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Seventy-first Session Provisional agenda item 12
G L O B A L S T R A T E G Y F O R H E A L T H F O R A L L B Y T H E Y E A R 2 0 0 0
The Director-General h a s the h o n o u ? to p r e s e n t to the E x e c u t i v e Board for i n f o r m a t i o n the attached draft of a summary of a review of developments in p r i m a r y h e a l t h care e n t i t l e d
"Assessing the M a r c h Towards H e a l t h for A l l " , p r e p a r e d for the forthcoming twenty-fourth session of the UNICEf/wHO J o i n t Committee on H e a l t h P o l i c y .
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WORLD HEALTH ORGANIZATION EB71/INF.D0C./3 ORGANISATION MONDIALE DE LA SANTE JC24/UNICEF-WH0/83.2 UNICEF/WHO JOINT COMMITTEE ORIGINAL： ENGLISHON HEALTH POLICY Twenty-fourth Session G e n e v a , 1-2 February 1983
GLOBAL R E V I E W OF PROGRESS AND I S S U E S , INCLUDING EPI AND CDD:
"ASSESSING THE M A R C H TOWARDS HEALTH FOR ALL"
SUMMARY OF A REVIEW OF DEVELOPMENTS IN PRIMARY HEALTH CARE
CONTENTS
Page
Chapter 1 . INTRODUCTION 3 1.1 Background and aims of the review 3
1.2 The countries reviewed 3
Chapter 2 . POLICIES AND PLANS 4 2.1 Socioeconomic and political realities 4
2.2 D i v e r s i t y of implementation patterns 4
2.3 L e g i s l a t i o n related to PHC 5 Chapter 3 . FINANCING THE PLAN - RESOURCE A L L O C A T I O N S 5
3.1 Allocating financial resources to PHC 5 3.2 Information needs for effective planning 6
3.3 Mechanisms for external support 6 Chapter 4 . O R G A N I Z I N G PHYSICAL RESOURCES FOR PHC 7
4 . 1 Infrastructures 7 4.2 C o v e r a g e , accessibility and referral 7
4.3 A p p r o p r i a t e Technology (AT) 8
4.4 Urbanization and PHC 8 4.5 The role of nongovernmental organizations (NGOs) 9
Chapter 5 . M A N P O W E R - THE PLAN IMPLEMENTORS 9 5.1 M a n p o w e r development and m a n a g e m e n t 9
5.2 The role of intermediate and auxiliary manpower 10
5.3 The nurse and midwife in PHC 10 5.4 Community-based health workers 10
5.5 Physician production 11 5.6 Training needs in PHC 11 Chapter 6 . THE ROLE OF COMMUNITY INVOLVEMENT 11
6.1 Community-level contributions and infrastructure 12
6.2 Managing community involvement 12
The issue of this document does not constitute formal publication. (t should not be reviewed, abstracted or quoted w i t h o u t the agreement of the World Health Organization. Authors alone are responsible for views expressed in signed articles.
Ce document ne constitue pas une publication.
Il ne doit faire l'objet d'aucun compte rendu ou résumé ni d'aucune citation sans l'autorisation de l'Organisation mondiale de la Santé. Les opinions exprimées dans les articles signés n'engagent que leurs auteurs.
Mechanisms for cooperation 23 Experience with national health development networks 24
Intersectoral cooperation 24 Chapter 9 . TECHNICAL COOPERATION BETWEEN COUNTRIES 25
9.1 M o b i l i z i n g to share resources 25 9•2 R e g i o n a l and global support 25 Chapter 10 EVALUATING AND MONITORING PHC 26
10.1 Developing information systems 26 10.2 Approaches and mechanisms for m o n i t o r i n g and evaluation 27
10.3 Using indicators to monitor progress 28
Chapter 11 CONCLUSIONS 29 11.1 The countries reviewed in relation to the global indicators for H F A . . 29
11.2 Operational realities - concluding comments from countries and regions 31 ANNEX 1 . A review of PHC development - the seventy countries reviewed ( m a p ) . . .
ANNEX 2 . Access to water supply and sanitation in 1975 and 1977-79
A N N E X 3 . Estimated coverage for priority immunizations and g r o u p s , by region . . ANNEX 4 . Review of developments in Primary Health Care in 70 countries 1978-1981
34 35 36 37 Chapter 7 . CORE ELEMENTS OF PHC
Health education
Food supply and proper nutrition 7.2.1 Malnutrition
7.2.2 Action for food supply and n u t r i t i o n 7.3
7.4
7.5 7.6
7.7
W a t e r and sanitation
7.3.1 Action for the Decade • M a t e r n a l and child health . . 7.4.1 Progress towards M C H / F P Control of communicable diseases The curative aspects of PHC . • 7.6.1 The diarrhoeal diseases
7.6.2 Parasitic diseases and respiratory infections
Chapter 8 .
Provision of essential drugs 7.7.1 Action on essential drugs 7.8 The role of traditional medicine
7.8.1 Involving traditional m e d i c i n e in PHC
INTRASECTORAL AND INTERSECTORAL COOPERATION - ESSENTIAL DIALOGUES
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CHAPTER 1. INTRODUCTION 1•1 Background and aims of the review
In its twenty-second session in January 1979, the UNICEF/WHO Joint Committee on Health Policy (JCHP) requested that a progress report be prepared on the implementation of primary health c a r e . The progress report (JC23/UNICEF-WHO/81.2) presented to the twenty-third session of the JCHP in 1981， although not a detailed review of all n a t i o n a l and international activities in P H C , did however present a wide sampling of d e v e l o p m e n t s . At that time the JCHP suggested that indicators be developed on information gathered for the purpose of monitoring progress made in the years remaining to the year 2 0 0 0 . The information should
focus on what was happening in c o u n t r i e s .
As part of t h i s , in September 1981 the preparation began of a review of developments in primary health care with the purpose of learning what WHO Member States h a v e d o n e , and are d o i n g , with regard to progress towards the goals of Health for A l l . The m a i n emphasis was on learning from both positive experiences and from some of the problems and constraints encountered in the p r o c e s s . The review did not attempt to assess the present detailed status of PHC development for individual c o u n t r i e s . That can only be done adequately by countries themselves.
What the review did attempt to do was to highlight some of the present trends in the development of PHC and m a k e available to countries shared experiences w h i c h m a y assist them in their own planning and act ion for P H C . The emphasis then was on i m p l e m e n t a t i o n , not status or e f f e c t i v e n e s s .
1.2 The countries reviewed (see шар, Annex 1)
In preparing the review it was not considered possible to review information from all Member S t a t e s . Originally it had been hoped to select countries on the basis of their annual per capita expenditure on h e a l t h . H o w e v e r , as the interpretation of these data w a s unfortunately not uniform for all potential c o u n t r i e s , it was decided to select countries on the basis of the figures relating to Gross National P r o d u c t . A c c o r d i n g l y , 70 countries w e r e chosen in what has been termed the "low income" and "middle income"^ range.^ The 70
countries reviewed represent nearly half (44%) of WHO Member S t a t e s . The 70 countries also contain 64% of the total world p o p u l a t i o n . The review has focused then on that section of the w o r l d1 s presently underserved population which is particularly the target of action for H F A .
In presenting country information on developments in P H C , countries w e r e set within their different WHO regional c o n t e x t s . Information was also included which set countries within a global context of health p r o g r a m m e s , plans and e x p e r i e n c e s .
The present summary report is based m o s t l y on the conclusions of each of the chapters of the review and indicates trends in PHC d e v e l o p m e n t . The m a i n document (several hundred pages long) is available in English in the Division of Strengthening of Health S e r v i c e s , W H O , Geneva (document S K S / 8 2 . 3 ) .
World Development R e p o r t , World B a n k , 1 9 8 1 .
9 • . .
One country in the Region of the Americas (Canada) and one in the European Region (Finland) fall outside of these categories but the inclusion of h i g h e r income countries h a s demonstrated that the same framework for looking at PHC can be used in a variety of countries of differing socioeconomic c o n d i t i o n s . In a d d i t i o n , it has been w i d e l y accepted that the PHC approach is of relevance to all countries in achieving H F A .
CHAPTER 2 . POLICIES AND PLANS
The first section of the review considered p o l i c i e s , plans and legislation relating to PHC d e v e l o p m e n t . What kinds of policies and plans had been formulated; what planning m e c h a n i s m s had been used or suggested； what kinds of PHC targets had been set and on what b a s i s , and w h a t types of legislation had been introduced or p l a n n e d .
2•1 Socioeconomic and political realities
Of the 70 countries reviewed 42 (60%) have been signatories to specific charters and resolutions for H F A . Policies towards this end have also been enunciated by approximately 70% of the c o u n t r i e s . The evidence suggests that the figure could easily have been higher but for the fact that m a n y c o u n t r i e s , still scarred by the wounds of w a r , are needing to turn their at tent ion first to the provision of basic needs such as food• In another group of countries civil strife and displaced p o p u l a t i o n s , often in vast n u m b e r s , are also considered urgent priority p r o b l e m s . Some countries are also having to consider PHC in the context of rapid cultural and industrial p r o g r e s s , Significant elements therefore in these cases include the introduction or adaptation of health insurance schemes, emergency medical and health s e r v i c e s , rehabilitation and industrial m e d i c i n e . Preoccupation with the provision of an adequate health infrastructure emerges clearly from country policy statements and plans for H F A . In some cases these refer to the necessity to repair damaged facilities. In others they refer to the intention of having adequately functioning static and/or mobile health facilities at the peripheral and intermediate levels of the health services.
W h i l e recognizing that in some regions countries have been developing plans and programmes for extension of coverage of health services with primary care arid community participation since the early 1970s, the development of PHC as the major area of action is now m o r e clearly being d e f i n e d , particularly in connexion with the role of health as an integral part of national economic and social d e v e l o p m e n t .
2•2 Diversity of implementation patterns
In some countries PHC is seen as the basis for the whole national health strategy. In others it is one component of a health p o l i c y , as for example where it is implemented in a pilot area in a rural or peri-urban area for later adoption on a wider scale. Methods employed to advance the adoption of PHC have included country health programming, the introduction of PHC planning units in Ministries of H e a l t h , the creation of Institutes of Rural Health T e c h n o l o g y , the creation of PHC C o u n c i l s , district management teams and PHC c o o r d i n a t o r s , and devolution of responsibility for PHC to local government level with the M i n i s t r y of Health providing logistical and technical support. In some countries the m e t h o d s of PHC implementation have followed closely the traditional patterns of leadership and social o r g a n i z a t i o n . In others new patterns of social organization have determined the m e t h o d s of implementation. The need is recognized to establish PHC support mechanisms at n a t i o n a l , provincial and district level. This may involve extensive decentralization and/or realignment of a w h o l e health system. What is visualized by some countries is a new and standardized hierarchy of health services adapted to the country's real needs and allowing for the integration of health and development a c t i v i t i e s .
Effective planning for PHC necessitates cooperation with other technical and
administrative d i v i s i o n s . Some countries have established national health councils with representatives from other m i n i s t r i e s . A closer relationship is sought between health
planning and development p l a n n i n g , optimally linked closely to the political leadership. In one country a decision-making process based on programme budgeting and formal planning has been able to change the trends in resource distribution between the hospital and PHC s e c t o r s . The diversity of country planning m e t h o d o l o g i e s , definitions of objectives and t a r g e t s , and selection of country-specific indicators for monitoring and evaluation,
necessarily complicate regional definitions of strategies and objectives. For example in a region the same targets may appear modest in countries which have already overtaken them, or overambitious in o t h e r s . Their m a i n value may lie not so much in their numerical expression as in the attempt to promote studies and discussions leading to definitions considered closer to reality by all i n v o l v e d .
2.3 L e g i s l a t i o n r e l a t e d to P H C
A n u m b e r of c o u n t r i e s are in the p r o c e s s of introducing or u p d a t i n g legislation relating to e x i s t i n g h e a l t h p o l i c y - m a k i n g o r g a n i z a t i o n s or the i n t r o d u c t i o n of n e w o n e s , the
n a t i o n a l i z a t i o n of h e a l t h c a r e , m e t h o d s of a l l o c a t i o n of f i n a n c i a l r e s o u r c e s ,
p h a r m a c e u t i c a l s , t r a d i t i o n a l m e d i c i n e， h e a l t h m a n p o w e r , h e a l t h p l a n n i n g and r e o r g a n i z a t i o n of h e a l t h i n f r a s t r u c t u r e , c o n t r o l of foodstuffs and b r e a s t - m i l k s u b s t i t u t e s , w a t e r and e n v i r o n m e n t a l h e a l t h , p u b l i c h e a l t h , c o n t r o l of c o m m u n i c a b l e d i s e a s e s , m e n t a l h e a l t h , c o m p u l s o r y i m m u n i z a t i o n , c o o r d i n a t ion of the M i n i s t r y of H e a l t h w i t h the social security s y s t e m , and the r e g i s t r a t i o n of b i r t h s and d e a t h s .
C H A P T E R 3 . F I N A N C I N G THE P L A N 一 R E S O U R C E A L L O C A T I O N
F i n a n c i a l c o n s t r a i n t s to PHC are b e i n g e x p e r i e n c e d in m a n y c o u n t r i e s , with u r b a n - b a s e d and c u r a t i v e c a r e c o n t i n u i n g to absorb d i s p r o p o r t i o n a t e amounts of the a v a i l a b l e h e a l t h b u d g e t . Some of the small c o u n t r i e s p a r t i c u l a r l y are h e a v i l y d e p e n d e n t financially on the p r o d u c t i o n of single crops and are affected by the u n c e r t a i n t i e s of w o r l d c o m m o d i t y prices or r e l i a n c e on e x t e r n a l a s s i s t a n c e .
G l o b a l l y , in 25 least d e v e l o p e d c o u n t r i e s for which recent figures are a v a i l a b l e , the a v e r a g e public h e a l t h e x p e n d i t u r e is US$ 2.6 per head per y e a r . T h e e x p e n d i t u r e in these c o u n t r i e s ranges from US$ 1 to US$ 12: h o w e v e r , 23 out of these 25 c o u n t r i e s spend less than US$ 2 per head per year on h e a l t h . In 85 other d e v e l o p i n g c o u n t r i e s the average public h e a l t h e x p e n d i t u r e amounts to US$ 17 per head per y e a r . The range for these c o u n t r i e s is
from US$ 1 to US$ 9 4， but 65 out of the 85 spend less than US$ 8 per head per y e a r . In 28 d e v e l o p e d c o u n t r i e s , the a v e r a g e is US$ 277 : the range for these c o u n t r i e s is from US东 4 8 to US$ 6 4 4 . H o w e v e r , 26 out of the 28 spend less than US$ 252 per head per y e a r .
3•1 A l l o c a t i n g f i n a n c i a l r e s o u r c e s to PHC
In the countries r e v i e w e d f i n a n c i a l r e s o u r c e s a v a i l a b l e to the public h e a l t h sector are limited in relation to a l l o c a t i o n s to other d e v e l o p m e n t s e c t o r s . Some c o u n t r i e s , for e x a m p l e , have embarked on a g r o - b a s e d and i n d u s t r i a l reforms with a m a j o r p o r t i o n of the n a t i o n a l resources b e i n g invested in t h e s e , and less regard being paid to the social s e c t o r including h e a l t h . D e s p i t e plans to reorient the health sector to improve s e r v i c e s ,
p a r t i c u l a r l y for rural arid p e r i - u r b a n p o p u l a t i o n s , the rate of p r o g r e s s is severely limited b y the shortage of f i n a n c i a l r e s o u r c e s , m o s t of those w h i c h are a v a i l a b l e are o f t e n still being channelled into u r b a n - c e n t r e d , c u r a t i v e - o r i e n t e d c o m p o n e n t s of the health s e c t o r .
In countries w h e r e p u b l i c spending on health services is p r e s e n t l y a p p r o x i m a t e l y US$ 2-3 per c a p i t a per a n n u m , a d d i t i o n a l r e q u i r e m e n t s for PHC m a y be of the order of US$ 10 per c a p i t a per annum for r e c u r r e n t e x p e n s e s on e x t e n s i o n s of h e a l t h and m e d i c a l s e r v i c e s , e x c l u s i v e of o p e r a t i o n and m a i n t e n a n c e costs for w a t e r supplies and w a s t e d i s p o s a l , and of other i n t e r s e c t o r a l aspects of P H C . On the b a s i s of the a b o v e , it can be further e s t i m a t e d that the average a n n u a l r e s o u r c e gap w i l l be of the order of US$ 50 000 m i l l i o n (US$ 12.5 per head times the average e x p e c t e d p o p u l a t i o n of the d e v e l o p i n g c o u n t r i e s b e t w e e n n o w and the y e a r 2 0 0 0 ) . If 80% of this s u m can be found in developing c o u n t r i e s t h e m s e l v e s , the r e s i d u a l d e f i c i t to the m a g n i t u d e of US$ 10 000 m i l l i o n a n n u a l l y is still three times the p r e s e n t level of i n t e r n a t i o n a l t r a n s f e r s .
Evidence i n d i c a t e s , h o w e v e r , that in the A f r i c a n R e g i o n , for e x a m p l e , according to specific studies and c a l c u l a t i o n s， some c o u n t r i e s do c o n s i d e r that they have the p o t e n t i a l , w i t h e x t e r n a l c o o p e r a t i o n , to c o n f r o n t the costs of implementing the H F A s t r a t e g y . In the
South-East Asia R e g i o n it is c o n s i d e r e d that with the a d d i t i o n a l e x p e n d i t u r e of 1% to 2% of the a n n u a l per c a p i t a G N P , t o g e t h e r with e x t e r n a l f u n d i n g , a decent level of h e a l t h could be attained based on PHC by the y e a r 2 0 0 0 . I n t e r n a t i o n a l c o m p a r i s o n s using economic indicators are d i f f i c u l t in that some c o u n t r i e s use the G N P , others the G D P (gross domestic p r o d u c t ) or G N I (gross n a t i o n a l i n c o m e ) or G D I (gross d o m e s t i c income) for e x p r e s s i n g the share of h e a l t h ； and the d e f i n i t i o n (and a c c o r d i n g l y the a m o u n t ) is d i f f e r e n t in v a r i o u s c o u n t r i e s . N e v e r t h e l e s s the bulk of i n f o r m a t i o n from c o u n t r i e s included the p e r c e n t a g e of GNP spent on or a l l o c a t e d to h e a l t h .
3•2 Information needs for effective planning
The need is recognized to develop a m e t h o d o l o g y for classifying financial information, and identifying low-cost m e t h o d s of collecting it, aimed at facilitating the analysis of the existing situation in order to plan for action toward H F A o b j e c t i v e s . I n f o r m a t i o n is rarely available regarding total expenditure of other health-related sectors and a c t i v i t i e s , as for e x a m p l e , e d u c a t i o n , social security a g e n c i e s , n o n g o v e r n m e n t a l organizations and private sector s p e n d i n g . For an adequate estimation of health e x p e n d i t u r e information is also needed regarding health insurance o r g a n i z a t i o n s , outlays relating to n u t r i t i o n , w a t e r , s a n i t a t i o n , health e d u c a t i o n , m a n p o w e r t r a i n i n g , health r e s e a r c h , and payments in kind for health p u r p o s e s , as for example in the case of traditional birth a t t e n d a n t s . Private health practice often escapes any form of q u a n t i f i c a t i o n . Costs for some areas of PHC development w e r e available but in a piecemeal f a s h i o n . These included water and s a n i t a t i o n ,
immunization and d r u g s , m a l a r i a c o n t r o l , community level m a n p o w e r c o s t s , and i n f r a s t r u c t u r e . At country level the need is recognized to seize all opportunities to gain support for health from economic planners and institutions by convincing them that health is an integral and e s s e n t i a l part of general d e v e l o p m e n t . Also the specific goals and strategies of PHC m a y not be fully understood by the public at l a r g e , or at all levels of the health s e r v i c e s , and the benefits of PHC m a y even be attributed to services w h i c h are still largely
c u r a t i v e . Demand for curative care then i n c r e a s e s . In reality resource allocations for health are frequently decided by m a n y factors other than the real needs of the m a j o r i t y of the p o p u l a t i o n . The need is also recognized to m a k e the m o s t efficient use of existing resources both within and among c o u n t r i e s . W h i l e a substantial and major shift of resources w i t h i n countries may be u n l i k e l y , what can be expected is that real increases in resources should be predominantly directed to PHC a c t i v i t i e s .
M i n i s t r i e s of health in various countries are engaged in analysing needs in terms of c o s t s , m a t e r i a l s , and i n f r a s t r u c t u r e . They are also assessing the relative costs and benefits of alternative systems and t e c h n o l o g i e s , in addition to estimating the total financial resources necessary for strategy i m p l e m e n t a t i o n . The securing of financial resources will include obtaining external resources and c o n s i d e r a t i o n of alternative f i n a n c i n g , including for example the use of social security f u n d s . H o w e v e r , in the experience of the Region of the Americas ministries of health m a y h a v e little control over such f u n d s , and the programmes are often c u r a t i v e - o r i e n t e d . In addition some groups of the rural and poorest urban population help finance social security systems without receiving any b e n e f i t s . H o w e v e r , given a redefinition of policies and r o l e s , such systems have a
p o t e n t i a l l y constructive role to p l a y . Country m e c h a n i s m s for the m o b i l i z a t i o n of e x t e r n a l resources and their rational utilization w i l l be structured to incorporate monitoring
activities such as annual reviews and workshops to assess p r o g r e s s . 3•3 M e c h a n i s m s for external support
At global and regional levels attempts are being m a d e to rationalize the use of r e s o u r c e s , especially financial resources and to m o b i l i z e a d d i t i o n a l support for country strategies for H F A . One initiative is the Health Resources Group for Primary Health C a r e , w h i c h brings together country representatives and those from bilateral and m u l t i n a t i o n a l a g e n c i e s . The group has carried out country resource u t i l i z a t i o n reviews in nine
c o u n t r i e s . Systematic m e a s u r e s are being taken at international level to convince b a n k s , f u n d s , and m u l t i l a t e r a l and bilateral agencies to adopt firm policies of providing grants and loans for the HFA s t r a t e g y , in recognition of its contribution to h u m a n d e v e l o p m e n t .
R e g i o n a l mechanisms are being established to identify strategy needs and facilitate
m o b i l i z a t i o n of funds, as w e l l as transfers between c o u n t r i e s . Regional action has included the establishment of specific regional resource groups which include development b a n k s . Regional m e e t i n g s and workshops h a v e been h e l d . W H O is supporting research in this area in addition to m a n p o w e r training and the collection and dissemination of i n f o r m a t i o n .
At regional level the constraints have been emphasized of producing a quantified financial projection for a 20-year p e r i o d , complicated further by the uncertainties characterizing global economic a f f a i r s . In one region comparative m e t h o d s of financial estimation have been carried out using country examples and emphasizing the components central to P H C . In another region countries have participated in feasibility studies to
establish alternatives for p h y s i c a l infrastructure d e v e l o p m e n t projects and facilitate their e x t e r n a l f u n d i n g . Countries have b e e n assisted in improving the financial a d m i n i s t r a t i o n of their h e a l t h services and advised on h o w to secure e x t e r n a l l o a n s . C o o r d i n a t i o n has also been improved among regional financial agencies operating in the health f i e l d , and a d d i t i o n a l assistance requested from n o n - t r a d i t i o n a l s o u r c e s .
The importance of r e o r i e n t i n g cooperation activities is e m p h a s i z e d , to avoid d i s t o r t i o n s , d u p l i c a t i o n or gaps in p r o g r a m m i n g . This r e o r i e n t a t i o n of i n t e r n a t i o n a l c o o p e r a t i o n needs to be based on the n a t i o n a l analysis and p r o g r a m m i n g of e x t e r n a l
c o o p e r a t i o n requirements w i t h i n the framework of n a t i o n a l p r i m a r y care s t r a t e g i e s . It c a l l s for the development of c o o r d i n a t i o n and coopérât ion m e c h a n i s m s b e t w e e n the various
institutions of the s e c t o r , the n a t i o n a l economic and social planning u n i t s , and o t h e r n a t i o n a l agencies responsible for the programming and c o o r d i n a t i o n of e x t e r n a l c o o p e r a t i o n . These n a t i o n a l a n a l y s e s , evaluations arid p r o g r a m m i n g a c t i v i t i e s w i l l facilitate the
reorientation of policies and the c o o p e r a t i o n and c o o r d i n a t i o n activities of the United Nations a g e n c i e s , the b i l a t e r a l agencies and n o n g o v e r n m e n t a l o r g a n i z a t i o n s .
Some of the d e v e l o p m e n t a l a g e n c i e s , w h i l e u n d e r l i n i n g their k e e n n e s s to assist h e a l t h development p r o g r a m m e s , h a v e acknowledged their l i m i t a t i o n s . Some of these relate to the internal working of the a g e n c i e s , b u d g e t a r y c y c l e s , a d m i n i s t r a t i v e p r o c e d u r e s , and policy c o n s t r a i n t s . Some relate to impediments such as the health sector not h a v i n g a role in decision-making regarding the acceptance of external a i d .
CHAPTER 4 . O R G A N I Z I N G P H Y S I C A L R E S O U R C E S FOR PHC
Health services in m a n y countries have been structured according to p o l i t i c a l systems and dictates of policy which often reflect their historic a n t e c e d e n t s . Often in the past curative services w e r e generally u r b a n - c e n t r e d and r u r a l services w e r e largely r e s t r i c t e d to attempts to contain m a j o r e p i d e m i c s . In m a n y countries it is only in the p o s t - i n d e p e n d e n c e era that nationwide health services have b e e n o r g a n i z e d .
4.1 Infrastructures
The infrastructures described for PHC varied w i d e l y . In some cases w h o l e n a t i o n a l infrastructures w e r e described as being in support of P H C , O t h e r d e s c r i p t i o n s w e r e limited to PHC pilot areas or m o b i l e s e r v i c e s . Some c o u n t r i e s detailed plans for the future
development and strengthening of their infrastructures through n e t w o r k s c o m p r i s i n g d i s p e n s a r i e s , c l i n i c s , dressing s t a t i o n s , health s t a t i o n s , h e a l t h p o s t s , M C H u n i t s , PHC
u n i t s , specialized s e r v i c e s， m a t e r n i t y p o s t s , family life c e n t r e s , community w e l f a r e c e n t r e s , health centres and several categories of purpose-designed h o s p i t a l s . Some c o u n t r i e s
indicated that e x i s t i n g peripheral level h e a l t h infrastructures are being upgraded and that peripheral hospitals are being s t r e n g t h e n e d . From the information a v a i l a b l e it w a s
difficult to perceive the true extent and development of the primary level i n f r a s t r u c t u r e , or its equipment and m a i n t e n a n c e . In one region a training centre had been o p e n e d , and in another an inter-country project had b e e n initiated for repair and m a i n t e n a n c e of
electromedical e q u i p m e n t . While rigid facilities and equipment standards w e r e not considered appropriate due to n a t i o n a l and local d i f f e r e n c e s , the need was indicated for general guidelines based upon identification of the tasks to be performed at each level of the health s y s t e m . T h e health transport infrastructure was m e n t i o n e d as being e s s e n t i a l to adequate support for the delivery of P H C . Some countries m e n t i o n e d u p g r a d i n g in this
respect through the e s t a b l i s h m e n t of vehicle m a i n t e n a n c e repair units at c e n t r a l and provincial levels and technical assistance for training and m a n a g e m e n t .
4•2 C o v e r a g e， a c c e s s i b i l i t y and referral
There was considerable variation regarding the coverage e x p e c t a t i o n of PHC first level u n i t s . The range included one unit to 4000 people in a radius of 10 m i l e s in Sudan； one unit for 5000 in a radius of 4 miles in Pakistan； 500 people to one c o m m u n i t y w e l l - b e i n g centre in a radius of 10 km in Zaire； 15 000-20 000 people per PHC post in a radius of 20 km
in U p p e r Volta； one rural health post to less than 2000 in Nicaragua； one rural health unit to 10 000 p o p u l a t i o n in Egypt； d i s p e n s a r i e s arid m a t e r n i t y units to 4000 in the Lao People's D e m o c r a t i c Republic； one aid post per 5 0 0 - 2 0 0 0 in Papua New G u i n e a . (In the last four e x a m p l e s the radius w a s n o t m e n t i o n e d . ) In some instances c o v e r a g e was expressed in terms of goals since it was not always clear w h a t p r o p o r t i o n of units was in fact o p e r a t i o n a l . Several c o u n t r i e s gave specific indications of present coverage of p o p u l a t i o n w i t h h e a l t h s e r v i c e s . The range included 35% in L i b e r i a， 30% in M o z a m b i q u e , 60% of the total p o p u l a t i o n in H o n d u r a s， 75% in the D o m i n i c a n R e p u b l i c， 40% in C o l o m b i a , 86% in B u l g a r i a， two thirds in the Lao P e o p l e ' s D e m o c r a t i c R e p u b l i c， 25% (with Basic Health U n i t s ) in B h u t a n , 50% in the t o w n s h i p s of B u r m a , 80% in the rural areas of T h a i l a n d， and 73% of the total population in S r i L a n k a . Some countries reported coverage c o n s t r a i n t s , particularly regarding refugees and nomad p o p u l a t i o n s .
L i t t l e i n f o r m a t i o n w a s a v a i l a b l e regarding a c c e s s i b i l i t y . H o w e v e r , some of the m a i n r e a s o n s w h y existing h e a l t h facilities w e r e said to be rendered inaccessible included g e o g r a p h i c and seasonal o b s t a c l e s , lack of c o m m u n i c a t i o n s systems and economic and
s o c i o c u l t u r a l f a c t o r s . Linked to the issue of accessibility was that of e s s e n t i a l d r u g s supply in that the latter often d e t e r m i n e d w h e t h e r there was really a c c e s s i b i l i t y to the t r e a t m e n t p r e s c r i b e d . Some c o u n t r i e s indicated the existence of w e a k n e s s e s in the r e f e r r a l s y s t e m s , and alluded to the fact that integration of PHC at all levels of the health services had not yet b e e n a c h i e v e d . R e g i o n a l action regarding health facilities has included
r e g i o n a l p r o g r a m m i n g for their d e v e l o p m e n t and m a i n t e n a n c e , and the development and
r e m o d e l l i n g of primary level i n f r a s t r u c t u r e in c o n j u n c t i o n with the expansion and o r i e n t a t i o n of s u p p o r t i n g secondary and tertiary f a c i l i t i e s . S i t u a t i o n a l analysis has also taken place r e g a r d i n g the p l a n n i n g , d e s i g n , c o n s t r u c t i o n , equipping and m a n a g e m e n t of hospitals and other h e a l t h f a c i l i t i e s . One region emphasized the need to strengthen primary facilities in order to r e l i e v e the h o s p i t a l s of demands which could be better and possibly m o r e e c o n o m i c a l l y s a t i s f i e d e l s e w h e r e . A n o t h e r region alluded to the tendency towards consolidating smaller h e a l t h c e n t r e s or p o l y c l i n i c s , w i t h c o m m u n i t y involvement in m a i n t a i n i n g a larger and better e q u i p p e d h e a l t h c e n t r e . W o r k s h o p s h a v e b e e n held in some regions on health services
p l a n n i n g , m a n a g e m e n t , and c o m m u n i t y involvement and education regarding the proper use of h e a l t h f a c i l i t i e s .
4 • 3 A p p r o p r i a t e T e c h n o l o g y (AT)
A q u a r t e r of the c o u n t r i e s reviewed provided information on the o r g a n i z a t i o n ,
d e v e l o p m e n t and constraints connected w i t h a p p r o p r i a t e technology for P H C . Some c o u n t r i e s had b e e n involved with the p r i n c i p l e s and p r a c t i c e s of AT for m o r e than two decades : for o t h e r s it w a s a relatively new d e p a r t u r e . C o u n t r y - l e v e l AT action had included the s e t t i n g - u p of pilot p r o j e c t s , d e m o n s t r a t i o n u n i t s , intersectoral AT groups to develop t e c h n i q u e s and equipment for training c o m m u n i t y w o r k e r s , the compiling of n a t i o n a l
i n v e n t o r i e s of A T , the h o l d i n g of e x h i b i t i o n s and w o r k s h o p s , the e s t a b l i s h m e n t of committees for A T and the identification of institutes to serve as focal points for the c o l l e c t i o n , c o l l a t i o n and d i s s e m i n a t i o n of information relating to A T , and the e s t a b l i s h m e n t of resource c e n t r e s . Examples w e r e provided of specific l o w - c o s t , s a f e , a c c e p t a b l e and effective t e c h n o l o g i e s , particularly regarding oral r e h y d r a t i o n , improved water s u p p l i e s , s a n i t a t i o n , food s t o r a g e and p r e p a r a t i o n , solar r e f r i g e r a t i o n , and the provision of primary-level
e q u i p m e n t such as clay fetal s t e t h o s c o p e s . The need was seen for n a t i o n a l collections of AT i n f o r m a t i o n to assist d i f f e r e n t health p o l i c y - m a k i n g levels in realizing its importance in a c h i e v i n g greater coverage w i t h P H C . T r a i n i n g was recommended in AT for health and h e a l t h - r e l a t e d m a n p o w e r . The need was e m p h a s i z e d for coordinated b i o m e d i c a l and service r e s e a r c h and for m e c h a n i s m s for p l a n n i n g , supervising and evaluating A T , The activities of the g l o b a l p r o g r a m m e to promote AT h a v e included the c o l l e c t i o n , c o l l a t i o n and d i s s e m i n a t i o n of i n f o r m a t i o n , assistance to countries in identifying n e e d s , the e s t a b l i s h m e n t of guidelines to e n c o u r a g e and support A T d e v e l o p m e n t , the h o l d i n g of interregional w o r k s h o p s and s e m i n a r s , and p r o m o t i o n of T e c h n i c a l C o o p e r a t i o n among D e v e l o p i n g Countries (TCDC)•
4.4 U r b a n i z a t i o n and PHC
T h e factor of r a p i d l y expanding urban p o p u l a t i o n s was reported by over 10% of the c o u n t r i e s reviewed and is known to exist in m a n y o t h e r s . The implications for PHC of u n c o n t r o l l e d urban growth w e r e reported as : overwhelming demands on existing health
facilities, available sanitation and water supplies； pollution and other environmental problems； inadequate housing； unemployment; and increased poverty in terms both of physical health and the basic material essentials necessary to sustain even a minimally acceptable standard of living. Some country plans were outlined relating to the control of future u r b a n i z a t i o n . These included the establishment of "community villages" and satellite towns as the nuclei of future urban centres for agricultural and industrial development, and the introduction of urban living patterns which include housing units with vegetable-growing facilities.
Country-level action for urban PHC has included the training of community level m a n p o w e r , workshops for community leaders, the introduction of day-care centres, the upgrading of existing health facilities, and the introduction of nutrition programmes and cottage industry training. Multidisciplinary health teams are advocated, capable of providing continuity of health care and long-term monitoring of individuals and families.
D e c e n t r a l i z a t i o n , better planning, m a n a g e m e n t , intra- and intersectoral coordination are also a d v o c a t e d . Health centres are being used to provide entry points for integrated health and development activities• Somç countries emphasized the need to develop industrial and
emergency health facilities and occupational health and rehabilitation services. High-risk, underserved and unserved population groups are being identified, and further studies were recommended to obtain urban profiles, to review or introduce legislation as necessary, and to determine the patterns of existing urban health infrastructure and health care utilization.
4•5 The role of nongovernmental organizations (NGOs)
Little information was available from the countries reviewed regarding the often substantial nongovernmental contribution to the health sector. NGOs have had long
experience in pioneering PHC activities, and their present and future role in PHC development was seen to include collaboration in the formulation of HFA policies and plans of action, a continuing emphasis in their traditional role of deploying health resources in favour of the disadvantaged sections of the population， representation of community-level needs and
opinions at various levels of the national health systems, and the sharing of experiences in the future development of PHC activities through mechanisms such as health councils and networks in order to incorporate successful small-scale approaches and practices, where appropriate, into nationwide programmes• In over a third of the countries reviewed national-level agencies exist to coordinate NGO activities with those of the health
services. Commitment to national HFA strategies m a y , however, require in the case of some NGOs the resetting of priorities or an incorporation of increased PHC into their normal activities.
CHAPTER 5 . MANPOWER - THE PLAN IMPLEMENTORS
In order to effectively implement HFA/2000 policies and plans, countries emphasize that it is necessary to have a wide variety of appropriate and sufficient manpower from
professional to community level.
5•1 Manpower development and management
Despite the existence of national plans for health manpower development, few countries appeared yet to have evolved specific national health manpower policies covering such issues as overcoming prevailing manpower imbalances, developing career structures, rationalizing migration of m a n p o w e r , and developing team approaches in training. T h u s , a division often remains between health manpower development and health service delivery. What was advocated was concurrent development of health services and health m a n p o w e r .
Various steps have been taken by countries to improve coordination, as for example the introduction of national-level coordinating mechanisms such as health manpower offices or units within ministries of h e a l t h , interministerial collaboration, or provineial-level coordination effected through federal committees which include representatives of services
and training. The variety of national manpower development plans includes the creation and expansion of manpower training institutions for all categories of health m a n p o w e r , the training of trainers, continuing education, and revision of training c u r r i c u l a .
Little information was available regarding health manpower m a n a g e m e n t . The symptoms of inadequate management were identified as uneconomic utilization and inadequate productivity of staff, imbalances in overall composition of the health labour force and inequitable geographic distribution. Improper management was said to stem largely from improper planning. Steps are being taken in a few countries to improve career development in order to increase productivity and job satisfaction, despite a continuing excessive emphasis on paper qualifications.
The health manpower distribution pattern varied considerably among the countries reviewed. In most countries the professional categories were largely urban-based; in others there was a relative scarcity of middle-level personnel; others continued to encounter difficulties in meeting their manpower needs in all categories. Ratios of specific health manpower to population also varied interregionally and within countries themselves. Manpower development plans are aimed in some countries at increasing
middle-level personnel to ensure adequate supervision, training and logistics in connexion with increases in the use of community-based health workers； 1 per 500-1000 population often being the ratio sought. In the Region of the Americas for example, of the additional
million health workers required by 1990, 65% are envisaged as being auxiliary personnel, 25%
technicians, and 15% physicians.
5•2 The role of intermediate and auxiliary manpower
Increases in a wide range of intermediate and auxiliary manpower are envisaged by many countries to extend coverage to deprived populations. This category of health manpower often takes full responsibility for significant and vital health tasks and is relied on to staff PHC services. Some are specialized in such fields as environmental h e a l t h , maternal and child h e a l t h , and family planning. The development of training curricula is being related to the specifics of each country's own h i s t o r y , characteristics, c u l t u r e , needs and resources. Some countries report insufficient training facilities. Mechanisms are needed by which intermediate and auxiliary manpower can express themselves regarding expectations, needs, rights and constraints.
5•3 The nurse and midwife in PHC
Nurses and midwives of various categories are continuing in many countries to provide the greater part of PHC within the health services. Despite the often traditional
institution-oriented characteristics of some nursing structures, national nurses1
associations in some countries have established committees to develop and m o n i t o r
strategies. Present nursing roles include assessing the health status of individuals and communities, community mobilization for involvement, provision of integrated health care including treatment of emergencies and referrals, maintaining epidemiological surveillance, training and supervising other health w o r k e r s , collaborating with other development sectors, and monitoring progress in P H C . In some countries nurse training curricula have been
revised in line with their actual or potential role in P H C . Some nurses are also receiving training as community health practitioners to provide health services at the p e r i p h e r y . 5.4 Community-based health workers
The vast majority of the countries reviewed are using community-based health workers as part of their PHC strategy, but the information available does not clearly show the scope of their deployment despite some specific indications of large-scale national plans: for example, in Burma where 13 000 will be produced in five years, or India, w h e r e , since 1977, 183 750 community health volunteers have been trained. Extensive experience has been gained regarding community-health-worker training in producing appropriate training curricula, materials and trainers. H o w e v e r , there was little evidence of the continuing training and career advancement of community-based health w o r k e r s , and few results of their educational role relating to social change were given. Existing studies had tended to focus on the effectiveness of their technical health skills, especially those of traditional birth attendants.
Teamwork for PHC is emphasized by most countries - some of which have achieved increased nationwide coverage by the deployment of health teams - and the use of community-based health w o r k e r s . In some training centres all members of the health team, for example from the physician to the medium-grade technician, receive common t r a i n i n g . Personnel from other s e c t o r s , such as agronomists, sociologists and community development o f f i c i a l s , have also been included.
5.5 Physician production
There were wide variations regarding the rate of physician p r o d u c t i o n , r a n g i n g , for e x a m p l e , from 196 000 estimated as graduating in the Region of the Americas over the next six years (which exceeds the optimally stated number) through approximately 1000 produced
annually in N i g e r i a , to Zambia where it was reported unlikely that even a quarter of the national needs for physicians would be met by the year 2000 at the current rate of
production. Little information was available regarding the role of the physician in P H C , for example as relating to teamwork.
In recognition of the need to reorient medical education to the goals of H F A / 2 0 0 0 , curricula have been reviewed and innovations implemented. In India these include the involvement of medical colleges with health programmes in the surrounding a r e a , the spending of half of the last year of m e d i c a l studies in a second country in order to focus on social medicine and preventive and educational activities relating to PHC in rural a r e a s , and the
incorporation of the social and behavioural sciences into specific m e d i c a l education
programmes. In 1979 the Network of Community Oriented Educational Institutions for Health Sciences was established, to support or strengthen schools already engaged in or committed to such an approach. Research topics advocated in manpower development include stimulation of health workers to continue their education, assessment of training effectiveness and optimum
length of training, evaluation of teaching m a t e r i a l s , and effective dissemination of research findings•
5.6 Training needs in PHC
In order to respond to training needs for PHC d e v e l o p m e n t , a range of appropriate educational materials has been produced. These include WHO m a n u a l s in several l a n g u a g e s , and locally produced or adapted manuals - some entirely in pictures for TBAs who are not literate. In some countries the ministry of health is facilitating the distribution of these materials to training c e n t r e s . The need is recognized for teacher training for all levels of health m a n p o w e r . National and regional workshops and meetings have been held；
some regions have developed networks of training c e n t r e s . Emphasis is also being placed on training health personnel in health m a n a g e m e n t , particularly planning and e v a l u a t i o n , and on orienting health manpower at all levels to P H C . National initiatives in this respect have included the holding of provincial and district-level seminars.
CHAPTER 6 . THE ROLE OF COMMUNITY INVOLVEMENT
The antecedents of community involvement for HFA include traditional patterns of self-help, experience of the community development approach in past d e c a d e s , the use of awareness-creating educational techniques for development, and the PHC orientation as adopted at Alma-Ata in 1978.
Presently, both community participation and involvement^ are viewed by countries in a variety of w a y s . These include the notion of "dialogue" for health development；
needs-identification devices； methods of improving health services organization； and the
1 The term "community involvement1 1 in health is currently used by WHO to describe a process in which partnership is established between government and local communities in planning and implementation of health activities in order to benefit from increased local self-reliance and social control over primary health care infrastructure and t e c h n o l o g y .
idea of involvement being just one component or part of a health d e v e l o p m e n t strategy rather than the philosophy and approach that suffuses the total s t r a t e g y . Community involvement is a l s o regarded in some c o u n t r i e s as itself the r e s u l t of a new political c o n s c i o u s n e s s .
S t r a t e g i e s and approaches in PHC development and community involvement vary then from country to c o u n t r y 一 or even w i t h i n a c o u n t r y .
6•1 C o m m u n i t y - l e v e l c o n t r i b u t i o n s and i n f r a s t r u c t u r e
In m a n y of the countries reviewed community p a r t i c i p a t i o n and involvement h a v e included c o n t r i b u t i o n s of l a b o u r , m a t e r i a l and financial r e s o u r c e s , and the m o b i l i z a t i o n and/or use of c o m m u n i t y level o r g a n i z a t i o n s . In N e p a l， for e x a m p l e , land has been donated for the
c o n s t r u c t ion of w a t e r s u p p l i e s，g r a i n s t o r e s , m a r k e t places and roads； in Gambia a
l a b o r a t o r y and m a t e r n i t y ward are n e a r i n g c o m p l e t i o n as a result of community self-help； in N i g e r i a m u l t i p u r p o s e v i l l a g e c e n t r e s , a l i b r a r y , bridges arid town halls h a v e been
c o n s t r u c t e d . Benin lists c o m m u n i t y activities as including the b u i l d i n g of v i l l a g e health u n i t s , p a y m e n t of v i l l a g e h e a l t h w o r k e r s , and r e p l e n i s h m e n t of drugs and m a t e r i a l s used by the local health u n i t s . In Sudan a blood b a n k and h o s p i t a l extensions have been
c o n s t r u c t e d . In one e x a m p l e the c o m m u n i t y pays a small v o l u n t a r y fee 一 "Health H e l p M o n e y " 一 for each service received； in smaller h o s p i t a l s relatives help with the provision of food for i n p a t i e n t s . The financial c o n t r i b u t i o n from community participation is often s i g n i f i c a n t . In G u a t e m a l a in some rural water supply p r o j e c t s , 36% of the costs were r e p o r t e d l y b e i n g m e t by the сoiranunitу, 13% by the G o v e r n m e n t , 47% by UNICEF and 4% by other d o n o r s . In Senegal c o m m u n i t i e s w e r e reported to have c o n t r i b u t e d , besides labour, up to 80%
of the c o n s t r u c t i o n costs of h e a l t h f a c i l i t i e s . C o m m u n i t y level organizations are being m o b i l i z e d . In T h a i l a n d "health c o o p e r a t i v e s " sell simple m o d e r n m e d i c i n e s as w e l l as
t r a d i t i o n a l and herbal m e d i c i n e s . Some village stores sell a n t i b i o t i c s . Religious b o d i e s and Boy Scout brigades also c o o p e r a t e with health c e n t r e staff and solicit financial and m a t e r i a l s u p p o r t . In other c o u n t r i e s , f a r m e r s ' a s s o c i a t i o n s arid urban n e i g h b o u r h o o d g r o u p s , y o u t h , w o m e n ' s and w o r k e r ' s o r g a n i z a t i o n s , and local councils are involved in PHC a c t i v i t i e s .
N e w categories of local-level m a n p o w e r and infrastructure are being introduced such as c o m m u n i t y - b a s e d health and d e v e l o p m e n t w o r k e r s , and the creation of o r g a n i z a t i o n s such as v i l l a g e and d e v e l o p m e n t c o m m i t t e e s and local-level insurance s c h e m e s . H o w e v e r , their
e f f e c t i v e n e s s depends often on existing p o l i t i c a l , social and administrative s t r u c t u r e s , arid a c l e a r u n d e r s t a n d i n g of the role of local-level innovations and o r g a n i z a t i o n s . For e x a m p l e , the success of a v i l l a g e health c o m m i t t e e w i l l be partly determined by its o r i g i n , c o m p o s i t i o n , and r e l a t i o n s h i p to both the community and the health s e r v i c e s .
6•2 M a n a g i n g community involvement
I m p r o v e m e n t of local-level m a n a g e r i a l processes and capacities for m a n a g e m e n t of c o m m u n i t y involvement is reported as often m o r e effective at central level than at the p e r i p h e r y • There is a l s o often a lack of a d m i n i s t r a t i v e capacity regarding follow-up and c o o r d i n a t i o n of c o m m u n i t y involvement a c t i v i t i e s . Social research projects are in progress in w h i c h m u l t i d i s c i p l i n a r y teams are focusing on the community involvement component of P H C , and d e s i g n i n g and implementing specific operational studies in order to provide guidelines
for future policy d e v e l o p m e n t . R e g i o n a l goals include the development of n a t i o n a l policies for c o m m u n i t y involvement in h e a l t h and development relating to n e e d - i d e n t i f i c a t i o n ,
p l a n n i n g , i m p l e m e n t a t i o n and e v a l u a t i o n . For e x a m p l e , a "research and d e v e l o p m e n t " approach can g e n e r a t e information on c o m m u n i t y involvement which is fed b a c k to develop appropriate c o m m u n i t y involvement and PHC approaches and t e c h n i q u e s .
S t r a t e g i e s are being sought to improve local-level intersectoral p l a n n i n g , and
c o o r d i n a t i o n b e t w e e n the h e a l t h sector and the c o m m u n i t y . The roles of health personnel and c o m m u n i t y leaders are b e i n g r e v i e w e d . The identification is also necessary of v i a b l e
c o m m u n i t y - l e v e l w o r k i n g groups to serve as entry points for promoting community involvement in h e a l t h and development a c t i v i t i e s . There is reported to be in some areas a lack of u n d e r s t a n d i n g among h e a l t h m a n p o w e r , d e c i s i o n - m a k e r s and health planners concerning community i n v o l v e m e n t in P H C . C o m m u n i t y involvement in planning for PHC is still the exception rather than the r u l e , and there is a need to develop m e c h a n i s m s to allow communities a role in both short and long-term p l a n n i n g .
To assist the community involvement process networks are being set up in one region to coordinate self-help and self-care activities. Exchange of information and experience is advocated in all regions regarding audio-visual and media technology in support of community involvement for P H C . The need for a holistic approach to community involvement is
increasingly rioted. The view was expressed that community involvement in PHC never begins effectively in reality prior to communities reaching a certain threshold in economic, social and educational development. Past experience indicates that fragmented approaches in community involvement have had only limited overall effectiveness.
CHAPTER 7 . CORE ELEMENTS OF PHC 7•1 Health education
Information on health education was obtained from half of the countries reviewed. Some saw its function as that of eliciting participation in health service and/or community-based health activities； for others it implied a dialogue between people and health workers； for others it was also concerned with creating an awareness in individuals and communities that would lead not only to improved health but also to improved socioeconomic conditions.
Many countries reported that the role of existing health education structures is being examined to improve coordination of activities within the health sector, and new mechanisms and structures are being considered and implemented at central, provincial and district level, These include, for example, health education units at ministerial arid departmental level, and the creation of associations, councils, panels and bureaux, including village health committees. The need was stressed for central and provincial health education units whose staff would be able to prepare other workers for their health education functions and collabórate with them in the preparation of m a n u a l s , evaluation, follow-up of activities and research.
The role and training of specialist and non-specialist manpower in health education is being examined, with emphasis on the concept of every health and development worker being a potential health e d u c a t o r . The promotion of practical, field-based training is advocated, particularly in terms of short-term intensive courses emphasizing communications skills and community organization approaches and m e t h o d s , and planning, monitoring, evaluation
approaches, mechanisms and skills. Innovative and dynamic teaching methods are sought particularly to train manpower to reach peripheral segments of the population and those beyond the periphery of the health services. A general lack of health education specialists is also rioted. Also sought are a range of health education approaches and techniques from national to local level and effective patterns of supervision. Priorities are being
identified in the development of effective national and regional health education programmes, in addition to the strengthening and coordination of existing health education components of PHC programmes. One such priority is education regarding family life.
The development of communications strategies and improved media facilities are also sought, in addition to more effective use of mass media methods and methods of traditional social communication. The need is seen for better integration between mass communication and personalized communications channels. Within the country-spec ific context of the
potentiality and status of the mass m e d i a , the increased preparation of educational materials and visual aids is advocated.
Cooperation with other sectors is being promoted through, for example, the use of
existing formal and non-formal educational structures and an emphasis on health education in primary and secondary schools and in teacher training colleges. Teacher manuals and
instructional materials are being prepared for primary schools. In some countries health education is in the process of being promoted into national development programmes. Joint programmes to promote health education are being planned and implemented between W H O , other organizations of the United Nations system, and nongovernmental organizations. Applied research is both under way and advocated regarding analysis of the health education component of activities outside the health sector, methods of improved utilization of past and present
research f i n d i n g s , identification of the s o c i o c u l t u r a l o b s t a c l e s to e f f e c t i v e P H C , the d e v e l o p m e n t of improved a p p r o a c h e s , procedures and instruments of c o m m u n i c a t i o n , and the i d e n t i f i c a t i o n of strengths and d e f i c i e n c i e s in existing c o u n t r y i n f o r m a t i o n s y s t e m s .
In the regional and c o u n t r y strategies for H F A / 2 0 0 0 the role of h e a l t h e d u c a t i o n is b e i n g c l a r i f i e d in relation to obtaining specific PHC p o l i c i e s , priorities and g o a l s , and e s p e c i a l l y in connexion w i t h the c o m m u n i t y involvement p r o c e s s .
7•2 Food supply and proper n u t r i t i o n
In 98% of the countries reviewed m a l n u t r i t i o n was cited as an e x t e n s i v e cause of m o r b i d i t y and m o r t a l i t y and a c o n s t r a i n t to d e v e l o p m e n t . P r o t e i n - e n e r g y m a l n u t r i t i o n ,
a n a e m i a , v i t a m i n A d e f i c i e n c y and h y p o t h y r o i d i s m w e r e the m a i n d i s o r d e r s c i t e d . 7.2.1 M a l n u t r i t i o n
L i t t l e indication was obtained r e g a r d i n g r u r a l / u r b a n d i f f e r e n t i a l s in m a l n u t r i t i o n although rates are known to be h i g h e r in the rural areas of m a n y of the c o u n t r i e s s t u d i e d . In P e r u， for e x a m p l e , the p r o p o r t i o n of the p o p u l a t i o n w h o w e r e estimated to be m a l n o u r i s h e d in rural areas w a s 60% as against 40% in urban a r e a s . H o w e v e r , it is also known that the level of m a l n u t r i t i o n encountered in some urban a r e a s , and in areas of rapid u r b a n g r o w t h , is h i g h e r than in rural areas； e . g . , in B o l i v i a ’ B u r u n d i , D o m i n i c a n R e p u b l i c， India and
M o z a m b i q u e • Some countries are only now u n d e r t a k i n g surveys in order to d e t e r m i n e precisely the e x t e n t of the problem and the v u l n e r a b l e g r o u p s . The links b e t w e e n n u t r i t i o n and
infection are also being perceived m o r e c l e a r l y . It is recognized that health sector r e s o u r c e s , m o r e than those of any other s e c t o r , are absorbed by the effects of m a l n u t r i t i o n . 7.2.2 A c t i o n for food supply and proper n u t r i t i o n
The m a n y and complex factors affecting food supply and proper n u t r i t i o n include for some c o u n t r i e s d r o u g h t , i n f l a t i o n , c o n f l i c t s , level of food p r o d u c t i o n and a v a i l a b i l i t y , w a g e levels of low-income g r o u p s , the p r e v a i l i n g cultural p a t t e r n s , the growth and geographic d i s t r i b u t i o n of the p o p u l a t i o n , storage and d i s t r i b u t i o n p r o b l e m s , lack of g e n e r a l e d u c a t i o n , and lack of communications s y s t e m s . The planning process for action is complicated in some p l a c e s by the lack of concrete results from previous food and n u t r i t i o n p r o g r a m m e s .
H o w e v e r , there is generally an increased awareness of the socioeconomic implications of integrated applied n u t r i t i o n p r o g r a m m e s .
R e c o g n i z i n g that there is no single sectoral solution for solving food and n u t r i t i o n p r o b l e m s , the need for intersectoral c o l l a b o r a t i o n is e m p h a s i z e d in the formulation of p o l i c i e s , plans and p r o g r a m m e s . The factors actually d e t e r m i n i n g the a v a i l a b i l i t y ,
c o n s u m p t i o n and b i o l o g i c a l u t i l i z a t i o n of f o o d , and therefore levels of n u t r i t i o n are to be found in other development sectors as w e l l as that of h e a l t h . A c t i v i t i e s in c o n n e x i o n w i t h food supply and proper n u t r i t i o n are being integrated into PHC in the form of n u t r i t i o n a l s u r v e i l l a n c e , prevention and control of d e f i c i e n c y d i s o r d e r s , the p r o m o t i o n of sound dietary p r a c t i c e s including b r e a s t f e e d i n g , direct treatment of m a l n u t r i t i o n , oral r e h y d r a t i o n
t h e r a p y , food supplements or feeding programmes for v u l n e r a b l e g r o u p s , i m m u n i z a t i o n , and i o d i n a t i o n of s a l t . A c t i v i t i e s are also being linked to w a t e r and s a n i t a t i o n , family planning and m e n t a l h e a l t h . C o u n t r y - l e v e l action has also included the linking of a c t i v i t i e s for food supply and proper n u t r i t i o n w i t h n u t r i t i o n education for t e a c h e r s ,
f i s h - f a r m i n g , animal h u s b a n d r y , the creation of small d e m o n s t r a t i o n f a r m s , the d e v e l o p m e n t of c o o p e r a t i v e s , home i n d u s t r i e s , income-generating p r o j e c t s , increased a g r i c u l t u r a l p r o d u c t i o n , a v a i l a b i l i t y of equipment and f e r t i l i z e r s , a g r i c u l t u r a l credit f a c i l i t i e s , better food
d i s t r i b u t i o n and m a r k e t i n g f a c i l i t i e s , the d e v e l o p m e n t of transport and c o m m u n i c a t i o n s s y s t e m s , and land r e d i s t r i b u t i o n .
The p h y s i c a l infrastructure being used to promote food supply and proper n u t r i t i o n includes the use of special u n i t s , such as r e h a b i l i t a t i o n u n i t s , and of h e a l t h centres as entry points for integrated PHC activities which include n u t r i t i o n . The m a n p o w e r resources u t i l i z e d h a v e included the creation of special n u t r i t i o n "corps" and the training of other c o m m u n i t y - b a s e d health w o r k e r s such as the V H W , the ТВA, v o l u n t e e r s and p a r e n t s . The m a i n role of the c o m m u n i t y - l e v e l w o r k e r is seen as n u t r i t i o n s u r v e i l l a n c e , e d u c a t i o n and
r e h a b i l i t a t i o n . In some c o u n t r i e s n u t r i t i o n t r a i n i n g is a l s o b e i n g g i v e n to w o r k e r s f r o m o t h e r sectors such as rural d e v e l o p m e n t and a g r i c u l t u r e . F o r all c a t e g o r i e s of m a n p o w e r the need for p r a c t i c e - b a s e d t r a i n i n g is e m p h a s i z e d , p r e f e r a b l y b a s e d on the a n a l y s i s of p r i o r i t y n u t r i t i o n - r e l a t e d p r o b l e m s i d e n t i f i e d t o g e t h e r w i t h the c o m m u n i t y •
Specific t a r g e t s b e i n g set u p b y c o u n t r i e s r e l a t i n g to food s u p p l y and p r o p e r n u t r i t i o n i n c l u d e : r e d u c t i o n of the infant m o r t a l i t y r a t e and m o r t a l i t y in the 0 - 5 - y e a r - o l d s , c o v e r a g e to a s p e c i f i e d e x t e n t and on a specific t i m e - s c a l e of a t a r g e t group w i t h a s p e c i f i c
i n t e r v e n t i o n ( e . g . , v i t a m i n A c a p s u l e s to 90% of the c h i l d r e n in a g i v e n p o p u l a t i o n by the y e a r 2000)； r e d u c i n g the i n c i d e n c e of low b i r t h w e i g h t to 10%； r e d u c t i o n of a n a e m i a in p r e g n a n t w o m e n from 55% to less than 2 0 % , or c o v e r a g e of t w o - t h i r d s of the t o t a l n u m b e r of v i l l a g e s in a s p e c i f i c area w i t h a n u t r i t i o n p r o g r a m m e by 1 9 8 4 .
A t n a t i o n a l and r e g i o n a l l e v e l , c o n f e r e n c e s h a v e focused on a p p r o p r i a t e n a t i o n a l food and n u t r i t i o n p o l i c i e s . F u r t h e r a c t i o n in this r e s p e c t h a s included the f o r m a t i o n of t e c h n i c a l g r o u p s in n a t i o n a l p l a n n i n g o f f i c e s to a n a l y s e the n u t r i t i o n i m p l i c a t i o n s of d i f f e r e n t e c o n o m i c and s o c i a l d e v e l o p m e n t p r o g r a m m e s and p r o j e c t s . T h e n e e d is r e c o g n i z e d for p o l i c i e s w h i c h are o p t i m a l l y b a s e d on c o m m u n i t y i n v o l v e m e n t surveys to d e t e r m i n e local food a v a i l a b i l i t y and the d e v e l o p m e n t of a p p r o p r i a t e t e c h n o l o g i e s for food p r e p a r a t i o n . N a t i o n a l n u t r i t i o n c o u n c i l s and c o m m i t t e e s h a v e a l s o b e e n c r e a t e d . I n t e r c o u n t r y m e e t i n g s h a v e been h e l d to focus on the d e v e l o p m e n t of n u t r i t i o n s u r v e i l l a n c e s y s t e m s . B e s i d e s t e c h n i c a l s u p p o r t the need is r e c o g n i z e d for the d i f f u s i o n of i n f o r m a t i o n , i n c l u d i n g the u s e of the m e d i a , and for g r o u p e d u c a t i o n a c t i v i t i e s •
Past e x p e r i e n c e in i n t e g r a t e d n u t r i t i o n p r o g r a m m e s h a s d e m o n s t r a t e d the n e c e s s i t y for good m a n a g e m e n t and m o r e e f f e c t i v e m e t h o d s for a s s e s s i n g i m p a c t .
R e s e a r c h is also a d v o c a t e d on infant feeding and w e a n i n g p r a c t i c e s and on the
i n t e r s e c t o r a l i m p l i c a t i o n s of e f f e c t i v e a c t i o n for food s u p p l y and p r o p e r n u t r i t i o n . Some c o u n t r i e s are p r o m o t i n g c o n s u m e r e d u c a t i o n on b o t h the level of the i n d i v i d u a l p u r c h a s e r and that of i n t e r n a t i o n a l m a r k e t i n g i s s u e s . In some c o u n t r i e s (the m i n o r i t y of those r e v i e w e d ) n u t r i t i o n p r o b l e m s are also b e i n g e x p e r i e n c e d in r e l a t i o n to a f f l u e n c e , such as o v e r w e i g h t and o b e s i t y and those a s s o c i a t e d w i t h c a r d i o v a s c u l a r and h y p e r t e n s i o n - r e l a t e d d i s e a s e s . 7•3 W a t e r and s a n i t a t i o n
In 1980 the G e n e r a l A s s e m b l y of the U n i t e d N a t i o n s p r o c l a i m e d the I n t e r n a t i o n a l D r i n k i n g W a t e r Supply and S a n i t a t i o n D e c a d e . M e m b e r c o u n t r i e s c o m m i t t e d t h e m s e l v e s to b r i n g i n g a b o u t a s u b s t a n t i a l i m p r o v e m e n t in the s t a n d a r d s and levels of s e r v i c e s in d r i n k i n g - w a t e r s u p p l y and s a n i t a t i o n by the y e a r 1 9 9 0 . The D e c a d e a p p r o a c h e m p h a s i z e s c o m p l e m e n t a r i t y in the d e v e l o p m e n t of w a t e r supply and s a n i t a t i o n , a focus on r u r a l and u n d e r s e r v e d p o p u l a t i o n s , e v e n t u a l a c h i e v e m e n t of full c o v e r a g e through r e p l i c a b l e , s e l f - r e l i a n t , s e l f - s u s t a i n i n g p r o g r a m m e s， the use of a p p r o p r i a t e t e c h n o l o g y , c o m m u n i t y i n v o l v e m e n t , i n t e r s e c t o r a l a c t i o n and close a s s o c i a t i o n of w a t e r and s a n i t a t i o n w i t h o t h e r h e a l t h p r o g r a m m e s • D e c a d e a c t i v i t i e s are seen as an i n t e g r a l part of p r o g r e s s t o w a r d s the goals of H F A and those of g e n e r a l d e v e l o p m e n t .
7.3.1 A c t i o n for the D e c a d e
A t country level the m a j o r i t y of the c o u n t r i e s r e v i e w e d h a v e e s t a b l i s h e d a c t i o n
c o m m i t t e e s or c o u n c i l s for the D e c a d e . T h e s e focal p o i n t s are a s s o c i a t e d w i t h m u l t i s e c t o r a l a c t i o n , liaison w i t h i n t e r n a t i o n a l o r g a n i z a t i o n s , c o o p e r a t i v e act ion w i t h o t h e r m i n i s t r i e s and d e p a r t m e n t s , m a n p o w e r t r a i n i n g , and t e c h n i c a l s u p p o r t t e a m s . T h e latter o f t e n
c o o r d i n a t e i n t e r n a t i o n a l support for the n a t i o n a l D e c a d e a c t i v i t i e s .
C o m m u n i t y i n v o l v e m e n t h a s b e e n sought in terms of c o n t r i b u t i o n s of l a b o u r , m a t e r i a l s or f i n a n c e . This has included the digging of w e l l s， m a i n t e n a n c e r e s p o n s i b i l i t i e s , c o n s t r u c t i o n of l a t r i n e s , s e l f - h e l p d i s p o s a l s c h e m e s . H e a l t h e d u c a t i o n h a s been c a r r i e d out in s c h o o l s , and c o m m u n i t y a w a r e n e s s has been p r o m o t e d through c o m m u n i c a b l e d i s e a s e c a m p a i g n s .
