Report of the Sub-Committee of the Regional Committee on Programmes and Technical Cooperation, part II : monitoring of implementation of national strategies for health for all by the year 2000

WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

Regional Office for the Western Pacific Bureau regional du Pacifique occidental

REGIONAL COMMITTEE Thirty-ninth session Manila 12-16 September 1988 Provisional agenda item 12

WPR/RC39/7 Corr. 1 27 July 1988

ORIGINAL: ENGLISH

REPORT OF THE SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON PROGRAMMES AND TECHNICAL COOPERATION PART II MONITORING OF IMPLEMENTATION OF NATIONAL STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000

CORRIGENDUM Pages 18-19 Replace these pages with revised pages 18-19, attached.

WPR/PTC/3/88.2 page 17 Annex 1

With regard to environmental health, the coverage of the population of the countries and areas of the Region with safe water and adequate sanitation facilities remains about the same, keeping pace with population growth. However, these data also reflect continuing disparity between services available in urban and rural areas, with most reporting countries indicating over 80% of the urban population covered but considerably lower coverage in rural areas. Ten tables, which include all data reported through the monitoring report, are attached as Appendix 1. They are based on the Revised Common Framework and supplemented by data available from other sources in the countries concerned.

WPR/PTC/3/88.2 page 18

Annex 1 CHAPTER 6. CONCLUSIONS Most countries and areas imply through their monitoring reports that they are generally satisfied with the progress of their activities in implementing health-for-all strategies. This regional synthesis highlights some notable features of health-for-all activities and suggests some possible implications for the overall health-for-all movement. Firstly, it may be noted from the 1985 evaluation report that a substantive part of the conclusion at that time was the increased awareness on the part of health leadership that fundamental changes were required at least in the orientation, processes and structure of the health system if health-for-all values were to have any real impact on the quality of life of the people. The regional strategy for health for all indicates that the starting point for these changes is the recognition that health for all implies an equal partnership between those who are conventionally referred to as the health providers, the other sectors of society, and the community. It is clear from this monitoring that the situation has progressed from awareness building to the formulation of an action-oriented vision of health for all. This conclusion is based on the content of new policies which reflect this vision, on strategies to revitalize the health system, and on evident commitment to practising the principle of partnership as the basis for · sharing accountability and responsibility for health. While a pro-active vision of health for all is taking shape, a viable leadership role in the health sector is emerging. The regional strategy indicates that the partnership concept requires changes in the traditional role of the health sector. These changes involve the health system beyond providing basic health services. The monitoring reports indicate that within the health sector, collaborative efforts are becoming increasingly important. Governments are recognizing that they have a leading and facilitating function rather than a purely directing one. Beyond the health sector, concern and attention are being directed to how other sectors contribute to health system development. Health system development activities generally aim to make health knowledge and resources more directly accessible to the community. From the 1985 evaluation, the process for achieving this goal was vaguely formulated around methods of decentralization and improving human capabilities, depending on the situation of the country concerned. The monitoring reports indicate a further elaboration of this positive direction. For example, in countries embarking on formal decentralization, the specific processes and structures to support the concept have been clearly specified by means of the district health system approach. For countries or areas where formal decentralization is not the overall concern, emphasis is being placed on increasing human capabilities. This is being done by expanding existing programmes or adding new ones, or by efforts to change the way existing staff perceive and carry out their respective roles. The effort to improve intersectoral collaboration appears from the monitoring reports to have been extensive, but most countries and areas indicate that this process is not yet consolidated, streamlined nor institutionalized. Most countries and areas report the increased use of specific mechanisms, namely formal and informal bodies and agencies, to promote intersectoral collaboration on health matters. However, the perennial constraints of differing opinions between sectors as to the definition of roles and responsibilities, and excessively bureaucratic procedures for sharing information and decision-making, persist. The positive results in this area, however, reflect stronger leadership in the health system, which is attempting to overcome these constraints.

WPR/PTC/3/88.2 page 19

Annex 1

The monitoring reports clearly indicate the continued priority that countries or areas give to strengthening the supportive mechanisms that are necessary to obtain the desired results from their health-for-all policies and strategies. These mechanisms concern the managerial process, human resource development and financing. Strengthening the managerial process as a trend highlighted in the 1985 evaluation report is clearly reinforced in the monitoring reports. Two elements of this trend include managing information and managing resources in a comprehensive fashion. There are clearly identifiable efforts to relate information processing to decision-making and to take into account the implications of such relationship for resource allocation and use. There is an increasing recognition that as health-for-all strategies evolve, the managerial process must respond accordingly. A similar positive trend is observed in the area of human resource planning and development. Countries and areas recognize that with the increasing rate of change occurring in society in general, and particularly in the health sector, the health system has a responsibility to support individual staff in responding effectively to these changes. Consequently, training programmes now include sessions on decision-making, team work and communication, along with the conventional themes of improving technical skills. Rising costs and diminishing financial resources continue to preoccupy most managers, but the mobilization of additional resources appears to be the least developed of the strategies for resolving this concern. On the other hand, positive results are being achieved in improving allocation decisions. Even for allocation decisions, however, significant difficulties still exist in linking them with appropriate requirements and in obtaining valid information on what and where the real needs are. In summary, the monitoring reports show positive results that national health-for-all strategies are clearly evolving along the lines originally envisaged in the regional health-for-all strategy and are being implemented more effectively. The salient features of this process include an emerging health leadership that is able to translate the health-for-all concept into an appropriate vision for the country concerned and facilitate its implementation on the basis of the primary health care approach. This process is far from complete or efficient, as the details for developing and reorienting a health system based on primary health care are extremely complex and elusive. However, an overall framework for handling this complexity, in the form of a partnership with communities, is also evolving as a strategy to manage this situation more effectively. It is in this arena of information, knowledge and resource sharing - both nationally and internationally - that the health sector faces its next major challenge.

WPR/PTC/3/88.2 page 20



WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

Regional Office for the Western Pacific Bureau Rgional du Pacifique occidental

REGIONAL COMMITTEE Thirty-ninth session Manila 12-16 September 1988

WPR!RC39n

11 July 1988 ORIGINAL: ENGLISH

Provisional agenda item 12

REPORT OF THE SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON PROGRAMMES AND TECHNICAL COOPERATION PART II MONITORING OF IMPLEMENTATION OF NATIONAL STRATEGIES FOR HEALTHFORALLBYTHEYEAR2~

The plan of action fotifupl¢Ji1eriti~g)~¢ ~egiori.~lStr~t¢gy fo(Healthfrif}\U by the Year 2000 was accepted by th¢ :RegioriaLCotrimittee·· iri its > resohitioli WPR/RC32..R5 .. in 198i. If stipUlated .J hat> ari • ·evaluation ·of natiOnal strategies should .be dorte every six yearS . • \Yltli a.monitoring repOrt every two .yearS; •.•'thci rn<>riltoril1g schediJle was > subSequently reViSed·to three years, WJ>R/Rc36.R8.>·· The Iasfadi\1it}r w8S the evaluation carried oufin.1985, ··using a< Common .Framework #rid Forma(for evaluating the·heal th;.for-'aU strategies. .The·Sub~Coinmittee of the Regional COmmittee 011 Programmes and Technical Cooperation was requested, by resolution WPR/RC35.R6; tO •rontillue to review; monitor and evaluate the implementation•or·tiie strate~6t Countries or areas wererequest&ftosubnut their monitoring·reports .based ·R.egthnal· Director . by Apri[l988 for on< a .reVised common framework to the> eventual incorporation in ·a regional report. . The regional·progress •report ts now .submitted for the oonsideration of the tfegional Committee as an annex under Part llofthe Sub'"Committee's rep<>rt The report proVides a synthesis of country or area reports which review progress in the implementation of healtb..for-'all strategies for national health development As not all< the countries or areas have submitted progress reports, supplementary information .·reported by.· governments on other occasions has been included in the report in order to reflect the real situation in the Region more fully. The Regional Committee is requested to review and comment on the regional progress report, which~ if it agrees, will be submitted t.o the Director·General for eventual inclusion in the global monitoring report.

WPRJRC39n page2

The plan of action for implementing the regional strategy for health for all by the year 2000 was accepted by the Regional Committee in its resolution WPR!RC32.R5 in 1981. It stipulated that an evaluation of national strategies should be done every six years with a monitoring report every two years. The monitoring interval was subsequently revised to three years, WPR/RC36.R8. The last activity was the evaluation carried out in 1985, using a common framework and format for evaluating the health-for-all strategies. The Sub-Committee of the Regional Committee on Programmes and Technical Cooperation was requested, by resolution WPR/RC35.R6, to continue to review, monitor and evaluate the implementation of the strategies. Within the above framework, the Sub-Committee reviewed the draft second report on the monitoring of implementation of national strategies for health for all by the year 2000. This report provided a synthesis of findings from the country or area reports which were based on the revised common framework for monitoring. The Sub-Committee noted that as of the date of the meeting, only 22 out of 35 countries or areas had submitted monitoring reports. 1 It noted further that supplementary information made available by governments had been included in the monitoring report in order to reflect more fully the real situation in the Region. In reviewing the report, the Sub-Committee concluded that progress had been made in all countries and areas which reported. It noted that in the current monitoring exercise, countries and areas indicated a much clearer understanding of issues to be addressed and of the mechanisms available for doing so. It also noted that most of the reports indicated that great efforts had been made to overcome the problems and constraints previously identified and that encouraging progress had been made. It concluded, however, that the overall rate of progress was not uniform, that in many cases it was not as rapid as had been anticipated in the regional strategy for health for all by the year 2000, and that accelerated effort was needed for the goal to be achieved. The Sub-Committee recommended that Member States should be urged to make additional efforts to reach health targets in order to achieve the goal of health for all by the year 2000. The Sub-Committee was concerned that the reports received from countries and areas did not reflect this monitoring exercise as part of their planned national monitoring activities. It felt that the evaluation of health-for-all strategies was more useful for the planning purposes of countries than the current monitoring exercise. The monitoring report did not cover such issues as the extent to which countries were satisfied with their progress on specific issues, the amount of debate that took place at various levels on health issues and the effect this had on the health care system, and the degree of consensus within the country on policy and strategy development. The Sub-Committee expressed serious doubts as to whether any useful conclusions could be drawn from Chapter 4 (International Action), as the reporting lacked specificity. It felt that the current monitoring exercise was not the most appropriate vehicle for such an ambitious review of international action. Important issues that were not reported included the systems utilized for attracting international cooperation, how priority areas are identified and proposed to prospective collaborators, and whether or not such cooperation adequately addressed priority issues for countries. 1Between the dates of the meeting and the finalization of this document, one additional country report has been received, bringing the total to 23. As recommended by the Sub-Committee, the contents of this report have been reflected in Annex 1.

WPR/RC39n page3 The Sub-Committee concluded from the regit:mal teport that a much clearer vision of health for all by the year 2000, together with an emerging health leadership capable of implementing that vision, was now apparent in most countries and areas which responded. These conclusions reflected the increased attention paid in country reports to such issues as equity of health care, community involvement, intersectoral collaboration and management improvements. The Sub-Committee recommended that WHO should respond effectively to the concerns and deficiencies mentioned above, particularly with regard to the evaluation of health-for-all strategies to be conducted in 1991. The Sub-Committee recommended in particular that WHO should arrange national or intercountry workshops on information support to the management process for national health development using the forthcoming evaluation exercise as a theme. It recommended that special attention should be paid to developing evaluation/monitoring plans and techniques as part of overall national health management. The Sub-Committee recommended that the regional monitoring report, which is attached as Annex 1, 1 should be accepted by the Regional Committee for submission to the Director-General, for eventual inclusion in the global monitoring report.

1Document WPR/PTC/3/88.2.

page4

WPR/PTC/3/88.2

ANNEXl

MONITORING OF IMPLEMENTATION OF NATIONAL STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000

page6

WPR/PTC/3/88.2

Annex 1

TABLE OF CONTENTS Page EXECUTIVE SUMMARY INTRODUCTION CHAPTER 1. THE MONITORING PROCESS CHAPTER 2. HEALTH POLICIES AND STRATEGIES CHAPTER3. DEVELOPMENTOFHEALTHSYSTEMS 1. 2. 3. 4. 5. 6. 7. 1

3

5 6 6 8 9

Organization of health systems based on primary health care Intersectoral collaboration Community involvement Managerial process Health manpower . . . Research and technology Resource utilization and mobilization

10 11 12 12 14 14 14 15

CHAPTER 4. INTERNATIONAL ACTION 1. 2. 3.

International transfer of resources . . . Intercountry cooperation . . . . . . . International cooperation (including WHO)

CHAPTERS. HEALTHSTATUS CHAPTER 6. CONCLUSIONS APPENDIX 1

16 18 21

page8

WPR/PTC/3/88.2 Annex 1 (i) EXECUTIVE SUMMARY

In 1979, the Thirty-second World Health Assembly launched the Global Strategy for Health for All by the Year 2000. It invited Member States of WHO to act individually in formulating national policies, strategies and plans of action for attaining this goal, and collectively in formulating regional and global strategies. The plan of action for implementing the global strategy for health for all calls on Member States to review and assess periodically their national policies, strategies and plans. The present report is a summary· of the monitoring of the activities currently being conducted in the countries and areas of the Region. It highlights two themes: (1) new initiatives that have been started since the 1985 evaluation; and (2) the processes being used to plan, implement and evaluate the health-for-all strategies. The health-for-all movement has had a significant impact on improving the managerial process of most countries and areas. All countries or areas report that they have an active national health-for-all monitoring process at the central level, but at lower levels of the health system a monitoring process is less regularly found. Problems encountered previously in monitoring and evaluation have stimulated the strengthening of health information systems in many countries and areas, which has resulted in improved capability for monitoring progress towards health for all. A number of features common to the policies and strategies of several countries can now be found which reflect the influences of health-for-all values. In general, the health-for-all vision appears to be becoming much sharper. More of the new policies and strategies are firmly based on the principles of primacy health care rather than those of traditional basic health services. This trend strongly suggests that health for all is a real vision for the countries and areas of the Region. The process of organizing a health system bastXJ on primacy health care may be described as twofold: one aspect is upgrading the system, the other is reorienting it. In terms of upgrading, the population coverage of health services has generally increased, and there has been a trend towards expanding services and improving their quality. Reorientation has involved structural measures such as decentralization and the provision of special training for health workers to provide them with a better understanding of their new role in the health system. It is recognized that there is a close relationship between health and overall socioeconomic development. The monitoring reports all include frequent allusions to this fact, and this reflects widespread recognition of the importance of improved intersectoral collaboration. The attention given to this is encouraging, although it is not yet clear what its impact will be.

WPR/PTC/3/88.2

Annex 1

(ii) The overall impression is that community involvement is growing, and that much effort is being directed towards overcoming the factors which make it seem difficult. These factors are not new; they include the community's belief that the government is responsible for its health, the lack of leadership and organization, and the pressure of poverty which makes income a more pressing concern than health. Many countries report specific interventions to improve management rather than general statements on the need for this. There is also a trend towards developing a comprehensive system rather than tackling single aspects of management, such as information or evaluation, as isolated problems. Specific issues and recent developments in management were reported in the areas of intersectoral involvement, the participation of all levels of management in the decision-making process, and decentralization. The vast majority of ongoing or new human resource development activities reflect responses to system changes. These activities mainly consist of training, but they are highly focused on specific undertakings, such as strengthening local in-service training, strengthening formal training institutions, scheduling retraining courses and providing for management skill development and supervision. The need to establish specific mechanisms to formulate policy and review activities related to research and technology was reported by many countries and areas. Countries which have such mechanisms report the need to strengthen them and improve coordination with the various agencies involved. The majority of countries and areas indicate that no specific resource mobilization and utilization plans have been prepared, but they also indicate that financial planning has a high priority as a routine component of all national and operational planning functions. In conclusion, most countries or areas imply in their monitoring reports that they are generally satisfied with the progress of their activities in implementing health-for-all strategies. This regional synthesis has highlighted a few new features of health-for-all activities and suggests what these new features may mean for the health-for-all movement as a whole. For example, the effect of the viable leadership role emerging in the health sector, together with the widespread emphasis on health system development activities, is to make health knowledge and resources more directly available within the community. In summary, the monitoring reports show positive results that national health-for-all strategies are clearly evolving along the lines originally envisaged in the regional health-for-all strategy and are being implemented more effectively. This process is far from complete or efficient, however, as the detailsJor developing and reorienting a health system based on primary health care are extremely complex and elusive.

WPR/PTC/3/88.2 page 1 Annex 1

INTRODUCfiON In 1979, the Thirty-second World Health Assembly launched the Global Strategy for Health for All by the Year 2000 and invited Member States of WHO to act individually in formulating national policies, strategies and plans of action for attaining this goal, and collectively in formulating regional and global strategies. A regional strategy for health for all was formulated and adopted by the WHO Regional Committee for the Western Pacific at its thirty-first session in 1980. A Global Strategy was adopted by the Thirty-fourth World Health Assembly, 1 a~d a revised strategy was adopted by the Regional Committee at its thirtysecond session in September 1981.2 The plan of action for implementing the global strategy for health for all, approved by the Thirty-fifth World Health Assembly in May 1982, calls on Member States to periodically review and assess their national policies, strategies and plans of action.3 A monitoring of progress is to be done every three years and an evaluation of effectiveness every six years.4 The global plan also called on the Regional Committee to prepare indicators for monitoring and evaluating the regional strategies. The Regional Committee, at its thirty-third session in 1982, approved a list of indicators that would be relevant for the regional monitoring and evaluation of the health-for-all strategies. A Common Framework and Format was prepared for the monitoring and evaluation of national, regional and global strategies. Its basic aim was to stimulate a national process for monitoring the implementation of health-for-all strategies. The results of national monitoring were to be used to prepare regional and global reports on the progress in implementation of the global strategy. The first regional monitoring report was reviewed by the Regional Committee at its thirty-fourth session in 1983;5 Subsequently, a revised Common Framework and Format for evaluation of the health-for-all strategies was formulated to guide the national evaluation process, and the first evaluation was conducted in 1985. This evaluation aimed at assessing the relevance, progress, adequacy, effectiveness and efficiency of the national health policies and strategies in achieving national healthfor-all goals. The regional evaluation report was reviewed by the Regional Committee at its thirty-sixth session in 1985, and eventually became a part of the Seventh Report on the World Health Situation.6

1Global strategy for health for all by the year 2000. Geneva, World Health Organization, 1981 (Health for All Series No. 3). 2Regionol strategy for health for all by the year 2000. Manila, World Health Organization, 1982. 3Plon of action for implementing the global strategy for health for all. Geneva, World Health Organization, 1982 (Health for All Series No. 7).

4Monitoring is the term used for the continuous follow-up of activities to ensure that they are proceeding according to plan. Evaluation is the systematic assessment of the relevance, adequacy, progress, efficiency, effectiveness, and impact of a health programme (from the Glossary of Terms used in the "Health for All" Series, Nos. 1-8). 5oocument WPRJRC34n.

6Evaluation of the strategy for health for all by the year 2000: Seventh Report on the World Health Situation, Volume 7, World Health Organization, Regional Office for the Western Pacific, Manila 1986.

WPR/PTC/3/88.2 page2 Annex l

A revised Common Framework was then prepared to assist Member States in collecting and analysing relevant information for monitoring further progress in the implementation of their national strategies for health for all. Countries or areas were requested to submit their monitoring reports to the Regional Director for eventual incorporation in a regional report. Monitoring reports have been received from twenty-three 1 of the thirty-five countries or areas in the Region. Health for all is the basis for national health development in all countries or areas in the Region. In the management of their healthfor-all strategies, countries or areas have already established routine monitoring and evaluation processes. Consequently, the aim of the current national monitoring activity is to report to WHO on the progress being made in implementing their national health-for-all strategies. The country or area reports consist of information that is being systematically collected and analysed to support national health development efforts. The present report is a summary of the monitoring of the activities that are currently being conducted in countries or areas of the Region. It will also highlight two important themes: (1) new initiatives or activities that have been started since the 1985 evaluation to promote and achieve health-for-all goals; and (2) the processes which are being used to plan, implement and evaluate the health-for-all strategies. The following sections give a regional synthesis of findings from the national reports on monitoring of health-for-all strategies.

1As of 11 July 1988.

WPR/PTC/3/88.2 page3

Annexl CHAPTER 1. THE MONITORING PROCESS The health-for-all movement has had, among many other positive outcomes, a significant impact on improving the managerial process of most countries and areas. This is demonstrated by the amount of effort that is now going into monitoring and evaluation. All countries and areas report that they have an active national health-for-all monitoring process at the central level. At lower levels of the health system, a monitoring process is less regularly found, but a few countries report widening use of monitoring to support management. Most countries and areas indicated that their monitoring process involves gathering the traditional type of health service information on morbidity and mortality. This information is then used to update the global and regional indicators that have been selected for monitoring the progress of health-for-all strategies. A few countries referred to difficulties they had in obtaining data for specific global indicators. Global indicator 2, for example, on mechanisms for involving people, was not routinely reported and was difficult to quantify, as was global indicator 5 on equitable distribution of resources. Several countries did not have data on the weight-for-age portion of global indicator 8. Particularly for very small countries and areas, such as Tokelau and American Samoa, global indicator 10 on life expectancy was unavailable or of questionable accuracy. Some countries, both small and large, did not have routine data for global indicator 11 on literacy. Some countries continue to struggle with major problems of accuracy and completeness of reporting, but frequently, it is the analysis of data that is observed to require improvement. Even when these obstacles are overcome, it is often necessary to orient managers towards making better use of available information for monitoring. A minority of the reports described significant advances in the management of information systems which are clearly directed at monitoring important health-for-all issues. For example, measures have been employed to follow the effects of changes in health financing, or of resource allocations or special programmes aimed at disadvantaged groups. Selected information on specific areas of the country may show where special attention to improvements is needed. Regardless of the variations in stages of development in these health information systems, there is much evidence of active efforts to overcome deficiencies. The Department of Health in the Philippines has embarked on a sustained effort to improve the quality and timeliness of data through a major revision of its health information system, as well as increased input from surveys and surveillance activities. Viet Nam, since 1985, has improved statistical forms through considering what is most needed for primary health care indicators and has organized training every year to support the health information system. Fiji, likewise, has increased its training efforts in this field. Solomon Islands has established a statistical unit in the Ministry of Health. Kiribati has instituted regular feedback of information to field staff, which has motivated more regular reporting. In Australia, there has been considerable progress in developing information support for health for all since the establishment in 1985 of the Australian Institute of Health,

WPR/PTC/3/88.2 page4 Annex 1

In summary, problems encountered previously in monitoring and evaluation have stimulated strengthening of the health information systems of many countries and areas. This, in turn, has resulted in improved capability for monitoring progress towards health for all.

WPR/PTC/3/88.2 pageS

Annex 1 CHAPTER 2. HEALTH POLICIES AND STRATEGIES The 1985 evaluation report provides a point of reference with which the present results of monitoring can be compared. That report indicated that the specific content of a country or area's health-for-all policy and strategy was influenced by its political, cultural and, most importantly, its socioeconomic situation. All countries and areas of the Region had formally endorsed the health-for-all goal, but the impact of the endorsement varied from country to country. A number of features common to the policies and strategies of several countries reflecting the influence of healthforall values are apparent. Reports now more frequently emphasize critical areas such as management, legislation, community involvement, intersectoral collaboration, development of human resources and research. In general, the health-for-all vision appears to be becoming much sharper. More of the new policies and strategies are firmly based on the principles of primary health care rather than those of traditional basic health services. In some cases, the vision is quite explicit, as in policy statements concerning equity of care and providing services specifically for those who are underserved or at high risk. Equity was already a major policy consideration throughout the Region, and has received added attention. Examples are an Australian policy to ensure that programmes are responsive to the needs of groups with special health requirements, and the increased priority in Cook Islands for support to underserved outer islands. New policy formation is tending to deal with multisectoral areas, such as food and nutrition and environmental improvements, rather than being restricted to traditional health programmes. An example is Vanuatu's 1986 approval of a national policy on food and nutrition. Another is the recognition in both Samoa and the Republic of Korea of the need to form an intersectoral national council for health, bringing together different departments which have significant training on the health of the people. In mo~t of the countries and areas, intersectoral cooperation had been highlighted previously, bttt now the strategies related to it have become more specific and detailed. The fruit of experience; is seen, for example, in descriptions of the types of health sector leadership needed at all levels, br of the give and take of different sectors cooperating to support each others' programmes. For example, health authorities in the Philippines have initiated multisectoral consultative workshops in all regions of the country. Some countries and areas have not developed any new policy or strategy initiatives, but report no problems in these areas. On the other hand, those who express major concerns about strategy formulation have also indicated realistic measures for overcoming problems. They call for wider involvement throughout the managerial process, from the initial planning to the evaluation phase of any given activity. Many also indicate training measures for overcoming problems in the managerial process, though training here is seen as facilitating managerial development rather than transferring traditional academic knowledge. In summary, the trend strongly suggests that health for all is a real vision for the countries and areas of the Region. The definition of health policies and strategies based on the principles of health for all has become much clearer.

WPR/PTC/3/88.2 page6

Annex 1 CHAPTER 3. DEVELOPMENT OF HEALTH SYSTEMS 1. Organization of health systems based on primary health care

For monitoring purposes, the process of organizing a health system based on primary health care may be described as consisting of two aspects. One is upgrading the system. This may involve increasing population coverage or providing more types of activities and services, or making improvements in quality. The other aspect is the reorientation of the system, which may involve changing relationships within the system, as well as the attitudes and approaches of the people involved. In general, the population coverage with health services has improved. Global indicator 7 attempts to measure population coverage with some of the elements of primary health care. For the measure based on treatment of common diseases and injuries, including the supply of 20 essential drugs, 13 countries and areas reported 100% coverage. (This is 2 more than in the 1985 evaluation.) Only 6 reported that this care was available to less than 90% of the population, and only 2 that it was available to less than 80%. Similarly, attendance by trained personnel was reported for 90% or more of pregnant women in 20 countries and areas, and only 4 countries reported lower coverage. Activities leading to these increases in primary health care coverage were described in more detail by several countries. In Vanuatu, for example, more aid posts, now totalling 104, had been set up in isolated communities. In the Republic of Korea, the building up of the rural system, begun in 1981, had continued, and a start was made in 1987 in providing health stations in needy urban districts. The Philippines is increasing the intensity of coverage through acceleration of five impact programmes. These are: (1) comprehensive maternal and child health, including immunization, nutrition, breastfeeding advocacy, family planning and dental health; (2) tuberculosis control; (3) malaria control; ( 4) schistosomiasis control; and ( 5) control of diarrhoeal diseases. In a small minority of countries, there was still a long way to go before reaching full coverage. For example, in the Lao People's Democratic Republic, the expanded programme on immunization had reached about one-third of the population, safe water 42% and sanitary facilities 11%. In most of the countries and areas, water and sanitation coverage was closer to targeted levels, but had not changed greatly since the 1985 report. Now, however, more detailed information was supplied. For example, more than twice as many countries provided a breakdown between urban and rural coverage with water and sanitation. New services have been introduced into the health systems of the Region. Such new specific health programmes are exemplified by Hong Kong's development of occupational health services and expanded community nursing and psychiatric nursing services. Singapore has developed plans for community hospitals located close to the people, to cater for patients not requiring the sophisticated high technology care of the existing general hospitals. Australia, Singapore and other countries have also introduced measures for control of acquired immunodeficiency syndrome (AIDS), with emphasis on preventing its transmission by means of educating the public. New Zealand reports pilot programmes, such as women's health centres, union health centres, independent nurse practitioners and a cervical cancer screening project. Cook Islands formed a Health Education Unit in 1985/1986, and many other countries and areas have expanded their health education activities.

WPR/PTC/3/88.2 page7

Annex 1 Improvements in quality are recorded in health facilities in Tuvalu, where new dispensaries were built for all outer islands. In Singapore, old, inefficient dispensaries are being replaced by new polyclinics with improved equipment and laboratory services. To ensure better services, Malaysia has develped a quality assurance programme. The other aspect to consider is the reorientation of the health system. Reorientation of relationships within the health system may involve decentralization, with or without formal reorganization, and may also involve improved coordination within the sector and improvements in referral systems. In the 1985 evaluation, it was mentioned that a number of countries were initiating actions to strengthen the district level of the health system. The present reports reinforce this trend in various ways. It may be relatively informal, as with increased delegation of responsibility in Kiribati, introduction of training for teamwork among health officials at township level in the Republic of Korea, or beginning work towards the integration of vertical programmes at intermediate levels in Viet Nam. In Malaysia, where there is already a certain amount of decentralization to state and district levels, efforts to increase managerial expertise have begun. This has involved district-level team training with intersectoral participation. The Lao People's Democratic Republic is redefining services and staffing at district, commune and village levels in order to build a health system based on primary health care. A more formal reorganization has been going on in New Zealand since 1984, following legislation facilitating the voluntary establishment of area health boards, to assume devolved and unified responsibility for regional health activity. Subsequently, the Department of Health itself has started major restructuring to make the head office more flexible in response to changing needs and more supportive of the primary health care approach. In Hong Kong, a contrasting structural response has been decided upon, with plans to create a Hospital Authority. Decentralization is also making an impact on coordination within the health sector. Most of the reports indicate improved coordination. American Samoa has introduced medical staff rotation to promote coordination between hospital and health centres. The Commonwealth of the Northern Mariana Islands notes improved coordination following the creation of a Department of Primary Care unifying outpatient, public health, school, village and home health-care services. Papua New Guinea reports that use of the National Health Plan at provincial level has greatly improved coordination. Nevertheless, there is still room for improvement in coordination, even within government health services, as mentioned, for example, by the Federated States of Micronesia. More difficult intrasectoral coordination problems may occur where there is a large component of private practitioners or voluntary agencies. New Zealand reports fragmentation of services which cause problems within and between primary and secondary health-care levels. The fragmentation is related to the multiplicity of funding arrangements and professional groups. It may be hard to make referral systems function well, particularly where there are problems, such as fragmentation in the health system. Because of the importance of referral as a back-up to primary health care, the rponitoring format included a question about the adequacy of referral systems. However, only limited data were provided in the reports on this subject. Tonga recognized the need for attention to establishing an efficient referral system. Papua New Guinea noted an increasing tendency of communities to by-pass the lowest level of service provision. Several of the reports indicated that referral systems were satisfactory, though smaller countries and areas, such as the Northern Mariana Islands, observed that they must make constant efforts to contain the costs of overseas referrals.

WPR/PTC/3/88.2 pageS Annex l To make the many changes needed for building a health system on the basis of primary health care, health workers require extensive reorientation. A number of countries, including the Federated States of Micronesia, Malaysia, Samoa, Tonga and Vanuatu, indicated that reorientation of their health staff was a key step in removing the barriers to progress towards health for all. Viet Nam reports that it is reorienting training for primary health care programmes (at commune, "intercommunal polyclinic" and district levels) from a hospital-based to a community-based approach. In other countries as well, a great deal of energy is being devoted to a variety of measures, such as reorientation courses for doctors and nurses, curriculum reviews, management workshops, meetings of health workers at all levels, and conferences. ·Encouraging results have been reported, such as the strong support for primary health care of organized nursing in New Zealand and the general good understanding and acceptance of primary health care in Hong Kong and New Caledonia.

2.

Intersectoral collaboration

It is recognized that there is a close relationship between health and overall socioeconomic development. This idea is an essential part of the health-for-all goal, and it is generally recognized that an important aspect of any health-for-all strategy is its approach to intersectoral collaboration. In the 1985 evaluation, health authorities generally reported a weak development of intersectoral linkages. Now in 1988, there are major advances. The monitoring reports all include extensive discussions on this topic, which reflect widespread recognition of the importance of improved intersectoral collaboration. The attention given to this is encouraging, although it is not yet clear what its impact will be. The discussion on intersectoral collaboration can be broken into three parts: (1) the particular level at which collaboration occurs; (2) the content and purpose of collaboration; and (3) the process of improving collaboration. The reports indicate intersectoral collaboration being attempted at all levels, but mainly at the community and the central levels. At the community level, there may be village development committees, as in Malaysia, Papua New Guinea and elsewhere. There may also be bodies with more specific purposes, such as the village water committees in Tonga. Churches, local officials and informal channels are also seen to be involved in intersectoral action. The intermediate level is mentioned less often in the monitoring reports. It may nevertheless offer a key area for action, as in the case of Malaysia's district development committees, Papua New Guinea's provincial management teams and rural development planning bodies and New Zealand's area health boards. These are examples where decentralization and intersectoral coordination have effectively reinforced each other. Each country or area also reports specific committees or bodies at the central level which are important avenues for intersectoral collaboration. Mention was made of developmental planning, environmental, nutritional and various other interministerial bodies, as well as ad hoc committees, special purpose boards, etc. High level legislative and executive organs may be important official channels where coordination can have a major impact on health, although such

WPR/PTC/3/88.2 page9

Annex 1 action is mentioned by only a few countries. Serious intersectoral involvement may lead to extensive informal and formal links, as described by New Zealand. Some smaller countries tend to use informal channels predominantly. The content of intersectoral collaboration most often concerns education, nutrition, water and sanitation and support to the health services themselves. However, many other areas are cited in some of the reports, such as road safety, housing, food safety, safer use of pesticides and other chemicals, avoidance of the adverse effects of development schemes, workers' health, programmes for handicapped children or the elderly, drug and alcohol programmes and anti-smoking actions. Most countries and areas believed that such collaboration had yielded benefits by preventing negative effects on health. New Zealand, for example, has encouraged the safe disposal of toxic chemicals by means of communication between health officials, the agencies and the special interest groups involved. Malaysian health authorities have stimulated the Agricultural Department to educate farmers about eliminating pesticide residues on food. Collaboration has also minimized duplication and poor coordination of services in areas where several agencies were involved. Major positive contributions to health were less often cited. They appear to be more likely to occur in countries or areas where national policy is explicitly holistic in its approach to development, such as Hong Kong, Kiribati and New Zealand. To improve intersectoral coordination, the health sector has to display leadership to inspire other sectors to make contributions to health. Likewise, it has to contribute to the interests of the other sectors. Health officials of Malaysia and Tonga report having devoted themselves to the latter approach by helping in the health-related training of workers in ministries and agencies. Sometimes, as in certain provinces of Papua New Guinea, it has been the health workers' enthusiasm that has stimulated broader socioeconomic development. Other approaches mentioned were to increase the communication of ideas and policies and to promote the goals of health more actively. American Samoa indicated that it was important to promote the health-for-all strategy at the highest level of government. Papua New Guinea also stressed the need for political will in order to sustain the overall coordinated development which has a large potential to improve health. 3. Community involvement

The 1985 evaluation report analysed community involvement in terms of how the health system defined the role of the community. The distinction was made between a role in which the community gave support to services that were directed by the health system, and one in which the community had major responsibility. In the present reports, this distinction is still apparent, but it also appears that in many countries and areas, both types of role belong to the community, as well as intermediate functions in which the community may contribute to decision-making without assuming full responsibility. Communities in Papua New Guinea, for example, vary from displaying dependent attitudes to participating in the management of health services. The overall impression is that the extent and variety of community involvement is growing, chiefly in proportion to the effort that health and other governmental agencies put into it. That effort is increasing in most countries and areas, and Malaysia has reached the point of establishing posts entitled Assistant District Officer, Community Development. Singapore plans to involve the community in the management of the

WPRJPTC/3/88.2 page 10

Annex l new community hospitals. New Zealand has introduced grants for community self-help projects concerning health. Health committees representing communities have been introduced by legislation in Cook Islands. In Fiji, communities have intensified their own fund-raising efforts for health projects, and in Samoa, construction of three health sub-centres was financed by villagers. This was one of many instances in Samoa in which great reliance is placed on community participation to support the implementation of health programmes. To increase community understanding of health problems and what can be done about them, most countries and areas are expanding their health education efforts. In most cases, conventional approaches are being used, but there is increasing recognition of the need to use a combination of approaches linking mass media with person-to-person communication. Cook Islands used surveys to help develop its health education. Vigorous health promotion campaigns have been launched in Hong Kong and New Zealand. In a minority of cases, there have been some problems of coordination, as separate health education efforts are made for different health programmes. Coordination can also require attention with regard to the contributions of nongovernmental organizations to health, though in most countries and areas, these contributions are welcomed with enthusiasm and are increasingly beneficial. The frequent involvement of women's organizations is noteworthy, along with a wide variety of religious, philanthropic and other groups. The latter include societies dealing with specific diseases such as leprosy, cancer and heart disease. In the Philippines, research was done on the factors which facilitate or obstruct linkage between the work of nongovernmental organizations and that of the Government in order to systematize improved mutual cooperation. Broad efforts are being made to overcome the factors seen to be working against community involvement. These factors are not new; they include the community's belief that government is responsible for its health, the lack of leadership and organization, and the pressure of poverty, which leads to preoccupation with income before health. Most countries and areas remain convinced that progress can be made in overcoming these constraints by continuing their efforts to involve communities, by improving the training of staff in community development and by bringing social and economic development together into one coherent process.

4.

Managerial process

Many countries report specific interventions to improve management rather than general statements on the need for this. There is also a trend towards developing a comprehensive management system rather than tackling single aspects of management, such as information or evaluation, as isolated problems. Several countries, for example the Northern Mariana Islands and Papua New Guinea, have defined priority areas for immediate attention on the basis of national plans and assessments of current capabilities. Specific issues and recent developments in management were reported in the areas of intersectoral involvement, the participation of all levels of management in the decision-making process and decentralization. Strategic planning was mentioned by several countries. All of these are positive signs that countries and areas are now more aware of the need to improve management as part of the development of their health systems.

WPR/PTC/3/88.2 page 11 Annex l

The types of intervention being used to strengthen the managerial process are varied, but in most cases, they focus on broad management issues. An example is training, within which, however, specific purposes are identified, such as clarifying roles and responsibilities. Another intervention to improve management reported by some countries is the introduction of special mechanisms such as health systems research or quality assurance. A number of countries also mention the need for reorganizing and restructuring to enhance the management of their system. The Philippines reports decentralization of planning and budget responsibility and the strengthening of monitoring mechanisms at all levels. Malaysia and Tonga report using methods to make planning more participatory. They involve more people in the planning process at a given level of the health system, as well as the participation of other levels and of other sectors. Other organizational features for improvement reported include establishing criteria for assessing the appropriateness of new technology, using the legislative process and strengthening overall supervision of the health system. Finally, the Lao People's Democratic Republic, which did not have a formal planning activity before, is in the process of developing one. 5.

Health manpower

Human resource development in most countries or areas was indicated to be in harmony with the overall development of the health system. The vast majority of ongoing or new human resource development activities reflect responses to system changes. These activities mainly concern training, but are highly focused, and consist of specific types of activity, such as strengthening local in-service training (both formal and informal) as reported by Malaysia and Tonga, strengthening formal training institutions reported by VietNam, scheduling retraining courses and providing for management skill development and supervision. All these activities reflect a positive response on the part of manpower planners to the changes that are occurring in the health system. Other activities dealing with deployment of health personnel also reflect response to changing patterns of health care provision. Specific efforts to improve personnel coverage of rural and remote areas were mentioned by most countries. Improved and more relevant training, as well as allocation of staff, was highlighted in many reports. Constraints and problems reported by countries ranged from general statements on lack of manpower to specific issues, such as the lack of appropriate educational background for entry into educational institutions abroad. Some smaller countries reported that time taken for training significantly depletes currently available manpower, and Samoa cited emigration of qualified manpower as a serious constraint to health personnel planning. Several countries reported difficulties in coordination between the education and health sectors. The Republic of Korea reported an insufficient change of emphasis in training from curative to preventive, and Fiji reported problems in providing incentives to work in remote areas as obstacles to appropriate manpower development. These are all very positive signs that the human resource component is playing a strong role in the overall health system development.

WPRIPTC/3/88.2 page 12

Annex l 6. Research and technology

The need to establish specific mechanisms to formulate policy and to review activities related to research and technology was reported by many countries and areas. Countries which have such mechanisms report the need to strengthen them and improve coordination with the various agencies involved. Most countries report that it is the responsibility of existing planning oommittees or statutory bodies to review technology for its appropriateness to support health policy. In some cases, like New Zealand, ad hoc committees were formed to advise the Ministry on the appropriateness of new technologies. Otherwise, it often remains in the domain of individuals or institutions directly involved in the use of the proposed technology to advise on those matters. The situation was reported to be similar in the area of health and medical research. However, it differs in the case of most industrialized countries and Malaysia, where special bodies have been established to review health and medical research needs. These bodies may also have responsibility for allocating some of the funds that are available for research. It is apparent that in those countries where formal research coordination bodies are established, priorities for research are changing from the traditional medical areas to issues of health and development, and include community and behavioural studies. However, most countries, developed and developing alike, continue to report that there is a shortage of expertise in this field.

7.

Resource utilization and mobilization

As noted in the 1985 evaluation report, all countries and areas indicate that management continues to devote a significant amount of time and energy to the issue of resources, that is, of how to finance the health sector. Responses are usually some combination of three main approaches: (1) mobilization of additional resources; (2) equitable distribution of resources; and (3) the most effective and efficient utilization possible of resources.

The subject of mobilizing additional resources was the least addressed in the current set of responses. Community resources, such as labour, were mentioned in the Cook Islands report, and experience with cost-sharing was reported by the Philippines, Samoa and Viet Nam. The Republic of Korea is implementing nationwide community medical insurance, and several other countries indicated further development of existing health insurance schemes. On the issue of improving decision-making on the allocation of resources to ensure equitable distribution, two major constraints were identified by several countries: (1) current decision-making procedures do not adequately link allocation decisions with requirements; and (2) available information on equity based on needs is lacking in most countries. However, a few countries reported new initiatives in this area; for example, Kiribati indicates that the number of peripheral staff had been increased; Malaysia indicates that priority for allocation and posting of staff is given to remote areas; in New Zealand, there is a mechanism to review all new programmes with criteria related to primary health care policies; and in the Republic of Korea there is a legal restriction on further extension of services in urban areas considered to be overserved with health facilities.

WPRJPTC/3/88.2 page 13

Annexl Almost all countries reported new initiatives in the area of attempting to use their existing resources more effectively. The response from a number of countries indicated that explicit procedures are now in place for routine financial monitoring and review of implementation. Other countries reported that information systems and management training are being used to make the utilization of limited resources more effective. Reports from Hong Kong and Viet Nam indicated that efforts at restructuring and reorganization were taking place to improve the effective use of resources. Papua New Guinea and the Philippines report decentralization as a specific measure to improve the effective use of resources. Percentage of gross national product spent on health and percentage of health expenditure devoted to primary health care showed almost no difference from the 1985 evaluation report. The majority of countries or areas indicate that no specific resource mobilization and utilization plans have been prepared, but they also indicate that financial planning has a high priority as a routine component of all national and operational planning functions. Many countries report financial and development planning using a combined approach.

WPR/PTC/3/88.2 page 14 Annex 1 CHAPTER 4. INTERNATIONAL ACTION

1.

International transfer of resources

Information on this subject from the monitoring reports is quite scant. Obviously, many countries rely heavily on international resources, but most countries reported limited concerns in this area. Very few countries or areas report that specific plans are made to highlight their need for external support, and they do not report that this information is expected to be available through their routine planning and budgeting mechanisms. Papua New Guinea reports inclusion of priorities for external assistance in the National Health Plan. Reporting on sources of external assistance reveals a wide variety of situations, ranging from the predominance of a single bilateral donor or associated government to the strong presence of multilateral organizations. A significant increase in the number of volunteers was also mentioned. The question on how much external assistance was required and how much was actually provided was generally not answered in numerical terms, although major programme areas requiring further input were identified by some countries, and the Philippines reported lack of adequate support to projects involving the overall development of economically depressed areas.

2.

Intercountry cooperation

The monitoring reports indicate that much remains to be done in the area of technical cooperation among countries. The traditional types of activity most frequently reported include training, assessing programmes and providing information. The medium for exchanges most frequently noted continues to be interpersonal, either through meetings and conferences, or through consultants and visiting fellows. There is some increase in the exchange of technical expertise between countries, particularly in areas of training and technical programme review and assessment. There are fewer negative responses in the area of constraints to technical cooperation among countries, most of which can be categorized as financial. On the positive side, there were several expressions of willingness to further explore intercountry cooperative approaches. This was particularly noted by a few countries in relation to arrangements they have with neighbouring countries, for example, Lao People's Democratic Republic and other Indo-Chinese countries, Fiji and Tonga and several of their neighbours.

WPR/PTC/3/88.2 page 15

Annex 1 3. International cooperation (including WHO)

The responses from countries or areas on international cooperation were almost exclusively related to WHO. The comments on relations with WHO in all cases were quite positive. All countries or areas indicated that cooperation with WHO involved one or more of the following: consultants, training and financial support. Few countries mentioned that cooperation also involved information. Almost all countries and areas responded to the issue of how to improve the efficiency of their cooperation with WHO. A number of countries indicated that improvements were made or could be made through better monitoring, periodic reviews, improved communication, regular meetings, and placement of intercountry staff. Others gave general management responses in addition to improved planning and using more qualified managers to review their programmes with WHO.

WPR/PTC/3/88.2 page 16 Annex 1

CHAPTERS.HEALTHSTATUS Population-based indicators of health status are not usually used for programme monitoring but rather for evaluating the effectiveness or impact of programmes. Reference has been made earlier in this report to the continuing problems associated with the countries' ability to obtain these data in an accurate and reliable form. Although these limitations should be borne in mind, it is useful to review selected indicators for monitoring purposes in the Region. The population of the Region has remained relatively stable, and annual rates of growth range from 0.4% to 4.5%. All those with a population growth of more than 2.6% are the smaller island countries or areas. Demographic change will not be reviewed in this document, and indicators for analysis have been selected mainly on the basis of their relation to the health of mothers and children. The infant mortality rates reported in the Region continue to be lower than the global target of 50 per 1000 live births in all but three countries. In eleven countries and areas, this indicator is below 15 per 1000. The range of life expectancy at birth continues to show little change since the last reporting period, remaining at 45-72 for those reporting data. These two closely interrelated variables seem to be improving, with most of the countries well above the global target figures. Maternal mortality shows a very marked improvement over levels reported in the initial 1983 monitoring report. In 1983, maternal mortality rates ranged from 0 to 5 per 1000 live births, but now no country has a rate higher than 1.8 per 1000, which places all well below the regional target of 3 per 1000. Two factors affecting the viability and healthy growth of children in general have continued to show good progress in the Region. The proportion of children cared for up to at least one year of age by trained personnel has reached at least 70% in all reporting countries of the Region compared with a range of 40-98% reported during the 1983 monitoring. Birth weight continues to show some variation, but only six countries in the Region continue to report more than 10% of their newborns with a birth weight of less than 2500 grams. Recording and reporting with regard to children fully immunized against the target diseases of the expanded programme of immunization continue to present problems. Only five countries were able to report on this item in more than one monitoring/evaluation exercise. The percentage of children fully immunized for each of the target diseases, however, shows remarkable progress in coverage between 1982-1983 and 1986-1987. Overall regional coverage has improved since the first monitoring report as follows: 1982-1983 1986-1987

BCG DPT3 Poliomyelitis Measles

60% 40% 30% 10-15%

68% 61% 75% 60%

WPR/PTC/3/88.2 page 17

Annex 1

With regard to environmental health, the coverage of the population of the countries and areas of the Region with safe water and adequate sanitation facilities remains about the same, keeping pace with population growth. However, these data also reflect continuing disparity between services available in urban and rural areas, with most reporting countries indicating over 80% of the urban population covered but considerably lower coverage in rural areas. Ten tables, which include all data reported through the monitoring report, are attached as Appendix 1. They are based on the Revised Common Framework and supplemented by data available from other sources in the countries concerned.

WPR/PTC/3/88.2 page 18 Annex 1 CHAPTER 6. CONCLUSIONS Most countries and areas imply through their monitoring reports that they are generally satisfied with the progress of their activities in implementing health-for-all strategies. This regional synthesis highlights a few new features of health-for-all activities and suggests what they may mean for the overall health-for-all movement. Firstly, it may be noted from the 1985 evaluation report that a substantive part of the conclusion at that time was the increased awareness on the part of health leadership that fundamental changes were required if health-for-all values were to have any real impact on the quality of life of the people. The regional strategy for health for all indicates that the starting point for these changes is the recognition that health for all implies an equal partnership between those who are conventionally referred to as the health providers, the other sectors of society, and the community. It is clear from this monitoring that the situation has progressed from awareness building to the formulation of an action-oriented vision of health for all. This conclusion is based on the content of new policies which reflect this vision, on strategies to revitalize the health system, and on evident commitment to the principle of partnership as the basis for sharing accountability and responsibility for health. An additional and equally significant conclusion to be drawn from these observations, is that a viable leadership role in the health sector is emerging. The regional strategy indicates that the partnership concept requires changes in the traditional role of the health sector. These changes partly involve recognizing that the purpose of the health system is more than providing basic health services. They also involve playing a leading and facilitating rather than a purely directing role. This new role must be played not only within the health sector, but equally in relation to other sectors of society as well, in order to influence health system development.

The general aim of the health system development activities is to make health knowledge and resources more directly accessible to the community. From the 1985 evaluation, the process for achieving this goal was vaguely formulated around methods of decentralization and improving human capabilities, depending on the situation of the country concerned. The monitoring reports indicate a further elaboration of this positive direction. For example, in countries embarking on formal decentralization, the specific processes and structures to support the concept have been clearly specified by means of the district health system approach. For countries or areas where formal decentralization is not the overall concern, emphasis is being placed on increasing human capabilities. This may be done by expanding existing programmes or adding new ones, or by efforts to change the way existing staff perceive and carry out their respective roles. The effort to improve intersectoral collaboration appears from the monitoring reports to have been extensive, but most countries and areas indicate that there is still a great need in this area. Most countries and areas report the increased use of specific mechanisms, namely formal and informal bodies and agencies, to promote intersectoral collaboration on health matters. However, the perennial constraints of differing opinions between sectors as to the definition of roles and responsibilities, and excessively bureaucratic procedures for sharing information and decision-making, persist. The positive results in this area, however, reflect stronger leadership in the health system, which is attempting to overcome these constraints.

WPR/PTC/3/88.2 page 19

Annex 1

The monitoring reports clearly indicate the continued priority that countries or areas give to strengthening the support mechanisms that are necessary to obtain the desired results from their health-for-all policies and strategies. These mechanisms concern the managerial process, human resource development and financing. The trend of strengthening the managerial process highlighted in the 1985 evaluation report is clearly reinforced in the monitoring reports. The trend is towards managing information and resources in a comprehensive fashion. There is an increasing recognition that as health-for-all strategies evolve, commensurate changes must take place in the managerial process to support them. A similar positive trend is observed in the area of human resource planning and development. Countries and areas recognize that with the increasing rate of change occurring in society in general, and particularly in the health sector, the health system has a responsibility to support individual staff in responding effectively to these changes. Consequently, training programmes now include sessions on decision-making, team work and communication, along with the conventional themes of improving technical skills. Rising costs and diminishing financial resources continue to preoccupy most managers, but the mobilization of additional resources appears to be the least developed of the strategies for resolving this concern. On the other hand, positive results are being achieved in improving allocation decisions. Even for allocation decisions, however, significant difficulties still exist in linking them with appropriate requirements and in obtaining valid information on what and where the real needs are. In summary, the monitoring reports show positive results that national health-for-all strategies are clearly evolving along the lines originally envisaged in the regional health-for-all strategy and are being implemented more effectively. The salient features of this process include an emerging health leadership that is able to translate the health-for-all concept into an appropriate vision for the country concerned and facilitate its implementation on the basis of the primary health care approach. This process is far from complete or efficient, as the details for developing and reorienting a health system based on primary health care are extremely complex and elusive. However, an overall framework for handling this complexity, in the form of a partnership with communities, is also evolving as a strategy to manage this situation more effectively. It is in this arena of information, knowledge and resource sharing - both nationally and internationally - that the health sector faces its next major challenge.

WPR/PTC/3/88.2 page 20

TABLE 1:

SELECTED DEMOGRAPHIC AND SOCIAL INDICATORS

-------------------------------------------------------------------------------------------------------------------------------------------------------Population :-------------------------------------------: Rate of Adult literacy rate Bi t·th natut·a 1 :-------------------------------: Death Countt·y/An;a Year

Total <In 'OOOsl :37 1601:::: 226 1045:320 17 750 179 122 561:3

R,_wa 1

:=====================================================================================================================================================: lAMERICAN SAMOA I AUSTRALIA

c,:>

rate <0/00)

t·ate

i net· ease

Total

: Female (i;)

(1)/00)

c':>

c,:>

:Brunei Darussalam

lChina, People's Repllblic of lCOOf< ISLANDS lFLII lFt·ench F'olynesia :GtJam

:HONG KONC'i !.Japan

19:0::7 1':l::::6 19::::6 19:36 19BE. 19::::7 19eE. 1'?86 19::::7 19:36 19:35

40.9 2:3.1

:36.7 29.7

2.9 10.5 2.9

54.:3

49_:::: :36.3

4.0 :3.:3

lKIRIE:ATI :LAO PEOPLE'S DEMOCRATIC REP_ :Macao :M.ALAYSIA : NatH·u

:NEW CALEDONIA lNEW ZEALAND :Niue

:PAPUA NEW 13UINEA :PHILIPPINES :REPUBLIC OF KO~:EA :SAMOA :SINGAPORE :SOLOMON ISLANDS :TOKELAU :TONGA : COMM_ OF NORTHE~:N MARIANAS :Republic of Marshal I Islands lFED. STATES OF MICRONESIA : Repub 1 i c of Be 1all I TUVALU :VANUATU lVIET NAM, SOCIALIST REF'. OF :Wallis and Futuna

1':1:36 1986 19:36 19::::2 19::::6 19S6 1'1:36 1986 19:37 19f:E. 19:36 1986 1986

121672 6:3 :36'.3:3 417 16109 7

JB.O :34.:3 22.6 21.5 ::;:;::_ '?

0.:3 :3.0 ::::- :3 10.3 5.8 :3.0

43.2 25.0

14.6 40.6 6:3.4 70. 1 :30.0 61.0 60.5 6.0 2:3.0 66.5 :35.0 0.0 65.0

4LE. 15.2

4.7 7.2 3.2

:30.4 17_e 24.0 29.:::: :30.6 27.1 12.5

6.6 5.6 5.6

0.79 2.74 L 12 1. 40 2.40 2.50 2. 10

:::::3_ 0 80.:3

:32. 0

7'1.0 a/

90.0 :34.0 a/

85.0

74_0 a/

5.4 :3.7 4_ :3

11.4 37.5

E._ 2 13.9

0.76 0.52 2.40 2. ·~o

6.0 :3.:3

:37.:3 36.2

46.1 17.9 :31.7 19.:3

17- 1 3.2 5.0 4.5 5.8

1.50 2.E.7 1. 50

96.4 96.4 96.5 :::o_ 2 8:3.4 96.2 99.7b: 99.:3 '19.5 95.0 :35.0 90. 1 92.6 :::5_9 72.0 J-88;R-76 lU-74;R-59J

14:::: :3:307 :3 :3419 57:356 41865 159 2586

25.0 4:3.0 41.5 :39.7

6.2 10.5 6.0

41.5 :32.0

26.2 15.:::

19B6 19:36 1987 19:35

2 '17

4B.1 2:3.9 49.0 46.:3 :3'?- 1

:3.4 :3.4 4.:3 4.2 :3.0

78.0 ::::7-0 59.0 :36.0 70.'1 0.0 :3:3.4

29.2

:34.7 :31.:3 19.4 29.7 15.2 44_1)

8.4 7.8 12. 1 7.6 6_ 1 7- 1 5.0

:3.0 7.4 3.:3

68.2

:36 28

22.0 24.5 :37.9

11.0 7.0 :3.6 3.6

100.0 )70.0 0.80 2. 10 2.26 30.0 2.37 :38.0 1.:3:3 :96.0-97.0 1.60 1.0:3 :3.30 1. 50 99.0 0.90 2.93 95.0 50.0

2_ 09

79.9 79.0 77.5

39.7 JLS 45.5

19B6 19:36 1986 19:37 19B6 19:::7

94 14 ::: 145 64105 14

4.9 2.E. o;:)._l_ ._1

,-,c

c

BLO

27.5 27.6 42.8 29.5

4.5 9.3 LBO

)90.0 96.0

9.2 6.9

:3.20 2.10

----------------------------------------------------------------------------------------------------------------------------------------------------Names of countries in capita 1 1ettet·s t·efet· to those who have submitted a t·eport on Monitoring the Strategies for Health For All by the Year 2000, 1988. U - Urban; R - Rural Information not available a/ Tota 1 91/S4/:32 ) Male 90/8:3/81 Speak/Read/Write French Female 91/:35/8:3 b/ Percent of those who completed primary education

TABLE 2:

GOVEI<:NMENT E:,<PEND ITUPE ON HEALTH

Country /At·ea

F'er capita GNP (where noted, GDP) (US$)

Pet·centa9e of GNP <GDPl spent on health

of hea 1th e:x:pendi t...we devoted to pt·irnat·y health care

Percenta·~e

"0 "0 ~

>

"0 ()Q

Ill ~

'"C

~

:==================================================================================================================: : AMEI<:ICAN SAMOA : AUSTf?ALIA :Brunei Darussalam :China, F'eop le · s F;epo.~b 1 i o: of :COOK ISLANDS :FI.JI :French Polynesia :Giuaro :HONG KONG :.Japan :UPIBATI :LAO PEOPLE'S DEMOCRATIC REP. (19:35) (1986-:::7) (1986) (19:::5) (19:::7) ( 1986) (1'1:32) (19B6l (1986) (19:::4) (1985) o9::m (19:::2) (19:36) (1984) (19:36) (1986) (19B6 Apt·i 1) (19:::6) (1980) (1986) (19:::6) (1987) (1986) (est.) (1987) (1984) (1983) (1986) (19:::6) (19:::6) 1750a/ 12427b/ 12754 :300 9:30 DOO. 70 4700 9175 6945b/ 1046:3 :324.09 202 1500 1682 ( 19:37) (1985-:::6) (19:34) (1987) (1984-85) (198:3) (1986) (19:3:3) (1985) (1'1:34) (1986) (CiDPl 21.09/ 7.7 :::. 0 Appt"O>o:. (1985) (1986) ( 19:34) (1987) (1984) (198:3) (198:3-84) (1986) (19B5l (1985) (19B4l (1986) (1986) (198:3) (1987) (1987) (1985) (1988) (1988) (1986) (1986) (1986) (1982) (1987) <1987) ( 19:::6) (1986) (1985) (est.) 10.3 3:3. 6f I

-

::1 0.. !><"

N N

~

:-:;

w ~ N

(S

9.7 11.0 11.55d/: 4.32 65.0 41.4 16.9 11.27 40.0 50.0 12.0 24.4 20.6 20-25 55.0 4.2 10.0 2::::.o 10. 0

5_22e/: 10.0

5_(1 1_ 58

:Macao :MALAYSIA : Nat~rt.J

:NEW CALEDONIA :NEW ZEALAND :Niue :PAPUA NEW GUINEA :PHILIPPINES :REPUBLIC OF KOI':EA :SAMOA iSINGAPOPE :sOLOMON ISLANDS iTOf<ELAU :TONGA :COMM. OF NOPTHEPN MAPIANAS :Republic of Marshall Islands :Fed. States of Micronesia : l':ept~b 1 i c of Be 1at~ :TUVALU :VANUATU :VIET NAM, SOCIALIST PEP. OF : Wa 11 is and Futuna

5242 6:364.:39 6Hlb/ 5:::9.41 2296 (1987) (1987) (1987) (1988) (198:3) (1986) (1'1:36) (1986) (1987) (1987) (1986) (1987) <GDPl 7.0

3. 1 5.:3h/ (est.> 6.4

(est.)

298.97 7576 470b/ 1560

1 • .L. .-, Appro>:. 5_0 7.:3 (5.0 17.9 12.0 10.7 11.3

Appro>;. 50.0 85.0

500 2163

25.:3 20.0

DOle/ 1300 :334.20 114.E.6 104.46

LO Appro:oc 45.0 50.0

-----------------------------------------------------------------------------------------------------------------... Information not available a/ Mean pet· capita income <wa9es on 1y) b/ Pet· capita Gross Dornest i c Pt·oduct (l;;[lp) c/ Gross Island Product per head d/ Percenta9e of territorial bud9et e/ Medical care expenditure as a ratio of GNP f/ Percenta9e of total national expenditure 9/ Percenta9e of total 9overnment 9eneral fund expenditure for basic operations h/ Pet·centa9e of national budget

TABLE :3:

COVEF.:AGE OF POPULATION BY HEALTH CAF.:E

%of population covered by health car-e

% of infants receiving ro~tine care from trained health personnel

% of pregnant women attended by trained personnel during chi 1dbirth

~===============================================================================================================================~

:AMEF.:ICAN SAMOA : AUSTF.:AL I A :Bnmei DanJssa 1arn :China, People s F:epub ·i i c of :COOK ISLANDS :FI._II :French Polynesia

(19:::7) (19:::4) ( 19:::7) (19:::t:.) (19:::4) ( 198:3) ( 19:::7) (19:::4) (19:::5) (19:::4) (1986) (19:::1:0.) (1':1:::7) (1987) (1984) (1':t:::7) (19:36) (1987) (19:35) (19::::6) (1986) (19:::6) (19:::7) (19:37) (1':i86) (1984) (1987)

100- 0 96.0 U-99; R-90 99 9 :::o_ o 100.0 99.0 100_0 100.0 66.7 100.0 a/ 9:::_ 0 1(11)_(1 100.0 96_(1 101)_1) 100.0 100_0 :::o- 0 100.0 100.0 1 0(1_ 0 75.0 100- 0 :::o- 0 97_0 ( 1')::::6) (19:~:2)

( 19::'::4) (1987) (19:36) (1984) (19:::7) (19:::4)

100.0 U-100;R-99 :::9_ (I 100.0 91.52 100.0

(19:::7) (19:36) (19:::4)

96_1) 99.0 100.0

(1987) (19:::6) (1986)

98.0 100.0 90.5

JGuam : HOM.l KONG : ._Iapan : f<IF.:IE:ATI :LAO F'EOPLE 'S DEMOCF:AT I C REP_

(1987) U-99;R-98 (1986) 97_(1 (19:34) 100.0 (1985) 97.0 ( 1976-::::3) 99_5 99_(1 (198:3)

( 19:::7> U-100;R-99 (19:::6) 97.5 ( 19:34) 100.0 (19:::5) 99.9 (1976-87) 99.5 (1984) 100.0+:

:Macao :MALAYSIA :Naun< :NEW CALEDONIA :NEW ZEALAND :Niue :PAPUA NEW GUINEA :PHILIPPINES :REPUBLIC OF KOF.:EA :SAMOA : S I NGAPOF.:E :SOLOMON ISLANDS :TOKELAU :TONI::\A :COMM_ OF NOF.:THEF.:N MARIANAS : F.:epub ·: i c of Mat·sha 11 Islands :FED_ STATES OF MICRONESIA : F.:epub 1 i c of Bel au :TUVALU :VANUATU :VIET NAM, SOCIALIST F.:EP_ OF :wallis e-.nd Futuna

(1986) (19:::7) (19:::6) ( 19:::7) (19:::3) (1 ''187) ( 1'JE:E.) (19::::6) (19:::6) (19:::7)

U-100;R-90 U-95;F:-85 87.0 71.0

(1986) <19::m (19:::7) (1984) ( 19:::7) (1986) <19E:7) (1984) (19E:6) (19:36) (19:::6) (1987) (1987)

75_

(I

(19:36) (19:::6) (1987) <19E:7) (1984) (1987) (19:::6) (1986) (1987) (19::::4) (19:::6) (1986) (1986) (19:37) <19E:7l (19:36) (19::::6) (19:37)

100.0 :::6_ 7 U-100;F.:-95 100.0 100.0 31.0 95_(1 77.2 Appt-o>::. 95.0 99 - .-. C• 75_1) 100.0 93_(1 100.0 90.0 100.0 86.0 90.0 I

U-100;F.:-95 95.0 1(1(1_(1 E-4. 0 93.8 Appt·o;c 50.0 95.0 90.0 100.0 93_(1 100.0 :3o_

:::o_ o Appt·o;-::_ 50.0 75_1) 9(1_(1 60-:::o 100_(1

o

100.0 90.0

(19::::6) (1986) (1987)

100_1) 75.0 9:3.0

---------------------------------------------------------------------------------------------------------------------------------' ___ Infonr.ation not available· U - Urban; R - Rural a/ Peninsular Malaysia - 95%

-

TABLE 4:

SELECTED INDICATORS OF HEALTH STATUS

I. of newborns with Co1.1ntry I Area birthwei9ht of at least 2500 grams (1987) (1984) 0984) (1987) (1979) (1984) (1986) (1986) (1985) (1985) 0987) (1986) (1986) (1987) (1985) (!985) (1987) (!985) (1986) (1987) (1986) (1986) (1986) (1986) (1987) 0979-81)

1; of children with :wei9ht-for-age corresponding: to reference values

Infant marta l i ty W/OOl

~·ate

Life expectancy at birth (years)

'"0 '"0 (!I

>-

'"0 (1Q ~

(!I

:--------------------------------------------: Total Male 51. 7c/: 70.1 68.9

Female

:================================================================================================================================================================: :AMERICAN SAMOA :AUSTRALIA :Brunei Darussalam :China, People's Rep1.Jb l i c of :COOK ISLANDS :FLII :French Polynesia :Guam :HONG KONG :Japan

96.8 : 94.7d/: 90.0 U-97 .1); R-96.0 86.1 92.7 92.9

(1984) (1987)

:35.0 U-94.0;R-90.0

M-95.9;F-95.3 94.3 ·~3.4

:KIRIBATI :LAO PEOPLE'S DEMOCRATIC REP. :Macao :MALAYSIA :Nauru

86.8

95.5 91.2a 95.0

(1987) (1986) Wi86l (1985) (1986) (1986) (1984) (1986) 0987) (1986) (1985) (1985) (1986) (1986) (1982) (1985) (1982) (1987) (1987) (1986) (1986) (1986) (1986) (1986) (1986) (1987) (1985)

10.4 8.8

10.2 36.0 21.6 19.8 18.5

(1987) (1986) (1984) (1985) (1'~87)

$<" 0..

;::)

N

~

Q w

~ >-1

~ ::0 '"d

9.7 7.5 5.2 T-82; M-87; F-76 117.0 7.2 b/ 16.8 10.9 0.0 72.0 54.1 31.8 24.0 9.4 46.0 14.8 8.v ,, 19.0 33.0

(1976) Wi80-85l (1986) (1986) 0986) (1985) (1987) (1985) (1986) (1981-85) (1985)

72.8 70.1 67.0 64.0 60.7 65.5 69.5

72.3 53.0 45.0 71.5

74.1 75.2 50.6 44.6 68.5a:

79.1 72.7 71.0 70.0 63.9 67.8 75.6 79.6 80.9 54.6 47.5 73.7a: 71.4 76.8

~ N

:NEW CALEDONIA :NEW ZEALAND iNiue

(1'~87) :PAPUA NEW GUINEA (1987) 62.0 49.6 :PHILIPPINES (1987) (1985) 33.4 63.7 61.9 65.5 :REPUBLIC OF KOREA (1985) 64.9 71.3 :SAMOA (1987) 90.0 (1985) 92.0 63.0 65.0 :SINGAPORE (1986) 92.0 71.1 76.1 :SOLOMON ISLANDS 80.0 (1986) 60.0 :TOKELAU (est.) 91.0 (1986) 91.5 :TONGA (1986) 98.0 98.4 (1986) 63.0 :COMM. OF NORTHERN MARIANAS 92.0 (1987) 50.0 47.0 52.0 :Repub 1i c of Marsha 11 Islands 94.0 (1984) 65.7 :FED. STATES OF MICRONESIA :Rep,Jb l ic of Belau (1985) (1985) 18.0 60.0 :TUVALU (1986) U-96. 0; R-88. 0 (1'186) U-74.0;R(1986) T-56.3;U-30.3;R-26 (1986) 57.0 60.0 :VANUATU (1986) 95.0 (1986) M-63.5;F-73.8 (1986) 61.1 59.3 :VIET NAM, SOCIALIST REP. OF (1986) 82.9 (1':185) 53.1 (1986) (1982) 36.6 64.0 62.0 66.0 :Wallis and FutLma '' -----------------------------------------------------------------~----------------------------------------------------------------------------------------------:

94.3 96.5 75.0-79.0 84.6 95.7

(1987) Wl85l

95.0

68.0

97.0

64.9 71.0

Information not avai ]able T - Total; U - Urban; R - Rural T - Total; M- Male; F - Female a/Peninsular Malaysia only b/PeninsLllar Malaysia- 15.5 Sabah - 21.1 Sarawak - 10.2 c/Average age at death d/Excltldes information from Queensland and the Northern Territory

TABLE 5:

PERCENTAGE OF POPULATION WITH SAFE WATER IN THE HOME OR WITHIN 15 MINUTES' WALKING DISTANCE AND ADEOUATE SANITARY FACILITIES IN THE HOME Of<: IMMEDIATE VICINITY Safe water· Sllpply %population covered Sanitary facilities %population covered Total (19::::::) (19B6l (1 '):34) 7:3.0 90. 0 :::o- 0 100.0 99. 0+ 99 (I 6B. 0 42_ 0 100. 0 100.0 60. 0

-------------------------------------------------------------------------------------------------------------------' Countr-y I Ar-ea

:----------------------------------------:-----------------·-------------------------: Total Urban Ur-ban .-.C' 0

P1.-1ral

:=================================================~================================================================:

:AMERICAN SAMOA : AUSTF.:ALIA :Brunei Darussalam :China, People's Republic of :COOK ISLANDS : FLII :French Polynesia lGuam

<19:::::n 62.0 (19:::6) (est.l95.0 (19:34) 90.0 <19B7l (19B7l ( 19::::3) (19:::7) (19B7l <19B5l (19:::5) <19B7l (19:::6) <19B6l (1987) (19:::7) (l':l:::7) (19:::7) (1985) <19B7l (19:::6) <19B5l (19:36) (1986) (1987) (19:::5) (19:37) (19:::5) (1986) (19:::6) (19:37)

•:0·-'-

(est.l

90.0 :30.0 99.0 95.0

(19:37) (19S:3l (19:::7) 100. 0 (19:::7) 99.0 (19:3:3) 99. 0 (19:35) Appr·o:'c 63. (I (19:37) 11. 0 9:::_(1 (19S6l (Ll:::6) (19:::7) (19:::7) 70.0

:36.0

:HONGi KONG t.Japan

: Kif.UBATI :LAO PEOPLE'S DEMOCRATIC REP_ :Macao

:MALAYSIA : Nau~-u

100.0 100.0 76.:3

66.5

:NEW CALEDONIA :NEW ZEALAND :Niue

95_

(I

:PAPUA NEW GUINEA :PHILIPPINES : REPUBLIC OF KOREA :SAMOA :SINGAPORE :SOLOMON ISLANDS :TOKELAU : TONC'iA : COMM. OF NOF.:THERN MARIANAS :Republic of Marshall Islands :FED. STATES OF MICRONESIA :Republic of Belau :TUVALU :VANUATU :VIET NAM, SOCIALIST REP. OF : Wa 11 is and F1.-1hma Information not avai !able

10. 0 ::::3_ 0 90. Oa/ 99.0

:::o ~ 5

67.7

90.9 10 0- 0 100. 0 100.0 :31. 1 60. 0 61. 1 100. 0 66. 0 70.0 :39.0 :35.0

(19:::7) (10.0 (19:::7l (1 9:35) 1 0 0- 0 (19B7l Appro:":. 84.0 (19:36) 95.0 (19B5l (1':l:36) 100.0 (1986) 70-:3::: (19:37) (19:35) :36.5 (19:::7) 60.0 (19:35) E._ 1 (19:::6) 70.0 <19S6) (19:::6) 66.6

65_ ·~

90- 0

:::o_o

"0

"0 (n

> "0 Q:> (J!:l

......

::s 0. s:<•

>:a ~ Q (,;J

"'d ~

~

(n

a/90% of the population has drinking water avai ]able in the home or within 15 minutes' walkin9 distance_ However· applying str·ict WHO standards for safe drinking water, nowhere is drinking water "safe" in Samoa.

N. VtN

~

TABLE 6: PERCENTAGE OF CHILDREN FULLY IMMUNIZED AGAINST THE TARGET DISEASES OF THE EXPANDED PROGRAMME ON IMMUNIZATION (EPil Country/Area :AMERICAN SAMOA :AUSTRALIA :Brunei Darussalam :China, People's Republic of :COOK ISLANDS lFLll :French Polynesia :Guam lHONG KONG :Japan :KIRIBATI lLAO PEOPLE'S DEMOCRATIC REF'. :Macao

Year 1984 1986 1985 1987 1987 1984 1984-85 1987 1984 1985 1985 19:36 1986 1987 1986 1984 19:37 1987 1986 1987 1986 1987 1986 1986 1987 1984 1987 1984 1986 1986 1987 1982

All EPI diseases 90

Diphtheria/pertussis/tetanus : Measles

:Poliomyelitis : Tuberculosis :

"0 "0 (I)

>-

"0 C)

:===============================================================================================================================: 91.3 73.3 88.0 71.0 95a/: 97-99b/l 83.0 98.1 15.3 28.1 80.0 66.7 90 60.0 43.4 45.0 73.0 U-90; R-85 93.0 6:3.7 }90 75 fl

100.0 83.6 70.0 61.0 c/ 72.9d/ 3.0 33.2 88.0 50.2 60.0h/ 51.8 36.9 67.2 85.0e/ 63.7 96.0

91.1 83.9 81.0 73.0 86.0 98.4d/ 6.8 27.6 82.0 66.7 67.0 43.4 45.5 73.2 94.0 76.9 91.8

91.6 58.9

x·

c.

0

~ ~ :xl N 0\

0:0

84.0 96.0 97.0 84.6d/ 62.1 59.3 100.0 97.0

~ N

(5 w

:MALAYSIA :Nauru

lNEW CALEDONIA :NEW ZEALAND :Niue

lPAF'UA NEW GUINEA lF'HILIF'PINES :REPUBLIC OF KOREA :SAMOA :SINGAPORE :SOLOMON ISLANDS :TOKELAU :TONGA :COMM. OF NORTHERN MARIANAS :~:epub 1i c of Marsha 11 Is 1ands lFED. STATES OF MICRONESIA lRepLtb l ic of Be Jau :TUVALU :VANUATU lVIET NAM, SOCIALIST REP. OF :Wallis and Futuna Information not available U - Urban; R - Rural a/ b/ c/ d/

41.1 74.4 89.0 92.0 74.4 100.0

91.0 75.8 91.7

65 g/

73.0 67.1 59.6 72.1

65.0 61.9 47.9

73.0

66.7 64.0

92.0 92.4 67.9 100.0

-------------------------------------------------------------------------------------------------------------------------------

ExclLtding measles Diphtheria/pertussis/tetanus/measles Not applicable, only given after one year of age BCG- infants under 4 years old Polio III - infants between 3 and 48 months Measles - infants between 12 and 72 months e/ Proportion of children below the age of 2 years immllnized against measles

f/ For OPT III, Polio Ill, MMR: 48% (2 yrs. o1d) ; 96% (6 yrs. o1d) g/ For OPT !II, Polio III, MMR: 92% (2 yrs. oJd) ; 9'3% (6 yrs. oJd) hi 12-15 months

TABLE 7: :

EFFECTIVENESS OF IMMUNIZATION AS SHOWN BY REPORTED NUMBER OF CASES OF DISEASES NUMBEP OF CASES

--------------------------------------------------------------------------------------------------------------------------------Cotmtr-y I Area : Population : (' 000) :36 16100 226 1045:320 17

Year

:-------------------------------------------------------------------------: : Diphtheria :Pertussis : Tetanus • 0 : Measles

:Poliomyelitis :Tuberculosis: 0

:======================================================================================================·=========================: :AMERICAN SAMOA :AUSTRALIA :Brunei Darussalam :China, People's Republic of 19:::6 19:37 19:::6 19:36 1'01:36 19:::6 1'1:::6 1986 19:::7 19:36 1'0/:35 19:36 19:36 19:36 1986 19:::6 19:::6 1986 19:::6 19:37 1986 19:36 1986 19:36 19:::6 19:::6 19:::7 19:35

0

(I

0 0

6

:3:3 0

6

2

:COOK ISLANDS :FI.JI :French Polynesia :Guarn

72:3 179 122

7:::7 0 0 0 0 (I

::::3979 0 0

440 1'):::7:38 16 2 ·-:·

1116 212 21 199 94 (86c) 49 7269

1:::44 0 0 I)

7 0

4:3 6

0

:HONG KONG :.Japan

:KIF.:IBATI :LAO PEOPLE'S DEMOCRATIC REP_ :Macao

:MALAYSIA : Naurt~

561:3 121672 6:3 :36t:::: 417 16109 7

0

9 0

10:37 1:;:::::

:37 0 0 0 0 (I (I

62 10 4:3 (I

194 6:32:3 2015

0

22 (I

51a/: 0 I)

1:367 104 4697 1 950 7

18 (I (I

152 1514 420 9421 :::

:NEW CALEDONIA :NEW ZEALAND :Niue

:PAPUA NEW GUINEA :PHILIPPINES :REPUBLIC OF KOREA :SAMOA :SINGAPORE :SOLOMON ISLANDS :TOKELAU :TONGA :COMM_ OF NORTHERN MARIANAS :Republic of Marshall Islands

14:3 :3266 :3 :3419 57:356 41:::65 159 :::6 L

0 0

0

756 (I

24:::7 6060 1:::::: 0

·-' "'

76 1829 ·-=· (I

19024 5955:::

24 2:30 0 0 2

181::: 0

7596 1:39272 10:3699 1765 261 ·-:·

21::: 0 (I (I

0

0

0 (I

97 20 94 14 145 64:::6:) 14

0 (I (I

4 0 0

0 0

:31 59

0

4 (I

0 0 0 0

16 98

:FED_ STATES OF MICRONESIA :Republic of Belau

:TUVALU :VANUATU :VIET NAM, SOCIALIST REP_ OF :Wallis and Futuna

19::.:7 1987 19f:6 19:::6 19:::7 1987

0 0 (I

1:::o 0 (I

0 (I

0 (I

1:3::: 125:36 I

iOtA 774 0

:35 27 140

619 (I

0

1:30:39 721

940b/: 0

:34

Information not available c = cases confirmed in laboratories a/ Tetanus neonatorum b/ 19t:6

-

TABLE :3:

SELECTED NUTF.:ITIONAL INDICATORS

:=;==============================================================================================================: lAMEF:ICAN SAMOA lAUSTRALIA lBnmei Darussalam :China, People's Rep,Jbl ic of :cooK ISLANDS :FI.JI lFt·ench Polynesia lJ?iuam :HONG KONG :.Japan : KIF.:IBATI lLAO PEOPLE'S DEMOCRATIC F.:EP. lMacao lMALAYSIA :NaW"IJ :NEW CALEDONIA lNEW ZEALAND lNiue lPAPUA NEW GUINEA :PHILIPPINES IPEPUBLIC OF KOREA lSAMOA l S I NGAF'OF:E :SOLOMON ISLANDS lTOKELAU lTONGA lCOMM. OF NOF.:THERN MAF.:IANAS :F.:epubl ic of Mat·sha ll Islands lFED. STATES OF MICRONESIA lRep,Jbl ic of Bel au lTUVALU lVANUATU lVIET NAM, SOCIALIST PEP. OF :wall is and Futuna Information not avai Jable (19:35-::::6) (1984) (19::::2) (1979) <1-:r::w (1':.1:3:3) (1985) (19:35) (1987) (1977-79) (19:32-84) :34:39 2959 24:34 2577 :3747 1'105 :3402 20::::::: 1842 2181 2549 (19:35-86) (19:::4) (1982) (1979) <19B2l (198:3) (1985) (19:35) (1'187) ( 1'::!77-79) (1977) 98.4 73.7 67.0 56.8 11:::.96 :::o- 0 99.0 79.0 47.7 57.9 57.6

Daily per capita calorie availability exceeds 2500 calories

Daily per capita protein supply e:x:ceeds 70 9rams

(19::::1) (1975-77) (1985) (1985) (1985) <19S3)

:3119 2247 2214 2125 :3983 2922

(19:::1) (1975-77) (1985) (19:::5) (1'1B5) (19:3:3)

97.0 4:iw8

60.0 67.5 96.0 71.8

(1983)

2750

<1975-77)

61.2

(19S7)

1976

(1':i:35)

52.0

-----------------------------------------------------------------------------------------------------------------

WPR/PTC/3/88.2 page 29

Appendix 1 TABLE 9: Country/Area SELECTED FAMILY HEALTH INDICATORS

: Maternal mortality rate : Annual population growth rate ((1/00) (/;)

:=~======================================================:================================:

lAMER I CAN SAMOA :AUSTRALIA :snmei Darussalam :China, People's Republic of :cooK ISLANDS :FI.JI : Ft~enr:h Polynesia IGuam :HONG f<ONG :.Japan :I<I F.: I E:A TI lLAO PEOPLE'S DEMOCRATIC REP. :Macao :MALAYSIA :Nauru iNEW CALEDONIA :NEW ZEALAND :Niue I PAPUA NEW GUINEA :PHILIPPINES lREPUE:LIC OF ~;OREA :SAMOA :SINGAPORE :SOLOMON ISLANDS iTOf<ELAU :TONGA iCOMM. OF NORTHEF.:N MAF.:IANAS : F.:epub 1i c of Marsha 11 Islands lFED. STATES OF MICRONESIA lRepl.lbl i c of Bel au lTUVALU lVANUATU lVIET NAM, SOCIALIST PEP. OF :wa 11 is and Futuna ___ Information not available

(1986) (1986) (1986) (1986) (1982) (1986) ( 19:37) (1'01:36) (1985) ( 19:37) (1986) (19:36) (1984) (1985) (1985) (19:37) (1986) (19:::6) (1986) (1986) (198::i)

(1_(1(1(1

0.060 0.000 <:1.000 0.032 0.000 0.040 (I- 1:35 0.880 0.0:35 0.000 0.250 (I-

(1986) (1985-86) (1984) (1985) (1987) (1982) (1977-8:3) ( 1980-:36) (19:37) ( 1980 -:35) (1985) (19:35) (1986) ( 19:36) (1983) (1985) (1980-85) (1980-85) (19:37) (19:36) (19:36) (1986) (1986) (198:)) (19:34) ( 19:36) (1973-:30) (1983-84) (19:::6) (1987) (1985)

1. 90 1.:37 2~50

1. 20 0.60 1. 80 :3.03 2.20 1. 50 0.70 2.10 2.90 4.50 2.65 1. :30 0.36 -0.20 2.20 2. 40 1.24 0.40 1- (I (I :3.50 (1_(1(1

160 0- 150

1.800 0.800 0.330 0.400 (I_ 100 0.:300 1.200

0.90 2.90 3_ 00 1. 80 1. 50 3.20

(1986) (19:36) (1986)

0.000 0.350 1.420

2.15

TABLE 10:

E:,<TENT OF COMMUNITY INVOLVEMENT FOR EIGHT COUNTPIES : %of local commi.Dlities %of community contribution in :with voluntary and formal: cash and in kind to primary : community organizations : health care action programmes (1984) (1978-:::5) (1983) (19:34) (19:36) (19:34) (19:37) (19:36) :37 (1987) 5-10

Country/Area

!==============================:=========================:=============================== lChina:o People's F.:epubl ic of : COOf< ISLANDS :.Japan

: KI RIE:ATI :LAO PEOPLE'S DEMOCRATIC REP. lMALAYSIA lF'HILIF'F'INES :SAMOA :TUVALU ___ Infonnati on not available

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