda of production, levels of living, attitudes, inatitutIons, and policies. It was pointed out that there waa a two-way relationShip between health and each of these dimenaiona of development. Thus, output and incomes were influenced by health through the productivity impact of health services on labour. The higher a person IS producti vi ty, the gr_ ter the value to him of an inorease in healthy time. Output and incomes also affected health through an ability to make larger allooationa to health programmes. Certain methods of industrial production created health hazards, and the health services had to cope with this "pathology of development". Rising levels of living improved the ability of the community to pay for their health services. These, provided free or at low direct oost to the lowerincome groups, tended to raise standards of living. Attitudes determined, especially in the developing countries, the extent to which the people made use of health services. An improved framework of institutions would help rationalize the administration of health services and augment their efficiency while a larger and more effioient provision of health services would build up its own institutional infrastructure. Finally, polioies for development determined the type and nature of health programmes. It was argued that this development approach to health would emphasize the essential similarities of the tasks of the health development planners.

- 6 Describing the similarity of these tasks from the point of view of the health planner, it was observed these comprised (a) devising indicators of the current health situation; (b) assessing the future situation over the development plan period in terms of growth factors such as population and income, structural factors such as expected improvements in medical technology, and "water-front" factors such as the eating and living habits of the people: (3) an iterative process of planning, chiefly in relation to resource requirements and availabilities: and Cd) allocation of scarce resources among competing projects in terms of present value, and fUture assessment of cost flow, benefits, and the "externalities" of the health projects. Health was considered as an important element conducive to both accelerated development and improved planning procedures. In the social sectors health was relatively more adv~nced in working out methods of planning. One factor contributing to ~his particular situation was the possibility of determining the interaction between the improved health of a society and the rise in its product.ivity. Another was that planning for health was leS3 closely associated with the maintenance of differential advantages of different strata in the population with regard to status, income and power. In fact, improving the health of the groups most Busceptible to disease constituted a safeguard to those with better access to health services. Moreover, these services were more affected than other social sectors by the rapid advances made in science and technology, and, accordingly, could take better advantage of such advances. In viewing health as a social sector, and therefore a part of the social system whose forward movement was development, the Conference felt that two other decision-making processes should be introduced in planning for the health of the community. One was the ethical process of decision-making by which the planner could make a contribution to the quality and flow of life by the provision of proper health care. The other referred to the political dimension. In formulating the health plan and in appraising health projects it was desirable to identify in advance the particular social group of the country that was going to benefit from the plan or the project, the time at which the benefits would accrue to the group and the duration of these benefits. For example, a decision to set up a specialized hospital for cancer in a metropolitan area at a time when the rural areas were ravaged by communicable disease, was in effect, to favour the older age groups in the cities as against the young in the rural areas. Similarly, improving the drinking-water supply in urban areas favoured the city people who had and could afford more than the farmers, who might need better nutrition for their children but did not have the income to procure the essentials of life. Special mention was made of the health hazards created by the development process itself. It was argued that each development project had its own built-in health hazards and the health plan would have to provide enough physical and manpower resources to deal with them. In other words,

- 7 the health situation of a country could be divided into two Jarts -- the health problems inherited and those created by the devel0Jmlent process. It was observed that while all the current allocations for health IU.ght be used for dealing with the existing or continuing health probl_, addi tiona! resources would have to be found for dealing with the health hazards of deve!oJmlent as part of the cost of the non-health develoJmlent projects. '!he subject of eduoating the people in healthful ways of living and finding the nanpower nece••ary for implementing the health plana acre effectively resulted in an extended discussion. The Conference felt that the problem of "brain drain" was too CCDplicated to be disposed of briefly. A separate meeting for the purpose would be necessary. However, it was observed that it was illperative to take whatever steps were feasible to stop the "brain drain" and to use sub-professional personnel whenever possible to illplement health plans. Scientification and standardization, where feaSible, of indigenous lIedicine and co-ord1nating the activities of private practitioners with the public sector plan, would help deal with the paucity of health manpower oreated by the migration of doctors, nurses and technicians to more developed countries. The strengthening of rural health services was also discussed. These services of a basic character, if made available judiciously and adequately, could stimulate public JarticiJation in health projects and create a body of public opinion in favour of health planning. It was recognized that basic health services could not be treated independently of other services, such as agricultural extension and other education and social welfare services. What was needed was a community develoJmlent service combining health and non-health services for the rural people. Such a "package" would be more viable because it would have a synergistiC effect. While the Conference appreciated tully that health servic •• should be oriented to the extent possible in serving the needs of develoJmlent, it felt that one should not lose sight of the tact that they lIight be regarded as desirable in thEIIIsel ves. Tha t is, while health services were to be prized for their instrumental value and illpact on development, as the health projects happened to have a large element of "externalities", it might not always be necessary or appropriate to insist on the "development term" in the evaluation of health projects. The intangible and indirect benefits which could not be measured by any known means of quantification were sometimes so preponderant that it would be a distortion of fact to justify health proJeots solely on the basis of their contribution to development. However, insofar as development was recognized as a process of augmenting the weI tare of the community, it would be appropriate to Justify health projects on the basis of the "externalities" to which they give rise.

- 8 3. REVIE\oI OF CURRENT SITUATION ON NATIONAL HEALTH PIANNING IN THE WESTERN PACIFIC REGION This report (document WPRI'NHPI7) was prepared on the basis of replies from fifteen of the seventeen countries and territories invited to participate in the Conference. The information given by governments was grouped under the following headings: status of countries on national development planning; countries with independent planning for health; nationally constituted health planning unit for co-ordinating and formulating the national health plan: countries without national health plans, information for health planning; health planning; training in health planning and collaboration of external agencies in national health planning. The following summary review of the information under these headings was presented. National development planning was progressing modestly in countries/ territories of the Region. Provisions were being made for the necessary planning machinery, the enabling legislation and firm financial commitment regarding investment outlays covering the entire plan period. It was significant that all the development plans contained a sector for health with the planning units~odies of health ministries having close link~ with national planning bodies. lnformation had been divided under two main groups: basic and ecologic factors. Basic factors were those immediately related to the health field and ecologic factors concerned on the Bocio-economic aspects. It was evident that increasing attention was being given to the collection and processing of information either related to health or influencing health planning. However, there was a need for more effort in this area and the elimination of non-relevant data. Information on mortality, morbidity, and manpower which were essential for planning, was rated as satisfactory in less than 50 per cent. of the countries/territories replying. Information on ecologic factors necessary for the meaningful co-ordination of the health plan with the overall development plan was also considered satisfactory in less than 50 per cent. of the countries/ territories replying, particularly in regard to nutrition, social characteristics, environmental factors and internal extra-budgetary sources of assistance to health activities. The general approach to health planning showed variations in the application of the four broad categories,- viz., formulation at central level from "up down", formulation from "down up", formulation on the basis of related projects simultaneously undertaken (cluster projects), and formulation concerned merely with improving the performance of the health agency in terms of the functions assigned to it by law. The "up down" approach referred to planning done principally at the central

- 9 level with information fed from the local and intermediate levels of the health services organization. In some countries, the regional levels of the organization actively participated in the planning prooess. No country followed the "down up" approaoh. The value of incorporating the public and private sectors in the health plan was recognized but in most countries/territories the public sector was given priority at the early stage of health planning. I t was also evident that in the majority of places, health planning had just started as a national exercise. The same conclusion was arrived at in the study conducted by the Regional Office in connexion with the resolution on long-term planning in the field of health adopted by the Regional Committee at its twenty-second session l • Eleven of the 14 countries/territories with a national health plan had a separate organization attached to the health ministry and 10 had an advisory planning group. Most countries/territories were considering the steps necessary for the program.ing and exeoution phases of implementation. As national heal th planning was in the early stage, current measures in programming and execution were more concerned with temporary adjustments to the existing organizational structure. The majority of the planning countries/territories included mid-term and terminal evaluation exercises. A closer look at the mechanics of evaluation would be useful to all governments. This could very well be the subject of a future study. Many areas in the field of health planning were receiving assistance from external agencies. There was, therefore, a need for more exchange of information and·improved co-operation among these agencies. In seven of the fifteen responding countries/territories, planning was undertaken by professional personnel who had received training in planning. To ensure that adequately trained national staff were available, external training f'ao1li ties were being used. Some had national courses for profeSSional training in planning. In the ensuing discussion, the partioipants furnished additional information. In Guam, there was a Liaison and Technioal Evaluation Coaaittee consisting of professional and technical representatives fra. the various government agencies. This committee included the Administrator of the Office of Ca.prehensive Health Planning and other health administrators from the Department ot Public Health and Sooial Services. This ensured the consideration and inclusion ot the health sector in the total planning for develoPllent. '!he health intonation syst_ needed to be improved, particularly for planning purposes. An Executive Order (67-16) issued in November 1967. oreated the Comprehensive Health Planning Agency (administratively under the Department of Public Health and Social Services)

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Resolution WPR/RC22.RI3.

- 10 and a Planning Council for the co-ordination of health and social services in the Office of the Governor. The Council, whose members (51% are consumers and the rest, technical/professional men) were appointed by the Governor was charged with providing guidance in the development of an efficient and comprehensive health and social services programme. Various task forces had been created. In June 1970, another Executive Order created a Territorial Planning Commission to plan the physical and economic aspects of development and to update the total Comprehensive Environmental Master Plan which included social elements. :n Japan, the Economic Council of the Economic Planning Agency under the Prime Minister's Office (having functions of developing and/or revising the national economic development plan) had formulated two development plans in 1969 and 1970. The latter plan (The New Economic and ~ocial Development Plan for 1970-1975) had a broader scope and ineorporated to a greater extent the health and welfare sector. The health component was not identified separately nor brought out in detail under the overall national development plan. The Health and Welfare Statistics Department had been established within the Ministry with a computer system. Information systems which could effectively be used for national health planning were being studied. There were some seventy health and sanitary laws which served as guidelines in developing measures against health problems in each of the political/administrative units of the country. It was within this context that categorical national health plans were made usually every year. As a result, however, of the socio-economic changes in the decade of the 1960's, the necessity for a more comprehensive and different type of national health planning became increasingly recognized with emphaSis on overall social and economic development. The Planning Unit of the Ministry of Health and Welfare (i.e., the Office of Programme Evaluation and Planning), which was established following the enactment of the Health and Welfare Establishment Law in 1949, had, in 1970, developed a plan for health and welfare administration which included certain "well investigated health prospects". At present this Planning Unit is collaborating with the Economic Planning Agency for a new five-year health and welfare development plan (1973-1977). In the Khmer Republic, there was a governmental order to establish planning sub-committees in each ministry which were expected to work in close relationship with the Planning Ministry. Although no planning unit had been set up in the Ministry of Health, programmes and proJects for health had been formulated according to the needs of the community and priorities given. However, as a result of the war, there would be a need to reconstruct the socio-political and restore sanitary conditions. For this reason a very elastic system of planning would be necessary. In Laos, there existed an Executive Committee with the Minister of Planning as Chairman and the Commissioner of Planning as Vice-Chairman. This body reviewed annually the implementation of plans in the light of funds available. A five-year plan adopted in 1969 gave priority to the productive sectors while the social sector received one-third of the total funds.

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In Malaysia. three five-year national development plana had been implemented successfully during the past seventeen years. The Government was now in the process of implementing its fourth five-year plan Which commenced in 1971. The National Economic COWlcil, which was a ministerial body, had been set up Wlder the chairmanship of the Prime Minister. Its secretariat was the Economic Planning Unit. A National Development Planning Committee comprising senior public officials was responsible for the detailed preparation of the National Development Plans. It had two SUb-committees: the Estimates Sub-committee and a Standards and Cost Sub-committee. These were served by the Economic Planning unit. Administrative planning in relation to development was primarily the function of the Development Administration Unit attached to the Prime Minister's Department. Planning and research units had been established in major ministries and departments and there was one such Wlit in the Ministry of Health. Planning units also existed at state (State Development Committee) and district levels (District Development Committee). There was a DiviSion of Planning and Development in the Ministry of Health which worked closely with the specific offices of the Economic Planning Unit. In order to avoid duplication, inter-agency planning groups had been set up to study in detail the presentation of plans by various interrelated ministries and departments. In the Ministry of Health, there was proviSion for intra-sectoral collaboration in the formulation of plans. Its Division of Planning and Development was responsible for the formulation and implementation of the health development plan, and for periodic review and evaluation of the various programmes and activities being carried out. This Division worked in. conjWlotion with the Divisions of Health, Dental and Patients CAre in the preparation of detailed guidelines (in keeping with the directives issued by the Economic Planning unit) which were transmitted to state level. Preliminary work in the details of plan formulation was done at this level. Subsequently, the plan was processed at the Ministry level by the Division of Planning and Development. Constant dialogue was maintained with the other divisions of the Ministry during the final plan formulation stage. In Papua New Guinea, the Health Planning Unit had collected a large amount of data and was currently preparing a volume on the diseases and health services in Papua New Guinea. This was expected to be used as an objective baSis for planning. An administrative health structure was being evolved, defining three levels of authority. At headquarters level, a national health board was under conSideration with an executive arm to be called the Senior Staff Conference, consisting of the key headquarters staff of the Public Health Department with the Director as Chairman. At district level, there would be a District Health Board with an executive arm to be called the District Health Committee and at subdistrict level, community health zones. Thoughts on health planning put forward in 1970 by a number of medical officers in Papua New Guinea had produced interest but few concrete results. In 1971, a number of papers had been written on the need to rationaliZe the services and these had incorporated the ideas of King and Bryant. In June 1971, the Director of the Health Department started the planning process by making a national inventory of health

- 1? -

resou rceS. An outlin e was produ ced p~rtaining to the conce pt of dealin g with the healt h servi ces as a major busin ess. Late in 1971, the Minis ter and the Direc tor, with the suppo rtir.!": opinio n of a WHO consu ltant decid ed forma lly to go ahead with natio nal healt h plann ing. A distr ict healt h offic er was asked to head the Healt n Plann ing Unit. It was decid ed that in addit ion to a medic al healt h plann er, the follow ing were neede d: econo mist, management speci alist, proje ct resea rch offic er, and a repre senta tive of the churc hes (who would work with the unit and event ually be a member of the Natio nal Healt h Plarill ing comm ittee) . The Unit had been in opera tion since Janua ry 1972. In order to obtai n as wide a partic ipatio n as possi ble, comm ittees were create d to look into proble ms fallin g under speci fic progra mmes . A time- limit was set withi n which the programme comm ittees would give their recom menda tions. The polic ies or direc tions agree d upon by the Healt h Plann ing Unit and the Programme Comm ittees were subm itted to the Natio nal Healt h Plannin~ Comm ittee for review and recom menda tions to the Minis ter. The assis tance of a WHO advis er in plann ing and admin istrat ion had been reque sted. In the Philip pines , follow ing recom menda tions of the Reorg aniza tion Commission which had starte d its studi es a few years previ ously , the proce ss of reorg anizin g the struc ture of the Government was takin g place . In the reorg aniza tion propo sal two speci fic provi sions were of immed iate inter est to healt h plann ers. These were: (a) the creat ion of an overa ll plann ing body calle d the Natio nal Economic Devel opmen t Autho rity, which would take over the funct ions of the Natio nal Economic Counc il and the Presi denti al Economic Staff ; and (b) the creat ion of a plann ing offic e in each depar tment of the execu tive branc h of the gover nment . A review of the inform ation and repor ting system had been under taken . Under the curre nt reorg aniza tion plan of the Gover nment , the Healt h Plann ing Offic e would be one of the major offic es under the Secre tary of Healt h and would have respo nsibi lities for the formu lation and evalu ation of the natio nal healt h plan. The Offic e would have three divis ions, namel y: Divis ion of Plann ing and Progra mming , Divis ion of Proje ct Devel opmen t and Evalu ation , and Divis ion of Resea rch and Stati stics . In the Repub lic of Korea , the Economic Plann ing Board was the highe st plann ing body in the count ry. It review ed propo sals, made neces sary adjus tment s, and incor porat ed the healt h plan in the Natio nal Economic Plan for submi SSion to the Presi dent, who in turn subm itted it to the legis lativ e body. There were proble ms of under -repo rting as well as unrel iable repor ts on the cause s of death s in remot e areas where there were very few docto rs. The situa tion was being corre cted throu gh speci al studi es, re-exa minat ion of legis latio n. and a review of the repor ting system . Every year, an ad ~ body, the Socia l Secur ity Resea rch Commission of the Minis try of Healt h and Socia l Welfa re, condu cted healt h care utiliz ation studi es. In 1971, two offic es (the Healt h Plann ing Offic e and the Socia l Plann ing Unit) were creat ed under the Direc tor-G enera l for Planning and Co-or dinati on of the Minis try of Healt h and Socia l Welfa re. The Healt h Plann ing Offic e, in co-op eratio n with the Socia l Plann ing Unit, formu lated and co-or dinat ed long- range healt h plans and review ed the annua l healt h budge t propo sal befor e the Minis try prese nted them for review to the Economic Plann ing Board .

- 13 In the Republic of Viet-Nam, the current plan was formulated at the central level without close relationship with the National Development Plan. The sectors were allowed to plan with quite a great deal of autonomy. Planning was started in 1971 in the face of two conflicting views. Those with training abroad were afraid to start planning because of lack of resources, manpower and reliable information. Another group wanted to plan, based on what was available, to use common sense and to improve the tools and data as well as the technical skill of the staff. The main purpose of the latter group was to formulate a transitional plan until the country situation improved. In Singapore, the Statistical Commission appointed by the Government had recommended the establishment of a Statistics Research Institute for developing indicators for planning purposes. Planning for health services had been ad hoc and were based on the directives of the Cabinet with emphasis on providing more medical care services. However, trends indicated that comprehensive health planning would be undertaken. For example, there were proposals to amalgamate the curative and preventive sections of the Ministry of Health, to include health aspects in township development programmes, and to establish a health planning unit.

---

In Tonga, there was a central body, the Development Co-ordinating Committee, which was under the Ministry of Finance. This committee was responsible for co-ordinating requests and plans from the various sectors, determining priorities and allocating funds. Two five-year development plans had been formulated, approved and implemented since 1965. A development economist from the national planning body was available to the Health Planning Committee during the formulation of plans. The Ministry of Health was represented in the deliberations of the Development Co-ordinating Committee. There was currently an ad hoc National Health Planning Committee in the Ministry of Health which had responsibility for national health planning. This was chaired by the Minister of Health with the Director of Health and heads of the various divisions as members. The members undertook this function on a part-time basis. For a small country, this approach was considered adequate and there was no need for the employment of a fulltime planner or planning specialist. In Western Samoa, economic development planning since 1962 was undertaken by the Section of Treasury. This lasted until 1967 when the Economic Development Ministry was created. In 1968, the national health development plan was incorporated into the national development plan. An ad hoc planning committee was created in the Ministry of Health in 1962 and strengthened in 1967/1968. It was headed by the Minister of Health with members composed of the heads of all divisions. There were two ex officio members. At present, there was no health planning unit as such but in the reorganization of departments, one such unit was proposed in addition to the Committee, to be directly under the Office of the Director. This Unit would be charged with overall health planning of the Department.

- 14 TECHNIQUES AND PRO~S OF HEALTH PlANNING

4.

4.1

Pre-planning Considerations (document WPRINHP/6)

This working paper, prepared by the WHO Secretariat, pointed out that the political decision to plan was an important pre-condition of planning. The decision should indicate a firm commitment on the part of the Government to plan as well as to implement the plan. Important factors making planning feasible were: (a) the developnent of a favourable mental attitude, (b) intra-sectoral commitment and inter-sectoral co-ordination, and (c) the establishment of a planning machinery. It was emphasized that planning was essentially an administrative f1.mction and that key staff of ministries, being managers, were bo1.md to exercise this f1.mction. It was further stated that the administrative capability to carry out a health plan, while considered very important, was not a prerequisite to planning. The development of this capability, however, could very well be one of the major subjects of the plan. There were differences of views as to whether the collection of the necessary planning data was a part of the preparatory phase of planning, or a part of the actual planning exercise. All agreed that there were certain basiC data necessary for the planning process. Although it was generally agreed that a firm political commitment to planning was an essential prerequisite, it was felt that the establishment of health planning units did not necessarily require legislative action. In many instances they could be established on the basis of existing legal dispositions. Administrative capability should be considered a function of the type of plan to be worked out. Consideration of training in modern management techniques was also important. Provisions should be made for a statistical system as part of the planning structure. It was recognized that while sources of data outside the health sector might be useful, they should be considered with caution when the information had been compiled for other purposes. The co-operation of all workers participating and those whose work would be affected by the plan (a) by the proviSion of training or orientation in of planning, and (b) through consultations as part gathering process. in the planning process could be enhanced the appropriate aspects of the basic information-

The existence in a C01.mtry of a formal organization responsible for general socio-economic planning would facilitate the task of a health planner. The absence, however, of such an organization should not deter the health authority from formulating its sectoral plan. There was general agreement on the value of a health planning unit. The place and staffing of such a unit within the health organizational

- 15 framework were matters for decision on the basis of national characteristics. An important function of the health planning unit was to act as liaisnn betwp~n the Ministry of Health and the national planning body, where one existed. It was agreed that advisory committees for the health planning unit should be established to permit consultations and exchanges of views with representatives of various health professions (public and private) and, where applicable, conSUMers. 1~.?

Health Planning Methodologies: i documen t \OlPR /NHP/8 )

Concepts and Problems

Tn introducing his paper, Dr Tejada pointed out that health planning in the context of overall development planning was relatively new. Its conceptual framework and operational contents had been derived from a wide varipty of disciplines. The conceptual aspects and problems had been briefly described in the working paper which offered a concept-oriented approach to the subject. Dr Tejada's working paper had enumerated the following: a 1

Health planning was a difficult undertaking. This would be recognized the more one learned about the health system as well as its interrelationships with the other components of the socio-economic system of which health was a part. Planning should not be regarded as the answer to all health problems in the developing countries. The main value of planning was in making one aware of problems, including those which may not have been recognized before. Planning methodologies should not be considered as "cook-book" recipes for the handling of country-wide planning in the health sector. There were many gaps in the techniques presently available and a lack of knowledge in the methodological approaches. Each country possessed unique pconomic, social and political characteristics, which influenced public administration and health services. The latter factors, in turn, affected the health status and problems of the country. There were occasional other factors capable of generating critical changes within a short period of time. Since planning operated in a dynamic sitUation and not in ~, it must deal with all these factors. The planning process must be tailored to the particular characteristics of the country. The methodologies should not be considered as the most important element in planning. They offered guidelines for the analysis of problems. Their use was conditioned, however, by intrinsic limitations, as well as the experience acquired in their use. A planning methodology must be tailored to the particular process adopted for the country in consideration of its unique characteristics.

(b)

(c)

(d)

(e)

- 16 Plans were the formal outputs of planning. Their formulation should not, however, be mistaken for existence of a sound planning process. SoundneSS could be assessed by analyzing the contents of the plan. Planning was one of the tools for introducing rationality and foresight in all levels of decision-making. Its final aim was to obtain the best obtainable efficiency in the use of available resources, as well as the best possible changes in the context of a previous ideological understanding of, and political approach to the situation. Planning could be used for two purposes, namely: (i) (ii) to keep the status ~, in which case it was concerned )nly with efficiency; to introduce change in a given situation and with it to promote efficiency in order to meet the demands of develoJXllent.

(f)

(g)

(h)

Planning in isolation would not ensure the introduction of changes. It was necessary that planning received from government be a clear, honest and firm commitment to carry out these changes and that the consequences of such changes had acceptance before, during and after their introduction. Commenting on the subJect, Dr Ruderman stated that perhaps the most important point brought out was that each country was unique and must be considered separately in terms of its social and economic status, political context, etc., and that one could not recommend a priori some single way of health planning for all countries. There were highly developed countries with plentiful resources and sophisticated health administrations, where a separate planning unit was not needed because the one-year or two-year budgets and the five-year budget forecasts represented, in effect, a carefully constructed and comprehensive health plan. At the other extreme there were oountries which were less developed, but were so small that one person on a parttime basis was all that was needed. The whole plan could be an intuitive appreciation of the local situation in one man's mind. Formal planning units and systems were mainly required in countries that (a) were not so advanced administratively that the process was taken for granted and (b) were big enough that a fOraJ&l mechanism was needed to replace individual intuition. This described many but by no means all the countries of the Western Pacific Region. ---In countries where health care was a universal right and provided entirely in the public sector, the health authorities would find that most of their time was taken up with questions of medical care rather than promotion and prevention, because that was where most of the money

- 17 was spent and personnel employed. In countries where most of the money was in the private sector, effective planning could well be limited to the smaller public sector and thus have little impact on the health care system as a whole. As an economist, he expressed concern about the basically normative nature of most health plana because need was not the same as demand. Perhaps a good health plan should s~with surveys of utilization in order to find out what people wanted and to provide such wants. In this system, serving health needs was a sort of involuntary by-product. Many of the formulas heard about -- PAHO/CENDES, PERT, PPBS, etc. were really handy aids that helped statistical clerks work out points of detail. Overall health policy and programme planning had to take place at a higher level of abstraction. A little effort over the fundamental philosophical questions now would help health planners develop a sense of proportion and learn how to choose the most appropriate working methods later. In this sense, the consideration of problems of concept and method was in itself a fundamental pre-planning consideration. The Latin American health planning training programme was then reviewed by Dr Tejada in terms of both its past and current activities and orientation. During the period 1962-1970, the emphases were on training of staff for the preparation of health plans, establishment of formal elements of the planning process (e.g. the organization of sectoral planning units), local level planning in line with the PAHO/CENDES methodology (evolved in 1962), and the efficient use of resources. A later evaluation revealed that the courses tended to make the trainees consider the methodology, notwithstanding all its mathematical complexities and efficiency orientation, as an answer to all the problems of health planning. This made the trainees overly confident immediately after the course, only to be frustrated once they attempted to apply fully the method to their own country's situation. Based on this evaluation, a change of policy in training was introduced and implemented in 1971. Under the new policy, emphasis was given to providing the administrators with tools for their planning function. A number of tools had been developed to deal with particular si tua tions and the final choice depended on individual country situations at specific periods of time. This left the planners the option of making the choices as the situations warranted. Training was diversified, taking into consideration the type of personnel to be trained, their pOSitions, the nature of their work and the level of their responsibility. Thus, in some instances, basic planning courses were given while in others specialized types of training were offered to answer specific needs. The locale for training was changed so that courses or seminars were no longer confined to one training centre in Chile but were offered in selected schools of public health in the South American continent.

- 18 Five schools of public health were chosen and given assistance from the Economic commission for Latin America and "Instituto Latinoamericano de Planificacion Economico Y Social" with the intention of eventually phasing out this assistance and for the schools ultimately to take over responsibility. These schools were selected on the basis of strategic location, each having its own sub-region to serve. In the ensuing discussions the Conference took up the following points: Since health planning must be carried out at (national, regional and local) and faced problems nature and required different treatments in terms and timing, recourse to a combination of planning different levelS which differed in of operative solutions methods would be needed.

For the needs at the national level and for the purpose of defining the most important country-wide problems, a method known as "sectoral diagnosis and institutional analysis" had been developed. The term "institution" would refer to health agencies (e.g. Ministry of Health, National Health Service, Social Security Agency, health agencies in the private sector, etc.). The main steps in the diagnostic phase of this method included: a preliminary analysis of the health sector as a whole. This would comprise the definition of the health sector in terms of fields of responsibility (e.g. medical care, environmental san1tation, etc.). more specific areas within each field (e.g. water-supply systems in rural areas, air pollution, industrial health, etc., within the field of environmental sanitation), and the goods and/or services produced by the health sector in relation to each area. Based on this output, a list of inst1tutions (public and private, whether or not oreated for the specifio purpose of produc1ng health services) was drawn up in order to establish the "institutional structure" of the health sector. By using a set of "master charts" it was poss1ble to obtain a clear p1cture of the important diagnostio facts related to legal responsibility versus actual output, geographical and popua tion coverage, inst1 tutional participation in the total production and expenditures of the seotor. These findings would lead to others in terms of types of aotivities produced and population groups covered by health services, e.g. important health fields in addition to neglected geographical areas and population groups. selection of the most important institutions for a fUrther and more detailed analysis, criteria for seleotion based on geographical and population ooverage. produotion, monetary resouroes budgeted and legal oountry-wide responsibilities for setting national health standards and polioies. Institutional analysis was undertaken for the selected institutions. This oomprised a study of the formal legal instruments that created the institution with reference to type and contents. FOr example, it was important to know whether these instruments considered the purposes, objectives and functions of the institution as well as the financing, organization and administrative systems and procedures. An administrative study of the functioning of the institution was done in order to discover

- 19 the actual structural distortions due to "empathy", political power, technical influence, "grape-vine" commlmication, etc., that is to say, the real situation as opposed to formal authority, official channels of corrmlmication, etc. Finally, a study of the resources was Imdertaken: monetary (financing and expenditures) as well as real (physical facilities, manpower, consumption inputs, etc.), the production of those resources (goods and/or services) and the efficiency of the production (using certain gross ratios as expenditures-production, resources-production, etc.). The diagnostic findings served only for the detection of problem areas or "bottlenecks" and obtaining a knowledge of the future problems such as those arising from financial aspects. In this way, preliminary diagnostic conclusions could be drawn. With this comprehensive knowledge of selected institutions the conclusions d:'awn from the analysis were carried back to the "master charts" in order to ascertain whether the problems were repeated within the sector, i.e. of a sectoral nature or common to the whole public administration. At this stage, the "sectoral diagnosis" was completed. The preliminary conclusions based on the selected institutions WOuld be corrected in order to avoid contradiction with those of the sectoral diagnosis. The latter was the framework for the former. The next important step was "explanation". This was a process of analysis by which an attempt was made to.establish the factors that brought about the situation indicated by the "diagnostic" findings. (In diagnosis one dealt with "results'~ in the same way that in arriving at a medical diagnosis one started with the "findings, signs and symptoms"). Having accomplished the "explanation", it was then possible to deal with the factors effectively, as in medicine one did not prescribe specific treatment until the etiological backgrolmd of the problem had been established. The search for causal factors proceeded to a political analysiS, enabling the recognition and evaluation of conflicting interests, pressures and/or power groups which are always present in a problem situation. The "explanation" could be considered as a natural bridge enabling the utilization of the diagnosis for the formulation phase, just as in photography, copies from the "negative" could be obtained. Arranging all the problem areas in terms of causal factors permitted an indication of the main direction of possible solutions to be obtained. The formulation phase would therefore only require the determination of alternative solutions, the establishment of criteria for the best solutions, and the ranking of these solutions. The proposals chosen would now be presented in the form of a "Basic Health Policy". The next step was the formulation of strategies for the implementation of that policy. Here once more, use was made of the political analysis. It was essential that prediction be made of the reaction of interested and power groups affected by the policies. During the strategy formulation for the implementation of policies the possibility of changing the definition, timing and priority setting of some of the proposals might arise. Certain proposals might even need

- 20 -

to be eliminated. on the other hand, certain specific action might be incorporated into the policy although they were not originally considered. Formal health pol1cies in general had to be arranged systematically by utilizing a number of criteria for the listing of the proposals. The different aspects covered by the policies would be those related to the categories used in the sectoral diagnosis and in the institutional analysis for diagnostic purposes. For the needs at local level and for the purpose of helping promote efficient performance of health services in the community, another method which had developed, was "local planning methodology" (PAHO/CENDES). The efficiency in the delivery of health services was promoted by the maximum use of resources in solving the most important local health problems. However, priority determination, according to the criteria based on local information, was carried out within the framework of basic health policies as formulated at national level. The same steps were valid for ensuring efficiency in relation to the use of reSources. The method required further definition of local health programme areas. These were established according to certain criteria, such as existence of a minimum of health resources, an agreed size of population accessible to the health services and the complete coverage by administrative units of the registration of vital statistics (births, deaths, and stillbirths at least). The local area should have a health officer with authority to co-ordinate the health services within the geographical limits of the area (hospitals, health centres, etc.), When the number of health services was large and could be grouped according to types and sizes, a sample was recommended to economize on efforts in the process of analysis. The main steps in the diagnostic phase consisted of the following: (1) Analysis of the local area of the population and their health level in terms of mortality and morbidity. This method would require both mortality and morbidity to be broken down into what were called "heal th hazards". A health hazard was defined as a single disease or a set of diseases grouped, not according to their etiology, but to the technical procedures employed to combat them. It was suggested for convenience that the classification should not contain more than 25, or less than 15, health hazards. Mortality data were derived from death certificates or information already processed. Morbidity data were restricted to information from in-patients at hospitals (discharges) and from ambulatory services in hospitals, health centres and other health facilities. In other wordS, an attempt was made to measure the morbidity structure as demands on the health services • .(2) As ecological factors conditioned the health level of the population in many ways, information related to nutritional, socio-economic and environmental factors was collected or requested from the proper agencies. These were then related to the specific health hazards.

- 21 -

(3) Finally, health resources available in the local area were considered. An inventory by types, numbers and relevant aspects was undertaken. This information was processed according to specific procedures to analyze the ways in which they were organized. At this point the concept of "instrument" was described as it was important in the analysis. "Instruments" were interpreted to mean "how all kinds of resources are combined in order to produce health activities", (e.g., a hospital-bed was considered an instrument and was, in fact, a set of many different resources: the bed, physicians, nurses, equipment, food, technical standards, etc.). In this way some indicators of efficiency could be studied if the instrument attributes (such as quantity and cost) were related to activities produced and the population benefited. (4) The health situation as measured through the health level of the population, the availability of the resources and the degree of efficiency in their use, as well as the measurement of the ecological condi tioning "actors, were projected for the planning period. This would constitute a baseline for future plan evaluation.

(5) The diagnostic phase ended with the explanation of the health situation. This was a causal factorial analysis which attempted to detect local constraints and show the main problem areas for consideration in the plan formulation. The plan formulation phase began with the setting of priorities (among health hazards) by mean~ of different criteria, such as incidence and prevalence, social concern and available technology for attacking the diseases. The basic health policies formulated at national level played a decisive role in the setting of these priorities. Objectives and quantified targets were then set for each health hazard. Objectives were drawn up which defined the population to be covered, technology to be used, expected levels of protection or prevention, etc. Targets were determined which expressed the activities to be produced over a specific time period. The total amount of activities that the local programme area had to produce would indicate the amount and quality of resources required. However, one had to work at this point with a "normative model" of the instrument's attributes which would represent the degree of improvement in efficiency that the local· area was set to achieve. For needs at regional level the method was simpler. It should ensure the implementation of the basic health policies approved at national level, co-ordinate implementation of the objectives and targets set up in the different local programme areas administratively covered by the health region. For specific regional problems a similar process to that used for the local level was applied. There were a number of important fields which should be incorporated in the final formulation of national, regional and local plans. Among these would be manpower, capital investments in health, research, specific regional health plans in support of geo-economic regional development projects, etc. These fields would need to be tackled by other methods specifically designed for each purpose.

- 22 -

The data and inform ation requi red would vary accor ding to the level and metho d used. At natio nal level the inform ation had to be of a highl y aggre gativ e natur e, while at the local level info~tio n was neede d in more detai l. A large propo rtion of the data for secto r~l diagn osis and instit ution al analy sis" had to be colle cted as an histo rIcal serie s cover ing a perio d of five to ten years . The "norm ative model s" emplo yed durin g the diagn ostic phase would vary accor ding to the level and metho d used. In dealin g with "sect oral diagn osis and instit ution al analy sis" the model was mostl y polit ically orien ted, while in the case of local plann ing, this was techn ically orien ted and prima rily conce rned with effici ency. 4.3 Co-or dinati ng the Healt h Plan with the Devel opmen t Plan (docum ent WPR/NHp/4)

The Confe rence consi dered this quest ion in the light of the close relati onshi p which existe d betwe en healt h and develo pmen t, and which confe rred on healt h the chara cters of consu mptio n, inves tment , and a means as well as an objec tive of develo pment . There was agreem ent that a common framework of plann ing was appli cable to both develo pment in gener al and the develo pment of healt h. The opera tiona l steps of plann ing in both areas were essen tially the same as, for instan ce, in targe t settin g, worki ng out resou rce requir emen ts for achie ving targe ts, making inves tment alloc ation s and choos ing betwe en altern ative techn iques of produ cing the goods and servi ces requi red. It was furth er agree d that the healt h plan could be co-or dinat ed with the develo pment plan regar dless of the level at which plann ing for healt h and gener al develo pment was under taken , i.e., eithe r at the micro (proj ect) level or at the macro (aggr egativ e) level . The Confe rence discu ssed the natur e of certa in condi tions which might be condu cive to the effec tive co-or dinat ion of these plans . It was the gener al view that some of these condi tions were: (a) (b) (c) a co-ter minou s time horiz on for the develo pment and the healt h plan: 11ais on with the centr al plann ing agenc y throu gh a plann ing cell locat ed in the Minis try or Depar tment of Healt h: reque sts for incre ased resou rce alloc ation s for healt h to be suppo rted by propo sals of healt h proje cts which were appra ised from the point of view of their socia l and econo mic viabi lity; traini ng healt h plann ers in the techn iques of develo pment plann ing: appri sing develo pment polic y maker s of the impor tance of healt h to deve lopmen t; and

(d) (e)

- 23 (f)

harmonizing to the extent feasible the private medical interests inoluding indigenous medicine with the administrative framework of the health plan.

The main lines upon whioh the health plan might be co-ordina ted wi th the development plan and the means by which co-ordination could be achieved were discussed. It was agreed that the first line of co-ordination was between the objectives of the development plan and those of the health plan. The latter had a favourable impact on the side of equity in the equityefficiency balance which was sought to be provided by the development plan. Secondly, the health plan would contribute to raising the "relevance" level of the development plan. It would tend to reorientate this development plan towards essential consumption which catered to the needs of the lowerend income groups. This would faCilitate co-ordination of the health and development plans in the area setting sectoral production priorities. Thirdly, the health plan would be co-ordinated with the development plan by having a health component built into the process of appraising the nonhealth development projects, i.e., it would enable resources to be earmarked for health in appraising non-health development projects to cover their built-in health hazards. Fourthly, as health happened to be a public good which was largely supplied by the government, the techniques of allocating resources between the government and private sectors in general development programmes also became applicable in health planning. Insofar as government was a more economical and efficient producer of goods and serVices, a diversion of resources from the private to the government sector would result in an overall inorease of productivity. Fifthly, it was suggested that since health projects had a large element of "externalities" in the benefit flows to which they gave rise, it would be deSirable to use a lower discount rate in evaluating the measurable benefits of these projects. The point of co-ordination in this regard was provided by the time-r.&ctor in development in terms of differential discount rates which crucially determined all policy choices. Sixthly, the question of substituting the concept of net national welfare to net national products. The thinking behind this concept was that income produced by certain types of activities which catered to the essential needs of the people should be given greater emphasis than income produced by other activities. It was felt that since health projects catered to the essential needs of the people, the income produced by them should be given a weight of greater than unity. This idea would enable the health plan to be co-ordinated with the development plan in the process of measuring development. The suggestion that private medical interests should be harmonized into the national health plan was extensively discussed. Doubts were expressed whether it would be possible to do so in view of the fact that the private medical sector was large. It was pOinted out that immediate action in this regard was not possible though it was certainly desirable to have the private medical interest represented in the advisory team of the national health planning unit. It was also pointed out that the national health plan would be indicative in character insofar as the prIvate medical interests were concerned. It would contain some guide-posts which would help shape the nature and development of the private medical profession.

- 24 -

The Conference agreed that science and standardization of indigenous medicine would likely augment the health resources of a country. However, it was felt that certain kinds of indigenous medicine, whose structure was faith-oriented, should be allowed to wither away. 5. COllABORATION OF EXTERNAL AGENCIES IN NATIONAL HEALTH PLANNING

Dr Djukanovic introduced the working paper ent! tIed "An outline of WHO's Assistance to Countries in Promoting, Developing and Implementing National Health Planning" (document WPRI'NHP/5) and stated that WHO assistance was based on its Fifth Programme of Work as approved by the World Health Assembly for the period 1973-1977. one of tht principal objectives of WHO under the Fifth Programme of Work was the strengthening of health services. In its efforts to strengthen national health services, the Organization would concentrate on: (1) health planning, (2) development of health services, (3) functioning and management of health services, (4) health services information system, and (5) health technology. In health planning, emphasis would be laid on: (1) strategic approaches aimed at long-term policy formulation rather than on tactical approaches concentrating on immediate needs; (2) systems analySiS, operational research and the normative approach; (3) cost-benefit and costeffectiveness analyses as auxiliary methods in priority determination; (4) increased harnessing of health statistics; (5) utilization of epidemiological factors, existing health services, health manpower and financial resources both current and potential; (6) promotion of the health education components of health problems; and (7) stimulating the introduction of modern scientific and technical methods to enhance the efficiency of administration and management, taking into account the existing local situation and its foreseeable trends. Whatever the problems encountered, WHO would endeavour to assist, upon request, in solving them. There were, however, no ready-made answers to all the problems that may arise. The World Health Assembly had, on several occasions, drawn the attention of Member States to their responsibility in the carrying out of combined measures for the protection and continuing improvement of health of the population and for promoting, as far as pOSSible, their active co-operation in this field. ~~O assistance took different forms such as: (1) the organization and strengthening of the health planning machinery, improvement of the information system, strengthening of managerial capacity, improvements in the formulation and presentation of plans to make them more understandable to decision-makers and consumers, etc., (2) evaluation of health plans, (3) the preparation of guidelines and development of standards, (4) training of national health manpower in order to make them components for the responsibility of planning, organizing and implementing their health plans, (5) research in national health planning, and (6) dissemination of information concerning national health planning.

- 25 Mr Y. Darwish, Regional Director of UNICEF, East Asia and Pakistan, stated that in the field of health planning, international assistance could be under four headings: (1) (2) 0)

education of national health planners, preferably at country level; research in national health planning; exchange of information in the fields of planning and administration through meetings, etc.; development support and communications service, including services in nutrition, community development and education. In this connexion, reference was made to the UNDP/UNICEF Development Support and Communication Service in Bangkok.

(4)

He emphasized, however, that UNICEF was interested in extending assistance concerned with the in-country training in planning of national staff and in development support and communication service. Assistance to the Philippines was cited as an example of the help being given in the training of staff and in building up the national health planning unit. Stipends, supplies and equipment were being provided. Countries interested in this kind of assistance could therefore submit appropriate requests. In the general discussions the following comments were made. WHO assistance given by way of consultants or advisory services and fellowships should be continued. A suggestion was made that WHO should collect and disseminate an up-to-date information system in the field of national health planning. Training programmes should preferably be at the country level so that a number of public health administrators could be oriented simultaneously. The need to develop a health planning methodology to suit individual countries was stressed. The practice of importing health technology was expensive and at times unsuitable. It was suggested therefore, that the technology be developed or adapted in the country concerned and that WHO should collaborate actively. Attention was directed to the need to reorganize the collection of information and data required for planning purposes. Workshops at country level were suggested for promoting health planning. The assistance of WHO staff at these workshops was considered useful as it would make available to the country, opportunities for consultations and exchange of views. In addition to WHO, external assistance was provided by the Colombo Plan and bilateral agencies. Training of government health personnel in the fields of development planning was a regular activity of the United Nations Asian Institute for Economic Development and Planning in Bangkok. As assistance in the field of national health planning was available from many sources, co-ordination was essential. International assistance to countries extended by the United Nations and its Specialized Agencies was co-ordinated either on the initiative of the country or among the

- 26 Agencies themselves. In some countries committees existed for the co-ordination and better planning of external assistance. The Twentyfourth World Health Assembly had declared co_ordination a prime responsibility of the governments with reference not only to their own programmes but also to the help they received from external sourceS. The assistance given by short-term consultants was reviewed. One point of view was that short-term consultants had not been able to do justice to their assignment because they were not aware of the country situation, particularly in the complex field of national health planning. Another viewpoint was that they were hampered because of the inadequate preparatory work by requesting countries. The scarcity of experts in the field of national health planning resulted frequently in delays in the extension of assistance to requesting countries. In response to a query, the activities of the ~mo Regional Office for the Western Pacific in the field of health planning were discussed. Annual courses in health planning had been conducted since 1968 in collaboration with the University of the Philippines. Beginning in 1973 in-country training of national staff would be started in Malaysia, while a subregional course would be held for countries and territories in the South PacifiC. A course would also be held in the Philippines, if time permitted. Short- and long-term advisory services in health and manpower planning continued to be extended on the basiS of requests from individual countries. There were three aspects of planning which were now receiving increased attention, viz., national health planning, project formulation and health practice research. In national health planning, attention was being directed to the development and further improvement of planning methods that could provide a more adaptable framework for undertaking planning in the developing countries. There was an increasing need for formulating, with the use of systems analYSis, development projects in health within the frame of the national health plan. WHO assistance in this regard was available to requesting countries. In many countries health practice research was needed in order to develop more effective and efficient staffing patterns and better means of organizing and promoting improved health services delivery. WHO had begun to extend this type of assistance. Health practice research was useful in planning because the results obtained served as bases for the formulation of norms and standards essential to the planning process. The Regional Office was also providing fellowships in planning. The requirement had been made that national staff undertaking observation studies abroad on national health planning, should first attend the regional course in order to provide them with a better orientation of the activities they would study. Apart from assistance in the development of national statistical services , loJHO was also developing a system for organizing a statistical and recording

system that would cover information on services and administrative activities which would be useful to planning. As this information was intended to assist the Regional Office in its formulation of long-term assistance to countries, based on needs, it was anticipated that the system, would be of practical use to the countries themselves.

- 27 -

5.

CONFERENCE RECOMMENDATIONS

A meeting of the Resolutions Drafting Committee was convoked following completion of the agenda to formulate the draft recommendations of the Conference. The participation of the consultants and resource persons, as well as the Conference secretariat, was sought during this formulation process. The draft recommendations were then submitted formally to the Conference at a plenary session which, after further debate, adopted the following text of the Conference Recommendations: (1) An annual review of national health planning in the context of development planning should be undertaken by the countries and territories of the Region. The WHO Regional Office should prepare a suitable outline for this purpose. On receipt of the review information, the Regional Office should prepare a consolidated report for the Region as a whole and circulate it among countries and territories of the Region. In order to ensure a regular flow of information required for health planning, an information system should be organized in countries and territories of the Region. In this connexion, it is important to give due attention to the administrative and technical capacity of the country or territory. The WHO Regional Office should assist countries and territories of the Region, upon request, in setting up such a system as well as in obtaining financial aid from other sources for the purpose. In order to enable countries and territories in the Region to undertake effective health planning, training of personnel should be considered of high priority. In this regard, arrangements should be made for the training and orientation of the different types and levels of personnel concerned with health planning. This should be designed to promote problemsolving and decision-making skills, thus enabling the partiCipants to utilize properly the variety of technical tools and health planning methodologies available. It is also essential that a selected number of officials in each country and territory should be familiar with the concepts and techniques of development planning and the relationship of the development plan to the health plan. Particular attention should be given to the training of officials in the techniques of health manpower planning and health project appraisal and development. Efforts should be made to ensure that the training be suitable to the needs of the countries concerned. The WHO Regional Office should assist in the training and orientation of professional staff. Countries and territories should be encouraged to request from WHO whatever assistance they require in organizing national courses.

(2)

(3)

- 28 (4) Applied research on health planning should serve two purposes: (a)

the improvement of available methodologies and development of new tools of planning sui table for the countries of the Region, and the development of teaching aids to assist in training.

(b)

(5)

In order to up-date the knowledge of staff in the field of health planning, the WHO Regional Office should continue to organize seminars, workshops, etc. on a regional or in-country basis in collaboration, if possible, with other international agencies. As non-health development projects may involve health hazards, it should be the declared policy of governments to see that resources are earmarked to deal with these hazards and made part of the investment and operating costs of such non-health development projects. WHO should make available technical literature on national health planning, promote research on matters relating to health and development and render assistance in organizing and conducting periodic evaluations of the health planning process. The countries and territories of the Region should avail themselves of assistance in the field of planning from external sources, particularly from WHO and other United Nations agencies. It is important to provide machinery within the country/territory to co-ordinate the different kinds of assistance received from external sources. adequate preparation to receive and utilize effectively the services of consultants in health planning and administration.

(6)

(7)

(8)

(9) Countries/territories, when requesting assistance, should make

- 29 ANNEX 1

LIST OF PARTICI PANTS. SECRETARIAT AND OBSERVERS PARTICIPANTS GUAM

Mr Joaquin C. camacho Deputy Director of Public Health Department of Public Health and Social Services Government of Guam P.O. Box 2816 Agana Dr Masami Hashimoto Chief, Department of Public Practice Institute of Public Health 6-1, Shirogane-dai 4, Minato-ku Tokyo Japan Dr Pruoch Vann Directeur general adjoint de la Sante Ministere de la Sante Publique. du Bien-etre et du Developpement pharmaceutique Phnom Penh Dr PhQuy Phoutthasak Directeur general Ministere de la Sante Publique Vientiane

JAPAN JAPON

KHMER REPUBLIC REPUBLIQUE KHMERE

LAOS

MALAYSIA MALAISIE

Dr Gurmukh Singh Deputy Director Planning and Development Ministry of Health Kuala Lumpur Dr S.K. Mukherjee Director of Medical Services Medical Headquarters Kuching. Sarawak

PA PUA NEW GUINEA PAPUA-NOUVELLE-GUINEE

Dr J .0. Tuvi Acting Assistant Director Maternal and Child Health Department of Public Health P.O. Box 2084 Konedobu

- 30 -

Annex 1 PAPUA NEW GUINEA (cont'd.) PAPUA-NOUVELLE-GUINEE (suite) Dr C.O. Bell

SSMO (Epidemiology) Department of Public Health Konedobu Dr Antonio Acosta

PHILI PPINES

Medical Adviser Office of the Secretary Department of Health Manila Dr Jesus B. Almonte Chief, Field Health Operations Departmen t of Heal th Manila REPUBLIC OF KOREA REPUBLIQUE DE COREE Mr Won-Kyu Kim Director-General for Planning and Coordination Ministry of Health and Social Affairs Seoul Dr Jong Huh Chairman Department of Health Administration School of Public Health Seoul National University Seoul SINGAPORE SINGAPOUR Dr Andrew Chew Guan Khuan

Deputy Director of Medical Services Ministry of Health Palmer Road Singapore 2 Dr Supileo Foliaki Director of Health Ministry of Health Nuku 'alofa

TONGA

VIET-NAM

M. Tran Van Nhleu Directeur de cabinet Ministere de la Sante 59, Hong-Th§p-Tu Saigon

- 31 -

Annex 1

VTET-NAM (cont'd.)

M. Bui Khiet Chef du Bureau de la Planification sanitaire Ministere de la Sante 59, Hong-Thip-Tu Saigon Dr Tapeni Fa 'ai 'uaso Control of Communicable Diseases Port Health and Leprosy Ward Heal th Department Apia

\·iESTERN SAMQ,\ SAMOA-OCCIDENTAL

SECRETARIAT Technica.l Staff Personnel technique Dr A.A. Angara Assistant Director of Health Services WHO Western Pacific Regional Office Manila Dr Ezequiel Paz Medical Officer, National Health Planning WHO Western Pacific Regional Office Manila

Dr P. Rajasingham Consultant WHO Western Pacific Regional Office Manila Dr V. Djukanovic Programme Leader Development of Health Services WHO Headquarters Geneva Consultants: Dr Arne Barkhuus Professor of Public Health Practice School of Public Health and Administrative Medicine Columbia. university Uni ted States of America

- 32 -

Annex 1

SECRETARIAT (cont 'd.) Consul tants: Dr M.S. Jillani Regional Adviser on Social Development Planning Economic Commission for Asia and the Far East Bangkok, Thailand Dr D. V. Ramana Development Economist Asian Institute for Economic Development and Planning Bangkok, Thailand

Tectmiclll Staff Personnel tectmique

Dr A.P. Ruderman Professor, Health Administration School of Hygiene Toronto University Ontario, Canada Dr David Tejada Director, Pan American Health Planning Centre Santiago,Chile

Resource Persons: Personnel d'appoint: Dr W.G. Baker WHO Technical Officer (Economist) Asian Institute for Economic Development and Planning Bangkok, Thailand Dr Jose Cortes, Jr.

Professor, National Health Planning Institute of Public Health University of the Philippines Manila Mr George Dorros Technical Officer (Project Systems Analyst) WHO Western Pacific Regional Office Manila

- 33/3~ Annex 1 SECRETARIAT (cont 'd. ) Techn1cal Staff Personnel technique Resource Persons: Personnel d'appo1nt:

Dr D.H.S. Griffith WHO Public Health Administrator As1an Institute for Econom1c Developmen t and Planning Bangkok, Thailand Dr Remigio Mercado Professor, Nat10nal Health Planning Inst1tute of Public Health University of the Philippines Manila Public Information Officer Adm1n1strateur (information ) Interpreters Interpretes Mr Jose Abcede WHO Western Pac1f1c Regional Oftice Manila Miss Genevieve CHment WHO Western Pacific Reg10nal Oftice Manila Miss Nicole LaffBrgue WHO Western Pacific Regional Office Manila Mr Pierre Lambert WHO Headquarters Geneva OBSERVERS OBSERVA TEURS Mr Y.H. IRlrwish Regional Director UNICEF East Asia and Pak1stan Bangkok, Thailand

Dr Andres Galvez Medical Spec1a11st Regional Health Office No. 3 Departmen t 0 f Health Manila

- 35 ANNEX 2

PROVISIOOAL RULES OF PROCEDURE

I.

Introduotion

The WHO Regional Office for the Western Pacific has over the past years been promoting national health planning. The means it has employed for this purpose have been a seminar on national health planning, regional training courses, provision of advisory and consultant servioes in health and manpower planning, extension of fellowships, and the holding of technical discussions on the topics of national health and manpower planning in two Regional Committee Meetings. The time is now deemed ripe for taking stock of the present situation and for countries to consider future lines of action in this area. Accordingly, a Regional Conference on National Health Planning is being organized with these aims in view. The Conference will bring together senior professional health staff at the level of directors of medical or health services or their equivalents, who have decision-making functions in relation to national health planning. National participants who attend will represent their governments. Opportunity will thus be afforded countries in the Western Pacific Region to pool their knowledge, experience and ideas and seek a measure of agreement on important areas for action in the field of national health planning. The Conference has the following objectives: (1) (2) To review the current situation in national health planning in countries and territories of the Western Pacific Region. To discuss, in the context of national health planning as part of development planning, alternative ways of undertaking national health planning within differing socio-economic milieus. To outline the assistance which WHO and other external sources might provide to promote, develop and implement national health planning. To formulate reeollllllendations whioh may assist countries in the Region in the organization, preparation and implementation of national health plans where they do not yet exist and in improving and updating regularly such plans where they do exist.

(3)

(4)

- 36 Annex 2 II. Participation

Rule 1 - Participants The governments of Member States of the Western Pacific Region invited by the WHO Regional Office for the Western Pacific shall be entitled to take part in the First Regional Conference on National Health Planning with the right to vote. Rule 2 - Representatives and Observers 2.1 2.2 Member States and agencies invited by WHO may send observers. Representatives of organizations or agencies and national observers may participate in the work of the Conference without the right to vote,subJect to Rule 9.3.

III.

Organization of the Conference

Rule 3 - Election of Officers The Conference shall at its first meeting elect a Chairman, ViceChairman and two Rapporteurs (English and French). Rule 4 - Resolutions Drafting Committee 4.1 4.2 The Conference shall establish a Resolutions Drafting Committee which may co-opt other members of the Conference as necessary. The Committee established by the Conference shall elect its own committee chairman, and if necessary,a rapporteur.

Rule 5 - Steering Committee There shall be a Technical Steering Committee conSisting of the Chairman or in his absence, the Vice-Chairman, the two Rapporteurs and the Secretary of the Conference. \-.'HO consultants and WHO secretariat staff shall be available as necessary to assist this Committee. The Committee shall meet at a convenient time agreed upon after each day's sessions. This Committee shall be responsible for preparing the report of the session for the day.

- 37 Annex 2 IV. Conduct of Business

Rule 6 - Duties of the Conference Chairman 6.1 In addition to exercising the powers which are conferred upon him by the Rules of Procedure, the Chairman shall open and close each plenary meeting of the Conference. He shall direct the discussions, ensure observance of the rules, accord the right to speak, put questions to the vote and announce decisions. He shall rule on points of order and, subject to the Rules of Procedure, direct the proceedings and maintain order. He shall not vote unless to break a tie. place shall be taken by the Vice-Chairman. The Vice-Chairman acting as Chairman shall have the same powers and duties as the Chairman. Pule 7 - Plan of the Conference 7.1 The loIHO Operational Officer for the Na tional Health Planning Conferenc e shall function as Secretary of the Conference and assist the Chairman in carrying out his duties. The draft conference report and resolutions embodying the recommendations shall be ma~e available in time to the delegates for review on the last day of the Conference. The amendments proposed and accepted by the Conference shall then be incorporated in the draft report and the final report presented to the Conference on the same day for its adoption.

6.2 If the Chairman is absent during a meeting or any part thereof, his

7.2

7.3 The cloSing ceremonies shall follow immediately after adoption of the report. Rule 8 - Quorum 8.1 8.2 At plenary meetings a quorum shall consist of a majority of the participating States referred to in Rule 1. At meetings of the Resolutions Drafting Committee, a quorum shall consist of the majority of the States referred to in Rule 1 which are members of the body in question. The Conference and its Resolutions Drafting Committee shall not decide on any matter unless a quorum is present.

8.3

Rule 9 - Order and time-limit of speeches 9.1 The presiding officer shall call upon speakers in the order in which they signify their wish to speak.

- 38 Annex 2 9.2 The presiding officer may limit the time allowed and see that the observations made by speakers follow the outline for the current topic under discussion. An outline of the topic under discussion shall be made available to participants in advance by the Secretary of the Conference. recognition given by the presiding officer. Rule 10 - Points of order 10.1 During a discussion, any State delegation may raise a pOint of order, and such point of order shall immediately be decided upon by the presiding officer. An appeal may be made against the ruling of the presiding officer. Such appeal shall be put to the vote immediately and the presiding Officer's ruling shall stand unless overruled by a majority of the participants present and voting.

9.3 Representatives and observers referred to in Rule 2 may speak upon

10.2

Rule 11 - Procedural motions 11.1 During a discussion, any delegation may propose the suspension or adjournment of the meeting or the adjournment or closure of the debate. Such a motion shall be put to the vote immediately.

11.2

Rule 12 - Resolutions and amendments 12.1 Draft resolutions shall be proposed by the Resolutions Drafting Committee referred to in Rule 4 and shall be transmitted in writing to the secretariat of the Conference which shall circulate copies to all delegations. As a general rule, no draft resolution shall be discussed or put to the vote unless it has been circulated sufficiently in advance to all delegations in the working languages of the Conference.

12.2

Rule 13 - Working languages 13.1 13.2 The working languages of the Conference shall be English and French. Speeches made in any meeting of the Conference in one of the working languages shall be interpreted into the other working language.

13.3 The documents of the Conference shall be issued in English and French.

- 39 Annex 2

Rule 14 - Voting 14.1 The delegation of each State referred to in Rule 1 shall have one vote in the Conference and in the Committee in which it is represented. Subject to the provisions of Rules 8.3 and 17, decisions shall be taken by a majority of the delegations present and voting. For the purpose of the present rules, the expression "delegations present and voting" shall mean delegations casting an affirmative or negative vote. Delegations abstaining from voting shall be considered as not voting. Voting shall normally be by a show of hands. When an amendment to a proposal is moved, the amendment shall be voted on first. When two or more amendments to a proposal are moved, the Conference shall first vote on the amendment deemed by the presiding officer to be furthest removed in substance from the original proposal, and then on the amendment deemed by him to be next furthest removed therefrom and so on, until all the amendments have been put to the vote. If one or more amendments are adopted, the amended proposal shall then be voted upon as a whole.

14.2 14.3

14.4 14.5

14.6

14.7 A motion is considered an amendment to a proposal if it adds to, deletes from or modifies part of that proposal. Rule 15 - Records 15.1 15.2 The Conference shall adopt a report on the results of its work, including such resolutions as it may have adopted. After the close of the Conference, the final report shall be published by WHO. V. Secretariat of the Conference

Rule 16 - The WHO Secretariat of the Conference 16.1 The technical staff will consist of the following: Dr A.A. Angara, Assistant Director of Health Services, Western Pacific Regional Office (Secretary) Dr E. Paz, Medical Officer, National Health Planning, Western Pacific Regional Office

- 40 -

Annex 2

Dr P. Rajasingham, Consultant, Western Pacific Regional Office Dr V. Djukanovic, Programme Leader, Development of Health Services, WHO Headquarters, Geneva Dr Arne Earkhuus, Professor of Public Health Practice, School of Public Health and Administrative Medicine, Columbia University, United States of America (Conference Consultant)

Dr M.S. Ji11ani, Regional Adviser on Social Development Planning, Economic Commission for Asia and the Far East, Bangkok (Conference Consultant) Dr D.V. Ramana, Development Economist, Asian Institute for Economic Development and Planning, Bangkok (Conference Consultant)

Dr A.P. Ruderman, Professor of Health Administration, School of Hygiene, Toronto University, canada (Conference Consultant)

Dr David Tejada, Director, Pan American Health Planning Centre, PAHO,1N.HO, Santiago, Chile (Conference Consultant)

Dr W.G. Eaker, WHO Technical Officer (Economist). Asian Institute for Economic Development and Planning, Bangkok (Resource Person)

Dr Jose Cortes, Jr., Professor, National Health Planning, Institute of Public Health, University of the Philippines (Resource Person) Mr G.L. Dorros, Project Systems Analyst, Western Pacific Regional Office (Resource Person)

Dr D.H.S. Griffith, WHO Public Health Administrator, Asian Institute for Economic Development and Planning, Bangkok (Resource Person)

Dr Remigio Mercado, Professor, National Health Planning, Institute of Public Health, University of the Philippines (Resource Person) 16.2 The members of the secretariat referred to in 16.1 above shall participate in the work of the Conference without the right to vote. They may, upon request of the Chairman or on their initiative make either oral or written statements to the Conference or to its Committees on any question under discussion.

- 41/42 -

Annex 2 16.3 The secretariat shall receive, translate and distribute all official documents of the Conference and interpret the discussions, as provided in Rule 13. It shall also assist in drawing up the reports of the Conference and perform all other necessary duties. VI. Adoption and Amendment of the Rules of Procedure

Rule 17 - Adoption The Conference shall adopt these Rules of Procedure by a decision taken in its first plenary meeting by a simple majority of the delegations present and voting. Rule 18 - Amendment The Conference may amend these Rules of Procedure by a decision taken in plenary meeting by a two-thirds majority of the delegations present and voting.

- 43144 -

ANNEX 3 LIST OF WORKING PAPERS I

WPRINHP/l

The Relationship Between Health and Developnent as Seen by a Health Economist by Dr A.P. Ruderman, Professor of Health Administration, School of Hygiene, University of Toronto, Toronto, Canada Public Health and Development by Dr Arne Barkhuus, Professor of Public Health Practice, School of Public Health and Administrative MediCine, Columbia University, New York, United States of America A Developnent Approach to Health by Dr D. V. Ramana, Development Economist, United Nations Asian Institute for Economic Development and Planning, Bangkok, Thailand Co-ordinating the Health Plan with the Development Plan by Dr D. V. Ramana, Development Economist, United Nations Asian Institute for Economic Developnent and Planning, Bangkok, Thailand An Outline of WHO's Assistance to Countries in Promoting, Developing and Implementing National Health Planning by Dr D. V. Djukanovic, ProgI'lUlllle Leader, Developnent of Health Services, Division of Strengthening of Health Services, WHO Headquarters, Geneva Pre-Planning Considerations by the" Secretariat Review of the Current Situation in National Health Planning in the Western Pacific Region by the Secretar.iat Health Planning Methodologies: Concepts and Problems by Dr David Tejada, Director, Pan American Health Planning Centre, PAHO/'WHO, Santiago, Chile The Social Aspects of Development Planning: Some Additional Dimensions by Dr Ramon Hermano, UNICEF Professor of Social Planning, United Nations Asian Institute for Economic Development and Planning, Bangkok

WPRI'NHP/2

WPRl'NHp/3

WPRlNHP/4

WPRINHP!S

WPR/NHP/6 WPRI'NHP/7

WPR/NHP/8

WPRI'NHP/9

Copies can be obtained from the WHO Regional Office for the \'!estern Pacific.

1

- 45 ANNEX 4 SUMMARY OF THE HEALTH PIANNING METHODOLOGY AS TAUGHT IN THE WHO COURSE ON NATIONAL HEALTH PIANNING ORGANIZED IN COLIABORA'ITON WITH THE INSTITUTE OF PUBLIC HEALTH, UNIVERSITY OF THE PHILIPPINES

by Dr E. Paz. Medical Officer, WHO Dr J. Cortes, Jr., Associate Professor, Institute of Public Health Dr R. Mercado, Associate Professor, Tnstitute of Public Health

1. The general features of the planning methodology may be summarized as follows: 1.1 The methodology assumes the creation of conditions favourable to its application after the political decision to plan has been made. The favourable conditions required had been presented in the discussion on pre-planning considerations. 1.2 The methodology is composed of several steps. Some of the steps can be done separately; the other steps are very closely related and thus must follOW a specific sequence for their completion. 1.3 The planning process will utilize available national expertise; such expertise and advice need not be confined to the strictly technical groups in the health field but also those in the other sectors; and lay and political groups need further to be consulted. 1.4 Planning efforts will be initiated substantially at the central level with the intermediate and peripheral levels of health administration acting mainly as sources of information. Over a period of time as planning capability expands, substantial efforts will be contributed from the intermediate and peripheral levels. 1.5 The methodology recognizes the problems posed by the heterogeneity of conditions in different parts of a country. Aside from national priorities, local priorities would also exist. 1.6 The methodology, at each step can be modified according to the country condition as may especially be required by the planning data available. 1.7 Common objections to planning, such as the paucity of data and the non-existence of needed administrative and managerial ability to carry out the plans are considered and actually form part of the subjects of the planning process and of the plan.

- 46 Annex 4 2. Steps

2.1 The methodology starts with the preparation of guidelines for the planning exercise. This would define the technical, administrative, legal and physical boundaries of the plan and its directions. 2.2 The diagnostic phase follows through the analyses and projections of the levels and status of health, population, ecologic factors (economic, social and environmental factors among others) and the health sector, following which identification is made of problem diseases and problem areas of the year under analysis and that of the planning horizon. Explanations for the existence of such problems are brought out through constraint analysis. 2.3 The constraints are studied further in consultation with health administrators as to the extent by which they can be eliminated. A list of the changes to be made to overcome the constraints and the changes which are expected to result will be used to prepare the second set of guidelines. The latter, together \111 th relevant parts of the first guidelines, will guide the formulation phase of the planning exercise. 2.4 The formulation phase starts with the identification of priorities following such criteria as technical, administrative, financial and political feasibility, magnitude of the problem, and social concern. Whenever possible, the considerations of cost-benefit and/or costeffectiveness are also brought in. The final basis for the decision should however be recognized as a political one. Even so, the methodology provides the basis for explaining to the political decision-maker the consequences of the alternative actions which may be taken. 2.4.1 Given the priorities, the results of the diagnosis and the guidelines, the main objectives of the plan can then be stated. 2.4.2 Final programmes (e.g., MCH, Communicable Disease Control, Environmental Sanitation, etc.) are selected with a view to carrying out the main objectives. At this step, statements on the specific objectives of each programme are stated. These specific objectives are then converted into tentative targets in accordance with certain criteria based on the feasibility of their accomplishment which in turn are influenced by the degree of removability of important constraints previously identified and the realistic norms which have been worked out. 2.4.3 Given the targets and norms, the activities designed to accomplish them are selected in accordance with such criteria as availability, effectiveness and cost. 2.4.4 The resources for carrying out the activities are then costed either uniformly for the whole country or by region or by area depending on the conditions existing in different parts of the country. The steps mentioned are those done for the integrated programmes contemplated.

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- 47 Annex 4 Vertical programmes are worked out separately, according to the same approach. The aid of consultants and advisers may be sought out in preparing for these activities. 2.4.5. Supporting programmes such as laboratory, training, information system, etc., are then worked out in accordance with the project developmental approach. 2.4.6 Given the resource requirements of the programmes, the required resources for supervisory services are calculated on the bases of the proposed distribution and organization of the programme resources which, in turn, will be determined according to the guidelines given. 2.4.7 The type and number of facilities necessary and their costs are then calculated on the basis of the last two factors previously mentioned. Based on the norm of cost, capital expenditures are determined. 2.4.8 All calculated expenditures are then aggregated to give the total requirements of the plan. The aggregated sum is then compared with the allocation available. Depending on the results of the comparisons, a positive or negative recycling is carried out as may be guided by the priority ranking that has been worked out and accepted by the decisionmaker. A positive recycling means setting the targets higher, while a negative recycling means reduction of the activities and thus lower targets. The first approximation and the recycled plan should be presented and explained to the decision-maker. 2.5 Pending the approval of the plan, the planner proceeds to work out the implementing phase of the plan. This phase deals with two activities, viz., programming and execution. 2.5.1 Programming activities are those that are carried out to create the necessary capability for delivering the services needed by the plan objectives. Such activities are guided by the list of changes previously generated at the end of the diagnostic phase. These are roughly categorized into technological changes, staff changes, changes in operating procedures, changes in administrative procedures (such as control procedures and reporting systems) and activities, designed to achieve desired policy changes. The activities are then translated into a PERT diagram. 2.5.2 Plan execution

2.5.2.1 The plan is broken down into expected activities and resources by geographical areas. Use is made of the proportional participation of these areas in the basic planning data that were used in the diagnostic phase.

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2.5.2.2 The planning unit will assist in overseeing the carrying out of the prescribed changes. 2.5.2.3 The planning unit is also expected to assist in services delivery through monitoring of the activities. 2.6 Plan evaluation Evaluation is carried out on the basis of the following: 2.6.1 Performance of activities, operating and activties as well specified in the plan the health service~ that is to say, whether the procedures, targets for attributes of resources as administrative, financial and technical support are being achieved or not.

2.6.2 Efficiency by means of relating the cost of operation with the performance. 2.6.3 Effectiveness by means of comparing certain indices of health before and after the plan implementation, e.g. case fatality rates, cost incurred for what have been achieved. 2.6.4 Evaluation of objectives and targets of health.