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[Unpublished] 1993 Dec. xii, 217,  p. (Report No. 12577-AFR)The World Bank has recommended a blueprint for health improvement in sub-Saharan Africa. African countries and their external partners need to reconsider current health strategies. The underlying message is that many African countries can achieve great improvements in health despite financial pressure. The document focuses on the significance of enhancing the ability of households and communities to identify and respond to health problems. Promotion of poverty-centered development strategies, more educational opportunities for females, strengthening of community monitoring and supervision of health services, and provision of information on health conditions and services to the public are also important. Community-based action is vital. The report greatly encourages African governments to reform their health care systems. It advocates basic packages of health services available to everyone through health centers and first referral hospitals. Health care system reform also includes improving management of health care inputs (e.g., drugs) and new partnerships between public agencies and nongovernmental health care providers. Ministries of Health should concentrate more on policy formulation and public health activities, encourage private voluntary organizations, and establish an environment conducive to the private sector. African countries need more efficient allocation and management of public financial resources for health to boost their effect on critical health indicators (e.g., child mortality). Public resources should also be reallocated from less productive activities to health activities. More commitment from governments and domestic sources and an increase of external assistance are needed for low income African countries. The first action step should be a national agenda for health followed by action planning and setting goals to measure progress.
WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES. 1987; (755):1-61.This is a WHO technical report reviewing how control of disease vectors may be integrated into the primary health care system. The concept of vector is defined broadly as any primary or intermediate invertebrate or vertebrate host or animal reservoir of human disease. The section headings are: present magnitude and status of vector control; means of delivering vector control in primary health care at the community level; communication, feedback and epidemiology; suitability of specific control measures for primary health care; human resource development and the core concept; research topics and recommendations. It is estimated that the size of the problem is hundreds of millions of cases of vector-born disease, with malaria, chagas disease, schistosomiasis, filariasis probably leading the list. Recent efforts on the community level, in Africa for example, have garnered enthusiastic support of villagers, while many nationally sponsored programs on the Health Department level have been less effective. Dozens of specific examples of how vectors may be controlled at the household and village level are cited. Some of these are bed-nets, repellents, aerosols and fumigants, fly traps, water filters, clean-up, biological control agents such as larvivorous fish . In many cases the peridomestic hosts are inhabiting man-made environments, such as thatched roofs, poorly stored food or discarded containers. The primary health care model includes planning at the local level, intersectorial cooperation, and a district management team. Information flow should involve use of the microcomputer and simple flow charts or algorithms, to facilitate feedback between the core group in the central government and the local district health management team. The operations aspects of vector control are emphasized, in both the research needs and the broad agenda of recommendations that end the report.
Hospitals and health for all. Report of a WHO Expert Committee on the Role of Hospitals at the First Referral Level.
WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES. 1987; (744):1-82.The World Health Organization (WHO) Expert Committee on the Role of Hospitals at the First Referral Level met from December 9-17, 1985, to review the role of the hospital in the broader context of a health system. The Expert Committee recognized that different strategies could be used to define the role of hospitals in relation to primary health care and that, for example, it would be possible to begin by analyzing what hospitals currently are doing with respect to primary health care, describe the different approaches being used, and then formulate guidelines to be followed by hospitals that are seeking to strengthen their involvement in primary health care. A shortcoming of this strategy is that it is based on what hospitals are already doing in particular circumstances, rather than helping people to decide what is required in a wide range of different settings. Consequently, the Expert Committee undertook to provide an analysis of primary health care, particularly in relation to the principles of health for all, to specify the components of a district health system based on primary health care, and to use this information as a basis for describing the role of the hospital at the first referral level in support of primary health care. This report of the Expert Committee covers the following: hospitals versus primary health care -- a false antithesis (the need for hospital involvement, the evolution of health services, expanding the role of hospitals, delineation of primary health care, hospitals and primary health care, and the common goal of health for all); components of a health system based on primary health care (targeted programs, levels of service delivery, and the functional infrastructure of primary health care); role and functions of the hospital in the first referral level (patient referral, health program coordination, education and training, and management and administrative support); the district health system; and approaches to some persistent problems (problems of organization and function; problems of attitudes, orientation, and training; and problems of information, financing, and referral system). The report includes recommendations to WHO, to governments, to nongovernmental organizations, and to hospitals. The Expert Committee considered that the conceptual focal point for organizational and functional integration should be the district health system encompassing the hospital and all other local health services. Further, the Expert Commitee was convinced that organizational and functional interaction (focused on the district health system) is imperative if full and effective use is to be made of the resources of the hospitals at the first referral level and if the health needs of the population are to be met.
Health manpower requirements for the achievement of health for all by the year 2000 through primary health care. Report of a WHO Expert Committee.
World Health Organization Technical Report Series. 1985; (717):1-92.Health manpower development is central to effective primary health care, and appropriate manpower policies must form the basis for national strategies aimed at health for all. Moreover, these policies must be coordinated with the political, social, and economic goals at the national level and anchored in national strategies to achieve health for all. This volume sets forth numerous recommendations for strengthening health manpower development. It is urged that the World Health Organization (WHO) support Member States in their efforts to formulate or revise national health manpower requirements to achieve health for all by the year 2000. Permanent mechanisms for manpower development should be established or strengthened, in conjunction with national health councils and health development networks. It is further urged that Member States design country-specific mechanisms to ensure the fair participation of all sectors of the community, including the less privileged, in health manpower development activities and community involvement in all aspects of manpower development. Decentralization of decision-making power and management functions will make the health system infrastructure more responsive to community health needs. In addition, WHO should encourage Member States to include in training programs for all health workers the acquisition of skills needed to elicit community involvement, undertake activities aimed at changing the value orientations of health workers from profession-based to people-oriented, and develop a system of accountability of training institutes and health services to community bodies. Also recommended is the development of a global health manpower data base system. It is noted that trained health manpower will have only a limited role in the development of health systems based on the primary health care approach unless such manpower is properly deployed and utilized through effective management.
WORLD HEALTH FORUM. 1993; 14(4):333-44.WHO evaluated the implementation of the health-for-all strategy using data from 151 countries. 110 countries still endorsed the strategy. 95 have either completely implemented or further developed community involvement. Just 33 countries had more equitable distribution of resources. The percentage of gross national product (GNP) that the government dedicated to health rose in the least developed countries. Developed countries spent a higher proportion of their GNP on health than did developing countries (3.3% vs. 0.9%, 1991). Maldistribution of health personnel continued to be a major problem. Between 1985 and 1990, the proportion of people in developing countries with access to safe water rose from 68 to 75%. Adequate sewage disposal coverage rose from 46 to 71% (1985-1991). Prenatal care coverage by trained personnel increased from 58 to 67%. Tetanus toxoid coverage of pregnant women only increased from 24 to 34%. Most maternal deaths were a result of inadequate prenatal care, inadequate care during childbirth, pregnancies spaced too closely, multiparity, and poor health and nutritional status before the first pregnancy. Immunization coverage rose considerably in every region (e.g., 47-83% for diphtheria). Nevertheless, substantial differences in coverage existed between countries. A substantial trend towards more integrated primary health care occurred. Child survival rates improved, but the gap in infant mortality rates between developed countries and the least developed countries widened. The gap in health status between the poor and the wealthy had become larger. Developing countries in the process of the epidemiological transition continued to be burdened with both infectious and degenerative diseases. GNP and adult literacy rose, but less so in the least developed countries. These findings suggested that governments must sustain the commitment to reduce inequities, realign health systems, improve health financing systems, improve coordination between health sectors, and improve linkage between health and development.
Policy aspects of community participation in maternal and child health and family planning programmes.
Geneva, Switzerland, World Health Organization, 1989. , 56 p. (WHO/MCH/89.14)The International Conference on Primary Health Care (PHC) organized by WHO and UNICEF in Alma Ata in 1978 pointed to involving the public in health care services including planning, implementation, and evaluation. These projects, experience in other areas of community participation (CP) as well as a meeting that was organized by WHO and the UN Fund for Population Activities (UNFPA) in Zimbabwe in October 1986 are detailed. The rationale for CP is to improve health service delivery and to enable health service users to have more control. Emphasis is placed on women in communities as the key participants in maternal and child health/family planning (MCH/FP) programs to increase their status. Women are the beneficiaries of MCH/FP services with traditional responsibility for the health of their families. They make up the majority of nurses, modern and traditional midwives, and paramedical workers within the formal system. In traditional communities women become community health workers (CHWs) and village development workers. WHO has supported research to assess the health impact of community participation in health services. UNICEF has focused on a more integrated approach where community participation is promoted through community development activities. UNFPA has supported projects in which traditional birth attendants or village health workers are trained to improve their skills in MCH/FP. Some policy issues for CP implementation in MCH/FP programs include: decentralization of the health care systems; health care information and education; training; resources for CP in MCH/FP activities; implementing MCH/FP activities in the community (antenatal care, delivery care, child care, and FP care); promoting multi sectoral collaboration; and evaluating and monitoring community participation. Some international research projects initiated are the PRICOR operations research project on the implementation of the PHC (supported by USAID), and ESCAP's cross-cultural research project about constraints on community participation in national FP programs (supported by UNFPA). Governments are urged to hold workshops for policymakers, train district and local officials in managerial skills, develop guidelines for medical preventive health training curricula, and develop management information systems.
Joicfp Review. 1985 Oct; 10:28-31.Umati is a nongovernmental and nonprofit voluntary family planning organization which pioneered family planning activities in Tanzania in 1959. Umati was also assigned a role in the MCH program to ensure that the family planning component be given equal priority with the other components of the health program. Umati assists the Ministry of Health in its efforts to increase awareness of the advantages of family planning and responsible parenthood; gives advice on service delivery as well as assists the Ministry of Health in its task of training family planning service providers; and assists the Ministry of Health in the procurement and distribution of contraceptives and equipment. Umati is supported by the International Planned Parenthood Federation (IPPF). The integrated project aims to compensate for some of the deficiencies inherent in the MCH program. The project should respond to other community needs in order to attract and sustain the interest and active participation of community members. Parasite control and nutrition have been selected as priority health concerns. The integrated project must belong to the community. The following channels are being utilized on the local level: the local steering committee; the project volunteers; the Family Planning Association of Tanzania; MCH unit of the government; the government environmental sanitation unit; primary schools; religious institutions; the village government; and information, education and communication. The project should be evaluated and should be flexible.
Who Chronicle. 1984; 38(4):187-9.Objectives of the interregional Conference on Primary Health Care, organized by the World Health Organization (WHO) Regional Office for Southeast Asis together with the government of the Democratic People's Republic of Korea, were as follows: to exchange country experiences in the organization and implementation of primary health care; to assess primary health care development vis-a-vis national socioeconomic development and national health systems; to define alternative approaches to the development of the health infrastructure for inntegrated implementation of the 8 essential elements of primary health care; and to define the coordinating role of governments and international organizations in supporting and mobilizing resources in support of primary health care to to formulate recommendations for the organization and furthr development of primary care. The conference was attended by 35 participants from 18 countries in all 6 WHO regions and by representatives of 5 UN agencies. Conference recommendations include: a program of public information and health education should be launched to create and strengthen the desired awareness and commitment among the people and their representatives; the national health policy on primary health care should be broadly disseminated among all professional groups and functionaries involved in community development activities both in the health sector and outside it; concerted action by all health related development sectors should be initiated and strengthened to support the health sector in acheiving the goal of health for all; appropriate mechanisms relevant to the local situation should be evolved to give suitable training, orientation, and motivation to the community and opinion leaders in order to ensure their total involvement in the implementation and management of their own health care; governments should ensure the allocation of adequate funds for the smooth implementation of the program and that preferential allocation of resources be made for activities in the underserved areas; more rapid measures should be taken to extend primary health care services to all segments of the community that are still not covered; and the shortage of personnel available for providing primary care should be made up by reorienting existing personnel, accelerating the pace of basic training for primary health workers, and possibly also by inducting the health manpower available under traditional systems of medicine.
Geneva, Switzerland, World Federation of Public Health Associations [WFPHA], 1984 Aug. vii, 78 p. (Information for Action)This bibliograph contains 4 parts. Part 1 is anannotated bibiography covering the following topics: an overview of health care in developing countries; planning and management of primary health care (PHC): manpower training and utilization; community participation and health education; delivery of health services, including nutrition, maternal and child health, family planning, medical and dental care; disease control, water and sanitation, and pharmaceutical; and auxiliary services, Part 2 is a reference directory covering periodicals directories, handbooks and catalogs, in PHC, as well as computerized information services, educational aids and training programs, (including audiovisual and other teaching aids), and procurement of supplies and pharmaceuticals. Also given are lists of international and private donor agencies, including development cooperation agencies, and directories of foundations and proposal writing. Parts 3 and 4 are the August 1984 updates of the original May 1982 edition of the bibliography.
World Health. 1984 Apr; 24-6.Women in 24 villages throughout Africa are participating in the World Health Organization's (WHO) African Regional Program for Women in Health Development. This program involves women's organizations in primary health care delivery through a system of self-reliant cooperatives that work for rural development. WHO's African Regional Office works with the women's organizations to identify areas where their activities could have an impact, to establish links with government officials, and in project planning and fund raising. Local thrift and credit clubs, state-run cooperative societies, traditional age-grade unions, religious groups, and market women's associations have been identified as potential points of impact. Male elders are drawn into the projects in the preliminary stage in order to break down prejudice and produce unified communalism. To prepare a project proposal, a consultant is sent to live in the village for a 3-week period to learn about the resources and expressed needs of the community. The program has emphasized training that will enable women to plan their own income-generating activities. The most difficult problem has been to motivate the involvement of national and international organizations. The ultimate objective is to turn self-development and self-reliance for promoting health-related projects into permanent features of the village women's social activities. Through the process of participating in health development, African women have realizaed their potential leadership skills and are submerging longstanding sex prejudices.
In: Wood C, Rue Y, ed. Health policies in developing countries. London, England, The Royal Society of Medicine, 1980. 11-7. (Royal Society of Medicine. International Congress and Symposium Series; No. 24)In developing countries systems of "bare-foot doctor" health care are being used. The goal is to provide a health service that is within the reach of each individual and family in the community, is acceptable to participants, that entails their full participation at a cost suitable to the individual and the nation. As opposed to hospital oriented Western medicine, there is usually a health officer from the local community, trained and provided with a dispensary, who returns to the home community. 2 projects in progress which were having negative results, 1 in Zaire and 1 in Senegal, were evaluated. The principles which redirected the programs are discussed. Problems such as mobile centers versus fixed sites for health centers, single aim projects and self-administration of the centers are explored. The acceptance of responsibility by the local public by using funding and resources of its own was judged to run the least risk of failing in the long term. In Senegal a new law on administrative reform was passed which allowed district health committees dealing with about 100,000 people to be set up. With a system of self-financing, more than 500,000 people were treated in 3 years. The fees were modest and 65% of the income from fees was used to keep drug supplies up to date. 3 dangers were identified and overcome: risk of embezzlement by district treasurers, overconsumption of drugs, and stocking excessively expensive products. The basic conditions necessary to provide an efficient network of health services in a rural environment (Zaire) and an urban environment (Senegal) are joint financing of activities through contractual financial participation, local administration, improved medical personnel, standardized medical procedure, and continuous supervision in collaboration with non-professional health workers.
New policies for health education in primary health care. Background document for Technical Discussions Thirty-sixth World Health Assembly, 1983.
Geneva, Switzerland, WHO, 1983 Feb 25. 32 p. (A36/Technical Discussions/1)The 36th World Health Assembly Technical Discussions, which will focus on "New Policies for Health Education in Primary Health Care," seek to support efforts aimed at promoting community involvement and self-reliance, a greater diversity of objectives in policy making, harmonization of national and local plans, and facilitation of intersectoral action and the use of appropriate technology. As a basis for discussion, a 12-step model of the contribution of health education to primary health care strategy is proposed: 1) the movement starts with the people, 2) verification of whether felt needs reflect community issues is obtained, 3) priorities are dilineated, 4) central support comes into play in plan formulation, 5) implementation and coordination of resources begins, 6) action develops and the technology's appropriateness is evaluated, 7) program effectiveness is evaluated, 8) new needs emerge and unused resources are identified, 9) the cycle for increased involvement and self-reliance develops at another level, 10) the community develops new resources, 11) central and local activities are evaluated, and 12) greater involvement of all sectors fills existing gaps and self-reliance is realized. Health education must be supported by policies which: reflect a commitment to the equitable distribution of resources; provide for its integration at stages of the health care process where people's involvement and increased self-reliance requires additional understanding and skills; stress the need for coordination and an intersectoral approach; assign health education responsibilities to all health workers, teachers, and media personnel; provide an institutional framework and economic and legislative supports for increased individual, family, and community responsibility for health and welfare; and specify clearly the fundamental objective of health education and community involvement, i.e., to help each individual, family member, and community to acheive the harmonious development of their physical, mental, and social potential. Development of skilled manpower trained to introduce the educational dimension, linkages of the mass media to the development process, research on priority areas of input, and collaboration with nongovernmental agencies are essential to this process.
Contact. 1983 Oct; (75):1-16.Investigates health planners' assumptions about community particiation in health care. Primary health care aims to make essential health care accessible to all individuals in the community in an acceptable and affordable way and with their full participation. It is the strategy propagated by the World Health Organization to provide health for everyone by the year 2000. Community participation is seen as the key to primary health care and has raised many assumptions and expectations among health planners. Community people are seen as a vast untapped resource which can help to reduce the cost of health care by providing additional manpower. It is also expected that community people want to participate in their own health care because they wish to serve their community and to have a part in decisions which affect them. In the early 1970's, programs were developed out of church-related efforts. They pioneered many of the ideas which became principles of primary health care. The church-related programs were nongovernmental and therefore flexible. They had the same goal of letting the community take responsibility for their own health care; program planners were primarily medical people trained in Western medicine. The planners were concerned with the plight of the poor. However, the programs tended to reflect planners' hopes for, rather than the community's understanding of, the community health problem. The author concludes that the assumptions that planners make about their programs need to be critically analyzed. Investigations need to be made into community perceptions and expectations of their role in health programs. Studies need to be undertaken to identify the potentials and problems of community participation and the record of established community health care programs needs to be examined.
Geneva, World Health Organization, 1983. 105 p.The Inter-regional Seminar on Primary Health Care was held to examine the Chinese system of health care and to consider the lessons that other countries can draw from this unique experience. 4 specific areas were examined: China's 3-level (county, commune, and brigade) health care network, involvement of the people, health manpower development, and financing of rural health care. In China, health is seen as the goal of all sectors, not simply the health sector alone. The organizational structures of the brigades and communes, designed primarily for production, are utilized for health campaigns and other social development projects. The Patriotic Health Campaigns, which emphasize disease prevention and general health promotion, have mobilized people on a large scale and achieved outstanding results in the field of parasitic diseases and vector control. Health manpower development initially placed emphasis on meeting the basic needs of the community, notably through the introduction of new categories such as the barefoot doctor. With the achievement of basic coverage, there was a shift to the upgrading of both the status and professional competence of each personnel category. The degree of decentralization is such that over 80% of health expenditure occurs within the 3-level network system, and 65% at the commune level or below. 4 factors were identified as having contributed to the high level of primary health care in China: 1) political commitment to the task of changing the quality of life of all people, especially the rural population; 2) reorganization of China's social and economic structure, including its decentralization, and the integration of the health sector with all aspects of social and economic development; 3) concerted action in many sectors (e.g., income distribution, family planning, mass education) aimed at improvement of health status; 4) participation of the people in the provision of health services, management of the system, and mass campaigns; and 5) use of appropriate technology. The Chinese experience shows that health for all can be achieved despite limited resources and a low per capita income.
[Geneva, Switzerland], WHO, 1982. 17 p. (HRG/CRU.1/Rev.1/Mtg.1)In 1979, a WHO team collaborated with national personnel in The Gambia in developing a comprehensive primary health care (PHC) plan of action for the period 1980/81 - 1985/86. In his address to the legislature in August, 1980, the president declared that the plan involved the active participation of local communities and emphasized programs for health promotion and disease prevention. This monograph reports on a meeting of the Gambian Ministries of Economic Planning and Industrial Development and of Health, Labor and Social Welfare in June 1982. Improvements in rural health are a basic need. In order to provide PHC, it was fully realized that a strong supportive infrastructure was essential. The village sensitization program was considered as vital for success. Not 1 village has rejected PHC or its responsibilities. The training program for community health nurses, village health workers and traditional birth attendants was proceeding according to plan for the various levels. Recognizaing that an efficient drug supply was essential, concomitant action had been taken to reorganize the central store. Another essential element without which success could not be achieved related to provision of transport and facilities for their maintenance, so that communications could be assured with rural areas. The need for a radio network to link 6 staions and 26 sub-stations was stresses. The list of participants and the agenda are attached as are the requirements for external support for the planned provision of PHC which were considered by the participants of the meeting.