Primary health care in Europe

H4^4oU EURO Reports and Studies 14 Pnimilu lleallfi Ea in tu Leo A. Kaprio REGIONAL OFFICE FOR EUROPE World Health Organization COPENHAGEN t I r F I I r @ EURO Reports and Studies 14 Pnimilu fleall[ Gane in [unone Leo A. Kaprio Regional Dirutor World Health Organization Regional Office for Europe REGIONAL OFFICE FOR EUHOPE World Health Organization COPENHAGEN 1979 @ rsBN 92 9020 153 3 @ World Health Organization 1979 Publications of the World Health Organization enjoy copyright pro- tection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part ot in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scheriigsvej 8, DK-2100 Copenhagen Q, Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not men- tioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. PRINTED IN DENMARK Reissued under ISBN: 9789289024532 (print) in 2025. Originally published under ISBN-10: 9290201533. ISSN 0250-8710 (print) CONTENTS Preface l. Introduction. 1.1 The setting of PHC and main principles 2. Health and the development ofhealth services in the European Region ' ' ' 2.1 Changiry patterns of living in Europe 2.2 Thehealth of EuoPe. . . 2.3 The development of health care in Europe 2.4 Primary medical care in Europe today . . 2.5 Summary 3. The main problems of PHC in the European Region . 3.1 Introduction. . 3.2 The relationship between health and society . 3.3 Operational and technical obstacles to the application of the PHC approach to health care in Europe 3.3.1 Accepting the principles of PHC 3.3.2 Probiemsrelated to the principle that health care should be "needs reiated" and universally accessible and acceptable ' ' 3.3.3 Problems related to the principle that community participation is essential in PHC. 3.3.4 Problems related to the principle that PHC should be effective and efficient 3.3.5 Problems related to the principle that PHC should be part of all development and of the wider health care system. 3.3.6 Problems related to the envhonmental health component of PHC 3.3.7 Problems of training for primary health care 3.3.8 Problems of indices of health and the survival of the unftt' ' ' 4. Towards new solutions: some new strategies for PHC in the European Region . 4.1 Introduction. 4.2 Regional contributions. 4.3 The health centre and polyclinic movement: unification of services ' 4.4 The health care team . 4.5 Health and education. 4.6 Community participation, the family, and the individual 4.7 Some important contributions from research 4.8 Theimportance of PHC: new recognition? - . . 4.9 The future . Annex I Annex II Annex III Declaration of Alma-Ata . Other publications of the WHO Regional Office for Europe relating to primary health care Publications and documents on primary health care distributed at the Alma-Ata Conference by Member States of the \ilHO European Region . Page v I 1 4 4 4 7 9 9 l0 10ll t2 t2 l3 l6 t7 18 19 2l 2l )) 22 22 24 26 27 27 29 30 30 33 3',t 38 PREFACE The Intemational Conference on Primary Health Care, held in Alma-Ato, U^SSR rn September 1978, issued a Declaration embodying the fundunental principles of pimary health care and urging national and intemational action to translote those pinciples into practical programmes. Inevitably the Dec' loration, and indeed the Conference itself, stressed the need for urgent action in those areas of the world in which the population has no occess to ony per' manent form of health care. Europe is clearly not one of those areos; the ma-joity of the Member States of the la/HO European Region are industrialized and provide highly organized systems of medical care for their people. Although the pimary health care approach in Europe is different from that envisaged for the developing world, the Declaration of Alma-Ata, the text of which is reproduced as Annex I, p.33, identifies several principles thqt apply equally to both developed and developing countries. (a) heolth care should be related to the needs of the population; (b) consumers should participate, individually and collectively, in the planning and implementation of health care; (c) the fullest use must be made of ovailable resources; and (Q pnmary health care is not an isolated approach but the most local part of a comprehensive health system. These pinciples are not only relevant to the European Region but are actually being put into practice in several countries and analysed in many of the cunent programmes of the Regional Office. It is timely, therefore, to review the present situation in Europe, the problems that must be overcome in implementing the pimary health care approach, and some of the develop' ments that are taking phce. This publication is based largely on my report to the Alma-Ata Con' ference. I wish to acknowledge the valuable contibutions to our thinking on pimary health care in the European Region made by my colleagues in the Regional Office, in particular Dr D.K. Sokolov, Dtrector, Development of Comprehensive Health Semices, and Dr J. Jiroui, formerly Regional Offtcer for Development of Community Services. I am also indebted to Professor E.M. Backett, Department of Community Health, Univercity of Nottingham, United Kingdom for stimulating discussions and editoial assistance. The v final reports on meetings ananged by the Regional Oflice, as well as anum- ber of background documents, have been particularly helpful. I have referred to some of these reports and documents to illustrate certain points; many more, though rutt quoted, hove been sources of inspiration to me in prepaing this presentation. Leo A. Kaprio vl I. INTRODUCTION The contribution of the European Region to the Alma-Ata Conference consists of a review paper comprising three main parts. In the first I describe briefly the changing- pitte.ns of life in the Region and the main features of healtti and illnesi against which primary health care (PHC) must be seen, and I also briefly outline the development of the complex and highly organized health care and the social and welfare services found in the Region. In the second part I describe the main problems impeding the full development of the PHc approach in the Region. Finally, in a section I have called "Towards new solutions: some new strategies for PHC in the European Region", I indicate some of the developments that are taking us in Europe quite near to achieving some of the goals set for PHC in the rest of the world. The views expressed here are my own and do not reflect the opinion of Member States or of the Regional Committee, although I would hope that both could agree with much of what I have to say. l.l The setting of PHC and main principles It is necessary first to consider PHC in the setting of a region that is technically and industrially advanced and where medical care is highly or- ganized. fu you are aware, in the vocabularies of WHO and UNICEF the ierm ..primary health care" has a special meaning in relation to the develop- ing countries. In the early days of wHo we used to speak of "local health services"; in the 1960s the term used was "basic health services", and now we speak of "primary health care". However, the terms "local health services" and "basic health services" in a way reflected ideas imported into the devel- oping countries either by outside advisers or through the views of "elitist" health leaders in those countries. Primary health care, on the other hand, is intended to develop from the people themselves and, according to Dr Halfdan Mahler, DrectorCeneral of the World Hedth Organization, "should fit the life pattems of the community it serves and should meet community needs and demands". Thus, in the developing world, it is seen as something much more than the primary medical care provided in Europe. However, in spite of this fundamental medical emphasis, PHC developments in the European Region at all levels share a number of common or basic principles with PHC in the developing world. I The lirst and most important of these pinciples is that there is a close rehtionship between health needs, the associoted tosks, and the vaious caing roles thot are developing in health care. Fundamental to much of the recent writing on PHC is a relatively simple conceptual model that links the health care needs of a population (descrip- tions of which are a feature of many recent epidemiological studies) to the health care tasks involved in meeting those needs. These tasks and the related skill constitute the care needed and thus define the educational and organi- zational objectives involved. It is of great importance that much of the care needed falls within the scope of PHC. In simple terms, the ideas that form much of the current model for pHC are derived first from a study of the broad spectrum of health needs of communities. These needs should define the community response towards health care. The necessary tasks and skills cluster together, some being ap- propriate to the physician, some to the nurse, others to various categories of medical auxiliaries, and most important, still othen to providers of non- medical primary care coming from the community itself - indigenous health practitioners (where they exist), the individual's neighbours and relatives, and even the individual himself or herself. Such care is, of course, at least in theory, universally accessible and acceptable. The value of such a framework is principally that it provides appropriate and integrated task and role analyses that are at the one time iraditional features of medical care (the physician, the nurse, etc.) and also, in medical terms, unconventional (the health attendant, the family, and self-care by the individual). In short (and in conf<rrmity with views now current in wub), a "needs derived" frame for discussion of PHC places more emphasis than other frames of reference on nonmedical care, health education; family and self- care, indigenous health care, and spontaneous community-based movements towards PHC. Next are those notions deiving from the ideal of communitya participo- tion in heolth. Here, the notion of PHC requires that the care given should involve the local community. care should, if possible, result from community activity, or at least be a part of it in the sense that the local community takes an active, or even sponsoring, role. Locally derived priorities a.e se*ed and local community resources used, as far as possible. A more subtle and more im-portant feature, mentioned above, is that PHC is not imposed from outside and is always in harmony with the life style and culture oi the community. It follows that health is often defined in local, rather than in .,imported,' - o lt is not always clear what is meant by "community". The local small group of vil- lages concept is often inappropriate in the European Region, where some tLa or tocat authority or regional administration is often substituted. the two concepts are, of course, quite different from the point of view of pHC. 2 medical, terms. It also follows that the life style and culture are likely to carry a great deal of weight in modifying the health status of the community. Another shared fearure of PHC k the notion that it must use its resources as effectively and as efficiently as possible. PHC is effective in that it promotes health and prevents and cures disease, and cost-efficient in that it does all this while strictly conserving resources; therefore, the community can afford it. Part of this notion is that PHC is comprehensive, that is, it takes into account the ecosystem in which com' munities live and recogtizes that many interrelated conditions (some of which, like poverty, housing and education, are very complex) have a strong influence on health. This principle also implies that PHC is distributed ac- cording to need, that is, PHC aims at the most vulnerable sections of the com' munity, and those most in need, and distributes resources accordingly. Finally, PHC is not seen as an isolated approach to health care, acting on its own, but as the most local (i.e., community based) part of an integrated and comprehensive health system. Thus PHC is seen as bringing together primary, secondary, and tertiary levels of care, including prevention, promotion, and diagrostic and curative services, rehabilitation, and after-care. It follows that PHC is seen as making its contribution to general development along with education, agriculture, industry, transport, etc., which also use local resources and which, acting in combination, play a part in promoting health and in enhancing the quality of life. This brief summary shows that while the basic principles of PHC are most readily applied in the developing countries where needs are greatest and resources least (and where action to control the environment, to dis- seminate the most elementary and basic knowledge about health, and to promote caring services at the village level are of the utmost importance), they are also relevant to the European Region, but in a different way. In the European Region the health care situation and the needs, de' mands, and caring services are, at least in the industrialized areas, completely different from those in the developing world. For the most part services are highly organized, coverage is complete, and PHC is thought of in less general terms but particularly as medical care since it is usually organized by medical personnel.a Several countries in the European Region a-re well on the way to reaching the goal of "health for all by the year 2000"D and their varied experiences o A few countries in the Region that have less developed services, however, ex- perience the need for PHC in the way it is formulated for the developing world. DSee Mahler, H. Health for all by the year 2OOO. wHO chronicle,2g: 457 -461 ( 197s). 3 in this direction are highly valuable for other countries, which can profit from their mistakes and achievements. For all countries the PHC concept has much to offer, but it must be adapted to European cultural and devel- opmental achievements. Keeping the major differences between the developed and developing countries in mind, and emphasizing the importance of primary medical care in the European Region, I now consider the background to ourpresent situation and PHC problems in the Region, proposing finally some tentative steps towards the solution of these problems. 2, HEALTH AND TIIE DEVEIJOPMENT OF HEALTH SERVICES IN THE EI.]ROPEAN REGION In order to visualize the nature of PHC in the European Region, and the difficulties met in providing this type of care, we must view it in the light of the life style and the major and characteristic challenges to health experienced there. These health challenges and the changing contributions of the health services, social welfare, and education, as well as the assaults on the individ- ual made by environmental deterioration and industrial development (to mention only some of the factors that influence the human ecosystem and thus the health of European populations) form the, admittedly, crude back- ground to our understanding of the situation. 2.1 Changing patterns of living in Europe With few exceptions, affluence and generous supplies ofenergy and food, together with good transport and communications and universal education have brought about the transformation of even the rural areas. Europe now comprises populations where the most arduous and disagreeable tasks are mechanized, where technology has entered the sphere of family life, where families are smaller and geographically scattered, where there is little il- literacy, and where religious and cultural traditions are changing rapidly. As a consequence, there are great differences in the attitudes of the different generations, and in all European countries there are increasing numbers of lonely old people as a result of the greater life expectancy and of its variation in men and women. At the same time, the vast majority of people enjoy economic security, even in old age. 2.2 The health of Europe Europe is becoming healthier, death rates (which we must use in spite of their being a poor indication of health) are falling, and patterns of need are 4 changing. The number of deaths from infectious diseases declined sharply during ihe last decade, and with rising living standards have come increases in de-aths from the chronic degenerative diseases and from such extemal causes as accidents, violence, and suicide. Cardiovascular diseases account for more than 5Wo of the deaths in one third of our Member States and for more than 4ovo in another third. Maligrrant neoplasms cause about 2Vo of deaths. Two important trends may be seen. First, there is the change in the con- tribution of chronic degenerative disease and accidents, etc., to total mor- tality; here, there is a massive increase that corresponds to the aging of our populations. Second, there are the trends in the age+pecific death rates, most, bui not all, of which are declining. These trends reveal our successes in con- trolling infectious and acute disease and our failure to control such con- ditionJ as lung cancer and heart disease or the modern "epidemic" of road traffic accidents. Our information on "health" is, as usual, deficient and that on morbidity is less complete than that on mortality. Nevertheless, the available data show that some of the notifiable acute communicable diseases have disappeared although others show only slowly decreasing numbers of cases. Reported cases of typhoid fever, for example, still reach several thou' sand eacli year, and cases of diphtheria several hundred. Meanwhile, there is no apparent change in morbidity from infectious diseases due to viruses (upper respiratory infections, influenza, etc.). while diseases asociated with infectious agents form a smaller but con- tinuing problem, pathological conditions determined by a combination of geneti-, environmental, and behavioural factors are beginning to dominate the health scene and intrude into family and community life, and are chal- lenging society as well as medical science to hnd ways of controlling them. conditions such as allergy and juvenile diabetes are increasingly important. Socially sensitive mortality rates, such as infant mortality rate, are declining fast in most countries and in some have already reached a steady low level. A new picture of child health is emerging: the most important health problems of the young are congenital disorders, accidental injury, maligtant neoplasms, and mental and social maladjustment (often manifested by alco- holiim and drug dependence, and sometimes by suicide). There is relatively little malnutrition in the Region and mortality indices for this are low, but in some countries there are problems of dietary imbalance and ovemutrition. In older persons, particularly in countries where those aged 60 years and over comprise between 15% arld 2wo of the total population, the chronic degenerative diseases (including mental disorders) are, of course, frequent. Their increasing contribution to total mortality and morbidity dominates the health picture. Although the countries of the Region differ as much in their respective health situations as in their ways of life, they can be divided very roughly into four main groups. 5 Group I consists of countries with the lowest overall mortality and an infant mortality rate below 20 deaths per 1000 live births. The tuberculosis mortality rate in these countries is less than 5 per 100000 and deaths from infectious and parasitic diseases are under l0 per 100000. With a few ex- ceptions, the countries in this group have low reproduction rates. Age- and sex-specific death rates from cardiovascular diseases vary but mostly show an upward trend; this is probably due to a real increase in these diseases. Mortality rates from malignant neoplasms in most of the countries rank high and, with a few exceptions, show a slight upward tendency - mostly due to cancer of the lung and bronchus. Group 2 consists of countries with an intermediate overall mortality and an infant mortality rate below 30 per 1000 tive births. The tuberculosis mortality rate is less than l0 per 100000 and infectious and parasitic disease mortality rates are 20 per 100000 or lower. The majority of countries in this group have the lowest reproduction level and rank high in cardiovascular disease mortality. Mortality from malignant neoplasms is relatively high and, as in group l, shows a tendency to increase. Group 3 countries have the highest overall mortality and an infant mortality rate ranging from about 30 to over 50 per 1000 live births. The tuberculosis mortality rate is over 20 per 100000 and the infectious and parasitic disease mortality rates rise to over 35 per 100000. The level of reproduction varies from relatively low to very high. The same applies to mortality from cardiovascular diseases and malignant neoplasms. However, an upward trend is so far apparent only in mortality from neoplasms. For all the countries in groups l, 2, and 3 fairly complete health in- formation is available. Group 4 comprises the few remaining Member States of the Region; for these less exact information is available, but the health situation is evi- dently much less favourable. These countries still face a large number of health problems that are characteristic of the developing world and which range from communicable and parasitic diseases through high infant mor- tality to unsatisfactory sanitary conditions and poor nutrition. Countries in group 4 (about lO% of the Member States, representing perhaps 8% of the total population of the Region) are at the point in their development where an active PHC approach is likely to be immediately rewarding. The need here is for what might be termed "developing world" PHC. The development of the other three groups of countries is advanced(by any standards) and their PHC needs are different; this is the pattem ex- perienced by the vast majority of the population of the Region, and the problems it gives rise to are the subject of this paper. To summarize, we can point to the emergence in Europe of chronic degenerative disease and accidents as the major challenges to life, the aging population as the main challenge to caring, and reduced fertility (or at least smaller completed family size) along with child survival, safe childbirth, and 6 planned families as the main achievements of family health. Extreme Poverty is uncommon and, with two or three exceptions, countries of the Region are relatively affluent. The diseases associated with poverty, though still present, are sporadic rather than prevalent in their occurrence. As regards health, however, there is still some way to go, and epidem' iologists are aware of shortfalls in all our crude measures of health. Although disease is less often the result of, for example, infected water supplies or in- sanitary waste disposal, the data point to new and subtle causes of illness reflecting the presence of new toxic substances in the physical environment coming from industrial activities, the unsatisfactory nature of our psycho' logical environment, stresses associated with urban living, and changing family structure. The patterns of demand for health care are changing also, and these often indicate a less-than-satisfactory quality oflife. 2.3 The development of health care in Europe It is axiomatic that health, particularly those aspects of health that are subtle and not reflected in morbidity and mortality rates, is affected by most of the conditions present in the human ecosystem. One of these is availability of health care. In this section I deal briefly with the resPonse of European society to its health problems, that is, the growth of the health and social services. Most of these services, though often fragmented, are intimately linked with current ideas about welfare, health insurance, and the interaction of health with education, industrialization, and growing affluence. In European and indeed in all industrialized countries the health services and some aspects of what is now called PHC have grown up over the last hundred years in response to the needs and demands of the community. Health services changed as the demands of society changed. The one did not always follow the other, however, and much of the care provided was in- effective, but PHC in Europe today can only be understood in this historical context. Towards the end of the nineteenth century the "public health revolution" that was sweeping across Europe caught up with the effects of universal education (in some countries at least), with new and higher standards of living (again, in some countries only), and with new attitudes towards poverty and degradation. The basic principles of the "welfare" movements that grew up in a few countries became widely accepted, and by the turn of the century the early forms of social security and personal preventive medicine (im- munizations and nutritional supplements for schoolchildren, for example) gradually helped to promote the idea of health care as a universal need. [,ater, and only in some countries, this became a universal nglrf. Out of the multitude of charities for the sick and needy came the beginnings of the comprehensive health services of today. 7 Elementary public health systems were founded in several countries and industrial workers were insured against absences from work due to sickness and for medical care costs. l,ater (and in some cases earlier), this insurance was extended to civil servants, the armed forces, and the police. The part played by the state in these early beginnings of community care was not always clear and rwtional health services ciune, if at all, much later. By the end of the nineteenth century efforts were already being made in Europe to promote PHC in the form of limited "front-line" preventive, pro- motive, and medical care services at the community level, although these efforts were by no means always successful. However, health service coverage for populations in the Region has always been broad and the indigenous caring systems, which are still important in other parts of the world, were soon made redundant. In most countries of the Region they were superseded by organized medicine, at first by private insurance systems then gradually by state or state-supported insurance. Early PHC was provided by midwives, health visitors, and nurses who visited peoples' homes and were in many ways closer to the community than the physicians who followed them. Early experimental health centres,a though few, had been tried by the early 1920s, and the same ideas were applied in the polyclinics and dispensaries that succeeded these health centres in some countries. In the USSR, where aftet l9l7 a new social system devel- oped, first priority was given to health care for children and workers in industry and agriculture. [,ater, this system of priorities provided the pattem for delivery of health care in other countries with similar social and health care systems. Advances in medicine and the provision of new health services, however, seemed always to be followed by newly perceived needs and thus by ever increasing demands for health services in all countries - a phenomenon suggesting that the notion that health care means more health and therefore less demand was wrong. The new demand was rarely for primary health care. There were other problems too. For example, increased knowledge led to much specialization in medicine and to the largely uncontrolled pro- liferation and fragmentation of the health services. This in tum led many countries to develop what amounts to distntegrared systems of health care dominated entirely by health professionals. As a consequence, lack of coordination of services, particularly the absence of links between primary and specialist outpatient and inpatient care, gradually became a serious problem. Coverage suffered, and in some cases resources and manpower were wasted. In spite of these problems a By this is meant the Anglo.saxon notion of a place of work for the primary health care team consisting of a physician, a nurse, a midwife, and possibly a social worker. 8 sophisticated medical services in the Region have, in broad terms at least, been following the apparent demands of the people: babies are now bom, and old peopli are dying, in hospital, and high-technology diagrostic services .r. pro"id.d'to satisiy patients and their families that everything possible is beini done for their -wi[being. Expectations are high and-rising, influenced often by considerations far distant from those ofgood health care' 24 Primary medical care in Europe today In the final analysis, Europe is characterized by a multitude of different health care systems, 'but all of these are based on some kind of general prac' titioner - .'primary health care physician" - whose narrow role as "physician of first contact" reflects the status of PHC in the Region. At present, methods of providing primary medical care differ between those countries where there is a tradition of private practice by physicians and those where medical care is provided as a social service. Primary care is provided in a wide variety of ways, which comprehend different kinds of physician/patient relationship. These range from traditional private medical practice, where the patient pays for services rendered, to complex primary medical services organized and paid for by the state and provided free of charge to the whole population through an easily accessible network of instiiutions and healttr professionals. Between these two extlemes are the primary medical care services organized by social security institutions, Ly ..mutual" or "friendly" societies, and by public and- private social wel- fire services, all of which provide for selected Sroups of people, depending on their sources of finance. The type of service provided is fundamentally important when efforts are made io secure the better utilization of available resources and the more efficient functioning of the total system. Some countries, for example, in attempting to bring about such improvements, have been obliged to con- centrate their efforts at the local level; other countries have been able to start improving their health services at the national or regional levels through the introduction of new administrative structures for primary medical care. However, in spite of their differences all European countries aim-, at least in principle, to provide health care, and in particular primary health care, of th; high;st technical quality to the largest possible number of persons in the community. I deal with the constraints preventing the realization of this ideal in the next section. 2.5 Summary In the European Region over the last 100 years the total health care system, including "front'line" PHC (as it is undentood in Europe), has evolved in parallil with social and economic development, reflecting not 9 only advanc€s in medical science and the (often parochial) outlook of many health professionals but also, especially at the local level, the true wishes of the population. The growth of front-line care has not always progressed smoothly and evenly in all the countries. Overemphasis on sophisticated hospital-based care for example, has often been detrimental to primary care. Therefore, the new worldwide emphasis on PHC is particularly welcome in the European Region. 3. THE MAIN PROBLEMS OF PHC IN THE EI.'ROPEAN REGION 3.1 Introduction In this section I list and discussbriefly some of the main obstacles to the realization of the new and broader approach to the organization of health care implicit in the concept of PHC. As I have pointed out, the principles of PHC can be properly applied (i.e., in the way in which they have been newly formulated for the developing, and largely rural, countries) in only a small proportion of countries in the Region. In all the other countries of the Re- gion historical influences, relative affluence, and an abundance of medical care have strongly modified the familiar problems, making them highly distinctive. The difficulties encountered in applying PHC concepts to the relatively rigid and fixed health care systems of the highly industrialized countries are the well known problems associated with innovation and change. These could well serve as wamings or danger signals to the developing world. Here, it may be said, are some of the difficulties they are likely to encounter, and which foresight might prevent. First, we must be clear about the relationships between health care, man's environment and human behaviour, and current ideas about health in industrialized societies. I wish to stress particularly the recent advances in our understanding of interactions between the general factors influencing health. These suggest, for example, that the best way to improve health may be through behavioural and environmental improvements combined with the provision of care. Next, I present a number of examples of technical and operational obstacles impeding the application (and in some cases the acceptance) of PHC ideas in the Region. The list is not exhaustive because each country has its own difficulties (and some examples apply not only to PHC but to all l0 health care), but I give one or two examples of problems in the application of each of the principles mentioned in my introductiona and a few more from my own specialized regional experience. 3.2 The relationship between health and society Several complex notions are involved in this most important relationship. At its most theoretical, modem thinking about the health of populations places increasing weight on the intenelationships between facton rather than on their individual contributions. Health is seen as a function of the whole social system. Thus the contributions made to health by, for example, nutri' tion, education, the environment (both physical and sociopsychological), and the socioeconomic complex of relative poverty do not depend on the "weighting" that can be attributed to these elements individually but to the degree of interaction, or synergism, between them. The PHC approach recognizes these interrelationships and demands (through the somewhat vague term "integration") that they should be applied for the improvement of health care. With even stronger reason, it sees health and enhancement of the quality of life as just one element contributing to the whole process of development. Much of the thinking underlying the notion of integration in health care stems from the findings of research on the human ecosystem, particu- larly that which seeks to quantify the various contributions to health. Thus it is seen that health services as such, though of vital importance to the health of populations (and probably of special importance where there is much ill' ness), may be no more (and sometimes even less) important than, say, the complex of relative poverty and poor education, "unhealthy" behaviour pattems, inappropriate smoking, dietary, and drinking habits, lack of exer- cise, and perhaps poor housing or a polluted environment. It follows at the practical level that the minimum demand for the PHC approach is intersectoral collaboration in the management and planning of care. This, in many European countries, conflicts with the logical and his' torical development of, for example, separate (and often mutually antago- nistic) central government ministries and departments. At the regional level fragmentation of the contributory elements to health is often even worse and, o These are'(l) that health care should be "needs related", universally accessible, and accep- table; (2) that community participation is essential; (3) that PHC should be effective and efficient; and (4) that PHC should form part of all national development and of the wider health care system. ll although the interaction of, say, education and health has long been recog- nized and respected in Europe (and statistical data exist to support the rela- tionship), wholehearted integration (in the schools and community health services, for example), or even collaboration, sometimes present almost insuperable problems. Even the preventive and curative aspects of care are only occasionirlly to be found working together. To summarize, therefore, it must be said that modem knowledge of the interaction of factors in sustaining the health of populations demands that fragmentation of these components should be avoided. Coordination is the aim. At the community level collaboration is vital to community health and may be simpler to arrange locally than within large health care systems, the rigidity of which has been confirmed by time and tradition. 3.3 Operational and technical obstacles to the application of the PHC ap- pmach to health care in Europe Beyond the major impediment of the fragmentation of caring services mentioned above there are a number of other barriers to the implementation of the PHC approach in the European Region. 3.3.1 Accepting the pinciples of PHC Perhaps the greatest obstacle is PHC itself. As I have said, primary care in Europe is thought of as medical care, and the dramatic and important widening of this concept is not easily accepted. Tradition and the weight of medical opinion are both respected in the Region and neither will yield easily to a holistic, interactive hterpretation of health. Professionalism and private practice exert their pressures on decisions about who can and who cannot be involved in care, and benevolent paternalism rather than partici- pation characterizes the relationships between providers and consumers of care. There are enough physicians to meet the demand for medical care in Europe, and thus one of the several reasons put forward for diversification of caring roles in the community is invalidated. Teamwork in caring is, however, well accepted and may be the European solution to primary health care. To advocate caring roles that are "nearer to the people", a much pub- licized aspect of PHC, is less compelling when the social and educational distances between the people and the physician are small. Criticisms of high technology, excessive specialization, and the primacy of the hospital, which are reasonable and comprehensible features of PHC advocacy iri poverty- stricken societies, are less convincing in an affluent society where these developments result from popular demand and are readily afforded. This is particularly true where the hospital-based technologies (renal dialysis or some aspects of intensive care, for example), costly though they are, may actually r2 be of value. Hip replacement illustrates this point well. At first, both the operation and the prosthesis were a costly use of resources. Two develop' ments followed: the prostheses became better and cheaper and estimates of the quality of life enjoyed by the patient before and after the operation showed a very great improvement in the successful cases. It is clear that technology, the primacy of the hospital, and excessive specialization can only be reasonably attacked when they start to detract from a more holistic and effective approach to care; when, for example, focusing attention on the hospital causes wastage of human resources, de- stroys continuity of care, costs more than simpler ways of improving health, and removes preventive medicine, other forms of community develop- ment and the consumer from the caring scene. As I shall show later (see p.27\, constructive criticism along these lines has begun in the European Region. 3.3.2 hoblems reloted to the pinciple that health care should be "needs relsted" ond universally occessible and acceptable (a) Policy, planning, evaluation, change, and innovatton in health care After acceptance of PHC principles the next main obstacle is connected with that part of the PHC approach that leans heavily on the definition of health care needs and analysis of the tasks involved in meeting those needs as the proper starting point for policy and planning. Although this is both a logical and a necessary starting point for the planning of health care in the European Region, it is unlikely to do more than provide a con- ceptual framework for discussion of PHC. Health care systems are not regu- larly evaluated, and innovation and change, when they come, are the result of highly specialized political decisions rather than systematic analyses, scientifically based though these may be. WHO has given much consideration to the quality of care and has in particular sought to promote the use of planning cycles where the efficiency and cost+ffectiveness of care are measured repeatedly. These measurements form the basis ofinnovations that bring health care services closer to the ideal of meeting the health needs of the population. (b) Research on health service organization and function Health care research in the European Region is not contributing as much as it could to the effectiveness of care. Biomedical researchhashigherprestige, better facilities, and more resources, but research on how best to meet the health needs and demands of populations should probably be given higher priority than it has at present. l3 (c) Delivery of care by health personnel other than physicians, including self care It follows from (a) above, and from the fact that PHC is seen in the Euro- pean Region as medical care, that health care by personnel other than physi- cians, and particularly the vital role of the family in its own health care, has been neglected in the Region.a This is also one, but not the only, reason for so little enthusiasm being strown h the European Region for the self care movement, now widely supported in some other WHO regions, and a major reason for the objections to extending the caring roles of pharmacists, nutses, medical auxiliaries, and the few remaining indigenous health practitioners. The position, importance, and status of the physician in Europe goes a long way to explaining why "health by the people"' - an essential element in PHC - is almost universally rejected in the European Region. There are also other reasons. For example, small and isolated com- munities are less frequent, family size is smaller, and the expensive network of services in most European countries lessens individual and community responsibility for care. (d) Curative versus preventive medicine The separation of preventive services from curative services and the neglect of the former is an example of imbalance, indicating disregard for the growing challenge of preventive medicine. Specialization in preventive med- icine is lacking in prestige and status for the physician; specialization in cur- ative medicine, on the other hand, flourishes and attracts recruits. The effect of these status differences on the application ofPHC in the European Region is profound. There is an urgent need for prevention, much of which is within the scope of PHC, but curative care has a dramatic quality, it demands high technology, and is more at home in the hospital than in the polyclinic, dis- pensary, or health centre. These values are passed on to the consumerswho, quite reasonably, become more concemed with curative than with preventive care. Separation of the curative and preventive aspects of care does not stop here. Medical educational systems, govemmental policies, research pro- griunmes, and the important voluntary caring agencies (which are numerous in Europe) all reflect the high status of curative care compared with pre- vention. As a consequence comprehensive care, in the PHC sense, is often lacking. a This generalization does not mean that delivery of health care has been totally neglected (see part 4), only that there is sufficient neglect for this to prove an obstacle to the application of PHC. 'See Newell, K.W., ed. Heolth by the people. Geneva, World Health Organization,1975. 14 (e) The ineffectiveness of some cumtive medical care Widespread recognition of the interacting determinants of health has come from further studies of the human ecosystem, from understanding of the detailed etiology of many pathological conditions, and from ana- lysis of the effects of control progrirmmes. The balance between medical care, socioeconomic conditions, behaviour, culture, and the various aspects of the physical environment are now better understood, and it is becom- ing more obvious than ever before that in spite of the dramatic effective- ness of some medical care (and of course the right of each individual to receive such care), curative medicine alone cannot sustain the health of whole populations. For this, a total ecological approach is necessary. A large proportion of the adjustments necessary for promoting health are nonmedical in nature and well within the competence of either the com- munity (for example, in housing or environmental control) or the indi- vidual and the family; many of these necessary adjustments have little to do with medicine in the strict sense but are concemed with the unequal distribution of wealth, education, communications, etc. As I have said ear- lier, improved health is more likely to be achieved by an attack using all these resources than through curative medicine alone. (/) Distorted technologt and pioities I have already referred to the question of what is appropriate med- ical technology. This is a particularly complex question because demand often conflicts with measures of the effectiveness of equipment. Thus the problem has special importance only in the presence of constraints on re- sources. Waste on inappropriate and costly technology does, of course, occur in the European Region, but this has little adverse effect on health where plenty of human and other resources are available. Where these re- sources are scarce, high technology almost always claims more than its proper share. Thus it is not the technology but its use that may be wrong in diverting resources from areas where they could be used more effectively. Decisions must, of course, reflect the demand for care and the cost+ffectiveness of the care provided. The results of such evaluations are often painful; for example, the effectiveness in terms of unit cost of much modern medical equipment is currently being questioned. Priority analyses based on costs and benefits are now much simpler as new data become available and where resource constraints exist they will show clearly the importance of diverting resources to PHC. The harnessing of very high technology to the needs of PHC is a new and challenging idea, and there are new tasks of considerable complexity l5 that will have to be undertaken ifthe quality and effectiveness ofcare is to be enhanced. Many of these are applicable at the pHC level.aI would like to conclude these brief comments on technical progress by stating that we in the industialized countries are already used to a rather high level of medical technology; our medical system relies on it, we need it, and we stand to benefit considerably from its results. clearly, however, we overemploy such technology, frequently using it in the *.ong iiu..r, generally at unnecessary expense and much too late in the life of anindividui -thutis, close to the terminal phase. I therefore feel that it is essential to reappraise our regional health services in order to determine where these new tiChnol- ogies should properly be used. 3.3.3 Problems relatld to the pincipre that community participation is essential in PHC (a) Community nonparticipation A general problem_in the European Region is that of community non-participation in medical !"p. _Il our Region the physician remains supremein all, or most, fields of health care and the community usually respects this arrangement. However, the relationship is not a participant one, and onlyin a few countries does the care "spring from the communiiy" in the idealistic s€ns: rl which this phrase is used in pHC. More usually, the many different methods of payment, issrres of confidentiarity, and emphasis on the physician/patient relationship preclude extensive community involvement iir medicai care. However, it is not clear that this threatens the health of our populations in any significant way. (b) Undenerved populations A special problem is that of the "underserved" population, where the uptake of available care is lower than it should be and less than might be expected. Need exists but services are not utilized. There are a number of possible explanations for this, some of which highlight the value of the participant PHC approach. It is possible, for example, that if the services nearer to the community were better understood and accepted, or even associated with some community activity or dispensed by an acceptable community leader, the differences would disappear. Among those who under- utilize services are the very old,adolescents, andthe relativelyunderprivileged - all ofwhom are in special need ofcare. a For example, portable electronic preprogrammed aids to effective diagnostic and therapeutic action would alter completely the effectiveness of some caring teams. Other examples are blood pressure measuring equipment for family use and "dipstick" indicators. l6 (c) Collobomtion between consumet and providen The demands made on the community by some of the newer methods of controlling chronic disease, particularly the screening of total populations, has forced health providers to consider how and why populations collaborate in medical care research. Now it is apparent that much more population research is needed, demanding a high level of collaboration, acceptance of common objectives, and mutual understanding. It also involves entirely new relationships because, for example, the population under scrutiny is usually not a population of patients. This, and other developments, will be a testing ground for much of the PHC approach. 3.3.4 Problems rehted to the pinciple that PHC should be effective and efficient (o) The need for evaluation in care I have already referred to this and only mention it again because it is a major problem in all of health care and particularly in PHC. It is of the greatest importance to find out whether the care achieves what it sets out to do. Unfortunately, in the European Region it is only in the field of drug evaluation that effectiveness is rigorously and regularly tested. (b) Allocation of resources One indication of the high status of curative care is that resource allo- cation in the health field is, more often than not, decided by medical inter- ests, expertise, and pressures rather than by the real distribution of need or demand in the community, which is likely to be a more effective, and perhaps more efficient, basis for allocating resources. A feature of PHC is the con- gruence of need and resource allocation, based partly on its demonstrable effectiveness and partly on the philosophy ofequity. In only a few countries is congruence of need and resources founda and it seems more likely to occur in countries with decentralized systems than in those where resource al- location is made far from the communities to be served. (c) Information systems Another serious obstacle to the application of PHC in the European Region is the scarcity of data on the health care needs and demands of our populations. These inadequacies reflect not only the historical trend towards a In dispensaries in the USSR and in the resottrce allocation formulae used in the United Kingdom, for example. t7 pluralistic systems but also the very recent development of ideas about the uses of such data. In particular, the proper planning of PHC demands high quality information, which should preferably be linked so that the health experience of a population over time may be studied. Such data linkage, which so clearly serves the interests ofthe population as regards their health, runs contrary to accepted views about confidentiality. Consequently, it has had only limited trials. (d) Screening for disease Two kinds of screening are possible: for vulnerability and for existing, usually presymptomatic, disease. The aim should be to identify, within reasonable limits, those who need care now and those who will need care in the future. Screening of all kinds is likely to be a feature of PHC and, since the value of these activities has not yet been fully established, this must be approached as a research project. The mass screening of total populations that has occasionally been tried in the European Region makes little use of our new knowledge about special risk groups, a failure that brings this at- tempt at preventive medicine into disrepute. 3.3.5 Problems related to the principle that PHC should be part of oll development and of the wider health care system (o) The health centre, the polyclinic, and the team The notion is growing in Europe of the health centre or polyclinic as the physical centre for PHC. However, "health centre" still suggests narrow cur- ative care and such centres are invariably run by physicians without much help from other health workers or consumers. The notion of a PHC team with differing skills, each appropriate to some of the needs and demands of the population and all working together, is rarely put into effect. The even more unusual notion of a health centre as the centre of community leisure enjoy- ment, education, and recreation, as well as care (including prevention, re- habilitation, etc.), is very rare indeed. (b) Separation ofhealth and social care An entirely artificial division between health care and social care has grown up in some countries of the Region. In at least one of these the dis- tinction has been drawn as a result of the overlapping roles of physicians and social workers, who of course approach the patient differently. If we concede that an important feature of PHC (in this case primary medical care) is therapeutic collaboration between social case workers and physicians, then this has only been partially achieved in a few countries of the Region. l8 The distinction between medical and social need is rapidly becoming an artificial one, especially with the recogrition of the care needs of, for ex- ample, the very old, the handicapped, and the mentally disturbed. (c) Separation of PHC from hospital care In several countries of the Region there is a clear pathway through the medical care system, which starts with primary care - normally a general medical practitioner - and then passes on to hospital specialties, eventually reaching the "super-specialties" of very advanced and complex care. With such an arrangement the referral chain is clear and the place of primary care within the wider system well defined. However, in many countries of the Region the relationship between PHC (in its narrow medical sense) and the hospital is not clear. Functions overlap and the notion ofintegration is lost. (d) Poyment systems It is not my intention here to discuss the effects on health care of dif- ferent methods of payment for services received. However, it is important to note in passing that the ideal of PHC as an integral part of the wider health care system can be effectively ended if health personnel are paid indepen- dently of that system. At the same time, much cooperation is possible, and several countries have achieved a high degree of integration in spite of their loissez -faire payment systems. (e) PHC and development pioities Few countries in the Region see PHC, even its medical aspects, as part of community development. A very large degree of intersectoral collaboration would be necessary and, although that exists to some extent in most coun- tries, the contribution of health to development has rarely been explored. 3.3.6 Problems related to the environmental health component of PHC (a) Definition ond extent of the problems Among the basic requirements for health are adequate supplies of safe water, provisions for the hygienic disposal of waste, satisfactory housing, and measures to ensure food safety. In industrialized countries there are also other environmental problems to be considered in connexion with PHC, including the effects on health of toxic materials reaching man through air, water, and food, and occupational risks. Although the importance of a healthy environment is generally recognized within the Region, work towards improvements is not always integrated with other aspects of PHC to the l9 extent desirable. In many countries legal and administrative responsibility for different aspects of environmental protection is divided between different ministries and authorities, often those not immediately responsible for other aspects of health care, and other considerations are sometimes given priority above health aspects. There is a need to develop a holistic aPproach where' by, for example, the development of water resources or air pollution con- trol programmes are not considered in isolation. Consideration must be given to the total picture of environmental hazards in relation to overall human health. In most countries within the European Region there is a basic structure of legislation but the implementation is often uneven and unsatisfactory. More attention must be devoted to surveillance and control and also to infor' mation exchange and training activities. In order to ensure community participation it is important that decisions concerning environmental health should be made at the local level. Coop- eration must be established with consumer groups and the general public to ensure that activities are understood and accepted before important changes are introduced. It is important in the industrialized countries to attempt to distinguish between basic health requirements and what may be termed "comfort require- ments ", which go beyond basic health needs. (b') hiority areas In most countries within the Region urban populations have generally adequate basic sanitation facilities but there are a number of areas, including backward rural and urban fringe areas, where standards are still unsatisfactory. Adequate supplies of safe water are not only needed for drinking and for food processing but also for washing and for household hygiene .The minimum requirement in urban areas within the European Region may be considered one tap per dwelling with a permanent service. In rural areas a lower standard of service might be acceptable on an interim basis, but it might be regarded as desirable that power-operated pumps be used, since drawing large quanti- ties of water by bucket or hand pump is physically tiring and this discourages people from satisfying all their needs for adequate hygiene. In most parts of the Region the heating of water is also a basic requirement in order to ensure adequate individual hygiene, particularly during the winter months. The provision of clean and adequate facilities for domestic liquid and solid waste disposal is a fundamental basic sanitation requirement. Within the European Region satisfactory means of waste disposal are available in most urban areas but in some urban fringes and in many rural areas the facilities are still unsatisfactory. In addition, many families in industrialized countries now have summer houses and basic sanitation facilities are often lacking; this becomes more important as the density of such dwellings increases. 20 Under European climatic conditions adequate housing is important in order to provide a satisfactory level of family hygiene. Minimum require- ments include the provision of satisfactory heating during the winter months with adequate lighting and with necessary equipment for toilets, for washing, and for preparing food. Heat and noise insulation is important, but ventila- tion must also be adequate. If the walls, roof, and floor are of reasonable quality and if there are adequate waste disposal facilities and the property is well maintained the problem of vector control should not be a major one. Despite great improvements in standards of living during the last 30 years within the European Region, a substantial proportion of both urban and rural populations still live in substandard housing from the public health point of view. Food hygiene forms an integral part of individual, family, and com- munity hygiene and in yiew of growing problems concerning biological and chemical contamination of food it is important that it is regarded as a com- ponent of primary health care. There is wide disparity in the organization of all these services. Public health authorities are usually responsible for monitoring hygienic conditions at individual and community level, but their efficiency depends on the number, qualifications, and motivation of the environmental health inspec- tors employed. In many countries the number of properly trained inspectors is still inadequate. 3.3.7 Problems of training for pimory health care The redesigning of part of the training programmes for all health pro- fessionals and the radical reappraisal of related programmes for schools, adult education, and the family is urgently needed for the proper understanding and successful application of PHC. Health education of the general population is in disrepute in many countries, but new approaches more closely adapted to PHC are being tried. Physicians are often poor educators, and there is much to be said for the community itself assuming these responsibilities. 3 .3.8 Problems of indices of health and the survival of the unfit I should like to end this section with a word of warning. As we work for the better health of populations we are inclined to use mortality rates - I re- fer particularly to perinatal mortality rates - as indices ofsuccess or failure. Quality of life, a much more vague and difficult measure,couldbe jeopardized by the undoubted success of our specialized health care. We must be careful lest in reducing perinatal mortality, for example, to a very low level (a recent achievement in at least one European country) we excessively increase disability and handicap. I do not think this is happening, but I would like to see developed new indices for the quality of life, which concerns us all so much. 2t 4.1 lntroduction Only a relatively small fraction of the hedth problems of the European Region,in both the developing and the industrialized countries, can be solved by-curative medicine. The risulting, and inevitable, emphasis placed on PHC - pievention, prornotion, hedth education , rehabilitation, and social measures - requires a more systematic approach to individud bohavi,our patterns, social "onditionr, and health in relation to development. Many countries in Europe have already reached the target of full primary medical care coverage for the poprlation. The task now is to convert tJis medical care into the broader, more comprehensive (and ecologically satisfying) heolth cue. In thi previous section I listed some of the problems we face in broad- ening our rigional primary medical ciue approach to embrace the ideas of PHC. In this section I touch on a few features of the largely medical scene that ele beginning to show 1 congruence with these new ideas. Most of these developments are in general practice (or "first-line" medical care in the polyclinic or dispensary) and some are attempted solutions to problems men- iioned in section 3. However, in spite of the emphasis given to general prac- tice a few of these developments have a much wider significance;these are both challenging and new. It seemi likely that as the ideas surrounding the PHC approach are ad' apted and changed in the European Region they are slowly modiSing Euro- pean systems of care. A number of significant steps in this progress can be seen. 4. TOWARDS NEW SOLUTIONS: SOME NEW STRATEGIES FOR PHC IN THE EI.'ROPEAN REGION 4.2 Regional contributions Reports on Regional Office meetings on the role of the primary physi- cian in health services (/) and on education and training in long-term and geriatric care (2) illustrate the diffusion of ideas. Both meetinp emphasized the need for PHC by the community, the individual and, above all, the family. It was also suggested that a permanent first-line service is essential in all medical care systems and that this would have particular responsibilities in the care of the aged, in the prevention of chronic disease and accidents, and in promoting mental health. The role of the nurse in primary care (3) has properly been considered as vital to the development of the whole PHC concept. The nuning content of PHC is seen as a very broad spectrum of care ranging from generally ac- cepted nuning roles, through many aspects of preventive medicine and screenings, to problems of psychosocial adjustment. The high status of the )) nurse in the European Region and her special skills give her a particularly important responsibility in broadening the concept of PHC. Thus, she is a major contributor to health. The reports of two symposia on the efltciency of medical carc (4, 5) and efforts to define parameters of efficiency in PHC (6) illustrate growing preoccupation with the evaluation of care in the European Region' ' Thi use of medical auxiliaries has been studied in one or two demon- stration areas, and the effects of regionalization, particularly on the organ' ization of primary services, is under scrutiny in a number of countries in- cluding Italy, Malta, Portugal, Turkey, and Yugoslavia. A- mori comprehensive approach has been introduced and studied in Gabrovo, Bulgaria (7), where primary care is seen to include early detection of disease through screening of entire registered populations, expansion ofdis' pensary care and, of course, total population coverage through polyclinics. This regionalized system is a demonstration of a holistic approach to care with a satisfying removal of intersectoral boundaries. The "dispensarization" meth' od brings a new appraisal approach to all compenents of primary health care. Primary care ihrough health centres is the subject of special studies in France (8) and England. A wide network of outpatient polyclinics ensures primary medical care in the USSR and in other countries that have a sim- ilar health service concept (9, 10). In these countries the planning and co- ordination of intersectoral collaboration and the coordination of community development approaches the PHC model and, in addition, the consumers at various levels are involved. The role of polyclinics and outpatient care estab- lishments in the delivery of community health care in Algeria has recently been described (11). Active community participation is a major objective in the joint WHO/ UNICEF project at lvanyica, Yugoslavia, (12) while the North Karelia project(/3) for the control of cardiovascular disease is unique in that it arose from community recogrition of a serious health threat and resulted in joint com- munity action for its control, thus qualifying as one of the most important experiments in PHC in the European Region. Such a progr:rmme of primary prevention, health education, social action, and now health legislation is at once comprehensive and fully participant, and arises from the people. A WHO global programme on the health care ol the elderly for which responsibility has been entrusted to the Regional Office for Europe, is giv- ingparticular attention to five characteristic elements of PHC: (a) a multidisciplinary approach to problems; (D) integration ofhealth and social services; (c) health education; (rI; community participation in caring; and (e) the role of the family. 23 Comparable objectives are to be found in the quite different, but equally important, WHO global programme for the prevention of road traffic ac- cidents;a responsibility for this programme has also been delegated to the Re- gional Office for Europe. A large-scale (23country) study of health service concepts in the Euro- pean Region was undertaken in 1977 (14). This provided information on the present position of primary care in the Region and also suggested some in- dicators of future trends. So many countries are exploring the organizational possibilities of PHC that we may leam much from their different approaches to what is basically the same problem. 4.3 The health centre and polyclinic movement: unification of services Our study of health centres and polyclinics in the European Region showed that ministries and departments of health in all European coun- tries agree on two points. l. There is a need to strengthen primary care and relieve the hospital of demands that are better, and possibly more economically, satisfied else- where. 2. Such strengthening implies that primary care can no longer be adequately provided by the single-handed medical practitioner; supporting staff and facilities must be provided, and their coordination requires some kind of organization. However, the individual health practitioner is still rather common in many European countries, especially in central Europe, and is supported in his activities by the financial arrangements based on social security. I per- sonally (and clearly the ministries also) feel that this pattern will gradually change towards grouporiented practice, but the specific rights of the in- dividual medical practitioner will continue to be important in such organi- zation and may perhaps be a brake on the development of the broader con- cepts of primary health care. In spite of this, the major trend is towards what is called in some European countries a "health centre" and in others a "poly- clinic". Curative and preventive care is available in both, though neither has yet achieved its full potential (see section 3.3.5 (a)). a See, for example, The epidemiologt of road traffic accidents. Copenhagen, WHO Regional Office for Europe, 1976 (WHO Regional Publications, European Series No. 2). 24 In general, there are three organizational models for the health centre. l. A coordinating agency that may or may not provide services to patients 2. An integrated system of primary care facilities, such as a health centre together with its subcentres. 3. A facility where a variety of primary care services are provided under one roof. While the third model is perhaps the most common in countries where the organization of primary care is left largely to the initiative of independent providers of care, or where there are no remote areas to be served by satel- lite facilities, the existence of subcentres functioning under the supervision of a central centre is found where a policy of regionalization of health serv- ices exists, and where services have to be extended to outlying areas. Team work and coordination do not necessarily require a common physical base, nor do good premises necessarily produce good team work. A well integrated team can provide first-rate primary care from accommodation that is incon- venient or even unsuitable. However, facilities of some kind and adequate resources must be available and properly coordinated for proper functioning of the health centre. The policy regarding the attachment to health centres or polyclinics of beds for inpatient care varies but, except in remote areas, the practice is un- common. In some highly urbanized countries there is a tendency towards con- solidation of smaller health centres or polyclinics and for several communities to join in maintaining a common,larger, and better equipped health centre. This trend goes hand in hand with the consolidation of other community services such as schools and churches. The health centre's (or polyclinic's) degree of dependence or independ- ence varies greatly according to the health system of which it forms a part. In a system with strict regionalization the primary health care centre is a link in the hierarchical organization of the system with accountability upwards, and structured paths of referral and channels of consultation, combined in some situations with a horizontal relationship with the health committee of the lo- cal council. The extent and intensity of the last relationship varies with the local community's responsibility for service organization and particularly with the method of financing primary care services within the community's bound- aries. Under other systems this relationship will be transferred to a sponsoring agency such as an insurance carrier, a religious body, or a labour union. So far, I have been describing health centres that are based on a rather "traditional" health services system. Personally, however, I would prefer an 25 even broader option: I would like to see the social welfare and health services of a community collected together in one place (perhaps called a health centre). The population would know that in such a centre they could discuss their problems, whether relating to a child, an elderly person, or a working adult, and whether the need was for health promotion and prevention, first- aid and primary diagnostic services, or encouragement to try to solve the problems themselves within the family or at their place of work. I am sure that this type of community service could provide better care for the individual in t}re community than existing, often fragmented health care and welfare services. At the health centre the individual would meet a counterpart who would listen sympathetically and advise - a kind of "patient advocate". This person need not necessarily be a physician but might be a psychologist, physiotherapist, occupational therapist, employment counsel- lor, public health nune, or midwife. However, the two would be able to work together in the care of, for instance, the elderly, the alcoholic, or the handi- capped. These are multidisciplinary problems and the individual, through his counterpart, would have access to expert advice, if required. 4.4 The health care team In the health centre concept, whatever its form, is the notion of a pri- mary care team. In Europe the team includes a physician, who is considered the team leader. There are, however, variations on this theme and some health centre-like organizations combine services to some, but not all, members of the team, and in some cases there is no physician. [n some of the more com- plex health centres the team includes midwives, nurses, social workers, health visitors, records officers, and administrators. These penonnel are sometimes provided by the health and social services and sometimes by voluntary agencies. The health care team, however it is constituted, is considered to play a very important role in PHC and is included in all the new developments in the European Region. It is becoming increasingly obvious, even in the strongly medically oriented services of Europe, that in order to meet the broad ob- jectives of PHC it is necessary to develop a team approach. However, with- out shared common objectives and clearly defined tasks the team cannot function effectively and tends to resolve itself into a group of individuals uneasily hamessed together. In whatever way the team develops, the prac- tice of primary medicine in a private, individual, "one man" practice seems to be slowly disappearing to make room for group practice using shared prem- ises. I regard this as a wholly good development because it opens the way to the somewhat broader and less exclusively medical care that I have men- tioned above. The caring roles of nonprofessional personnel are increasingly being recognized in the European Region - although we are still only at the 26 beginning of this trend. Neighboun, pharmacists, associations of persons with similar problems (handicaps, drug dependence, etc.), the family, and the individual wiil all have increasingly important roles to play. This is recognized in Europe, and a few small studies support the ideas, but the Region has such a wealth of medical skills available that progress in this direction will be slow. 4.5 Health and education Over the last two decades there has been a great expansion in the cover- age and discussion of health problems by the mass media of communication in the Eu.opean Region. This trend is producing dramatic changes in popular knowledge and understanding of health and disease. Radio and television pro- grammeJand newspaper and magazine articles have only been evaluated in a iew countries but there is some evidence that they have beneficial results. Some of these programmes and articles are, quite frankly, highly dra- matic and often promote expectations beyond what is possible. Others, however, are soberly concerned with preventive care and with some of the broader aspects of PHC. The good effects of these should not be under- estimated, particularly as consumer participation is featured in many of the radio and television programmes. The role of the health professional in health education in Europe has not been well evaluated but the results are probably poor. Specially trained health educators are being tried in a number of countries and - again belatedly - some medical and nursing schools are teaching their students how to educate. There is new interest in health education in some countries, particularly where statutory provision is made for health educators to work within the health services. Many medical schools in the Region give special attention to the edu- cation of physicians in the medical aspects of PHC. General practice as a subject or as part of community medicine is included in an increasing number of curricula. 4.6 Community participation, the family, and the individual The extent of community participation in PHC undoubtedly reflects community participation in other major aspects of communal life. Some European populations are more participant than others, but the underlying principle is gaining general acceptance. Medical professionalism is still, of course, the main barrier to full participation, but consumer movements in medical care are seen in several countries. A recent study made for the Regional Office (15) assesses the nature and scale of the contribution to health being made by the consumer of such care. For the majority of people it appears that self care is the form of con- sumer involvement most often resorted to. The report suSSests that the 27 self care movements reported from several countries, though not yet strong, must indicate some rejection of medical care and a move towards the no' tion of health by the people. This is hardly the participant relationship we seek. The cooperation of the consumer is important and even crucial in the prevention and treatment of disease or disability and in convalescence. It applies to all conditions irrespective of their duration but is of the greatest importancc in those that are chronic or acute. The role played by penonal relationships and the morale of the patient in the processes of healing, re- covery, and rehabilitation are well known. The reasons and justifications for encouraging consumer responsibility and participation in the different areas and processes ofhealth care are mani- fold. They include the fostering of good physical and mental health, potential therapeutic benefits, greater effectivenes in the use of resources, and the value of social activities directed to the common good. The patient or disabled or elderly person should be encouraged towards certain goals or values such as independence, self determination, maintenance or improvement of personal status and self esteem, full access to the op- portunities and entitlements of citizenship, and maximum feasible partici- pation in the processes of treatment, support, rehabilitation, and other measures directed towards the alleviation of his condition. In recent years consumers have become increasingly active in combating environmental pollution, and at the same time have become better informed about the parts played by environmental and behavioural factors in chronic disease. The association between, on the one hand, ovemutrition, smoking, excessive drinking, insufficient exercise and stress and, on the other hand, obesity, alcoholism, coronary heart disease, and cancer are well known. Growing numben of directly affected individuals and their families are engaged in preventive, supportive, and curative activities. Sophisticated technolory is not always necessary in order to meet fundamental sanitation needs. Basic services such as safe water supply, adequate waste disposal systems, food safety, and hygienic housing should be developed and operated by using appropriate local technologies, which may be different in some respects in rural areas from those required in towns and cities. Community participation should be ensured by adequate consultative procedures and by dissemination of information relating to all aspects of personal, family, and community hygiene. The consumer is increasingly represented on decision-making bodies and thus taking more responsibility in the organization of medical care. Consumers are sometimes elected, but usually they are nominated by rep- resentative bodies such as local councils, trade unions, or voluntary organi- zations. They perform various functions including acting as observers or as guardians or advocates of consumer interests or, less often, sharing in the formulation of policy and running the services. 28 while this is not exactly the participation envisaged in much of the literature dealing with PHC, it represents the European equivalent of some of those ideas. Foi this, as well as for other reasons, this development is to be welcomed. 4.7 Some important contributions from research Apart from the resurgence of interest in consumerism there are a number of other, perhaps less fundamental developments relevant to PHC in the European ife6on. They will undoubtedly, when taken beyond the research stage, influence the effectivness of PHC. (a) Computertssisted decision-making. For both diagnosis and manage- n1.ni ih. equipment is becoming simple and portable. The parallel develop' ment of algbrlihms, check lists, and score sheets, also both diagnostic and managerial,-seems likely to be of profound importance in medical care and of even more importance as an aid in nonmedical PHC. (b) Total population registration.I have already referred to th_e value of total population data to planners and others seeking to improve PHC. A few countries organize theii PHC so that total populations are registered' The resulting information is therefore approaching the quality necessary for the systematic planning of health care. (c) Data linkage. Where countries also have a PHC system that ensures continuity of care with linked data for the health of the whole population the effeciiveness of PHC is considerably enhanced. A computer terminal linked to a central information bank offers the primary health care team access to diagnostic and therapeutic assistance, enabling them to take part in building ,p i lint.a centralized records system, which is a prerequisite for comprehensive care. (d) Evaluation by new indices of health. Evaluation of care requires in- dices of outcome, and measures of mortality and morbidity have always existed. New and more subjective indices, suitably standardized, are becoming available and offer new opportunities for evaluation in PHC. (e) Measuing need.Measures of the extent of need for PHC can only come from studies of whole populations, but in most countries of the Region such surveys are difficult. In one or two countries, however, very large populationi have been studied for elementary morbidity, for long-term needs ioi care, and for changes in disease pattems. The results of these surveys have important implications for the organization, evaluation, and planning of PHC. 29 (f) Screening of populations. Research on the costs, benefits and ef- fectiveness of presymptomatic screening (an activity seen in some countries as part of PHC) is developing, but although much important research is being performed this has not yet influenced social policy. (g) Appropriote technology. As already mentioned, there is a movement among health professionals, economists, and social administraton seeking to use more appropriate technology in PHC. While activities have related mainly to the developing world, some work is being done in the European Region. Of particular interest, for example, are some simple devices (sphygmomano- meters, ECG machines, dipstick testing, peak flow meters, etc.) now being developed. These could markedly improve accuracy in general practice and make accurate techniques available to other health professionals. (h) Resource ollocation and isk. Some experimental work and certain policy decisions in the Region support the idea of relating resources to need and risk. Essentially, this is a managerial strategy that seeks to allocate resources (nursing time, health visitor visits, screening, etc.) to those most in need and in proportion to their need. (i) New phnning ond manageriol techniques. A number of planning and managerial techniques developed during the last decade a.e b.inging rbout a revolution in national health care organization. of these, the so- called. planning or cybemetic cycle, which applies a systems analytical ap- proach to health care, is likely to provide a scientific basis for much pHt development. 4.8 The importance of PHC: new recogrition? ln reviewing some of the possible solutions to regional problems in the field of PHC, I have been struck by the growing recogrition of the importance of primary medical care and by its gradually widening scope. New health services research groups, the new recogrition by the medical schools, the special and extensive education of primary care teams: these are some of the sigrs. The socalled renaissance in general practice may foreshadow new understanding of PHC in the Region. 4.9 The future It is possible to group the developments of pHC in the European Re- gion into four main areas of concem; these are the challenges for thi future. Management, policy planning, and the organization of care; changes inprofessional and lay roles in care; and community (especially consumer)participation are the principal areas where we are advancing. Thi fourth area 30 comprises a number of special programmes, all of which have important implications for community health. In addition, we must utilize the findings of research teams and promote further research. In the fields of medicine and epidemiology new research is needed on the prevention of ill health through education, on population screening, on ways of improving the effectiveness of care, and on how best to use resources - human, material, and economic. To do all this we must know more about the outcomes of care, and we need new sensitive measures, which include such real, but difficult, concepts as "quality of life". Also, we need to conduct more trials of different health care strategies that could be appropriate to dif- ferent cultures. We are now on the threshold of a truly quantitative revolution in health care and the new numerical methods must be employed in modelling health care systems, for instance. Then we must study methods and effects of inter- sectoral collaboration in the provision ofcare and the use ofhigh technology, as well as in the production oI more appropriate technology. At the sociological level we must define relationships between sectors, particularly between health and social welfare. We must learn more about the dynamics of need and demand, and become more sensitive to social and cultural pressures within our communities. We must study the dynamics of the health care team and the changing role of the consumer, and we must discover how to work with the consumer in achieving optimal organization of care. Finally, we must leam much more about the origins of our own at- titudes towards the populations we hope to serve. 3l REFERENCES l. WHO Regional Office for Europe. The role of the pimory physician in health servtces: report on a Conference. Copenhagen, l97l (EURO 0380). 2. WHO Regional Office for Europe. Education and taining in long-term and geiatic carei report on a Working Group. Copenhagen, 1973 (EURO s30l). 3. WHO Regional Office for Europe. The role of nuning in pimary health care: repoft on a Working Group. Copenhagen, 1976 (ICP/SHS 004). 4. WHO Regional Office for Europe. The efliciency of medical carei report on a Symposium. Copenhagen,196T (EURO 294.2). 5. WHO Regional Office for Europe. The efficiency of medical core: report on a Symposium. Copenhagen,l9T4 (EURO 4308). 6. WHO Regional Office for Europe. The deftnition of parameters of ef- ftciency in pimary care: report on a Working Group. Copenhagen, 1976 (rCP/SHS 039). 7. WHO Regional Office for Europe. The Gabrovo health services model in the People's Republic of Bulgoia.l977 (unpublished document ICP/HSD 004). 8. Soumia, l.C. Health insurance and pimory care in France. 1978 (EURO unpublished document). 9. Novgorodcev, G.A. The organization and stotus of outpatient-polyclintc care, including pimary health care, in the USSR. 1978 (EURO unpub- lished document). 10. Novgorodcev, G.A. Primary medical care in the national health service of the German Democrqtic Republic. 1979 (EURO unpublished document). I l. Benadouda, A. The role of polyclinics and outpatient care establishments in the delivery of health core to the community in Algeia. 1978 (EURO unpublished document). 12. Nicolic, A. et al. The health programme in lvanjica, Yugoslavia. In: Djukanovic, V. & Mach, EP.,ed,.Altemorive approaches to meeting basic health needs in developing countries. Geneva, World Health Organization, 1975, pp. 67 -70. 13. WHO Regional Office for Europe. Comprehensiye cardiovascular com- munity control programmes. 1977 (unpublished document ICP/CVD 018(2). 14. Kohn, R. The organization of pimary care - some general obsemations on the situation in the Europeon Region. 1978 (EURO unpublished document). 15. Greve, l. Consumer participation and responsibility in the phnning and delivery of health care. Copethagen, WHO Regional Office for Europe (EURO Reports and Studies, in preparation). 32 Annex I DECLARATION OF ALMA.ATA4 The Intemational conference on Primary Health care, meeting in Alma- Ata this twelfth day of September in the year Nineteen hundred and seventy- eight, expressing the need for urgent action by all govemments, all health *i a"r.ioprneit workers, and the world community to protect an9 pro- mote the health of all the people of the world, hereby makes the follow- ing Declaration: I The conference strongly reaffirms that health, which is a state of com' plete physical, mental andiocial wellbeing, and not merely the absence of air".r. or infirmity, is a fundamental human right and that the attainment oi the highest poeiibte level of health is a most important world-wide social goal whole realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status of the people, particu' larly between diviloped and developing countries as well as within countries, is politically, socially and economically unacceptable and is, therefore, of common concem to all countries. Economic and social development, based on a New Intemational Eco- nomic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. Thi promotion and protection of the health of the people is eisential to sustained economic and social development and con- irlbutes to a better quality of life and to world peace ' m a Reprinted ftom Alma-Ata t 978: primary health care. Report of the International Conferen& on primary Health Care, Alma-Ata, USSR, 6- l2 September 1978. Geneva, World Health Organization, 1978. 33 ry The people have the right and duty to participate individually and col- lectively in the planning and implementation of their health care. v Govemments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures. A main social target of governments, intemational organizations and the whole world community in the coming decades should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of socialjustice. VI Primary health care is essential health care based on practical, scientif- ically sound and socially acceptable methods and technology made univer- sally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the fint element of a continuing health care process. vII Primary health care: l. reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results ofsocial, biomedical and heatth services research and public health experience; 2. addresses the main health problems in the community, providing pro- motive, preventive, curative and rehabilitative services accordingly ; 3. includes at least: education conceming prevailing health problems and the methods of preventing and controlling them; promotion of food 34 4supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family plan- ning; immunization against the major infectious diseases; prevention and control of locally endemic diseasesl appropriate treatment of common diseases and injuries; and provision ofessential drugs; involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors: 5. requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate edu- cation the ability of communities to participate; 6. should be sustained by integrated, functional and mutually-supportive referral systems, leading to the progressive improvement of compre- hensive health care for all, and giving priority to those most in need; relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. VIII All govemments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehen- sive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country's resources and to use available external resources rationally. x All countries should cooperate in a spirit of partnenhip and service to ensure primary health care for all people since the attainment of health by people in any one country directly concems and benefits every other coun- try. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world. 7 35 xAn acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world's resources, a considerable part of which is now spent on armaments and military conflicts. A genuine policy of independence, peace, d(tente and disarmament could and should release additional resources that could well be devoted to peace- ful aims and in particular to the acceleration of social and economic develop- ment of which primary health care, as an esential part, should be allotted its proper share. **tt The Intemational Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New In' ternational Economic Order. It urges govemments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral ag- encies, non€ovemmental organizations, funding agencies, all health workers and the whole world community to support national and international com- mitment to primary health care and to channel increased technical and fi- nancial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration. 36 Annex II OTHER PUBLICATIONS OF THE WHO REGIONAL OFFICE FOR EUROPE RELATING TO PRIMARY HEALTH CARE WHO Regional Office for Europe. Health planning and organization of medical care. Copethagen,lgT2 (Public Health in Europe, No. l) WHO Regional Office for Europe. Trends in the development of pimary care: rcpott on a Working Group. Copenhagen, 1973 (EURO 4309) WHO Regional Office for Europe. The development of comprehensive mental health semices in the community: report on a Conference. Copenhagen, 1973 (EURO s414 r) WHO Regional Office for Europe. Psychiatry and pimary medical care report on a Working Group. Copenhagen, 1973 (EURO 5427 l) WHO Regional Office for Europe. The role of social insuronce institutions in preventive medicine: report on a Symposium. Copenhagen, 1974 (EURO 430s) Kohn, R. Coordination of health and welfare services in four counties: Austia, Italy, Poland and Sweden. Copenhagen, WHO Regional Office for Europe, 1977 (Public Health in Europe, No.6) 37 Annex III PUBLICATIONS AND DOCUMENTS ON PRIMARY HEALTH CARE DISTRJBUTED AT THE ALMA.ATA CONFERENCE BY MEMBER STATES OF THE WHO EUROPEAN REGION BULGARIA Primary health care in the Bulgarian National hrblic Health System. Sofia, Medical and Public Health Scientific Information Centre, 1978. CZECHOSLOVAKIA The Czechoslovak Health Service. Prague, Ministry of Public Health [undated]. Les fondements de la santi publique socioliste de la Tch4coslovoquie. Prague, Institut d'Education pour la Sant6, 1978. DENMARK Fog, J. Primary health care in Denmark. Copenhagen, National Health Service of Denmark [undated] . FINLAND Primary health care in Finland. Helsinki, Ministry of Social Affairs and Health, 1978. FRANCE Sournia, l.C. Assurance muhdie et soins pimaires- Paris, Ministdre de la Sant€ et de la Famille ,1977. GERMAN DEMOCRATIC REPUBLIC Medical care in the German Democratic Republic: report to the Inter- national Conference on Primary Health Care, Alma-Ata, 1978 [1978] . GREECE Liaropoulos, L. Primary health care in Greece: cunent situation and perspectives for the future. Athens, Ministry of Social Services, 1978. HUNGARY Health care in Hungary. Budapest, Ministry of Health, 1978. 38 MALTA Primary health care within the fromework of the health services in Malta. Valletta, Ministry of Health and Environment [undated] . MOROCCO Les soins de santt pimaires. Rabat, Ministdre de la Santd publique, 1978. Organisotion des services de santi publique au Maroc. Rabat, Ministdre de la Sant6 publique [978] . NETHERLANDS Primary health care in the Netherlands. Leidschendam, Ministry of Health and Environmental Protection, 1978. POLAND Cwirko, H. & Szeszenia-D4browska,N. Primary employee health care in the heolth core system in the Polish People's Republic. Warsaw, Polish Medical Publishers, 1 978. Dawydzik, L. & [.ewartowski, B. Pior to and postgraduate education of metlical personnel for the needs oJ' pimary health care in the Polish People's Republic. Warsaw, Polish Medical Publishers, 1978. Ehrmann, Z. Health care in the Polish People's Republic. Warsaw, Polish Medical Publishers, 1978. MiSkiewicz, M. & Orzeszyna, S. Role and place of pimary healtlt care in the Polish People's Republic. Warsaw, Polish Medical Publishers, 1978. ROMANIA Le concept et le dtveloppement des soins de sanft pimaires dans la R2publique socialiste de Roumanie. Bucharest, Ministry of Health lle78l. SWEDEN Nicolausson, U. Primary health care: a Swedish project. Stockholm, National Board of Health and Welfare, 1977. USSR Lidov, I.P. et al. Soviet public health and the organizotion of pimary health care for the population of the [/SSR. Moscow, Mir, 1978. Lisitsin, Yu. & Batygin,K. The USSR - public health and social secuity. Moscow, Progress Publishers, 1978. Petrovsky, B.Y. The main stages, the stote and prospects for developing therapeuticol and preventive aid for the population of the USSR. Mos- cow, VNIIMI,1978. 39 Sharmanov, T.Sh. Experience of organization of pimary health care in Kazakh SSR. Alrna-A ta, "Zaly n", 197 8. Sharmanov, T.Sh., ed. htblic health in Kazakhstan. Alma'Ata, "Kazakh' stan", 1978. 40 No. I No. 2 No. 3 No. 4 No. 5 No. 6 No. 7 No. 8 No. 9 No. l0 No. ll No. 12 No. 13 PREVIOUS ISSUES IN THE SERIES EURO REPORTS AND STUDIES Sentice-oiented research in adolescent fertility: report on a WHO Meeting.1919,37 pages, Sw.fr. 5. Sodium, chloides, and conductivity in dinking-water: report on a WHO Working Group. 1979,63 pages, Sw.fr.7. The child and the adolescent in sociery: report on a WHO Con- ference. 1979,60 pages, Sw.fr.7. Evaluation of inpatient nuning practice: report on a WHO Working Group. 1979, 18 pages, Sw.fr. 4. The role and lunctions of national institutions of ophthalmo' logt: report on a WHO Meeting. 1979,17 pages, Sw.fr. 4. Continuing education of health personnel as a factor in career development: report on a WHO Working Group. 1979,34pages, Sw.fr.5. Environmental health impact assessment: report on a WHO Seminar. 1979,31 pages, Sw.fr.5. htblic health aspects of alcohol and drug dependence: report on a WHO Conference. 1979,31 pages, Sw.fr. 5. Manpower development in toxicology: report on a WHO Con- sultation. 1979, 20 pages, Sw.fr. 4. Health education: smoking, alcoholism, drugs. 1979 (in pre- paration). Principles and methods of heolth education: report on a WHO Working Group. 1979,17 pages, Sw.fr. 4. The management of sexually transmitted diseases: a gaide for the general practitioner. 1979,79 pages, Sw.fr. 9. Ainical pharmacological evaluorion in drug control: report on the Seventh European Symposium. 1979,31 pages, Sw.fr.5. WllO publlcatlonr may br obtlnod, dlr.ct or throuoh boolrcllrrr, lrom: AI.OBTIA AR,OENTINA AUgTRALIA HUNGARY ICBLAND INDIA CHINA COLOMEIA czEcHo- SLOYArIA DENMARK BCT.,ADOR BOYPT EL SALVADOR FI'I FINLAND FRANCE GERMAN DBMOCRATIC REPUDLTC GERM^NY, FEDER.AL REPI'ELIC OF GREBCE HAITI IIONO KONG Scl&6 Nrtlorb d'Edldd ct d. Dlftdo. 3 bd Zhour youct Al.oarr CrIlo. HlE(t SRL. ftorldr 165. Cdsbr G038. Errltorlo 453/6:t. EutrE AIrl' Mall Orhr &lcs: Aurnllra Gorcmtrr Publbhlas Sarvioa E@bhoo.. P.O. lc ta. C^Ntru A.C.T. 2600; q ote,b cmtc. /ar.'Aul'llLD GoEnrmt hutado rrl l{ulr, OaGlrra rt : I lil-l 15 Lood@ Chqdr. C^NrBrA GtY A,C.T. 2600 : SboD 't2. th. 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KIP 5R5. Cmrpttd.ac. cm.rillns srbselt toB slt& b &cscd ,o ,tE Wot'd llrlrh Orsmlatio. Dbrdburlor lrat SrL.. l2l l Orxw^ 27. Srlrraclud Cttil Nrtlond hbllotloil lmDon corDoEtloD, P.O. Ec 8t. Ertxo Dltrrlllbr6 Lrd., Plo Alrorc Gud., Csncn /ar, Na 36-119. carraotN^ Ardr, Vc So..frcb lO, lll 27 Pr^our I Enu MuDl.|rud Lrd.. Ntttlit& 6. 116l @trml^otN K IJbffih Chtl0cr S.4., P,O. Bor 162. Lu{a 223. Ou^v^Qutr Nrb.r El Fltr looldroD, 55 S.rd Zrsnldl ltrsct. Ar[^xDx^ Llbrcdr E$udrudl. Edlicto Comrcrrl B No 3, Awnidr Llbcrlrd, S^r{ llarv^Er Thc WHO Prorrrfrm Codlmror, P.O. Bor tll, Suv^ Ahlccnlncn Klrlrtrup!.. Kdtutrau 2. mlol llIr-xrj l0 LlbrrHc ArDrrc, 2 ru CulolnDchvltDa, 75(16 P^us BlEhiru lrlgds, Fo.rfich l.O.7Ol l-Dzto Goylv6lrs CmbH. Ghnlrimnlnc lO. Po.rfrcb 5l@.6ir!6 ElctDrr{ - W. B. !l[r6aEb. Patf8b tot 610. Folbilrr& 2, 5 @rooNr t - Alcr. Hm, SpLs3lir$ 9. PdrrcL t3alr. 6200 W!tt^D3x G. C. E&ftbssdrtb S.4., IlbnlrL latcrorloilh, rE Nili3 4. AreN (T. 126) Mar EoucicEru, Llbniric "A ls CuwtL", BotE ganrh tll-8, Folr-^u-htxcf Hont Kda Govcmcnt tdmdm SGnhcr, EGro60Gld Hoe. fitr Flu. (h!C[! Rod. Ccnrnl. VIcrcu Kulrun, P.O.E. 149. EuDAtE r 62 - Atrddmbi KonvBbolr. Vlcl ur.. Zl. DuD tl,r V Smbirm ,oEoo & @.. P.O. &r ll3t. Hrlhslr&d 9. Rwsavtr wHo Rc3tilt Oae ln Soutt Et.r Ad.. wortd Hc.lrh Hor' ltrdn9ntttl E lrb, Rl[r Rad. Nry Dn E r l0(x)2 - Orford Eot il Strriomrv co.. Scindh Hor, Nlw Du t l(Ilx, : l7 Prrt Stca. C^Lcura ?(ml6 (&rb.r.t ) Mjr Kdma Eoor Scrl,oc Ld.. ,lr. CItiri &.vr No.63' P.O. Eot 3lo5rJtl. J^r^$^ tnolrn Aill8rmi.d Dlttrlbudm AiGDc/, f 5l Khirb.o Smrr. TrEux Mlobutr or ln omtlon. NrrloEt Houac fos hrblbtrIDa, Dlirtbu(nS ln l Adwrdtlnr, aaortD^D Thr Sutlorry OtEcc, Duu,rN a Hcillsa. & Co,, , Nithrtr strru Sarart, ,rrulau Edlrlml Min3 v. Mcdkr, Com Enmaa! b!-s5, 10126 TmH . vir trErffi 3' 2ot(p Mlt^r MmEn Co. Ltd.. P.O. Eor 5O5O, TorYo ltrl.mrlonrl. lU)-31 Thc wHO Protmm Coo(dloraor. Ccnml P.O. 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Ed 5896. Eororo Wcld Hcalrh OnLdzarlon, Rc&onal OEs ftr th Wc|tom Prctic, P.O, bt 29t2. MANrL^ -Thc Modcm Emt ComDrny Inc., P.O. bx 6t2,926 Rlral AEnlr, MaNtra Skladnl6 Klhfrnfr. u0 Mrrcelccka 9. 0@r2 W^$^w (crccD, Derlodtcah/ - DKWZ Ruct. ul Wronir 123, m&O W^$^w (nildlcab oilly) Llmrtr Rodrlss. t86 Ru do Ourc, LEEoN 2 Nrsb Unlrcnlty Collc& Bootrho, (Uniycnlly ol Stm lronc), Hvstc Mlll Ber. Furmwx Thc WllO Prcrmmc Cordlnrtor, lrl4 Moulmch Rod. G,P.O. Eox 3457. SNo^rorB I - SotccrB@ft (nc) Lid, 215 Trns[n S]hoDptas Cmut. 2/F, 19 Tru8ll! Rod. Stxo rorr t0 Van Schsil'. Betrtorc (fty) Ltd, P.O. Box 724, 26t C'hurch Stroc!, Prtmr,ra 0q[Coffiid ArbGncun S.A.. Coulo dc Cicuro 130-t36, B^rctLoN^ l5 i Ocrrsl Macard6 29. M^DrD 20 - Ubcrh Dl.r da Sant6, LrsaE 95, MaDD 6: ErlG alT y 419, B^rcroNA 6 ,". Indh, WHO Rctlml Oilc. Atticbolard C.E, Frlla Kutl. govbokh.D&1. Rcfcrln8rrrt ! 12. l0l21 SMrflou M.dlrinilctrcr Vcrbi Hrnr Hubcr, L"largls ltar$ 76. ,0t2 EuNr 9 M. Frm Kcthfr. 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(rctail oaly) Fu ?..d.rt tt thc USSR ?.oublra RKlon drroE.' KomaoDolrkjJ DroDGkr 18, Mcdlshttrh Knlss. M6cow - Fot nofuH Nttldc ilu USSr rcqut?W Rtssla.drloB: Kuaccll, Eat t8,Mcldurcdnda Knl8a, M6cow G-2d, Edlrorlrl Intcnmriqnr & Vculr C.4.. ADoflsdo 5(185. C^uc^! 105 - Ub[trb dcl Es!r. Apsr!.do 60337. Cecs l(b ,us6lovcDlr Kn lga. Tcnzlrc 27lII, lloU) BEoMD! Llbniric udvcEltrirc, !vG!& dc la Pah No 167. E.P. 1682. KtNms^ I UNTTBD STATES OF AMERICA Speclal termt lor developlno countrles are obtllnabl€ on appllcrtlon to the WHO Proorlmme Coordlnatorc o, WEO Reelonr! Of,lcoi llated above o, to tho World Hoalth Orclnlzallonr Dlrtrlbutlon rnd Sal.r Servlce. t21t Goneyr 27, Swltzerland. Orderr trom count?ler wh€re r.lsa acont3 hlyc not yet beon lppolnted mly alto be rent lo the Geneva .ddre.3, but murt be paid lor ln poundr 3terllng, US dollarr, or Swl$ francr. Prlce: 3w. tr.s.- Prlca3 aro tublect to chrnge wllhout nollco.