World Health Organization -/.. ~ Regional Office for Europe i ~ Copenhagen ~ ~ EURO Reports and Studies 102 Planlling and management for health Report on a European Conference The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this Organization, which was created in 1948, the health professions of some 160 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially a nd economically productive life. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region has 33 active Member States,0 and is unique in that a large proportion of them are industrialized countrie with highly advanced medical services. The European programme therefore differs from those of other regions in concentrating on the problems associated with industrial society. In its strategy for attaining the goal of"health for all by the year 2000" the Regional Office is arranging its activities in three main areas: promotion of life- styles conducive to health; reduction of preventable conditions; and provision of care that is adequate, accessible and acceptable to all. The Region is also characterized by the large number of languages spoke n by its peoples, and the resulting difficulties in disseminating information to all who may need it. The Regional Office publishes in four languages - English, French, German and Ru sian - and applications for rights of translation into other languages are most welcome. 0 Albania, Aus1ria, Belgium, Bulgaria, Czechoslovakia . Denmark. Finland. France. German Democra1ic Republic, Federal Republic of Germany, Greece. I lungary, Iceland, Ireland, Israel , ll aly. Luxembourg, Malla. Monaco. Morocco, Nc1herland . Norway, Poland, Portugal. Romania, San !vlarino. Spain. Sweden, Swi1zerland. Turkey, USSR, United Kingdom and Yugoslavia. World Health Organization - f- ~ Regional Office for Europe ~ • I Copenhagen ~ ~ EURO Reports and Studies 102 Planning and management for health Report on a European Conf ere nee The Hague 27 August-I September 1984 ICP/ MPN 001 ISBN 92 890 1268 4 ISSN 0250-8710 © World Health Organization 1986 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Conven- tion. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0 , Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publi- cation 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 authorit ies, 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 o r recommended by the World Hea lth Organiz- ation in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The views expressed in this publication are those of the participants in the meeting and do not necessarily represent the decisions or the stated policy of the World Health Organization . PRINTED IN DENMARK r, CONTENTS Page Introducti o n .. ... .. ............................ .... ........ ...... ..... ....... .. .. .. .. .. ..... .... ..... .. . Opening discussions .. .. .... ... ....... .............. ......... ............ ......... ........... ... . 3 Trends in hea lth pla nning a nd manage ment .... .. ............. .. ...... ..... .. ..... .... 3 Health pla nnin g and ma nage ment structures and processes in Europea n Member States - a n ove rview of the sta te of the art ......... .. ... ... ....... 4 Issues in pl a nnin g a nd managemen t fo r hea lth .. ... ..... ..... ......... ...... ......... 6 Main subj ects of discussio n ................. ........... ...... ... ... ...... ..... ............. 9 Balance betwee n ce nt ra liza tio n a nd dece nt ra li za tion ...... ...... .. .... ..... ....... 9 Pa rticipati on in decision-ma king processes in health ..... .......... ........ ... .... 11 Resource a ll oca tio n in periods of econo mic stringency .. ........ ................. 12 Econo mic implica tio ns of the H FA2000 po licy.......... ...... .. ... .... .......... ... 16 Mechanisms fo r mult isecto ra l collabo ratio n ..... .. .. ....... .. ....................... .. 21 Leadership in plan ning a nd ma nagement fo r health ............................... 26 Future-orie nted approaches in health pla nn ing a nd ma nage ment .. ........ . 27 Conclusions and recommenda tio ns .................... ............... ...... .... .... 29 Reco mmendations fo r Membe r States ... . .... ....... ........ .... .... ... .. .. .. ...... .... .. 30 Reco mmenda ti ons for the WHO Regio na l Office for Euro pe ... ....... ....... 32 Annex I . Participa nts. .... ..... ............... ....... .... ......... ... ....... ......... .. ..... . 34 Summaries in French, Germa n and Russian ............. ... .... .. ......... .. 47 INTRODUCTION The European Conference on Planning and Management for Health, convened by the WHO Regional Office for Europe in collaboration with the Government of the Netherlands, was held in the Hague from 27 August to I September 1984. The purpose of the Conference was to promote and strengthen the development of appropriate managerial processes for health for a ll by the year 2000 (HFA2000) in countries of the European Region. The main aim was the exchange of ideas and experiences on ways of encouraging change towards more equitable and compre- hensive health policies and programmes for improving health and, hence, a more efficient use of resources . More specifically, the Conference was intended to: 1. review developments in health planning and management that have occurred in Member States of the Region since the Euro- pean Conference on National Health Planning (Bucharest, 1974) and to consider the suitability of existing managerial systems for the achievement of HF A2000; 2. examine solutions applicable to such crucial issues in plan- ning and management as: the balance between centralization and decentralization in the managerial and planning process and the ro le of various levels of health administration in that process; the more general involvement of the community and of various categories of health provider in decision-making and health planning; mechanisms for intersectoral action and coordination in the field of health; prospects for health planning given the present economic stringency and instability; research and training requirements for health planning and management development; 3. analyse the possible economic consequences of the HF A2000 policy; 4. discuss means of planning and studying alternative ways of implementing the regional strategy for HFA2000 by the develop- ment of scenarios. The Conference was attended by representatives from 21 Member States oft he European Region and from Canada, as well as from the Commission of the European Communities, the Association of Schools of Public Health in the European Region, the European Association of Programmes in Health Services Studies, the Inter- national Council of Nurses and the International Hospital Feder- ation. In addition, 26 temporary advisers were present, together with staff members from WHO headquarters and the Regional Office for Europe. The Conference was opened by Dr Leo A. Kaprio, WHO Regional Director for Europe, in the gracious presence of H.M. Queen Beatrix of the Netherlands. Participants were wel- comed by Mr J.P. van der Reijden, State Secretary for Health, Welfare and Cultural Affairs, who gave a keynote address; state- ments were also made by Dr J. van Lon den, Director-General of Health of the Netherlands, Dr S. Khanna , Senior Medical Officer, Health for All Strategy Coordination, WHO headquarters, and Dr Leo A. Kaprio. Dr J. van Landen and Dr O.P. Scepin were elected Chairman and Vice-Chairman of the Conference respectively. Dr D.M. Pen- dreigh was the Rapporteur and Dr J.E. Asvall, Director, Pro- gramme Management, WHO Regional Office for Europe, acted as Secretary. 2 OPENING DISCUSSIONS At the opening session the following papers were introduced: "Trends in health planning and management in the Euro- pean Region", by Dr I.S. Luculescu, Regional Officer for Country Health Programming, WHO Regional Office for Europe; "Health planning and management structures and processes in European Member States - an overview of the state of the art", by Mr D. Affeld and Dr S.E . Ekeid; "Issues in planning and management for health", by Dr D .M. Pendreigh. Each in a different way gave a synoptic view of the present and the recent past with regard to health planning and management in the European Region against the background of the global and regional HF A strategies. Trends in health planning and management Dr Luculescu's paper summarized significant events in the devel- opment of health management in the European Region and noted that the policy and managerial initiatives of WHO reflect the chang- ing environment in the Region, and also the introduction of the HF A2000 movement. Main features of the managerial process required for the successful implementation of HFA strategies were li sted and commented upon . Since the 1974 Conference on National Health Planning, certain concepts specifically related to the management of HFA have become more clearly defin ed; these were identified as follows: the new integrated relationship between planners and those respons ible for healt h management and decision-making, and the acceptance of such a relationship in WHO's methods of work; th e concept of multisectora l planning as an aid in taking a comprehensive view of health and in address ing the determi- nants of health status; 3 participation in the planning process as a means of making planning res pond better to real need~, thus increasing satis- faction, favouring the acce ptance a nd approval of proposed measures and, ultimate ly, ensuring their implementation; such participation, to be successful, should include both users and providers of health care and decision-makers; the need for emphasis o n strategic health planning, es- pecially wh en long-term planning develops against a back- ground of uncertainty regarding the future ; the need to avoid rigidity and bureaucracy, and to co nsider such aspects as decentralization and continuous monitoring, evaluation and rep rogra mming, as integral parts of any so und planning process; the consequences for health planning likely to res ult from the present period of economic stringency and insta bility; the need to examine how HF A2000 policies might best be implemented in the less st ructured , pluralist ic health systems. After discussing and taking stock of new developments in respect of the above-mentioned points, the paper outlined the main activities of the WHO Regiona l Office for Europe in the area of health management and plann ing, carried out in close collaboration with Member States. Health planning and management structures and processes in Euro- pean Member States - an overview of the state of the art This paper, introduced by Mr D. Affeld, was essentially a distillate of the discussions of the Working Group on Health Planning and Manageme nt Requirements for HF A2000 Development , held in Athens in September 1983 . During that meeting, which helped to organize the present Conference, experts representing 12 European Member Sta tes examined to what extent existing hea lth management and planning sys tems complied with HFA2000 requirements and identified some critical areas in promoting or perfecting managerial practices. The paper was supplemented by written con tributions received from 15 Member States, which described a nd ana lysed their experiences in this field. These papers provided a significant 4 stimulus for discussion and were substantially drawn upon in the ensuing debate. The discussion in Athens and the written country contributions revealed general agreement on the broad policy basis for HF A2000 targets. With regard to the policy basis for management and planning, the point was made that most WHO documents could be interpreted as promoting a somewhat rigid view of management and especially of planning. It was therefore felt necessary to redefine planning as the search for all mechanisms, whether formal or less formal, aimed at systematically improving future health development. This is a reality in the European setting where a variety of planning solutions exist, ranging from formalized planning, well illustrated in the papers from Bulgaria, Czechoslovakia, the Ger- man Democratic Republic and Poland, to highly devolved and less formal mechanisms that mix steering and control with nego- tiation and competition in order to regulate the development of the health sector and reach a consensus among the various indi- viduals or groups involved, as exemplified in the papers from Belgium, the Federal Republic of Germany, Luxembourg and the Netherlands. It was shown in the discussion that a wide range of steering, planning and management approaches exists in the European Region. In some countries, parts oft he health services are subject to only minimal governmental control, but attempts are made to achieve results through negotiation and consensus on the part of the professions, the consumers, social insurance agencies, pressure groups, etc. By contrast, the role of the government in those settings was seen as that of a partner in and a provider of a framework for negotiation and a promoter of the agreed ideas, rather than a supreme authority in decision-making. Other countries have a clearly defined legal basis for the governmental direction of plan- ning. However, a factor common to all systems is their acceptance of the general goals of the HFA2000 movement in terms of general health policy. In the discussion, it was acknowledged that achievements in health service delivery and health status are not necessarily related to the planning methods chosen by different countries. Over the last few years, a number of countries, particularly in the Mediterranean area, have moved towards the establishment of national health service systems and concomitant national health 5 planning systems. The paper from Spain brought this out clearly. On the other hand , in a number of countries in the Region that already have comprehensive national healt h service systems, such as the United Kingdom , a relatively substantial private health sector is beginning to appear a longside the national health service system . The goal of HFA2000 will require a comprehensive approach going far beyond the health sector , yet existing planning practice in many countries concentrates predominantly on the health care sector, although a deliberate shift of emphasis towards integrated health care planning was perceived. However, the participants were unable to identify any substantial trend towards comprehensive planning for health , except in a few countries where health planning forms an integral part of the plans for socioeconomic development. Some participants reported the existence of long-term forma l- ized planning, but it was obvious that , due to the present climate of economic instability, health policy formulation which often con- tains strategic elements has replaced long-term planning in a large number of countries. In almost all countries, planning is oriented to input/resources and output/delivery. Attempts are being made in some Member States to move towards outcome planning and pro- gramming in certain fields , especially when addressing specific health problems. Countries with centralized systems seem to rely on normative planning approaches, in that planning proposals emanating from the local level and harmonized at central level, once approved, take the form and force of law, whereas countries with governmental systems oriented towards regionalization or decentralization tend to have indicative planning at the national level, such planning becoming more prescriptive at local levels. Issues in planning and management for health This paper, presented by Dr D . Pendreigh, considered issues of concern to the WHO Regional Office for Europe in terms of its means of encouraging, promoting and supporting activities related to the managerial process for national health development (MPNHD), developing appropriate networks, initiating training activities and furthering multisectoral collaboration and coordination. Issues arising from current planning trends were then con- sidered and compared particularly with some of the views that 6 emerged fro m the 1974 C o nference o n Na tio na l H ea lth Pl a nning. These iss ues were di scussed under th e headings o f: health pla nning o r hea lth service pla nning; the changing ro le of pl a nners; the changing planning ho rizon; pla nning as a ma nageria l process; pl a nning - different dimensions a nd a pp roac hes; the strategi c co ncept ; the emerge nce o f sce na ri os. The eco no mic issues res ulting fro m th e cha nging enviro nment were a lso d eba ted. The enviro nment for hea lth pl a nning a nd ma n- agement has changed in two ways in pa rticula r: the ava ilab le resources no lo nger gro w as they o nce did a nd new goa ls have bee n fo rmul a ted fo r the deploy ment o f these reso urces. The co nfli ct between sho rt-ra nge sectora l interes ts a nd lo ng-ra nge a ims is o bvio us. Mo reove r, to di ve rt new reso urces to hea lth p ro moti o n and disease preve ntio n whil e a t the sa me time ma int a ining th e present level of hea lth se rvices ca lls for cha nges in the wa y tha t these se rvices a re p la nn ed and ma naged . Ha nd in ha nd with such co nsid- era ti o ns mu st go th ose rela ting to the d evelo pment of grea ter cos t- co nscio usness a mo ng prov iders a nd co nsum ers. The pa pe r identifi ed a co nsid erable number o f exa mpl es of th e unsuitability o f prese nt ma nage ment structures fo r la un ching H F A2000 stra tegies and fo r a ppl yi ng MPNHD . C losely rela ted to this were iss ues co nce rning th e bal a nce th a t sho uld be stru ck betwee n the centrali za ti on a nd dece ntrali za ti on of hea lth ma nage- ment structures. In the fi e ld of pa rti cipa ti o n, a who le ra nge of issues was o utlin ed tha t require deba te, no t o nl y in term s of th e co m muni ty but a lso in terms o f the hea lth profess io ns a nd o ther sec to rs. F ina ll y, th e ques- ti o ns th a t need to be ad dressed in the fi elds o f ed uca ti o n , t ra ining and resea rch were li sted . * * * 7 The three papers and the ensuing plenary discussion highlighted the shifts of emphasis since the 1974 European Conference on National Health Planning. Such shifts include the concept of plan- ning broadly for health rather than health services planning, the greater emphasis on policy formulation and on the political and social processes in planning as distinct from simply the technical aspects, and the acceptance that planning cannot be divorced from management , hence the emergence of MPNHD as an integrated approach. The evolutionary relationship of MPNHD to earlier WHO thinking, e.g. concerning planning, programming and budget- ing systems (PPBS), project systems analysis (PSA) and country health programming (CHP), was recognized in the discussion. In their written contributions, many countries also gave valuable insights into the continuing development of management and plan- ning approaches. The discussion helped to clarify the status, activities, relevance and impact of health planning in different Member States of the Region. It was accepted that the planning and management approach largely reflected the politico-administrative structure and organization of a country, and that there was therefore a wide variety of models in Europe. Two particularly critical issues emerged from the discussion: (a) how to achieve user or consumer participation in decision- making, and (b) how to strike a balance between centralization and decentralization in different health systems. The objective should be to retain those aspects of centralization that facilitate geographical and social equity in health, whilst also securing those elements of a decentralized approach that make the administration more likely to be sensitive to the various needs and aspirations of local communities. Such issues were subsequently addressed in detail by the Confer- ence. The point was also made that a health system, whether of a unitary or pluralistic nature can , by and large, insure against the development of bureaucratic tendencies by building in means for its regular review, appraisal and consequent adjustment. Since planning is a wide concept with a large variety of different potential approaches, it is important to use the most appropriate approach for a particular situation. Therefore, given that planning is a concerted set of policies a nd/or actions designed to improve the future, each country can develop its own mechanisms, in which the degree of formalization, the balance between centralization and 8 decentralization, and the timescale, can vary considerably depend- ing on the national "environment". MAIN SUBJECTS OF DISCUSSION Balance between centralization and decentralization Discussion at both group and plenary sessions produced a wealth of detailed observation and comment. The main points that emerged and on which there was a significant consensus were as follows. o The main determinant oft he balance achieved and the form the system takes will follow the basic politico-administrative pat- tern of the country concerned. o A balanced system is necessary in order that the centralized component can aim to achieve geographical and social equity; at the same time, there should be a sufficient number of decentral- ized elements, so that the administration remains sensitive to local needs and aspirations. o Some centralized arrangement can be positively beneficial to local interests as it can often provide more comprehensive back- up and support (e.g. information services, supply services, health manpower development). o In almost any system it is of critical importance that there should be a clear, explicit definition and distribution of mana- gerial responsibilities and functions at every level. The lowest level, having control of resources and able to take decision s on its own, determines the degree of decentralization of a given health system. O It should be borne in mind that the health sector is in a dynamic situation; requirement s are constantly changing, and what is the most appropriate balance at a given time may therefore also need to be adjusted over time, or it may differ according to the various problems being addressed . It was noted, for instance, that in many Member States that are considered to be of the 9 centralized type , there is now an obvious tendency towards decentralization. On the other hand , some other Member States, although basically of a decentralized type, are engaged in creat- ing mechanisms to ensure greater coordination. o It is probable that the greater the degree of decentralization, the more likely one is to achieve effective and direct consumer involvement. o It is important to support the system by having a good infor- mation service that can su pply feedback to managers, providers and users. Various administrative and managerial levels require specific information that often differs in content from the information needed for the clinical management of cases. O If the health system is to be effectively decentralized a similar effort is required in all other sectors. Also, it is essential to have properly qualified management personnel at local levels. o At a time of economic austerity, decentralizing may be one way of spreading the burden, although in most cases the central authority still maintains control over resources and decisions. o Especially in countries that are at present carrying out a major reorganization of the health sector, there may be a case for conducting pilot projects in selected areas, in order to test out new strategies. A pilot project can give, among other things, valuable information about managerial capabilities at the sub- national level. o The expected adoption by the thirty-fourth session of the Re- gional Committee for Europe of clearly defined regional targets (cf. document EUR/RC34/7) should stimulate countries to ex- amine the appropriateness of their systems to deal with HF A managerial requirements, namely, long-term orientation, em- phasis on strategic and outcome elements, more broadly-based participation and political acceptance, cost-consciousness and cost-effectiveness in selecting strategies, equity, and last but not least, responsiveness to ever-changing needs. Participation in decision-making processes in health Although participation by users, providers and other sectors was being proposed for consideration here, priority was rightly given in both group and plenary discussions to aspects of participation by users ( or consumers) of health care, as multisectoral collaboration was being discussed later in the week, and as many countries currently had better defined means of participation for providers than for users. The following main points emerged. O The question here is really how one handles pressure for change, given the varying perceptions and interests of different groups of users and providers and the fact that the roles of providers and users may from time to time be interchangeable. o An important topic in many countries appears to be the mem- bership of representative participating organizations; in particu- lar, should members be directly elected or should they be appointed in more indirect ways? In structuring such groups one should always keep in mind the potential risk that the interests of the poor, migrants and other vulnerable groups may be overlooked. o Participation seems necessary at both local and central levels, and there should be adequate two-way communication between them, with the emphasis on the expression of "grass roots" opinions, since the latter are often neglected. o In a way , the balance between direct and mediated participation depends upon the equi lib rium between centralization and decentralization and therefore upon the overa ll administrative and political system of each country. A move towards the regionalization and decentralization of health systems should faci litate better participation and, in particular, make direct participation more viable. o A supportive information system is essential in order to inform and educate users about resource and other constraints, but also to brief planners on the needs and demands of different groups of users. In this context, there is a case for the use of opinion polls. Such activities should be seen as strengthening the demo- cratic process. 11 o The training of health professionals should indicate how they might not only invoke and take into account the views of users, but also establish active working relationships with users' groups. O Although formal means of communication and participation are essentia l, encouragement shou ld also be given to additional informal links, which in some systems play an important role. o To ach ieve really effective participation, users must be better informed not only about the various economic constraints, but also about the very complex choices that have to be made in the health sector. It is essential to reconcile individual and group concerns with public interests. o More and better social and behavioural research should be encouraged on how to foster more meaningful participation in decision-making. Resource allocation in periods of economic stringency To focus discussion on this subject, the paper "Planning and man- agement for health in periods of economic st ringency and instabil- ity" was introduced by Professor A. van der Werff. Its contents are summarized below. The mid-I 970s marked the end of the longest period of uninter- rupted economic growth in history. After the oi l crisis, in particular, there was a sharp decrease in the rate of real growth of the world's economy. At the same time, a process of drastic change has begun to take place in the international economic structure; stagnation and instability are affecting Europe and other parts of the world.Not only are countries with an open-market economy suffering from economic contraction, but the rate of growth in countries with a planned economy also seems to be slowing down. The developing countries are the most badly hit by the recession, however. In association with the growth in prosperity in past years the pattern of health problems has changed and is still changing. The demand for health care has continued to rise, though with little improvement in health status and with little being done to ensure that the necessary changes occur within the limits of shrinking resources and allotted time-spans. The change in priorities indicated by the HF A2000 strategies must be seen against the background of aging populations, socia l instability and 12 the continuing development of new lifestyles which are often not healthier. The economic outlook also looks as if it will remain bleak. Economic circumstances are influencing the context in which planning and management are conducted . A different "planning environment" may require a different "planning concept" and a different "style of management". With the passage of time planning concepts and management also have to undergo modification. In periods of economic expansion planning concepts and styles of man- agement may differ from those in periods of economic contraction. The paper analysed the changed planning conditions in periods of economic stringency and instability and made recommendations as to what type of health planning and management might success- fully be used to bring about the policy reorientation envisaged by HFA2000. Basically, however, it did not set out to make an evalu- ation of different cost-containment strategies. The main characteristics oft he planning environment were con- sidered and the causes of and background to changes that might occur under pressure of economic stringency and instability were analysed. Changes in the health system itself (i.e. changing health problems, concepts of policy-making in health, the health services system, and the development of resources and financing) were considered. The changing sociopolitical context of health planning and management styles was discussed, in particular changing atti- tudes towards planning, and resistance to change. Due attention was also given to the administrative setting in which planning and management are conducted. In this connection, the effects of econ- omic recession on the scope and extent of government control, multisectoral coordination and decentralization were examined. The impact of economic stringency and instability on decision- making processes in general was analysed in the paper. An impor- tant issue in this respect is the change in the role and power of those involved in decision-making in the field of health. The growing complexity of decision-making and the possibilities and limitations of "regulation" under pressure of cost-containment were also dis- cussed. Finally, the questions to be addressed in education, training and research were listed. * * * 13 The main points made by participants in group and plenary discus- sion on the subject of resource allocation in periods of economic stringency may be summarized as follows. O Austerity can force individuals and systems to make difficult priority choices, and this can induce more concern, closer involvement, better evaluation and a greater sense of responsi- bility, all of which can only be beneficial. o However, in periods of economic stringency there is a great danger of cost-control measures being quickly introduced to reduce inputs, while at the same time not enough thought is given to what outcomes are desirable or, indeed, how they would be affected by these measures. o There may be a tendency to sacrifice the impetus in the longer- term fields of prevention and health promotion for shorter-term objectives; this must be resisted. O Health systems will have to be better informed of the effective- ness and efficiency of different health actions and prepared to be more flexible and monitor and reprogramme more frequently. o Rather than manipulate prices to users as a means of cost- containment, one way forward is the introduction of incentives designed to make providers more effective and efficient. o Better indicators and more specific objectives are required in situations of economic stringency in order better to defend the priorities that have been set and to ensure accurate evaluation of results. Moreover, since resources are scarce, the health sector ought to be ready to demonstrate more convincingly the value of investments in health compared with other types of investment and to protect its share of the budget. o Conflicts with users and providers are probably more likely to occur, and health managers may at times require the authority to initiate measures such as the strengthening of primary health care, despite the views or interests of health professionals or consumers. 14 o Disparities have a tendency to be emphasized in times of eco- nomic stringency since the latter may hinder the introduction of new services and approaches for underprivileged groups . O In times of austerity there is a lso often a trend towards regional- ization and decentralization. In such cases, the economic burden is transferred to lower levels, but the central authority sti ll maintains control of resources. o Zero economic growth, budget problems and the need for cost- containment by themselves do not automatically have either positive or negative effects on HF A2000 goals; what really matters are the reactions of given societies, economies and governments to economic pressures . O In some countries, coa litions of users and providers have led to a stabilization of systems at given levels of service and utilization, so making them not easily amenable to change. Policy shifts mi ght only be achieved, therefore, by very purposeful govern- ment action, which may conOict with the aim of greater con- sumer participation . O Since health is largely conditioned by factors other than health care, specific indicators to demonstrate and measure the role of the health care sector should be designed . These would be especially useful, as a period of economic austerity may nega- tively inOuence trends in health status, independently of health care efforts. o HF A policy onginates from the need to make better use of scarce resources and to cope with rising health expenditure. Therefore, there should be no contradiction between HF A and sound cost-consciousness and cost-containment policies . None- theless , it is still necessa ry to make this point clear and generally accepted . O Economic pressure may augment the tendency for primary health care to become the main means of health protection. However, although they are willing to develop primary health care, some countries whose health care delivery systems are 15 based on hospital care may see such development as increasing health expenditure, since almost everywhere it is extremely diffi- cult to reduce hospital expenditure . O Economic pressure may act as a stimulus to revising the division oflabour between the medical and other health professions with a view to achieving fewer resource-consuming so luti o ns. o Economic instability introduces new constraints in planning, especially in long-term planning, since the time horizon of meaningful projections is drastically shortened. This calls for new planning techniques, greater flexibility and ability to re- adjust in planning practice, an emphasis on strategic rather than resource planning and, in general, more responsiveness to the changing environment. o The World Health Organization has clear responsibilities in assisting Member States in this area. Economic implications of the HFA2000 policy The keynote paper, "Resource mobilization: the economic task of planning and management for HFA2000" , by Professor A. May- nard, is summarized in the following paragraphs. The present structure of health care systems is characterized by a rather inefficient use of scarce health care resources and by in- equa lities in health and health care. This is the product of insti- tutions whose incentive structures reward inefficient and inequi- table behaviour. Health care systems, public and private, offer producers and consumers no incentives to economize on scarce economic resources or to achieve the goals of equity set out in public policies. In almost all cases, third parties (the state or the insurance companies) pay; they do not monitor and have little control over the services for which they freely dole out scarce resources . The production of health, which could be quantified by the maximization of the number of quality-adjusted life years (QAL Ys) , is complex and affected by factors other than health care. The incomplete evidence that is avai lable indicates that the contribution of health care to the production of health is limited. What individuals do to themselves during their li fe cycle is the principal determinant 16 of their health. To change the behaviour of populations is a difficult task and one that is complicated by the fact that it imposes a loss of income and employment on firms producing hazardous substances (e.g. tobacco) and a loss of satisfaction on the part of consumers who like using their products . Any policy change has opportunity costs, however: to increase QAL Ys , income and employment patterns must change to the detriment of some groups. Because of opportunity costs and the ubiquitous problem of scarce resources, these resources need to be used efficiently. Efficiency means minimizing the cost per unit of output. Decision-makers (e.g. doctors) who work inefficiently deprive potential patients of care. Such inefficient behaviour is unethical: efficiency minimizes opportunity costs and maximizes the production of QAL Ys. To evaluate health care and the production of health it is neces- sary to use cost-effectiveness and cost-benefit analysis techniques. Furthermore, it is necessary that the thinking behind these tech- niques should become more widely understood. Such evaluation provides, in an explicit framework, estimates of the costs and bene- fits of alternative strategies and alternative ways of treating patients. Economic evaluation does not provide full information: it provides more information in a rigorous framework. It is to be hoped that improvements in the flow of such relevant information may improve decision-making. At present most medical therapies have not been evaluated in a scientific fashion, i.e. they have not been subjected to randomized controlled trials with an economic element. Because of this lack of evaluation, it is not possible to determine whether the present level of quality of hospital care will survive a shift of resources to the primary sector, nor is it possible to ascertain the cost-effectiveness of primary health care. This should not inhibit action in pursuance of policies: most health policies are adopted and implemented in the absence of evidence to sustain their use. Such radical policies as those advocated in the HFA2000 strategy require , however, that there should be careful evaluation (not merely description and monitoring) of the cost and benefits of these policy innovations. It will not be easy to transfer resources to primary care and prevention, because the "losing" groups will oppose such shifts of resources, while the "gaining" groups will tend to be poorly coordi- nated in their support of primary health care policy. Altering the 17 incentive structure in primary and secondary (hospital) ca re will assist this process of resource movement. For instance, redistrib- uting the budget to primary hea lth ca re tea ms responsible for giving comprehens ive care to their patients and th en charging them for the se rvices they use (such as hospital ca re) would give them a n incen- tive to be cos t-co nscio us. Furthermore, if any budget surpluses accrued to primary health ca re team members as inco me or re- sources for their use, th ey might more rigorously evaluate costs , benefits and each o ther' s behaviour. An incentive structure will only be effective if it penalizes the inefficient as well as rewa rding the efficient. Such incentive syste ms are rare in the health care sector , but th ey are essent ia l if reso urces are to be used efficiently and eq uitab ly. The press ure groups th a t will be adversely affected by H FA2000 a re numero us and powerfu l in man y countries. The hea lth care ma rk et is highl y regulated a nd regul at io n favours the regulated . To a lter the hea lth care system in favour of primary health ca re will alter incomes and employment. Shareholders in the tobacco a nd alcohol industr ies will use politica l institutions to direct innova tive activity into channels th at will not injure th eir int erests. If QAL Ys a re to be increased, however, and th e ci tizens of the Europea n Regio n are to be given longer an d better-qua lit y li ves, such obstacles will ha ve to be circum ve nted. T o facilitate this p rocess it is necessary for resea rch to address the following ques tions. o What a re exis ting po li cy targets and how is mo ney spent in the sys tems that affect heal th? o Who control s resource a llocatio n, particularly a t the margins? O What is th e existi ng incent ive system, particular ly a t the mar- gins, a nd what are the a lterna tives? O What a re the rat io ning criteria in hea lth care sys tems? Who gets what, a nd why? o Wh o a re the decisio n-makers (e.g. doctors) and how ca n th eir management tra ining be improved? 18 o How can economic evaluation be carried out and how can information systems be improved to permit the evaluation of performance criteria, monitoring mechanisms and effective sys- tems of reward and penalty. Answers to questions such as these may enable resources to be shifted into efficient modes of primary care and cost-effective areas of prevention. * * * Particular areas on which the Conference participants focused their discussion when considering the economic implications of HFA2000 policies were: the economic implications of becoming healthier; economic aspects of prevention; evaluation of the costs and benefits of health care; economic instruments for reorienting the health system; and the role of health economics in improving decision- making. The following specific points were raised. o Demographic change has obvious economic implications, such as the financial burden resulting from an increasingly elderly population (though, conversely, there will also be some saving in health care expenditure, since there will be relatively fewer infants, children and pregnant women). This whole area, particu- larly the question of how health care costs vary over the life cycle, calls for further research. o What happens when technical change frees resources? To where are they then switched? How can future technological changes and their possible effects on health care patterns be better studied and foreseen? o The cost of many forms of prevention is very low, especially if change is marginal or gradual. In other words, prevention can be expensive if it seeks total control and eradication, and far more economic if less ambitious goals are pursued, such as a reduction of hazards, a decrease of incidence , etc. 19 o Why does there appear to be only slight interest in some coun- tries in strengthening prevention and health promotion? Is it because some politicians are only interested in short-term as opposed to long-term gains? o Clinical medicine has a very effective lobby. Research efforts should be directed towards ways of organizing a strong preven- tion and promotion lobby. The collaboration between minis- tries of health and university departments of social and com- munity medicine and schools of public health might be helpful in this respect. The same holds true for collaboration between WHO and nongovernmental organizations, such as European institutions offering postgraduate training to health personnel in the fields of public health and health management. o Greater efforts must be made to ensure awareness of basic economic concepts among the health professions and the public. Case studies and the systematic education of health profes- sionals and managers should be encouraged. o Countries should study the cost-effectiveness of alternative solutions to the health problems; options for the future must be seriously addressed; finding the cheapest way of generating maximum health should be the concern of all, i.e politicians, decision-makers, managers and planners, providers and users. o The use of scenario techniques which illustrate the hypothetical economic consequences of alternative strategies is likely to gain in momentum and to facilitate the promotion of HF A2000 . o There is a need to examine to what extent the solutions sug- gested in the HF A strategy document are economically feasible. Their social, political and economic consequences in different European settings require to be studied. o The economic "spill-over" benefits outside the health sector (e.g. for industry, famili es, etc.) stemming from implementation of HF A2000 should receive close attention and be used to convince potential partners. 20 O Financial mechanisms need to be reviewed so as to allow the appropriate implementation of HF A2000 policies, i.e. financing should be justified by the overall results expected, while the financing of individual parts of the health service structure shou ld be a less important consideration . o There is a need to change and improve information systems in many countries. At present, some systems cannot confirm whether resources are being al located appropriate ly for the priorities agreed. O There may be unanticipated economic side effects of the HF A2000 policy which will require study. Here again, scenarios could clarify some issues. Mechanisms for multisectoral collaboration The two papers presented prior to discuss ions on this topic were: "Multisectoral participation in protecting the health of the popu- lation - a fundamental prerequisite for achieving health for all by the year 2000", by Dr 0. P. Scepin; and" lntersectoral collaboration in the health field: s ituation in countries with a decentrali zed politi- cal stru cture" , by Mr C. Kleiber. The first paper described the experience gained in the USSR in this fi eld a nd made th e following main po ints. World health care development is marked at prese nt by a shift from the medical trea tment of diseases to community public health . The latt er is a typical feature in the socialist countries, where state health sys tems are aimed a t the maintenance and steady improve- ment of the health of th e people, thus providing optimal conditions for work, leisure and family life, for population growth, for the harmonious ph ysical and spiritua l development of the individual and for a long active life for every member of soc iety. All this has become possible as a result of the population's involvement in decision-making on health-related issues. In the USSR there is a compre hensive multi sec tora l approach, based on legis lation, to the problem of health protection and pro- motion and the participation of state and public organizations in health-related activities. The coordination of the interdisciplinary activiti es of different ministries and departments is the responsibility 21 of seve ral intergove rnmenta l bod ies, including th e Co mmissio ns of People's Deputies for Hea lth a nd Social Welfa re (a t a ll sta te levels fro m loca l sov iets to th e Supreme Sov iet o f th e USSR) , th e Exec u- ti ve Co mmittees of Peo ple's Dep uti es, th e sta te pl a nnin g co mmis- sio ns of th e USSR a nd Uni o n Republics, hea lth a uth o riti es a t a ll leve ls, a nd th e Inte rdepa rtm enta l Co un cil at th e USSR Mini stry o f Health . Publi c hea lth in the Sov iet Uni o n , as pa rt of th e na ti o na l eco n- o m y, is deve lo ped according to the Sta te Pl a n, whi ch is fo rmula ted o n a sc ientific basis, to meet, as fa r as possibl e, the growing de ma nds o f th e po pula tio n fo r high-qu a lit y medi ca l ca re based o n effec tive d iagnos is, trea tment a nd preve ntio n. The scie ntifi c bas is fo r pl a nnin g is p rovided by extensive resea rch into th e requirements fo r hea lth services a nd pe rso nnel, the wo rkl oad of hea lth personnel, the eco no mi c effec tiveness of public hea lth , a nd demogra phic mo rbidity trends. Speci a l experimenta l studi es ha ve a lso yielded res ults o f pa rticula r interes t. Two d oc uments, " The co mprehensive p rogra mme of wo rk to enh a nce the preve nti o n o f di seases a nd p ro mo te the hea lth of the po pula ti o n fo r the period up to 1990" , a nd " The co mprehensive programme o f scientifi c a nd techn o logica l progress in the USSR fo r th e peri od up to 2005" , a re good exa mpl es o f multisecto ra l p ro- gra mm es a nd ta rge t-o riented pl a nn ing in indust ria l, soc ia l a nd hea lth-rela ted a reas. The multisectora l a pp roac h, when a pplied to hea lth p ro tec ti o n p ro blems in co mbin a ti o n with bio medica l resea rch ac hieve ments a nd the furth er deve lo pment o f public health se rvices, has a most pos itive bea ring o n th e hea lth sta tus of th e po pula ti o n a nd is a majo r facto r in the impl ementa ti o n o f WHO's st ra tegy o f hea lth fo r a ll by the yea r 2000. By co ntras t , th e seco nd pa per perta ined ma inl y to dece nt ra li zed a nd plu ra listic societies a nd used exa mples fro m Swit ze rl a nd . A mo ng the aspects covered we re the fo ll owing. Intersecto ra l co lla borati o n is p ro ba bl y o ne o f the mos t p ro- mising a pproac hes to resolving the co ntradicti o ns tha t charac te ri ze hea lth eco no mi c deve lo pment in Eu ro pe. In co untri es with a de- ce nt ra lized po liti ca l st ru cture, wh ere dec isio n-ma king power is di f- fu se a nd where th ere is considera ble ove rla p o f admini stra ti ve, eco no mic a nd politi ca l respo nsibilities, intersectora l ac ti vities a re 22 generally undeveloped at present. This is due to the following different types of resistance: intellectual resistance: multisectoral action is complex and calls for what is still an unfamiliar mental process based on understanding and interactions; political resistance: multisectoral action calls administrative hierarchies into question, and may involve a redistribution of power; - psychological resistance: multisectoral action has little or no appeal in situations where "institutional narcissism" is prevalent. In countries with a decentralized structure, multisectoral action is further complicated by the dispersion of power, the existence of a mixed economy, and the coexistence of multiple and sometimes contradictory interests. Under these conditions, programmes of multisectoral action, which are now becoming more attractive owing to the present limitation of resources, should: o at the outset, have sectoral objectives that are as little antagon- istic as possible; O be tailored to local requirements and existing political, cultural and other circumstances; O use institutional narcissism to advantage, rather than combat- ing it; O pursue objectives that do not relate only to health, so as to expand the scope of the programme and give encouragement to partners outside the health sector; O be managed on a basis of joint representation, with due respect for the right of each of the sectors concerned to make decisions. Quite apart from the health objectives of multisectoral action, it has considerable educational value and can gradually help to make the different sectors of activity in a country aware of health issues. * * * 23 These two "catalytic" papers were followed by considerable discus- sion, during which it was repeatedly stressed by many participants that there was "still a long way to go". The following points were made. o At present, various arrangements are adopted in different coun- tries in respect of collaboration between the health sector and other sectors. Some countries have strong formalized mech- anisms, intended to provide integrated socioeconomic devel- opment in which health is an important component. In other countries, these mechanisms are less obvious, although the political, legislative, economic and financial structures and pro- cesses do also fulfil such coordinative functions as are required. Last, in some Member States, market laws play a regulatory function and various partners reach consensus through negotia- tion , bargaining, incentive development and so on. o To help clarify how various sectors collaborate in solving mat- ters pertaining to health, one should examine at least the following. To what extent is the health sector consulted by other sectors at present? To what extent does the health sector monitor and inter- vene in activities of other sectors, when these have a bearing on health? Does the health sector itself consult other partners when its own activities have "extrasectoral" effects or need a "multi-actor" commitment for their successful implementation? Are there any multisectoral programmes that include health elements? Who has the initiative and the leader- ship? How is the health sector represented in such joint developments? o For many countries, the priority areas for multisectoral collabor- ation on policy formulation seem to be food and nutrition, health and social services cooperation , addiction , occupational health, accident prevention, housing and the environment. 24 o The level of administration helps to determine the functions and activities in which there is collaboration. For in stance, at national level it is likely to be in the fields of legislation, adminis- tration, and resource allocation. On the other hand, it is prob- ably more effective to have the different types of consultation at local level. o At present , skills and expertise in multisectoral collaboration and coordination are often lacking, although the multidisciplin- arity of teams in each individual sector ought - in principle - to facilitate a dialogue . o The interchange of managers a nd planners between sectors can only be beneficial, in that it provides additional insights and facilitates collaboration. o Progress is only possible in multisectoral collaboration if con- flicts and disagreements are aired and thoroughly debated and incentive structures properly developed . o Health development networks should be established among the appropriate sectors and encouraged. A special effort should be made to identify ways of developing collaboration among sec- tors in countries with pluralistic forms of economy. O Means should be designed to compensate for the often inherent weakness of the health sec tor relative to other sectors. For instance , legislation might be used to make multisectorally agreed policies binding; also, there should be emphasis on what the health sector can do to aid other sectors, and vice versa. o Economic arguments showing the benefits of investment s in health might be used to stimulate other secto rs and promote collaboration. o Present financing sys tems often militate aga inst multisec to ral collaboration because of their complexity and rigidity. One way of facilitating multisectoral collaboration might be to introduce joint funding arrangements. 25 O Legislation is an essential element for multisectoral collabor- ation, since it is obvious that if laws have only a sectoral scope, collaboration cannot be encouraged. Conversely, multiactor confrontation and debate is always a positive factor when promulgating laws. Furthermore, the HF A policy , owing to its multisectoral character, calls for a review of existing health legislation. o WHO should play a greater role in promoting and supporting multisectoral collaboration in individual countries. o The WHO Regional Office for Europe might consider dissemi- nating the experiences of various countries in the field of multi- sectoral collaboration and might also at some point consider proposing multisectoral collaboration as a specific subject for debate at a seminar or meeting. Leadership in planning and management for health The two papers on multisectoral collaboration also led to consider- ation of the subject of leadership in planning and management for health. Discussions on this topic were mainly concerned with the actors involved, sources of authority, and the roles and tasks of leadership, particularly from the point of view of the need for multisectoral collaboration in health. The principal ideas put for- ward were the following. o The style of leadership is determined to a considerable extent by the type of structure of a health system and, in particular, by its degree of centralization or decentralization . o At present, leadership more often than not seems to consist simply of crisis management. In the future, leaders should be better able to anticipate crises and take the appropriate initiatives. o Another principal function of leadership should be to initiate and sustain dialogue between individual actors and sectors, including organized communities and the general public. 26 O The leadership role may change from tim e to time, depending o n th e iss ues, the o bjectives and the po liti ca l e nviro nm ent. At times , leaders hip ma y eve n be exercised by a sec tor o th er than the health sector in a multi sec tora l situati o n. o An important aspect of leader hip in the hea lth sec to r is not unnecessarily to impose problems upon o ther sec to rs; in a multi- sectora l situat ion it is rather the task of lead ership to identify clear responsibilities fo r the different agencies, to stimul a te th e deve lopment of hea lth-oriented indicat o rs in o t_her related secto rs, and to ensure that common stra tegy choices are impleme nt ed . Future-oriented approaches in health planning and management Contributions on one aspect o f such approaches, na mely the use of sce nario techniques in hea lth planning. were made a t th e Confer- ence by Dr G. Dahlgren and Mr M . Lagergren (o n the Swedish ex peri ence) , Dr C.O . Pannenborg (on the Netherl a nds ex peri ence) a nd Dr M. Murt o maa (o n th e Finnish ex perience). Releva nt written co ntributions from o ther co untries were also submitted . Illustra ti ve mat eria l was drawn from the problem areas of agin g, lifes ty les, cancer and heart di ease, and presented to the gro ups pri o r to disc uss ion . The spea kers attempted to id entify th e po tenti a l a nd a lso the limitati o ns of th e sce na ri o a pp roac h in ge nera l. as well as th e possible adva nt ages and disadva ntages of thi s approac h. Swedish ex perience indi ca ted a lo ng-term planning a pproac h in lin e with the HF A stra tegy. The Dutch contribution foc used o n the meth odo log ical aspects of sce nar io deve lo pment a nd co nsidered how sce nari os might poss ibl y be rel a ted to po liti ca l planning pro- cesses. The Finnish exa mpl e showed how corre la ti ons cou ld be es tab li shed between scenarios, strategies and plans. Discussion a lso revea led tha t such tec hniques had proved helpful in o ther sectors and indeed had previously been used in the health sector to advantage. Dutch, Finnish and Swedish a pp roaches to lo ng-term health policy formulation seem to be broadly simil a r , but there a rc some var ia ti ons. The Swedish experie nce can be taken as an exa mpl e of broad strat egy deve lo pment with , a t th e mome nt. littl e ex plicit use of sce nari o tec hniqu es . The Dutch ap proach is more a meth odo log- ica l experiment as far as its int rod ucti o n int o the political planning, decision-making a nd planning process is co nce rn ed. The Finnish 27 example seems to give the clearest picture of how there might be procedural correlations between scenarios, strategies and plans, none of them, of course, being a substit ute for the other. * * * Discussion on this topic was complemented by examples of scenario use in the health policy field in the Federal Republic of Germany and the United States. The experience gained in the United States shed some doubt on the usefulness of scenarios that took as their starting-point very limited or disease-oriented issues, e.g. the problems of cancer or cardiovascular diseases. Emphasis might better be placed on more general, strategic variables of health development (the whole-picture approach). The application of the scenario technique in the Federal Republic of Germany in 1980- 1981 to health manpower development produced some evidence that it would not make an impact on health policy until it was introduced and fully accepted as an additional tool for broad, public and largely open political debate that did not avoid conflicts. In the discussion, participants appeared impressed by the work already done in the Netherlands, especially by the cautious and common-sense approach to the possible procedural weaknesses of scenarios used in isolation. The danger of scenarios developing into broad overstatements or quasi-forecas ts was clearly recognized. The point most strongly stressed, however, was the limited knowledge available about the likely interactions between planned change and significant, inde- pendent developments in society and the economy. Nevertheless, scenarios seem a valuable addition to the learning environment, the improvement of information being a central feature in this respect. The scenario technique gives a significant stimulus to techno- cratic health planners to attune themselves to the political processes that need to be adopted if progress towards the HF A2000 goals is to be achieved. Apart from some methodological and procedural dif- ferences, the Dutch, Finnish and Swedish approaches have in com- mon the explicit goal of using long-term-oriented documentation, scenarios and plans as a stimulus for public discussion of health 28 l policy. Therefore, whatever technique is used, it should be capable of popularization to meet the requirements of the mass media and the subsequent public political debate. The Conference considered that efforts should be made, especially by the WHO Regional Office for Europe, to further develop the momentum and to prevent the scenario approach from becoming just another tool of "profes- sionalized" and non-participatory hierarchical planning pro- cedures. The technique should perhaps be expert-guided, but not expert-dominated. With this in mind, it could help the incipient process of scenario- setting if the Regional Office would take a lead in gathering and supplying the relevant material for future-oriented research. Such research can and should profit from international comparison and the sharing of experience, as well as from the development of methodologies . Finally, the Regional Office could assist in overcoming the resource, manpower and information problems associated with scenario approaches. Without this assistance, the adoption of such techniques might be difficult in countries with manpower problems in the field of health planning. It should also be kept in mind that scenario approaches, even when successfully adopted, are no substi- tute for strategic and steering, controlling, planning and managing mechanisms . There was a general consensus that scenarios are a valuable addition to the techniques for probing the future , but that much technical work remains to be done. Nevertheless, there was general support for the continuance of such efforts and the Conference felt that WHO should continue to support such initiatives and stimulate the widespread adoption of such approaches. It was also agreed that scenarios were a useful means of fostering public interest in decision-making with regard to health issues and in mobilizing political support. CONCLUSIONS AND RECOMMENDATIONS Following its wide-ranging discussions in both group and plenary sessions , the Conference made the following recommendations. 29 Recommendations for Member States I . The pledges made by WHO's Member States to formulate, implement, monitor and evaluate country-specific health develop- ment strategies in line with global and regional HF A strategies and targets create an urgent need for some countries to strengthen and complement their planning and managerial processes. 2. The term "health planning and management" shou ld be under- stood to comprise all purposeful approaches to promoting health and improving the equity, effectiveness, efficiency and quality of health systems. The most appropriate approach should be selected on the basis of the goals and objectives to be achieved, and the situational determinants, which differ from country to country and change over time. 3. Although the health planning and management mechanisms will have to vary greatly according to the prevailing political and administrative structures of each Member State, the HFA policies and the present economic outlook mean that national health plan- ning and management systems will have to be strengthened to ensure that they are outcome-oriented in terms of reducing health hazards and improving health status, amenable to cost-effectiveness analysis and capable of producing long-term solutions that favour health promotion and the prevention of health problems. 4. A multisectoral approach is essential in planning and manage- ment for health. The practical mechanisms for intersectoral col- laboration require considerable strengthening in most Member States to enable HFA strategies to be implemented. Where approp- riate, managerial, financial, legal and other mechanisms, whether formal or informal, at both central and local levels, should be reviewed and improved as necessary. The expertise and skills required for multisectoral collaboration should be enhanced by research and, for example, continuing training and education, through national health development networks. 5. Although almost all health systems have different degrees of centralization and decentralization in terms of the level at which decisions are taken and resources committed, countries should strive to achieve an optimal balance that furthers social and 30 geographical equity in health and health services while at the same time fostering the participation of the people. Whatever the accept- able balance, countries should try to ensure, if they do not already do so, that there is a clear definition and assignment of functions and responsibilities at every level, corresponding with the relevant competences, together with a supporting information service. 6. Information support, including the relevant indicators, could usefully be developed further to allow the selection of the most appropriate strategies, monitoring and continuous reprogramming of national processes for HF A development. Thus, countries could develop more appropriate and comparable methods for the evalu- ation and monitoring of health hazards and the health situation, and of the cost-effectiveness of health policies, activities, services and technology. 7. There is a need for effective mechanisms to enable users and providers of health services to participate in the health development process. Such participation would be strengthened by the estab- lishment of a two-way information system on health policies, health hazards, health problems, available resources and constraints, as well as on the needs and aspirations of local communities. 8. In their training, health personnel need to be made aware of how to take into account the views of health service users and how to establish active working relationships with user groups. They also need to be made aware of the situational and cost constraints and to be able to assess the opportunity costs of different strategies. 9. Research capacity needs to be increased and priority given to research in areas that are important for national health develop- ment, such as: the situational determinants of planning and management approaches; methods of assessing health hazards and health status; effective health information systems; methods for determining the efficacy, cost and benefits of alternatives; 31 promotional strategies to give health personnel a population- oriented perspective; the development of management skill s; the development of skills in intero rganizational and inter- sectoral cooperation; behavioural skills, particularly in conflict resolution; the consequences of economic stringency for health and health management; the development of policy formulation skills; alternative methods of design and strategy selection. 10. There is room for the encouragement and promotion of posi- tive leadership in the health sector, particularly from the point of view of developing forward-looking health policies and stimulating and orchestrating multisectoral initiatives and cooperation in the field of health promotion and prevention . I I . There is a need to promote and develop proven methods, such as long-term planning and, where appropriate, to test new tech- niques that support management and planning, such as health scenarios and modelling, in order to respond to the continuously changing environment. In all cases, attention should be paid to continuous monitoring and reprogramming. Recommendations for the WHO Regional Office for Europe I. As part of the World Health Organization's role to stimulate the development of HF A policies and programmes in all countries, the Regional Office for Europe should cooperate technically, on request , with individual Member States in their efforts to strengthen their national managerial systems for health development. 2. The Regional Office should act as a European clearing-house to collect and disseminate information on relevant experiences in health planning and management, including mechanisms for the participation of users and providers, evaluation, monitoring of health situations, and cost-benefit analysis of health policies, activi- ties and technology. 32 3. The Regional Office is advised to continue promoting and refining the development of the training of health managers, all other health personnel and key personnel from other sectors in the managerial process for national health development. This might include specific components on the identification of benefits in terms of the reduction of health hazards, cost-effectiveness analy- ses, conflict management, cooperation with users and with other sectors, etc. The Regional Office should encourage the provision of such training at both regional and national level. 4. The Regional Office should promote research and development on topics of particular importance in the formulation, acceptance, implementation and evaluation of national HFA strategies, includ- ing ways of developing the managerial process for national health development that best suit the needs of individual countries. 5. The Regional Office's assistance to countries would be extremely helpful in the promotion and development of well proven methods of planning, as well as in the testing of new techniques such as health scenarios, which are intended to study different hypothetical devel- opments and/or strategies in support of national HFA policies. International collaboration in this respect should be encouraged. 6. The Regional Office should also develop a network of collabor- ating centres that would facilitate the endeavours of Member States to develop and implement their national strategies and would sup- port their training and research activities. 33 Annex I PARTICIPANTS Austria Dr G. Liebeswar, Deputy Director of Public Health, Federal Ministry of Health and Environmental Protection, Vienna Belgium Dr E. Mintiens, Office of the Minister, Minister of Health and Education (French-speaking Community), Brussels Dr P. de Schouwer, Secretary-General, Ministry of Public Health and Family Affairs, Division of International Re- lations, Brussels Ms M. Smet, Medical Sociologist, Sociological Research Insti- tute , Leuven Mr R. Urbain, Minister of Health and Education (French- speaking community), Brussels Canada Dr M. Jerome-Forget, Assistant Deputy Minister, Policy Plan- ning and Information Branch, Ministry of National Health and Welfare, Ottawa Czechoslovakia 34 Dr E. Klivarova, Director, Foreign Relations Department, Min- istry of Health of the Czech Socialist Republic, Prague Professor J. Prokopec, Minister of Health , Ministry of Health of the Czech Socialist Republic , Prague Denmark Dr N. Rosdahl, Deputy Director-General, Chief of Division for General Hygiene, National Board of Health, Copenhagen Dr G. Schioler, Deputy Director-General, Head of Hospitals Department, National Board of Health, Copenhagen Finland Dr A. Niemi, Director, Department of Primary Health Care, National Board of Health, Helsinki France Mr V. Comiti, Technical Adviser, Directorate-General of Health, Paris Dr J .-P. Picard, Director, National School of Public Health, Rennes Dr M. Rochaix, Former Director-General, Hospices civils de Lyon German Democratic Republic Dr A.H. Bar, Head of Department , Institute for Social Hygiene and Organization of Health Protection, Berlin Dr U. Schneidewind, Deputy Minister, Ministry of Public Health, Berlin Germany, Federal Republic of Dr R. Mattheis, Senior Medical Officer, Senate of Health, Family and Social Affairs, Berlin (West) Mr W.F. Schrader, Institute for Health and Social Research (IGES), Berlin (West) 35 Dr H. Stein, Health Policy Officer, Federal Ministry for Youth, Family Affairs and Health, Bonn Greece Dr C. Dervenis, Member, Hospital Committee, Central Health Council, Athens Dr A. Philalithis, Member, Executive Committee, Central Health Council, Athens Dr K. Sfangos, Vice-President, Central Health Council, Athens Professor A. Sissouras, School of Engineering, Department of Operational Research, University of Patras Italy Professor M. Colombini, Director, International Relations Office, Ministry of Health, Rome Luxembourg Mr G. Bosseler, Directorate of Health, Luxembourg Morocco Dr A. Cherkaoui, Chief, Division of Technical Cadre Training, Ministry of Public Health, Rabat Mr M. Laaziri, Chief, Bureau of Research and Evaluation Oper- ations, Ministry of Public Health, Rabat Dr A. Mechbal, Chief, Infrastructure Division (in charge of Health Planning), Ministry of Public Health, Rabat Netherlands 36 Mrs J. Bruinsma-Kleijwegt, Friesland Province House, Leeu- warden Dr R.G. Greve , Director of Planning and Building, Ministry of Welfare, Health and Cultural Affairs , Leidschendam Mr C. Korver, Member of the Board of Government of the Province of Noord-Holland, Haarlem Dr J . van Londen, Director-General of Health, Ministry of Wel- fare, Health and Cultural Affairs , Leidschendam ( Chairman) Professor A. van der Werff, Director, Staff Bureau for Health Policy Development , Ministry of Welfare, Health and Cul- tural Affairs, Leidschendam Norway Dr A. Alvik , Deputy County Medical Officer, Oslo Mr J . Tvedt, Head of Division, Ministry of Social Affairs, Oslo Dr G. Vandeskog, Deputy Director-General , Ministry of Social Affairs, Oslo Portugal Dr J .G. Avila, Assistant Director, Regional Directorate of Health , Angra do Heroismo, Azores Dr J .A. Lopes da Nave, Director, Regional Directorate of Health , Angra do H eroismo, Azores Spain Dr I. Alvarez, Adviser, Directorate-General for Health Plan- ning, Ministry of Health and Consumer Affairs, Madrid Dr J.M. Carro Ramos, Assistant Director-General for Territor- ial Planning, Ministry of Health and Consumer Affairs, Madrid 37 Sweden Mr G. Dahlgren, Director, Department of Health and Medical Care, Ministry of Health and Social Affairs, Stockholm Mr B. Larsso n, Deputy Head of Division, National Board of Health and Welfare, Stockholm Switzerland Mr E. Tromsdorff, Chief, Hospital s Department, Cantonal Department of Health , Aarau Mr U. Wienke, Architect and Planner, Swiss Hospitals Institute, Aarau Turkey Dr D. Boztok, Public Health Specialist, General Directorate of Primary Health Care , Ministry of Health and Social Assist- ance, Ankara Union of Soviet Socialist R epublics Dr I. Nikitin, Adviser, External Relations Department , Ministry of H ea lth of the USSR, Moscow Dr I.V . Pustovoj, H ead of the Chair of Health Management , Economics and Planning, Central Institute for Advanced Medical Studies, Moscow Dr O.P. Scepin, First D eputy Minister of Health, Mini stry of Health of the USSR, Moscow ( Vice-Chairman) United Kingdom 38 Mr K. Barnard , H ead, Nuffield Centre for Health Services Studies, University of Leeds Mr M.A. Clark, Principal Nursing Officer, Department of Health and Social Security, London Representatives of intergovernmental organizations Commission of the European Communities Dr A.E. Bennett , Director, Directorate of Health and Safety, Luxembourg Representatives of nongovernmental organizations Association of Schools of Public Health in the European Region Professor F . Doeleman, Oegstgeest, Netherlands European Association of Programmes in Health S ervices Studies Professo r E. Kroger , President , Academy of Public Health , Diisseldorf, Federal Republic of Germany International Council of Nurses Mr C.P. de Winter, School of Post-Basic Nursing Education, Lensden, Netherlands International Hospital Federation Mr R.M . Nicholls, Regional Administrator, South Western Regional Health Authority, Bristol, United Kingdom Temporary advisers Professor C. Altenstetter, City University of New York, NY, USA 39 40 Dr A. Aromaa, Director, Medica l Research Group, Research Institute for Social Security, Social Insurance Institution , Helsinki , Finland Professor H.L. Blum,0 School of Public Health , University of California, Berkeley, CA, USA Dr I. Bukarev, Chief, Department of Health Planning and Econ- omics, Ministry of Public Health, Sofia, Bulgaria Dr L. Elias, Chief Physician , Ministry of Health, Budapest , Hungary Dr A.Y. Ellencweig,° Research Associate, Hebrew University, School of Public Health , Jerusalem, Israel Dr S. Gladilov, Assistant President, Medical Academy, Sofia, Bulgaria Dr A.S. Haro,° Kallionlaita 2, Espoo, Finland Dr B. Horisberger,° Director, St Gallen Interdisciplinary Re- search Centre for Public Health, Switzerland Professor J. Indulski , Ministry of Health and Social Welfare, Warsaw, Poland Mr C. Kleiber, Department of the Interior and Public Health, Public Health Service , Lausanne, Switzerland Mr M. Lagergren, Secretariat for Future Studies, Stockholm, Sweden Dr K. Leppo, Directo r, Department of Planning and Evalu- ation, National Board of Health, Helsinki , Finland Ms H.M.T. van Maanen, 1100 Gough Street, San Francisco, CA,USA a Participation expenses not paid by WHO. Professor A. Maynard, Centre for Health Economics, Univer- sity of York , United Kingdom Dr M. Murtomaa , Director, Department of Environmental Health and Health Promotion, National Board of Health, Helsinki , Finland Dr A. Najzer, Deputy Under-Secretary, Ministry of H ea lth, Budapest, Hungary Dr C.O. Pannenborg, Chief, Strategic Health Plan ning, Minis- try of Welfare, Health a nd Cultural Affairs, Leidschendam , Netherlands Mr P. Pflaum,° First Assistant Director-General , Management Services Division , Commonwealth Department of Health , Woden, Australia Dr A. V. Prims ,a Professor of Medical Care Organization and Health Legislation, Linden , Belgium Dr S. Schepers.a Director-General, European Institute of Public Administration , Maastricht, Netherlands Dr D. Schwefel,° Institute for Medical Informatics and Health Services Research (M EDIS), Oberschleissheim, Federal Repub- lic of Germany Dr B. Skupnjak, Director, In stitute for Health Organization and Economics, Zagreb, Yugoslavia Dr R. Vasa ma, Director, Department of Hospital Care, National Board of Health , Helsinki, Finland Ms A. Marques Vicente, Francisco Suarez 14, Madrid, Spain Dr C. Wlodarczyk, Inst itute of Occupational Med icine, Lodz, Poland a Participation expenses not paid by WHO. 41 Observers 42 Dr H. Anoez, Chief, Bureau of Organization , Ministry of Health , Indonesia Mr J.F.G .M. de Beer, Director, VTA, Ministry of Welfare, Health and Cultural Affairs, Leidschendam, Netherlands Dr J.B. van Borssum, Chief Inspector of Mental Health, Minis- try of Welfare, Health and Cultural Affairs, Leidschendam , Netherlands Mr D .J .D . Dees, Zandbergbaan 7, Breda, Netherlands Mr T. van den Grinten, National Centre for Mental Health, Utrecht, Netherlands Ms L.J. Gunning-Schepers, Staff Bureau for Health Policy Development , Ministry of Welfare, Health and Cultural Affairs, Leidschendam , Netherlands Mr J.P.N . Hendriks, National Boa rd of Health , Zoetermeer, Netherlands Professor H.H. W. Hogerzeil, Institute of Social-Medical Science, State University of Groningen , Netherlands Professor P.A. Idenburg, Chairman, Coordination Board for Social Welfare Policy (HR WB), The Hague, Netherlands Mr G.C. Kaper , Staff Bureau for Health Policy Development , Ministry of Welfare , Health and Cultural Affairs, Leid- schendam, Netherlands Mr L.H .A.M. van de Kerkhof, Head, Department of Social Affairs and Health , Dutch Union of Municipalities, The Hague, Netherlands Dr B. Kleczkowsk i, Karowa 14/ 16 m37, Warsaw, Poland Ms J.H. Krijnen , Emancipation Council, The Hague, Nether- lands Ms E.J.J.E. van Leeuwen-Schut, Lutherseburgwal 10, The Hague, Netherlands Mr W.B. Meijer, National Board of Health, Zoetermeer, Netherlands Dr G . Mik, Quintuslaan 3, Groningen, Netherlands Ms I. M iiller van Ast, Binnenhof I A, The Hague, Netherlands Dr E.W. Roscam Ab bing, Director, Health Care, Ministry of Welfare, Health and Cultural Affairs, Leidschendam, Netherlands Dr G. Schryvers, Institute of Health Sciences, State University of Utrecht, Netherlands Dr A.J. van der Staay, Planning Bureau for Social and Cultural Affairs (SCP), The Hague, Netherlands Mr P.G.J.J. Stevens, Staff Bureau for Health Policy Devel- opment, Ministry of Welfare, Health and Cultural Affairs , Leidschendam, Netherlands Mr L. Vijverberg, Binnenhof I A, The Hague, Netherlands Mr T. Vroon, Director, Public Health Department , Province of Zuid-Holland, The Hague, Netherlands Dr F.J. Werner, Director, Health Care Financing Department , Ministry of Welfare, Health and Cultural Affairs, Leid- schendam, Netherlands Mr B. Wijnberg, Staff Bureau for Health Policy Development , Ministry of Welfare, Health and Cultural Affairs, Leid- schendam, Netherlands 43 Consultants Mr D. Affeld, Chief, Health Economics and Planning, Federal Ministry of Labour and Social Affairs, Bonn-Duisdorf, Fed- eral Republic of Germany Dr S.-E. Ekeid, Assistant Deputy Director-General , Direc- torate of Health , Oslo, Norway Dr D.M. Pendreigh , Department of Community Medicine, Usher Institute, Edinburgh, United Kingdom (Rapporteur) World Health Organization 44 Regional Office for Europe Dr J.E. Asvall, Director, Programme Management (Secretary) Dr J.-P. Fortin, Senior Technical Adviser in Morocco Mr J.M. van Gindertael, Public Information Officer Dr L.A. Kaprio, Regional Director Dr I. Kiekbusch, Regional Officer for Health Education Dr P.A. Lamarche, Programme Planning Officer Dr I.S. Luculescu, Regi o nal Officer for Country Health Pro- gramming Dr H . Vuori, Regional Officer for Primary Health Care Dr A. Wojtczak, Director, Resea rch , Planning and Hum a n Resources Dr H . Zollner, Regi o nal Officer for Health Economics Headquarters Dr S. Khanna , Health for All Strategy Coordination Dr S. Moday , Managerial Process for National Health Devel- opment Dr Y. Nuyens, Health Systems Research 45 RESUME Introduction Cette conference devait promouvoir et renforcer le developpem ent de processus gestionnaires appropries a la strategie de la Sante pour taus d'ici l'an 2000 (SPT2000) dans les pays europeens. II s'agissa it essentiellement de permettre aux pays de proceder a des ec hanges d'idees et de donnees d'ex perience sur la fac;on d'encourager une evo lution dans le sens de politiques et de programmes de sante plus efficaces et plus complets, afin d'ameliorer la sante et, ce faisant, d'utiliser les ressources avec davantage d'efficacite. Plus precisement, la conference devait: I. examiner les changements survenus en matiere de planification et de gestion de la sante dans les Eta ts Membres europeens depuis la conference europeenne de 1974 sur la planification sanitaire natio nale et examiner l'adequation des systemes de gestion existants pour la realisation de la SPT2000; 2. etudier les solutions possibles aux questions cruciales de la planification et de la gestion, en particulier: a) l'equilibre entre centralisation et decentralisation et, en consequence, le role des divers echelons de !'administration dans le processus de gestion et de planification; b) la participation de la collectivite et, d'une fac;on plus gene- rate , celle des consommateurs, ainsi que de diverses categories de fournisseurs de soins de sa nte , a la prise de decision et a la pl an ifica- tion de la sante; c) les mecanismes de participation et de coordination inter- sectorie lles en matiere de sa nte; d) les perspectives o ffertes a la planification sanitaire dans le contexte actuel d'austerite et d'instabilite economiques; e) les besoins a satisfaire sur le plan de la recherche et de la formation pour promouvo ir la planification et la gestion sanitaires; 47 3. analyser les consequences economiques possibles de la poli- tique de la SPT2000; 4. examiner les moyens de prevoir l'avenir et d'etudier les diverses fayons possibles de mettre en reuvre la SPT2000 dans les Etats Membres europeens grace a l'elaboration de scenarios. Vingt-et-un participants venus des Etats Membres de la Region europeenne et du Canada ont assiste a cette conference a laquelle ont ete egalement representes la Commission des Communautes Europeennes, I' Association des ecol es de sante publiques de la Region europeenne, I' Association europeenne des programmes dans les etudes pour Jes services de sante, le Conseil international des infirmieres et la Federation internationale des hopitaux. Etaient egalement presents 26 conseillers temporaires et des membres du personnel du Siege de l'OMS et du Bureau regional de l'Europe. Recommandations a /'intention des £tats Membres I . A la suite de ('engagement pris par les Eta ts Membres de l'OMS de formuler des strategies nationales de developpement sanitaire et de mettre en reuvre, de surveiller et d'evaluer ces strategies par rapport aux strategies et aux cibles mondiales et regionales de la SPT, ii est devenu urgent, dans certains pays, de renforcer et de completer les processus de planification et de gestion. 2. L'expression "planification et gestion sanitaires" doit etre comprise com me englobant toutes les approches deliberees visant a promouvoir la sante et a ameliorer la justice, l'efficacite, l'efficience et la qualite des systemes de sante. Le choix de l'approche la plus appropriee devrait se faire en fonction des buts et des objectifs a atteindre et des determinants conjoncturels, qui different d'un pays a l'autre et evoluent avec le temps. 3. Bien que les mecanismes de planification et de gestion sanitaires soient appeles a varier fortement selon les structures politiques et administratives des divers Etats Membres, les politiques de la SPT et les perspectives economiques actuelles rendent necessaire de ren- forcer les systemes nationaux de planification et de gestion sani- taires afin de faire en sorte qu'ils soient orientes vers les resultats, 48 qu'il s'agisse de reduire les dangers pour la sante ou d'ameliorer l'etat de sante, qu'ils se pretent a une analyse cout/efficacite et qu'ils soient capables de produire des solutions a long terme favorisant la promotion de la sante et la prevention des problemes de sante. 4. II est indispensable d'adopter une approche multisectorielle dans la planification et la gestion sanitaires. Les mecanismes pra- tiques de la collaboration intersectorielle demandent a etre conside- rablement renforces dans la plupart des Etats Membres afin de permettre la mise en reuvre des strategies de la SPT. Le cas echeant, les mecanismes administratifs, financiers,juridiques et autres, offi- ciels ou non, a !'echelon central ou local, devront etre revus et ameliores. Les connaissances et les aptitudes requises pour la col- laboration multisectorielle devront etre accrues par la recherche et, par exemple, la formation et !'education permanentes grace a des reseaux nationaux de developpement sanitaires. 5. Bien que presque tous les systemes de sante connaissent des degres differents de centralisation ou de decentralisation, s'agissant du niveau auquel les decisions sont prises et Jes ressources engagees, Jes pays devraient s'efforcer d'arriver a un equilibre optimal qui favorise l'equite sociale et geographique en matiere de sante et de services de sante, tout en encourageant la participation de la popu- lation. Quel que soit l'equilibre acceptable, les pays devraient essayer d'assurer , si cela n'a pas deja ete fait , la claire definition et la nette repartition des fonctions et des responsabilites a tous les mveaux, selon les competences, avec service d'information a l'appui. 6. On pourrait avoir interet a developper encore l'appui infor- mationnel, y compris les indicateurs pertinents, afin de permettre la selection des strategies les plus appropriees et la surveillance conti- nue et la reprogrammation permanente des processus nationaux pour le developpement de la SPT. Les pays pourraient, par exemple, mettre au point des methodes plus appropriees et mieux com- parables d'evaluation et de surveillance des dangers pour la sante et de la situation sanitaire, ainsi que du cout/efficacite des politiques , des activites, des services et de la technologie de sante. 7. II faut pouvoir disposer de mecanismes efficaces permettant aux utilisateurs et aux fournisseurs de services de sante de participer 49 a u processus de developpement sa nitaire. Cette pa rticipa ti o n serait renfo rcee pa r l'eta bli sse ment d ' un sys teme d ' in fo rm ati o n bidirec- ti o nnel sur Jes politiques et Jes p ro blemes de sa nte, les ressources et Jes contraintes, ainsi qu e Jes besoins et !es as piratio ns des po pu- la tio ns locales. 8. Les personnels de sa nte doi ve nt etre fo rm es a tenir co mpte des o pinio ns des utilisa teurs des se rvices de sa nte et a eta blir des rela- tio ns acti ves da ns leur trava il avec !es groupes d'utilisa teurs. Ils do ivent egalement etre averti s des contra intes co nj o ncturelles et fin ancieres et savo ir eva luer les couts d 'opportunite des differe ntes st ra tegies. 9. II fa ut a ugmenter la ca pacite de recherche et do nner la prio rite a ux rec herches sur des qu es ti o ns impo rtantes po ur le deve lo ppe- ment sa nita ire na tio na l, a savoir: 50 les determina nts co nj o ncturels des a pproches a l'ega rd de la pl a nifica tio n et de la ges ti o n; !es meth odes d 'eva lua ti o n des da ngers po ur la sa nte et de I 'e ta t de sa n te; les systemes efficaces d ' in fo rm ati o n sanita ire; !es meth odes de determina ti o n de l'effi cacite et des co uts et ava ntages des di ve rses soluti o ns possibl es; les strategies de promo ti o n do nna nt a u perso nn el de sa nte une o ptique o rientee vers la po pula ti o n; !'acquisitio n d'a ptitudes a la ges tio n; !'acquisitio n d 'aptitudes a la cooperatio n interorga nisa ti o n- nell e et intersecto rielle; !'ado ptio n de compo rtements a dequa ts, no ta mment po ur reso udre les co nflits; les repercussio ns des cont ra intes econo miques sur la sa nte et la ges tio n de la sa nte; !'acqu is iti o n d 'aptitudes a la fo rmula ti o n des po litiques; !es di ve rses st ra tegies a pplica bles dans le p rocessus co ncep- tuel et la se lecti o n des st ra tegies . I 0. Le besoin se fait sentir d'encourager et de promouvoir l'adop- tion d'une attitude positive chez les responsables du secteur de la sante, notamment en vue de l'elaboration de politiques de sante tournees vers l'avenir et de la stimulation et de l'orchestration d'initiatives et d'une cooperation multisectorielles en matiere de promotion de la sante et de prevention. 11. II est necessaire de promouvoir et de developper des methodes eprouvees, com me la planification a long terme, et de faire l'essai de techniques nouvelles pour appuyer la gestion et la planification, par exemple, en construisant des scenarios et des modeles, le cas echeant, afin de faire face a la perpetuelle mutation de l'environnement. En tout etat de cause, ii faudra aussi se preoccuper de la surveillance continue et de la reprogrammation. Recommandations a /'intention du Bureau regional de /'OMS pour /'Europe I. L'Organisation mondiale de la sante ayant pour role de stimuler !'elaboration de politiques et de programmes de la SPT dans taus Jes pays, le Bureau regional de !'Europe devrait cooperer technique- ment, sur demande, avec les divers Etats Membres, dans leurs efforts pour renforcer leurs systemes nationaux de gestion pour le developpement sanitaire. 2. Le Bureau regional devrait assurer la fonction d'un centre europeen d'echange d'informations, afin de collecter et de diffuser les informations concernant les experiences acquises en matiere de planification et de gestion sanitaires, y compris les mecanismes prevus pour la participation des utilisateurs et des fournisseurs, !'evaluation et la surveillance continue des situations sanitaires et !'analyse cout/avantages des politiques, des activites et des techniques de sante. 3. II est conseille au Bureau regional de continuer a promouvoir et a affiner le developpement de la formation des gestionnaires de la sante, de tousles personnels de sante et des personnels cles d'autres secteurs en matiere de processus gestionnaire pour le developpe- ment sanitaire national. L'identification des avantages, en termes de reduction des risques pour la sante, la pratique de !'analyse 51 co ut-effi cacite, la gesti o n des crises, la cooperatio n avec !es utilisa- teurs et avec !es a utres secteurs, etc., po urra ient nota mment fi gurer da ns la fo rm ati o n a insi dispensee. Le Burea u regio na l devra it , par a ill eurs, encourager la mise en place d 'acti vites de fo rma ti o n au nivea u regio na l et na ti o na l. 4. Le Burea u regio na l devra it pro mo uvoir la recherche et le deve- lo ppement sur des suj ets d' une impo rta nce pa rticuli ere po ur la fo rmul a ti o n , !'acce pta ti o n , la mise en ce uvre et !'eva lu a ti o n des st ra tegies SPT na ti o na les, y co mpri s !es moye ns de mettre a u po int des p rocess us ges ti o nnaires pour le develo ppement sa nita ire na ti o na l q ui repo nde nt a uss i bien q ue poss ibl e a ux beso ins des divers pays. 5. II se rai t ext remement ut il e que le Burea u regio na l a ide !es pays en ma tie re de pro mot io n et de develo ppement de methodes eprouvees de pla nifica ti o n, a in si q ue po ur l'essa i de techniques no uve lles , telles que !es sce na rios de sa nte, qui do ive nt perm ettre d'etud ier di f- fe rentes hypo th eses et/ou d iffe rentes stra tegies a l'a ppui des po li- tiques na ti ona les de la SPT. La coll a bo ra t io n interna ti ona le a ce t ega rd devra it etre enco uragee. 6. Le Burea u regio na l devra it ega lement developper un resea u de ce ntres co ll a bora teurs a fin de fa ciliter enco re plus !es effo rts des Eta ts Membres en ma ti ere de developpement et de mise en ce uvre de leurs st ra tegies na ti o na les et d' a ppu ye r leurs ac ti vites de fo rm ati on et de recherche. 52 ----- -- ZUSAMMENFASSUNG Einleitung Der allgemeine Zweck dieser Konferenz bestand darin , die Entwick- lung zweckmal3iger Managementprozesse zum Konzept "Gesund- heit 2000" in den europaischen Landern zu fordern und zu intensi- vieren. Das Hauptziel dabei ist der Austausch von Gedanken und Erfahrungen der Lander iiber die Art und Weise, wie die Gesund- heitspo litiken und -programme gerechter und umfassender gestaltet werden konnen, um auf diese Weise die Gesundheitslage zu ver- bessern und damit die Ressourcen rationeller zu nutzen. Im einze lnen hatte sich die Konferenz folgende Aufgaben gestellt: I . die Entwicklung der Planungs- und Managementverfahren im Gesundheitswesen der europaischen Mitgliedstaaten im Zeitraum nach der Europaischen Konferenz iiber die Planung im Gesund- heitswesen im Jahre 1974 zu iiberpriifen und zu untersuchen, ob die gegenwartigen Managementsysteme zur Erreichung des Ziels "Ge- sundheit 2000" geeignet sind, 2. die Antwo rten auf entscheidende Planungs- und Management- fragen zu finden, wie z.B.: a) das Verhaltnis zwischen Zentralisierung und Dezentralisie- rung, und damit verbunden die funktionsmal3ige Abgrenzung der verschiedenen Verwaltungsstufen im Gesundheitswesen im Hin- blick auf den Management- und Planungsproze/3 b) die Einbeziehung des Gemeinwesens und, aufbreiterer Basis, der Verbraucher in die Entscheidungsprozesse und Planung des Gesundheitswesens sowie die Beteiligung verschiedener Arten gesundheitsrelevanter Leistungsan bieter c) Mechanismen, die eine intersektorale Verkniipfung und Koordinierung im Gesundheitsbereich ermoglichen 53 d) die Zukunftsaspekte der Gesundheitsplanung angesichts der gegenwartigen schlechten Wirtschaftslage und Instabilitat e) die Forschungs- und Ausbildungserfordernisse auf dem Gebiet der Gesundheitsplanung und Entwicklung von Management- verfahren 3. die potentiellen wirtschaftlichen Konsequenzen der Stratcgie "Gesundheit 2000" zu analysieren, 4 . die Zukunftsplanung zu diskutieren und anhand von Szenarios Alternativen zur Umsetzung der Strategie "Gesundheit 2000" in den europaischen Mitgliedstaaten zu untersuchen. Ander Konferenz nahmen Vertreter von 21 Mitgliedstaaten der Europaischen Region und Kanada sowie nachstehender Organi- sationen teil : KEG, ASPHER (Vereinigung der Lehranstalten fur offentliches Gesundheitswesen in Europa), EAPHSS (Europaische Vereinigung fur Programme Ober Gesundheitssystemstudien) , ICN (Weltbund der Krankenschwestern und Krankenpfleger) und IHF (Internationaler Krankenhausverband). Aul3erdem waren 26 Be- rater auf Zeit sowie Mitarbeiter der WGO-Hauptverwaltung und des Regionalburos fur Europa anwesend. Empfehlungen an die Mitgliedstaaten I. Da die Mitgliedstaaten der WGO zugesagt haben , in Anleh- nung an die globalen und regionalen Strategien und Ziele des Kon- zepts "Gesundheit 2000" landesspezifische Gesundheitsstrategien zu formulieren, umzusetzen, zu uberwachen und zu evaluieren, besteht in einigen Landern die dringende Notwendigkeit , ihre Planungs- und Managementprozesse starker auszubauen. 2. Der Ausdruck "Gesundheitsplanung und-management" umfal3t alle zielbewul3ten Vorgehensweisen, um das Gesundheitsniveau zu fordern und die Chancengleichheit, Effektivitat, Effizienz und Qualitat der Gesundheitssysteme zu verbessern. Ein optimaler Ansatz sollte von den ins Auge gefal3ten Zielen und den situations- bedingten Determinanten ausgehen, die von Land zu Land ver- schieden sind und sich im Laufe der Zeit andern. 54 3. Auch wenn die Planungs- und Managementmechanismen des Gesundheitswesens je nach den politischen und administrativen Gegebenheiten der Mitgliedstaaten sehr unterschiedlich sein miissen, verlangen die Grundsatze des Konzepts "Gesundheit 2000" und die gegenwartige Wirtschaftslage, dafi die Planungs- und Management- systeme im Gesundheitsbereich gestarkt werden miissen; sie miissen resultatorientiert sein, d.h. die Gesundheitsrisiken abbauen und den Gesundheitsstatus verbessern; sie sollen sich zur Kosteneffektivitats- ana lyse eignen und schlie(\lich Iangfristige Losungen ermoglichen, die eine Forderung der Gesundheit und Vorbeugung gegen Ge- sundheitsprobleme begi.instigen. 4. Bei der Planung und organisatorischen Fiihrung im Gesund- heitsbereich ist ein multisektoraler Ansatz von Bedeutung. Die praktischen Mechanismen der intersektoralen Zusammenarbeit bediirfen in den meisten Mitgliedstaaten einer betrachtlichen Inten- sivierung, wenn die G FA-Strategien ("Gesundheit fur alle") umge- setzt werden sollen. Wo angebracht, sollten organisatorische, finanzielle, gesetzgeberische und sonstige Mechanismen offizieller oder inoffizieller Art sowohl auf zentraler als auch ortlicher Ebene iiberpriift und notigenfalls geandert werden. Die zur Durchfiihrung einer multisektoralen Zusammenarbeit erforderlichen Kenntnisse und Fahigkeiten sollten <lurch Forschung und Tatigkeiten eines landesdeckenden Netzes von Zentren zur Forderung des Gesund- heitswesens, beispielsweise Ausbildung und Weiterausbildung, er- weitert werden. 5. Obwohl fast alle Gesundheitssysteme in bezug auf den Zentralisierungs- bzw. Dezentralisierungsgrad, d.h. hinsichtlich der jeweiligen Ebene, auf der Entscheidungen getroffen und Res- sourcen zugewiesen werden, voneinander abweichen, sollten sich die Lander doch bemiihen , soziale und geographische Nachteile hinsichtlich der Gesundheitslage und der Verfiigbarkeit von Gesund- heitsdiensten auszugleichen und gleichzeitig die Mitwirkung der Bevolkerung anzuregen. Wie ein solches ausgewogenes System auch immer beschaffen sein mag, sollten die Lander, falls erforder- Iich, dafiir sorgen, dail auf alien Ebenen die Funktionen und Kom- petenzen klar festgelegt und entsprechend den Qualifikationen zugewiesen werden; gleichzeitig sollte es einen lnformationsdienst geben. 55 6. Es ware ni.itzlich, wenn die informatorische Untersti.itzung weiter ausgebaut wi.irde - dadurch wi.irde die Wahl der am besten geeigneten Strategien, die Oberwachung und die fortlaufende Neu- programmierung der in den Landern laufenden Prozesse der G FA- Entwicklung ermoglicht werden. Dann konnten die Lander zweck- mafiigere und komparable Evaluierungs- und Oberwachungs- methoden hinsichtlich der Gesundheitsrisiken und der Gesund- heitssituation sowie in bezug auf die Kosteneffektivitat der Gesund- politiken und -aktivitaten, -dienste und -technologie entwickeln. 7. Es sollten effektive Verfahren entworfen werden , damit die Benutzer und Anbieter von Gesundheitsleistungen an der Entwick- lung des Gesundheitswesens teilnehmen konnen. Eine derartige Einbeziehung wi.irde durch eine beidseitige Informierung i.iber nachstehende Bereiche gefordert: Gesundheitspolitik, Gesundheits- probleme, verfi.igbare Ressourcen und Hindernisse sowie die Bedi.irf- nisse und Wi.insche des ort lichen Gemeinwesens. 8. Das Gesundheitspersonal sollte wahrend der Ausbildung dar- i.iber informiert werden, wie es die Ansichten der Gesundheitslei- stungsempfanger beri.icksichtigen und eine aktive Arbeitsbeziehung mit den Leistungsempfangergruppen aufbauen so il. Das Gesund- heitspersonal muB sich auch der situationsbedingten und kosten- maBigen Hindernisse bewufit und fahig sein, die Opportunitats- kosten der verschiedenen Strategien beurteilen zu konnen. 9. In bezug auf Bereiche, die allgemeine Forderung der Gesund- heitslage von Bedeutung sind, sollte die Forschungskapazitat erwei- tert und ihnen eine Vorrangstellung eingeraumt werden; solche Bereiche sind u.a.: 56 situationsbedingte Determinanten fur den Planungs- und Managementbereich Verfahren zur Beurteilung der Gesundheitsgefahren und der Gesundheitslage effektive Gesundheitsinf orma tionssysteme Methoden zur Bestimmung der Wirksamkeit, Kosten und Nutzen von Alternativen Forderungsstrategien, um dem Gesundheitspersonal eme bevolkerungsorientierte Haltung zu vermitteln Vermittlung von Managementqualifikationen Vermittlung von Fertigkeiten in bezug auf eine zwischen- organisatorische und intersektorale Zusammenarbeit Unterweisung in Methoden zur Entscheidungsfindung in Konfliktsituationen die Auswirkungen der schlechten Wirtschaftslage auf Gesund- heitssituation und Management im Gesundheitswesen die Vermittlung von Fahigkeiten zur Formulierung von (poli- tischen) Grundkonzepten alternative Strategien zur Auswahl der Ansatze und Strategien. 10. Es bleibt noch em1ges zu tun iibrig, um das Konzept einer eindeutigen Fiihrung im Gesundheitssektor anzuregen und zu for- dern, insbesondere aus dem Blickwinkel, zukunftsorientierte Gesund- heitspolitiken aufzustellen und multisektorale Initiativen und koope- rative Bestrebungen im Bereich der Gesundheitsforderung und Pravention anzuregen und in konzertierter Weise durchzufiihren. 11. Es herrscht kein Zweifel, dal3 erprobte Methoden wie die langfristige Planung und die Erprobung neuer Verfahren zugunsten von Management- und Planungssystemen (Gesundheitsszenarios und -model le) im Bedarfsfall gefordert und weiterentwickelt werden miissen, damit sie den sich standig andernden aul3eren Gegeben- heiten entsprechen. Auf keinen Fall sollte man die kontinuierliche Oberwachung und Neuprogrammierung vernachlassigen. Empfehlungen an das WGO-Regionalbiiro fiir Europa I. Im Sinne der Aufgabenstellung der Weltgesundheitsorgani- sation, die Ausarbeitung von gesundheitspolitischen Richtlinien und Programmen gemal3 "Gesundheit 2000" in alien Landero zu fordern, sollte das Regionalbiiro fur Europa auf Anforderung fach- lich mit den einzelnen Mitgliedstaaten zusammenarbeiten, wenn es darum geht, deren Managementsysteme zur Weiterentwicklung des Gesundheitswesens zu unterbauen. 57 2. Das Regiona lbU ro sollte da fi.i r sorgen , daB eine europa ische Clea ring-Stelle einge richtet wird ; ihre Aufgabe ware, lnformatio nen Uber relevante Erfahrungen bezUglich der Pl anung und orga nisa to- ri schen FUhrung im G es undheitswesen einzusa mm eln und weiter zu ve rmitteln . Da runter fa ll en Mec hanismen bezUglich der Einbezie- hung von Leistu ngse mp fa nge rn und Leistungsa nbietern , der Eva - lui erung und Uberwac hung von G es undheitss itua ti o nen sowie hin- sichtlich der Kosten/ Nutzen-Ana lyse d er G esundh eitspo litiken , -a ktivitaten und -techn ologie. 3. D em Regio na lbU ro wird a ngera ten, weiterhin die Hera nbil- dung vo n Ma nagern des G esundheitswese ns zu fo rde rn und weiter a uszuba uen ; dasse lbe gilt fi.ir so nstiges G es undheitsperso na l und Perso na l a nderer Sekto ren , das mit Bezug a uf die Manage ment- p rozesse zur Ent wicklung eines o ffentli chen Ges undheitswese ns eine Ro lle spielt. In eine solche Unterweisung ko nnen spezifische Ko mpo nenten ei nge ba ut werden , z. B. Uber d ie Erk ennung vo n Nutze na rten im Sinne einer Redu zierun g d er Ges undh eitsgefa hr- dungen, Kosteneffektivitatsanalysen, Konfliktmanagement , Zusa mmen- a rbei t mit Leistu ngse mpfange rn un d a nd eren Se kt oren u.m . Das Regio na lbU ro so llte ein e solche A usb ildung auf regio na ler und La ndesebene fo rdern . 4. D as Regio na lbU ro sollte di e Fo rschung un d Ent wicklun gs- a rbeit in bezug a uf die nachstehenden beso nde rs wichtigen Themen- kreise fo rdern : Fo rmulie run g, Billigung, Umsetzung und Eva luie- rung na ti o na ler G F A-S tra tegien einschli el3lich der A usa rbeitung vo n Ma nage mentp rozesse n fi.ir die Ent wic klun g des offentli chen Gesundheitswese ns, d ie den Gegebenhe iten des betreffe nden La ndes o ptima l entsp rechen. 5. Fl a nk iere nde MaB na hmen des Regio na lbU ros gege nUber den La nd ern wUrden sta rk d azu beitragen, da B erp rob te Pl a nungs- meth oden , di e Erp ro bung neuer Verfa hren wie z. B. G es undh eits- sze narios (zur Unters uchung ve rschiedene r hypothetischer Ent- wicklungs moglichkeiten oder Stra tegien in Ve rbind ung mit na tio na- l en GFA- Po litiken) geforde rt und entwickelt wUrden. In di ese r Beziehun g sollte ma n a uch die intern at io na le Zusa mmena rbeit a nregen . 58 6. Das Regionalbiiro sollte desgleichen ein Verbundsystern von Kollaborationszentren einrichten, dessen Ziel es sein sollte, die Berniihungen der Mitgliedslander hinsichtlich der Entwicklung und Verwirklichung ihrer Strategien sowie ihrer Ausbildungs- und For- schungstatigkeiten zu unterstiitzen. 59 PE3UME 8Be,D€HH€ Uem, KoH¢epeHUlli1 COCTOR.Tla B TOM, '-ITOCibJ CO.DeHCTBOBaTl:, yKpenneHHID H pa3BHTHID B eEponeHCKHX CTpaHax npoueccoB ynpaB- n€HHR CTpaTenfflMl-! ,DOCTH)r;€HH.R 3.DOPOBbR ,I;n.R BC€X K 2000 ro.r.y (3,ll82000). nepe,ll CTpaHali..H - yqacTHHuaMH KoH¢epeHl.lID1 CTORna 3a,lla'4a OOM€H.RThCR MH€HHRMH C nyT.RX pa3BHTH.R Cior.ee cnpaBe,D,JIH- BbIX H KOMnn€KCHbJX nporpaMM H nor.HTHKH 3,DpaBooxpaH€HH.R B uenRX yny'4l!leHHR cocTO.RHHR 3,nopoB1,.R HaceneHHR H oeecnetieHHR Cior.ee 9¢'¢€KTHBHOro HcnOJll,30BaHli.R pecypcos. nepe.o KoH¢epel-il..Il1€H CTC.RJU1 cne.nyIDl!lH€ KOHKp€THbI€ 3a,na'-1H: 1. npoaHaJJH3HpoBaTh H3M€H€HH.R B oonacTH nJJaHHPQBaHHR H ynpasneHH.R 3.rpaBOOxpaHeHHeM s rocy;:;apcTBaX - v,eHax EspcneH- cKoro pernoHa, npoHc111e.L11IHe nocne npose.neHHOO c 1974 ro.na EsponeHCKOO KOH¢epeHUHH no n.r.aHHpoBaHHJO HaUHOHaJU,HCro 3,llpaBOOXpaH€HH.R, a TaKJI\€ COOTB€TCTBH€ ,D€HCTBYIO!UHX CHCT€M ynpa sneHHR uen.RM ,DOCTH!<.eHH.R 3,f.82000; 2. paccMOTp€Th B03MOJl'.Hbl€ nyTH pe111eHHR cne,I:!YIDlllHX KnIDtieBhJX npceneM s n.naHHposaHHH H ynpasneHHH: 60 a) cCiaJJaHCHpoBaHHCCTb U€HTpaJU130BaHHb!X H .neueHTpar,H- 30BaHHb!X pe111eHHH H, cne.noBaTem,Ho, ¢YHKUHH pa3JlH'4HbIX YPOBHeH CHCT€Mhl 3,npaaooxpaHeHHR B npouecce ynpaaneHHR H nnaHHPCBaHHR; 6) ytiacTHe HaceneHH.R H oor.ee 111HpoKoe npHBnetieHHe noTpeCiHTenat K nnaIDIJ)OBaHHID H ynpasneHHID 3,npasooxpaHe- HHeM, yqacTH€ B 9TOM npouecce pa3JU1'lHbIX KaTeropl-ili Me.DHUHHCKoro nepcoHana; B) M€XaHH3MLI M€ll'.C€KTopam,Horo yqacTHR H KOOp,DHHamrn B oCinacTH 3,npasooxpaHeHH.R; r) B03MOll\HOCTII nJJaHHpoBaHHR 3,IipaBOOXpaHeHHR B yCJJOBWIX SKOHOMJ.iqeCKHX TPY.llHCCTeH H HeyCTOH~BccrH; .n) noTpeC5HOCTH B Hay'4Hbl.X HCCJ1€.DOBaHHRX H no..croTOBKe, CBR3aHl-lh!e C nJJaHHpoBaHHeM H ynpaBJJeHHeM 3,CpaBCOXpaHeHHeM; 3. paCCMOTpeTb nOJJHTHJ<H 3.ll.8200O; BO3MOllHJ,J€ SKOHOMH'4€CKH€ nocne,r.cTBWI 4. oC5cy,cHn, nyTH nnaHHpoBaHHR MeponpHRTHH H H3Y'4HTb am,-repHaTHBHbJ€ BO3MO!\HOCTH OCYll!€CTB11€HHR CTpaTerHl1 3.f482OOO B eBponeHCKHX rocy.i:,apcTBaX-qJ]€HaX B pe3ym,TaTe pa3pa6oTKH cueHapHeB. 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PernOHaJlbHCMy 610po peKOMeH,nyeTCR npo,LOJl!-HTb paOo-ry no pa3BHTHIO H COBepmeHCTBOBaHHIO no.orOTOBKH opraHH3aTOJX)B 3~pa- BOOXpaHeHH.R, Bcex .opyrnx paC5oTHl1l<OB 3,tpaBOOXpaHeHH.R, OTBeT- CTBeHHW< paC5oTHl1l<OB ,npyrnx ceKTOpoB, CBR3aHHOH C npoueccaMH yr.paBJJeHM pa3BHTHeM HaUHOHaJlbHOrc 3,[;,paBOOXpaHeHW!. 3TH Mepw MOryT BJ<JliO'laTb cneUH¢HqecKH€ KO.MnOHeHTbl, KacaIOlllH€C.R onpe.oeneHH.R B03MOlllHl,IX nor.Ollll-lTE.r>bHblX pe3ym,TaTOB B cOnaCTH COKpameHH.R qHcna ¢aKTopoB PHCKa, aHa.ll1-!3a 9KOHOMHqeCJ<OH 9¢¢eKTHBHOCTH, npeo.ooneHH.R KOH¢JlHKTHblX CHTyaUHH, CCTpy,.r.HHqe- CTBa C nOJlb3OBaT€11RMH H .r.pyrnMH ceKTOpa.MH H T • .r.. PernoHaJJb- Hoe OIOpo ,.UOJI»IO CO.DeHCTBCBaTb opraHH3aUHH TaKOH nc.r;roTOBKH Ha pernoHam,HOM H HaUHOHaJlbHOM ypoBHRX. 64 4. FernOHaJn,Hoe OIOpo ,DO.n.aHO CO,LeHCTBCBan, HaY'iHblM HCCJie,Lo- BaHJ1RM H pa3paCioncaM B oO.nacTRX, npe.[lC'I'aB.TLIUQnHX ocoOl>!H HHTe- pec C TO'-U<H 3peHHR ¢opMy.11HpoBaHHR, yTBePZ.OeHHR, OCYl!l€CTMe- HHR H oueHJ<H HfillHOHaJll:,HhlX CTpaTerHH 3.I4B, BKJllOtlaR nyTH pa3BH- THR npoueccoB ynpaMeHWi pa3BHTHeM HaUHOHa.TlbHOro 3,LpaBOOXpa- HeHHR, KOTOP&Ie B Ha.HCio.libllleH creneHH COOTB€TCTBYIOT nOTpeCiHOC- TRM OT,LeJU,HbJX rocy,napc:TB. 5 . Pernctta.ru,Hoe CiIOpO MOZeT OKa3an, cy111eCTBeHHylO nOMOllll, B paCIIIHpeHHJi HCTIOJlb30BaHHR H B ,Da.llbHeHll!eM pa3BHTHH HCllhlTaHHhlX MeTO,IJOB nliaH11poBaHHR, a TaKJl(e anpoCiHpoBaHHH HOBblX MeTO.DOB, TaJ<HX, KaJ< cuettapHH 3,0paBOOXpaHeHWi, KCTOpble npe.nycMaTPHBalOT H3y1.l€HH€ pa3JlHtU-lb!X nmOTenftlecKHX Mep H/HJU.1 CTpaTerHH B no.n.nep»J<y HauHOHaJlbHOH nOJU,tTHKH 3.I48. Cne.nyeT CTHMy.1!HpOBaTh pa3BHTHe MeZ,OyHapo,nttorc COTPY.DIDN€CTBa B STOH o0.JJaCTH. 6. 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Всемирная организация здравоохранения (ВОЗ / WHO) · Publications
Planning and management for health: report on a European conference, The Hague, 27 August–1 September 1984
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