WORLD HEALTH ORGANIZATION
OR.GANISATION HONDIALE DE LA SANT~
r. REGIONAL OFFICE FOR THE WESTERNPA<:IFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL P. O. Box. 2932, MANILA
REGIONAL COMMITTEE
TECHNICAL DISCUSSIONS WP/RCll/rnl 21 March 1960 OlUGINAL: ENGLISH
Eleventh Session Manila 12-17 August 1960 RlRAL HEAm'H SERVICES*
The attached technieal paper is presented at:l background inforna tion for the participants attending the Technical Discussions to be held during the eleventh session of the Regional Committee for the Western Pacific. It is hoped that this working paper will bo useful to the
regarding this document are invited and should be directed to the Regional Director.
*Abstract
of the Report on the Regional Rural. Health Conference held in New Delhi in 1957 under the aegis of the WHO South-Bast .Asia Regional Office.
.
TT /J!..Cll/TDl
RURAL :HEALTH SERVIC"'.:ES
CONTENTS
r
l.
PREAMBLE •••••••••••••••••••••••••••••••••••••••••••••••••
1
<J/
2. ~.
INTRODUCTION •••••••••••••••••••••••••••••••••••••••••••••
1 2
PLANNING ••••••••••••••••••••••••••••••••••••••••••••••••• LOCATION OF HEALXH CENTRES ••••••••••••••••••••••••••••••• SERVICES •••••••••••••••••••••••••••••••••••••••••••••••••
4. 5. 6.
3 ,
ORGANIZATICti AND ADMINISTRilTION •••••••••••••••••••••••••• 1. General ••••••••••••••••••••••••••••••••• ~............ 2, Staff ••••.••••••.••••,................. •••.••••••••••• ~
S ,
,. Size of the population •••••••••••••••••••••••••••••• ,
7
4. Facilities ••••••••••••••••••••••••••••••••••••••••••• 5.· Programme •••••••••••••••••••••••••••••••••••••••••••• 5.1 Maternal and child health •••••••••••••••••••••• 5.2 EnvironaentaJ. sanitation ••••.•••.••••• ,; ••••••••••• 5.3 Nutrition •••••• f/ • • • • • •, • • • O'f/' • • • • ~,~·~ • •·tI ••••.•• , • • • • 5,4 Records, reports and statistics ••'........ i •••••• !t
7 8
, , 8 9 11
5.5 Administration
and supervision •••••••••• , ••••••• • 0'
'.'1 B. 9. GENERAL
;.6
Financing •••••••'••••••••• ,. ......... f/'"
.r'~ •••••• "
12
Special health activities
I' • • • • • • • • • • • • • • • • • • • • • •
a 13 14
TR.AININ'G ••••••••••••••••••••••••••.'••••.••••• ., .'............. .
MEDICAL CARE IN RURAL HOSPITALS
•......... ..............• ~
CONSIDERATION ••••••••••••••••••••••••••••••••••••
lS
WP/RCU/TDl page 1
1.
PREAMBLE
A long-felt need to exchange views on the subject of rural health services resulted in a regional conference being held in New Delhi from 14 to 26 October 1957. A balanced representation consisted of a general public health administrator, pUblic health administrators specifical~ dealing with rural health or public health officers actively working in rural areas, publie health nurses, sanitar,y engineers working in the field of rural sanitation and teachers of public health or preventive medicine. All the delegates I observers and consultants contributed their knowledge and experience to the common pool. The average attendance at the conference was in the region o! forty persons. 2.
INTRODUCTION
MOst of the countries in South-East Asia and in the Western Pacific Regions have undertaken one or another type of programme to provide health eare to the peoples living in rural areas. The average country plans envisage the rural health centre as a basic unit for services which ultimatelY will extend into all areas of' a country. The developnent of rural health services appears to be related to such obvious factors as (1) strengthening of the central health administration for the organization and direction of the programme, (2) availability of funds and (3) availability of trained personnel. The question arises, however, if these factor s need to be as limited as they appear. This question raises the desirability of reviewing our present concepts and aims' of rural health services and of exploring new approach s to expanding than. Of importance is the study of the utilization of local resources and the strengthening. of the participation of local people as a means of enhanCing financial resourees and collaboration. The examining of the criteria for location of health centres, types of services to be given, placement and use of ~rsonnel, adequacy of administrative and supervisory services in relation to programme development and the effectiveness of health services are worthy of evaluation. A factor of practical importance is the need to keep under constant review the techniques and methods to be followed and to make periodical assessments of the results of the policies and plans adopted.. Since the human factor is largely concerned in the successful. implementation of the programme, there is no roam for set or rigid ideas. The plan must be flexible enough to admit modifications in the light of experience as it accumulates with the progress of the schemes. There is general acceptance of the concept of a rural health unit as a medium for providing a programme of integrated health services to a given population group within a limited rural area. The acceptance of this principle poses its own IX'oblems in the organization, administration, staffil}g and financing of rural health services. What should bhe size and location ot a mUJ. tipurpose rural health centre be in relation to the colrt;ent of IIBdical and preventive services to be provided? What is the type of organization best suited to the felt need; the metJ10ds of integrating medical care and the activities directed aga:inst fP ecific diseases into a comprehensive, functional health programme; the compositioi of the. staff to be employed, the kind of supervision required, th types ot . training courses needed to prepare the necessary staff, the participation. of people in too plarming and organization of local health services?
WPJRCll/TDl
page 2 What should the minimum. requirement\. and facilities, equipment and reports on statistics be in order to provide/functional basis for rural health care? These important questions need review, discUSsion and universally accepted conclusions which could be broadly followed by countries in the Western Pacific and adjusted to their own particular local condition. The significance of the discussion is that we can examine the generally adopted methods of organization and amninistration, relate them to conditions in a given countr,y, and through discussion and exchange of ideas and experience evolve patterns for rural health adapted 'to a given set of purposes, thus moving forward more rapidly towards the goal of a healthier nation. - . .., ~
3.
,
PLANNING
'-
Nearly every country in the Western Pacific has undertaken one or another programme for rural development. The sta.tus of the programme mq vary from preliminary planning to a well advanced organization of community projects covering a oOllAiderable number of vUlages. Recognizing the interrelationship of the health of peoples and the total socio-economic advancement of a nation, governments in this region have placed emphasis on the establishment and extension of health services in the rural areas as a part of rural development programmes or as an initial service within their area. There is a wide variation of the pattern of services provided. The question . arises as to whether it is basically sound to advance rural realth indepem.. ent of the related rural problems. Disease is the weak link in the endless chain of diseases, ignorance a.nd poverty, and while greater benefits would accrue to people through a co-ordinated approach, it would be illogical and economically unsound to neglect the health needs of rur aJ. peoples while awaiting the developnent of the co-related problems. It is considered fundamental that a vigorous attack on diseases should be undertaken to break the recurrence of illness and poverty. It is felt that the t~e has come to place much greater emphasis on public-health administration. This concept relates to (l) the rural. health unit of the smallest organization to administer rural. health services; (2) basic services including medical care on the control of communicable diseases, maternal and child health, environmental sanitation, school health services, health education, vital statiSt"1cs, and (3) the minimum staffing pattern which would be a medical officer in charge of a lJ'6cifio nwnber of nurses, midwives, sanitarians and other auxiJ.iaries that the service calls for. It is recognized that those standards would serve as a goal, but there is a wide gulf between the present conditions and the achievement of that goal. There are certain factors which, with the prevailing shortage of personnel and lack of sufficient funds, require attention. These are (a) location of rural health centres, (b) the services to be rendered, (c) the organization and administration of the unit, (d) staffing, and (e) financing. It might be useful to agree on the following terminology which is frequently used in the discussion of rural health services:
.;:>
,.
lwl;m.th Org. techn. Rep. Sere 55 and 83
-
-
WP/RCU/TDl page; :j:~
"Rural health unitaa is a functional organization providing health eervices under the direct supervision of a physician. "Rural. health centre" is the place in which basic health services are rendered. "Integrated health serviceslt are health services, including medical care, rendered either by a health unit or by several. agencies with proper co.ordination so that necessary health protection will be provided in a given area. "Comprehensive health services" means basic health services rendered by the rural health unit as mentioned under 2 above. "Limited health services" is a programme limited to a selection of the components of the basic health services listed under 2 above •
. 4.
LOOATION OF HEALTH CEN'lRES
The criteria used for locating health centres during the process of expat:lsion vary from country to country and even within the country; there appears to be no set of criteria which could be consistently applied, The selection of a site for the location of a health centre could be usefullY based on the following criteria:
"(1) needs of the area, as determined by a survey or appra:i.sal. of health conditions and organizational pattern3;
(2) accessibility and facUities for travel wi. thin the area, which must be adequate to permit the extension of services to all the villages included,;
(3) size of the population to be served; (4) accessibility of well-equipped hospitals and other specialized services;
(5) existence of other community services, such as rural develop"F:
ment programmes, schools, other governmental and voluntarY health services and community organizations, and
(6) the expressed interest of the people in supporting and co-operating with the health organization,"
5.
SERVICES
The rural health servioes should be planned on a conrprehensiv basis to include medical care, maternal and child health, communicable diseases control, envirorunental sanitation, school health services, health education and vital statistics. Such services to be effective should be rendered to a limited population within well delineated areas.
WP/RCll/TDl
page 4 The size of the population and the extent of the area would be detemined by local conditions and the adequacy of the health unit staff and facilities. There is a natural tendency for those services to be concentrated in the neighbourhood of the rural health centre and that limited services would be rendered to the remaining population. The potential danger would be that the dilution of services in the outlying area or "sub-centre" may become so thin as to make them ineffective. It is essential, therefore, to have a clear concept of the services to be given in the peripheral area and the population and/or areas 'WOuld have to be kept within the bounds so that the objectives of the programme might be obtained. In connection with the provision of limited health services, the following points should be taken into consideration, (1) nexibility of the programme planned based on the most urgent health needs of the area rather than an established plan devised for all areas; activities unless carefully planned and adequately supervised tend to become too diluted to be effective; steps to be taken in subsequent development towards a comprehensive service should be carefully considered before a limited service starts. Plans should be made to provide personnel, facilities and funds; fUll cognizance should be taken of the existing heal. th services such as hospitals, dispensaries and all programmes already going on which have some health aspects (rural development programmes, schools, etc.) It is essential that the services of the health unit should be planned to co-ordinate such activities in order to provide better cOlllllunity services.
(2) (3)
(4)
The following conclusions' can be drawn in respect of the limited health services, (1) (2) the emphasis in such a programme should be on the major health needs of the area as determined by previous survey; the personnel should be assigned according to health problems to be solved rather than programmes developed on the basis of the category of personnel available; medical relief should be provided; in the peripheral areas beyow the immediate environment of the health c entre emphasis should be placed on environmental sani tation, health education, maternal and child care and medical relief.
(3)
(4)
;,,:x
WP;RCll/TDl page 5
(5) before a limited health service programme is initiated plans should be made for steps to be taken in developing a comprehensive health service, including the provision of facilities and personnel as well as for financing expanded services. In all rural health services it appears that integrated health service is being included, name1Y, one with both public health and medical care. The type of IOOdical care provided would be linked with the qualification of the worker. Persons working on the village level (midwife, sanitarian) should be equipped with medical chests containing first aid supplies and simple drugs for treatment of minor ailments. Wherf3Ver a pnysician is stationed, out-patient clinics should be held and when local conditions permit, the provision of mobUe dispensary staffed by a pnysician and an auxiliary health worker should be considered as a support 1:-0 village services. The survey of health needs of the area would determine the public health services to be included in a limited programme. Considering the universal lack of safe water supplies, the wide prevalence of faulty sanitar.r conditions and the lack of understanding of health matters among the village people, it is felt that emphasis should be placed on environmental sanitation and health education in all rural heal th servic es.
~~
rI"'o
6. ORGANIZATION AND ADMINISTRATION 1. General
rr-"0
The variations in the organization and administration of health services in the countries in this region are apparent. It is f air to state that the variations are more marked on the national and intermediate levels than in the local health units and are connected with the different broad political organizations or administrative divisions. It is felt that the weakest link in the organizational and administrative structure is the intermediate level. Generally, a unit at this level is relatively loosely organized, possesses limited authority, is not always adequately staffed and frequently is unprepared to carry out the responsibilities of administration and supervision of the rural health units under its jurisdiction. At the level of the local health unit, the differenc~s that exist are not those of the concept of structure and function but due to the variation in staffing. In some instances cited where a good working relation had been established between the local and intermediate level, the local unit possesses greater autonoIl\V in the conduct of its own activities. In this connection, it is fair to state that some clarification is required concerning designated responsibilities and an oppo!tunity should be provided to review the adequacy of the administrative structUr:'e along the lines of modern concepts of administration. A clear stateroont of the organization and function of, as well as the authority for, each level of health organization should be developed by the national health
WP/RCll/T01 page 6 agency and distributed to all personnel having administrative and supervisory responsibilities. The rigid hierarchical system under which most health administrations function, in practice, mitigate against consultations, discussions and interchange of opinions among the different levels. In some .instances, suggestions from subordinates may not be encouraged and the administrative d.irective comes by one-way channel from hjgher to lower level. Supervision also may follow too frequently the administrative channels and is concerned with corrective measures which further contribute to the attitude of "carry out the letter of instruction and play safe". During the New Delhi Conference, each country stated t hat the rural health unit should serve 20 000 to 60 000 persons. In practice, however, a health unit may be covering from 30 000 to 200 000 people. In practice it has also been noticed that resources in trained personnel and funds are slender and it follows that onlY mdJUUmwn services can be rendered by a sk 1 ton staff. The value of a health unit in a rural area lies in its ability to bring health services to families in their homes and villages and to stimulate the interest and co-Operation of the people in improving their health practices. The effectiveness of the service will depend, in a larg measure, Upon the balance between the size of the staff and the pOpulation to be served, the content of too programme and the facilities provided. The problan which require. decision in the planning of the service is to assess the prevailing staffing pattern and to develop suggestions "with respect to size of pOpulation, programme and facilities whioh could serve as guides in the organization and administration of a health unit and in carrying forward an effective balanced service. 2. staff
\.
The minimum staff of the health unit should be a plw'siciar}" a public.. health nurse or health visitor, chief sanitarian, one midwife to each 5000 - 6000 people" one sanitary assistant to each 10 000 - 15 000 people and the required number of subsidiary personnel. Adjustments in the staffing pattern would need to be made in accordance with the training and qualifications of individuals" and in relation to community health needs for emphasis of the progranune. Experiences "in SOOlO oountries indicate that the rnunber of deliveries made by one midwife during a year varies from 80 - 100; each maternity Case receives ante-natal care and is visited dailY for 5 - 10 d~s after deliver.r. The expected number of births in a population of 6000 based on the average birth rate in some countries would approximate 250. It is considered, therefore, that the midwif under"" . supervision and functioning in olose relationship with other services provided by the health unit would be able to increase the case load and oater to the maternal and infant care needs in an area of 5000 - 6000 people. The ratio of one sanitary assistant to 10 000 "'" 15 000 people is based on two considerations, (1) the need to expand activities in environmental. sanitation and to place greater enphasis
WP/RClljrm page 7 on rural sanitation in health problems and (2) the need for defining the duties of the sanitarian and adjusting his work load so as to allow for the major activities to be concerned with community sanitation. In considering the staffing of the health unit and in order to main.tain an effective comprehensive health service, the minimum staff should work as a team. While we can consider that the minimum staff of a rural health unit should consist of at least one physician, one public-health nurse or health visitor, one chief sanitarian, one midwife for each 5000 6000 people and one sanitary assistant for each 10 000 - 15 000 people and tbB required subsidiary personnel, it is also emphasized that the duties of each staff member should be def:ined in relation to the programme of the health unit, and the work load of each staff member should be reviewed periodically and adjusted in accordance with the training efficiency and quality rather than quantity of work.
3.
Size of the population
The size of the population served by a rural health unit with a min1mum staff provid:ing a comprehensive health service should be between 20 000 and 30 000 people as an optimum.
4.
Facilities
The health centre should consist of the main headquarters buUd1ng, sub-centres ar.rl mobile health vans if provided (each adequately equipped to support the required activities, as well as quarters for the staff). The site should be sufficiently extensive to provide for the health centre building, staff's quarters and an area for the construction of wells, latrines and other sanitary facilities for demonstration purposes and allow for the proviSion of a safe water suppl¥ and human waste disposal for the health centre building and statfls quarters. It is felt that each country may wish to develop a typical design for a health centre or sub-centre building, taldng into consjderation the fioor plans and such points as a waiting room sufficiently large to serve for group meetings and demonstration; an office room for each key staff member (physician, nurse, sanitarian); a record room where statistical data and case records could be kept and storage space for supplies and demonstra.tion material. A health centre should also include space for out-patient medical care and a smal.l laboratory for sinq:>le routine work. In addition to t he centrally located health centre, it is essential to develop subcentres each catering to a groUp of villages making Up a total population between 5000 - 6000. The sub-centre usually staffed by a midwife should provide a cleaning room, examination room, office and conference room as well as storage for equipment and supplies, including demonstration and visual. a1d materials for individual or group instruction.
WP/RCll/T'fiJ., page 8 The facilities for rural health units, should be based on the considerations that. ' (a) The rural health unit should be housed in a rural hea1.th centre, in order to provide adequate space for the various functions of the health unit.,. The health centre should be acieq~tely equipped to permit effective implementation of the ~ural health programma.
(b)
(c) , Quarters should be provided for the ent:u-e start at the health centre" (d) SUb-centres should be established in accordance ~th the health needs of the area, each to' cater to a population of approximately 5000 to 6000.. !
(e)
At each sub-centre, provision should be made for a building which should be equipped to serve as a base for p:'ogranme activities; further, accommodatio~ for the staff of the sub-centre should be provided. Suitable and adequate transport tor all tield staff should be available ..
(f)
5.
PrOgrfD1!1!
The programme of a rural. health unit serving a population of )0 000, and adequatelJr staffed, should provide preventive service, but ourative service should also be provided to the anent proportional with oOlllllUDit:r needs, health centre facUities, work load of staff and. &Ccessib:U1ty ot msp! tals or other medical care serv1ces. When .planning a prograrrrne, it should. be. kept in mind that anphasi8 should be placed on those fields which r.pr.ent major health problans ot the area. A clear-cut concept of the ,conlponents of service, that in any activity would have the most itrmed1ate stfeet of producing the desired r aults, should be kept in mind. In co~id"1ng the basic servicet,the following points of interest should be noted! •. 5.1 Maternal andchlld health Maternal. and chUd health should not be, consideI'ed as a speCialized, separately administrative service, but as integral part of the total health unit organization and operation. fbi. is especially true where such hazards exist as poor sanitation.. malnutrd.ti~n and canmunicable diseases. These unxerlie many of the conditions ins~f1ciently' dealt with when individual care is given to a mother or infant. A home visit to a mother or a child should be made as a family visl=t.: The health needs of the whole family should be observed and catered 10 instead of such visits
an:
a
}
1t
WP /RCUtro1 page 9
being allowed to become a routine materpity o'r child care observation for recording purposes. In providingmaternaJ. and child heal t~ ~ervices, one should be on guard against the tendency to concentrate act1~ties of ante-natal. work and conduct of deliveries to the neglect of l.nfant and child care. Infant and child care should, therefcr e, be extended beyond the neonatal. period to at least the time when the infant is wea,ned and when communicable diseases seem most prevalent. 5.2 Environmental sanitation
. The need, forimproveJnent in village sanitati'6ri~"1~' 1iSiiilly- '·so great and the of trained personnel 80 limited that all re80urces of the community should be utilized. It is important to teach village workers engaged in rural development projects or agricultural extension, the simple methods of well construction, latrine installation, compost pil,es and drainaee facilities which they could perform under the supervision of a sanitarian. The promotion of adequate and safe community water supplies should receive special attention.
number
5.3 Nutrition Malnutrition" a source of ill-health, in itself often forms the background against which all other disorders must be viewed. For that reason, nutrition requires special attention in rural health programmes. Close collaboration should be maintained with agricultural services and emphasis plaCed on the need for qUalitativ~ as well as quantitative production of foodstuff II It is important/w8rk out educational materials on nutritional matters and foodstuff values, based on local practices and local foods which could be translated into simple measures directed towards solving major food deficiencies in one particular area.
5.4 Records, reports and statistics There is a general feeling that the amount of paper work is frequentJ.y excessive in relation to: (1) the time necessary for the ch~es taken. either at the expense of performing other duties or by working overtime and (2) the returns of benefits obtained from data recorded and submitted, The value of good records and statistics cannot be contested and good planning and design of these records are essential. Before any record or reporting :vstem is adopted, a clear understanding of how a document is ,to be used and what purpose it serves should be considered. The following types of reccrds can be usefully considered: (a) Aiministrative reports which account for money spent on health services and to plan services and w orkloada. Usually such repar1s 1'urn1sh 1n1'ormation on facilities, type of service, personnel on duty and services rendered.
lVP/RCll/TDl page 10
(b) C ~se records, which should be vital working documents in all rural health units. The case records Should be basod on a family folder EtVstem which would provide g~mral information ccncerning the family unit; the individual records of "members of the family should be kept in. the single family folder. The installation of such a system would require planning, revision of existing records, and instruction of staff members in their use. Those records if properly kept should form the b a.sis of eva.luation a.nd ass~ssment of the growth of service. They will serve as useful yardstick for changes in programmeomphasis, worldoads for staff manbers and qu~ity of service. (c) Vital statistics are admittedly incomplete and inaccurate in most of the rural areas of the Regi.on. The health personnel should continually try to effect improvements in the system through gathering reliable infonnation on birth, death and illness through keeping in close contact with the persons in the vUlages charged with gathering data and by aasisting t1'em in bettering their recording methods. Concerning the programme for a rural health unit it can be concluded thats (a) The programme of a rural. health unit should include the tollowing basic services: communicable-disease control, maternal and child health, enviroIlIl1Elltal sanitation, health education, maintenance of records and stat1stics and medical care (to the extent compa.tible with community needs, existing facilities and staff); if conditions require a limited programme, the basic services rendered should be in those fields which represent the major ~alth problems in the rural unit area.
(b) A clear concept of the minimum service to be provided should take into consideration the population and/or &rea so that programme objeotives may be attained,; it a comprehensive health programme, including all basic services, is to be provided by a minimum staff, the components of eaoh aotin ty should be reviewed and only those services (within a total activity) performed that would provide the most iIl'lnediate benefit in relation to the health needs of the area. (c) The health services in a local health unit should be oo-ordinated with all hj$alth activities in the area and eftorts made to avoid d.uplication of any ~xisting services.
WI> /RCll/TDl pnge U
5.'
Administration and supervision
--r-
tiThe rural health unit must depend on the next higher organizational and administrative level for certain specialized services and supervision. It is sometimes difficult to define what is next higher level because of the variation in country patterns of health organization. A local health, service should combine medical care and public health activities in its programmes and at this level some degree of medical care is given~1I At the next level, however, such integration is not always achieved so that direction and ~dministrative control of local services are ~ov1ded by district (provincial) officers of public health, while hospitals or medical services remain under a separate authority. The medical care and public health service at the district (provincial) level should be combined. so that administrative ani supervisory direction of local health activities would be vested in a single intermediate unit. Such integration of service at the intermediate level would be a definite step towards improving the administrative relationship between the intermecU.ate and local health organizations. Such a step if adopted would imply the need. far an anal¥sis of the administrative responsibilities at the several organizational levels in order to delegate broader administrative authority to the district and local levels. In order to achieve a better working relationship, periodic conferences or staff meetings between the intermediate and local health unit staff members should be encouraged as well as more frequent visits of keysta.f'f to the local health centre for administrative or supervisory purposes. An important answer to the problEm, is, however., the attitude of the persons charged with administrative responsibility. Understanding, lsadership and tolerance should be characteristic of supervisory attitude. The degree of autonoIrijT for internal administration of the unit should depend on the eJeperience, adequacy and' qualification of the staff. If the situation warrants it, the local health organizations should be given greater responsibility and the accompanying authority to administer the local health prograrrune within the local health unit area. Supervision can be considered frequently a weak link in the administraUve structure. The following conclusions might be of interest with respect to the administration and supervision: (a) The administrative responsibilities of health organizations at the different levels should be analyzed and efforts made to delegate broader authority to district and local levels. A study of the amo1.mt of paper work required of local health personnel should be made, in an effort to reduce to a min:i.mlml the nl.Unber of communications, reports and forms to be conpleted. Report forms used in clinics and other services should be analyzed with a view to eliminating unnecessary items.
(b)
(c)
WP/RCll/TDl page 12 (d) The administrative relationships between the rural health unit and higher levele should be organized so as to provide for greater participation of the local. staff in the planning and administration of local health services, and provision should be made for a more effective exchange of information and ideas through ,conferences, staff meetinGs and field visits.." Supervision should be provided on a comprehensive, consistent and constructive rather than $ corrective basis ,:. Personnel having supervisory responsibilities should be given training in the methods and techniques of supervision,. Supervision of the overall activities of the rural health unit and the direction of the staff should be the responsibility of the medical officer in charge •
(e) (f)
(g)
(h). Supervision of personnel of various categories with respect to the professional and technical aspects of their services should be vested in persons in the local health unit who are trained in the same category, i f such parsons are aVailable,; otherwise, such superviSion should be provided from the district level.
0.6
FinanCing
Most, i f not all, financial support for ru:.v.a.l he,alth services is provided by national governments. With rural services gathering importance, it is felt that the governments from their total resources or from within the budget of the health organization should increase tte funds allocated to rural health services. In certain situations the analysis of cost" even roughly done, of the medical care expenditures for diseases for which there are known means of prevention or control, will prove the validity of increasing the financial support to rural health services. People in the rural areas should be encouraged to contribute labour ~ materials and other available local resources in constructing, maintaining and operating the health services.
,. T Sp oial health aotivities One should consider the role of the looal health service ~th
respect
to mass C8ll1paigns, such as yaws control" malaria, leprosy, tuberculosis, whioh are centrallJr administered, operated by' special teams and usually supported by international agenoies. These activities frequently tax the resources of the countries in providing personnel and ~ose 'a burden which cannot be borne indefinitely. In some cases the success of these campaigns have served to disclose and emphasize the importance of the load of oiher infections which remain untouched by speoialized caqlaigns and which require well developed rural. health services to oombat. It is essen"ial that the rural. health services be developed rapidly and effectively provide comprehensive health care when the mass caq:,aign against a angle dis ase has reduced the load to a min1mum level, and to take over as far as practicable the spec;1.al services andthoir personnel; otherw1s , the
"0
disease in question may recover its endemicity~ The following conclusions might be useful in connection with special health activities: (1) When mass campaigns are being carried on, staff 0 f the rur al health unit should actively co-operate with the special services staff and should receive in-service training during the campaign stage. Planning for the liquidation of a mass campaign and for the ultimauetwflo,tover of the services to the local health .units i· i should take place at the beginning ,of a mass campaign, and steps should be taken to augment and prepare the rural health unit staff to assume the responsibility for the control measures required on the termination of the campaign. Before special services are started, pilot studies should be undertaken to determine the most economical, efficient and practical way in which the rural health unit should operate when it takes over; such stuiies would merit the support of international agencies.
(2)
(3)
7.
TRAINING
The discussion of Rural Health Centres would be incomplete unless reference is made to training. The following points might be 0 f :interest: (1) Public health and preventive ne asures should be inCluded as part of the curriculum in the basic training of all categories of professional personnel as an essential preparation for rural" health work. Each country should make adequate provision for orientation of personnel to be employed in local health units, i f possible before they are posted,; the training unit area should be located where field experience can be obtained,; a special staff for training should be provided, and c lose co-ordination should be maintained between the training staff and rural health unit staffj the techniques and methods used in developing and maintaining good personal and community relationships should be included as a part of Ot'ientation courses for all personnel. In-serVice training should be incorporated as a part of supervision, as being essential to the professional growth of personnel and to the improvement of techniques used to increase the effectiveness of services, but should not be aonsi.d red as a substitute for the organized formal training of personnel. of all categories.
(2)
(3)
page 14
WP/RCll/TDl
8.
MEDICAL CARE IN RURAL HOSPITALS
One of the basic functions, of the rural health centre is nradical care. The'type of nedical services given at the local level varies considerably in the countries of the Region but in all rural health services some provision has been made for the care or treatment of minor illness or injury. In some countries the village health worker has had some training in first aid and is prOvided with a "kit" of first aid supplies and simple medication. The midwife working in sub-centres, maintaim a simUar "ohest" of medication. Out-patient care is a common pattern in the health centr or in a nearby dispensar,r to ~ich patients are referred. This service in some cases can be given by means of a mobile van which visits out~ng vUlages. thder those circumstanoes it is apparent that above the level of the rural health unit, the provision of substantial hospital services is required. If the hospital is located within the health unit area,- its services should be integrated with those of the health unit and beoone a functional part of the total service. The concept of "rural hospital" providing institut;.ional. care for ill persons in the health unit area could be considered. If located at the next higher level of the lealth serv:me, it should be integrated with the local service and provision should be made for ''''ready referral of patients and interchal€e of information before admission and following discharge. The rural hospital should provide simple laboratory procedures beyond the capacity of the health centre, maternity wing, paediatric section, small isolation block, facUities for general surgery and wards for surgical and medical cases. The size of the hospital would depend on the need of the community. Staff would include a phy~'cian providing necessary surgical and medical care, if possible, a woman physician in charge of the gynaecological, obstetrical and paediatric sectionsj a trained super. vising nurse; a trained midwife; a trained laboratory technician and the required auxiliary statf. Services and equipment Spould be geared to the endemo-epidemic diseases pattern of the area. In an attempt Solve the problem of the rural hospital, a study should be made of the organization and function of the medical care service and facilities at the health centre, rural hospital level in order to establish criteria to determine the type of facilities required, the neoessar,y equipment staffing patterns, criteria for referral of patients, etc. Suoh a ' study should be preferably made by a selected group at tb3 national level with the consultation and advice of an international agemy.
....
to
. WP/RCll/'ml page 15
9.
GENERAL CONSIDERATIONS
The national health organization of each country should establish a section to plan and conduct studies applicable to the different levels of organization with the chief function of suggesting and directing lines . of' enquiry and assisting in the analysis of the results. Such a section would indicate and corrluct more broadly based studies and research on heal. th problems and on the administration and effectiveness of health programmes. This section would also consider the relationship of a rural health unit against the background of a general canmunity development which is of primary importance in making a realistic approach to the problems of rural hea.lth services.
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