W 0 R L D H E -A L · T H ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR
THE WESTERN PACIFIC
BUREAU 1\~GIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL
COMMITTE~
WPR/RC36/6 9 August 1985 ORIGINAL: ENGLISH
Thirty-sixth session Manila 16-20 September 1985 Provisional agenda item 12
REPORT OF THE SUB-COMMITTEE OF THE REGIONAL COMMITTEE ON THE GENERAL PROGRAMME OF WORK PART II EVALUATION OF THE STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000- SEVENTH REPORT ON THE WORLD HEALTH SITUATION -REGIONAL EVALUATION-
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 WPRfRC32.R5 in 1981. The plan of action stipulates that an evaluation of national strategies wiH be done every six years and that the first evaluation will be carried out in 1985. A Common Framework and Format for evaluating the health-for-all strategies was formulated to guide the national evaluation process and was approved by the Regional Committee at its thirty-fifth session in 1984. Countries or areas were requested to submit their evaluation reports to the Regional Director by March 1985 for eventual incorporation in the regional evaluation report. The Sub-Committee of the Regional Committee on the General Programme of Work was requested, by resolution WPR/RC35.R6, to .continue to review, monitor and evaluate the implementation of the strategies. This evaluation report is now submitted for consideration by the Regional Committee as an annex under Part II of the Sub-Committee's report. The report provides a synthesis of the findings of country or area reports, which have used the Common Framework ·and Format for assessing the effect of their health-for-aU strategies on national health development. As not aH countries or areas have submitted evaluation reports and as some information required for the regional evaluation was not requested in the country or area reports, supplementary information has been included in the analysis in order to more fully reflect the real situation in the Region. An executive summary is included for the convenience of representatives. The Regional Committee is requested to review and comment on the regional evaluation, which, if it agrees, will be submitted to the Director-General for eventual inclusion in the global evaluation of the health-for-all strategies.
WPR/RC36/6 page 2
Within the framework of its review, monitoring and evaluation of the implementation of the strategies for health for all by the year 2000, the Sub-Committee had before it for review the draft regional evaluation report on implementation of the national strategies, l which provided a synthesis of findings from the reports which had been received from countries or areas in the Region and which were based on the Common Framework and Format for evaluation of the health-for-all strategies. The Sub-Committee noted that, as not all countries or areas had submitted evaluation reports and as some information required for the regional evaluation had not been requested in the country or area reports, supplementary information had been included in the analysis in order to more fully reflect the real situation in the Region. In reviewing the report, the Sub-Committee expressed satisfaction with the progress made, noting, however, that the progress indicated by countries or areas was often achieved as a result of actions taken prior to the formal adoption of the health-for-all strategy. Nevertheless, it was apparent that progress had been made in implementing the health-for-aU strategies and that the results were significant enough to be used as a guide for planning further developments. It was noted that twenty-three out of thirty-two countries or areas had submitted evaluation reports. While this was a better rate of reporting than for the monitoring reports in 1983, the Sub-Committee urged the national authorities to develop or further improve their evaluation processes and, in the case of those countries or areas that had not so far submitted reports, to endeavour to do so as early as possible in order to assist WHO in fulfiUing its reporting commitments to governing bodies of the Organization on their behalf. The Sub-Committee noted with concern that the information from countries or areas provided in the context of the Common Framework and Format primarily reflected the point of view of the health authorities. This was particularly highlighted in relation to issues concerning community involvement. Noting that, by the very way the Common Framework and Format had been organized, it would mainly reflect the views of the health authorities, the Sub-Committee wished to bring this potential bias in the evaluation process to the attention of Member States. A further concern was expressed by the Sub-Committee with regard to the lack of content in replies concerning the effectiveness of WHO's collaboration in implementing health-for-al! strategies. It urged Member States to be more specific in providing feedback to WHO. The Sub-Committee considered that, in general, the replies from countries or areas were satisfactory and noted particularly the wiHingness of some countries or areas to draw attention to their weaknesses as well as their positive achievements. The Sub-Committee recommended that the regional evaluation report, which is attached as Annex J, should be accepted by the Regional Committee for submission to the Director-General, for eventual inclusion in the global evaluation report.
1Document WPRJGPW /85.3.
WPR/GPW/85.3
ANNEXl
EVALUATION OF THE STRATEGIES FOR HEALTH FOR ALL BY THE YEAR 2000 - SEVENTH REPORT ON THE WORLD HEALTH SITUATION
TABLE OF' CONTEN'l'S
EXECUTIVE SlJMMARY INTRODUCTION
....................................... • • • • •
( i) 1
••••• .- ••••••••••••• " ••••.•••• • • • • • • • • • • • • • • • -• • • •
CHAPTER 1.
MAJOR DEVELOPMENTS IN SOCIOECONOMIC AREAS/ SECTORS AFFECTING THE HEALTH STATUS OF THE POPULATION • • • •• • • •• • • •• • • • • • • •• • • • • • • • • • ••• • •• •
5
1.1 1.2 1. 3
The regional development scenario •••••••••••••• Demographic tr~nds ••••••••••••••····•······· ••• Economic trends . . . •. . ••. •. . . . . . . . . . . . . . . . . •. . . .
5 9 13
1.4 1.5
Social trends ••••••.••••••••••••••••••••••••••• Intersectoral cooperation and description of the health component in economic development schemes . . . •. •. . . •. . . . . . . . . . ••••. . . . . . . . . . . . . . . •
16 18 20 20
CHAPTER 2.
DEVELOPMENT OF THE HEALTH SYSTEM Introduction
................................... ••.•••••••.•••.••.••••..•..•
2.1 2.2
Health policies and strategies ••••••••••..••••• Organization of health systems based on primary health care
21 25 28
2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11
Managerial process ••••••••••••••••••••••••••••• Supporting legislation ••••••••••••••••••••••••• Co~unity involvement .....•........•••.•.•....• He8 1 th manpow~r .•...•...•...••••.•.•••......... Mobilization of resources •••••••••.•••••••••••• Health research · Coordination within the health sector; collaboration with other sectors and countries WIIO cooperation ............................... . He a 1 th care ••••.•..............•...............
..................... ......... .
29 30 32 35 38
42 46 49
CHAPTER 3. 3.1 3.2 3.3
PATTERNS AND TRENDS IN THE HEALTH STATUS Patterns and trends in morbidity, disability and mortality •••••••••••••••········••••••••••• Patterns and trends in health-related behaviour • Environmental factors •••••••••••••••••••••••••• Implications for socioeconomic policy ••••••••••
55 55 61 67 68
3.4 CHAPTER 4. 4.1
ASSESSMENT OF ACHIEVEMENTS
............ ....... . •·
70 70 72
4.2 4.3 CHAPTER 5,
Achievements •...........•... "' •..............•.. Effectiveness and efficiency of results •••••••• Relation to health-for-all goals •••••••••••••••
74
OUTLOOK FOR THE FUTURE
.........................
78
WPR/GPW/85.3
(i)
EXECUTIVE SUMMARY
The Thirty-fifth World Health Assembly in 1982 called on Member States to periodically revie-•1 and assess progress in implementing their health-for-all policies, strategies and plans of action. A monitoring of
progress was completed in 1983 and an evaluation of effectiveness was carried out in early 1985.
A synthesis of the country or area reports on
this evaluation has been prepared and documented in the form of a regional evaluation report.
Health for all is a part of the overall national
socioecono~ic
processes, which are influenced by specific demographic, economic and social trends in the countries or areas of the Region. In demographic
terms, the Region had an estimated population in 1984 of 1.4 billion, which is expected to grow to 1.7 billion by the year 2000. The average of the Recent
national annual growth rates was 2% for the period 1975-1980.
evidence suggests that the rate of population growth has tended to decline; pace; migration from rural to urban areas is taking place at a slower and the labour force h as
dependency ratios have tended to be high;
continued to increase .
Most of the countries or areas have generally recovered economically from the low economic rates of the early 1980~.
However, although the
Region has experienced a generally satisfactory rate of growth during the past few years, this does not necessarily imply that the benefits of economic growth have been equally distributed throughout the population.
WPR/GPW/85.~
(ii)
In social terms, the Region is characterized by a generally high rate of adult literacy. High priority continues to be given to education
throughout the Region as indicated by the large primary school enrolment, which has been increasing for most of the 1970-1980 period. Although
women's participation in socioeconomic activities has increased, their conditions of work, wages and enjoyment of benefits such as access to education, health and other social goals do not seem to have improved connnensurately.
Within an environment characterized by these demographic, economic and social trends, most countries or areas of the Region have adopted health-for-all strategies which are laying the foundation for development that will ensure socially and economically productive lives for their people. Twenty-seven countries or areas have explicitly endorsed the
health-for-all strategies, while the intent of the policies and strategies of the remainder is the same as that of those countries that gave a formal endorsement. The health development strategy is unique for each country or
area; however, it is recognized that some fundamental changes are required in many functions of the health system if the health-for-all goals are to be achieved.
All countries or areas are attempting to provide the eight essential elements of care at the initial point of contact wi-th the community. those countries or areas providing information, the delivery of the essential elements of primary health care is very encouraging. Thus, most In
WPR/GPW/85.3
(iii)
countries reported that at least 80% of their population now have access to health care, including availability of at least twenty essential drugs, and that 80% are within walking distance of a safe water supply and have adequate sanitary fac i lities at or near their homes. maternal and child health are impressive. or more of Achievements 1n
Most countries reported that 90%
women were attended by trained personnel during pregnancy, 80%
of deliveries were similarly attended, while at least 90% of infants were followed up, resulting in 80% or more being fully immunized against all diseases in the expanded programme on immunization.
A number of changes are taking place 1n the health systems of the Region to further improve the delivery of essential care. These changes,
depending on the country or area, includ e d ecentralization, reorganization o f health services, allocation of ~ larger share of health service responsibility to the private sector, approaches to upgrade the quality of manpowe r , expansion o f c ommunity - c entred primary health care workers and more e ffective utilization of health services.
Countries or a r eas have recognized that, to support thes e significant structural changes, commensurate i mprovemen t s mus t be made 1n their managerial processes. Most countries have, therefore, improved their
planning and administrative procedures, utilizing information which is c ol l ected through an improved health in f ormation system and throug h spec ial s urvev s and stud ies . J Plann1'ng L : s· n ow v1 · e we d a s a cont inu ; ou s proce ss wi th a Significant progress has been achieved 1
broad base of participation.
n
WPR/GP¥1/85.1 (iv)
promoting people's involvement not only in planning but in implementation as well. Countries or areas have exerted considerable efforts in enhancing
the effectiveness of existing mechanisms for community participation, while some have established new mechanisms.
In the field of intersectoral coordination, fourteen out of twenty-four countries or areas stated that their health plans are integral parts of their national development plans. Inter-agency planning groups or
similar mechanisms have been established at national levels to permit a continuous and meaningful dialogue in setting health priorities and in coordinating implementation of their respective activities.
The dominant theme of health manpower development plans, as reflected in the reports, is the increase in the productivity and effectiveness of existing personnel, with only a few countries planning an increase in their absolute numbers. There is a definite trend towards the development of
village health workers, and those countries reporting have expressed satisfaction with their approach. Comprehensive reviews have been
undertaken of training programmes for various categories of health personnel and changes have been introduced in the curricula. Reorientation
has been undertaken of existing health personnel to enhance health skills, strengthen management and supervision, and correct weaknesses in the provision of administrative support.
WPR/GPW/85.3
( v)
The majority of countries or areas currently allocate a reasonable percentage of their gross national product to health. The exceptions are
those countries which ha\1e been severely affected by recent economic hardships. Countries or areas are now attempting to develop a resource
allocation process designed to influence the appropriate development of the health system, veering away from the traditional practice of simply adding a percentage increase to the previous year's budget in preparing estimates for the following year. As a first step in this direction, five countries
are now either conducting or preparing to conduct exhaustive studies of their current financial situation, including their programme budgeting and monitoring procedures.
The important contribution of scienti fie research in planning health development is widely recognized in the Region. Nonetheless, it is
primarily in the developed countries and in three developing countries that attempts are being made to formulate comprehensive research policies which will provide direction and coordination of studies in support of national health development. While this may be so, it should be noted that a number
of developing countries have implemented research and development projects 1n primary health care, studies on specific operational problems concerned with the delivery of health servtces, and studies on traditional medicine. In the field of biomedical research, attention has focused mainly on tropical diseases such as malaria and filariasis.
WPR/GPW/85.3
(vi)
The present pattern of morbidity and mortality throughout the Region 1s changing rapidly as a result of socioeconomic development. While
conventional health problems such as communicable diseases are generally under control or declining in importance, an increasing number of persons in both developed and developing parts of the Region seem to have problems related to undesirable health behaviour. the past gave priority to econom1c growth. National development policies in There is no question that the However,
results of these policies also had a positive impact on health.
based on the assessment that many of the current health problems are associated with behavioural and social issues, it is important that future development policies should be more explicit on the role of health in development.
The first evaluation of the implementation of health-for-all strategies is primarily an assessment of efforts and approaches that have been in place for many years. However, it has been possible to isolate
achievements which relate to progress in . strengthening the processes used in implementing health for all. At the political level, for example, there
has never been such a concerted effort to involve political leaders in the formulation of health policies. Progress has also been made in translating This task has been In addition,
policies into meaningful development programmes.
facilitated by the comprehensive health-for-all framework.
there has been progress in strengthening the role of communities in health development activities.
WPR/GPW/85.3
(vii)
The health-for-all evaluation has prompted countries or areas to take stock of what is happening in their health sector. Much concern has been
expressed about the rising cost of maintaining health services. Consequently, one can expect a great deal of energy to be channelled into determining more precisely how resources are being utilized, how manpower productivity can be enhanced, which technologies are the most appropriate, and into exploring alternative means of funding the health services.
In the past, evaluation was often little more than a rationalization of past events. This picture is in sharp contrast to the present
situation where clearly development is considered a force that can be directed to achieving the social goals which have been defined for the nation. This trend is supported by a number of developments, such as,
among others, the change in emphasis from physical infrastructure development to social development, and the special attention now accorded to processes which view the health system in its totality and which aim to secure as broad a participation as possible in health development.
The Western Pacific Region has experienced rapid changes in the past decade in all areas of social, economic and political development. There
is every reason to believe that, in most countries or areas, this pace of development will continue through the year 2000. Even though the immediate the
economic future can be faced with guarded optimism, over the long term vast investment made in human resource development has the potential for contributing to a collectively strong and viable economy in the Region.
WPR/GPW/85.3 page l
INTRODUCTION
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. Subsequently, the regional
strategy was revised in the light of the Global Strategy adopted by the Thirty-fourth World Health Assembly. by
1
The revised strategy was adopted
the Regional Committee at its thirty-second session in September The plan of action for implementing the global strategy for
1981. 2
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 health policies, strategies and plans of action. 3 A monitoring
of progress is to be done every two years and an evaluation of effectiveness every six years. The global plan also calls on the Regional
lclobal strategy for health for all by the year 2000. Health Organization, 1981 (Health for All Series No. 3). 2Regional strategy for health for all by the year 2000. World Health Organization, 1982. all.
Geneva, World Manila,
3plan of action for implementing the global strategy for health for Geneva, World Health Organization~ 1982 (Health for All Series No. 7).
WPR/GPW/65.3 page 2
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 of national, regional and global strategies. This was approved by the The basic aim
Regional Committee at its thirty-third session in 1982. 1
of the Common Framework and Format was to stimulate a national process for monitoring the implementation of health-for-all strategies. The results of
the national monitoring were to be used to prepare regional and global reports on the progress in implementation of the global strategy. The
first monitoring report reviewed the relevance of national health policies to the attainment of health-for-all goals and the progress in implementing national health-for-all strategies. The regional monitoring report was
reviewed by the Regional Committee at its thirty-fourth session in 1983. 2 This report was submitted as the regional contribution to the
global report, which was considered at the Thirty-seventh World Health Assembly in 1984.
lsee resolution WPR/RC33.R8. Handbook of Resolutions and Decisions of the Regional Committee for the Western Pacific, Vol. II, Fourth Edition, 1976-1983, p.4. 2nocument WPR/RC34/7.
WPR/GPW/85.3 page 3
The global plan of action stipulates that an evaluation of national strategies will be carried out every six years and that the first evaluation will be in 1985. A Common Framework and Format for evaluation
of the health for all strategies was formulated to guide the national evaluation process, and approved by the Regional Conunittee at its thirty-fifth session 1n 1983. 1 National reports on the results of the
evaluation have been received from twenty-three out of thirty-two countries or areas in the Region. The first evaluation is aimed at assessing the
relevance, progress, adequacy, effectiveness and efficiency of the national health policies and strategies in achieving national health-for-all goals.
Health for all is the basis for national health development in countries or areas of the Region. Health for all is not a separate
developmental activity that has been added on to other development schemes. Hence, no new evaluation processes have been established just to On the contrary, the goal is to
assess the progress of health for all.
integrate the value systems and concepts upon which health for all is predicated irito the overall national managerial processes.
All countries or areas of the Region are struggling with the problem of implementing an evaluation process that is responsive to assessing national development goals. However, based on the evaluation reports
received from countries or areas, it is very encouraging to note that some
lsee resolution WPR/RC35.R5. Report of the WHO Regional Committee for the Western Pacific, Thirty-fifth session, 1984, page 25.
WPR/GPW/85.3 page 4
progress has been made in expanding traditional evaluation methods.
Most
countries or areas indicate that their health-for-all evaluation 1s based on central level mechanisms that start with planning. It is the central
planning unit that collects and analyses information for national assessment purposes. Most countries or areas realize that the evaluation This
process must have a more pervasive impact through the health system.
will be a recurrent theme throughout the evaluation synthesis and indicates one of the positive impacts that health for all has had on changing managerial processes in countries or areas of the Region.
The following sections give a regional synthesis of findings from the national reports on evaluation of the health-for-all strategies.
WPK/GPW/85.3 page 5
CHAPTER 1.
MAJOR DEVELOPMENTS IN SOCIOECONOMIC AREAS/SECTORS AFFECTING THE HEALTH STATUS OF THE POPULATION
1.1
The regional development scenario
The Western Pacific Region of the World Health Organization cotisists of thirty-two countries or areas with an estimated population 1n 1984 of 1.4 billion; seven countries account for 96% of this total. 1 The Region There are
is heterogenous in political, economic and demographic terms.
countries following free-enterprise market economies, centrally planned econom1es and mixed economies. The Region has highly industrialized
developed countries, newly industrializing countries or areas (NIC) 2 , developing countries or areas and least developed ones. It also has large
and small countries, land-locked and island countries providing diversity in development potential and in opportunities for and constraints on the exploitation of this potential. In spite of its diversity, the Region
shares a common belief in the need for rapid development in a peaceful env1ronment.
lunited Nations World Population Chart, 1984. Seven countries with the largest population are China (1 051 million), Japan (119 million), Viet Nam (58 million), Philippines (53 million), Republic of Korea (40 million), Australia (16 million) and Malaysia (15 million). 2The term "Newly industrializing countries or areas" refers to countries or areas which have a high share of manufacturing output in their exports and gross domestic product such as Hong Kong, the Republic of Korea and Singapore.
WPR/GPW/85.3 page 6
The regional situation has taken a decided turn for the better during the last few years in regard to the political and economic climate which favours the continued dynamism of the Region. Mutual cooperation and
defence or security treaties and agreements have remained in force with some problems related to the implementation of their provisions. The
fourteen-member South Pacific Forum, at its meeting in August 1984, voiced its desire to keep the area a nuclear-free zone. In South-East Asia, the
scope and functions of the Association of South-East Asian Nations (ASEAN), which was established in 1967 to foster regional economic development rather than military cooperation, were expanded to include the promotion of regional peace and security. Darussalam. Its membership was extended to Brunei
The present conflict in the Indo-Chinese Peninsula continues
to evade solution.
An important event, reflecting the emphasis on
accommodation rather than confrontation, was the signing in Beijing of the joint declaration by China and the United Kingdom on the future of Hong Kong. Politically, the Region is undeq~oing
transition with a number of 1
countries or areas becoming independent and self-governing.
In some countries or areas of the Region, the population consists of diverse ethnic and religious groups and, although occasionally some problems arise, in general they have managed to live in peace and harmony. The countries are charting a course away from extremism, dogmas and ideology and towards pragmatism and moderation. 2 The combination of the
lKiribati, Solomon Islands, Tuvalu, Trust Territory of the Pacific Islands and Vanuatu in the Pacific and Brunei Darussalam have become independent in the last few years. 2Asia yearbook 1985. pp. 12-16. Hong Kong, Far East Economic Review, 1985,
WPR/GPW/85.3 page 7
socialist and capitalist approaches to economic development is a feature of the situation in most of the countries in East Asia that have had successful economies with a high growth rate, even during the period of global recession. In these countries, the governments play a leading role
in directing and reguhting their economies by selectively supporting those industries and firms which can contribute to a high economic growth.
High economic growth was achieved in most of the East and South-East Asian countries through technology-based and labour-intensive development approaches that depended on the economic performance of industrial countries. However, these countries resorted to external sources to
finance their investment, which led to increased debt-service problems in some of the countries. A number of countries were able to control domestic
inflation and to reduce their trade deficits and debt-service ratios. 1 As these developments unfolded, the Asian Development Bank (AsDB) and the World Bank were reviewing the relevance of their policies to development support. Insofar as the Asian Development Bank is concerned, the pattern
of lending was "distinguished by very sharp rises in the amount of loans channelled into the Energy and Transport and Communication sectors. other hand, there were significant declines in lending for Social Infrastructure and Development Banks." 2 On the
lAnnual report 1984. 2rbid., p.6.
Manila, Asian Development Bank, 1985.
WPR/GPW/8-5.3 page 8
The social status of women in the Region is influenced by cultural bias and prejudice, not only in such areas as education but also in other aspects related to their role and status in the family and community. The
preference for male children is still a widely shared value in a number of countries; the practice of certain taboos during the menstruation, pregnancy and lactation periods adversely affects the health of women. Traditional beliefs regarding the division of labour between sexes and the status of men and women limit the scope, nature and estimated value of women's productive capacity. Traditional functions assigned to women are
being evaluated in order to make their participation in comDI\lnity activities aimed at better living and environmental conditions more effective. Demands for women's social and economic participation have also
increased though the degree of such participation varies among countries. Socialist countries of this Region present a more favourable picture of equality in occupational status with men. In general in the health field, It is noted that,
women are regarded as the main health care providers.
while women form a majority of total health personnel, the top positions are still occupied by men. 1
Although women's participation in economic
activity has increased, their conditions of work, wages and enjoyment of benefits such as access to education, health and other social goods do not seem to have improved commensurately. 2
lwomen, health and development (WHO document WPR/RC35/10), 1984, PP• 4-5.
the Pacific 1984. Bangkok,
WPR/GPW/85.3 page 9
The problem of refugees is becoming significant in a countries.
nu~nber
of
While a great deal of support is given by international ~n
agencies to alleviate this problem, the burden on some of the countries the Region has been heavy.
Strange as it may seem, a number of countries
have become both the haven and source of refugees.
1.2
Demographic trends
The regional population was estimated at 1.4 billion in 1984 and is expected to grow to l. 7 billion by the year 2000. growth rates was
The average of national Recent evidence
2.0% per annum for the period 1975-1980.
suggests that the rapi'dity of population growth has tended to abate; migration from rural to urban areas has continued but at a slower rate; dependency ratios have tended to be extraordinarily high and the labour force has continued to increase. 1
Governments' perceptions with regard
to the size of the population and the rates of growth have changed over the past d eca d e, aga~n
. . d egrees b etween to vary1ng
countr~es.
.
2
Of the
twenty-one countries for which data are available, twelve considered their population size and growth rate to be too high, six found them to be at an acceptable level and three found them to be too low. Policies of
intervention to modify the rates of growth have, however, been in force 1n most of the countries and areas in the Region.
!Economic and.social survey of Asia and the Pacific 1984. United Nations, 1985 (ST/ESCAP/313), p. 115.
Bangkok,
2Third Asian and Pacific Population Conference (Colombo, September 1982). Selected papers. New York, United Nations, 1984 (Asian Population Studies Series No. 58) (ST/ESCAP/267), p. 123.
WPR/GPW/85.3 page 10
With regard to age structure, with . the exception of a few low-fertility countries, the majority of the population is still concentrated in the young age groups. However, the proportion of elderly
persons aged 65 and above has increased from an average of 4.2% in 1970 to about 5.1% in 1980; this aging phenomenon is expected to continue and even accelerate around the year 2000. The developed countries of the Region are Japan, for example, 1s aging fast e r With a 50% increase in life expectancy
already facing the problem of aging. than any other nation in the world.
from 1950 to 1984 and a decline in the post-Second World War birth rate, it is estimated that, by the year 2000, nearly 25% of Japan's population will be over the age of 65. 1
The dependency ratio for the ESCAP region, defined as the ratio of the number of children below the age of 15 and elderly persons aged 65 and above to the number of persons of working age, declined in 1980 compared with 1970. In 1980, there were about 71 dependants for every 100 persons of working age compared with 80 dependants in 1970. Indeed, as fertility
declines further, and the transition from young to mature population distribution occurs, it is to be expected that an increasingly larger proportion of the population will be in the age group 15-64 with corresponding declines in the dependency ratio. 2
lAsia yearbook 1985. P• 41.
Hong Kong, Far East Economic Review, 1985,
2Third Asian and Pacific Po ulation Conference (Colombo, September 1982 • Selected papers. New York, United Nations, 1984 (Asian Population Studies Series No. 58) (ST/ESCAP/267), pp. 16-17.
WPR/GPW/85.3 page 11
In the past few decades, increasing concern has been expressed by governments with regard to the distribution of population. It
is
anticipated that the problems of urbanization and growth of cities will assume serious proportions in the future with a continuing increase 1n the size of the urban population. There was a small but steady increase of
about 4% during the period 1970-1980 in the proportion of urban population in the Region. Japan, the Republic of Korea and Singapore are the most
urbanized because of the colllbined effect of rapid economic growth and falling population growth rates. The pace of internal migration over the
past decade, characterized by the flow from rural to urban areas in general and indicative of the mobility of the agricultural workforce, is reported to have slowed down slightly. However, current observations show that this Although this
flow is now mainly directed towards the large urban centres.
implies that the urbanization is a phenomenon usually associated with development, recent experience indicates that the characteristics of urbanization in the larger process of development are changing. Urbanization may not always reflect the level of development. Contrary to
the early experience of the industrialized countries, increasing urbanization in developing countries seems not to be associated with the degree of industrialization and with successful rural development programmes. The United Nations has estimated that of three factors -
natural increase, reclassification of rural places to urban places, and migration - natural increase contributed to about 40% of urban growth in the developed countries, while migration and reclassification accounted for the remaining 60%. In the developing countries, however, the contribution
WPR/GPW/85.3 page 12
of natural increase to urban growth was about 61%.
1
It is estimated that
the Region's urban population growth between 1975 and 2000 will be almost double that during 1950-1975. urbanization Another area of concern associated with There were only
is
the excessive growth of large cities.
three cities (Beijing, Shanghai and Tokyo) with a population of 10 million and above in 1980, and it is estimated that by the year 2000, there will be six cities in the Region with a population of 10 million and above.
During the 1970s, international migration was an important component of population growth in Australia, Brunei Darussalam, Hong Kong and New Zealand and to a less extent in Halaysia and Singapore. Temporary
migration for employment in the different countries, particularly the oil exporting ones, has become a significant factor in the large outflows taking place in the Philippines and the Republic of Korea. Though small 1n
relation to total population, international n1igration has increasingly become a significant instrument for socioeconomic change in the Region. Apart from economic costs and benefits for sending and receiving countrie s are the social and psychological adjustments required from immigrants themselves. As the labour migration created opportunities for national
benefits, it also caused shortages of workers with crucial skills in the domestic economy and socia l problems for the families left behind.
!urbanization in the ESCAP region. In: Third Asian and Pacific Population Conference ( Colombo, September 1982). Selected Papers. New York, United Nations, 1984 (Asian Population Studies Series No. 58) (ST/ESCAP/267), p. 160.
WPR/GPW/85.3 page 13
1.3
Economic trends
The Region, which consists of developed countries, newly industrialized countries or areas (NICs) and developing countries or areas, including the least developed among them, has been experiencing increases in the gross domestic product growth rates, the highest increase being . d ustr1a . 1' . among the new 1y 1n 1z1ng ones. 1
Most of the developing countries
have generally recovered from the exceptionally low growth rat e s of 1982 and the average GDP growth rate of the developing ones in the Region during 1983 and 1984 was higher than that of 1982, though it was below the average rate during the past decade. 2
An external environment characterized by
high interest r a tes, volatility in foreign exchange rates, scarcity of capital inflows, continued weakness of primary commodity prices and difficulty of access to manufactured exports through the proliferation of protectionist trends is inhibiting the sustained development of the . . 3 . d eve 1 op1ng countr1es.
The performance of countries or areas like Hong
Kong, the Republic of Korea and Singapore has been remarkable, particularly with respect to the export of manufactured goods, following the economic recovery of the developed world. 4 As the growth rate of the gross
lThe per capita GNP of most of the countries 1n the Region was at least us$ 250 as of 1982. 2Annual report 1984. Manila, Asian Development Bank, 1985.
3Economic and Social Council, Official Records, 1985. Supplement No. 12. Economic and Social Conunission for Asia and the Pacific. Annual report 28 April 1984 - 29 March 1985. Bangkok, United Nations, 1985 (E/1985/33; E/ESCAP/470), p. 35. 4Economic and social survey of Asia and the Pacific 1984. Un ited Nations, 1985 (ST/ESCAP/313), p. 27. Bangkok,
WPR/GPW/85 •.3 page 14
national product increased, so did the real burden of external debt in some of these countries or areas. A number of them have adopted structural
adjustment programmes and are modifying their economies and introducing flexibility in economic management. However, in spite of a steady
improvement 1n the world economy during the past two years favouring export-oriented economies, the external environment facing these countries in the Region is still uncertain and far from reassuring. 1
The least developed countries of Lao People's Democratic Republic and Samoa had low growth rates in outputs and less than robust growth in export earnings. These have resulted in austerity measures, the implementation of
which is very difficult in the context of near subsistence incomes and high unemployment and underemployment. For the most part, these countries have
followed prudent policies of economic management and it is hoped that the growth of their econom1es will be maintained, though not necessarily accelerated.
Imbalance continues in the supply and demand for labour in most of the developing countries. Labour force growth continues to outstrip the Rapid growth in the
capacity of the econom1es to generate employment. 2
working-age population makes the attainment of optimal employment more
lworld economic outlook, September 1984; revised projections by the staff of the International Monetary Fund. Washington, D.C., International Monetary Fund, 1984 (Occasional Paper No. 32), p.l. 2Review of demographic trends and population policies and programmes in the countries of the region (United Nations document E/ESCAP/POP.3/1), 1983, P• 20.
WPR/GPW/85.3 page 15
difficult as well as costly.
In v1ew of the difficulties in creating
sufficient urban industrial jobs to absorb the growing work force, agriculture will have to absorb most of the new entrants into the labour force. This could be accomplished through the expansion 1n land under
cultivation, through capital investment or through adoption of labour-intensive technology.
In the Region, trade offers the greatest opportunities for sustained growth, faster modernization and technological transformation. As efforts
are made to expand interregional trade, countries should not overlook the possibilities of intraregional trade. The relatively rapid increase 1n
intraregional trade, observed to be growing at twice the rate of interregional trade, indicates the strong potentiality of the former for improving the economic structure and growth of these countries. Cooperation in trade among countries or areas in a heterogenous region like the Western Pacific Region will expand the market s1ze for individual countries and thus contribute to their economic growth.
Although a number of countries or areas have achieved a generally satisfactory rate of economic growth during the past few years, this does not necessarily imply that the benefits of economic growth have been equally distributed throughout the population. For this to happen, t
national strategies which translate economic growth into better well-being should have been designed to focus on the poorer segments of society. It
is known that some developing countries, particularly those with a large population, have adopted such a strategy in this Region. Strategies in
these countries included facilitation of social ownership of the means of
WPR/GPW/85.3 page 16
production as in China and Viet Nam, radical redistribution through wide-ranging land reform as in the Republic of Korea, and distribution of assets to the poor as in Malaysia, which has large unutilized land resources. These countries seem to have been relatively successful ~n
eliminating the worst forms of deprivation and have gone a considerable way towards satisfying the basic needs. Available data show that, for a
majority of countries or areas, the regional targets have been met for daily per capita calorie and protein supply, infant mortality rate, life expectancy and adult literacy rates. These indicators reflect the outcome
of a pattern of development in which the basic needs for a satisfactory quality of life have received a relatively high priority. However, in many
countries or areas, the data on these indicators are not available for sub-groupings of the population; hence disparities that may exist among thes e groups are not known.
1.4
Social trends
The adult literacy rate is generally high for most of the c ountries or areas 1n the Region. Primary school enrolment is also high and has
increased for most of them during 1970-1980, the sex difference not being significant. When efforts are concentrated on ensuring a minimum education
for as large a proportion as possible of an expanding group of school-age children, fewer resources are avail ab le for improving quality in such ways as upgrading teachers, improving pupil-teacher ratios and providing better
WPR/GPW/85.3 page 17
equipment. 1
Recently, the social relevance of present educational
policies and programmes with regard to the attainment of "education for all" has been reviewed in the context of the International Development Strategy for the Third United Nations Development Decade. to improving education and its role in a change is emerging 1.n some places. s~ciety
A new approach
which is undergoing rapid
It concerns the school as a system of
interacting parts and advocates the need for improvement not only 1n teaching or in the curriculum but also in increasing the capacity of young people to learn on a continuing basis on their own. At the same time, the
values inherent in primary health care such as equity and quality are also emerging in the educational sector. The rapid expansion of education 111 With a
the 1960s and 1970s came at a time of rapid economic growth.
lowering of the economic growth rate, increasing attention is being given to allocation of public funds for education, and to the need to strike a balance between expansion and improvement in the quality of education.
Daily per capita calorie supply has exceeded the regional target of 2500 in most of the countries in the Region. Since 1982, there has been an
1ncrease in daily per capita protein supply as well and most countries report a daily supply of protein in excess of the regional target of 70 grams. In general, the daily per capita calorie and protein supply
reported in 1985 has been the same as or more than the values given 1n the
lReview of demographic trends and population policies and programmes 1n the countries of the region (United Nations document E/ESCAP/POP.3/l), 1983, p. 19.
WPR/GPW/85.3 page 18
1983 monitoring reports.
The nutrition situation based on the availability However, it should be noted
of calories and protein appears satisfactory.
that these are supply and not consumption figures, and thus do not reflect distribution and wastage.
1.5
Intersectoral cooperation and description of the health component economic development schemes
~n
Owing largely to economic factors beyond their control, countries or areas of the Region are faced with rapidly rising costs for the provision of health services. However, the increase in costs has not resulted in a Furthermore, the problems of
commensurate expansion of health services .
equitable distribution of health services, increasing population and concomitant expanded demands for health care are not amenable to solutions within the health sector alone. It
is becoming increasingly clear that
ways and means of coordinating or redistributing responsibility for the health services between the government and private sectors and other sectors of the socioeconomic system must be found.
There has been a growing trend 1.n recent years to formulate health plans in the context of the overall development policies and to integrate health plans into national development plans. At least eleven out of
eighteen countries or areas in the Region which submitted reports have stated that the health plan, or its essential features, is an integral part of their national development plans. In those cases where no development
plan exists, health priorities are taken into account during budget
WPR/GPW/85.3 page 19
preparation.
Inter-agency planning groups or similar mechanisms are being
established at national level to permit continuous and meaningful dialogues in setting health priorities. For purposes of coordination during
implementation, at least thirteen countries or areas have established mechanisms for consultation between the ministry of health and other development agencies concerning the health consequences of development.
WPR/GPW/85.3 page 20
CHAPTER 2.
DEVELOPMENT OF THE HEALTH SYSTEM
Introduction
The national development plans of countries or areas of the Region are predicated on policies which direct development towards ensuring socially and economically productive lives for their people. The regional
health-for-all strategy in support of national development goals is laying the foundation for a health development which recognizes the basic needs of food, water and shelter. The regional strategy also is quite explicit that
health development means more than providing for basic needs; these needs must be satisfied in an environment of social, political and economic justice and equity. With this expanded boundary for health development, it
becomes more apparent that the actions of the health sector depend on the actions of many other sectors. Consequently, the regional strategy
envisages a health system which encompasses the entire population on the basis of equity and responsibility, shares activities with other sectors, and is based on a primary health care approach consisting in the delivery of the essential elements of care at the point of first contact with the community. The health system is to be organized into levels of care and
support units, which are based on primary health care as the foundation of the whole system.
The health development process involves a variety of cultural, political and socioeconomic factors. Consequently, a health development The regional strategy,
strategy is unique to each country or area.
therefore, recognizes that it is not appropriate to describe the ideal
WPR/GPW/85.3 page 21
health system in terms of specific patterns of service, organizational structure and decision-making procedures. On the other hand, based on an
assessment of health systems in the Region, it is noted that, if health for all is to have an impact on health development, some fundamental changes are required in many functions of the health systems.
The functions noted by the strategy include management, legislation, community involvement, intersectoral collaboration, development of human resources, and research. The regional strategy therefore proposes to
countries or areas that, when reviewing their health system, special attention should be given to these functions and that they should be evaluated against the principles of a health system which is based on primary health care.
2.1
Health policies and strategies
It is apparen t from this evaluation that the formulation of a comprehensive health-for-all policy and strategy is influenced by two factors: (l) the socioeconomic structure of the country or area, and
(2) the prevailing v1ew on the role health servic es play in health development.
In those countries or areas of the Region where the bulk of the economic production and servtces is managed by the private sector, the mechanisms for reaching a c onsensus on social policy a re quite complex. the other hand, in those countries with a predominance of government control, it is easier to formulate an explicit social policy statement. On
WPR/GPW/85.3 page 22
It is suggested that the mechanisms for formulating policies and strategies are influenced by the socioeconomic structure of a country or area. However, the content of the policy and strategy is influenced more
by the prevailing views or assumptions on the role that health services should play in health development. The different views are illustrated in At
the way countries or areas implement a primary health care approach.
one extreme, primary health care is a way to extend the delivery of basic health services to a wider segment of the population. At the other end o f
the scale, primary health care is an approach to mobilize the community t o act as an equal partner in the development process.
The actual status of development in a particular country or area lies somewhere between these two extremes. The content of policy and strategy ~s
is obviously quite important, but the context
equally important, mainly
because policies and strategies are only part of the many interactive components of a development process.
The important point that must be noted at this stage of the r e giona l evaluation is that policies and strategies should not be evaluated in isolation. However, it is possible to make some assessment of policies and For example, by
strategies in relation to the total development process.
reviewing the types of information and the methods of decision-making used by countries in expressing their achievements and statement of problems, it is possible to make an assessment of major developments and progress. is along these lines that the country reports are used to assess the progress in evaluating the health-f or-all strategies. It
WPR/GPW/85.3 page 23
In twenty-seven countries or areas of the Region, health-for-all policies and strategies have had explicit endorsement by the government, the level of endorsement ranging from ministerial to cabinet or head of state. In most of the remaining countries or areas the intent of their
policy and strategy is the same as that of those countries that formally endorsed the policy of health for all.
Almost all countries indicate that their health policies and strategies are compatible with the regional health-for-all policy and strategy. Nonetheless, from a review and analysis of those policy and
strategy statements, it appears that a majority of the countries or areas really have policies which consider health as an integral part of a larger social development process. The policies of the remaining countries imply
that the provision of health services is the primary focus of developmental activities for the health sector.
A most significant achievement is the increased awareness of the value of policy and strategy statements in giving direction to the development process. However, there is still much to be done to more effectively
translate policies and strategies into programmes of action which actually reflect the goals of the policies.
The majority of countries or areas stated that they are reasonably satisfied with their policy and that no new health-for-all policies are needed. This is believed to accurately reflect their development, since in
most cases the national health policy does give a direction for development that ensures equity and justice in social, political and economic matters.
WPR/GPW/85.3 page 24
By examining the obstacles that countries are encountering in implementing their policies and strategies, it is possible tomake more specific statements on how policy and strategy are guiding the health development process.
The constraints fall into two broad categories.
One group consists of
problems associated with the assumption that health development means providing more health services. Countries falling into this category
stated that their problems concern the expansion of facilities and health programmes, lack of financial resources, dispersion of population and the need for better trained personnel, such as a new category of health worker. Countries or areas in this group have probably not come to grips
with the full implications of a health-for-all policy and strategy.
The other set of constraints is associated with the assumption that health development goes beyond the mere provision of health services. This
latter group is exemplified by Malaysia, which has stated its problems in terms of the need to have improved links with the private sector, improved coordination with all agencies involved in health, and development of specific mechanisms for community involvement, e.g. community mechanisms to handle the early discharge of patients. While these latter statements do
not provide absolute proof of a health perspective that is more comprehensive than the mere provision of basic services, they are an indication that the system is concerned about the broader issues of health development.
WPR/ GPW/ 85. 3
page 25
A majority of the countries expressed a concern that their development strategies must encompass more than the traditional health sector. A
common approach to resolving this concern involves the use of the political processes in their countries. Although these may be very positive trends,
the real issue is whether the purpose of the strategy is to get more agencies to provide services or to ensure greater community involvement 1n decision-making.
2.2
Organization of health systems based on primary health care
All countries subscribe to the regional strategy's position that the eight essential elements of care must be provided at the initial point of contact with the community. For those countries that provided information,
the situation revealed by the indicators on the delivery of the essential elements of primary health care is very encouraging. Ten out of fifteen
indicate that at least 80% of their population are within 15 minutes' walking distance of a safe water supply. In seven out of thirteen
countries, at least 80% of the population have adequate sanitary facilities at or near their homes. All the seven countries or areas reporting
indicate that 80% or more of their infants are fully immunized against all diseases in the expanded programme on immunization. All the eleven
countries or areas reporting indicate that at least 80% of the population has access to health care, including availability of at least twenty essential drugs. Nine out of twelve countries indicate that 90% or more of Eleven out
the women were attended by trained personnel during pregnancy.
WPR/GPW/85.3 page 26
of fourteen indicate that at least 80% of deliveries are attended by trained personnel. And seven out of nine report that at least 90% of
infants are cared for by trained personnel.
A number of significant changes are taking place· in the health systems of the Region to support further improvement in the delivery of essential care. One group of changes is concerned with the issue of For the smaller countri e s of the Region, this change is In both
decentralization.
best illustrated by Papua New Guinea and Solomon Islands.
countries most of the central government functions and services are being decentralized to provincial level. In both countries a priority issue ~s
to work out the appropriate role between the central and provincial bodies. In the Philippines, decentralization of authority is also
occurring but in the context of a comprehensive reorganization of health serv1ces.
Malaysia has set in motion a very significant s t ructural change i n i t s h ea lth system. Again more decentralized authority in the delive r y of
services is taking place, but in addition the Government is attempting to allot a larger share of responsibility for the health services to the pr i vate sector. China is a country with pla ns fbr both struc tural For example, within the
reorganization and expansion of servic e s.
framework of broad government policy, the heal t h sector is permitting more decision-making on health serv1ces to take place at lower levels of the sys t em.
WPR/GPW/85.3 page 27
In other countries, particularly the small island nations where coverage is at present relatively good, the priority concern the quality of services. ~s
to improve
The principal approach adopted by these countries
is to upgrade the quality of manpower and expand the use of community-centred primary health care workers.
A major obstacle for countries or areas attempting to introduce significant changes in the health system is the difficulty in influencing existing structures and decision-making processes to confront the new types of problems that emerge with these changes. Even for those countries where
the issue is primarily quality of care, it is still the existing decision-making processes which constrain progress. For example, if
personnel evaluation methods do not include quality of care as an integral component of a worker's job, it is quite difficult to institutionalize quality of care in the health system.
A significant development in the Region is the attempt by the health authorities to be more interactive in the political process. the Region the political issues are economics Throughout
(in the larger countries,
for example, to reduce costs) or more and better services (primarily in the smaller countries). A typical trend in the political process is the
apparent increase of political power away from the traditional power centres of the capital or major cities. The challenge for health
authorities is to find solutions which are a compromise between bureaucratic responses frequently proposed by politicians and solutions that are more in line with the regional health-for-all strategies.
WPR/GPW/85.3 page 28
2.3
Managerial process
The strengthening of health managerial processes 1n the Region falls into two approaches, again following very closely the apparent perspective of each country or area on the role of health in development. The largest
number of countries see managerial processes as an improved planning function and an administrative procedure for using information on the performance of service activities. In this group there has been Notably in the small
significant improvement in the planning function.
countries with centralized authority, more health staff are involved in planning, more personnel have been trained in planning , the plans are more comprehensive and the scope of collected information has been expanded to include communities. There has also been progress in the review and ~n
evaluation of implementation based
plans.
For those few countries that
have not developed a comprehensive national health planning function, major progress has been made in the planning, rev1ew and evaluation of health programmes.
In China and Papua New Guinea, for example, the traditional health planning and review perspective is the dominating force in the managerial process; however, they have decentralized the responsibility for planning together with other management functions.
The second approach to introducing a managerial process, exemplified by Kiribati on a small scale and Malaysia on a larger scale, is concerned more with how decisions are made and who makes them, in contrast to the former approach, which is concerned with the type of decision made. Two
WPR/GPW/85. 3
page. 29
characteristics of this second approach to the managerial process are predominant: (1)
planning is a continuous activity at all levels of the planning and Malaysia
health system with intersectoral involvement, and (2)
operational decision-making are integrated, again, at all levels. has not achieved all it desires in terms of an effective managerial process. However, many issues it has identified, such as improved
information support, intersectoral and agency coordination at high levels, and more decentralizat i on, are being actively addressed.
2.4
Supporting legislation
Some countries or areas in the Region have taken action on health legislation. Countries or areas that have sought WHO support for this
purpose are Lao People's Democratic Republic, Macao, the Republic of Korea and Vanuatu. Vanuatu has continued to undertake a comprehensive review of Macao has drafted
its health laws and has drafted proposed legislation.
basic legislation on such subjects as health policy and strategy formulation, health systems, and mechanisms for community involvement and intersectoral collaboration. Lao People's Democratic Republic has begun to
review and draft legislation directly or indirectly related to occupational health and environmental health issues. The Republic of Korea, in
connection with the review of policy and operations of its medical insurance scheme, has identified certain areas where health legislation support will be needed.
WPR/GPW/85.3 page 30
A number of countries or areas are introducing new approaches to the delivery of health care which will need legislation for their continued support. However, as it takes some time to fully develop such approaches,
countries are allowing for a sufficiently long test period before preparing the necessary legislation that will institutionalize the approach. Examples of approaches which need legislative support are the assigJ;llllent of curative responsibilities to health workers at the periphery, who, by existing laws, are not authorized to carry out such functions, and the practice of acupuncture.
2.5
Community involvement
Efforts to increase the involvement of people and communities in matters of health and development are making significant progress in the Region.
The scope of community involvement is dependent on the health system's perception of the role of the community in matters related to health. group expresses the need for couununity involvement in order to provide information for planning and to cooperate in the provision of services. Another group sees the role of the community as a catalyst and opinion leader. Clearly, both views find some degree of expression in most In most cases, however, it is One
approaches to community involvement.
possible to see one dominating view, which gives a clue to the system's overall perspective of health and development.
WPR/GPW/85.3 page 31
Some mechanisms for community involvement have a long history in many countries. Most countries are attempting to improve on the effectiveness
of the traditional groups and many new types of community mechanism are being attempted. Health planning committees, wellness task forces,
programme advisory bodies, village welfare groups, village women committees, local and area health councils, consumer groups and councils are examples of such mechanisms.
The majority of countries report health education as the principal strategy for promoting community involvement. It appears that the most
effective way to foster community involvement was found to be through local seminars and workshops. An exchange of views in the local setting enhances
the chances for positive results.
Two main constraints are frequently noted by health personnel as limiting community participation. First is the community's idea that the second, traditional Both these ~n
government should provide all the health services;
customs and beliefs held on the cause and nature of ill health.
points are significant barriers to the development of self-reliance community. Most countries are well aware of this dilemma and four
a
approaches have emerged as ways to overcome the problem:
(1) working more (2) using
closely with the community (promotion and confidence building); the local power structures; production and distribution; {3) improving appropriat~
information
and (4) establishing coordinating committees
focused on community involvement concerns.
WPR/GPW/85 .3
page 32
2.6
Health lla$-npower
The dominant theme of health manpower plans throughout the Region is to increase the productivity and effectiveness of existing pe.rsondel. There are two exceptions to this position. One concerns countries that are
in a rehabilitation atage where there is a severe shortage of all resources, including health manpower. The other concerns sotDe newly
independent island countries faced with a shortage of national health personnel, especially physicians, for example, Vanuatu and Solomon Islands. For such countries, increasing the $-bsolut:e number of pers.o nnel The
is still a priority. However, these are clearly the exceptions.
national policy in most countYies is to severely limit, if not reduce, the expansion of the public service. Such a policy can act as a definite brake
on the development of a health system unless the policy is accompanied by administrative procedures which allow for the restructuring of manpower patterns that are more in line with the requirements of the primary health care approach.
The political concern with limiting the expansion of the public serv1.ce, coupled with the recent economic setbacks, has motivated countries to undertake more comprehensive reviews of their health system. of these reviews is health manpower. One aspect
The range of approaches emerging from the current emphasis on manpower planning is quite comprehensive, even though an individual country may not have adopted all the approaches. The most common approach used to improve There
the effectiveness of manpower is based on some aspect of training.
WPR/GPW/85.3 page 33
is a significant increase in the use of in-service and retraining programmes. In China, for example, a major programme is the upgrading of
the technical skills of the barefoot doctor, who will now become a village doctor.
The reorientation training of most countries or areas now places equal emphasis on supervision and management. This reflects a common assessment
that additional gains in productivity and quality of care will derive from more effective supervision. Not all countries have made an analysis of Malaysia and
their system to define just what improved supervision means.
Papua New Guinea, on the other hand, have recognized that increased emphasis on supervision should be accompanied by a better classification of work, revised job descriptions, tasks, and objectives for the health worker.
In most countries, the nurse and allied health personnel are the backbone of any primary health care activity. The role of these health
workers varies from country to country; however, they commonly provide service, supervise other primary health care workers or village health workers, and cooperate with community organizations in health development activities. Few traditional nursing curricula provide exposure in these This deficiency is now being addressed in many countries. To address the
last two areas.
In the short term, retraining courses are being conducted.
same issue in the long term, the basic nursing curric,ula is being reoriented to provide training for the appropriate role the nurse ts expected to perform. Vanuatu is taking an additional development step by
assigning a reoriented nurse as the head of district services, replacing the traditional medical officer.
WPR/CPW/85.3 page 34
In addition to training, a number of countries are attempting to improve the effectiveness of their manpower through l)lanag~ent
changes.
While decentralization is a common approach to improving the effectiveness of the overall system, it is also anticipated that this will improve the utilization of manpower. In China, for example, responsibility for the Two problems in the
production of manpower is also being decentralized.
area of personnel management are being encountered with respect to decentralization. One is uniformity of personnel policies. Malaysia is
confronting this is•ue through the use of staffing standards and improved personnel evaluation procedures, including better promotion and career development schemes. The second problem of decentralization, particularly
for the smaller countries, concerns the development of mechanisms to ensure equitable distribution of the skills that are needed throughout the country. This can be done through reporting and feedback systems which
provide the decentralized agencies with the information needed for making their personnel decisions.
The reorientation of health manpower development to fit the needs of the reoriented health system in line with the primary health care approach is a task for almost all countries. It appears that training institutions
need to review their mission in order to be able to anticipate future health manpower requirements and to cooperate with health services in staffing them with the right personnel.
WPR./GPW/85 •.3
page 35
Some countries have felt the need to coordinate better the different phases of the health manpower development process. In Lao People's
Democratic Republic, for example, planning, training and continuing education will be coordinated within a unit of the School of Public Health. There is a move in other countries to follow a similar direction.
2.7
Mobilization of resources
The regional strategy indicates that, for the effective generation and mobilization of resources:
measures will be taken to promote community involvement, information on detailed resource requirements will be prepared, and mechanisms will be developed to effectively use and coordinate whatever funds become available. 1
A positive trend is reflected in the current evaluation reports concerning action to mobilize and use resources. Earlier, it was a common It ~s
feature to attribute poor implementation to limited resources.
no¥;
quite apparent that a more realistic approach is being planned for generating and mobilizing resources for health development.
lRegional strategy for health for all by the year 2000. World Health Organization, 1982, p. 46.
Manila,
WPR/GPW/85.3 page 36
The majority of
~ountd,f!$
in the Regi.o n eurreatly alloccte a The
reasonable percentage (5%) of gross national product to health. exception to this concerns th~
poorest countries in the Region and a few
countries that have been moat severely affected by recent economic hardships. Consequently, ttany countries a.r e realizing that the growth in nation~l
available resources for health is linked to overall growth.
economic
The implication of limited economic growth is that health
authorities must make better allocations and ensure more effective use of the resources that become available.
A common feature of budgeting procedures in the past was simply to add a percentage increase to the previous year's budget in preparing estimates for the following year. Countries now realize that this procedure
propagated ineffectiveness, i.e. the proportion of funds allocated to expensive services remained the same, making it difficult to increase services to underserved areas. As a result of this assessment, countries
are now attelllpting t .o develop a resource allocation process designed to influence the appropriate development of the health system. countries have been able to make this change effectively. Not many Papua New
Guinea, however, has been able to influence the allocation of financial resources in a positive way. It has been able to stop the growth in
hospital expenditures, for exatllple, devoting most of the increase in resources to the underserved segments of the rural areas. Most countries
in the Region do not have an accurate financial plan for their health system. The first step in developing an improved allocation process is to Malaysia, for example,
determine what the current financial situation is.
WJ!B/QPVI/85 • 3 page 37
has started a very comprehensive study of currellt health
s~r.vices
financing
and has also instituted improved prograJEe budgeting and monitoring procedures. This is the second step of the allocation process, namely, to
be able to provide information to manage the implementation of allocations. The Philippines, Solomon Islands and Vanuatu are also taking
steps to improve their knowledge of what is being accomplished with the money spent on health.
Most countries recognize an imbalance in the distribution of resources. As noted above, it is only very recently that studies have been
undertaken and changes made in the reporting systems to provide needed information for decisions to correct these imbalances. In the larger
countries, notably Malaysia and the Republic of Korea, the strategy is to change the way the health system is financed as a means of ensuring equity in the health sector. These countries also realize that concomitant
measures must be incorporated into management procedures to ensure that the appropriate type of care is available and used. These measures apply
particularly when the financing approach involves some form of health insurance programme.
There has been marked improvement in the way specific health programmes are being planned. In the formulation of projects, more In
emphasis is now placed on multisectoral involvement and participation.
Fiji, Kiribati and Vanuatu, for example, if the question of self-financing after the initial investment period cannot be resolved adequately, the
WPR/GPW/85 • .3 page 38
activities are not started.
In addition, very few countries now Utl.dertake
expansion programmes - especially out of external funding - if handling of operational expenses cannot be adequately incorporated into the recurrent budget.
2.8
Health care
The delivery of health care in the Region is assessed in terms of coverage provided, how well it is utilized and the quality of care given. As indicated by the progress achieved in meeting the regional criteria on essential primary health care services (see section 2.2), most countries or areas are satisfied with their health care strategy. The main exception
again applies to those few countries which are in the process of rebuilding their basic health delivery infrastructure.
This does not mean that further developments are not expected, quite the contrary. countries: scatter~d
Coverage, for example, is still a concern in many
in small island countries which have many sparsely populated islands, and in any country which has areas that lack minimum A second aspect of coverage
transportation and communication facilities.
which remains a persistent problem concerns population target or risk groups. These are groups which either are at a higher risk and in need of
special care or do not have, for social or economic reasons, equal access to care. Many of these target groups are now emerging in urban areas. For
both of these problems, the solutions are not completely dependent on financial resources. On the one hand, the expansion of the services
approach is often very costly and, on the other, the traditional delivery
WPR/GPW/85.3 pag.e .39
system has been found to be simply not effective in handling these problems, for example, in difficult urban areas. Consequently, the
solutions most often involve an effective primary health care approach using community involvement.
Many country reports indicate that the next phase of development to achieve better coverage must include approaches which go beyond the simple expansion of facilities. Today, development activities are giving equal
emphasis to technical and management upgrading of personnel skills. Emphasis is also being placed on assessing the appropriateness of the technology that is being used.
Appropriate technology applies to all levels of the delivery system
' and concerns the simplest as well as the most sophisticated health care. Three principles are used by countries to make better decisions on the appropriateness of technology. First, at the primary health care level,
health technology must be considered a resource to be shared equally by the community and the health system and not one for the exclusive use of the h~alth
system.
Second, there
~ust
be more interaction within the health
system to reach a consensus on the technology to be applied. If effective, this will reduce much of the duplication that now occurs in technology application. Third, there should be decision-making procedures for
selecting the level of sophistication in technology that is appropriate for the country. Decisions on this matter will obviously have to take int-o
account other social and economic issues and therefore require coordination and cooperation beyond the health system.
WPR/GPW/85.3 page 40
Most countries are reasonably satisfied with the progress being made in the utilization of the essential elements of primary health care serv1ces. Emphasis is now placed on directing the primary health care
approach to priority health problems in the community, and being responsive to changing conditions. This emphasis applies as much to countries where
communicable diseases are a concern, such as Papua New Guinea. as to countries where noncommunicable diseases are emerging as priority health problems. Again, it appears that countries adopting a partnership evolve the more effective
perspective in their work with communities will
solutions for handling these difficult health issues.
Many countries are increasingly concerned about the proper utilization of large hospitals. The demand for services provided by large hospitals 1s As noted previously, with the constraints on
growing significantly.
increasing manpower or financial resources, countries must find alternative solutions to meet this demand. Malaysia, for example, has been able to Some
significantly reduce the average length of stay in some hospitals.
countries (Philippines, Republic of Korea) have found that much of the demand at the major hospitals is simply not appropriate for that level of care. Other governments are questioning why people bypass certain It appears that
institutions, e.g. health centres and district hospitals.
the fundamental cause of this problem lies in the perception of an individual's right to receive the "best" care. Countries are seeking a
balance of approaches to obtain more effective utilization of services: mainly, incentives (positive and negative) to follow referral procedures, and promoting community awareness that the use of the most appropriate level of care is best for everyone.
WPR/GPW/85.3 page 41
The development of quality of care in the Region progresses in three stages. The first stage is the effective delivery of the eight essential The main indicator of progress in this As previously noted, with the exception infrast~ucture,
elements of primary health care. stage of development is coverage.
of the few countries that are rebuilding their health
countries of the Region are reasonably satisfied with the progress in increasing coverage.
The second stage is to improve the application of the technology and procedures in providing services. The main approaches used in this stage
include training, supervision, management, logistic support and reorganization of the health system based on primary health care. This
stage is exemplified by most of the small island countries and Papua New Guinea. These countries or areas are revising the basic nursing
curriculum; conducting training courses on supervision; upgrading their logistic and other support services; and improving their information and reporting procedures in support of primary health care.
The third stage of development is the establishment of a comprehensive quality of care assurance activity. Malaysia, for example, is in the This stage gives attention
process of institutionalizing such an activity.
to the development of standards of care and appropriate performance measures to assess quality of c:are. Additional courses of action may also
be required such as professional licensure, facilities accreditation and peer review mechanisms.
WPR/GPW/85.3 page 42
2.9
Health research
There is growing recognition in the Region of the important role that scientific research plays in planning development by providing guidance on how to handle major health issues. Nonetheless, it is primarily in the
developed countries that attempts are being made to formulate comprehensive research policies that are related to national development priorities. However, Malaysia and the Philippines are setting an example on how to coordinate research and prioritize research studies in relation to the national development plan, by establishing national coordinating bodies to outline policy and give direction for research activities.
Biomedical research has focused mainly on tropical diseases, priority being given to malaria. A number of significant results have been achieved
and further research is expected to yield scientific breakthroughs which may have a global impact. For example, Qinghaosu, an active compound which
was isolated from a herb, qinghao (Artemisia annua), in China, and its derivatives, have completely different chemical structures from other known antimalarials and are effective against chloroquine-resistant malaria. These properties justify the high priority given to the development of these compounds. Current studies on the series of these drugs include:
production and standardized preparation of artesunate and artemether according to internationally recognized methods.
WPR/Q¥W/85.3 page 43
Numerous laboratories are actively investigating various aspects of malaria immunity. sci·entists at the Walter & Eliza Hall Institute,
Melbourne, Australia, have succeeded in the cloning of DNA from the blood stages o.f Plasmodium falci2arum. The many clones producing antigens were
detected by screening with immune human sera.
The Malaria Eradication Service of the Philippines has been producing macro and micro test kits which are used to determine the resistance of
f·
falciparum to antimalarial drugs.
These kits are available for
distribution to scientists throughout the world.
In the context of filariasis, an in vitro culture technique was developed by the Institute for Medical Research, Kuala Lumpur for the production of fourth-stage larvae of Brugia malayi and
.!!· pahangi.
Stage
specific antigens, including moulting fluid, excretory and secretory antigens, are produced in the cu l tures and are important for use in irrnnunological studies.
There have been a number of research activities in the Region concerned with operational problems in the delivery of services. These
activities deal principally with the integration of traditional health programmes and vertical programmes into a primary health care approach, e.g. family planning and disease control programmes. On a larger scale, in
the Philippines, Malaysia and the Republic of Korea, major projects have
WPR/GPW/85.3 page 44
been undertaken to examine the delivery of health services.
The results of
these studies have contributed to significant changes in the allocation of tasks between services and types of personnel, integration of preventive and curative services and, in general, more effective management of services.
Research and development focused on the introduction of primary health care in the health system has been successful in Papua New Guinea, the Philippines and the Republic of Korea. The emphasis of this research has
been on obtaining connnunity involvement in a wide range of decisions related to health matters. Research and development in primary health care
approaches to urban health problems is also being conducted in the Philippines and the Republic of Korea.
Progress in behavioural research has lagged behind the achievements in other research fields. However, with the recognition that many of the
factors influencing change in the application of technology, community involvement, management and supervision are behavioural or social in nature, there has been a trend to include behavioural aspects in the research design of a problem.
Two main problems have been identified as major constraints on the effective use of research in support of health development: the generally
poor organization and coordination of research activities, and the lack of personnel skilled in research methods.
WPR/GPW/85.3 page 45
Malaysia has taken a positive step to resolve the problem of non-integratiOn. of research results into management decision-making. workshop was held for all parties involved in health systems research, through which it was possible for universities, res-earch institutes, hospitals and the Ministry of Health to examine Ciay's of coordinating the many research activities conducted in the country. Coordination of A
research work is a particularly significant problem in the larger countries. Traditionally, universities, research institutes and government This
agencies have adopted the approach that research is an end in itself.
situation is recognized as being counterproductive and various methods, as noted for Malaysia, are being taken to bring about improved coordination.
The second problem noted by countries is the lack of skilled personnel to undertake research. problem. In the smaller island countries, this is a real
However, in the larger countries, it is more a question of
coordination of resources than the lack of any one resource, such as personnel. Consequently, for the smaller countries which have recognized
the need to become more active in conducting research, such as Fiji, an approach is being used which begins by studying smaller problems that can lead to the strengthening cf research capabilities as well as the obtaining of new information on a priority issue.
WPR/GPW/85.3 page M>
2.10
Coordination within the health secton sectors and countritu~
collaboratio~
with other
A cOJillllOn theme expressed in most country or area reports is that the next significant gains in achieving health-for-all objectives will come about through improved management. A specific task within the management
function is to strengthen coordination within the health sector as well as with other sectors. The generally accepted strategy is that the health
sector must take the lead in advocating intersectoral coordination for health.
It
is anticipated that the general pattern of decentralization that is
occurring in some countries will significantly contribute to improved coordination. This assessment follows from the general phenomenon that the
lower levels of an organization have fewer bureaucratic constraints. Conversely, it is the bureaucratic behaviour of central level bodies that hampers the effective coordination of activities. A wide range of
approaches is being employed by countries or areas to improve coordination, many of which are specific to meet local situations. approaches can be observed. However, a few common
One is to improve the communications and flow It is frequently noted that
of information within the health sector.
information concerning the government's position and strategy on primary health care should be more broadly disseminated. Improved communication
within the health sector is also encouraged to avoid duplication of efforts.
WPR/GPW/85.3 pag~
47
Some countries, for example, Malaysia, Solomon Islands and Tonga, have noted that, as a result of increased attention being given to up<Jating job descriptions and clarifying roles, there has been improvement in coordination.
Traditionally, the health sector has always worked with other sectors. The development of health-for-all strat-egies has highlighted the
importance of strengthening collaboration with these traditional partners in health. In this respect, most countries or areas in the Region have
been collaborating with other national agencies responsible for agriculture, fisheries, education, waterworks, environment protection, family planning and church organizations. The main areas of collaboration
relate to nutrition, school health, water and sanitation, health education and family planning. The need to improve nutrition, water supply and
sanitation seem to have been the motivation for intersectoral collaboration in most of these countries. The need for further collaboration is observed
in Singapore with regard to housing and in Malaysia with regard to labour and local governments.
Many of the constraints on effective intersectoral collaboration are similar to those found to be hampering effective sectoral coordination; however, they are accentuated at the intersectoral level. These
constraints include differences of opinion, definition of roles and responsibilities, and bureaucratic procedures for sharing information and making decisions. A major problem relates to the lack of a formal approach
to develop and strengthen intersectoral collat;,oration · in the context of the
WPR/GPW/85.3 page 48
managerial process.
Measures to ensure intersectoral action are usually
established on an ad hoc basis, as for example in joint sponsorship of workshops, training activities and circulation of annual reports, bulletins and newsletters.
The simultaneous establishment at all levels of mechanisms for intersectoral collaboration has been found to be effective, particularly when this is preceded by top level administrative coordination among the agencies concerned.
Governmental directives are often used to sanction the establishment of interministerial groups to monitor the implementation of development activities. Major factors contributing to the incorporation of a health
component in development schemes are the early and active participation of the health ministry in project planning and implementation, involvement of village organization groups, and good personal relationships. It is also
important that explicit arrangements be made in the development plans for intersectoral collaboration , as in Fiji, Guam, Kiribati and Malaysia.
As these developments take place in countries or areas, intersectoral collaboration is also promoted by international agencies at intercountry or regional level. The Association of South-East Asian Nations (ASEAN),
Pacific Basin Economic Council (PBEC), South Pacific Bureau for Economic Cooperation (SPEC), Economic and Social Cormnission for Asia and the Pacific (ESCAP) and the South-East Asian Ministers of Education Organization (SEAMEO) have been active in encouraging increased dialogue among countries
WPlt/GPW/:a 5 • 3 page 49
in an interse-ctoral context.
The Asian Development Bank and the World
Bank, through their manner of financing health development p'l'ojects, are also contributing to collaboration between the health sector and other sectors.
2.11
WHO cooperation
2.11.1
Implementation of national strategies
Regional Office support has been extended to governments in formulating, implementing, monitoring and evaluating national strategies through WHO Programme Coordinators, Country Liaison Officers and regional and intercountry staff. Intercountry teams have provided support to the
managerial process for national health development, resulting in the production of materials . that form the basis of national and local health plans.
There has ·been a significant increase in the emphasis placed on research and management in WHO's collaboration. Attention has focused on
the management of health programmes rather than the improvement of technical skills. This collaboration applies, for example, to malaria,
maternal and child health, environmental health and leprosy. In the South Pacific, the development of a group of national staff has contributed to the preparation of training materials to improve the effectiveness of management functions in sucha:teas as drug supply, planning. s~pervision
and district
WPR/GPW/85.3 page 50
The principal regional mechanism for promoting and coordinating medical research is the Western Pacific Advisory Committee on Medical Research, wl,ich meets annually. The promotion of relevant research as well
as the development of national research programmes have been undertaken through various activities, including the Working Group on National Health Research Management, the Scientific Group on Research Needs for Health for All, the Working Group on Indicators for Monitoring and Evaluation of Strategies for Health for All, the Scientific Group on Viral Hepatitis B and its Related Liver Diseases, and the Meeting of Principal Investigators of Acute Respiratory Infection Studies.
Research and development projects on primary he-alth care have significantly contributed to increased knowledge on appropriate technologies and to intersectoral collaboration in Kiribati, Malaysia, Papua New Guinea, the Philippines, the Republic of Korea and Vanuatu, among others.
Various intercountry and national training activities have been conducted for the reorientation of health systems towards primary health care. Institutions are being encouraged to establish new training Modifications of existing
programmes in this reorien.tation effort.
curricula or new curricula for health staff have been introduced in some countries, such as Fiji, Kiribati, Papua New Guinea, the Philippines, the Republic of Korea, Samoa, Solomon Islands, Tonga and Vanuatu. The
promotion of reoriented training prograuunes has taken place during the country visits of members of the Sub-Co.m mittee on the General PrograDBne of Work, and during meetings of deans of schools of public health and dentistry and directors of nursing schools.
WPR/GPW/85. 3
page 51
WHO has collaborated with national authorities in preparing proposals for external funding for health. It has been very active in providing
support in the preparation of technical documents required by the World Bank and the Asian Developm~nt
Bank.
In addition, support has been
provided to countries in the preparation of proposals to UNFPA, UNICEF, UNDP and 1n bilateral negotiations.
2.11.2
Development and implementation of the regional strategy
Based on the synthesis of submissions from individual countries or areas, the Regional Office formulated the regional health-for-all strategy. Subsequently, countries submitted reports on their monitoring 1n
1983 and on their evaluation in 1985.
A key element of Regional Office support to the regional strategy LS
the maintenance of contacts with various agencies and organizations. Contacts with United Nations and other agencies such as UNICEF, UNFPA, SPC, SPEC and ESCAP have continued.
Liaison has been maintained with nongovernmental organizations having official relations with WHO. These organizations have been invited to
attend sessions of the Regional Committee, seminars, working groups, scientific groups, etc. Contacts are also maintained through
correspondence and briefings give.n to representatives who visit the Regional Office and through WHO Programme Coordinators.
WPR/GPW/85..3
page 52
A rev1.ew of the regional mechanism for exchange of information has revealed the need to accelerate activities for its development. As part of
its regular activities, WHO has compiled information on the socioeconomic situation in the Region, maintenance and distribution of country health information profiles, surveillance reports on communicable diseases and reports of WHO meetings.
A regional biomedical information programme to establish a network of library service centres has been under development since 1981. As part of
the programme, MEDLARS/MEDLINE services are provided to countries or areas under a special agreement with the Government of Australia. A list of
individuals or groups capable of serving as resource persons in support of the regi o nal strategy is availab le. A registry of research activitie s
(bi omedical, health systems) has aLso been developed.
The Tokyo Confe rence, c onvened 1n April 1985 to discuss new strategies for meeting future medical manpower ne ed s, 1s an example of how WHO uses a regional forum to address major development issues. The Declaration of
Tokyo outlines directions for the deve lopme nt of health manpower, including the contributions of training institutions, professional bodies and policy-maker s i n bringing about changes needed to supply manpower suited t o meet the future needs of society.
WPR/GPW/85. 3
page 53
2.11.3
Effectiveness of WHO collaboration
The regional strategy outlines the priorities for WHO collaboration 1n terms of support measures, generation and mobilization of resources, collaborative~eb4utisms,
and monitoring and evaluation.
These priorities
form the basis of WHO's regional medium-term programmes and biennial programme budgets.
WHO has been effective in mobilizing financial resources.
I t has
maintained effective relations with the developed countries of the Region, which contribute to the external funding that goes into the health sector. WHO
has also been able to mobilize financial resources from outside the Through its coordinative efforts in the planning and
Region.
implementation of external resources, the use of external resources has been enhanced. WHO
also plays an active role in support of bi-latera-l
negotiations and collaborates in national projects supported by international banking agencies.
WHO has promoted the need to enlist a wider base of political support
for national health-for-all strategies, but recognizes that much more remains to be done in this area.
As mentioned in other sections of this report, there has been a significant improvement in the planning function of most countries or areas of the Region. WHO has contributed to this progress through national
training workshops, intercountry meetings and direct collaboration in the preparation of national plans.
WPR/GPW/85.3 page 54
The present trend is to discontinue the use of long-term staff assigned to field projects. This trend refle.c ts the impact of WHO
collaboration with countries or areas in the development of national capabilities in various fields. WHO collaboration is prima.r ily impleGlented Such support
through short-term consultants and visits of regional staff.
focuses on specialized technical and managerial problems associated with the implementation of national development strategies. In addition,
collaboration is frequently provided in the form of supplies and equipment to support the needs of programmes that are being managed by personnel formally trained through WHO support.
Significant progress has been made in WHO's collaboration in support of the implementation of priority technical programmes. For example, the
expanded progratmne on immunization, water and sanitation, malaria, nutrition, and human resource development continue to be recognized by countries or areas as contributing to priority health-for-all programmes.
WPR/GPW/85.3 page 55
CHAPTER 3.
PATTERNS AND TRENDS IN THE HEALTH STATUS
3.1
Patterns and trends 1n morbidity, disability and mortality
In the majority of the countries or areas in the Region, the infant mortality rate is lower than the global target of 50 per 1000, although two countries continue to record a rate of over 100. Life expectancy at birth
is above 60 for most countries or areas with a range of about 44-77 for those that have relevant data. The situation regarding infant mortality
and life expectancy seems to be improving based on a comparison of data supplied in 1983 in national monitoring reports and in 1985 in national evaluation reports. There is a wide range in the maternal mortality rates
among countries in the Region varying from 0 to 5 per 1000 live births. However, most of the countries showed a maternal mortality rate below the regional target of 3 per 1000.
Low birth weight as an indicator of the risk to survival and healthy growth and development is conditioned by the health and nutritional status of the mother. Available data indicat~
a wide variation among countries or
areas in the Region with respect to low birth weight, ranging from 0.4% to 25% of live births. 1 A redeeming feature of the situaLon is the
lsee Malnutrition, growth and development - Technical discussions (WHO document WPR/RC35/Technical Discussions/1), 1984, p.5.
WPR/GPW/85.3 page 56
increase s1nce the earlier monitoring report in the number of cQuntries or areas with at le4st 90% of newborn infants having a birth weight of at least 2500 grams.
Protein .energy malnutrition is generally assessed through surveys using weight-for-age standards. The proportion of children under 5 years
whose weight-for-age is below 80% of the standards :Ln some of the developing countries or areas varies from approximately 5% to 44%. 1 again the comparison of prevalence rates over time of protein energy malnutrition among children indicates that the situation has not worsened among developing countries or areas in the Region. However, because of Here
population growth, there was a slight increase in the absolute number of malnourished children under 5 years compared with the situation ten years ago.
With regard tonutritional anaemia, the percentage of women aged 15 to 49 years with haemoglobin concentration below the normal varies from 26% to
77% among pregnant women Kll grams per 100 ml) and from 37% to 72% among non-pregnant women kl2 grams per 100 ml). Progress in the control of non
deficiency anaemia has been hampered by a number of factors, including the low rate of absorption of iron, long duration of treatment and frequency of side effects. Iron fortification of food, for example, rice measures to
overcome the effects of iron losses due to parasites, and promotion of less
lrhid., pp. 6-7.
WPR/GI'W/85.3 page 57
frequent pregnancies are some of the new initiatives in this regard. Estimates of the population at risk for iron deficiency diseases (IDD) indicate that more than 200 million people in six countries of the Region are at risk.
Endemic goitre is still a problem in some countries such as Fiji and Papua New Guinea, owing to a diet low in iodine in certain parts of the country. Xerophthalmia, an eye disease caused by vitamin A deficienc y, 1s
also seen as a serious public health problem in some countries such as Fiji, Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam.
In many countries or areas of the Region, with the decline in mortality fr om communicable diseases, a new public health problem has emerged: increas ing morbidity and mortality from noncommunicable diseases. It appears that the most significant other noncommunicable diseases are di a betes mellitus a nd rheumatic diseas e s.
Diabetes mellitus is very common among the Polynesian and Melanesian populations, a s in Fiji, Samoa ::m d Tonga . Indications are that t he
prevalence of this disease in these countries may be higher than in mos t o f the western countries. Studies have implicated c ertain environmenta l and The s e
behavioural factors in the cause o f major noncommunicable diseases. factors include:
obesity, die t (high in calories, animal fat , s ucrose ,
salt and low in complex carbohydrate and fibre), lack of physical activi ty, tobacco smoking, excessive alcohol and psychosocial stress.
WPRlCPW/85 .3 page 58
Crude death rates have declined throughout the Region during the last decade and the present rates vary from less than 5 per 1000 to more than 10 per 1000. A recent review of mortality trends confirms that at least 1.n
some developing countries like China, Papua New Guinea, Philippines, Republic of Korea, Singapore and Viet Nam, the reduction of mortality has been striking. This downturn in crude mortality may be due, among others,
to the introduction of comparatively cheap and effective technologies for the control of disease vectors, immunization and effective disease treatment. 1
The differences in the leading causes of death and illness
in the Region give some indication of the disparity in levels of development among different countries. For example, a high incidence of
communicable diseases and malnutrition is to be found in countries at the lower levels of development. In more developed countries, the principal
causes of death and illness are chronic degenerative diseases and accidents. In certain countries, however, where communicable diseases are
th e leading causes of death, chronic degenerative diseases and accidents have reached such a proportion that they are regarded as a serious public health problem.
The principal communicable diseases in the Region are acute respiratory infections, diarrhoeal diseases, tuberculosis and malaria. Hepatitis B virus infection and dengue fever have likewise become important public health problems. Lack of safe, accessible drinking water and
lsee Ruzicka, L.T. and Hansluwka; H. A review of evidence on levels, trends and differentials since the 1950s. In: !'lortality in South and East Asia A review of changing trends and patterns, 1950-1975. Manila, World Health Org~nization, 1982.
WPR/GPW/85.3 page 59
inadequate waste disposal have contributed to the high incidence of diarrhoea and favoured the high incidence of intestinal paroiisitism and skin diseases. Inadequate knowledge of sound nutritional habits in conjunction
with the high incidence of diarrhoea have resulted in malnutrition being a leading cause of illness in the Region as well.
In the developed countries of the Region, the common causes of illness and death are cardiovascular diseases, hypertension, cancer and accidents. Communicable diseases are of such low incidence that they are not considered a major health problem. Environmental pollution, health
problems of the elderly, mental health and drug- and alcohol-related problems are all major concerns in the developed countries and are now causing concern in developing countries also.
The incidence of diphtheria, tetanus, pertussis and poliomyelitis under 1 per 100 000 in five countries or areas - Australia, Hong Kong,
1s
Japan, New Zealand and Singapore - accounting for about 11% of the regional population. For these countries, the average annual incidence during
1978-1982 of measles was, however, 24 per 100 000 and of tuberculosis about 62 per 100 000. For countries or areas with a population of less than one
million, namely, American Samoa, Brunei Darussalam, Cook Islands, Fiji, French Polynesia, Guam, Kiribati, Macao, Nauru, New Caledonia, Niue, Samoa, Solomon Islands, Tokelau, Tonga, Trust Territory of the ,Pacific Islands, Tuvalu , Vanuatu and Wallis and Futuna, which account for about 0.2% of the regional population, diphtheria and poliomyP.litis are under control. The
WPR/GPW/85.3 page 60
annual incidence o.f tetanus was 1.7 per 100 000, of pertussis 52 per 100 000, of measles 374 per 100 000 .and of tuberculosis 154 per 100 000 for
these countries.
For the remaining eight countries, namely, Chixta,
Democratic Kampuchea, Lao People's Democratic Republic, Malaysia, Papua New Guinea, Philippines, Republic of Korea and Viet Nam, comprising 89.1% of the regional population, immunization target diseases still represent health problems giving an average incidence per 100 000 of 2.1 for poliomyelitis, 8.8 for tetanus (excluding China), 9.6 for diphtheria, 196 for tuberculosis, 222 for pertussis, and 252 for measles.
It is estimated that there are more than 100 million people with some form of disability in the Region, many of whom live in the rural areas of developing countries or areas and have relatively poor access to organized health care. The nature and extent of the problems of the disabled are a~curate
poorly understood in many countries and there is a dearth of
epidemiological information on which comprehensive planning could be based. In the past, care of the disabled has been split between special
interest groups according to the nature of the disability and little effective coordination has occurred at government level. Where such
support has been possible, it hasoften been fragmented between health, welfare, labour and other ministries.
In most countries or areas, rehabilitation has been most closely identified with long-term institutional care, mainly associated . with hospitals, long stay homes and special occupational centres. In recent
years, the development of physical medicine within general and orthopaedic hospitals has added to institutional facilities but little attention has been given to community care.
WPR/GPW/85.3 page 61
The major causes of disablement in the developing countries or areas of the Region, accounting for up to 70% of all disabilities, are malnutrition, communicable diseases such as malaria and leprosy, lack of perinatal care and violence (accidents of various kinds). and children ar~
Since infants
to a larse 4egree involved in these causal factors in the
developing countries, the resulting impairments tend to cause long-term, even life-long disability. Conversely, the greatest impact of effective
prevention can be expected among children and will be reflected in substantially reduced mortality and morbidity rates.
In the developed countries, accidents, chronic diseases, cardiovascular conditions, psychiatric illness and drug and alcohol abuse are the leading causes of disablement in the population and these are more evenly spread through the age groups.
3.2
Patterns and trends in .health-related behaviour
In most countries or areas in the Region, the population growth rate has declined in recent years. Most of the countries or areas have ·an
annual population growth rate of 1% and above, but governments' perceptions with regard to the size of population and rates of growth have changed 1 .n varying degrees. Of twenty countries or areas for which data are
available, ttrelve consider their growth _rates too high, six acceptable while two countries - Lao People's Democratic Republic and Nauru - consider it too low. A significant shift in perception over the last decade is
noticeable in respect of Malaysia and Singapore, which earlier in the
WPR/GPW/85.3 page 62
decade considered their rates too high, and now f{nd them acceptable, and China and the Republic of Korea, which, though experiencing significant declines in rates of population growth, continue to perceive them as still too high.
Policies of intervention to modify the rates of growth have been in force in almost all countries or areas with varying intensity but primarily through reduction of fertility. In most countries, there has been a
phenomenal growth in contraceptive use among married women of reproductive age but the use of contraceptives varies widely among countries. a
There is
noticeable trend towards the use of more reliable and permanent methods 1
of contraception like sterilization, particularly among females.
The
use of contraception increases consistently with the increase in the number of living children. While very few women with no living children practise
contraception, a sizable proportion of women with one living child do so.
A few surveys on infant and young-child feeding which were undertaken 1n developing countries in the Region point to an alarming decline in br e ast-feeding. In some major urban areas, the proportion of Awareness of
breast-feeding mothers has declined to as low as 20i..
loeterminants of recent declines in fertility in the ESCAP region. In: Third Asian and Pacific Population Conference (Colombo, September ..!2_82). Selected Papers. New York, United Nations, 1984 (Asia,n Population Studies Series No. 58) (ST/ESCAP/267), P• 56.
WPR/GPW/85.3 page 63
malnutrition and the importance of breast-feeding has been increasing and efforts are being made by most of the countries or areas in the Region to promote breast-feeding for a minimum period of four to six months. The
International Code of Marketing of Breast-Milk Substitutes has received almost universal acceptance in the Region and the health authorities are providing advice and guidance to their health personnel with regard to the promotion of breast-feeding. In China, Lao People's Democratic Republic
and Viet Nam, the threat to breast-feeding through marketing of breast-milk substitutes is minimal, and distribution of breast-milk substitutes is subject to state control.
As of 1984, national codes or legislative measures for the appropriate
marketing and distribution of breast-milk substitutes were enforced in Australia, Malaysia, New Zealand, Papua New Guinea and Singapore and are being finalized in Fiji and the Philippines. In addition, Australia and
New Zealand , the two countries in the Region that manufacture and export breast-milk substitutes, have indicated their willingness to comply with the spirit o f the International Code. While it is expected that the
situation will improve, special efforts are still needed to encourage breast-feeding among vulnerable population groups such as urban working mothers. 1
1Malnutrition, growth and development - Technical discussions (WHO document WPR/RC35/Technical Discussions/U, 1984, p. 12.
WPR/GPW/85.3 page 64
Increasing evidence of the positive relationship between smoking and ill-health has caused a number of countries or areas 1n the Region to initiate activities to discourage smoking and to promote measures to reduce tobacco consumption. Information available on eighteen countries or areas
indicates that there is an increasing recognition of the smoking problem and that population surveys on smoking behaviour are being carried out to assess the extent of this problem and initiate appropriate programmes. prevalence of the smoking habit varies from 19% among the 15 years and above age group in Hong Kong to about 30% in Australia, China, Japan and New Zealand. Sex differentials reveal a striking picture. In Australia The
and New Zealand, prevalence is higher among males than among females but the difference is not much. In China, Hong Kong, and Japan, the prevalence 1
is nearly six times higher among males compared with females.
Death rates from lung cancer in women rose from 8.9 per 100 000 in 1975 to 14.1 per 100 000 in 1982 in Australia and a similar situation in regard to smoking-related diseases is expected in New Zealand. In Japan,
the prevalence of the smoking habit increases to 71.3% among those aged 30-39 years and falls thereafter to 56.5% among those aged 60 years and over. Both in Australia and New Zealand, women in the younger age groups
are smoking more compared with the others and it seems that giving up the habit is more difficult for women in the younger age groups than for men.
!Prevalence rates are 39% and 26%, respectively, for men and women aged 25-64 years in Australia, 35% and 29% for men and women aged 15 years and above in New Zealand. Rates are 66% for males and 13.5% for females in Japan, and 33% for males and 5% for females in Hong Kong.
WPR/GPW/85.3 page 65
Consumption of tobacco has decreased in some countries like Japan and New Zealand. Most of these eighteen countries or areas have initiated
anti-smoking campaigns as they undertake activities related to the formulation of more comprehensive approaches to controlling ill-health due to smoking.
Drug dependence has been a serious and long-standing problem in many countries or areas of the Region. 'The situation has worsened recently as a
result of rapid socioeconomic and cultural changes that are taking place. Among drug dependants, there has been an increase in the use of psychotropic drugs as well as in opiate derivatives together with a tendency towards m\1l tidrug abuse. Adolescent drug abuse is posing a 1
particularly alarming problem in many countries.
There is no significant drug dependence problem 1n China or in the Republic of Korea. Yne problem with narcotics abuse in the southern part In other countries or areas,
of Viet Nam has apparently been contained.
there has been little observable change, apart from the trend towards multiple drug abuse. The drugs of major concern include amphetamines
(Japan), heroin (Macao), heroin and opium (Hong Kong, Malaysia and Singapore), opium (VietNam), psy chotropics and heroin (Australia), and psychotropics ( Ph i lippines). Use o f inhalants by the young as in Japan and
the Republic of Korea is emerging as, at least, a potential problem in a number of countries.
!Report.: of the Working Group on the Prevention and Control of Drug Dependence, M < mila, 28 June - 4 July 1983 (WHO document (WP)MNH/ICP/MNH/001), 1983, p. 23.
WPR/GPW/85.3 page 66
In the developing countries of the Region, the problems perceived to relate to alcohol abuse include road accidents, criminal offences, marital breakdowns, impaired productivity, social disruption, violence and public drunkenness. In a number of countries or areas such as Fiji, Solomon
Islands and Tonga, an increasing proportion of criminal offences is reported to be alcohol-related.
Some developing countries like Malaysia and the Republic of Korea are concerned about not only injuries caused by accidents and violence but also the effects of long-term consumption. In recent years, the Republic of
Korea has reported that from 3% to 6% of psychiatric patients are hospitalized for alcoholism or alcoholic psychosis. Similarly, from 1971
to 1980 in Peninsular Malaysia, there was an increase of 32% in admissions for alcoholism. u1
There have also been increases in alcohol-related problems
developed countries in the Region over the past twenty years.
Australia, Japan and New Zealand have all reported increases in hospitalization for alcoholism and in mortality from cirrhosis of the liver. Alcohol-related traffic accidents and morbidity are also considered
significant in Australia and New Zealand.
With respect to the health implications of driving behaviour, available data on road traffic accidents indicate that the problem is increasing. Males between the ages of 15 and 24 account for approximately
one third of the deaths due to motor vehicle accidents in Australia, New Zealand and Singapore, while in Hong Kong those aged over 65 years have the highest percentage of the total motor vehicle accident mortality
WPR/G-PW/85. 3 page 67
(22%).
In the Philippines, road accident mortality for t:he under 15 years With the exc.aption of Japan, the number
age group is 26% of the total.
killed on the roads in countries or areas of the Region has increased, the extent of this increase being more marked in the developing countries.
3.3
Enviromnental factors
A number of countries in the Region are susceptible to natural disasters. In the South Pacific, typhoons, hurricanes and cyclones, on the
one hand, and volcanic eruptions and earthquakes, on the other, cause natural disasters. In bo~h
Bast and South-East Asia, the principal causes As
are reported to be typhoons or cyclones, floods, earthquakes and fire.
part of disaster preparedness and relief coordination, countries have been formulating n·ational plans and are setting up appropriate infrastructure 1.n the context of the plans. While there has been an appreciable reduction 1.n
the loss of life due to these disasters during the last few years, material, economic and social . loss is becoming substantial. Efforts are
being made by both national and international agencies to coordinate their activities to avoid possible overlaps leading to wastage and confusion.
Countries or areas are be-coming increasingly aware of the impact of environmental pollution, which has grown in proportion to the increase 1n population, growth of industry and intensification of mining and agricultural activities. Resulting problems are the degradation of air,
water and land resources and the increased generation of waste products which have an impact on the health and well-being of citizens. The
recognition and control of environmental hazards has become a major programme in developed and developing countries ot areas.
WPR/GPW/85.3 page 68
In some countries or areas, all new physical development proposals must be accompanied by an analysis of the environmental impact of the project. The disposal of solid waste is becoming an acute problem in many pa~ticularly
countries or areas,
in urban centres, the effective solution Consequently, in
of which usually calls for costly capital expenditure.
this period of scarce financial resources, the allocation to solid waste disposal schemes has failed to keep pace with the growing needs.
In rural areas, significant progress will be made to reduce environmental pollution when countries or areas take more poaitive action to coordinate the activities in water and sanitation development schemes.
3.4
Implic.ations for socioeconomic policy
The present pattern of morbidity and mortality in different countries or areas of the Region is changing rapidly in response to socioeconomic development. While conventional health problems such as communicable
diseases are under control or decr-easing, an increasing number of persons in both developed and developing parts of the Region seem to have problems related to undesirable health behaviour. the past gave priority to economic growth. National development policies in There is no question that the However,
results of these policies also had a positive impact on health.
based on the assessment that many of the current be.tlth problems are associated with behavioural and social issues, it is important that future development policies should be more explicit on the role of health in development.
WPR/ GPW/85. 3
page 69
It
is becoming increasingly clear that health development activities
should be geared to solving existing and potential problems of economic growth in a country or area. Health policies and strategies need to be
formulated in the context of overall development policies and progranmes formulated within the framewo;ik of the nation•l development plans. need for a high degree of intersectoral development a~encies
The
coord~1la~ion , among
various national
must be emphasized.
The health-related behaviour of individulillS influences, and is influenced by, the fatnily and the collliDUnit:y they live in. Specific
problems can be individualized, but their solution requires the involvement of not only the individual but also the family, the community, the organized health services and other related social and economic sectors. The principles underlying health systems based on primary health care emphasize various requirements like intersectoral action and community involvement. Consequently, given the patterns and trends in health status
as described in this chapter, it is anticipated that any development based on these principle's will go a long way towards alleviating the health problems associated with dev~lopment.
WPR/GPW/85.3 page 70
CHAPTER 4. - ASSESSMENT OF ACHIEVEMENTS
4.1
Achievements
This is probably the first time that there has been such a comprehensive regional assessment on the contribution of the health sector to overall socioeconomic development. To begin with, almost all the
country or area reports indicate that the starting point for the current evaluation is some time much earlier than the date when their health-for-all strategy was formally adopted. the period following the Second World War. A common referertce point ~s
China, for example, commonly Many countries in the
uses 1949 as the starting point of its modern era.
Region use the dates of their independence as the time when major socioeconomic change began.
It is clear that this first eval~atiort is primarily a report ori the consolidation of efforts and approaches that really have been in place for many years. There is little doubt that many valiant efforts have been made
to develop strategies which will lead to the achievement of health for all. However, when countries or areas began their evaluation, it became
obvious that the existing information generated from development activities did not fit into the information required for the health-for-all model. a result,
As
it is difficult to make a clear demarcation between achievements For
anterior to or subsequent to the introduction of health for all.
example, major information gaps exist in regard to the progress achieved towards meeting social goals. There was, in most situations, a complet e
WPR/GPW/85.3 page 71
information void on the condition of social, political and decision-making processes - the main pillars of the support mechanisms to achieve health for all. Consequently, the majority of national reports reflect an
evaluation of the traditional model of basic health services, with a caveat from time to time indicating that there may be limitations in their evaluation processes.
Based on this traditional model, however, countries or areas report that tremendous gains have been made to provide greater access to health services for the population through the expansion of health centres, village clinics and community health workers. Concurrent with this is the It is also
adoption of preventive services such as disease control.
reported that many developments occurred to increase the effectiveness of health technology for diseases like malaria, pneumonia, tuberculosis and other communicable diseases.
Altogether 75% of the countries or areas report that their health system provides the essential elements of primary health care - as defined by regional indicators - to 80% of the population. These countries or
areas also show that the health status of their people is nearly at or above the level corresponding to the targets fbr the Region. It must be
noted that the indicators used to assess target achievement normally require a time-frame of more than four years if reliable conclusions are to be drawn. However, even within the last four years, some countries have
indicated that additional progress has been made, for example, in maternal and child health, the priority health programme in most countries or areas. One negative development reported over recent years has been the
resurgence of malaria.
WPR/GPW/85.3 page 72
The most significant achievements relate to the progress that has been made in strengthening the processes used in implementing health for all. At the political level, for example, there has never been such a concerted effort to involve political leaders in the formulation of health policies. While much remains to be done, progress has been made in translating policies into meaningful health development strategies and programmes. This task has been facilitated by the comprehensive framework provided for health for all, for example, the regional strategy and plan of action. In
addition, there has been progress in strengthening the role of communities in health development activities. Community involvement is perceived as The
more than a means of providing better services in a rural setting. role of the community is recognized as vital to the decision-making
processes at all levels of the health system and over the whole range of service activities.
4.2
Effectiveness and efficiency of results
As noted previously, there has generally been a concomitant health status improvement with increased services. In the years following the
Second World War, basic health services in many countries or areas were essentially non-existent. particularly for rural areas. In Papua New
Guinea, for example, as early as 1960 the infant mortality rate was estimated at 200 per 1000 while the 1984 rate was 72 per 1000. The period
following the 1960s was also a time of economic boom; consequently the health system cannot presume to take all the credit for the gains in health
WPR/GPW/85.:3 page 73
status. 3n
However, it is quite apparent that countries or areas experienced
improved health status at a time when development strategies were These
dependent on continued availability of sizable financial resources. resources were used to expand facilities and increase manpower.
The period of relative prosperity may be over and concerns about efficiency are setting the tone of management. Forces extraneous to
health, mainly economic and political, require that the health system take action to address these concerns.
Most countries or areas are very concerned about the rising cost of maintaining health services. Unfortunately, the reporting systems which
have been developed to date are oriented to the delivery of health services and not to providing appropriate information in response to the questions that are being asked today, such as questions on intersectoral actions on health, community involvement, managerial process and financing. Consequently, a great deal of energy is now being expended by some countries or areas, for example, in determining more precisely how they are using their resources.
The question of efficiency is not confined to financial resources alone. Countries are also studying the most appropriate technology and mix For example, an expanded role for nursing is a common
of manpower.
approach to improving efficiency, particularly in small island countries or areas.
WPR/GPW/85.3 page 74
The main conclusion reached with respect to efficiency is that countries or areas s ervices. ha~e
equated efficiency with the expansion of health
However, it is now quite obvious that the next significant gains
in health development will most probably be a result of efficiencies achieved within the framework of current available resources. crisis coming when it did could be a stroke of fate. The economic
For example,
experiences from the developed countries show that a unit cost of service when coverage is above 80% can potentially be much higher than for a unit of service when coverage is less than 80%. Consequently, careful planning
is needed to ensure that the approach tb reach total coverage can be afforded by the nation.
4.3
Relation to health-for-all goals
It is quite likely that during the early 1980s most countries or areas used the health-for-all model as a way to rationalize existing health development approaches. This position is supported by the observation that
the initial content of the health-for-all strategies reflects a preponderance of discussion of issues concerning basic health services, an expansion of health programmes, an increase in health manpower and a primary health care approach which is used to provide more services in the community.
On the other hand, the emergence of health for all was not devoid of a foundation based on social values. Since the precepts of health for all
imply that many changes are needed in the health sector, it is not surprising that these changes have still to be brought to the forefront as developments to be acted upon. Thus, health for all has made a significant
WPR/GPW/85.3 page 75
contribution to the Region by providing a new framework for guiding health sector reorientation. Previously, countries or areas sensed that a
reorientation was needed, but did not have sufficiently comprehensive models upon which to base their strategy.
The conclusion that can be reached is that much of the value of the present evaluation is to be found not only in the statement of achievements but, far more importantly, in what is noted as not being achieved. The
significance of the conclusion is that health for all has sensitized the health system to the need to consider areas which previously were not included as factors that have an impact on health development. It was 1n
these new areas that countries found their health system lacking.
The change in emphasis from physical infrastructure development to social development as a regional phenomenon began to be widely expressed 1n national development plans throughout the 1970s. Health for all, of
course, became the way to realize this goal in the health sector. Health-fo. r -all strategies obviously emphasize health processes as be i ng equally important to the content of programmes, since social goals are concerned with equity and justice rather than simply access to more and better services. This change necessitates very fundamental reorientations
in the way decisions are made, and obviously requires a period of readjustment.
WPR/ GPW /8'5 . 3
page 76
The examination of country or area reports indicates that nations are struggling with this dilemma. This conclusion is supported by two
consistent statements in country or area evaluations, namely, the reference to changing patterns of ill health and the need for changes in relationships within the health sector, e.g. better coordination.
Even the countries or areas at the lower end of the economic spectrum are experiencing social change, which in turn is altering life-style behaviour, causing new forms of ill health. For countries at the higher
end of the economic scale, these new patterns of health problems are the priority issues of today.
The second feature of the current evaluation is the emphasis placed on relationships within the health sector rather than the absolute number of personnel or facilities. For example, more clearly defining a job By
description illustrates concern for making a relationship decision.
contrast, indicating the number of new health inspectors added to health centres shows that the point of relationships has been overlooked.
Three types of relationship are emphasized in the evaluation reports, namely, those within the health sector, intersectoral relationships and community relationships. Health sector relationships will be improved in
some countries through decentralization and, in addition, for most countries, through improved management and supervision. The emphasis on
intersectoral relationships, which in effect is a recognition that the health sector can no longer work in isolation, has led to measures such as joint planning, the use of planning perspectives which define problems in
WPR/GPW/85.3 page 77
such a way as to be independent of traditional ministerial boundaries, and joint coordinating or implementing committees. Insofar as the health
system and the community . are concerned, the key to a stronger relationship is to be found on the partnership concept. It is Bncouragirtg to see that
most countries or areas are beginning to express the partnership perspective in their development approaches.
The health-for-all strategy evaluation has prompted countries to take stock of what is happening in their health sector. The specific
indications of achievement, which are significant, are rather a manifestation of strategies initiated partly within the framework of health for all rather than a total reflection of change brought about by such a framework. Hbwever, it is quite possible that health for all has
stimulated the development of processes which are a prerequisite for the achievement of the health-for-all objectives. These processes involve
(1) the establishment of a more rational framework to support activities that were already in place, (2) the significant improvement of comprehensive planning functions, and (3) the development of managerial procedures to support the entire health-for-all effort.
The past can be characterized as a time when evaluation was often a rationalization of evolved events. This situation was due to limited
skills and experience in development as well as the fact that many events of the past were influenced by forces beyond the control of governments. This picture is in sharp contrast to the present situation where clearly development is considered a force that can be directed to achieving the social goals which have been defined for the nation.
WPR/GPW/85.3 page 78
CHAPTER 5.
OUTLOOK FOR THE FUTURE
The Western Pacific Region has experienced rapid change in the past decade in all areas of social, economic and political development. There
is every reason to believe that, in most countries or areas, this pace of change will continue through the year 2000.
On a global basis, the Region's economic performance has been above average. Even though the inunediate economic future is faced with guarded
optimism, over the long term the vast investment made in human resource development has the potential for contributing to a collectively strong and viable economy in the Region.
The economic foundation for most countries or areas will continue to be in agriculture. There have been many setbacks in the agricultural It remains, however, a priority
sector during the past few years.
development sector and new policies and strategies for agricultural development are expected to produce significant gains. In other parts of
the Region, such as Japan, Hong Kong, the Republic of Korea, and Singapore, the economies are based on manufacturing and service industries. While
these economies are expected to perform well, the countries will experience different types of challenges in meeting the social changes brought about by economic factors.
Despite impressive economic gains in the Region, there is concern that social development has not kept pace. reach some needy segments of society. Economic development has failed to The implication is that the past
economic policies and strategies did not pay sufficient attention to equity
WPR/GPW/85.3 page 79
and justice in distributing the benefits of econom1c ga1n.
It appears that
the political processes have recognized this dilemma and are now assigning high priority to problems associated with poverty, hunger, ill health, unemployment, rapid population growth, migration, poor housing and child labour. There is increasing doubt, however, that current development
approaches will be adequate to correct the historical imbalances. Consequently, there is an obvious urgent need to adopt more coherent approaches to development which encompass both economic and socia l goals. The challenge of the future is to define policies and strategies which consciously strike a balance between economic and social goals at the planning and implementation stages.
The assessment of achievements in health development is a ·mirror 1mage of achievements in most of the other sectors. There has been significant However,
progress in improving the overall health status of the people.
there is evidence to suggest that these achievements have not been equitably distributed throughout society: some forms of malnutrition exist in most countries or areas; many individual health conditions are detected in advanced stages; easily preventable maternal deaths continue to occur, while infants die as a result of dehydration.
A national policy to improve equity in the distribution of development benefits is similar in many ways to an individual's desire to lead a healthier life-style. For an individual, the changes needed are quite
obvious, for example, moderation in smoking and drinking, a balanced diet with adequate exercise. The dilemma becomes manifest when the effort is Similarly, with a national policy
made to achieve this behavioural change.
on equity, which requires a change in priorities to incorporate social
WPR/GPW/85.3 page 80
goals in planning and implementation through a broader base of participation in all aspects of management, barriers to change are encountered. These barriers do not melt away overnight.
The adoption of health for all has provided most countries or areas in the Region with a comprehensive framework for developing health policies and strategies that are in line with national socioeconomic goals. formulation of policies and strategies is only the first step in the process of achieving an impact on the development goal. The next step, The
where most difficulties will be encountered, is the preparation of programmes and implemention plans which reflect those policies and strategies.
This is not a simple matter of preparing better plans.
The
implementation must take into consideration the obvious constraints on change that are being encountered. Many existing organizational
structures, for example, are not designed to support intra- and inter-sectoral cooperation. Some social practices are not conducive to
good health while certain political actions are motivated by personal considerations rather than by concern with the attainment of societal goals.
There are a number of trends emerging in the Region which may overcome these constraints in the present development processes. The current
evaluation has highlighted the fact that most health information systems fail to provide an accurate description of the underserved segments of society. More emphasis will be placed in the future on collecting
WPR/GPW/85.3 page 81
information on the underserved as well as on changes in the types of information needed to reflect trends in social development and not just service delivery.
The trend towards expansion of research on social issues will intensify. With the recognition that many of the constraints on
development are behavioural or social in nature, the emphasis on research will shift from developing health technology to improving its application. This applies not only at the practitioner's level but equally to the provision of management and support services, for example, for problem solving as much as for maintenance of systems.
The application of appropriate health technology will become an increasingly important concern; this involves factors of equity, cost and quality of care. The introduction of decision-making procedures on
selection of appropriate technology based on a balance of cost arid equity will continue. There will also be more attention paid to cost-benefit This will apply not only to the more
criteria in selecting technology.
sophisticated technology, but also to technology that is applied at the primary health care level.
There are stillmany problems to be resolved regarding the application of health technology at the user's point of first contact with the health system. Such problems include, among others, sociocultural biases, lack of
logistic support, and misconceptions and assumptions within the health system. Decisions on appropriate technology are also a way to give Thus there will be a
substance to the importance of community involvement.
WPR/GPW/85.3 page 82
trend to increase the participation of individuals or communities 1.n decision-making processes for the selection or adoption of specific health technologies.
In many countries or
areas~
the trend towards integration of In most
traditional and modern medicine is expected to gain momentum.
countries or areas, it is modern medicine which legitimizes the component of traditional medicine that is considered to be acceptable. medicine adopts a
Unless modern
more open position towards understanding traditional
medicine, it is very likely that the value systems and conceptual basis for many of the traditional practices will be lost. This is particularly
relevant, as many aspects of traditional medicine are closer to being in consonance with social goals than some of the practices of modern medicine.
There will also be an increasing movement towards three significant structural changes in the health sector. These are decentralization, alternative methods of financing, and integration of primary health care. The development of a system which produces equity and justice is frequently manifested by the relinquishment by higher levels of decision-making authority and responsibility. One of the tn.ore significant changes required
to strengthen decision-making is the process of decentralization. Consequently, it is quite likely that, in most countries or areas of the Region, this trend will continue for some time.
Countries or areas have been forced to re-examine methods for financing the health sector, primarily as a result of . limitations in funding available to the public sector. For the immediate future, this In the long run, however,
search for alternative financing will continue.
WPR/GPW/85.3 page 83
techniques of financing may also be used to resolve problems in quality of care, as well as in equity of service. The introdu~tion
or expansion of
medical insurance as well as an expanding role for the private sector will most likely be observed throughout the Region. It is clear from the
experience of many developed countries that these approaches can give r1se to serious problems if they are not carefully planned and managed. It is
anticipated, therefore, that countries or areas will proceed with caution in this field, taking diligent note of the experiences of developed countries and paying due attention to testing and reviewing approaches before they are finally adopted. ·
Despite the many constraints, health systems are now being developed in consonance with the primary health care approach. Countries are There is a
undertaking reviews of their health systems and making changes.
noticeable trend towards the integration of preventive and curative services, and the sharing of authority and responsibility between the central and peripheral levels of administration. Efforts are being exerted
to promote intersectoral coordination and coDDDunity participation in health development.
In summary, it is anticipated that there will continue to be major changes in the health sectors of the Region which will be guided by the processes of health for all. Awareness of the need for these changes was
highlighted by the adoption and now the initiation of a process for evaluation of health for all. This evaluation indicates that in many areas This should be
more concerns have been identified than have been resolved.
WPR/GPW/85.3 page 84
interpreted as a very positive result since it may have led to a more thorough and comprehensive examination of the role of the health sector the context of national socioeconomic development. ~n
Three broad areas were highlighted as the loci for the reorientation of health systems to permit them to perform and produce results compatible with the health-for-all goals. These were the improvement of the value
system of the health sector; the continuous review of the technology used by the health system; and the introduction of structural changes which more effectively support the new reorientation of the health sector.
The implication for concomitant change throughout the health system is wide ranging. There will be changes in the content of training programmes,
both technical and managerial, while administrative systems will need significant process revisions to be able to support the trends that are in motion.
The relevance of the present system of health manpower development being questioned and some countries have already introduced significant changes. Many countries are undertaking the training of village health This is leading to the
~s
workers and promoting the concept of self-care.
development of training programmes based on a community approach to learning.
Most countries are exerting efforts to develop a sound managerial process for health development and are placing more reliance on scientific investigation and research as the basis for major decision-making.
WPR/GPW/85.3 page 85
The trends in health system development apply to most developed and developing countries or areas in the Region. While many such changes are It is
being initiated, all of them are at an early stage of development.
important, therefore, to ensure that they are maintained and s trengthen·ed ~ and gain momentum. In particular, it is important to direct attention to
the need for greater support and commitment to primary health care, and this applies especially to the promotion of health for all in all segments of society. It
is only with such support that major developmental
activities can be pursued to their logical conclusion.