WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RtGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Thirtieth session Singapore 2-8 October 1979 Provisional agenda item 17
WPR/RC30/l5 9 August 1979 ORIGINAL: ENGLISH
COUNTRY ,HEALTH PROGRAMMING
1.
INTRODUCTION
Document WPR/RC30/15 is presented to the Regional Committee in pursuance of discussions at the twenty-ninth session. It briefly describes the policy background to country health programming; past and present efforts, global and regional; procedures and methodology; the role of country health programming as an instrument for technical cooperation in health development; mechanisms to support country health programming in the Western Pacific Region; and plans for further development. Representatives are invited to review the document and give their views on the development of country health programming in the Region.
2.
POLICY BASIS
Since country health programming (CHP) was introduced in 1973, at the expressed demand of Member States, who wished to be provided with an approach that would assist them in identifying major health problems for which priority programmes should be formulated, it has been the subject of discussions and important decisions and resolutions of the Executive Board and the World Health Assembly. The most significant was a resolution (Annex 1) adopted by the Thirty-first World Health Assembly, which stresses the importance of country health programming as a systematic and continuing multisectoral, national process, that helps governments to take political decisions concerning health development in the spirit of national self-reliance in health matters and to develop efficient national health systems. The resolution urges Member States to introduce and strengthen· the country health programming process and to develop adequate corresponding structures for implementation, training and research.
WPR/RC30/15 page 2
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It requests the Director-General to cooperate with Member States in the further development and application of country health programming, to promote training and research and to evaluate progress throughout the world. Closely related to resolution WHA31.12 is ~esolution WHA31.43 on the managerial process for health development, also adopted by the Thirty-first World Health Assembly (Annex 2).
3.
PRINCIPLES OF COUNTRY HEALTH PROGRAMMING •
Country health programming is conceptually a systematic process, which has the objective of facilitating political decision-making on the part of governments. It is a national approach to country-wide planning, programming and the management of health systems. One of the fundamental principles of country-health programming is to emphasize interaction between the health sector and other relevant sectors, thus placing health in the broader perspective of total socioeconomic development. It is a flexible method for applying systems analysis to the health planning and management process in varying country situations.
4.
PROCEDURES FOR COUNTRY HEALTH PROGRAMMING
The procedures for country health programming can be divided into the following four stages, from initiation of the process to its conclusion: Stage 1 - Establishment of a policy basis, collection and analysis of data; Stage 2 - Preparation of a sitUational analysis and broad programming; Stage 3 - Detailed health programme formulation; Stage 4 - Implementation of country health programming within the national health development programme, including continuous evaluation. Details of the steps which should be followed as closely as possible, although local conditions may call for adaptation, are given in Annex 3. ~
WPR!RC30!15 page 3
Since the country health programming process is continuous, and since documents arising from the process may not have been officially approveo "in toto" but have nevertheless been used by countries in preparing their programme budget proposals, it is not easy to state at exactly which paint Stage 2 ends and Stage 3 begins. Stage 4 is not a stage in the same sense as Stages 1 and 2. It consists in implementation, continuous monitoring, evaluation and rephasing/reprogramming. Successful implementation will depend on the work done at previous stages, particularly the programming stage. Continuous monitoring and evaluation require mechanisms and structures that have to be specified in the programming stage and planneo in detail in project formulation. The entry point for country health programming as a continuous process might be evaluation and improved management in some countries or, in others, development of regional capabilities in planning and management. Insofar as methodology is concerned, the WHO Western Pacific Regional Office has used as a basis a planning methodology developed under an intercountry advisory services on national health planning project, published in late 1977. 1
5.
PAST EFFORTS
From 1973 to 1918, country health programming activities were undertaken in 38 countries or areas of five WHO Regions. In addition, one interregional and one biregional seminar, two interregional consultations and one interregional workshop were conducted by WHO. Another interregional seminar is planned for late 1979. In those group activities, national participants, together with WHO staff, discussed and made recommendations on the following aspects of country health programming: organization and promotion, research and training, and methodology. For 1919, activities are planned to assess the process, based on experience from all Regions (Annex 4). In the Western Pacific Region, country health programming is considered to be continuous. It is an extension of activities and approaches under the intercountry advisory services on national health planning project, which started in 1969, and the project systems analysis exercises carried out in the Region. The first activity conducted under the label of country health programming was the exercise in Lao People's Democratic Republic in early 1975. In 1977, the document approved by the Government at that time was reviewed and modified.
1Health Planning in the Western Pacific, Public .Health Paper No. 2 of the WHO Regional Office for the Western PaCific, Manila, 1917.
WPR/RC30/l5 page 4
In Fiji, country health programming was initiated in 1976. During 1977 the information document was studied and revised. The programme proposal document is expected to serve as an important basis for the national health development plan. In Samoa, the documents for Stages 1, 2 and 3 have been completed. The programme document prepared in 1978 is being examined by the national authorities concerned. In Solomon Islands, Stage 1 and a large part of Stage 2 were completed in September 1978. The programming stage is expected to be completed during 1979. In Papua New Guinea, Stages 1 and 2 were completed during the first half of 1978. Stage 3 is now in progress and is expected to be completed during 1979. Following the Bi-regional Workshop on Country Health Programming organized by the WHO Regional Offices for South-East Asia and the Western Pacific, held in Bangkok in June 1978, the Government of the Philippines took steps to develop a country health programming process and a national health development collaborating system. The activity is progressing and a detailed plan of action has now been prepared.
6. COUNTRY HEALTH PROGRAMMING AS AN INSTRUMENT FOR TECHNICAL COOPERATION
In 1976, the Twenty-ninth World Health Assembly adopted a resolution on reorientation of the WHO programme budget in order to promote health development at country level. 1 In 1977, the Thirtieth World Health Assembly adopted a resolution deciding that the main social target of governments and WHO should be attainment by all citizens of the world by the year 2000 of a level of health that would permit them to lead socially and economically productive lives. 2 The Thirtieth World Health Assembly also defined technical cooperation as activities that had a high degree of social relevance for Member States, in the sense that they were directed towards defined national goals and that they contributed directly and Significantly to the improvement of the health status of populations through methods that governments could apply now and at a cost they could affordnow. 3 The Thirtieth World Health Assembly accepted the
lSee resolution WHA29.48, WHO Handbook of Resolutions and Decisions, Volume II (3rd edition), 1979, pages 2-3. 2See resolution WHA30.43, WHO Handbook of Resolutions and Decisions, Volume II (3rd edition), 1979, page 3. 3S ee resolution WHA30.30, WHO Handbook of Resolutions and Decisions, Volume II (3rd edition), 1979, page 102.
WPR/RC30/15 page 5
recommendations of the Executive Board made in relation to the organizational study on WHO's role at the country level, that one of the essential functions of WHO is to cooperate with countries in the planning, management and evaluation of their own health programmes. That type of cooperation should enable them to select the activities they wish to undertake in order to solve their priority problems and to determine in which fields further cooperation from WHO will be most effective. 1 country health programming is seen as an important instrument to implement the above-mentioned decisions and recommendations in Member States and in WHO. In countries, it serves as a tool for the reexamination of policies and for their translation into operational programmes. It also serves as a tool for the identification of needs for technical cooperation from WHO and other international aod national agencies. It is particularly important in ensuring interface between health and health-related socioeconomic sectors for joint efforts in health development. In WHO, it· serves for the preparation of medium-term programmes, for programme budgeting and for identifying areas for technical cooperation with Member States, based on identified problems and strategies to solve those problems. .
7.
MECHANISMS TO SUPPORT COUNTRY HEALTH PROGRAMMING
For country health programming to be effective it should be supported by a health councilor an advisory committee or some other form of advisory bOdy, depend~ng on the wishes of the government and on the local situation, able to mobilize professional and public support for the development and implementation of policies, strategies and plans of action, and to provide advisory services to the Ministry of Health or its equivalent. Technical expertise for the process would generally come from the Ministry of Health, supported by that of other ministries. The mechanism would be either to establish panels of conSUltants or experts, or to organize groupings of experts and institutions as national centres for health development. National centres for health development are concerned with development of the country health programming process, investigation and clarification of the management aspects of primary health care delivery, and related research.
1See resolution WHA30.16, WHO Handbook of Resolution and Decisions, Volume II (3rd edition), 1979, page 144.
WPR/RC30/l5 page 6
In WHO, support for the country health programming process comes from the WHO Programme Coordinators, or, in some Regions, their national equivalent. In the Western Pacific Region, further support is provided by staff assigned to country and intercountry health services development projects. In the Regional Office, a team composed of staff responsible for country health programming, management training and support, information systems development and evaluation, coordinates the support provided to Member States at various stages in the country health programming process. Close coordination is also maintained between primary hp.alth care, health services development, health manpower development and other programmes, at regional and at country level.
8.
FURTHER DEVELOPMENT OF COUNTRY HEALTH PROGRAMMING
It is planned further to develop country health programming in the Region. In the medium-term programme for country health programming, emphasis is placed on the necessity to create core groups of national health officials, through training at home and abroad and the establishment of national centres for healh development. The medium-term programme also provides for technical support at the various stages of country health programming. It is proposed that national centres for health development eventually become sub-regional or regional centres by offering their services to other countries. They will form a regional network for technical cooperation among developing countries. The centres should also be able to provide national experts to advise the WHO Regional Office for the Western Pacific. •
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ANNEX 1 RESOLUTION OF THE WORLD HEALTH ASSEMBLY
THIRTY-FIRST WORLD HEALTH ASSEMBLY
WHA31.12 18 May 1978
COUNTRY HEALTH PROGRAMMING The Thirty-first World Health Assembly, Endorsing resolution EB61.R25; Reiterating the bnportance of country health programming as a systematic and continuing multisectoral, national process that help's governments to take political decisions concerning health development, in the spirit of national self-reliance in health matters, and to develop efficient national health systems as called for in resolution WHA23.6l; 1. URGES Member States: (1) to introduce or strengthen the country health programming process for national health programme development; (2) to establish adequate mechanisms in ministries of health, or other ministries and institutie.ns concerned, for the initiation and maintenance of country health programming as a conti.nuing health development process; (3) to establi~h national centres or institutions of other types that countries may consider appropriate for the development of, and for research and training in, country health programming; (4) to cooperate with other countries through the exchange of information on country health programming methods, procedures and experience and through exchanges of personnel; (5) to cooperate with WHO in developing further the country health programming methodology in the light of experience in its application;
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(6) to introduce country health programming into undergraduate and postgraduate training wherever possible and/or necessary. for health and related personnel in order to familiarize them with the process and to increase substantially the number of well-trained personnel in this field; REQUESTS the Executive Board to review progress in country health programming from time to time, as appropriate; REQUESTS the Director-General: (1) to continue to cooperate with Member States in the further development and application of country health programming; (2) to promote training in the country health programming process, as well as the research required for its development and application, in national as well as in selected international collaborating centres;
3.
(3) to evaluate the progress of cou~try health programming throughout the world and report thereon to the Executive Board and the World Health Assembly as appropriate.
Tenth plenary meeting, 18 May 1978 A3l/VR/10
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WPR/RC30/1S page 9 ANNEX 2 RESOLUTION OF THE WORLD HEALTH ASSEMBLY
THIRTY-FIRST WORLD HEALTH ASSEMBLY
WHA3l.43 24 May 1978
MANAGERIAL PROCESS FOR HEALTH DEVELOPMENT The Thirty-first World Health Assembly, Bearing in mind the importance of applying appropriate managerial processes for health development; Recalling resolutions WHA3l.10, WHA31.11, WHA3l.12 and WHA3l.20; Stressing the need for a unified, managerial process for national health development, incorporating country health programming, national health programme budgeting and health programme evaluation, as well as adequate information support; 1. URGES Member States: (1) to introduce or strengthen, as applicable and as appropriate to their social and economic conditions, an integrated process for defining health policies; for formulating priority programmes to translate these policies into action; ensuring the preferential appropriation of funds from the health budget to these priority programmes; delivering these programmes through the general health system; monitoring, controlling and evaluating these health programmes and the services and institutions that deliver them; and providing adequate information support to the process as a whole and to each of its component parts; (2) to make use, as applicable, of the methods developed under the aegis of WHO for country health programming, national health programme budgeting, health programme evaluation and national health information systems; (3) to provide appropriate training for all health workers in the field of managerial processes and continued education in this field, particularly for health administrators; (4) to collaborate with WHO and among themselves, as required, in applying these methods as integral parts of the health development process; (5) to cooperate among themselves and with wao for the exchange of experience and information on these managerial methods for health development, and on their practical application in an integrated and effective manner. 2. REQUESTS the Director-General: (1) to ensure that managerial methods for health development are devised and applied by WHO in an integrated manner; (2) to promote and conduct research for the further improvement and integration of these methods; (3) to collaborate with countries, on request, on the application of their managerial process for national health development;
WPR/RC30/15 Annex 2 page 10
(4) to foster appropriate training in health management, particularly through learning-by-doing; (5) to formulate the organization's mediu~term programmes wherever possible with indications of priorities between programmes on the basis of information resulting from national health development processes, of the prevailing General Programme of Work and programme budget policy and strategy, and of relevant resolutions of the World Health Assembly, the Executive Board and the Regional Committees; (6) to continue to develop in an integrated manner the Organization's processes for medium-term programming, programme budgeting, health programme evaluation and the provision of adequate information support; and (7) to report on progress periodically, as appropriate, to the Executive Board and the World Health Assembly.
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Thirteenth plenary meeting, 24 May 1978
A3l/VR/13
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WPR/RC30/1S page 11 ANNEX 3
STAGES AND STEPS IN COUNTRY HEALTH PROGRAMMING STAGE 1 Step 1 Step 2 Step 3 STAGE 2 Step 4 Step 5 Step Step Step Step 6 7
ESTABLISHMENT OF A POLICY BASIS. COLLECTION AND ANALYSIS OF DATA Analysis and formulation of policy, establishment of terms of reference Collection of data Analysis and presentation of data PREPARATION OF A SITUA~IONAL
ANALYSIS AND BROAD PROGRAMMING
8 9
Step 10 STAGE 3 Step 11 Step 12 Step 13 Step 14 Step 15
Definition of priority health problems Assessment of current activities and resources devoted to the solution of health problems Setting of objectives Definition of health strategies Setting of quantified targets Development of proposals for broad priority health programmes Policy decisions on programming
DETAILED HEALTH PROGRAMME FORMULATION Selection of detailed programmes Formulation of detailed programmes Objective setting, quantified targets and evaluation criteria Analysis of constraints and redesigning of programmes Preparation, submission and approval of the country health programming document
STAGE 4 Step Step Step Step Step
IMPLEMENTATION OF COUNTRY HEALTH PROGRAMMING IN THE NATIONAL HEALTH PROGRAMME
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16 17 18 19 20
Development of a national medium-term programme Programme budgeting Programme management Programme evaluation Development of programme management information systems
...
Fig. 1.
Flowchart of the Health Planning
~ethodology
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rj Preparation and acceptance of the planning terms of referenc~
Analysis of Population data collection description projection ~
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Analysis of Health Status: data collection description projection
I--! r'l Programmes Formulation of main health objectives; establishment of priority among health tobjectives; formulation of basic strategy guidelines Planning of
Briefing on the planning exercise, scheduling, and assignment of work
tt1 H ~:
Identif i ca ti.on Analysis of Ecological and explanati.OI: Factors: of problems; I---' data collection ~ identification description of areas of projection change
Identification of projects
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Budget Estimates: - operating - capital
~Design
Analysis of Health Resources: - data collection description projection
of the 'lhealth service Approval of the plan
H
Evaluation projects programmes objectives
Implementation: - legal authorization - disaggregation ~ - project planning - monitoring - promotion
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WPR/RC30/15 page 13 ANNEX 4
SUMMARY OF COUNTRY HEALTH PROGRAMMING ACTIVITIES BY REGIONS AND COUNTRIES FOR THE PERIOD COVERING 1973 - 1978
1.
CHP initiation, programming and programme formulation activities Country Angola Cape Verde Congo Activities CHP Workshop CHP, Stages 1 and 2 CHP - Restricted CHP Stages 1 and 2 in conjunction with AFRO Intercountry CHP Workshop CHP, Stages 1 and 2 including Workshop CHP workshop1 CHP, Stages 1 and 2 . CHP Workshop 1 CHP Workshop (see Zambia) PF in Basic Health Services including Workshop CHP Workshop CHP Stages 1 and 2 CHP Workshop2 May to July 1976 April to May 1976 March to May 1978 July 1978 1
Region African
Period May 1977 _November 1976 to March 1978.
March to April 1975 January to February 1978 April to May 1977 October to November 1976 May 1977 August to September 1977
Gambia Ghana Guinea Bissau Madagascar Mozambique Namibia Nigeria Uganda Upper Volta
.
Zambia
~raining activities only. 2with Namibia officials participating. CHP - country health programming PF - programme/project formulation
WPR/RC30/l5 Annex 4 page 14 Region South-East Asian Country Bangladesh Activities CHP, Stages 1 and 2 Review PF in Drug Supplies and Logistics CHP Case Study CHP second cycle, Stages 1 and 2 PF in Primary Health Care CHP, Stages 1 and 2 PF in Environmental Sanitation including Workshop CHP Case Study Period June to September 1973 March 1975 March 1975 October 1976 March to July ·1977 April to June 1978 March 1975 to March 1976 June to October 1976 October 1976
..
Burma
Nepal
CHP, Stages 1 and 2 including training workshop January to May 1974 Programme formulation in the areas of: Health Education ) Malaria ) Water Supply and Excreta Disposal ) June to Basic Health Services ) October 1975 Tuberculosis ) Nutrition/Goitre ) ) Health Intelligence ) June to October 1975 Leprosy ) Family P1anning/MCH Immunization within Basic Health Services July to August 1976 October 1976 CHP Case Study CHP, Stages 1 and 2 CHP, Stages 1 and 2 including training workshop Programme formulation. in the areas of: Core Development Programme (Provincial Health Care, Urban Health, Health Manpower) Special Development Programme (Nutrition, Dental Health, Malaria, Environmental Protection, Food and Drug Control) Support System Development Programme Workshop on problems of Implementation Management CHP Case Study November 1978 October 1974 to February 1975 ) ) ) ) )
.
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Sri Lanka Thailand
) April to August 1975 )
) )
) )
------------------------------------------------------.------._----------------CHP - country health programming PF - programme/project formulation
May 1976 October 1976
WPR/RC30/l5 Annex 4 page 15 Region European country Algeria Activities CHP preparatory visit Stages 1 and 2 including workshop Follow-up visit (preparation of implementation schedule) PF in MCH and FHE PF in Occupational Health PF in Sanitation PF in Information Systems CHP exploratory visit (programming of Community Health Care Services) CHP training course CHP(EURO) exploratory visit CHP preparatory visit Training workshop Intercantonal training workshop CHP exploratory visit CHP exploratory visit Period January 1975 January to May 1975 March 1976 May to June 1976 March 1977 March 1977 June to September 1977
Ireland
February 1976 April 1977 January to February 1978 March 1978 June 1978 December 1978 December 1978 December 1978
Portugal Spain Switzerland Turkey Yugoslavia
Eastern Mediterranean
Afghanistan
CHP preparatory visit Stages 1 and 2 PF in National Health Programme/ Immunization including workshop CHP preparatory visit Stage 1 Stage 2 including workshop CHP introductory visit Stage 1 CHP preparatory visit Stages 1 and 2 PF in Population Programme including workshop PF in Manpower Development including workshop
June 1974 October 1974 to July 1976 September to November 1976 December 1977 February 1978 March to April 1978 October 1974 February to March 1978 October 1974 November 1974 to February 1975 March to June 1975 May to November 1975
Democratic Yemen Iraq Pakistan
..
CHP - country health programming PF - programme/project formulation
WPR/RC30/15 Annex 4 page 16 Region Country Sudan Activities CHP, Stages 1 and 2 PF in Primary Health Care Southern Region Northern Region Pre-implementation activities in Primary Health Care Yemen Arab Republic CHP, Stages 1 and 2 PF preparatory visit PF - Primary Health care Period October 1974 to April 1975 November to December 1975 April to May 1976 November 1976 to February 1971 April to August 1976 November 1971 March 1978
...
--------------------------------------------------------------------------------Western Pacific Fiji Lao People's Democratic Republic Malaysia Papua New Guinea Stages 1, 2 and 3 Stages 1, 2 and 3 Reformulated Preparatory work Training course in programme management Stages 1 and 2 Stage 3 Training course in programme management Preparatory work Stages 1 and 2 Stage 3 Stage 1 Stage 2 Course in health management 1976 1975 1978 1978 ongoing 1977 1977/78 . 1978 ongoing 1977 1978 ongoing 1977 1918 1977 1978 ongoing 1978
..
Philippines
Samoa Solomon Islands Tonga
CHP - country health programming PF - programme/project formulation
..
WPR/RC30/15 Annex 4 page 17 2. CHP educational and information activities Lieu Ninth Training Course for WHO Representatives Interregional Workshop on CHP Intercountry Workshop on CHP Training Course in Health Management Workshop on CHP (Interregional) Planning Meeting in European Regional Office, one day's briefing on CHP for Regional Office Staff and WHO Representatives Training Programme for WHO Representatives and other Senior Health Managers - Workshop on CHP (Interregional) International Course in Health Development CHP Workshop Management Training Course - CHP component Meeting of WHO Representatives - one day's discussion on CHP Intercountry/Inter-agency CHP/PF/PM/FHE Regional Workshop Interregional Seminar on CHP International Course in Health Development, CHP lo.'orkshop Management Training Course - CHP development Course on the Social Implications of Development - CHP Workshop Management Workshop for WHO and national staff - CHP module Interregional Consultation on CHP Alexandria Brazzaville Brazzaville HQ, Geneva
Period March 1973 March 1974 April 1975 July 1975
Copenhagen
October 1975
HQ, Geneva
October 1975
Institute of Tropical Medicine, Antwerp March 1976 Manila Alexandria Brazzaville New Delhi 1976 April 1976 November 1976 February 1977
Institute of Tropical Medicine, Antwerp June 1977 Manila International School, Bordeaux New Delhi Bangkok 1977
March 1977 September 1977 October 1977
CHP - country health programming PF - programme/project formulation
WPR/RC30/l5 Annex 4 page 18 ~
.. Period March, July, December 1977 June 1977 April 1978 April to May 1978
USA 5300 - Health Planning (Second, Third and Fourth Meetings of Advisory Committee) First Workshop in Health Planning - USA 5300 Second Workshop in Health Planning - USA 5300 Management Workshop for Health Services Development (with CHP component) CHP Workshop as part of the International Course in Health Development Workshop on Planning and Management of CHP process CHP Workshop as part of the Course on Health Planning and Evaluation Interregional Consultation on CHP
Washington Copenhagen New Orleans Edinburgh Amsterdam Bangkok USSR Brazzaville
. April 1978 June 1978 June 1978 July 1978
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CHP - country health programming
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WPR/RC30/15 Annex 4 page 19 3.
CHP planned activities for 1979 Country or area Benin Central African Empire Senegal Tanzania Zanzibar Activities CHP CHP CHP CHP CHP Period
Region African
-------------------------------------------------._.---------------------------South-East Asian Bangladesh Mongolia PF in Primary Health Care CHP
-------------------------------------------------------------------------------Eur02ean Austria Algeria Bulgaria Portugal Switzerland Yugoslavia CHP training workshop PF in Health Manpower Development eHP training workshop Training workshop Training workshop National training workshop NO'lember October August/September June
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Eastern Mediterranean
Iraq Somalia
CHP, Stage 2 eHP
Started January
eHP - country health programming PF - programme/project formulation
WPR/RC30/lS Annex 4 page 20 Region Western Pacific Country or area Cook Islands Gilbert Islands Malaysia Activities CHP CHP Establishment of Health Development Centre Training course on programme management (with CHP component) CHP continuing Training course on programme management CHP continuing Establishment of Health Development Centre CHP CHP continuing Seminar Follow-up of intercountry training course on health management held in Tonga in 1978 Establishment of Health Development Centre Period
March
• November
Papua New Guinea Philippines
Tonga Solomon Islands South Pacific
January
------------------------------------------------------------------------------Interregional workshop on CHP (DAN IDA) Interregional seminar on CHP (DANIDA) Bangkok 10-17 June Yugoslavia 12-22 November
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CHP - country health programming