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The hospital in rural and urban districts. Report of a WHO Study Group on the Functions of Hospitals at the First Referral Level.
WORLD HEALTH ORGANIZATION TECHNICAL REPORT SERIES. 1992; (819):i-vii, 1-74.In 1992, the WHO Study Group on the Functions of Hospitals at the First Referral Level compiled a report on the functions of the hospital in rural and urban districts. It advocates that the 1st referral level hospital should be integrated into the district health care system, which is administered by a district health council. This approach strengthens primary health care and uses hospital resources to promote health. The most pressing need for this approach to work is changing people's attitudes and motivation. Various obstacles invariably slow this integration process such as resistance by central and local government officials and inadequate funding. The district hospital should help people to find health rather than just cure disease. Further it must accept the fact that it is not the center of the health system. This means a redistribution of both finance and effort. Governments need to improve the decentralization process to facilitate integration. The study group proposes a step by step methodology to integrate the health system. The 1st step is creating a district health council with representatives from the district health office, the hospital, other sectors of the health care system, and the community. The council determines the community diagnosis including population trends, patterns of morbidity and mortality, and disease and risk distribution by age and location. It also needs to review health services in the district. The council can divide these services into preventive, promotional, curative, rehabilitative, and organizational services. It also must reassess distribution of resources including people, buildings, equipment, and materials. The council must draft a plan and deliberate on implementing the plan. Once the council has taken these steps, it can then implement, monitor, and evaluate the plan and its results.
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.
Targets for health for all. Targets in support of the European regional strategy for health for all.
Copenhagen, Denmark, WHO, Regional Office of Europe, 1985. x, 201 p.This book sets out the fundamental requirements for people to be healthy, to define the improvements in health that can be realized by the year 2000 for the peoples of the European Region of the World Health Organization (WHO), and to propose action to secure those improvements. Its purposes are as follows: propose improvements in the health of the people in order to achieve health for all by the year 2000; indicate where action is called for, the extent of the collective effort required, and the lines along which it should be directed; provide a tool for countries and the Region to Monitor progress toward the goal and revise their course of action if necessary. The targets proposed are intended to indicate the improvements that could be expected if all the will, knowledge, resources, and technology already available were pooled in the pursuit of a common goal. The target levels set are based on historical trends in the fields concerned, their expected future evolution, and the knowledge available on the probable effects of intervention. These levels are intended to inspire and motivate Member States when they are determining their own priorities, targets, and capabilities and thus the degree to which they can contribute to reaching the regional targets. The base year for all the targets in 1980. The year 2000 is the completion data retained for all targets related to health improvements. Targets related to lifestyles, the environment and care respectively have 1990 or 1995 as their date of completion unless specific problems justify the allocation of a later year. Targets embodying measures to bring about the changes in research and health development support should be reached before 1990. The aim is to give people a positive sense of health so that they can make full use of their physical, mental, and emotional capacities. A well informed, well motivated, and actively participating community is a key element to the attainment of the common goal. The focus of the health care system should be on primary health care -- meeting the basic health needs of each community through services provided as close as possible to where people live and work, readily accessible and acceptable to all, and based on full community participation. Health problems transcend national frontiers.
International Journal of Gynaecology and Obstetrics. 1985 Sep; 23(4):247-8.The WHO is certain that the health of mothers and babies can be improved by giving traditional birth attendants (TBAs) special training and support to enable them to carry out their activities with greater safety. This is probably one of the most cost effective approaches to reducing maternal and infant mortality and morbidity. Some workers, however, stress that this approach is inappropriate to the real needs of the impoverished majority. They believe that the real causes of mortality are socioeconomic deprivation, top managerial incompetence and mass illiteracy. In addition to TBA training the WHO suggests strengthening the referral and support system and improvement and wide spread use of appropriate technologies. TBAs have been most successful when trained for a special skill, such as reducing neonatal tetanus. This supplement shows some of the achievements and problems that still exist. The material is presented to gain better understanding of obstetricians and support for simplified maternity care for mothers and babies in rural areas. Obstetricians can influence decision makers who allocate funds for health care to achieve a more equal distribution of resources. The articles are presented as part of a broader program of collaboration between the WHO and the International Federation of Obstetrics and Gynecology (FIGO) in their common objective of improving the health of women and children based on the principles and programs for primary health care. The 2 organizations have joined to form a WHO/FIGO Task Force for the Promotion of Maternal and Child Health (MCH), including Family Planning (FP), and Primary Health Care. The activities of the Task Force are: to put into effect the specific recommendations of the Joint WHO/FIGO workshop; to promote and support the MCH/FP elements of PHC at the national levels; and to promote the transfer, adaptation and further development of appropriate technologies for pregnancy, perinatal and family planning care.
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.
Doctors--barefoot and otherwise. The World Health Organization, the United States, and global primary medical care.
Jama. 1984 Dec 14; 252(22):3146-8.The international effort to provide primary health care (PHC) services for all by the year 2000 requires the development of appropriate manpower resources in the developing countries. Given the limited health budgets of developing countries, research on manpower development is necessary to ensure that funds for manpower development are used in the most efficient manner. In recognition of this need, the World Health Organization (WHO) and the International Organization for Medical Sciences convened a workshop, entitled "Health for All - A Challenge to Health Manpower Development Research" in Ibadan, Nigeria in 1982. The participants at the workshop agreed that manpower development strategies must be developed in the context of PHC, and that the current manpower development strategies in most developing countries do not provide the type of manpower required in PHC systems. Specifically, the workshop recommended that health manpower development strategies must 1) take into account the fact that health improvement is dependent not just on health services but on improvements in sanitation, water, housing, and nutrition; 2) recognize that PHC systems require an extensive cadre of health workers, paramedics, and auxiliary personnel, and that PHC systems are not highly physician dependent; and 3) recognize that medical schools must train physicians capable of serving the needs of the entire population rather than just the needs of the elite few. Participants also recognized that the development of effective strategies may be hindered by various professional, technical, financial, and bureaucratic factors. Given the pressing needs and scarce resources of developing countries, manpower development research must be highly policy oriented. The recommendations of the workshop were endorsed by WHO's Advisory Committee on Medical Research in 1983 and then distributed to WHO's 6 regional offices. The regional offices are currently discussing the recommendations with individual countries in an effort to determine how each country can implement the recommendations. The success of the effort to train appropriate manpower will require the assistance of developed countries and especially the US. The US can assist by providing training in US institutions for individuals from developing countries. Training programs, however, must be reoriented in such a way as to equip students to work in PHC settings. Medical personnel from the US can provide technical assistance in the developing countries, but efforts must made to ensure that this assistance is directed toward the development of PHC prsonnel and services.
[Unpublished] 1984. Presented at the WFPHA (World Federation of Public Health Associations) iv International Congress, "Quest for Community Health; Experiences in Primary Care", Tel Aviv, February 19-24, 1984. 6 p.Discussion focuses on a key aspect of primary health care (PHC) programs -- the training of personnel and includes a review of the current concept of primary care, linking it to the training of community health workers. The World Health Organization (WHO) in its early days had a highly technical orientation. WHO and international agencies generally viewed their role as conveyors of information from 1 country (usually developed) to another (usually less developed). Not until the 1970s were questions asked that concerned all rather than a specific developing country. Most important were questions about coverage of the populations of these countries with wome minimal health service. The rediscovery of China had a difinite impact on the posing of a new type of question. China seemed to demonstrate that a very poor country could achieve virtually universal coverage of its huge population with essential PHC services -- given a high level of political commiment. In 1973 new leadership was elected to WHO and a new look was taken at the WHO constitution. A sequence of insights culminated in the World Health Assembly resolution of 1976 which called on all countries to take action to mak PHC available to their entire population and thenthe dramatic follow-up of this by the Alma Ata Conference on Primary Health Care in 1978. The new strategy was essentially to encourage the concept of the "barefoot doctor." The idea of paramedical or subprofessional health personnel was not new, and these middle medical personnel had quite extensive education, although not university graduates. The challenge was to start with village dwellers, who might be barely literate, but who knew the people and were trusted by them. They should be trained in the local area for 6 weeks to 6 months. The training should provide the trainee with a certain number of practical skills. These individuals are most widely known as community health workers (CHWs). With such limited training, the performance and effectiveness of CHWs depended on their motivation, relationships with the community they serve, the ability to learn from experience, and support by an organized framework in a health system. The organized framework is very important and includes proper supervision, continuing education, available consultation and referral, and some type of compensation. Hundreds of CHW training programs have been developed throughout the world and in the 1980s are undergoing a period of assessment.
Indian Pediatrics. 1983 Apr; 20(4):235-42.This article discusses implementation of the Alma Ata Declaration on primary health care in developing countries, particularly in India. Tasks are outlined in the areas of health indicators, training of health personnel, allocation of resources, integration of traditional health workers, drug policy, and health delivery strategies. The success of the primary health care strategy hinges on the support of the rest of the health system and of other social and economic sectors. Each country will have to specify its own health goals and priorities within the context of overall development policies, particular circumstances, social and economic structures, and political and administrative mechanisms. The training of health personnel, which is an essential part of primary health care, should be geared to the health needs of the community rather than patterned after the health services in developed countries. In particular, greater use should be made of community health workers. Traditional practitioners represent another potential reservoir of personnel for primary health care, and their integration into the modern system of medicine should be organized. The Government of India has adopted a strategy aimed at integrating promotive, preventive, and curative aspects of health care through a decentralized approach that involves the community in planning, providing, and maintaining the health services. 580,000 community health volunteers, as well as 1 traditional birth attendant for each village, are scheduled to be trained. A subcenter with 1 male and 1 female multipurpose worker is planned for every 5000 population; a subsidiary health center staffed by a doctor, 2 health assistants, and 2 multipurpose workers is proposed for every 25,000 population; and a primary health center is proposed for every 50,000 population, with 1 in every 4 centers to be upgraded to a rural hospital. The Integrated Child Development Services (ICDS) program delivers maternal and child health services at the village level. The number of ICDS projects is proposed to be increased to cover 913 of the 5011 community blocks and 87 urban slum areas by 1985.
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.
Public Health Reviews. 1982 Jul-Dec; 10(3-4):223-7.Throughout the world and particularly in the developing and underdeveloping countries the health situation is less than satisfactory. In their report O'Mahoney and Dahlqvist listed 31 countries as being the least developed and with an average life expectancy of 45 years and 200/1000 children born dying within a year. With a world population of 4 billion people, 10 countries in the World Health Organization (WHO) South East Asian region alone have a population of about 1 billion. The common enemies of the population of this region are hunger, poverty, and ignorance. The health problems which are responsible for high morbidity and mortality are protein energy malnutrition, which aggravates the already prevalent common infectious diseases, and gastrointestinal infections due to bacteria and parasites. Tuberculosis, malaria, and acute hemorrhagic fever also require attention. The situation is worsened by very high birthrates (30-40/1000), resulting in high population growth rates (1.8-3.0%) in many countries in this region. The impact of medical care on health, not to mention health coverage, is only temporary. Health depends on a simple effective system within a community whose members are alert to their own health, since the number of professional medical personnnel will never suffice. Health is as much everyone's right as everyone's responsibility. It is essential to gear the education of the health professionals to the true needs of the people. The public requires a new kind of physician who is willing to attack the health needs of a total population and is committed to preventing, promoting, and rehabilitating as well as curing. Physicians need to be concerned with socioeconomic and health problems, and students must be trained to function as members of a larger group of health personnel, i.e., of a health care team. At the 30th World Health Assembly, held in May 1977, it was resolved that primary social target of WHO and its member states should be the attainment by the year 2000 of a level of health that will allow all the worlds' citizens to lead socially and economically productive lives. Essential elements for health as suggested by the Director General of WHO include: adequate food and housing; adequate supply of safe drinking water; suitable waste disposal; maternal and child health and family planning; immunization against major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; health education; and the provision of essential drugs. These are guidelines; each individual country has to work out its own strategies.
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.
In: Bannerman RH, Burton J, Ch'en Wen-Chieh. Traditional medicine and health care coverage: a reader for health administrators and practitioners. Geneva, Switzerland, World Health Organization, 1983. 231-9.This article discusses the status and functioning of the major systems of traditional medicine in Southeast Asia with particular attention to the activities of WHO. Decision regarding traditional medicine taken by health and political authorities in congresses and conferences from 1977 to 1979 are outlined. Intercountry projects to promote traditional medicine including 1 begun by WHO in 1978 and another 1 founded by the United Nations Development Programme in 1982 are described. The major systems of traditional medicine practiced in the region can be classified as 1) formalized systems which include Ayurveda, Siddha, Unani-Tibbi, the chinese system of medicine, and 2) non-formalized, traditional systems of medicine practiced by herbalists, bonesetters, practitioners of thaad (element system), home remedies and spiritualists. In addition yoga, nature cure and homeopathy are being practiced in some countries including Bangladesh and India. Almost all the countries have recognized the traditional systems of medicine and are making efforts to utilize the practitioners in their health care delivery programs. There are at present 750,000 practitioners of traditional medicine in the region. Health programs in Bangladesh, Burma, India, Indonesia, Maldives, Nepal, and Sri Lanka are discussed. Future efforts of WHO in the region will be related 1st, to reorient traditional healers to meet the needs of primary health care; and 2nd to support research on the treatment of diseases for which modern medicine has no cure, such a peptic ulcer, bronchial asthma, rheumatoid arthritis, urolithiasis, viral hepatitis, and diabetes mellitus.
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.