HEALTH CARE DELIVERY
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- HEALTH CARE DELIVERY
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-ON H .
RF_COM_H_5_A_SUDHA_PART _1
PCsSF-irs 3.3g
MEDLINE (R)
1/94-1/95
J'!k=iLANjx—<R) 1 7 9 4 - -1 / 95 usage is subject to the terms arid conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of 26
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Narked Record
TI: Educational programs in US medical schools. 1993-1994.
AU: Jonas-HS; Etzel—SI; Barzansky-B
AD: Division of Undergraduate Medical Education. American Medical Association,
Chicago, Ill 60610.
SO: JAMA. 1994 Sep 7; 272(9) : 694—701
LA; ENGLISH
ABs From the data on faculty, students, and curriculum, is it possible to
identify any responses to actual or anticipated health system changes? While
one could foresee medical school downsizing in response to a potentially more
competitive environment in which income from faculty practice would be reduced,
what has occurred, on average, is steady growth in the number of faculty
members across departments, with a large increase in the past year. However,
expansion is not consistent across staites, Between 1992—1993 and 1993—1994, the
number of full—time faculty members decreased 1.57 in California medical
schools., increased 37. in Minnesota medical schools, increased 67 in North
Carolina medical schools, and increased 107 in New York and Pennsylvania
medical schools. These differences may reflect the fiscal situation at the
state level as. well as differences in the practice environment in different
areas. For example, managed care has not had e major effect in many markets. It
will be important to monitor trends in faculty at both the national and
regional levels to understand the full impact of health system changes. There
is considerable diversity among US medical schools; in goals, in student
profiles, and in curriculum structure. A number of schools have goals or
objectives that contain a reference to the training of primMry care physicians.
The majority of these are public Institut3ons. but a number of private schools
have chosen to address the issue as well. Many schools, both public and
private, are under external scrutiny related to the performance and specialty
and practice location choices, of their graduates.(ABSTRACT TRUNCATED AT 250
WORDS)
2 of 26
Marked Record
TI; Communicat ion of the monitoring and evaluation process, through ths? use of
storyboards and story notebooks.
AU; Lewis-LC: Honea-SH; Kanter—DF; Haney--PE
S0 i Semi n-Ferioper-Nurs. 1993 ct; 2(4): 269-76
LA; ENGLISH
AB: In preparation for the 1993 Joint Commission on Ac c: red i t a t i on of He a 1 th
Care Organizations (JCAHD) survey, Audie L. Murphy Memorial Veterans Hospital
Nursing Service was faced with determining the best approach to presenting
their Total Quality Improvement/Total Quality Management (TQI/TQM) process.
Nursing Service management and staff. Quality Improvement Clinicians, and
medical staff used the Storyboard concept and the accompanying Story Notebooks
to organize and to communicate their TQI/TQM process and findings. This concept
was extremely beneficial, enabling staff to successfully present the
multidisciplinary TQI/TQM data to the JCAHD surveyors.
3 of 26
Marked Record
TI: A review of methods used for medical quality assurance in hospitals:
Wolff—AM
Wimmers Base Hospital, Horsham, Victoria.
J—Qua1 —C1 in—Pract. 1994 Jun; 14(2): 85—97
ENGLISH
This paper reviews the advantages and disadvantages of medical quality
assurance methods commonly used in hospitals. A computer-based literature
search up to April 1993 was done using the terms quality assurance, quality
conti-ol, audit, utilisation review, accreditation. occurrence screening and
total quality management. In addition, a manual search was- undertaken of
references, of papers obtained by the computer Search and of the contents of the
following jownals: Quality Review Bulletin, Australian Clinical Review and the
British Medical Journal. An assessment of the advantages and disadvantages of
15 quality assurance methods used in hospitals was made. Many quality assurance
metnods used in hospitals have significant disadvantages. A systematic method
that provides meaningful and useful information to clinicians and improves
patient care is urgently required. New methods such as occurrence screening and
total quality management are slowly emerging and have much potential.
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4 of 26
Marked Record
TI: The future of healthcare ethics committees.,
AU: Smith-ML
SO: Trends-Health-Care-Law-Ethi.cs. 1994 Spring; 9(2): 7-10
LA: ENGLISH
AB: Ethics committees are fairly common in healthcare ins111utions in the
United States. Comprised of a multidisciplinary membership, including
physicians, their functions within institutions are generally threefold: policy
recommendation, ethics education and case consultation. The number of such
committees will grow as a result of "Patient Rights" standards established by
the Joint Commission on Accreditation of Healthcare Organizations (1992
Manual), The author projects and discusses five areas of development and change
in the future of healthcare ethics committees. These five areas are: 1) renewed
efforts to educate healthcare professionals, 2) cooperation and col1 adoration
among ethics committees, 3) networking with community-based ethics groups, 4)
clearer delineation of responsibilities and limitations, and 5) continuous
quality improvement. The ability of ethics committees to address successfully
these areas of change will determine their future usefulness.
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5 of 26
Marked Record
Impact of increased intensive care on residents' education £ letter!
Carracic-CL; Berman-MA
Acad-Med. 1994 Jul; 69(7): 563—4
ENGLISH
6 of 26
Marked Record
TI: Quality assurance.
AU: Ku nk e1-MJ
AD: Yale University School of Medicine, New Haven.
SD: Hosp-Pract-Dff-Ed. 1993 Jun; 28 Suppl 1: 33-8: discussion 63-4
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ENGLISH
AB: At present, there are no accepted guidelines for quality assurance in the
outpatient setting, although they are being developed. Greater emphasis is
being placed on ongoing rather than retrospective improvement of quality, as
measured by the care-giving process and outcome. Thus, programs need to
incorporate sound methods for teamwork, communication, and documentation of
services.
7 of 26
Marked Record
iI 5 The measurement mandate: report card day is coming.
AU: 0'Leary-DS
AD: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook
ferrace, IL 60181.
SO: Am—j-Hosp-Pharm. 1994 Mar IS: 51(6): 757-61
LA: ENGLISH
8 of 26
M a r k ed R e c o r d
TI: Patient-centered outcome measures of ac-creditation ..
AU: Barr-JT
AD: Bouve College of Pharmacy and Health Science (NERCOA), Northeastern
University, Boston, MA 02115.
SO: J—Al 1ied—Hea1 th. 1994 Winter; 23(1): 47-50
LA: ENGLISH
9 of 26
Marked Record
TI: A futurist's view of hea1 th car® and education: impact on specialized
a c c red i t a t i on.
AU: Bezold—C
AD: Institute for Alternative Futures, Alexandria, VA 22314.
SO: J-Aliied-Health. 1994 Winter; 23(1): 3.9
LA: ENGLISH
10 of 26
Marked Record
TI: Critical challenges facing allied health accreditation: Pew Health
Professions Commission's recommendations.
AU: 0'Nei1-EH
AD: University of California at San Francisco 94109.
SO: J-Allied-Health. 1994 Winter; 23(1): 15-7
LA: ENGLISH
11 of 26
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Measuring the quality of hejgSth care.
Loegering-L; Reiter—RC; Gambone-JC
Scripps Clinic, San Diego, CA.
Cl in-Obstet--Gynecol . 1994 Mar: 37(1): 122-36
ENGLISH
12 of 26
Marked Record
TI:
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Quality improvement: then and now.
Meeker-CI
Maine Medical Center, Portland 04102.
Clin-Obstet-Gynecol. 1994 Mar; 37(1):
ENGLISH
115-21
13 of 26
Marked Record
TI: Enhancing faculty participation and interest in quality improvement in
academic c en te r s.
AU: Akpunonu-BE; Mutgi-AB; Federman-DJ; Wasielewski-N; White-P; Donabedian-H
AD: Department of Medicine, Medical College of Ohio, Toledo 43699-0008.
SO: Am-J-Med-Qua1. 1994 Spring; 9(1): 18-23
LA: ENGLISH
AE<: Continuous quality improvement (CQI) is necessary in maintaining and
improving the quality of medical care delivered. However, quality assurance
(QA) in the past was performed superficially to meet requirements of the Joint
Commission an Accredi tation of Heal th Care Organizations and other regulatoi y
agencies. Academic faculty participation in QA activity was also limited.
Faculty often assume that meaningful quality process demands excessive effor ts
and time unrewarded with career advancement, promotion, or monetary
compensation. In addition, unstructured QA leads to duplication of data and
loss of educational opportunity. We reorganized the QA process in internal
medicine using the CQI concept to: (a) improve academic faculty participation,
(b) incorporate educational concepts, (c) stimulate interest in outcome
research and CQI, and (d) integrate cost containment. A reorganized CQI format
has stimulated enthusiastic participation of faculty and residents, and has
generated conferences and grand rounds pertinent, to medical care, outcome
research, and cost containment. We conclude that academic faculty shouiu play
leadership roles in the CQI process and include teaching models. Improved and
increased academic faculty participation could be realized, when educational
values, research activities, and cost analysis are incorporated into the CQI
py DC &£■£• x.-
14 of 26
Marked Record
TI: Quality in hospital care.
AU: Novaes-H-de-M
AD: Health Services Development Program, Pan American Health Organization,
Washington, DC 20037.
/SO: World-Health—Forum. 1993; 14(4): 367—75
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ENGLISH
15 of 26
M a r k ed R e c o r d
TI: lAccreriitation is proof of good quality!
SO: Vardfacket. 1993 May 13; 17(9): 21
LA: SWEDISH; NON—ENGLISH
16 of 26
Marked Record
TI: The measurement mandate: report card day is coming.
AU : D' Leary-DS
AD: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook
Terrace, IL.
SO: Jt-Comm—J-Qua1—Improv. 1993 Nov; 19(11): 487-91
I.. A: ENGLISH
17 of 26
Marked Record
TI: The transition to continuous quality improvement: a home care model.
AU: Ruden-JC
AD: Community Health Accreditation Program, National League for Nursing, New
York, NY.
SO: J-Nurs-Care-Qual. 1994 Jan; 8(2): 9-15
LA: ENGLISH
AB: Managers of home care organizations in the 1990s are faced with serious
challenges. The magnitude of change occurring makes it difficult to distinguish
a reasonable course of action. Quality improvement techniques offer an exciting
opportunity for organizations to regain control of their strengths by
identifying and improving their weaknesses. This article presents a
transitional model for quality improvement involving structure, process, and
outcome variables adapted to home care organizations. It encompasses unique
committee structures mandated by licensure and certification requirements,
which can be adapted to quality improvement focus. Finally, it identifies
customer service trends that provide managers with information to fine-tune
good business practice.
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Marked Record
c<) .inging quality to the customers a new paradigm -For quality managers.
Largen-CW
’
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Department of Veterans Affairs Medical Center, Seattle., WA.
J—Nurs—Care—Qual. 1994 Jan; 8(2): 81-4
ENGLISH
transition of heal th care organizations to total quality improvement
(TCH) models has significant consequences for quality manager roles and quality
systems. Changing paradigms regarding one's quality role and programs requires
critical self-awareness, new knowledge, and a fresh approach to
employee-customer relations. The quality manager's challenges are to discover
one s own learning needs, integrate new philosophies into one's behavior, and
successfully model and mentor I QI to fellow heaI th ca re providers. Quality
managers have an opportunity to develop a vital and powerful leadership role
vis—a—vis TQ1 and the point c<f contact between he a 1 th c a r e provider and
patient.
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Harked Record
TI: Transition tc< quality improvement; adapting the quality management planAL!: Jo hn son—T
AD: Division of Surgery, Brookdale Hospital Medical Center, Brooklyn, NY.
SO: J-Nurs-Care-Qual. 1994 Jan; 8(2): 16-21
LA: ENGLISH
AB: Heal th care organizations across the country are in different phases of
transition from quality assurance to quality improvement. A plan is essential
to ensure quality assessment and improvement requirements are met while the
organization is in transition- Based on the hospital's commitment to quality
improvement, the Division of Nursing at The New York Hospital has built on the
strengths of the QA program and begun transition tc< QI by incorporating the
principles of QI and developing quality improvement teams with other
dis cip1ines and within n u r sin g.
20 of 26
Harked Record
TI: Total quality management in the hospital setting.
AU: Ernst-DF
AD: Department of Nursing, Georgia Southern University, Statesboro.
SO: JMNurs—Care-Qual. 1994 Jan; 8(2): 1-8
LA: ENGLISH
AB: With the increasing demands on hospitals for improved quality and lower
costs, hospitals have been forced to reevaluate their manner of operation and
quality assurance (QA) programs. Hospitals have been faced with customer
dissatisfaction with services, escalating costs, intense competition,. and
reduced reimbursement for services. As a result, many hospitals have
incorporated total quality management (TQM), also known as continuous quality
improvement (CQI) and quality improvement (QI), to improve quality care and
decrease costs. This article examines the concept of TQM, its rationale, and
how it can be implemented in a hospital. A comparison of TQM and QA is made.
Examples of hospital implementation of TQM and problems and issues associated
with TG<M in the hospital setting are explored.
21 of 26
Marked Record
TI: Preparation for hospital accreditation: an efficient and practical
.approach.
AU: 0'Connor—PT; Wolf f—AM
AD: Wimmera Base Hospital, Horsham, Victoria.
SO: Aust-Clin-Rev. 1993; 13(4): 157-63
LA: ENGLISH
AE<: Hospital .accreditation has been criticized for its emphasis on structure
and documentation. Less attention is given to the clinical process and outcomes
of care. How can the accredit at i on process become a meaningful part of
day—to-day hospitai management? Four approaches are discussed. (1) The
development of industrial type quality assurance programmes that, detect
negative patient outcomes and improve patient care. (2) The appointment of a
Quality Assurance/fleereditation Coordinator with appropriate authority. (3) The
establishment of an effective Quality Assurance/Accreditation Committee. (4)
The continuous review of acereditation standards through normal committee
function and department review, and trial surveys. Such strategies will enable
hospital accreditation to develop beyond a paper exercise and to provide the
foundation for excellence in heal th c a re delivery.
22 of 26
Marked Record
TI : Minimally invasive surgery. Implications for hospitals, health workers, and
patients.
AU s Bant a—HD
AD: TNG Health Research, Center for Medical Technology, Leiden, Netherlands.
SQ: BMJ. 1993 Dec 11; 307<6918): 1546-9
LA: ENGLISH
AB: Minimally invasive surgery is one of the great innovations of hea 1 th care
in the 2®th century. It promises to revolutionise surgery by allowing many
more operations to be performed with minimal hospitalisation. Pressure from
patients has caused many techniques to spread rapidly before they have been
adequately assessed. This must be resisted, and policy makers must pay more
attention to minimally invasive surgery to ensure that good assessments are
made. The widespread use of minimally invasive techniques has important
implications for hospitals and health workers. As more patients are treated on
an outpatient basis, fewer hospital beds will be needed, and traditional
operating rooms will have to adapt to a greater turnover of patients. Surgeons
will have to acquire new operating skills, possibly requiring formal training
and accredita tion, and, as different specialties fight for control of new
technologies, surgery may eventually be merged with internal medicine so that
specialists will deaal with organ systems. Postoperative care will have to be
carried out in the community rather than in hospitals, and policy makers will
need to reorganise their health systems to cope with these developments.
23 of 26
Marked Record
TI: As it was in the beginning.
AU: Wiison-LL
AD: dual—med Pty Ltd., Connell's Point, NSW, Australia.
SO: Aust-Clin-Rev. 1993; 13(3): 101-9
LA: ENGLISH
AB: A brief account of the obstacles faced during the introduction of hospital
accreditation in Australia is provided, with some insight into the politics of
change in heal th care. Some observations are made concerning critical elements
of the accreditation program and the implications for the future of the
A u s t. r a 1 i a n C o u n c i 1 o n Healthcar e S t and a r d s.
24 of 26
Marked R ec ord
TI: The peer review organization process revisited.
AU: Harris-MD
SO: Home-Healthc-Nurse. 1993 Sep-Oct; 11(5): 67-8
LA: ENGLISH
AB: The outcomes of patient care are of increasing importance in the 1990s from
a quality of patient care perspective. Most of the review processes that HHAs
are subjected to, including the Medicare certification survey, the
accred i t a t ion process by the Joint Commission on the Accreditat.ion of
Healthcare Organizations and the Community Health Accreditation Program, are
■focused toward patient outcomes. Also included is the PRO process that
addresses the quality of care issue when home care was provided as one of the
intervening care services if a patient is readmitted to an acute care facility
within 31 days of discharge, HHA standards as well as professional nursing
standards. There is no question that the care rendered and the complete and
accurate documentation by home healthcare nurses contribute to the minimal
number of confirmed quality of care problems that have been identified in HHAs.
We would appreciate findings reported in other states. Please share published
information on ths PRO activities in your state in care of Home Healthcare
Nurse. We look forward to hearing from you.
Marked Record
TI: Planning to meet the JCAHO standard; consideration of scientific findings.
All; Mayhew—PA
SD: Medsurg—Nurs- .1993 Oct; 2(5); 426-8
LA: ENGLISH
AB: Bringing research findings into practice does take some thought, and
planning, but most heal th c are i n s t i t u 11. on s already have committees,
departments, and positions- that can facilitate research utilization. It may
just, take some assessment of the roles and functions of these components to
more carefully plan for systematic use of research findings in practice. This
planning will pay off by enhancing the quality of nursing care and providing
documentation that review of policies and procedures, includes consideration of
current scientific and nursing research findings.
26 of 26
Marked Record
TI: Introduction of total quality management (TOM) into an internal medicine
residency.
AU: Ellrodt—AG
AD: Internal Medicine Training Program, Cedars-Sinai Medical Center, Los
Angeles, CA 90048SO: Acad—Med. 1993 Nov; 68(11): 817-23
LA: ENGLISH
AB: In spite of significant enthusiasm for the principles and methods of total
quality management (TOM) in health care organizations, there have been only a
few creative programs applying TQM to medical education. In addition, teaching
programs are under significant pressure to teach and practice cost-effective
medicine and to produce more sophisticated general internists. In July 1992,
the governance and operation of the internal medicine training program at
Cedars-Sinai Medical Center was restructured to integrate a TQM program with a
health services research section and a resource management department. This
restructured program transfers significant programmatic responsibility and
power to houseofficers. Within the playing field defined through a housestaff
•values statement and requirements of the Accreditation Council for Graduate
Medical Education and the American Board of Internal Medicine, the housestaff
have brought about substantial change. The first housestaff survey after the
new program was operational for six months revealed that 68% of the 77
respondents felt the housestaff had greater programmatic influence, 68% felt
that the rate of program change was "better,” and 63% felt the overall training
program had improved, while 3% felt it had worsened after the restructuring.
Fifty-six percent of the housestaff felt the new program should be continued
unchanged, and 29% felt it should be continued with changes. Housestaff teams
have approached educational issues, quality-of-care problems, and resource
management challenges through formal scientific problem-solving techniques.
This- article discusses the lessons learned in the first six months and the
program improvements that will be attempted in the future-(ABSTRACT TRUNCATED
AT .250 WORDS)
PC—SRIRS 3.30L.
MEDLINE <R)
MEDLINE(R) 1995 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
1 of 27
Marked Record
TI: Quality oversight: how much is too much?
AU: Kraft-JL; Dunham-Taylor-J
SC: Nurs-Econ. 1995 Sep-Det; 13(5): 272-5
LA: ENGLISH
AB: Concern for quality, which has created $1 billion/year quality oversight
businesses, has affected health care organizations financially in differentdegrees. The most costly is the JCAHD eccreditation process. Health care
organizations have the power to control these businesses and expenditures.
2 of 27
Marked Record
TI: How best to utilize limited resources.
AU: Forde r-AA
AD: Department of Medical Microbiology, University of Cape Town, Medical
School, Observatory, South Africa.
SO: J-Hosp-Infect. 1995 Jun; 30 Suppl: 15-25
LA: ENGLISH
AB: South Africa's new health policy embraces the primary health care (PHC)
approach for all its peoples and will include good primary, secondary and
tertiary care. The policy will hope to provide the highest possible stan_dard§.
of care, yet. be of a scale and complexity that the country can sustain into the
future. There will almost certainly be rationalization of many of the tertiary
teaching hospita 1s, with inevitable cut-backs in their budgets. This in turn
could carry the risk of damage to the fabric of these institutions, which might
be impossible to repair. Medicines offer a simple, cost-effective answer to
many health problems in Africa, provided they are available, accessible,
affordable and properly used. A looming problem in African drug markets is
inefficiency and waste. The use of counterfeit medicines has reached
unparalleled heights. It is vital that there should be a competent, honest,
accountable and independent national drug regulatory authority, secured in law,
to provide the necessary infrestructure for the acquisition of sound medicines.
Medicines are central to a sound national health policy, but there is great
public concern about their costs. Anti-infective drugs are amongst the most
widel?/ used class of drugs in the world. Inappropriate use of these agents is
widespread and guidelines need to be established for their correct use. The
control of all medicines in South Africa is governed by the Medicines & Related
Substance Act of 1965. The Medicines Control Council is mandated to ensure that
all medicines (including antibiotics) available to the public are efficacious,
safe and of high quality- An informally-constituted Antibiotic Study Group has
been established in order to monitor aspects of antibiotic therapy that impinge
on more general issues of public health, country-wide. The Antibiotic Study
Group has instituted an Antibiotic Surveillance Programme to monitor the
development of antibiotic resistance nationally. In addition the majority of
the tertiary teaching hospitals have comparable in-house antibiotic control
policies to help prevent such resistance and to cut costs. These issues need to
be debated and resolved. Once in place and working effectively, they will in
the long-term supply the most cost-effective means of providing health care for
all.
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Marked Record
TI: Quality with a human face? The Samuels Planetree model hospital unit.
AU: Blank—AE; Horowitz-S: Matza D
Al): Grants Management and Research Support, Beth Israel Medical Center, Mew
York, NY 10003, USA.
SC): Jt-Comm-J-Qual-Improv. 1995 Jun; 21(6): 289-99
L.A: ENGLISH
AB: BACKGROUND: Hospitals across- the country are seeking to restructure the
delivery of care- Planetree, an in ternational consumer health care
organization, works with hospitals to cultivate educated health care consumers
and to create caring inpatient environments. This article gives an overview of
Planstree's philosophy, examines staff and patient satisfaction, and cont
as
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is
Planetree with total quality management (TQM)/continuous quality improvement
(CGI) as practiced at one hospital. PLANETREE'S PHILOSOPHY: Planetree's model
differs from other patient—centered or patient—focused care models because of
its emphasis on educating patients and making them active partners in the care
process. To help make the hospital environment less forbidding, more homelike,
and more conducive to social interaction. Planetree physically redesigns the
hospital space. STUDY RESULTS: Planetree hopes to achieve many goals with its
restructuring of patient care, two of which are staff and patient satisfaction.
Preliminary surveys indicate that nurses and nursing assistants on Planetree
are more satisfied than are staff on comparable units. She results of patient
surveys, however, are more ambiguous. Planetree patients are no more, or no
less, satisfied with their care than patients on comparable units. DISCUSSION:
Both Planetree and TQM/CGI have goals of improving the delivery of patient
care, and there are times when these approaches work in concert. There are
times, however, when the different vantage points of TQM/CQI and Planetree may
raise different questions and foster different solutions. Questions are also
raised regarding whether Planetree benefits all patients in the same way.
Furthermore, since it is not clear if Planetree's vision of humanizing patient
care brings the results it hopes for, a long-term multifaceted research program
is called for.
4 of 27
Marked Record
TI: Sleep in hospitals at night: are patients' needs being met?
AU: Southwel1-MT; Wistow—G
AD: Nuffield Institute for Health, Community Care Division, Leeds, England.
SO: J-Adv—Nurs. .1993 Jun; 21(6): 1101—9
LA: ENGLISH
AB: Although the functions of sleep are not clearly understood, it is generally
accepted that it is necessary for the maintenance of good health, and that the
need for sleep increases with illness. The findings of a study on the hospital
in-patient night show that many patients do not consider that they have
sufficient sleep in hospital at night; that discomfort, worries and pain may
contribute to their wakefulness; that the sleep of many is disrupted by a
variety of sources of disturbances; that ward lights are dimmed for the night
for no longer than required by the average, healthy person; and that patients
continue to be woken early in the morning. A variety of ways of tackling these
problems is proposed. Differences in irhe perceptions of nurses and patients
about certain aspects of in-patient care at night, demonstrate the importance of
systematically asking patients about their experiences. Once viewed through
patients' eyes, the everyday procedures, routines and environments of the
hospital become visible and tangible influences on patient care, rather than
part of the taken-for-granted context in which patients receive that care.
5 of 27
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TI: Is quality in the eye of the beholder?
AU: Sales-A; Lurie-N; Hoseovice-I; Goes-J
AD: University of Minnesota, Institute for Health Services Research, School of
■'ublic Health, Minneapolis 55455-0381, USA.
SO: J t-Comm-J-Qua1 — Iisprov. 1995 May; 21(5): 219-25
LA: ENGLISH
AB: BACKGROUND: Relatively ignored in the literature on quality improvement
(QI) in health care is the question of who defines the issues- in quality of ,
care and decides how those issues will be addressed. MEIHODS: In late I/-.:, 669
hospital administrators, quality assurance (QA) coordinators, physicians, and
nurses in 72 hospitals in six states were surveyed by telephone. Respondents
were asked to identify the most serious issue related to quality of care in
their hospital. RESULTS: Of all the respondents, hospital administrators were
most likely to identify quality issues related to organ?, zational/ins-tituticna 1
issues. QA coordinators, most of whom had nursing backgrounds, were most likely
to identify organizational and patient care issues. Physician responses were
distributed approximately evenly across issues related to physicians, to the
organization, and to patient care. Nurses were most likely to identify issues
related to patient care and patient satisfaction. DISCUSSION: The findings
validate the viewpoint that "quality is in the eye of the beholder" and that
the eye is conditioned by the discipline in which hospital staff have been
trained ano socialized. As total quality management and continuous quality
improvement approaches are implemented, and participants from many disciplines
are involved in £31, a wide range of issues that have both a direct and indirect
effect on patient, care are likely to be addressed. CONCLUSION: The findings of
this study suggest that surveys that specifically target certain disciplinary
groups may yield important information about issues related to quality of care.
Marked Record
TI: The role of total quality management in patient-centered restructuring.
AU: Au ton—GM
AD: Sunhealth Alliance, Marietta, GA, USA.
SO: J—See-Heal th—Syst. 1995; 5(1): 63—71
LA: ENGLISH
AB: The fundamental structure and organization of the American hospital has
changed little in the past fifty years. The current and future environment
requires hospita1s to reconsider how basic patient care delivery systems are
organized and managed. Organizations are discovering how the traditional
structure limits a hospita1's ability to achieve sustainable improvements in
clinical and service quality. A number of pioneering hospitals have initiated
efforts during the past several years to completely redesign their
organizations to create systems that are patient-centered and customer
responsive. This paper discusses the opportunities and obstacles, of operational
restructuring and how total quality management principles can assist in
achieving an effective transition to a new system.
7 of 27
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/TI:
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Shared governance: first year experience.
Travi s-S
Nebr-Nurse. 1995 May; 28(2): 22
ENGLISH
8 of 27
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TI: From development to evaluation. Making a competency plan work.
AU: Britton-BP; Raper-JT; Walden-CM
SO: J-Nurs-Staff-Dev. 1995 Jul-Aug; 11(4): 210-4
LA: ENGLISH
AB: Staff development educators face numerous challenges because of the Joint
Commission on Accreditation of Heal theare Organizations (JCAHO) standards,
continuous quality improvement, and economic constraints. For many, the most
difficult challenge is complying with the JCAHO requirement for initial and
ongoing competency, which must be validated for all nursing personnel. In this
n,
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article, the authors describe how the educational nurse specialists of a
tertiary care, regional referral medical center facil itated the development,
implementation, and eval nation of a competency plan to validate initial and
ongoing competency for all personnel within Nursing Services.
9
Marked Record
TI: Determinants of compliance with a national smoke-free hospital standard.
AU: Joseph-AM; Knapp-JM; Nichol-KL; Pirie-Pi.
AD: Department of Medicine, Veterans Affairs Medical Center, Minneapolis, MN
/ 55417, USA.
SO: JAMA. 1995 Aug 9; 274(6): 491-4
LA: ENGLISH
AB: OBJECTIVE—To determine the extent of compliance with the new Joint
Commission on Accreditation of He? a 1 the are Organizations (JCAHO) standard
requiring acute care hospitals to be smoke-free, and to identify predictors of
adoption of smoke—free hospital policies. DESIGN—We conducted a survey of a
national sample of acute care hospitals and developed a predictive model for
implementation of smoke-free policies during multiple logistic regression. We
examined numerous factors that might predict adoption of smoke-free policies,
such as hospital characteristics, patient, care services, and experience with
smoke—free initiatives. SETTING AND PARTICIPANTS—A systematic 20% sample of
JCAH@-accred.ited hospitals in the United States (n = 1278). Military,
Department of Veterans Affairs, Indian Health Service, psychiatric, substance
abuse treatment, and children's hospitals were excluded. MAIN OUTCOME
MEASURE—Compliance with the JCAHO standard. RESULTS—The response rate was
85%. Six-five percent of hospitals were in compliance with the standard 16
months after it was introduced,. Factors that were independently and positively
associated with implementation of smoke-free policies were administrative
support (odds ratio EORJ, 7.82; 95% confidence interval lCII, 2.05 to 29.65)
and inpatient smoking cessation services (OR, 1.24; 957. Cl, 1.02 to 1.52).
Factors negatively associated with implementation of smoke-free policy were the
number of psychiatric treatment beds (DR, 0.57; 95% Cl, 0.14 to 0.81), number
of substance abuse treatment beds (OR, 0.17; 9571 Cl, 0.11 to 0.26), and
presence of an active task force to address smoking policy (OR, 0.56; 95% Cl,
0.40 to 0.77). CONCLUSIONS—The majority of acute care hospitals are in
compliance with the JCAHO national smoke-free policy initiative. The standard
is well accepted by most patients and employees. It is critical to address the
challenges presented by special populations, such as psychiatry patients, to
accomplish the goal of completely smoke-free hospitals.
10 of .27
Marked Record
TI: Smoking bans in US hospitals. Results of a national survey.
AU: Longo-DR; Brownson-RC; Kruse-RL
AD: Department of Family and Community Medicine, University of
Missouri.-Columbia School of Medicine, USA.
SO: JAMA. 1995 Aug 9; 274(6): 4S8-91
LA: ENGLISH
AB: OBJECTIVE—To examine compliance and characteristics of hospitals with
tobacco control standards enacted by the Joint. Commission of Acc r e d i t a tion of
Healthcare Organizations (JCAHO). DESIGN AND SETTING—On-site national survey
of hospitals as part of routine JCAHO accreditation visits. PARTICIPANTS—A
total of 3327 US hospitals received site visits in 1992 and 1993 and were
matched with American Hospital Association Annual Survey of Hospitals data.
MAIN OUTCOME MEASURES—Compliance or noncompliance with tobacco control
standards; location in a tobacco-producing state; and organizational
characteristics, including provision of psychiatric/alcohol-chemical dependency
services. RESULTS—Two years after implementation, 95.6% of hospitals met the
new JCAHO smoking ban standard; 90.9% of hospitals were in compliance with a
second smoking standard requiring development and use of medical criteria for
physician—ordered exceptions to the ban. Hospitals in tobacco producing state...
had higher—than—average rates of compliance when compared with hospitals in
other states. Hospitals- providing psychiatric and/or substance abuse services
had 1 ower—than—average rates of compliance. CONCLUSION
J his first
industry-wide smoking ban has been successful. However, hospitals should
consider evaluating the use of medical exceptions to this policy.
11 of 27
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TI:
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The future of the hospital epidemiologist in the 1990s.
Gross-PA
Department of Internal Medicine, Hackensack Medical Center, NJ 07601, USA.
Infect—Control-Hosp—Epidemiol. 1995 Mar; 16(3): 179—82
ENGLISH
12 of 27
Marked Record
TI:
/A U:
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Accreditation aches and pains Ced.itor.ial3
Alepach-G
Crit-Care-Nurse. 1995 Jun; 15(3): 13-5
ENGLISH
TI:
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13 of 27
Marked Record
Alternate site testing in hospitals—place in the future? EeditorialJ
Barlow-JF
S-D-J-Med. 1995 Mar? 48(3): 77-8
ENGLISH
14 of 27
Marked Record
TI: From the Joint Commission on Ac c r ed i t. a t i on of He? a I the are Organizations.
AU: Loeb-JM; O'Leary-DS
/AD: Joint Comission on A ccredit a t i on of Heal thcare Organizations, Oakbrook
' Terrace, IL, USA.
/SO: JAMA. 1995 May 10; 273(18): 1405
7 LA: ENGLISH
.1.5 of 27
Ma r k e d Record
TI: Essential components of growth and development.
AU: Frederick-C; Reining-KM
SO: J-Post—Anesth—Nurs. 1995 Feb; 10(1): 12-7
LA: ENGLISH
AB: The Joint Commission on ftccredita t.ion of Hea 1 theare Organizations'
standards require that documentation of age-appropriate care be done when a
child or adolescent is treated, with particular attention given to growth and
development, socialization, and other issues. The principles of growth and
development from infancy to adolescence are discussed, including physical,
psychological, and psychosocial needs. Nursing implications are presented to
improve understanding of growth and developmental stages as well as provision
of nursing care.
16 of 27
Marked Record
TI: Joint Commission on Accreditation of Healthcare Organizations.
AU: Patterson-CH
AD: Department of Performance Measure Development, Joint Commission on
Accreditation of Healthcare Organizations, Oakbrook Terrace, IL 60181-4813.
SO: Infect-Control-Hosp-Epidemiol . 1995 Jan; 16(1): 36-42
LA: ENGLISH
AB: The Joint Commission on Accred1 ta tion of Hea.l_thCjBrjB Organizations was
founded in 1951 as a private, not—for—profit organization that evaluates and
accredits hospitals and other healthcare organizations. In 1987, the JCAHG
launched its Agenda for Change to create a more modern and sophisticated
bccred5tation process to place primary emphasis on actual performance.
Coincident with this new emphasis, a number of task forces were established,
including two for infection control standards.
17 of 27
Marked Record
TI: The Project to Monitor Indicators: a collaborative effort between the Joint
Commission on Ac c r ed i t a t i on of Hea 1 the a re Organizations and <_he Society for
Healthcare Epidemiology of America [see comme'ntsl
AU: Kritchevsky—SB; Simmons-BP; Braun—BI
AD: Department of Preventive Medicine, University of Tennessee, Memphis.
SO: Infect—Control—Hosp—Epidemiol« 1995 Jan; 16(11: 33—5
LA: ENGLISH
18 of 27
Marked Record
TI: Duality measurement in nursing: where are we now?
AU: Rentz-MJ
AD: School of Nursing, University Hospital, University of Missouri, Columbia.
SO: J-Nurs-Care-Gual. 1995 Jan; 9(21: 1-7
LA: ENGLISH
AB: The American Nurses' Association commissioned a review of the nursing
quality measurement literature to understand the state of the art of nursing
quality measurement and to influence policy makers to include nurse-sensitive
quality measures in health care reform legislation. Using both computer and
hand searching methods, 158 articles that described measuring nursing care
quality were abstracted. Recommendations based on the analysis of literature
include implementing the Nursing Minimum Data Set (NMDS), documenting nursing
hours per patient and the education level of nurse providers in large data
sets, implementing a system for determining appropriate outcomes for patients
that, is sensitive to each individual's potential for self-care or recovery, and
continued research directed toward nurse-sensitive outcomes.
19 of 27
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Debate on the methods to improve health care.
Cairns-J
St Francis' Hospital, Katete, Zambia.
Trop-Doct. 1995; 25 Suppl 1: 9-12
ENGLISH
20 of 27
Marked Record
TI: Advance directives in the medical intensive care unit of a community
t e a c h i n g ho s p i t a 1 .
AU: Johnson-RF Jr; Baranowski-Birkmeier-T; 0'Donnel 1--JB
AD: Medical Intensive Care Unit, Blodgett Memorial Medical Center, Grand
Rapids, MI.
SO: Chest. 1995 Mar; 107(3): 752-6
LA: ENGLISH
AB: STUDY OBJECTIVE: To evaluate the frequency with which advance directives
(ADs) are available at the time of admission and their impact on subsequent
care in a medical intensive care unit (MICU) setting before and 9 months after
the implementation of the Patient Self-Determination Act (PSDA). DESIGN:
Prospective noprandomized cohort data collection and analysis. SETTING:
Thirteen-bed MICU of community teaching hospital providing primary and referred
care. PATIENTS: Consecutive admissions during 2-month periods separated by 1
y e a r 5 A la q is t —S e p L ember 1991 (91 ) a n d A la g la _• t — S e p t. em b er 1 '/ 2 ’. 9 2) u ) '1 L~ A dUF». F1 « F_»4 < «-•• <
The following were assessed: the presence and type or absence of AD at the Lime
of admission; the presence or absence of a written order to limit resuscitation
(WO—R) during the MICU stay; duration of MICU stay in hours; outcome; and
combined duration of use or administration of seven selected interventions.
MAIN RESULTS: Fifteen of 133 patients (11.37.) in the 91 group and 15 of 171
patients (8.87) in the 92 group presented with an AD. Ihis difference was not
significant (p — 0.578). Most patients in both groups (/5.9Z in 91 and 80.1/. in
92) presented without an AD and did not have a NG—R during their MICU course.
In addition, most patients who did present with an AD, 11 of 15 (73.37.) in the
91 group and 14 of 15 (93.37.) in the 92 group, did not have a WO-R. A subgroup
of older and more severely ill patients in both cohorts was identified; they
did not present with an AD but subsequently a WO—R was established. 1 hese
patients had the highest mortality, about 407, when compared with the overall
mortality of 8.27. CONCLUSION: Advanced directives were infrequently available
and had little impact on the pattern of care.
TI:
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21 of 27
Marked Record
From the -Joint Commission on Accrerii tat.ion of He a 1 the a re OrganizationsSeidenfeld-J; Hanoid-LS; Loeb—JM
Joint Commission on Accreditation of Heal thcare Organizations.
JAMA. 1995 Mar 1; 273(9):' 691“
ENGLISH
22 of 27
Marked Record
TI: Why has 'historic' public disclosure of hospital performance data attracted
so little attention? Enewsl
AU: Voelker-R
SO: JAMA. 1995 Mar 1; 273(9): 689-90
LA: ENGLISH
23 of 27
Marked Record
TI: Rural primary care, American College of Physicians.
SO: Ann-Intern-Med. 1995 Mar 1; 122(5): 380-90
LA: ENGLISH
AB: This overview of rural health care today shows the role that internal
medicine can and should play in delivering primary care to rural populations.
The American College of Physicians recommends changes to improve access to and
delivery of primary care in rural areas. There are six specific
recommendations. 1. Implementing universal health care coverage through a
system that makes primary care equally affordable to rural populations. 2.
Increasing the supply of primary care providers in rural areas by lessening
specialty and geographic differentials in physician income. 3. Increasing the
supply of primary care providers- in rural areas by changing medical education
to emphasize training enough rural physicians. 4. Decreasing professional
isolation in rural areas through accessible continuing medical education and
through telecommunications technology. 5. Identifying tertiary care needs at
the community level and using state and federal funds to assist rural haspita 1 s
where access to care would be threatened by hospital closure. 6. Using
innovative delivery systems that emphasize coordination and cooperation among
providers, institutions, and communities.
24 of 27
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TI:
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SO:
What information do consumers want and how will they use it?
Ware-JE Jr
Health Institute, New England Medical Center Hospitals, Boston, MA 02111.
Med-Care. 1995 Jan; 33(1 Suppl): JS25-30
LA: ENGLISH
25, of 27
Marked Record
TI : Performance measures. How are they developed, validated, and used?
/ AU: D' 1 .ea ry-DS
’ AD: Joint Commission on Ac c red i tation of Hea1 the ar e Organizations, Oakbrook
Terrace, IL 60181.
S 0: Med-Care. 1995 J an; 33 (1 Supp1>: J S13-7
LA: ENGLISH
TI:
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v AD:
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■ZL o o f
/
Marked Record
From the Joint Commission on Ac:creditation of Heal_thcar© Organizations.
Kdss-R; Nadzam-D; Loeb-JM
Joint Commission on Accredi tation of Hea1thcare Organizations.
JAMA. 1995 Jan 11; 273(21: 99
ENGLISH
27 of 27
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TI : Continuous quality improvement in inpatient clinical nutrition services.
AU: F1 ane1—DF; Fa i rc hi 1d—MM
AD: Department of Food and Nutrition Services, Yale-New Haven Hospital, Cl
06504.
SO: J-Am-Diet-Assoc. 1995 Jan; 95(1>: 65—74; quiz 75—6
LA: ENGL. ISH
AS: Defining quality patient care is a complex and often confusing issue. This
article describes one hospital's experience in applying quality improvement
theories to inpatient clinical nutrition practice. The key to measuring quality
was the use of standardized practice guidelines. In this article, terms such as
continuous quality improvement are clarified and fundamental assumptions such
as "quality is defined as conformance to requirements" are discussed. We review
a working model for the 10-step plan of the Joint Commission on Accreditat.ion
of Healthcare Organizations (JCAHO) and its application in practice, including
the indicators and measurement tools used. Actual results from ongoing quality
improvement efforts are addressed and compared to the JCAHO nine components of
quality patient care. Because of preexisting nutrition practice guidelines at
the Yale-New Haven Hospital, improvements in the delivery of patient nutrition
care could be demonstrated; these included enhanced efficiencies in screening
and intervention. Continuous quality improvement initiatives do work, and
practitioners can use the practice experience presented here as a conceptual
framework to Justify or validate the quality of patient nutrition care in their
own institutions.
PC-SPIRS 3.30
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MEDLINE (R) 1/96-10/96 usage is subject, to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws or your
country and/or by International Convention.
1 of 16
Marked Record
TI: Seven functions for network accreditation.
SO: Nurs—Qual—Connect. 1995 Sep-Oct; 5(2): 16
LA: ENGLISH
2 o f .16
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TI:
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Quality Q & A. Visual quality models.
Green-E
Nurs-Qual-Connect. 1995 Sep-Oct; 5(2):
ENGLISH
14
3 of 16
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TI:
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Ethics consultation quality: is evaluation feasible? EnewsJ
Phillips-DF
JAMA. 1996 Jun 26; 275(24): 1S66-7
ENGLISH
4 of 16
Marked Record
TI: The best system in the world.
AU: Brody-H
AD: Center for Ethics and Humanities in the Life Sciences, Michigan State
University, East Lansing, USA.
SO: Hastings-Cent-Rep. 1995 Nov-Dec; 25(6): SIS-21
LA: ENGLISH
5 o f 16
Marked Record
TI: How we lie.
AU: Annas-GJ
AD: Law, Medicine and Ethics Program, Boston University School of Medicine,
USA SO: Hastings-Cent-Rep. 1995 Nov-Dec; 25(6): S12-.1.4
LA: ENGLISH
6 of 16
Harked Record
TI: Lessons in cooperation: four hospital consortia relate their quality
improvement experiences.
AU: Kabcenel1-Al; Wakefield-D; Kaiden-SA; Thraen-I; Holland-M; Helms-C;
Jordan-C
AD: Program for Improving the Quality of Hospital Care, Cornell University,
11 haca, NY, USA.
SO: Jt-Comm-J-Qual-Improv. .1995 Nov; 21(11): 579-92
LA: ENGLISH
AB: BACKGROUND: In 1989, The Robert Wood Johnson Foundation launched a
demonstration project to test a consortium approach to quality improvement. As
part of this project, four hospital consortia in various parts of the United
States are currently sharing quality resources (for example, training) and
collaborating on various improvement efforts. The purpose of the project, is to
demonstrate that hospitals can take on more da. fficul t problems and accomplish
more in cooperation with each other than on their own. CASE STUDIES: The
Institute for Quality Healthcare (Iowa City,, Iowa) has built a comparative
database so that 40 member hospitals can make meaningful comparisons on various
aspects of performance; The Vermont Program for Quality in Health Care has
lowered the postoperative infection rate in Vermont by monitoring compliance
with consensus guidelines; Interwest Quality of Care, Inc, which has member
organizations in U ta h, Wyo m i n g , an d Id a ho, has adapted and disseminated
guidelines for diabetic care; and The Public Hospital Institute, in Berkeley?
California, has worked with the Joint Commission on Ac cred i t a t i on of Heal theare
organizations to develop a written guide to help surveyors understand the
unique operational traits of public hospitals. LESSONS LEARNED: Projects such
as those with champions in several member organizations- and comparative data
analysis lend themselves more easily to cooperative work than others. They also
provide some strategies for collaboration, such as continually reinforcing the
principles of collaboration, obtaining a fully informed commitment, beginning
with initiatives that are likely successes, and being serious and vocal about
the commitment to confidentiality. CONCLUSIONS: Col laborators in quality
improvement gain important resources, such as better information, more relevant
reference databases, colleagues and support for quality improvement
specialists, and economies- of scale in education programs, training materials,
and interaction with vendors. However, the difficulties in collaboration are
great. Hospitals must continually consider not only "What's in this for me,"
but also "What can we accomplish as a group that is greater than what each of
us can do alone?"
TI:
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7 o f 16
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From the Joint Commission on Accreditation of Healthcare Organizations.
Loeb-JM; Buck-AS
Joint Commission on Accreditation of Hea1thcare Organizations.
JAMA. 1996 Feb 21; 275(7): 50S
ENGLISH
S of 16
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TI: Joint Commission on A>cc. red i tat, ion of He st 1 thcare Organizations requirements
for sedation AU: Sklar-DP
AD: Department of Emergency Medicine, University of New Mexico School of
Medicine, Albuquerque, USA.
SO: Ann-Emerg-Med. 1996 Apr; 27(4): 412-3
LA: ENGLISH
9 of 16
Marked Record
TI: Strategies to Prevent and Control the Emergence and Spread of
Antimicrobial-Resistant Microorganisms in Hospitals. A challenge to hospital
leadership.
AU: Goldmann-DA; Weinstein-RA; Wenzel-RP; Tablan-OC; Duma-RJ; Gaynes-RP;
Schlosser-J; Martone-WJ
AD: Department of Medicine, Children's Hospital, Boston, Mass 02115, USA.
SO: JAMA. 1996 Jan 17; 275(3): 234-40
LA: ENGLISH
AB: OBJECTIVE—To provide hospital leaders with strategic goals or actions
likely to have a significant impact on antimicrobial resistance, outline
outcome and process measures for evaluating progress toward each goal, describe
potential barriers to success, and suggest countermeasures and novel
improvement strategies. PARTICIPANTS—A multidisciplinary group of experts was
drawn from the following areas: hospital epidemiology and infection control,
infectious diseases (including graduate training programs), clinical practice
(including nursing, surgery, internal medicine, and pediatrics), pharmacy,
administration, quality improvement, appropriateness evaluation, behavior
modification, practice guideline development, medical informatics, and outcomes
research. Representatives from appropriate federal agencies, the Joint
Commission on Accredi tation of Heal the3re Organizations, and the pharmaceutics1
industry also participated. EVIDENCE—Published literature, guidelines, expert
opinion, and practical experience regarding efforts to improve antibiotic
utilization and prevent and control the emergence and dissemination of
antimicrobial-resistant microorganisms in hospitals. CONSENSUS
PROCESS—Participants were divided into two quality improvement teams; one
focusing on improving antimicrobial usage and the other on preventing and
controlling transmission of resistant microorganisms. I he teams modeled the
process a hospital might use to develop and implement a strategic plan to
combat antimicrobial resistance. CONCLUSIONS—Sen strategic goals and related
process and outcome measures were agreed on. The five strategic goals to
optimize antimicrobial use were as follows: optimizing antimicrobial
prophylaxis for operative procedures; optimizing choice and duration of empiric.
therapy; improving antimicrobial prescribing by educational and administrative
means; monitoring and providing feedback regarding antibiotic resistance; and
defining and implementing health care delivery system guidelines for important
types of antimicrobial use. The five strategic goals to detect, report, and
prevent transmission of antimicrobial resistant organisms were as follows: to
develop a system to recognize and report trends in antimicrobial resistance
within the institution; develop a system to rapidly detect and report resistant
microorganisms in individual patients and ensure a rapid response by
caregivers; increase adherence to basic infection control policies and
procedures; incorporate the detection, prevention, and control of antimicrobial
resistance into institutional strategic goals and provide the required
resources; and develop a plan for identifying, transferring, discharging, and
readmitting patients colonized with specific antimicrobial--resistant pathogens.
10 of 16
Marked Record
TI: TeamWorks: a model for continuous quality improvement in the health care
industry„
AU: Hu n ter-DL ; Kern a n-MT; Gru b bs- MR
AD: Baptist Health Systems, Birmingham, AL, USA.
SO: Am-J-Med-Qual. 1995 Winter; 10?4>:'199-205
LA: ENGLISH
AB: Total quality management (TOM) or continuous quality improvement (CQI) are
terms nc< longer being used exclusively within the manufacturing industry
sector. Health care facilities, such as hospitals and nursing homes, are
beginning to actively compete with each other for patients as well as face new
regulations from the government. Hence, it is imperative that these facilities
reqS'aluate their services and correct any production problems in order to be
cost-effective and efficient in providing quality. Therefore, the objective of
this article is to describe a model developed for improvement of hospital-wide
services provided by the Baptist Health Systems' Montclair facility, a private,
community hospital located in Birmingham, Alabama. The TeamWorks for Quality
model, used to charter over 40 teams, illustrates how managers and employees
can build a multi faceted process that delivers services in excess of customer
e x pec t a t i o n s.
11 o f 16
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TI: The focused review process: a utilization management firm's experience with
length of stay guidelines.
AU: Nelson-MF; Christenson-RH
AD: Meridian Resource Corporation, Milwaukee, WI 53203, USA.
SO: Jt-Comm-J-Qual-Improv. 1995 Sep; 21(9): 477-07
LA: ENGLISH
Marked Record
TI: Hospital accreditation programmes; some international perspectives
I. editorial 1
Al!: Duggan-JM
SO: J-Qual-Cl in-Pract. 1995 Sep; 15(3): 129-31
LA: ENGLISH
13 of 16
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TI: Increasing the impact of quality improvement on health: an expert panel
method for setting institutional priorities.
AU: Rubenstein-LV; Fink-A; Yano-EM; Simon-B; Chernof-B; Robbins-AS
AD: Center for the Study of Healthcare Provider Behavior, Sepulveda Veterans
Affairs Medical Center (VAMC), CA, USA.
SO: Jt-Comm-J-Qual-Improv. 1995 Aug: 21(8): 420-32
LA: ENGLISH
AB: BACKGROUND: Successful implementation of modern ongoing quality improvement.
(QI) methods requires investment, of institutional resources, but can produce
significant improvements in medical care. A health care? organization's goals
and objectives for improving care are expressed in strategic plan documents,
which could provide a framework for planning quality improvement initiatives.
However, institutional strategic planning processes are often not well linked
to QI staff and resources. We developed the Quality Action Program (GAP) to
connect 01 to strategic planning. HISTORY: In 1991, Sepulveda VHAMC implemented
a major primary care initiative, documented in a comprehensive strategic plan.
The QAP was developed to enable the initiative to be evaluated within a QI
context. THREE-ROUND EXPERT PANEL PROCESS: To carry out the QAP, members of an
institution's quality council engage in a structured consensus process. The
first round involves reading educational materials and filling out a quality
action survey the second round includes participation in an expert panel
meeting, and the third round involves making final priority rankings.
EIGHT-STEP QAP IMPLEMENTATION PLAN: QI staff carry out activities to prepare
for and carry out the three-round expert panel process. RESULTS: QAP induced
significant institutional QI activity directed toward achieving the top-ranked
QI criterion—ensuring continuity of care. Continuity of care improved
significantly over time between the pre- and post-QAP periods. CONCLUSIONS:
Expert panel methods can be used to link strategic plan goals and objectives to
QI efforts.
14 of 16
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TI: The Australian Council on Healthcare Standards care Evaluation Program.
AU: Collcpy-BT: Ansari-MZ; Booth-JL; Brosi-JA
AD: Australian Council on Healthcare Standards Care Evaluation Program,
Me1bour n e, VIC.
SO: Med-J-Aust. 1995 Nov 6; 163(9): 477-80
LA: ENGLISH
AB: With the assistance of the medical colleges, the Australian Council on
Healthcare Standards (ACHS), through its Care Evaluation Program, has
established clinical performance measures which will assist both internal and
external review of care and enable hospitals to compare their quality of
patient care with that of other hospitals.
15 of 16
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TI: From the Joint Commission on Accreditation of Healthcare Organizations.
AU: Schyve-PM; Loeb-JM; Simmons-BP
AD: Department of Research and Evaluation, Joint Commission on Accreditation of
Healthcare Organizations, Oakbrook Terrace, IL, USA.
SO: JAMA. 1995 Nov 15; 274(19):
L A: ENGL ISH
1497
16 of 16
Marked Record
fl: 1 he availability of health care information for consumer use.
AU: Mowll-CA
AD: Joint Commission on Ac cred ita 11on of Hea1 the are Organizations, Oakbrook
Terrace, Illinois, USA.
SO: J—Hea1th-Care—Finance. 1995 Summer; 21(4): 31—44
LA: ENGLISH
AB: This study assesses the current availability of health care cost and
quality information at both the state and national levels. More than 130
sources were contacted, including all state commissioners of health and state
hospital associations. Eighty-one percent of the responding states report
provider-specific information to the public, 73% require providers to submit
data to the state, and the department of health or a state health care
commission is the data collection entity of 69% of the states. However
ambitious or mature some state health care data initiatives have become, the
comparative measures of provider performance are generally primitive, the data
sources are unreliable in many cases, and the data sources and measures are
widely variant across states.
*
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'S
*
MEDLINE (R)
1995
MEDLINE (R) 1995 usage is subject to the terms and conditions of the
Subscription and License Agreement and the applicable Copyright and
intellectual property protection as dictated by the appropriate laws of your
country and/or by International Convention.
.1. o f .2
Marked Record
TI: What (if anything) is wrong with residency overwork?
AU: Sreen —MJ
AD: University of Wisconsin—Madison Medical School, USA.
SD: Ann—Intern—Med. 1995 Oct 1; 1.23(7)5 51.2—7
LA: ENGLISH
AB: Long work hours during residency are a time-honored tradition. Efforts have
recently been made to shorten work hours. This paper examines the main
arguments supporting reform: that sleep deprivation is harmful to patients and
residents and that it is exploitative. Because the data on the harms and
benefits are mixed and because exploitation is difficult to prove, a stronger
argument for reducing work hours is an ethical one: that overwork interferes
with the development of professional values and attitudes that are an essential
part of the moral curriculum of residency. Providing a climate that promotes
moral, growth during training is an important curricular objective that may be
better achieved by shortening work hours, providing better resident
supervision, and using substitute workers for some of the noneducationa1 tasks
of residency.
2 of 2
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TI: Diffusion of standards of care for cancer pain [see comments!
AU: H agen-N; ¥toung-J; Mac Dona1d—N
.jk
AD: Department of Clinical Neurosciences, University of Calgary, Alta.
i/SD; Can-Med-Assoc-J. 1995 Apr .1.5; 152(8): 1235-9
L A : ENGL ISH
AB: The authors report the results of a symposium on improving the standards of
care for patients with cancer pain. The symposium was sponsored by the Advisory
Committee on Cancer Control of the National Cancer Institute of Canada and was
held Apr. 8 to 10, 1994, in Toronto. Participants included experts on control
/of cancer pain and on diffusion techniques, patients with cancer and
V representatives of regulatory agencies. They suggested the following strategies
&
to improve outcomes in patients with cancer pain. Processes for accreditation
of heal th care institutions should require documentation of cancer pain, its
treatment and its outcome. Tertiary care facilities that provide cancer
treatment should have expert, subspecialty, multidisciplinary programs for pain
control and should provide adequate psychosocial support to patients suffering
cancer pain. The Canadian Cancer Society should conduct a public-education
campaign to encourage patients to report pain to health care providers. The
National Cancer Institute of Canada should foster research on cancer pain by
restructuring its process for review of pain-research protocols. Examinations
for professionals who care for patients with cancer should include a defined
number of questions concerning pain and symptom control. Provincial programs to
monitor prescribing through the use of triplicate prescription pads should have
an educational as well as regulatory purpose.
rc-spirs
3.3a
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1 of 42
Marked Record
TI: NHS league tables: does a 5-star rating indicate 5-star care? £editorial 3
AU; MacAlister—L
SO: Br-J-Nurs. 1994 Jul 14-27: 3(13): 647-8
LA: ENGLISH
AB: The Hospital and Ambulance Services: Comparative Performance Guide
1993-1994 rates all major hospitais in England according to criteria drawn from
The Patient's Charter. It is important to interpret the performance ratings
/carefully as the data do not speak for themselves. Crude data about waiting
times may be misleading. An improvement in the waiting times for some
treatments may mask increased waiting times for others, perhaps painful,
treatments. More informative measures relating to the quality of care are
necessary to make meaningful distinctions between the? hGsj3i ta.l.s.
2 of 42
Marked Record
TI: Economic issues in managed care.
AU: Dobbins-R
AD: United American Healthcare Corporation, Detroit, MI 48207.
SO: J—Heal th—Care-Poor—Underserved. 1994; 5(3): 214-8; discussion 237—9
LA: ENGLISH
AB: Economic issues abound in managed care. The advent of health insurance in
the United States, which was created to ensure payment to hospital s. diminished
an early emphasis on charity care. Escalating health care costs have ensued.
Today, economic considerations dictate the need to control health care
expenditures while guaranteeing responsible care. Managed care organizations
can achieve both goals by establishing financial partnerships with physicians
while instituting quality-control audits, management review teams, and
home-care arrangements.
3 of 42
Marked Record
TI: The quality improvement strategy.
AU: Burns-LR; Beach-L.R
AD: Department of Management and Policy, College of Business and Public
Administration, University of Arizona, Tucson.
SO: Health-Care-Manage-Rev. 1994 Spring; 19(2): 21-31
LA: ENGLISH
AB: To prepare for managed competition, many hospita1s now focus on service
quality as a means to improve their competitive position. To aid in decisions
about where best to direct limited resources, managers need physician feedback'
about how the hospitai's services compare with its competitors' services
(competitive advantage), and about the degree to which the hospital's services
fall short of, meet, or exceed physicians' expectations (customer
satisfaction). This article describes a strategy for acquiring information
about competitive advantage and customer satisfaction and for using the
information to identify optimal service improvement opportunities. It then
presents a step-by-step application of the Quality Improvement Strategy (GilS)
for a large urban hospital.
4 of 42
Marked Record
TI: Cost containment: the Americas. Argentina.
AU: F'alizas-F: Gallesio-A; Wainsztein-N; Ceraso-D; Apezteguia-C; F’acin-J
AD: Intensive Care Unit, Clinica Bazterrica, Buenos Aires, Argentina.
SO: New-Horiz. 1994 Aug; 2(3): 336-40
LA: ENGLISH
AB: For many years, the evolution of Argentina's healthcare system has been
influenced by political and economic instability. Inflation and hyperinflation
have led to anarchic development of both health administration systems and
hospitals. Critical care grew in a similar manner, resulting in a mix of > 500
critical care units with very different levels of technology and trained
personnel. Cost-containment policies have been implemented mainly by health
administration systems. Public institutions (university and large provincial
and county hospitals) have suffered hard budget cuts that have resulted in a
decrease in the quality of care and the loss of trained human resources. Union
organizations, which cover the healthcare costs of > 607. of the population,
implemented a low reimbursement policy that resulted in low standards of care
for critically ill patients. The country's private hospital system is
extremely heterogenous, ranging from little, simple institutions with a 20- to
30—bed capacity to great private institutions with international standards of
care. Cost—containment efforts have been sporadic and isolated, and statistical
data to analyze the results are lacking. In order to formulate a strategy of
cost-containment in the? near future, accreditation and categorization of
critical care units and human resources training are being implemented by
heal th authorities and the Argentine Society of Critical Care Medicine.
5 of 42
Marked Record
TI: GUIDe (Guidelines for the Use of Intensive Care in Denver): a community
effort to define futile and inappropriate care.
AU: Murphy—DJ; Barbour—E
AD: Senior Citizen's Health Center, Presbyterian/St. Luke's Medical Center,
Denver, CD S0218.
SD: New-Horiz. 1994 Aug; 2(3): 326—31
LA: ENGLISH
AB: Several issues force us to critically evaluate futile or inappropriate
intensive care. These issues include cost control, quality of care, and
professional and family integrity. The debate has progressed along three
avenues; ethical discourse, prognostic scoring systems, and debate in the
courts. Despite these arenas of discussion, a consensus about, futile or
inappropriate care has not been reached. The healthcare profession and the
public need to work together to forge a consensus. We describe one model that
facilitates this political process. Guidelines for the Use of Intensive Care in
Denver (GUIDe) is a consortium of metropolitan Denver hospitaIs and other
healthcare institutions whose goal is to develop guidelines for the use of
futile or inappropriate intensive care. The building of consensus starts with
subcommittees (adult intensive care, neonatal intensive care, and long-term
care) that present proposals at plenary sessions. Other subcommittees (public
liaison and legal subcommittees,) facilitate dialogue with the public. Feedback
from the plenary sessions, the greater medical community, and the public lead
to proposal revisions. We expect to present hospitais with actual guidelines in
approximately 3 yrs.
6 of 42
Marked Record
TI: Care of dying patients in hospital.
AU: Mills-M; Davies-HT; Macrae-WA
AD: Department of Epidemiology and Public Health, University of Dundee,
Ninewells Hospital and Medical School.
-'"SO: BMJ, 1994 Sep 3; 309(6954): 5S3-6
LA: ENGLISH
AB: OBJECTIVE—To study the process of care of dying patients in general
hospita 1 s . DESIGN—Non-participant observer (MM) carried nu t regular periods of
continuous comprehensive observation in wards where there were dying patients,
recording the quantity and quality of care given. Observations were made in
1983. SETTING—13 wards (six surgical, six medical, and one specialist unit) in
four large teaching hospitais (bed capacity 504-796) in west of Scotland.
SUBJECTS—50. dying patients (29 female, 21 male) with mean age of 66 (range
40-89); 29 were dying from cancer and 21 from non-malignant disease.
RESULTS—Final period of hospitalisation ranged from 6 hours to 24 weeks. More
than half of all patients retained consciousness until shortly before death.
.Basic interventions to maintain patients' comfort were often not provided; oral
hygiene was often poor, thirst remained unquenched, and little assistance was
given to encourage eating. Contact between nurses and the dying patients was
minimal; distancing and isolation of patients by most medical and nursing staff
were evident; this isolation increased as death approached. CONCLUSIONS—Care
of many of the dying patients observed in these hospitaIs was poor. We need to
identify and implement practical steps tc< facilitate high quality care of the
dying. Much can be learned from the hospice movement, but such knowledge arid
skills must be replicated in all settings.
7 of 42
Marked Record
TI: Impact of qua!ity-of-care factors on pediatric intensive care unit
mortality.
ALU Pol lack-MM; Cuerdon-TT; Patel-KM; Ruttimann-UE; Getson-PR; Levetown-M
AD; Department of Pediatrics, George Washington University School of Medicine,
Washington, DC.
SO; JAMA. 1994 Sep 28; 272(12); 941-6
LA; ENGLISH
AB: OBJECTIVE—To determine the importance of the following care factors
previously associated with hospital quality on survival from pediatric
intensive care; size of the intensive care unit (ICG), medical school teaching
status of the hospital housing the ICU, specialist status (pediatric
intensivist), and unit coordination. DESIGN—After a national survey,
consecutive case series were collected at 16 sites randomly selected to
represent unique combinations of quality-of-care factors. SETTING—Pediatric
ICUs. PATIENTS—Consecutive admissions to each site. MAIN OUTCOME
MEASURE—Patient mortality adjusted for physiologic status, diagnosis, and
other mortality risk factors. RESULTS—There were 5415 pediatric ICU admissions
and 248 ICU deaths. The ICUs differed significantly with respect to descriptive
variables, including mortality (range, 2.2% to 16.4%). Analysis of
risk-adjust® mortality indicated that the hospital teaching status and the
presence of a pediatric intensivist were significantly associated with a
patient's chance of survival. The probability of patient survival after
hospitalization in an ICU located in a teaching hospital was decreased
(relative odds of dying, 1.79; 95% confidence interval ECI1, 1.23 to 2.61; P =
.002). In contrast, the probability of patient survival after hospitalization
in an ICU with a pediatric intensivist was improved (relative odds of dying,
0.65; 95% CI, 0.44 to 0.95; P = .027). Post hoc analysis indicated that the
higher severity-adjusted mortality in teaching hospitals may be explained by
the presence of residents caring for ICU patients. CONCLUSION—Characteristics
indicative of the best overall hospital quality may not be associated, or may
be negatively associated, with quality of care in specialized care areas,
i nc1uding t he ped ia t r i c ICU.
8 of 42
Marked Record
TIs Individualized developmental care for the very low-birth-weight preterm
infant. Medical and neurofunctional effects (see comments!
AU; Als-H; Lawhon-G; Duffy-FH; McAnulty-GB; Gibes-Grossman-R; Blickman-JG
AD: Department of Psychiatry, Harvard Medical School, Boston, MA.
SO: JAMA. 1994 Sep 21; 272(11): 853-8
LA: ENGLISH
AB: OBJECTIVE—To investigate the effectiveness of individualized developmental
care in reducing medical and neurodevelopmental sequelae for very
low—birth-weight infants. DESIGN—Randomized controlled trial. SETTING—Newborn
intensive care unit. PATIENTS—Thirty-eight singleton preterm infants, free of
known congenital abnormalities, weighing less than 1250 g, born before 30
weeks' gestation, mechanically ventilated within 3 hours of delivery and for
more than 24 hours in the first 48 hours, randomly assigned to a control or an
experimental group. INTERVENTION—Caregiving by nurses specifically trained in
individualized developmental care; observation and documentation of the
infants' behavior within 12 hours of admission, and subsequently every 10th
day; developmental care recommendations and- ongoing clinical support for the
nurses and parents based on regular observation of the infant by developmental
specialists; and the availability of special caregiving accessories. MAIN
OUTCOME MEASURES—Medical outcome, including average daily weight gain; number
of days the infant required mechanical ventilation, oxygen, gavage tube
feeding, and hospitalization; severity of retinopathy of prematurity,
bronchopuImonary dysplasia, pneumo thorax, and intraventricular hemorrhage;
pediatric complications; age at discharge; and hospital charges.
NeurodevelopmentaI outcome, including Assessment of Preterm Infants' Behavior
scale and quantified electroencephalography (2 weeks after due date); and
Bayley Scales of Infant Development and Kangaroo Box Paradigm (9 months after
due date). RESULTS—The infants in the experimental group had a significantly
shorter duration of mechanical ventilation and supplemental oxygen support;
earlier oral feeding; reduced incidence of intraventricular hemorrhage,
pneumothorax, and severe bronchopulmonary dysplasia; improved daily weight
gain; shorter hospital stays; younger ages at hospital discharge; and reduced
hospital charges compared with the infants in the control group. At 2 weeks
after their due dates, these infants, also showed improved autonomic regulation,
motor system functioning, self-regulatory abilities, and visual evoked
potential measures; and at 9 months, they had .improved Bayley Mental and
Psychomotor Developmental Index scores, as well as Kangaroo .Box Paradigm
scores. CONCLUSION—Very low-birth-weight preterm infants may benefit from
individualized developmental care in the neonatal intensive care unit in terms
of medical and neurodevelopmental outcome.
9 of 42
Marked Record
TI: Evaluating risk adjustment by partitioning variation in hospital mortality
rates.
AU: Smith-DW
AD: Biostatistics and Epidemiology Department, College of Public Health,
University of Oklahoma, Oklahoma City 73190.
SO: Stat-Med. 1994 May 30; 13(10): 1001-13
LA: ENGLISH
AB: The variation in mortality rates among haspi tais has often been described
informally as having three major components: patient severity, quality of care
and random variation. These informal concepts are characterized formally by
partitioning sums of squares and finding their expected values. The partition
relates to commonly used tests for whether individual hoepita1 s have unusual
mortality rates. Application of the partition to the hospital mortality reports
by the Health Care Financing Administration shows that their models for patient
risk account for about one-half the variation among hospital mortality rates.
An example using clinical measures of severity accounts for about two-thirds of
mortality variation among hospitals.
10 of 42
Marked Record
TI: Interim report of the Quality Indicator Study Group.
AU: Sc hec k1er-WE
AD: University of Wisconsin Medical School, Department of Family Medicine,
Madison 53715.
SO: Am—J—Infect—Control.
L A: ENGLISH
TI:
AU:
AD:
SO:
LA:
1994 Apr; 22(2): 30A—66A
11 of 42
Marked Record
Can we set futile care policies? Institutional and systemic challenges.
Mu r phy-DJ
St. Luke's Hospital, Denver, CD 80218.
J—Am—Geriatr—See. 1994 Aug; 42(8): 890—o
ENGL ISH
12 of 42
Marked Record
TI: Standardizing the language for nursing treatments: an overview of the
i ssues.
AU: Me Closkey-iJC; Bulechek—GM
AD: College of Nursing, University of Iowa Hospitals- and Clinics, Iowa City.
SO: Nurs-Oi.itlook. 1994 Mar-Apr; 42(2): 56-63
LA: ENGLISH
AB: The development and use of standardized language in nursing marks the
development of a new era of nursing science. It will assist the professional
nurse to communicate with colleagues in her or his own facility and across the
world. Being able to clearly articulate what it is we do makes visible what
previously has been invisible about nursing. When we use standardized language
to document the care we give,, then we can build large databases, which will
articulate with those of other health providers, that can be used to
demonstrate the effectiveness of nursing care. As we move into the 21st
century, the use of standardized nursing language will become one of the
hallmarks of the profession.
13 of 42
Marked Record
TI: CEO summit. The new delivery & financing realities. Fart II of III.
AU: Becker-BF; Cramer-H; Easley-D; Nathanson-P; Neeson-R; Raney-J; Samuelson-C;
Umme1-S
SO: Hosp—Health—Netw. 1994 Aug 5; 68(15): 86-8
LA: ENGLISH
AB: In cooperation with McManis Associates Inc., Hospitals & Health Networks
recently convened a summit on the integration of financing and delivery in
health care. This is the second of a three-part series on lessons learned by
those on the front lines of integration activity. The session was designed and
facilitated by senior associates at McManis. Among the issues discussed in this
second segment. What level of understanding do purchasers have of quality
differentiators in health care services? Can provider-driven integrated
delivery systems compete with insurer-driven ones? And what happens when, as .in
the Philadelphia market, a large integrated delivery system merges with a
dominant insurer? Can that model be replicated in other markets?
14 of 42
Marked Record
TI: Understanding patient-centered care in the context of total quality
management and continuous quality improvement.
AU: Wakefield-DS; Cyphert-ST; Murray-JF; Uden-Holman-T; Hendryx-MS;
Wakefield-BJ Helms-CM
AD: Graduate Program in Hospital and Health Administration, University of Iowa,
Iowa City 52242.
SO: Jt-Comm-J-Qua1-Improv. 1994 Mar; 20(3): 152-61
LA: ENGLISH
AB: BACKGROUND: Implementing patient-centered care (PCC) requires a fundamental
shift in thinking-from how to best provide a wide variety of independent
services- to how to effectively combine individual service components into an
integrated health care experience that meets patient needs and preferences.
DISCUSSION: FCC attempts to improve patient care by organizationally and
physically moving selected service functions such as basic laboratory,
pharmacy, admitting/discharge, medical records, housekeeping, and material
support services to patient care areas, thus effecting an organizational
restructuring. FCC creates teams composed of multiskilled or cross-trained
individuals capable of providing more of the services directly on the patient
care unit. Extensive redesign of the basic work processes as proposed by FCC
advocates may result in significant changes in employee job scope, task
responsibilities, professional autonomy, and reporting relationships. From the
employee's perspective such changes may be neither warranted nor welcomed.
Therefore, critical FCC implementation issues include obtaining employee buy-in
and establishing appropriate incentive structures to facilitate the desired
changes. How does FCC fit in with the popular improvement philosophies of total
quality management (TQM) and continuous quality improvement (CQI)7 Inherent
within TQM and CQI is the belief that it is wiser to maximize efforts to design
a product or process to be right the first time and to minimize resources
devoted to inspection and repair caused by poor processes. FCC builds upon
previous TQM/CQI health care efforts by focusing on ways to reduce the white
space handoff problem by examining what, if any, changes in underlying
structures and processes may be required. In the FCC hospital, TQM/CQI can
function as intended, as a methodology for examining and improving the process
of care and patient-care outcomes, regardless of internal departmental or
profession-based organizational boundaries. CONCLUSION: For hospitals to remain
competitive in today's rapidly changing environment, it is becoming necessary
to reevaluate both how they are organized and how their work processes have
been designed and controlled. The groundwork already laid by TQM/CQI
initiatives will facilitate the more fundamental and long-lasting improvements
derived from the redesign of the patient-care unit as prescribed by the goals
of FCC.
15 of 42
Ma r k e d Record
TI: Equity in the NHS. Monitoring and promoting equity in primary and secondary
care.
AU: Majeed-FA; Chaturvedi-N; Reading—R; Ben-Shlomo-Y
AD: Department of Public Health Sciences, St George's Hospital Medical School,
London.
AO: BMJ. 1994 May 28; 308(6941): 1426-9
LA: ENGLISH
AB: Although need is often assumed to be the most important, factor in
determining the use of health services, there are many inequities in the
provision and use of NHS services in both primary and secondary care. For
example, existing data from district child health information services have
been combined with census data for small areas to show wide variations in
immunisation rates between affluent and deprived areas. Purchasers of health
care are already responsible for assessing health needs and evaluating
services, and the process of monitoring equity is a logical extension of these
activities. Routine data sources used to collect activity data in both primary
and secondary care can be used to assess needs for care and monitor how well
these needs are met. Purchasers and providers should collaborate to improve the
usefulness of these routine data and to develop a framework for monitoring and
promoting equity more systems t.ica 11 y .
TI:
AU:
AD:
SO:
.1.6 of 42
Marked Record
A quality improvement focus for patient rights: advance directives.
Oleson-KJ; Jones-Schenk-J; Tuohig-GM
Nursing Practice Department, University of Utah Hospital, Salt Lake City.
J—Nurs—Care-Qual. 1994 Apr; 8(3): 52-67
LA: ENGLISH
AB; This article highlights the implementation and evaluation phases of
specific mechanisms developed in a university hospital setting to comply with
the Patient Self-Determination Act (PSDA) of 1991. The article describes the
program within the context of a continuous quality improvement cycle beginning
with a philosophy about patient involvement in health care decision making. The
article takes the reader through each phase of the process, culminating in the
development of a revised quality improvement plan.
17 of 42
Marked Record
TIs Interim report of the Quality Indicator Study Group.
AU; Sc hec k1er-WE
AD: University of Wisconsin Medical School. Department of Family Medicine,
Madison 53715.
SO: Infect—Control—HbSp-Epidemiol. 1994 Apr; 15(4 Pt 1); 265—8
LA: ENGLISH
IS of 42
Marked Record
TI: Financial and clinical performance: bridging the gap.
AU: Fleming—ST; Boles—KE
AD: University of Missouri-Columbia,
SO: Hea1th-Care—Manage—Rev. 1994 Winter; 19(1): 11-7
LA: ENGLISH
AB: The article explores the relationship between the cost and the quality of
hospital care by elaborating a conceptual model of hospital performance. The
model relates the financial health status of an organization (financial
integrity) to the quality of care provided by that organization (clinical
integrity) within an environment that is characterized by various forms of
risk. The model suggests, that both concepts determine the corporate destiny
(success, b a n k r u p t c y, or m e r g e r) of t he o r g a n i z a t. i o n. If t h i s m o d e 1 p r o v e s
valid empirically, the results could be used as an early warning system to
identify bospita1s that might experience financial or clinical distress.
19 o f 4 2
Marked Record
TI: What is interface audit?
AU: Baker—R
AD: Eli Lilly National Clinical Audit Centre, Department of General Practice,
University of Leicester, Leicester General Hospital, UK.
SO: J-R-Soc-Med. 1994 Apr; 87(4): 228-31
LA: ENGLISH
20 of 42
Marked Record
TI: Closing the gap between research and practice,
AU: Bostrom-J; Wise-L
AD: Stanford University Hospital, California.
SO: J-Nurs-Adm. 1994 May; 24(5): 22-7
LA: ENGLISH
AB: Currently, a 10- to 15-year gap exists between discovery of potential
innovations and implementation of these innovations into nursing practice. The
Retrieval and Application of Research in Nursing (RARIN) project is helping to
reduce this gap in one western hospital. The goal of RARIN is to improve the
quality of nursing care by facilitating the transfer of new and clinically
relevant nursing information to current practice. This is accomplished by
providing nurses with both the tools and training for rapid retrieval of
scientific information. Their work areas have been elec ironical 1y linked with
local, national, and international scientific information systems.
Marked Record
TI: Managed care plan performance since 1980. A literature analysis.
AU: Miller-RH; Luft-HS
AD: University of California-San Francisco, Institute for Health & Aging 94143.
SCI: JAMA. 1994 May IS; 271(19): 1512-9
LA: ENGLISH
AB; OBJECTIVE—To compare the health care utilization, expenditure, quality of
care, and satisfaction since 19S0 of enrollees in managed care and indemnity
plans. DATA SOURCES AND STUDY SELECTION—Studies selected met the following
criteria: data from 1980 forward, private insurance or Medicare enrollees, a
comparison group, a reasonable attempt at statistical adjustment for
noncomparable managed care and indemnity plan enrollees, and peer-reviewed
findings (with two exceptions). Few studies on preferred provider organization
plan performance met the selection criteria. DATA SYNTHESIS—Compared with
indemnity plans, health maintenance organization plans had somewhat lower
hospital admission rates, IX to 20Z shorter hospital length of stay, the same
or more physician office visits per enrollee, less use of expensive procedures
and tests, greater use of preventive services, mixed results on outcomes, and
somewhat, lower enrollee? satisfaction with services but higher satisfaction with
costs. The evidence does not support the hypothesis that prepaid group practice
or staff model health maintenance organizations are more effective than
individual practice association or network model health maintenance
organizations. CONCLUSIONS—Although this literature analysis found several
clear patterns of results, several factors, including unmeasured selection
bias, diverse and rapidly changing health plans and local market conditions,
and relatively few research results, suggest that generalizations must be made
w i t h c a u t i on .
22 of 42Marked Record
Impact on estimates of
TIs Variation in practice for discretionary admissions.
quality of hospital care.
AU: Miller-MG; Miller-LS; Fireman-B; Black-SB
AD: Department of Quality and Utilization, Kaiser Permanent© Medical Care
Program, Oakland, CA 94612.
SO: JAMA. 1994 May IB; 271(191: 1493-8
LA: ENGLISH
AB: OBJECTIVE—To demonstrate theoretically and empirically the existence of
systematic bias in commonly reported standardized hospital mortality ratios
when variation in hospital admission practice is not adjusted for in the
analysis. The underlying analytic model used in hospital mortality analyses is
specified and the confounding effect of selection bias arising from variation
in admission practice is shown. DATA SOURCES—An empirical example is presented
using state-level data from the Health Care Financing Administration's Medicare
Hospital Information Report for 1988 to 1990. STUDY SELECTION—The Medicare
Hospital Information data are used to demonstrate the effects of the bias
because they contain population-based admission rates and mortality rates. DA 1A
SYNTHESIS—Selection bias arising from variation in admission practice causes
the expected mortality rate to be overestimated for all hospita 1 s, but
especially for hospi tail s with more lenient admission practices. 'Using the
Medicare Hospital Information Report, the resulting standardized hospital
mortality ratios are shown to be significantly inversely correlated with higher
relative risks of hospitalization (P '■( .01). CONCLUSION—Standardized hospital
mortality ratios based on analyses that do not account for variation in
admission practice among hospitals are biased. Variation in admission practice
will cause any outcome measure based solely on hospitalized patients to be
similarly biased. Correction for selection bias is required to produce valid
measures of hospital quality.
of 42.
Marked Record
.TI: Targeting ambulatory care cases, for risk management and quality management.
AU: Macnee-CL; F'enchansky-R
AD: College of Nursing, Department of Family and Community Health, East
Tennessee State University, Johnson City 37614-0676.
SO: Inquiry. 1994 Spring; 31(1): 66-75
LA: ENGLISH
AB: Means are needed to identify "highly productive" areas for quality review
and risk management in ambulatory care; untargeted medical record reviews have
too low a yield and too high a cost to be useful. Highly productive areas are
those with important medical and economic consequences, large numbers of cases,
aspd a reasonable potential that problems exist. This paper describes untoward'
event screens to identify highly productive areas for review based on hospital
discharge diagnosis, procedure codes, and parameters such as length of stay and
cancer staging. The approach proposed has been eval listed in six ambulatory care
organizations and appears effective and efficient.
24 of 42
Marked Record
TI:
AU:
AD:
SO:
LA:
Corporate relations. Business ethics.
Keane-MM
Nova Care, Inc., Fairfax, Virginia.
ASHA. 1994 Feb; 36(2): 47-8
ENGLISH
25 of 42
Marked Record
TI: CThe evaluation of outpatient nursing care according to the client's
perception 1
AU: Sama-MC
SO: Rev-Esc—Enferm-USP. 1993 Apr; 27(1): 133-49
LA: PORTUGUESE; NON-ENGLISH
AB: This study revea 1 s the c 1 i en ts perception of a pediatric ambu 1 atc<ry in a
great University Hospital, about the quality of the offered nursing assistance.
An investigation was oriented by the phenomenalogic approach which propitiated
the reveling of reality investigated from the analysis of the interviewed
clients discourses. The studied answers were grouped in three categories: the
Nursing Work, the Nursing Attitude and the Evaluation of the Received
Assistance. Upon these topics the interviewed clients formed a not very clear
concept of nursing as science and as a profession. The related aspects and the
commentaries about the expected and the meeted behaviours by the nursing
professionals merited a larger part of attention by the interviewed clients.
The evaluation of the received attendance was centered on absence of
complaints. The interviewed clients expectancy is directed towards the
satisfaction of the? security and acceptance needs from which the mothers of
children are deprived. The attendance of this necessities give mothers
conditions for establishment of a professional-client link to a therapeutic
relationship. Which the devolution of the findings to the nurses responsible
for the ambulatory assistance, we pretended to contribute to the improvement of
the offered assistential quality.
26 of 42
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TI: Nursing quality management in The Netherlands.
AU: Giebing-H
AD: Nursing Quality Assurance Programme, Utrecht, The Netherlands.
SO: Int—Nurs-Rev. 1994 Jan-Feb; 41(1): 17-22
LA: ENGLISH
AB: Since 1979 the National Organization for Quality Assurance in Health Care
(CBC1) in the Netherlands has been offering support and training to healthcare
professionals in the application of structural and systematic quality assurance
activities in hospitals. Below, CBD's -Framework to develop nursing quality
management at institutional and national level, with the ultimate goal of
ongoing quality improvement of nursing care.
27 of 42
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TI: Withdrawing care. Experience in a medical intensive care unit,
AU; Lee—DK; Swinburne—AJ; Fedullo—AJ; Wahl—GW
AD: Rochester General Hospital, NV 14621,
SO: JAMA. 1994 May 4.; 271(17): 1358-61
LA: ENGLISH
AB: OBJECTIVE—To describe the process and outcomes of withdrawing
life-sustaining interventions in a medical intensive care unit (MICU).
DESIGN—Retrospective case series. SETTING—Medical intensive care unit in a
community teaching hospital. PATIENTS—Consecutive series of 28 patients in
whom mechanical ventilation, dialysis, and/or vasopressors were withdrawn. We
distinguished physiological, neurological, and functional rationales for care
withdrawal. MAIN OUTCOME MEASURES—Duration of discussions, MICU length of
stay, and hospital survival. RESULTS—Mean •<-/- SD Acute Physiology and Chronic
Health Evaluation (APACHE II) score was 27 1 +/- 7.3 on MICU admission, and
average +/— SD predicted hospital mortality was 61% +/— 22%. Discussions
leading to withdrawal of care occurred over an average +/- SD of 5.2 +/•- 5.5
days, with decisions achieved soonest in cases with poor neurological
prognosis. Average +/— SD MICU length of stay was 1.4 +/— 1.9 days following
decision to withdraw MICU care, and only four patients received more than 48
hours of additional MICU care. Four patients were discharged alive from the
hospital, CONCLUSIONS—Patients and their surrogates willingly considered
outcomes in addition to mortality when considering withdrawal of
life-sustaining interventions. Finding an accommodation between physician
judgments and patient preferences took time and effort but was an effective
means of limiting ineffective life-sustaining efforts. Withdrawing futile or
unwanted care was.not always fatal.
28 of 42
Marked Record
TI: Quality of health services in Papua New Guinea: what do we know?
AU; Thomason—JA
AD: Department of Community Medicine, University of Papua New Guinea, Port
Moresby.
SD: P-N-G-Med-J. 1993 Jun; 36(2): 90-8
LA; ENGLISH
AB: The discussion of quality issues in Papua New Guinea requires that
attention be focused on what is known about the actual quality of the health
care provided in Papua New Guinea. Since 1987 there has been increasing
evidence that there are serious deficits in the quality of care in rural areas
and that there are similar problems in the country's hospita1s, This paper
summarizes what is known and discusses the implications for the development of
quality assurance activities in Papua New Guinea. The paper concludes that many
of the deficiencies observed are amenable to improvement through simple and
inexpensive means and that with sustained commitment, improvements are
achievable.
29 of 42
Marked Record
TI: Consensus statement on the triage of critically ill patients. Society of
Critical Care Medicine Ethics, Committee.
SO: JAMA. 1994 Apr 20; 271(15): 1200-3
LA: ENGLISH
AB: The demand for medical services such as critical care is likely to often
exceed supply. In the setting of these constraining conditions, institutions
and individual providers of critical care must use some moral framework for
distributing the available resources efficiently and equitably. Guidelines are
therefore provided for triage of critically ill patients. There are several
general principles that .should guide decision making: providers should advocate
for patients; members of the provider team should collaborate; care must be
restricted in an equitable system; decisions to give care should be based on
expected benefit;, mechanisms for alternative care should be planned; explicit
policies should be written; prior public notification is necessary. Patients
who are not expected to benefit from intensive care, such as those with
imminently fatal illnesses, or permanent unconsciousness, should not be placed
in the intensive care unit. Hospita1s should assign individuals the
responsibility of intensive care triage, and a committee should oversee the
performance of this responsibility to facilitate the most efficient and
equitable use of intensive care.
30 of 42
Marked Record
TI:
AU:
SO:
L A:
Does the patient come first?
Aussie n-JI
Surg—Neurol. 1994 Mar; 41(3): 253
ENGLISH
31 of 42
Marked Record
TI: Computers, quality, and the clinical laboratory: a look at critical value
reporting.
AU: Tate—KE; Gardner-RM
AD: LOS Hospital/Brigham Young University, Salt Lake City, UT.
SO: Proc-Annu-Symp-Comput-App1-Med-Care. 1993: 193-7
LA: ENGLISH
AB: The reporting of critical values is an important function of the clinical
laboratory. The success of critical value reporting depends on laboratory
personnel recognizing critical values and effectively communicating them to
clinicians., and on clinicians correctly interpreting and using the critical
values to provide appropriate patient care. At LDS Hospital, we have conducted
a study of the critical value reporting process. Results of the study indicate
that few critical values are actually reported by the clinical laboratory (only
28 of 294 critical values during November 24-30, 1992). Data on the quality of
critical value documentation showed that 19 of 124 (IS'Z) patient charts audited
during January-February, 1993 contained no documentation that clinicians were
ever aware of the critical value, or that corrective actions were taken. Other
data on the quality of critical value reporting were also collected and
analyzed. Study results have been used to design and implement a computerized
critical value reporting system to improve the quality of critical value
reporting at our hospital.
32 of 42
Marked Record
TI: Evaluation of a treatment limitation policy with a specific
treatment-limiting order page.
AU: O'Toole—EE; Youngner—SJ; Juknia1is-BW; Daly—B; Bartlett—ET; Landefeld—CS
AD: Department of Medicine, University Hospitals of Cleveland, OH.
SO: Arch—Intern—Med• 1994 Feb 28; 154(4): 425-32
LA: ENGLISH
AB: BACKGROUND: Concerns about misinterpretation, misunderstanding, poor
communication, and lack of documentation prompted a revision of our hospita1's
treatment limitation policy. The revised policy was designed to explicate
do-not-resuscitate (DNR) orders, structure the use of DNR and other
treatment-limiting orders in a logical and standard way, and improve
communication. Use of a Specific Treatment-Limiting Order Page (STOP) was
required. METHODS: To evaluate the policy's effects, we conducted (1) a
prospective cohort study (involving 2733 patients) of treatment limitation
practices before and after the new policy and (2) cross-sectional surveys of 38
nurses and 62 physicians. Outcome measures included documented
treatment-limiting orders, documented discussions of these decisions, and
deaths. Staff opinions about effects on communication and patient care were
elicited. RESULTS: Rates of death (5.4% before and 5.6% after the policy; P ~
.80) and rates of DNR orders (9.3% vs 9.2%, P = .9) did not change. The use of
the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly
increased the frequency of orders limiting 12 other specific treatments for
conditions short of arrest. For example, before the policy, orders prohibited
mechanical ventilation in 2% of DNR patients, compared with 66% after the
policy (P < ,001). Staff reported that the policy improved communication among
health professionals, patients, and families.. CONCLUSIONS: The treatment
limitation policy with the STOP improved documentation and communication of
treatment—limiting decisions. On the basis of our results, we offer a STOP for
use and evaluation by others.
33 of 42
Marked Record
TI: Provision of postoperative care in UK hospitals.
AU: Crosby-DL; Rees-GA
AD: University Hospital of Wales, Cardiff.
SO: Ann-R-Col1-Surg-Engl. 1994 Jan; 76(1): 14—3
LA: ENGLISH
AB: Surveys have been undertaken of the clinical dependency of surgical
patients in eight United Kingdom acute general hospitais■ The findings indicate
that patients' needs are not always matched by appropriate levels of clinical
care. In particular, it appears that a significant number of surgical patients
need high-dependency care. Currently most of these patients are admitted to ITU
beds, or are at risk on surgical wards.
34 of 42
Marked Record
TI: Relating outcomes to processes of care: the Maryland Hospital Association's
Quality Indicator Project (QI Project).
AU: Kazandjian-VA; Lawthers-J; Cernak-CM; Pipesh-FC
AD: Maryland Hospital Association, Lutherville 21093-6087.
SO: Jt-Comm—J-Qual-Improv. 1993 Nov; 19(11): 530-8
LA: ENGLISH
AB: BACKGROUND: The Maryland Hospital Association's Quality Indicator Project
(QI Project.) is a program of indicator development and application that has
grown from 7 hospi ta1s in 1987 to more than 7BE hospitals today. METHODOLOGY:
Expert panels help to create sets of indicators that describe events involved
in a specific sequence of patient care. Each hospital collects data elements
for the 21 indicators on a quarterly basis using specifically designed
date-collection software. Indicator data are adjusted for case complexity, risk
of adverse outcomes, and patient group characteristics. A report is developed
that states the rate of occurrence of each indicator and how the hospita1's
indicator rate compares to other hos^i.ta.ls. in the database. Hospital s then use
this information to determine if specific processes in their delivery of care
yield results that deviate from those of other hospitals. The QI Project
promotes regional sharing of information about specific hospital initiatives
that might benefit other participants. It also provides a model to use in
interpreting what the indicator data reveal about hospital performance.
OPERATIONAL ISSUES: QI Project is testing process indicators for patient-level
and service-level data to supplement current aggregate-level trend and profile
analysis. Indicator data are shared solely with participating systems, but
changes in the confidentiality policy are being studied. Reliability assessment.
surveys are periodically conducted. EXAMPLES: Case studies portray improvement
of processes prompted by indicator data for unscheduled admission following
ambulatory surgery, for surgical wound infections, and for reducing emergency
room waiting times. CONCLUSIONS: The chief contribution of the QI Project and
similar projects may not be that they identify all issues of quality, but
rather that they may help develop a generation of hospital professionals who
will be better able to quantify, evaluate, and improve health care quality.
35 of 42
Marked Record
TI: Data-driven performance improvement in health care: the Joint Commission's
Indicator Measurement System (IMSystem).
AU: Nadzam—DM; Turpin—R; Hanold-LS; White-RE
AD: Department of Indicator Measurement, Joint Commission, Oakbrook Terrace, IL
60181.
SO: Jt—Comm—J—Qua1-Improv. 1993 Nov; 19(11): 492—500
LA: ENGLISH
AB: BACKGROUND: Since 1986, the Joint Commission has worked to create an
evaluation system that would remain standards based but would accent an
organization's performance as well as its capability to provide care. One
component is the Indicator Measurement System (IMSystem), which involves
continuous data collection and periodic, feedback about specific performance
measures, or indicators. An indicator is a quantitative measure of an aspect of
patient care. It is not a direct measure of quality; rather it is a screen or
flag which indicates areas for more detailed analysis. METHODOLOGY: Sets of
indicators, each set related to specific important health care functions such
as perioperative care, are established by expert task forces and are then
subject to two phases of testing. Alpha testing addresses face validity and
feasibility of data collection and may result in indicator revision. In the
beta phase, a large group of organizations test the indicators for validity,
reliability, and usefulness in improving performance. OPERATIONAL ISSUES: In
1994, the IMSystem will contain ten indicators and participation by hospitals
will be voluntary. One® the value of these date in the accreditation process
has been demonstrated—possibly as early as 1996—participation will become an
integral component of accreditation. Has pita1s will transmit indicator data to
the Joint Commission but no patient or physician identifiers will leave the
hospital. The system will provide organizations with information they can use
to monitor and improve their performance, while helping meet external needs for
performance measuremen t.
36 of 42
Marked Record
TI: Planning for patient care redesign: success through continuous quality
improvement.
AU: Smith-P; Adams-D: Bersante-S; Kalma-S
AD: Cardiopulmonary Department, St. Clare Hospital, Tacoma, WA.
SO: J—Nurs-Care—Qua 1. 1994 Jan; 8(2): 73—80
LA: ENGLISH
'AB: A key to improving patient care in hospitals is the use of staff nurses on
a continuous quality improvement team to redesign the patient care delivery
model. This article describes the planning process and strategies for patient
care delivery redesign on a medical-surgical unit in a small community
hospital. A team of 12 staff nurses working with trained facilitators and a
team leader began the seven-month project. The article describes how the team
assessed the needs of the customers, developed a plan for a pilot, and drafted
evaluation criteria.
37 of 42
Marked Record
TI: Quality improvement in discharge planning: an evaluation of factors in
communication between health care providers.
AU: Anderson-MA; Helms-LB
AD: University of Illinois at Chicago, College of Nursing, Rock Island.
SO: J-Nurs-Care—Glual. 1994 Jan; 8(2): 62-72
LA: ENGLISH
AB: Extending quality improvement principles to coordinating patient care among
multiple levels- of health care service providers has received only limited
attention. Referrals function by communicating information about patients'
continuing care needs between health care organizations as they transfer
responsibility for providing different levels of care. Our evidence suggests
several procedural improvements with immediate benefit for improving the
quality of referrals. These include employing standardized, written referral
forms; assigning responsibility for communication by requiring a signature on
each referral; and instituting an information feedback, system between sending
and receiving health care providers-.
38 of 4-2
Marked Record
TIs Equity and efficiency in Italian health care.
AU; Paci-P; Wagstaff—A
AD: Department of Social Sciences, City University, London, UK.
SO: Health-Econ. 1993 Apr; 2(1 Is 13-29
LA: ENGLISH
AB: Health care finance and provision in Italy is unusual by international
standards: public financing relies heavily on both general taxation and social
insurance, and although the vast majority of expenditure is publicly financed,
the majority of care is provided by the private sector. The system suffers,
however, from a chronic failure to control expenditures and its record on
perinatal and infant mortality is poor. Hospital_s in Italy have a low
bed-occupancy rate by international standards and the per diem system of
reimbursing private hospi tals encourages unduly long stays. Costs per inpatient
day are high by international standards, but costs per admission are close to
the OECD average. Ambulatory care costs are extremely low, hut this appears to
be due to the fact that GPs see so many patients that their role is inevitably
mainly administrative. Consumption of medicines is extremely high, but because
the cost per item is low, expenditure per capita is not unduly high. Despite
the emphasis on social insurance, the financing system appears to be
progressive. There is evidence of inequalities in health in Italy, and some
evidence that health care is not provided equally to those in the same degree
of need•
39 of 42
Marked Record
TI: Physician-Directed Diagnostic and Therapeutic Plans: a quality cure for
America's health-care crisis.
AU: Musfeldt-C; Hart-RI
AD: Ernst and Young, Chicago, IL.
SO: J-Soc-Health-Syst. 1993; 4(1): 80-8
L A: E M 8 LIS H
AB: The most effective way to improve quality is to reduce variation in the
processes of providing a service. Physician—Directed Diagnostic and Therapeutic
(PDDT) Plans are a proven methodology for reducing variation in clinical
processes and improving the quality of care. A major part of the PDDT Plan
process is the development of a critical pathway. Critical pathways are an
application of Total Quality Management (TQM) principles to clinical care which
have provided clear, tangible results in those hospita1s committed to this
process. These pathways define the processes, timelines and responsibilities
associated with the patient's clinical needs from preadmission to post
discharge. Representatives of the various health-care professions involved in
treating the specified patient populations work together, led by a physician,
to define the processes of care. When completed, everyone involved in treating
the patient understands what is to he done, by whom, and when. The pathways
allow clinicians to plan ahead and let the patient and family know what to
expect. Through establishing standards of care, these critical pathways also
reduce the uncertainty of treatment decisions and free physicians from having
to practice defensive medicine, and thus reduce cost. While the most visible
outcome of this process is the actual PDDT Plan, it is not necessarily the most
important. The very process of designing the pathway /improves intra-- and
interdisci.pl inar y communication, and fosters teamwork.
40 of 42
Ma r k ed Rec o r d
TI: Prioritization and organ distribution for liver transplantation.
AUs Bronsther-O; Fung—JJ; Izakis-A; Van-Thiel-D; Starzl-TE
AD: Pittsburgh Transplant Institute, University of Pittsburgh (Pa) Medical
Center.
SO: JAMA. 1994 Jan 12s 271(2): 140-3
LA: ENGLISH
41 of 42
Marked Record
TI: Inpatient standards of care and the suicidal patient. Part I: General
clinical formulations and legal considerations.
AU: Bongar—B; Maris-RW; Berman--Al ; Litman—RE; Silverman-MM
AD: Clinical Psychology Program, Pacific Graduate School of Psychology, Palo
Alto, CA 94303.
SD: Suicide-Life-Threat-Behav. 1993 Fall; 23(3): 243-56
LA: ENGLISH
AB: The most common legal action involving psychiatric care is the failure to
reasonably protect patients from harming themselves. In this regard it is
critical to understand that courts have tended to impose much stricter
standards on inpatient than on outpatient care; that at the present time, most
malpractice actions involve clinical activities related to inpatient care
(negligent admission, treatment, supervision, discharge, etc.). This article
reviews the current climate in the legal and clinical formulation of standards.
of care for hospitalized adult suicidal patients. It suggests general
guidelines for effective assesiSient, management, and treatment procedures that
balance the need for high-quality care by a reasonable and prudent practitioner
with the requirements of court—determined and statutory standards. The authors
specifically discuss court cases that show common failure situations in
ingatient care, discharge planning, and follow-up (e.g., problems in
pharmacotherapy, the decision to hospitalize, the assessment of imminence and
lethality, etc.). The paper also emphasizes the crucial element of clinical
judgment in developing any inpatient standard of care.
42 of 42
Marked Record
TI: Enabling more dying people to remain at home.
AU: Thorpe~G
AD: Moorgreen Hospital, Southampton.
SO: BMJ. 1993 Oct 9; 307(6909): 915-8
LA: ENGLISH
AB: When it comes to dying there is no place like home. Since earliest times
most cultures have accepted that dying people should remain at home. But this
was never possible for all. Some were destined to die in accidents, on
battlefields, by execution, and from catastrophic illness, maybe many miles
away. Nevertheless, with few exceptions people could expect to die in their own
beds and in the bosom of their families. In Europe from the Middle Ages until a
century ago there was a simplicity about dying. Aware that the end was
approaching, people would take to their sickbeds and preside over the ritual.
The family, including children, friends, and neighbours would congregate. The
ceremony was public and doctors often complained about overcrowding. Death was
not regarded as a frightening event and was accepted as an inevitable and
integral part of life. Dramatic changes in attitudes to death have taken place
since the mid-nineteenth century. The natural acceptance of a biological
reality has been lost and people are now unable to come to terms with their own
mortality. One consequence is that death has become institutionalised. This
paper seeks to answer Five questions. These refer to where people die. where
they would choose to die. where they spend their last year of life, the reason
for admission For terminal care, and whether more dying people could remain at
home. Discussion is restricted to adults in the United Kingdom. References are
mostly from the past decade.
Owtii 5 A
NATIONAL WORKSHOP
ON
‘‘ROLE OF VOLUNTARY
ORGANISATIONS IN HEALTH
CARE DELIVERY”
VIGYAN BHAVAN
NEW DELHI
JANUARY 4-5, 1988
PROGRAMME
directorate general of health services
NIRMAN BHAVAN, NEW DELHI-110011
Objectives of the Workshop
1,
To review the roles of various voluntary organisations
working in the health sector engaging in alleviating human
suffering and promoting health and quality of life.
2.
To identify the priority areas of voluntary participants in
the context of health for all by 2000 A.D.
3.
To work out a tentative programme of voluntary partici
pation indicating its nature, thrust areas, role of govern
ment agencies in supporting such participation etc.
Organising Secretary :
Dr. S. C. Sharma,
Asst. Director General (HA),
Directorate General of Health Services,
Nirman Bhavan,
New Delhi-II0011
Phones : 301-9366 (Off)
693291 (Res)
PROGRAMME
National Workshop on “Role of Voluntary Organisations
In Health Care Delivery” at Vigyan.Bhavan
JANUARY 4-5, 1988
Monday, the 4th January, 1988
0930 hrs.
Registration
Inaugural Session
: Dr. G.K. Visit wakarma,
Director General of
Health Services
1000 hrs.
Welcome address
1010 hrs.
: Shri S.S. Dhanoa,
Secretary, Ministry of
Health and Family Welfare
Inaugural address : Shri P.V. Narasimha Rao,
Union Minister of Human
Resource Development and
Health & Family Welfare
Vote of thanks
: Dr. A,K. Mukherjee,
Addl. Director General of
Health Services
1025 hrs.
1040 hrs.
Key-note address
TEA
Plenary Session-I
Chair Person
Mr. Ashish Bose,
President,
Indian Association for
the Study of Population
C/o Institute of Economic Growth
Delhi University
Speaker/Discussant
1100 hrs.
Topic
Dr. Harcharan Singh National Health Care
Adviser (Health)
Policy : Voluntary
Planning Commission Participation, National
Plan, Achievements and
Failures.
Topic
2000 A.D.
h.'.j; ol Voluntary Orgacisatii
—•ssueanc prospectus.
Z. Y . Mukherjee,
Z.ekiiuonal Director
of
Health S .■ . ices (>r.
1145 hrs.
Dr. D. Banerjee,
Prof, of Community
Medicine,
Jawaharlal Nehru
University
New Delhi-110067
Dimensions of Primary Health
Care Programme in the country
—Status Report
Health Care Delivery
in India
—A critical analysis.
Plenary Session-II
Chair Person
Mr. Bunkar Roy,
Consultant, (Voluntry
Agency Rural Development).
Planning Commission
1230 hrs.
1245 hrs.
1300 hrs.
Speaker Discussant
Shri P.K. L’mashankar.
Special Secretary,
M inistry of Health &
Family Welfare
Topic
Family Welfare Programme
in India: Situtation Analysis
Problems encountered ard
prospec.s.
Smt. Ababhai Wadia,
President,
Family Planning
Association of India,
Bombay.
Ncn-Governmental
Shri Alok
Mukhopadhyay,
Executive Director
Voluntary Health
Association of India,
New Delhi
Organisations: Family
Welfare & Child Survival
Services —Participation
and Contribution.
Partnership between
Voluntary Organisations
and the Government :
Challenges and Issues
1315 hrs. Discussion
1345 hrs.
Lunch
1445 hrs Formation of Groups,
Election of Chair-person,
Rapporteurs
and Rapporteur General
for Groups
1500 hrs. Group Discussion
1615 hrs. Tea
1630-1 SOOhrs. Group discussion continue
Tuesday, the 5th January, 1988
Plenary Session-Ill
Chair Person
Dr, A K. Mukherjee,
Addl. Director General of
Health Services (PH)
Speaker, Discussant
Topic
0900 hrs.
Dr. Indra Bhargava,
M C.H. and Immuni
Dy. Commissioner(MCH) zation Programme.
Family Welfare
0915 hrs.
Dr.(Mrs) Shanti Ghosh
Consultant in
Paediatrics
Child Survival : Issues
and role of Voluntary
Organisations.
0930 hrs.
Prof. B.N. Tandon
Deptt. of Gastro
enterology, AIIMS
New Delhi
Integrated Child
Development Services :
Achievements and Failures,
0945 hrs.
Mr. Bunkar Roy,
Integrated Rural
Consultant (Voluntary
Health Care
Agency Rural Develop
ment) Planning Commission
Spcaker/Discussant
Dr. Almas Ali,
Director, CRESEDA,
Bhubaneshwar
Topic
Health care programme
for tribals.
1015 hrs.
Dr M.I.D Sharma,
Former Commissioner
Family Welfare
Control of cominunicable diseases
1030 hrs.
Mrs. Rami Chhabra
Adviser (MM & C)
Min. of Health & F.W.
Community awareness
and involvement.
1000 hrs.
1045 hrs.
Discussion
1115 hrs.
Tea
1130 hrs.
Group discussion continue
1245 hrs.
Finalisation cf Group Reports
1345 hrs.
Lunch
1445 hrs.
Presentation cf the Group Repent.
|545 hrs.
Finalisation cf Report
|6 ill hi ri
lea
TERMS OE REFERENCE
GROUP-I
1509 to 1800
hrs.
Working Group for drafting plan of action and
modalities of co-operation between the Volun
tary Organisations and the Government of India
1..
To identify priority areas of co-operation for
Family Welfare & Primary Health Care Prog
rammes.
2.
3.
To identify inputs - material, manpower etc.
To formulate plan of action indicating guide
lines, format of proposals, periodic reporting,
nature of feed back etc.
GROUP-II
1500 to 1800
hrs.
1.
Working Group on training requirements.
To identify the topics and areas of training.
2.
To identify trainers/core-faculty from Voluntary
Organisations for various topics.
3.
To specify provisions of Scholarship/Fellowship
for training of personnel' of Government and
Non-Government organisations.
4.
To explore the possibilities of financial assista
nce to training institutions for imparting trai
ning in specific courses.
To suggest ways and means of procuring and
preparing publications, technical reference mate
rial, books, manuals etc.
GROUP-I1I
5.
1500 to 1800
hrs.
1.
2.
3.
Working Group on administrative matters.
To identify and consider administrative prob
lems and make suggestions for remedial measures.
To indicate norms of grant-in-aid to the volun
tary organisations.
To work-out a uniform service pattern in
voluntary organisations with regard to Primary
Health Care Programme.
NATIONAL WORKSHOP ON “ROLE OF VOLUNTARY
ORGANISATIONS IN HEALTH CARE DELIVERY”
AT VIGYAN BHAVAN ON 4-5 JANUARY, 1988.
List of documents/working papers and mimeographed papers
and others.
Government of India Publication
1.
Statement on National Health Policy, New Delhi, 1983
W.H.O. Publications
2.
Strengthening of Referral System for Primary Health CareSEA/HSD/97.
Primary Health Care Networks - SEA/HSD/112.
3.
4.
Primary Health Care Information Network - SEA/HSD/95.
Intersectoral Actions for Health - SEA/HSD/106.
5.
Report of the intercountry conference on Primary Heallh
Care Networks, New Delhi - SEA/HSD/74.
1.
UNICEF Publication
1.
The Status of World Children 1988.
Other Publications
1.
2.
3.
Chapter 5. Population and Family Planning Management of
Primary Health Care
O.P. Ghai
Elements of National Health Policy : Voluntary Health
Association of India, 1987.
Position Paper on National Health Policy, Amla Rama Rao
Voluntary Health Association of India, 1987.
4.
Summary of Problems in Primary Health Care
United Nations Development Programme
Evaluation Study No 9 p. 29-37
5.
Recemmendations for Strengthening Human Resource Deve
lopment for Primary Health Care through External Support.
United Nations Development Programme
Evaluation Study No. 9 p. 38-46.
*X--X-X■X
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PROGRAMME
^
.
* * ^
DIRECTORATE GENERAL of health services
NIR1Y1AN BHAVAN, NEW DELHI-110011
-X-X‘X-X’X-X-X-X-X-X-X-X-X-X-X--X- “X‘‘X,-X--X--X--X--X->Hr •X,X-'X--X
*-X
********** *
**************************************** *
4-5 JANUARY, 1988
*****************************
*
NATIONAL v/ORKSHOP ON ROLE OF VOLUNTARY
ORGAixiiSTfTONS’ ITTHeaEthTarSToelIvery
VIGYAN’mAVAN
,'/r,K--X--i('X,irX--A',X-X-'X"-X’X-wX"X’-X-")c-X-‘X"X-X--X--X-7(—X-K-X-
Objectives of the Workshop
1. to. r.e_vlew:.the roles ’-of various voluntary
organisations working in the health sector
engaging in alleviating human suffering
and promoting health and quality of life.
2. To identify the priority areas of voluntary participants in'the context of health
for all by 2000 A.D.
3. To work out a tentative programme of
voluntary participation indicating its
nature, thrust areas, role of government
agencies in supporting such participation
etc.
Organising Secretary,
Dr. S.C. Sharma,
Asst. Director General
of Health Services,
Nirman Bhavan,
New Delhi" - 110 011 .
PROGRAMME
’NATIONAL WORKSHOP ON RQLE OF VOLUNTARY
OROAITISAiTOrTTTHS-Tth aARE’njtTTWrr
AT VIGYAN BHAV7iN ON, 4^5~ JANUARY, 1986
Monday, the 4th January, 1988
0930 hrs.
Registration
Inaugural Session
1000 hrs.
Welcome .Address
Dr. G.K. Vishwakarma,
Director General of
Health Services.
1010 hrs.
Key note address
Shri s.S. Dhanoa,
Secretary, Ministry of
Health and Family Welfare
1025 hrs.
Inaugural Address
Shri P.V.-' Narasimha Rao,
.Minister of Health and
Family Welfare.
1040 hrs.
Vote of Thanks
Dr. A.K. Mukherjee,
Addl. Director General
of Health Services (PH)
Tea
I,
Plenary Session-I
Chair Person
Mr. A'shish Bose,
President,
Indian Association for
the Study of Population ■
C/o Instt. of Economic
Growth, Delhi University
Delhi-7.
Speaker/Discussant
1100 hrs.
Dr. Harcharan Singh,
Adviser, Health &
Family Welfare,
’Planning ’Commission,
Nev/ Delhi.
Topic
National Health Care
Policy: Voluntary .
Participation, National
Plan, Achievements and
Failures.
-2-
Speaker/Discussant
Topic
1115 hrs..
Dr. N.H. Antia,
Director Foundation
Research & Community
Medicine, Bombay.
Health for All by 2000
■A.L. ; Role of Voluntary
Organisations - Issues
and Prospects.-
1150 hrs.
Dr. A.K. Mukherjee,
■Additional Director
General of Health
Services (PH).
Dimensions of Primary
Health Care Programme
in the country - Status
Report.
1145 hrs.
Dr. D. Banerjee,
Prof, of Community
Medicine, Centre of
■Sociil Medicine and
Community Health,
Jawahar Lal Nehru
University, New Delhi—
Health Care Delivery in
India -A critical
analysis.
,
Plenary Session - II
Chair Person
Mr; Bunkar Roy,
Consultant, (Voluntary
Agency Rural Develop
ment), Planning Commi
ssion, Sansad Marg,
New Delhi - 110 001.
1230 hrs.
Shri P.K. Umashan'kar, •
Family. Welfare Programme'
Special Secretary to
in India; Situation
Govt, of India,
v.analysis', Problems enMinistry of Health and . countered and Prospects.
Family Welfare.
1245 hrs.
Smt. Ababhai Wadia
President,
Family Planning
Association of India,
Bombay.
■
Non-Governmental Organisations: Family Welfare and Child Survival
Services - Partici. pation and Contribution.
1 JOO hrs.
Shri Alok Mukhopadhyay',
Executive Director,
Voluntary Health As sociatioh of India,
.
New Delhi.
Partnership between
Voluntary Organisations
and the Government;
Challenges and Issjies.
-3-
1315 hrs.
Discussion
1345 hrs.
Lunch
1445 hrs.
'
Formation of Groups,
Election of Chair-person
Rapporteurs and Rapporteur
■ General > for Groups.
1500 hrs.
Group Discussion
1615 hrs.
Tea
1630 hrs. §
to
§
1800 hrs. §
'
'
Group Discussion continue
■
\
Tuesday, the 5th January, 1988
Plenary Session-Ill
Chair Person
Dr. A..K. Mukherjee,
• Addl. Director General
of Health Services (PH)
Speaker/Discussant
Topic
0900 hrs.
Dr. Indra Bhargava,
Dy. Commissioner(MCH)
M.C.H. and Immunization
Programme.
0915 hrs.
Dr.(Mrs) Shanti Ghosh
Consultant in Paedia
trics ..
Child Survival: Issues
and role of Voluntary
Organisations.
0930 hrs.
Prof. B.N. Tandon
Deptt.- cf Gastroentrology, All
India Instt. of
Medical Sciences,.
New Delhi.
Integrated Child
Development Services:
Achievements and Failures
0945 hrs.
■ Mr. Bunkar Roy,
Consultant, (Voluntary
Agency Rural Develop
ment), Planning Commi
ssion, Sanaad Marg,
Nev/ Delhi - 110 001.
Integrated Rural
Health Care.
-41000 hrs.
Dr. Almas Ali,
’
Director,
CREDEDA,
Bhubaneshwar, Oris sar.
Health Care Programme
for Tribals.
,
1015 hrs.
Dr. M.I.D. Sharma,
Former Commissioner,
Family Welfare,
Govt, of India.
Control-of Communicable
Diseases.
>
•
1030 hrs.
Mrs. Rami Chabra,
Adviser (M.M&C)
Min. of Health and
Family Welfare,
New Delhi - 110' 011.
■ Community Awareness and
Involvement.
•
'
"1045 hrs.
Discussion
1115 hrs.
Tea
■1130 hrs.
Group discussion continue
■
Finalisation of Group
■ Reports
1245 hrs.
1345 hrs.
Lunch
1445 hrs.
Presentation of the Group .
Reports.
1545 „hrs. -
Finalization of Reports
1630 hrs...
Tea
.
.
...
Valedictory Session
Chair Person
.
1645 hrs.
Ms. Mira Seth,
Addl. Secretary (Health),
Ministry of Health and,
Family Welfare, .
New Delhi.
. . •
,
,
. •
Valedictory Address
Kumari Saroj Khaparde,
Minister of State for
Health and Family Welfare,
Nirman Bhavan,
Nev/ Delhi - 110- 011.
.
-5TERMSOF REFERENCE
GROUP-1
1500 hrs.
to
1800 hrs.
Working Group for drafting plan of action and
modalities of co-operation between the’•’Voluntary
Organisations and the Government of India.
1.
Io identify priority areas of co-operation for
*
■ Family Welfare and Primary Health Care Programmes.
2.
!
3.
To identify inputs - material, manpower etc.
4.
To formulate plan of action indicating guidelines,
format of proposals, periodic reporting, nature - of
feed back etc.
Any other matter relevant to the topic with the
permission of the Chair.
.
1500 hrs.
to
1800 hrs.
•
GROUP-II
Working Group on training requirements.
T.
To identify the topics, and areas of training.
2.
To identify trainers/core-facuity from Voluntary
Organisations for various topics.
3»
To specify provisions of Scholarship/Fellowship
for training of personeel of Government and-Non- ■
Government organisations.
-
4.
To explore the possibilities of financial assistance
to training institutions for imparting training in
- specific courses.
5.
To suggest ways and means of procuring and prepar
ing publications, technical reference material,
books, manuals etc.
■6.
Any other matter relevant to the topic with the
permission of the Chair.
1500 hrs.
to
1800 hrs.
1.
GROUP-III
Working Group on administrative matters.
. ■
To identify and consider administrative problems
and make suggestions for remedial measures.
2.
To indicate norms of grant-in-aid to the
voluntary organisations.
3.
To work out a .uniform service, pattern in voluntary
organisations with regard to .Primary Health Care
Programme.
' Any other matter reiejyant 'to'the . topic .With" the
permission of the Chair.
4.
-
•
-6NATIGNAL WORKSHOP ON ROLE OF VOLUNTARY
ORGANISATIONS IN HEALTH CARE DELIVERY
' AT VIGYaN BHAVAN ON 4-5 JANUARY, 1988.
List of documents/working papers and mimeographed
papers and others.- ■ *
" ■
~
■r"i—
Government of India Publications
1.
Statement on National Health Policy, New Delhi, 1982.
2.
Dimensions,of Primary Health Care Programme in the
country- Status Report.
W.H.O. Publications
1.
Strengthening of referral system fop Primary Health
.Care - SEA/HSD/97.
.
2.
Primary Health Care Networks - SEA/HSD/112.
3. ■
Primary Health Care Information Network - SEA/HSD/95.
.4.
Intersectoral Actions for Health - SEA/HSD./1O6.
5.
Report of the intercountry conference on Primary Health
Care Networks, New Delhi - SEA/HSD/74.
UNICEF Publications'
1.
The Stautus of. World Children 1988.
Other Publications
1.
Chapter 5, Population.and Family Planning Management
of. Primary -Health Care: O.P, Ghai
First Published in India in 198'5.
2.
Elements of National Health Policy
Voluntary Health Association of India, 1987.
3.
Position Paper on National Health Policy,
Amla Rama Rao
A ■
Voluntary Health Association of India, 1987.
4.
VI.' Summary of Problems in Primary Heaith'Care
p.29-37 (1 set)
United Nations Development Programme
Evaluation Study No.9
■
Human resource development for Primary Health Care.
5.
Recommendations for Strengthening Human Resource
Development for Primary Health Care through External
Support, p.38-46. ■ United Nations Development Programme Evaluation Study No.9
Human resource development for Primary Health Care.
United Nations Development Programme
New York - December, 1983.
.
Q cm rt 5 >1
WORLD HEALTH
ORGANIZATION
— 3
ORGANISATION MONDIALE
DE LA SANTt
SOUTH-EAST ASIA REGION
SEA/HSD/74
21 May 1985
RESTRICTED
REPORT OF THE INTERCOUNTRY CONFERENCE ON
PRIMARY HEALTH CARE NETWORKS, NEW DELHI,
28 JANUARY - 1 FEBRUARY 1985
WHO Project: ICP PHC 006
UNDP Project: RAS/81/027
The Issue of this document does not constitute formal publication. It
should not be reviewed, abstracted or quoted without the agreement of the
World
Health Organization.
Authors alone are
responsible
for vi
appearing under their names.
SEA/HSD/74
CONTENTS
Page
1.
INTRODUCTION
1
2.
OBJECTIVE OF THE CONFERENCE
2
3.
PARTICIPANTS
2
4.
CONDUCT OF THE CONFERENCE
2
5.
DISCUSSIONS
3
5.1
5.4
Restructuring of Health Infrastructure for Health
Systems based on Primary Health Care
Development of Middle-Level Managers
Development and Utilization of Health Systems
Research
Regional PHC Network
6.
RECOMMENDATIONS FOR PLAN OF ACTION
7
7.
CLOSING SESSION
9
5.2
5.3
3
4
5
6
ANNEXES
1.
List of Participants and Secretariat
10
2.
Objectives
13
3.
Agenda
14
4.
Programme
15
SEA/HSD/74
1.
INTRODUCTION
The International Conference on Primary Health Care in Alma Ata
in
1978 affirmed that primary health care was the key approach to achieve an
acceptable level of health throughout the world. It also affirmed that the
primary health care approach connoted health as an integral part of social
development and implied a spirit of social justice.
Following upon the Declaration of Alma Ata, governments formulated
strategies for health for all, adopted plans of action, and started
orienting national health systems based upon primary health care. The
orientation of national health systems has made varied progress; such
progress is dependent upon political will with all the political, social,
economic and other realities which often are in conflicting arrangement. In
most countries of the Asia and Pacific Regions, the national health
infrastructure and services are still not able to undertake comprehensive
delivery of essential health care to all the people. Also, the health
infrastructure is not fully capable of absorbing and delivering the
available health technologies. Sometimes the technology that is available
is not the appropriate one for delivery through the infrastructure using
the primary health care approach.
Specifically, the orientation process in health infrastructure is
facing difficulties in regard to a credible and effective referral system
for primary health care.
Intersectoral collaboration is an essential
component of primary health care. Here too, there is much agreement on
principles but little evidence of action.
Though health services research has drawn so much debate and
emphasis during recent years, much remains to be done by way of simple,
practical and problem-solving research likely to be of immediate use. Much
of the health services research already conducted remains on the shelves of
academic circles. Careful selection of research subjects and mechanisms for
involving the health administrators and academicians in the design and use
of research results is urgently needed.
Mutual technical cooperation among countries has been unexceptional
in principle. But the great potential for such cooperation in health
development remains largely unexploited.
The Ministers of
Health
of
South-East Asia Region, in successive meetings commencing in 1981, have
provided strong support to the selection of specific areas and modalities
for mutual cooperation. This augurs well for a functional network in which
interested countries can cooperate bilaterally or multilaterally to their
mutual advantage.
This Intercountry Conference on Primary Health Care Networks was a
follow-up of the previous meeting on the same subject held in New Delhi
from 16 to 20 August 1983 (see SEA/HSD/65). The Conference addressed some
of the problems related to the restructuring of health infrastructure, use
of health systems research, development of middle-level managers and
functions of a regional network of primary health care.
SEA/HSD/74
Page 2
2.
OBJECTIVE OF THE CONFERENCE
The objective of the Conference was to develop a plan of action for
a functional network of primary health care in the Region. Within this
objective, types of activities in three broad subject areas were to be
identified for the plan of action for the period of 1985 and 1986. The
three broad subject areas were:
3.
(a)
Restructuring of health infrastructure
based on primary health care;
(b)
Development of middle-level health managers, and
(c)
Development and use of health systems research.
towards
health
systems
PARTICIPANTS
There were seventeen participants from nine Member Countries of
WHO/SEAR, and two from Afghanistan in WHO/EMR. One representative each from
UNDP and US AID in India participated. The WHO secretariat supporting the
Conference
consisted
of
ten
staff
members
including
one
from
WHO
Headquarters and one from the WHO country office, Bangladesh. The full list
of participants is at Annex 1.
4.
CONDUCT OF THE CONFERENCE
The Conference was inaugurated by Dr M.A. Rahman, Director Programme
Management, on behalf of the Regional Director of South-East Asia.
In his inaugural address, Dr Rahman drew attention to the facts that
primary health care could be established by activities of the health sector
alone, and that there was considerable similarity in the socio-cultural and
economic conditions amongst the countries participating,
which should
enable them to share the knowledge and experience gained in primary health
care. Thus there was need for close coordination and collaboration, both
intersectoral and within the health sector itself. He added that a regional
network of primary health care could be a good mechanism for cooperative
activities by the countries. There was good prospect of bringing the health
administrators and
research workers
together
to
solve
problems
and
procedures. Finally, Dr Rahman suggested that the regional network could
function at a number of levels - national, institutional, intersectoral and
international.
In his brief statement, Mr Michael E.
Smith,
Deputy Resident
Representative, UNDP, India, speaking on behalf of the UNDP, drew attention
to the meeting that took place in August 1983 on the subject of primary
health care network, and in particular, to the report of the evaluation of
the UNDP-funded intercountry project "Promotion and Development of Primary
Health Care”. He hoped that the findings and recommendations of this
evaluation report would be reflected upon by the participants at this
Conference.
Dr M.D. Saigal (India) was elected Chairman, while Dr
(Sri Lanka) and Dr Abdul Sattar Yoosuf
(Maldives)
were
Vice-Chairman and Rapporteur respectively.
C.D. Herath
elected as
SEA/HSD/74
Page 3
The objectives of the Conference (Annex 2) were adopted while the
provisional agenda (Annex 3) and programme (Annex 4) were adopted with
minor changes. Each agenda item in the programme was discussed both in the
plenary and group sessions. The participants were divided into two groups
for in-depth discussions on each agenda item and asked to produce group
reports with recommendations for the plan of action. Each group elected a
chairman and a rapporteur and used suggested guidelines for discussion.
5.
DISCUSSIONS
One participant from each country presented an overview of the
existing state of development of primary health care institutional network.
From these presentations, it was evident that the structural and functional
networks for primary health care were in different stages of development.
However, there was similarity in problems and opportunities for further
development in specific areas such as integrated disease control, referral
system, intersectoral collaboration, and management and supervision in
health
services.
Frequent
reference
was
made
to
the
need
for
action-research,
sharing of information and technology within various
levels of national health systems and amongst countries.
Dr B.C. Ghosal, WHO Consultant, presented a brief background of the
activities of the Project ICP PHC 006 and some thoughts on the possible
future
activities
required
of
the
project
in
the
light
of
the
recommendations of the tripartite review held in July 1984. He also
presented a
summary of
the
country
situation reports made
by
the
participants earlier.
5.1
Restructuring of Health Infrastructure for Health Systems Based on
Primary Health Care
An introductory paper on this agenda item was presented by Dr Uton
M. Rafei, Director, Health Promotion and Protection, which was followed by
another discussion paper presented by Dr Zakir Husain, Senior Public Health
Administrator (PHC), dealing with the referral system development and
intersectoral collaboration for primary health care. Besides the conceptual
framework of restructuring, referral system and intersectoral actions, the
possible strategy framework and suggested lines of action were presented.
Restructuring with particular reference to the referral system
should encompass much more than mere referral of patients to hospitals. In
the
context
of
health
systems
orientation,
logistics
support,
supervision-cum-training, and good communications were essential pillars of
a sound referral system. The strategic framework of a referral system
consisted of coverage of the entire population, health and health-related
services and strengthening of two-way support links throughout different
levels. Some of the essential steps for the design of a good referral
system would be the (i) quick analysis of the existing situation and
potential
in
manpower,
institutions,
and
other
facilities;
(ii)
selection/adaptation of health technologies and services at different
levels; (ill) combination of supervision and training in problem-solving;
(iv) monitoring of materials supply and utilization; and (v) coordinated
service and support with health-related sectors. Some of the early points
of action would include the first referral institution, balancing the
health facilities at various levels of the health system, appropriate
linkages amongst service, training and research facilities, and training
SEA/HSD/74
Page 4
and motivation of health and other workers for the referral system's
functions. Finally,
the referral system should be viewed as a broad
supportive system for enhancing the credibility of primary health care.
The subjects of referral system and intersectoral actions were
discussed
in
both
the
plenary
session
and
in
groups.
Practical
recommendations on the types of activities to be supported through the
regional primary health care network were formulated (see Section 6).
Several important Issues came up in group discussions. Reference was
made to the various action points inherent in the strengthening of referral
systems. There was need for developing the required technical expertise in
systems design; standards or norms for referral institutions were needed;
flexibility in operating
a
standard
referral
design
was
essential;
action-research was more relevant than model-building; manuals were helpful
and would have to be prepared; country studies on alternative systems for
supplies, logistics and maintenance were suggested. Based on these, a few
types of activities were selected for inclusion in the regional plan of
action for the years 1985 and 1986.
On intersectoral actions for health, discussions in the groups
identified several major problems and recommended the increased use of
existing bodies and avenues for collaboration amongst the various sectors
rather than creating new mechanisms exclusively for this purpose. The
groups also pointed to the need for careful selection of a few relevant
indicators for intersectoral collaborative actions to enable periodic
assessment of the progress, problems and prospects. A suggestion was also
made for some localised studies with a view to formulating some basic
guiding principles based on local experience.
A few approaches to the subject of intersectoral collaboration were
mentioned. One was to align the health goal with the broader development
goal. Another approach was to start from the end of community level
organizations as opposed to the official sectors' end. The initiative of
this
approach
was
in
the
hands
of
the
community
moving
towards
self-reliance with technical support,
where needed,
of
the
official
agencies. Yet another approach was to start and continue a systematic
review of health components of development activities at all levels with a
view to maximizing the internal linkages and complementarity. A few
recommendations on the types of activities were made for inclusion in the
regional plan of action.
5.2
Development of Middle-Level Managers
An introductory paper on this agenda item was presented in a plenary
session by Dr K.N. Seneviratne, bringing out the expected outcome of the
discussion on this subject, namely, to provide guidelines for work plan for
middle-level
management
training.
The
current
assessment
of
health
management situation in countries appeared to point to the priority need
for developing middle-level managers. Training of middle-level managers
would be one major contributor
to
this development.
Management was
essential for the optimum use of available resources in the context of
primary health care. The management needs for primary health care related
chiefly to self-reliance of communities for their health, decentralization
SEA/HSD/74
Page 5
of resources and responsibilities, progressively to peripheral levels and
greater
involvement
of
community
organizations
in
the
planning
and
management of local health care. In the context of middle-level management,
much of the training would need to be stressed to improve problem-solving
skills and the performance of programmes. It was felt that relatively more
attention would be needed for programmes/project planning, implementation,
management and monitoring programme performance. The training content might
also include leadership skills and management of staff, human relationships
and skills in the resolution of conflicts. Additional skills of financial
management and effective communication were required. The specific contents
and the preferred types of management training will be different in the
countries depending on their particular needs and priorities. Experience
during the past two decades in health
management training in the Region
seemed to confirm that in order to make training highly relevant and
effective it should focus more upon practical management competence and
less on generalized concepts and
principles.
Middle-level management
training had limited objectives and it should be seen within the broader
perspective of overall improvements in health management. It would deal
with developing skills as well as the appropriate attitudes. It would also
have to be linked with the process and progress of decentralization of
authority and responsibility.
During discussions in the plenary following the presentation and
in-depth discussion in the groups on this subject, further elaboration of
the contents of such training was made. There was a suggestion to include
training in basic epidemiological discipline while other suggestions were
for more personnel management, budget and financing control. The idea of
including management as a subject in basic educational curriculum did not
receive wide support. At the end of these discussions the groups agreed on
a few types of activities for the regional plan of action for 1985-1986.
Three major types of activities identified were:
5.3
(1)
A clearer identification of actual management training needs;
(2)
Strengthening
trainers, and
(3)
Development of a basic
adaptation in countries.
of
training
capabilities
module
at
the
of
institutions
and
level
for
regional
Development and Utilization of Health Systems Research
A paper on
this
subject
was presented in a plenary session by
Dr Mya Tu,
Director,
Health
Systems
Infrastrucutre,
WHO/SEARO.
Two
alternative approaches to health systems research were explained. One was
problem-oriented research-seeking information (PORTS) approach and the
second,
research
information
display/utilization
promotion
(RIDUP)
approach. Between these two, the PORTS approach was based on marketing
techniques and, therefore, was likely to assure better utilization of
research results. This approach relied on information-seeking behaviour of
the
decision-makers
and
tried
to
stimulate
that
behaviour
in
decision-making situations. The basic premise in this approach was that
managers faced with problems had to make decisions. If motivated to seek
essential additional information and if research attempted to generate that
information, it had a better chance of being accepted and used. On the
other hand, the RIDUP approach relied heavily on the initiatives of
researchers who, having obtained the findings, tried to sell their products
SEA/HSD/74
Page 6
to the user,
i.e., managers and decision-makers.
Naturally,
in this
approach the subject of research and the results might not be the ones that
the consumer wanted or needed. Thus, it was necessary to promote the PORIS
approach, which was more appropriate and gave some possibilities of being
accepted and utilized
by decision-makers
and managers.
The
present
situation in the field of health systems research was rather discouraging
although, by definition, health systems research was directly concerned
with the problems of organization, logistics, financing, etc. of the health
services and these appeared to be highly relevant for use by planners and
administrators, this had not in fact occurred to any large extent. More
often, problems continued to be chosen by the individual researcher in
academic institutions with or without the involvement of the health
services personnel. It was assumed that the results thus obtained by the
researchers and subsequently published in reputed or other journals would
be used. This did not happen. The subject of utilization of research
results had, in the past few years, been discussed in various forums. Many
suggestions had been made in this regard including the joint selection of
problems by service agencies and research agencies, and dissemination of
results in easily assimilable form. Suggestions were also made for a
dialogue between the users and producers at all stages. But the fact
remained that much of the research findings still remained unutilized.
The subject was discussed in the two groups with a view to
identifying a few specific types of activities for regional network to
support. The groups identified seven areas for health systems research in
the
context
of
primary
health
care.
These
included
supplies
and
procurement,
personnel
management,
behavioural
research,
financial
management, service delivery, appropriate health technology and training of
health workers. Specifically, three broad areas for research emerged.
First, operational research in the management of primary health care with a
built-in mechanism for the immediate use of findings. Second, development
of models in respect of urban primary health care with special attention to
slum population. Third, alternative and new approaches to implement primary
health care.
A major recommendation was made after discussions in groups and in
the plenary to support national efforts in health systems research (see
Section 6).
5.4
Regional PHC Network
Dr Mya Tu introduced this subject from an operational point of view.
The necessary preconditions of a successful network were reaffirmed.
It was essential that areas or problems amenable to network collaboration
were clearly defined and firmly agreed upon. A functional network was felt
to be more practicable than a structural network. In fact, a structural
network might be difficult to sustain. On the other hand, the proposed
functional network could benefit from linkages and sharing of information
with already established formal networks, e.g.,
ASEAN Training Centre for
primary health care, the Asian Pacific Academic Consortium of Public
Health, and the South-Asian Regional Cooperation.
SEA/HSD/74
Page 7
Following in-depth discussions in the two groups and presentation of
their reports to the plenary session,
a few recommendations on the
functioning of a regional PHC network were proposed (see Section 6). It was
the consensus of the Conference that some level of formal national networks
of designated
institutions or individuals was a prerequisite for
a
functional regional network. In this regard, WHO/SEARO was expected to take
some initiatives. The Conference also endorsed the view that functional
linkages with established mechanisms under geopolitical grouping, e.g.,
ASEAN, SARC, and other bi-regional networks were necessary.
6.
RECOMMENDATIONS FOR PLAN OF ACTION
As stated earlier, the discussions on the subject agenda items in
the two groups followed by review in plenary sessions crystallized selected
recommendations related to the plan of action for the regional primary
health care network during 1985 and 1986. The recommendations were in the
nature of broad indications of relevant types of activities that the
Conference suggested to be of high relevance to the needs of national
networks for primary health care. These recommendations constituted the
guidance for drawing up a detailed plan of action with budgets related to
the proposed activities under the intercountry project ICP PHC 006. The
recommendations are presented for each agenda item as follows:
(1)
Item 1 - Restructuring of PHC infrastructure
A.
Referral system
1.
Carry out rapid analysis of the existing situation in health
infrastructure - staff, facilities, equipment, institutions.
2.
Design and develop an action programme/pilot
project
and
implement measures to improve the referral system based in
particular on the following types of activities:
and
strengthening
of
(a)
Reorientation,
reorganization
referral institutions.
(b)
Orientation and training of health personnel at different
levels about the referral system.
(c)
Information and education of communities in the functions
of the system.
3.
Monitor, evaluate and reformulate a referral system.
4.
Produce
guidelines
and/or
guiding
application in the health system.
B.
Intersectoral action
1.
Carry out a qualitative analysis of the existing situation in
intersectoral collaboration at the implementation levels.
2.
Design and develop an action programme/pilot
project
and
implement measures to improve functional linkage within the
framework
of
existing
mechanisms
for
intersectoral
collaboration.
principles
for
wide
SEA/HSD/74
Page 8
and
formulate a mechanism
intersectoral
3.
Monitor, evaluate
collaboration.
4.
Produce
guidelines
application.
(2)
Item 2 - Development of middle-level health managers
and
or
guiding
for
principles
Collaboration with national institutions/focal points
middle-level management training programmes as follows:
for
wider
in developing
1.
Identify management
training
needs
of
middle-level
health
managers through different approaches such as job analysis,
interviews of health personnel, particularly observations, and
organization of workshops.
2.
Select and strengthen training capabilities of institutions and
trainers through:
a)
b)
c)
d)
trainers' training;
development and exchange of training materials;
curriculum development and adaptation, where relevant, and
exchange of trainers, guest speakers, and other relevant
resources.
3.
Development of management training module at the regional level
which could be adapted by countries. This module should include aspects
such as community organization, community mobilization and other contents
relevant to primary health care management.
Item 3 - Development and use of health systems research
Promote the development and use of health
supporting, through national and regional network
efforts in the:
systems research by
mechanisms,
national
1.
Identification
of
problem
areas
in
primary
health
care
management amenable to health systems research for solution.
2.
Review of
available
practical application.
3.
Design and conduct of operations research
objective
of
improvement
in
planning,
implementation of primary health care.
4.
Design and implementation
health care.
5.
Development of urban or semi-urban primary health care models
in pilot areas in selected countries, with particular reference
to slum areas.
relevant
of
studies
innovative
or
information
for
with the overall
management
and
approches
to
primary
SEA/HSD/74
Page 9
Development of Regional PHC Network
1.
National networks should be formed in countries consisting of
relevant individuals or institutions designated as national
focal points for primary health care. These focal points should
be able to communicate with each other, with the focal points
of Member Countries,
other existing networks
directly
or
through SEARO
acting
as
a
coordinator.
WHO/SEARO
should
initiate action.
2.
Relevant activities being carried out through other network
mechanisms like ASEAN Training Centre for PHC Development
(ATC/PHC), Aslan Pacific Consortium of schools of Public Health
(APCSPH), South Asia Regional Cooperation (SARC) should be
taken into consideration, and functional linkages established,
for sharing resources, experience and information and avoiding
duplication.
These recommendations
session.
7.
were
adopted
in
the
concluding
plenary
CLOSING SESSION
Dr U Ko Ko, Regional Director, addressed the concluding session of
the Conference. In his address, he reiterated the importance of the subject
of the Conference and thanked all the participants for having provided
useful and practical guidance for activities in countries that were highly
relevant, and their assistance in the formulation of a plan of action for
regional support.
In this context, Dr U Ko Ko invited particular attention of the
participants to the need for mobilizing resources through mutual technical
cooperation by countries
to
support
the
regional network.
He
also
highlighted the recognition of the fact that the training
of "Health for
All" leaders in countries was a subject of very high priority that the WHO
Executive Board endorsed for the coming years. Dr U Ko Ko further asserted
that the real action must take place in the countries and that WHO was
ready to support actions that countries themselves took to implement the
recommendations.
SEA/HSD/74
Page 10
Annex 1
LIST OF PARTICIPANTS AND SECRETARIAT
*
1. Participants
Afghanistan
DPR Korea
Mr Jong Kwang Hok
Chief, Science and Technology
Department
Democratic People's Republic
of Korea
Pyongyang
Dr Ainuddin Malyar
President of Basic Health
Services
Ministry of Public Health
Ka bul
Dr Abdul Saboor
President of Central Station
of Sanitation and Epidemiology
Ministry of Public Health
Kabul
Mr Kwan Song Yon
Office of the Ministry of
Public Health
Democratic People's Republic
of Korea
Pyongyang
Bangladesh
Col. M. Mozammel Hossain
Director, PHC/ITHC and
Disease Control
Ministry of Health and
Population Control
People's Republic of Bangladesh
Dhaka
Dr J.A. Rashid
Deputy Secretary
Ministry of Health and
Population Control
People's Republic of Bangladesh
Dhaka
Bhutan
Dr J. Norbu
Coordinating Officer
Department of Health
Thimpu
Dr Jigmi Singay
Coordinating Officer
Family Welfare Programme
Gaylegphug
India
Dr M.D. Saigal
Additional Director-General
(RHS)
Directorate General of Health
Services
New Delhi
Dr Somnath Roy
Director
National Institute of Health
and Family Welfare
New Delhi
Maldives
Mr Abdul Sattar Yoosuf
Director, Department of Publi
Health
Ministry of Health
The Republic of Maldives
Male
*Originally issued as document SEA/PHC/Meet. 10/2.
SEA/HSD/74
Page 11
Mongolia
Thailand
Dr J. Radnabazar
Deputy Minister of Health
Ministry of Health
Ulan Bator
Dr Dilok Thewtong
Public Health General-Inspecto
Ministry of Public Health
Devavesm Palace
Bangkok
Nepal
Dr Suniti Acharya
Deputy Chief
Integrated Community Health
Services Development Project
His Majesty's Government of Nepal
Kathmandu
Dr Mathura Prashad Shrestha
Professor
Institute of Medicine
Tribhuvan University
Kathmandu
Dr Sommart Wongkhenthong
ASEAN Training Centre for
Primary Health Care
Bangkok
Dr Prakrom Vuthipongse
Director, PHC Division
Ministry of Public Health
Devavesm Palace
Bangkok
Sri Lanka
Dr K.C.S. Dalpatadu
Medical Officer
National Institute of Health
Services Development
Kalutara
Dr C.D. Herath
Deputy Director (Medical
Services)
Ministry of Health
Colombo
2. United Nations and Other Agencies
Dr P. Diesh
Health and Nutrition Division
United States Agency for
International Development
New Delhi
Mr Michael E. Smith
Deputy Resident
Representative
United Nations Development
Programme
New Delhi
3.
WHO Secretariat
Dr Mya Tu
Director, Health System
Infrastructure
Dr Uton M. Rafei
Director, Health Protection
and Promotion
Dr B.A. Jayaweera
Director, Research and
Family Health
Dr Zakir Husain
Senior Public Health
Administrator (PHC)
SEA/HSD/74
Page 12
Dr S. Moday
Medical Officer
MPN Unit
WHO Headquarters
Dr Sombhong Kutranon
Regional Adviser on
Community Health Services
Dr K.N. Seneviratne
Regional Adviser on
Health Manpower Development
Mrs Saiyud Nyomviphat
Regional Adviser on
Nursing
Dr M. Otgon
Health Manpower
Development Officer
Mr George Jamieson
WHO Management Office
Bangladesh
Dr B.C. Ghoshal
WHO Consultant
Project ICP PHC 006
SEARO
SEA/HSD/74
Page 13
Annex 2
*
OBJECTIVES
1.
As a follow up of the recommendations of the Meeting on development
of Primary Health Care Networks in the Member countries, WHO/SEARO,
New Delhi, 16-20 August 1983, to develop a plan of action for the
development and functioning of regional primary health care networks
with special reference to the following network activities:
1.1
Restructuring of health infrastructure towards
systems based on primary health care;
1.2
Development of middle-level health managers, and
1.3
Development and use of health systems research.
*Originally issued as document SEA/PHC/Meet 1.1
national health
SEA/HSD/74
Page 14
Annex 3
*
AGENDA
1.
Review of the implementation of the PHC network and its activities
in the countries of the Region and to identify problems and
constraints.
2.
Development of a plan of action for the development and functioning
of regional primary health care networks with special reference to
the:
2.1
Review
of
the
functioning
of
the
restructured
health
infrastructure towards national health system based on primary
health care;
2.2
Development of middle-level health managers, and
2.3
Development and use of health systems research.
*Originally issued as document SEA/PHC/Meet. 10/1
SEA/HSD/74
Page 15
Annex 4
PROGRAMME*
MONDAY, 28 January 1985
0900 - 1030
1030 - 1115
1115 - 1200
Registration
Inaugural session
Plenary session
Adoption of Agenda
Objective of the Meeting
Procedures of the meeting and
administrative arrangements
1300 - 1500
and
1515 - 1630
AGENDA ITEM 1
Review of the implementation of the PHC
network and its activities in the
countries of the Region
Presentation by Member countries
TUESDAY, 29 January 1985
0900 - 1030
Summary of the country presentation and
the future
framework
of
the
primary
health care networking activities under
the project ICP PHC 006
Presentation by Dr B.C. Ghoshal
1045 - 1200
AGENDA ITEM 2
Development of a plan of action for the
functioning of regional primary health
care networks
2.1 Review of the functioning of the
restructured
health
infrastructure
by
the
Member
Countries
towards
national
health
system
based
on
primary health care
*Originally issued as document SEA/PHC/Meet. 10/1.3
SEA/HSD/74
Page 16
- Referral support for primary health
care
- Intersectoral action on primary
health care
- Presentations by Dr Uton M. Rafei
and Dr Zakir Husain
1300 - 1530
and
1545 - 1630
Group discussion on Agenda item 2.1
WEDNESDAY, 30 January 1985
0900 - 1030
Plenary discussion on Agenda item 2.1
1045 - 1200
2.2
Development
of
middle-level
managers - Plenary session
health
- Presentation by Dr K.N. Seneviratne
1300 - 1530
Group discussion on Agenda item 2.2
1545 - 1630
2.3
Development and use of health systems
research
- Presentation by Dr Mya Tu
THURSDAY, 31 January 1985
0900 - 1000
1000 - 1030
1045 - 1200
and
1300 - 1530
1545 - 1630
Plenary session on Agenda item 2.2
Presentation by Dr Mya Tu: Regional PHC
Network
Group discussion on Agenda items 2.3 and
2.3.1
Plenary
2.3.1
session
on
Agenda
items
2.3
and
FRIDAY, 1 February 1985
0900 - 1030
and
1045 - 1200
Preparation of and discussion on the draft
plan of action prepared jointly by groups
and adoption of final recommendations of
the Conference
1230 - 1300
Concluding session
-
Concluding remarks by the Chairman
RD's closing address
__
WORLD
health
-.__ Ctrrv) H ■-’A
3
ORGANISATION MONDIAI
DS’LA SANTS
ORGANIZATION
SOUTH-EAST ASIA REGION
SEA/HSD/74
21 May 1985
RESTRICTED
REPORT OF THE INTERCOUNTRY CONFERENCE ON
PRIMARY HEALTH CARE'NETWORKS NEW'de'lhiV
2~8 JANUARY - 1 FEBRUARY 1985
L
WHO Project: ICP PHC 006
UNDP Project: RAS/31/027
The issue of this document does not constitute formal publication.
should not be reviewed, abstracted or quoted without the agreement of t
World
Health Organization.
Authors alone are
responsible for vl<
appearing under their names.
SEA/HSD/74
1.
INTRODUCTION
The International Conference on Primary Health Care in Alma Ata
in
1978 affirmed that primary health care was the key approach to achieve an
acceptable level of health throughout the world, It also affirmed that the
primary health care approach connoted health as an integ’ al part of social
development and implied a spirit of social justice
Following upon the declaration of Alma At;,, governments formulated
strategies for health for all, adopted nl.am nr "cticn.
and started
orienting national health systems based upon primary health care. The
orientation of national health systems has made varied progress; such
progress is dependent upon political will with all the political, social,
economic and other realities which often are in conflicting arrangement. In
most countries of the Asia and Pacific Regions, the national health
infrastructure and services are still not able to undertake comprehensive
delivery of essential health care to all the people. Also, the health
infrastructure is not fully capable of absorbing and delivering the
available health technologies. Sometimes the technology that is available
is not the appropriate one for delivery through the Infrastructure using
the primary health care approach.
Specifically, the orientation process in health infrastructure is
facing difficulties in regard to a credible and effective referral system
for primary health care.
Intersectoral collaboration is an essential
component of primary health care. Here too, there is much agreement on
principles but little evidence of action.
Though health services research has drawn so much debate and
emphasis during recent years, much remains to be done by way of simple,
practical and problem-solving research likely to be of immediate use. Much
of the health services research already conducted remains on the shelves of
academic circles. Careful selection of research subjects and mechanisms for
involving the health administrators and academicians in the design and use
of research results is urgently needed.
Mutual technical cooperation among countries has teen unexceptional
in principle. But the great potential for such cooperation in health
development
remains largely unexploited.
The Ministers of
Health
of
South-East Asia Region, in successive meetings coiMi.v^cl.sg in 1931, have
provided strong support to the selection of specific areas and modalities
for mutual cooperation. This augurs well for a functional network in which
interested countries can cooperate bilaterally or mult[laterally to their
mutual advantage.
This Intercountry Conference on Primary Health Cave Networks was a
follow-up of the previous meeting on the same subject held in New Delhi
from 16 to 20 August 1983 (see SEA/HSD/65). The Conference addressed some
of the problems related to the restructuring of health infrastructure, use
of health systems research, development of mJddle-level managers and
functions of a regional network of primary health care.
SEA/HSD/74
Page 2
2.
OBJECTIVE OF THE CONFERENCE
The abjective of the Conference was to develop a plan of action for
a functional network of primary health care in the Region. Within this
objective, types of activities in three broad subject areas were to be
identified for the plan of action for the period of 1935 and 1986. The
three broad subject areas were:
3.
(a)
Restructuring of health infrastructure
based on primary health care;
(b)
Development of middle-level health managers, and
(c)
Development and use of health systems research.
towards
health
systems
PARTICIPANTS
There were seventeen participants from nine Member Countries of
WHO/SEAR, and two from Afghanistan in WHO/EMR. One representative each from
UNDP and US AID in India participated. The WHO secretariat support Ing the
Conference
consisted
of
ten
staff
members
including
one
from
WHO
Headquarters and one from the WHO country office, Bangladesh. The full list
of participants is at Annex 1.
4.
CONDUCT OF THE CONFERENCE
The Conference was inaugurated by Dr M...A. Rahman, Director Programme
Management, on behalf of the Regional Director of South-East Asia.
In his inaugural address. Dr Rahman drew attention m the facts that
primary health care could be established by activities of the health sector
alone, and that there was considerable similarity in the socio-cultural and
economic conditions amongst the countries participating, which should
enable them to share the knowledge and experience gained in primary health
care. Thus there was need for close coordination arid collaboration, both
intersectoral and within the health sector itself. He added that a regional
network of primary health care could be a good mechanism for cooperative
activities by the countries. There was good prospect of bringing the health
administrators and
research workers
together
to
solve
problems
and
procedures. Finally, Dr Rahman suggested that the regional network could
function at a number of levels - national, institutional, intersectoral and
international.
In his brief statement, Mr Michael E.
Smith,
Deputy Resident
Representative, UNDP, India, speaking on behalf of the UNDP, drew attention
to the meeting that took place in August 1983 on the subject of primary
health care network, an! in particular, to the report of the evaluation of
the UNDP-funded intercountry project "Promotion and Development of Primary
Health Care". He hoped that the findings and recommendations of this
evaluation report would be reflected upon by the participants at this
Conference.
Dr M.D. Saigal (India) was elected Chairman, while Dr
(Sri Lanka) and Dr Abdul Sattar Yoosuf (Maldives)
were
Vice-Chairman and Rapporteur respectively.
C.D. Herath
elected as
SEA/HSD/
Page 3
The objectives of the Conference (Annex 2) were adopted while t
provisional agenda (Annex 3) and programme (Annex 4) were adopted wi
minor changes. Each agenda item in the programme was discussed both in t
plenary and group sessions. The participants were divided into two grou
for in-depth discussions on each agenda item and ar Qd to produce gro
reports with recommendations for the plan of action. Each group elected
chairman and a rapporteur ajid used suggested guilelines for discussion.
5.
discussions
One participant from each country presented an overview of t
existing stale of development of primary health care institutional networ
From these presentations, it was evident that the structural at>d function
networks for primary health care were in different stages of developmen
However, there was similarity in problems and opportunities for furth
development in specific areas such as integrated disease control, referr
system, intersectoral collaboration, and management and supervision
health
services.
Frequent
reference
was
made
to
the
need
f
action-research, sharing of information and technology within vario
levels of national health systems and amongst countries.
Dr B.C. Ghosal, WHO Consultant, presented a brief background of t
activities of the Project ICP PHC 006 and some thoughts on the possib
future
activities
required
of
the
project.
in
the
light
of
t
recommendations of the tripartite review held in July 1984. He al
presented a
summary of
the
country
situation
reports made
by
t
participants earlier.
5.1
Restructuring of Health Infrastructure for Health Systems Based on
Primary Health Care
An introductory paper on this agenda item was presented by Dr Ut
M. Rafei, Director, Health Promotion and Protection, which was followed
another discission paper presented by Dr Zakir Husain Senior Public Heal
Administrator (PHC), dealing with the referral sytem development a
intersectoral collaboration for h
*ealth
primary
care. Besides the concepts
framework of restructuring, referral system and intersectoral actions, f
possible strategy framework and suggested lines of action were presented.
Restructuring with particular reference to the referral syst
should encompass much more than mere referral of patients to hospitals.
the
context
of
health
systems
orientation,
logistics
suppor
supervision-cum-training, and good communications were essential pillars
a sound referral system. The strategic framework of a' referral syst
consisted of coverage of the entire population, health and health-relat
services and strengthening of two-way support links throughout differs
levels: Some of the essential steps for the design of a good referr
system would be the (i) quick analysis of the existing situation a
potential
in
manpower,
institutions,
and
other
facilities;
(I
seleccion/adaptatlon of health technologies and services at differs
levels; (ill) combination of supervision and training in problem-solvir
(iv) monitoring of materials supply and utilization; and (v) coordinat
service and support with health-related sectors. Some of the early poir
of action would include the first referral institution, balancing t
health facilities at various levels of the health system, approprit
linkages amongst service, training and research facilities, and train!
SEA/HSD/74
Page 4'
and motivation of health and other workers for 'the referral system's
functions. Finally, the- referral system should be
■' wed as a broad
supportive system for enhancing the credibility of primary health care.
The subjects of referral system and intersectoral actions were
discussed
in
both
the
plenary
session ■ and
in
groups.
Practical
recommendations on the types of activities to be supported through the
regional primary health care network were formulated (see Section 6).
Several important issues came up in group discussions. Reference was
made to the various action points inherent in the strengthening of referral
systems. There was need for developing rhe required technical expertise in
systems design; standards or norms for referral institutions were needed;
flexibility in
operating a
standard
referral
design
was iessential;
action-research was more relevant than model-building; manuals were helpful
and would have to be prepared; country studies on alternative systems for
supplies, logistics and maintenance were suggested. Based on these, a few
types of activities were selected for inclusion in the regional plan of
action for the years 1985 and 1986.
On intersectoral actions tor health, discussions in the groups
identified several major problems and recommended the Increased use of
existing bodies and avenues for collaboration amongst the various sectors
rather than creating new mechanisms exclusively for this purpose. The
groups also pointed to the need for careful selection of a few relevant
indicators for intersectoral" collaborative actions to enable periodic
assessment of the progress, problems and prospects. A suggestion was also
made for some localised studies with a view to formulating some basic
guiding principles based on local experience.
A few’approaches to the subject of intersectoral
ollaboration were
mentioned. One wa»s to align the health goal with, the L-oader development
goal. Another approach was to start from the end of community level
organizations as opposed to the official sectors' end. The initiative of
this
approach
was
in
the
hands
of
the
community
moving
Cowards
self-reliance with technical support-, where needed,
of
the
official
agencies. Yet another approach was to start and continue a systematic
review of health components of development activities at all levels with a
view to maximizing .the internal linkages and complementarity. A few
recommendations on the types of activities were made for inclusion in the
regional plan of action.
5.2
Development of Middle-Level Managers
An introductory paper on this agenda item was presented in a plenary
session by Dr K.N. Seneviratne, bringing out the expected outcome of the
discussion oh this subject, namely, to provide guidelines for work plan for
middle-level
management
training.
The
current
assessment
of
health
management situation in countries appeared to point to the priority need
for developing middle-level managers. Training of middle-level managers
would be one major contributor
to
this development.
Management
was
essential for the optimum use of available resources in the context of
primary health care. The management needs for primary health care related
chiefly to self-reliance of communities for their health, decentralizatlor
■
SEA/HSD/’
Page 5
of resources and responsibilities, progressively to peripheral levels ar
greater
involvement
of
community organizations
ir
the
planning
ai
management of local health care. In the context of mi. u. e-level rnanagemeni
much of the training would need to be stressed to improve problem-solvii
skills and the performance of programmes. It was felt that relatively moi
attention would be needed for programmes/project, |tanning, implementatloi
management hnd monitoring programme performance. The training content migl
also include leadership skills and management of staff, human relationshij
and skills in the resolution of conflicts. Additional skills of financ.it
management and effective communication were required. The specific content
and the preferred types of management training will be different in tl
countries depending on their particular needs and priorities. Experient
during the past two decades in ’health
management training in the Regit
seemed to confirm that in order to make training highly relevant a:
effective it should focus more upon practical management competence ai
less on .generalized concepts and
principles.
Middle-level
managemei
training had limited objectives and it should be seen within the broadi
perspective of overall Improvements in health management. It would de:
with developing skills as well as the appropriate attitudes. It would all
have to be linked with the process and progress of decentralization ■
authority and responsibility.
During discussions in the plenary following the presentation a
in-depth discussion in the groups on this subject, further elaboration <
the contents of such training was made. There was a suggestion to inclu
training in basic epidemiological discipline while other suggestions we
for more personnel management, budget and financing control. The idea
including management as a subject in basic educational curriculum did n
receive wide support. At the end of these discussions the groups agreed
a few types of activities for the regional plan of action for 1985-198
Three major types of activities identified were:
5.3
(1)
A clearer Identification of actual management training needs;
(2)
Strengthening
trainers, and
(3)
Development of a basic
adaptation in countries.
of
training
capabilities
module
at
the
of
institutions
regional
level
a
£
Development and litilization of Health Systems Research
A paper on this
subject
was presented in a plenary session
Dr Mya Tu,
Director,
Health
Systems
Infrastrucutre,
WHO/SEARO,
1
alternative approaches to health systems research were explained. One v
problem-oriented research-seeking information (PORTS) approach and t
second,
research
information
dlsplay/utilization
promotion
(RIDl
approach. Between these two, the PORIS approach was based on market!
techniques and, therefore, was likely to assure better utilization
research results. This approach relied on information-seeking behaviour
the
decision-makers
and
tried
to
stimulate
that
behaviour
decision-making situations. The basic premise in this approach was th
managers faced with problems had to make decisions. If motivated to st
essential additional information and if research attempted to generate tl
information, ir had a better chance of being accepted and used. On 1
other hand, the RIDUP approach relied heavily on the initiatives
researchers who, having obtained the findings, tried to sell their produi
SEA/HSD/74
Page 6
to the user, i.e., managers and decision-makers.
Naturally,
in this
approach the subject of research and the results might nor be the ones that
the consumer “--anted or needed. Thus, it was necessary tr -tornote the PORTS
approach, which was more appropriate and gave some possibilities of being
accepted
and utilized
by decision-makers
and managers.
The
present
situation in the field of health systems research was rather discouraging
although, by definition, health systems research was directly concerned
with the problems of organization, logistics, financing, etc. of the health
services and these appeared to be highly relevant for use by planners and
administrators, this had not in fact occurred to any large extent. More
often, problems continued to be chosen by the individual researcher in
academic institutions with or without the involvement of
the health
services personnel. It was assumed that the results thus obtained by the
researchers and subsequently published in reputed or other journals would
be used. This did not happen. The subject of utilization of research
results had, in the past few years, been discussed in various forums. Many
suggestions had been made in. this regard including the joint selection of
problems by service agencies and research agencies, and dissemination of
results in easily assimilable form. Suggestions were also made for a
dialogue between the users and producers at all stages. Bui: the fact
remained that much of the research findings still remained unutilized.
The subject was discussed in the two groups with a view tc
identifying a few specific types of activities for regional network tc
support. The groups identified seven areas for health systems research it
the
context
of
primary
health
care.
These
included
supplies
am
procurement,
personnel
management,
behavioural
research,
financial
management, service delivery, appropriate health technology and training of
health workers. Specifically,
three broad areas for research emerged.
First, operational research in the management of primary health care with ;
built-in mechanism for the immediate use of findings. Second, development
of models in respect of urban primary 'ealth care with s acial attention t<
slum population. Third, alternative and new approaches -.. . implement primar;
health care.
A major recommendation was made after discussions in groups and i
the plenary to support national efforts in health systems research (se
Section 6).
5.4
Regional PHC Network
Dr Mya Tu introduced this subject from an operational point of view.
The necessary preconditions of a successful network were reaffirmed
It was essential that areas or problems amenable to network collabpratio
were clearly defined and firmly agreed upon. A functional network was fel
to be more practicable than a structural network. In fact, a structure
network might be difficult to sustain. On the other hand, the propose
functional network could benefit from linkages and sharing of informatio
with already established formal networks, e.g.,
ASEAN Training Centre fc
primary health care, the Asian Pacific Academic Consortium of Publi
Health, and the South-Asian Regional Cooperation.
SEA/HSD/7
Page 7
Following in-depth discussions in the two groups and presentation o
their reports to the plenary session, a few recommendatlons on th.
functioning of a regional PHC network were proposed (se
lection 6). It wa
the consensus of the Conference that some Level of formal national network
of designated institutions or individuals was a
prerequisite for
functional regional network. In this regard. WRO/FEAPO was expected to tak,
some initiatives. The Conference also endorsed the view that functions
linkages with established mechanisms under geopolitical grouping, e.g.
ASEAN,. SARG, and other bi-regional networks were necessary.
6.
RECOMMENDATIONS FOR PLAN OF ACTION
As stated earlier, the discussions on the subject agenda items i:
the two groups followed by review in plenary sessions crystallized selecte,
recommendations related to the plan of action for the regional primar;
health care network during 1985 and 1986. The recommendations were in th,
nature of broad indications of relevant, types of activities that th.
Conference suggested to be of high relevance to the needs of nations
networks for primary health care. These recommendations constituted th,
guidance for drawing up a detailed plan of action with budgets related ti
the proposed activities under the intercountry project ICP PHC 006. Th,
recommendations are presented for each agenda item as follows:
(1)
Item 1 - Restructuring of FHC infrastructure
A.
Referral system
1.
Carry out rapid analysis of the existing situation in healtl
infrastructure - staff, facilities, equipment, institutions.
2.
-Design and develop an action
programme/pilot
project
an,
implement measures to lmt rove the referr?
system based ii
particular on the following types of activities:
(a)
Reorientation,
reorganization
referral institutions.
(b)
Orientation and training of health personnel at differen
levels about the referral system.
(c)
Information and education of communities In the function
of the system.
and
strengthening
o
3.
Monitor, evaluate and reformulate a referral system.
4.
Produce
guidelines
and/or
guiding
application in the health system.
B.
Intersectoral action
1.
Carry out a qualitative analysis of the existing situation 1
Intersectoral collaboration at the implementation levels.
2.
Design and develop an action
programme/pilot
project
an,
implement measures to improve functional linkage within th,
framework
of
existing
mechanisms
for
intersectora
collaboration.
principles
for
wid,
SEA/HSD/74
Page 8
3,
Monitor,
formulate a mechanism
evaluate and
for
Intersectoral
collaboration.
4.
Produce
guidelines
application.
and
o..
guiding
-.rinc
(2) . Item 2 - Development of middle-level
les
for
wider
manngers
Collaboration with national institutions/focal points
middle-level management training programmes as follows:
in developing
1.
Identify management
training needs of middle-level
health
managers through different approaches such as job analysis,
interviews of health personnel, particularly observations, and
organization of workshops.
2.
Select and strengthen training capabilities of institutions and
trainers through:
a)
b)
c)
d)
trainers' training;
development and exchange of training materials;
curriculum development and adaptation, where relevant, and
exchange of trainers, guest speakers, and other relevant
resources.
3.
Development of management training module at the regional level
which could be adapted by countries. This module should include aspects
such as community organization, community mobilization and other contents
relevant to primary health care management.
Item 3 - Development and use of health systems research
Promote the development and u a of health
supporting, through national and regional network
efforts in the:
sys etns research by
me inisrcs, national
1.
Identification
of
problem ai't.is
u.
primary
health,
care
management amenable to health systems research for solution.
2.
Review of
available
practical application.
3.
Design and conduct of operations research with the overall
objective
of
improvement
in
planning,
management
and
Implementation of primary health care.
4.
Design and implementation
health care.
5.
Development of urban or semi-urban primary health care models
in pilot areas in selected countries, with particular reference
to slum areas.
relevant
of
studies’
innovative
or
information
approches
to
for
primary
SEA/HSD/i
Page 9
Development of Regional PHC Network
1.
*
National r.L.j.'ks should be formed in countries consisting o
relevant individuals or institutions designated as nations
focal points for primary health care. These focal points shoul
be able to communicate with each other, with the focal point
of Member Countries,
other existing
networks
directly o
SEARO acting
as
a
coordinator.
WHO/.SEARO
shoul
through
initiate action.
Relevant activities being carried out through other networ
mechanisms like ASEAN Training Centre for PHC Developmen
(ATC/PHC), Asian Pacific Consortium of schools of Public Healt
(APCSPHj, South Asia Regional Cooperation (SARC) should b
taken into consideration, and functional linkages established
for sharing resources, experience and 'information and avoidin
duplication.
These recommendations were
session.
7.
adopted
in
the
concluding
plenar
CLOSING SESSION
Dr ,U Ko Ko, Regional Director, addressed the concluding session o
the Conference. In his address, he reiterated the Importance of the subjec
of the Conference and thanked all the participants for having provide
useful and practical guidance for activities in countries that were highl
relevant, and their assistance in the formulation of a plan of action fo
regional support.
In this context, tr U Ko Ko Invited particular attention of th
participants to the need for mobilizing resources through mutual technics
cooperation
by countries
to
support
the
regional
network.
He
als
of "Health fo
highlighted the recognition of the fact that the training
All" leaders in countries was a subject of very high priority that the WH'
Executive Board endorsed for the coming years. Dr U Ko Ko further asserte,
that the real action must take place in the countries and that WHO wa
ready to support actions that countries themselves took to implement th,
recommendations.
WORLD
HEALTH
ORGANIZATION
--------------"ORGANTSATrONMONDIALI
WW
M “SANTE
•.SOUTH-EAST ASIA REGION
SEA/HSD/106
9 October 1986
RESTRICTED
INTERSECTORAL ACTIONS FOR HEALTH SOME ISSUES AND OPTIONS
WHO Project: ^ICP PHC 006
UNDP Project: RAS/81/027
The Issue of this document does not constitute formal publication. It
should not be reviewed, abstracted or quoted without the agreement of the
World Health Organization. Authors alone are responsible for views
appearing under their names.
SEA/HSD/106
o
CONTENTS
1
INTRODUCTION
2.
THE CONCEPTUAL FRAMEWORK
2.1
2.2
onomic and Human Development
INTERSECTORAL ACTION FOR HEALTH IN COUNTRIES OF
THE SOUTH-FAST ASIA REGION
1
2
2
3
3.2
3.3
Situation in the Countrie
Existing Mechanisms
Operational Constraint
3.5-
Critical .Issues,
4
4
5
METHODOLOGICAL FRAMEWORK FOR ANALYSIS OF
HEALTH PROBLEMS WITH IMPLICATIONS FOR
INTERSECTORAL ACTION
5
Methods of Analysing Health Problem:
Suggested Steps for Analysis
5
6
BASIC CONDITIONS NECESSARY FOR INTERSECTORAL
ACTIONS FOR HEALTH
6
CONCLUSIONS AND RECOMMENDATIONS
7
Creation of a Cell within the Ministry of
Health, for Intersectoral Action for Health
Plan of Action
•
8
8
Options For tiie Use of Existing Mechanisms and
Methodologies for Implementing Intersectoral
Action for Health
10
4.1
1.2
..1
nnex
3
SEA/HSD/1.06
1.
INTRODUCTION
An overview of the health and socio-economic situation in the
South-East Region of WHO shows close and complex links between health and
socio-economic development. Health is an investment in the development of
human resources. Improvement of the state of people's health results from
socio-economic development with distributive justice and not from mere,
economic growth, as evident from contemporary experience with development
strategies throughout the world.
- The
global
strategy
for
health
for
all,l
adopted
by
the
Member
States in the World Health /assembly in 1981,
calls for the mutual
reinforcement of health and- economic development policies. Achievement of
health goals is. to a considerable extent, determined by the policies,
strategies and programmes of other sectors of development. There are health
hazards associated- with economic under-development as there ' are with
unbalanced
economic
development.
Economic
planners
and
political
decision-makers need to be aware of the health implications of alternative
development strategies and programmes which either promote or threaten
health, National policies on poverty alleviation, agriculture and food,
water and sanitation, education and adult.literacy, housing;and. environment
have significant effects on the'health of the people.
Intersectoral actions for health through close coordination and
cooperation between the health and other social and economic development
sectors are essential for health development. Yet the.first evaluation of
national health-for-all strategics' points inter alia tc weaknesses in the
mechanisms and processes of international actions for health.
In order to promote an understanding of the conceptual basis and the
adoption of 'a simple analytical framework to examine the intersectoral
dimensions of health development, an Intercountry consultation was convened
in the WHO Regional Office, New'Delhi, from 28 October to 1 November 1985.
The main objectives of the cpnsultation were:
(1)
to
promote
clear
conceptual
intersectoral actions for health;
(2)
to develop a general framework for critical analysis of ■
sectoral strategies in relation to their effects on .
health, and
understanding
of
SEA/HSD/106
Page 2
(3)
2.
2.1
'
to stimulate the awareness of options for intersectoral
actions for health using the existing mechanisms of
intersectoral coordination in countries.
THE CONCEPTUAL FRAMEWORK
Health, Economic and Human Development
Experience confirms that improvement of the state of health results
from socio-economic development reflected in higher levels of literacy,
employment and Income, housing and sanitation, and standard of living.
Conversely, the process of agricultural and industrial development and
changes in life-style and food habits create new health hazards. Within the
overall socio-political. structure end environment, peoples' participation
in decision-making influences the development process and distribution of
resources, and thereby the health and welfare of the people.
Health
is not the concern of the health sector alone. It also
requires actions by other social and economic sectors. Health for all, as a
social goal, has to be integrated into social and economic goals, and
health strategies into the overall social development strangles.2■The Health-Related Sectors
Some of the sectors closely related to health development are
education, culture and life pattern; agriculture and food; environment and
sanitation;
general economic development and
growth;
industries,
and
housing. Much of the health problems and their manifestations are traceable
to the development activities in these sectors through dynamic processes
and linkages (Figure 1). There may be very few health problems that are
entirely amenable to actions by the health sector alone. More often, the
health-related sectors have a greater potential to contribute to overall
health development.
i
The rationale for Intersectoral actions for health is also, derived
from a hew and more meaningful development approach vzhich puts human
development at the centre of economic growth and' social development.
Achievement of sectoral goals cannot but be interlinked with the central
goal of human development in such a development approach. The health
effects of development strategies and programmes in all sectors become an
important concern for development planners and coordinators, health being
an inseparable component of human development (Figure 2).
Coordination and collaboration are conceptually dependent upon some
preconditions. Those who are expected to coordinate and collaborate among
themselves must perceive mutual problems, mutual benefits, and mutual
contributions. Mutualities of needs and interest are fundamental to a s'tatp
of active collaboration and willingness to submit to a mechanism and
process of coordination. These mutualities are also essential pre-requisites.
for willing and sustained cooperative actions amongst partners. These
pre-conditions may not be spontaneous, and may have to be consciously
generated. Efforts to sustain the mutuality of perceptions are essential.
Intersectoral actions for health cannot be left merely to ad hoc decisions.
A
r. ' !
permanent mechanism to generate
.•
a -Mltio' '
valid
Mr.'.
information on the health
■»?
1 1/ r pnd .ptions for
SEA/HSD/10
Page 3
; action to the decision-makers is an important constituent of the conceptua
framework.
■ 3’
.•3.1
INTERSECTORAL ACTION FOR HEALTH IM COUNTRIES OF
THE SOUTH-EAST APIA REGION
‘
Situation in the Countries
.
*
Generally speaking, in most of the countries, plans for developmen
and the allocation of resources are sector dominated and do not reflect t
a great extent either a policy commitment or programme support relate'
specifically to intersectoral actions for health.
All Member Countries of the South-East Asia Region of WHO are Imple
menting their strategies for health for all through the primary health can
approach. Intersectoral action for health is recognized as an importair
component of the strategies. Even though its importance is appreciated, am
mechanisms for coordination exist, intersectoral action for health remain.
a weak area in the implementation of health-for-all strategies.
There is inadequate analysis and projection of the mutual benefit;
which may accrue to the participating sectors through mutual collaboration
A review of the situation in the countries revealed that there seems to bi
a lack of concrete knowledge of the scope and nature of mutually supportlvi
actions among the different sectors, particularly in relation to health
The health ministry does not play a leading role in mobilizing tin
cooperation of other sectors in the reduction ol health-related problemi
which are amenable to activities by these sectors. The” is no mechanism t(
generate information of a convincing nature to make oluer sectors perceivi
the importance of their role and the specific health components that may bi
Incorporated in their goals and objectives.
In-depth studies of tin
programmes and activities of other sectors which Slave a bearing or. healtl
are seldom undertaken. There is no permanent mechanism such as a task forc<
or technical group in the ministry of health or outside it to undertake thi
task.
3.2
Existing Mechanisms
In all countries, mechanisms exist at the central level to assumi
the responsibility for bringing about coordination and intersectoral actioi
for national development. These mechanisms are usually in the form of t
cabinet-level committee, an inter-ministerial committee of secretaries, the
national socio-economic development board or council,
the ministry oi
planning or economic developments, or the national planning commission,
However, most of these mechanisms address coordination amongst sectors foi
economic growth and development, and not for health development as such.
Political commitment to the health-for-all goal led to the creatior
of national-level bodies in some countries, e.g., Health For All Steerin;
Committee (Napal), Primary Health Care Coordination Committee and National
Health For All Council (Bangladesh), and the National Health Council anc
National Health Development Networks (Sri Lanka). These national level
mechanisms vary in their composition, terms of reference, and level oi
activitiesAt the intermediate level, mechanisms for coordination among sector)vary even more widely in form, functions and operational efficacy. Recent
SEA/HSD/106
Page 4
efforts by governments to decentralize development activities to the
provinces.'istricts have only met with partial success. These remain,
by and large, weak with few exceptions, because of lack of institutional or
material resources. Occasionally, lack of clear directives and monitoring
procedures keeps the mechanisms dormant.
At the peripheral level, the participation of communities is being
encouraged tltoagh various types of representative local government bodies
in community development, notably integrated rural development programmes.
Workshops, seminars, distribution of education materials, and consultative
decision-making by community agencies are
some
methods
employed
in
countries to promote intersectoral actions for community development.
Occasionally, village councils are supported by executive bodies and
sector-specific technical personnel with advice and material assistance in
programme implementation. This process developed into a high degree of
functional decentralization when real resources and responsibilities were
delegated to representative local government bodies and when the people
themselves were involved in deciding on activities to meet their own need?
and implementing these activities themselves.
On some occasions
intersectoral action
has
been
achieved
by
integrating health care
with
programmes
such
as
rural
development,
nutrition, family planning, the basic minimum needs programme or even with
education as, for example, in Thailand, Nepal, Bangladesh and India.
As stated
before, the various mechanisms at different levels are
still evolving. These have met with various degrees of sucres
Their method
of work also differs. In countries where the higher echelons such as the
inter-ministerial coordination committee, the planning commission or the
national development council have strongly articulated:intersectoral actions
in their health policies and supported them by clear operational directives
at ail levels, there has been greater success. Orientation seminars on
health-for-all and the primary health care approach have also been helpful
in mobilizing the commitment of political leaders, such as In Sri Lanka.
3.3
Operational Constraint
The mechanisms established for promoting intersectoral coordination
have not necessarily resulted in coordinated actions for health. There
could be many reasons for this, an important one being the lack of a common
understanding of.a framework of intersectoral actions for health.
Actions for health by cooperating sectors resulted more often from
ad hoc perceptions and sporadic decisions. Besides, lack of skills to
translate policy decisions into specific operational activities rendered
agreements in principle and the- mechanisms ineffective. Poor communication
between the central and other levels, lack of motivation and inadequate
manpower skills in the health and often other ministries were additional
constraints.
....
3.4
Financial Constraints-
,
The countries in the Region were implementing their development
plans under severe financial constraints. Financial allocations and resource
adjustments were difficult exercises, especially in times of econoic crisis
SEA/HSD/106
Page 5
when different sectors compete with each other tor higher allocations. In
such a situation, adjustments and compromises more often affected the
resour
of rhe health and other social sectors. Owing to lack of
information and knowledge of viable options, resources of other sectors
were not used for bringing about the reduction of health problems or the
promotion of health. Analytical presentations of the inter-relationships
between economic and social development expenditures with health were
scarcely found.
3,5
Cel ileal Issues
Some of the critical issues in intersectoral actions for health
which reauire priority attention were identified at the consultation. These
have often been reported to affect adversely the efforts to foster
intersectoral action for health.
(1)
Problems
of
translating
political
commitment
into
specific operational means for intersectoral actions for
health.
(2)
Lack of multi-level mechanisms for policy formulation,
planning and implementation of intersectoral actions for
health in a systematic manner.
(3)
Inadequacy of analytical and action-oriented information
and associated problems of evolving clear directives for
actions and feed-back.
(4)
Insufficient criteria and
indicators to
monitor and
measure the impact of intersectoral actions for health.
(5)
Absence
of
simple
and
quick
methods
to
analyse
systematically the positive and
negative
impact
of
development on health, especially on’ the weaker sections
of society.
4.
METHODOLOGICAL FRAMEWORK FOR ANALYSIS OF HEALTH PROBLEMS
WITH IMPLICATIONS FOR INTERSECTORAL ACTION
4.1
Methods of Analysing Health Problems
Sound policy decisions require adequate and appropriate information.
In most countries,- the system of epidemiological intelligence did not
provide the type of information derived from careful analysis of health
problems resulting from activities in other sectors. Health ministries
usually
publish
progress
reports
of
activities
In
various
health
programmes. These reports give statistical information on health activities
but do not report on health problems in the perspective of developments
outside the health sector.
Health systems research was needed to generate Information of this
nature.
It should address specific health problems, and particularly
Intersectoral actions for health. Research into priority health problems
should highlight concrete evidence of how the activities of various sectors
either reduce or aggravate particular health problems Ln field situations.
New health hazards should be promptly reported and viable options for
actions should be discussed in such reports.
SEA/HSD/106
Page 6
Different types of health problems cdn be traced back to a single
originating source On the other hand, several serto-- mav contribute to a
specific health problem, for example, a highly endemic disease such as
malaria.
4.2
Suggested Steps tor Analysis
A methodological framework for the systematic analysis of a health
problem requiring intersectoral actions can be broken down into a series o;
sequential steps:
5'
(1)
Selection of a critical health problem should be the
first step. Specific criteria for selection should be
agreed. The amenability of a particular problem to
intersectoral actions should be an important criterion.
(2)
The direct and indirect causes of the selected health
problem or health hazard should be investigated. Side by
side, environmental factors which have a reducing effect
on the problem should be identified. It may be necessary
to commission short-term or on-going field studies to
generate this information. In most cases, this will
require a multidisciplinary team approach and possibly
multi-centre studies.
(3)
Considering the findings of the analysis and available
means, a number of options supported by a feasibility/
constraint analysis should be proposed.
(4)
A summary and a position paper containing
and options
to
the
policy-making
bodies
administrators should be prepared.
(5)
Policy decisions and
directives ’emanating
from
the
coordinating bodies should
be
fully
explained,
and
specified methods of implementation widely disseminated.
(6)
'flie results of implementation should be reported to the
coordinating mechanism, and to the concerned sectors.
information
or
sector
BASIC CONDITIONS NECESSARY FOR INTERSECTORAL
ACTIONS FOR HEALTH
Meaningful intersectoral actions
certain basic conditions are fulfilled.
for
health
may
be
sustained
(1)
Recognition and acceptance at all levels that health is
basic to human development, and Intersectoral action for
health is a core strategy for development as a whole.
(2)
An
agreed
and
accepted
conceptual
framework
of
intersectoral actions ice health and its adoption as an
instrument of national development policy.
(3)
A permanent and adequate mechanism to analyse health
problems and identify sector-specific health effects and
to provide viable options for intersectoral actions for
health.
if
SEA/HSD/106
Page 7
(4)
Mechanisms to translate stated policies and priorities
for intersectoral action into operative guidance.
(5)
Mechanism to monitor implementation.
Options for Prc-Eioting Intersectoral Action
'ihe
following
options
could
be
considered
Intersectoral actions for health. A detailed annotation
provided in the Annex.
(1)
6.
for
promoting
of options is
Strengthening the ministry of health by creating a
mechanism, cell or necleus, with the required technical
capability and some executive responsibility. This could
be
the
focal
point
for
promoting
and
sustaining
activities for coordinated intersectoral actions. Some
of the important functions of this cell or nucleus could
be:
(a)
to carry out specific situation analyses for the
health-related
programmes
in
health
and
other
sectors;
(b)
to identify priority economic and infrastructure
development
programmes
most
amenable
for
incorporation Into a health component;
(c)
to provide factual Information and options
decision-makers, and
(d)
to train and orient health staff towards improving
their analytical skills and attitudes.
to
the
(2)
Strengthening the existing health' planning units
health information sections to assist in some of
functions as listed above.
(3)
Designating a
commission
to
database
for
development.
(4)
Integrating health components into high priority social
economic
development
programmes
early
in
the
and
planning stage.
(5)
Involving the core administrative sectors, such as the
ministry of interior and the ministry of home,
to
Institutionalize the process of intersectoral actions
for health in the intermediate and local government
institutions.
and
the
section
or a
wing
In
toe
planning
generate
and
maintain
an
up-to-date
intersectoral
planning
and
programme
CONCLUSIONS AND RECOMMENDATIONS
All
countries
in
the
Region
recognize
the
importance
of
Intersectoral actions for health to attain the goal of 'Health for All by
SEA/HSD/106
Psge 8
the Year. 2000’. In all countries, mechanisms exist, starting with the
national cacj-slon-taaking bodies at the apex, to fortaulate policies, and
sometimes directives, for Intersectoral- actions. Alternative methods are
being evolved and applied in several countries. Owing to some inherent
constraints, the existing mechanisms are, however, not fully effective.
The participants in the Intereountry meeting reviewed the current
situation and the conceptual framework, and suggested a few short-term
actions to further promote intersectoral actions for health. Basically
these relate to the concept and critical issues: options for intersectoral
action; methodological framework for systematic analysis; and the creation
of a focal point/mechanism in the ministry of health. The recommendations
of the meeting are summarized below.
6.1.
Creation of a Cell within the Ministry of
Health for Intersectoral Action .for Health.
Sound policy decisions pre-suppose the availability of accurate,
adequate and appropriate information. For the collection, analysis and
interpretation of relevant data, creation of a cell within the ministry of
health was recommended by the participants. Its primary function could be
to compile relevant information from several sources and identify areas for
action. More specifically, its functions could be:
(1)
to classify and index information for locating problem
areas, their different dimensions and their short and
long-term implications;
(2)
to
assess
trends,
the
overt
and
latent
health
consequences
of
the
development
progammes,
and
projections of ■ the future, impact on health;
(3)
to identify specific sectoral actions and
whose collaboration will be required’:
the
agencies
(4)
to monitor the progress of implementation
feedback to decision-making bodies, and
and
provide
(5)
to prepare scientific reports, position papers, other
special documents,
etc.,
for the
use of different
sectors and their respective declsionr-making apparatuses.
The proposed cell will have to perform multiple functions, and
therefore will need to organize the right mixture of skills and methods of
work.
Its functions will include the exploration of basic information on a
given problem, diagnosis of the cause-effect complex of factors, monitoring
of the progress of actions, projections of effects and impacts, and acting
as a technical arm of the ministry of health.
6.2
Plan of Action
Participants from the countries drew up tentative short-term (for
1986) country plans of action for intersectoral action for health, starting
with a few activities.
11
SEA/HSD/106
Page 9
Some of the areas identified as part of
ction in the immediate future could be as follows;
country-level
follow-up
(1)
Relevant ancj timely information on health effects due to
sectoral activities.
(2)
Orientation of staff of different sectors at all. levels,
to improve the conceptual understanding of intersectoral
action for health..
(3)
The need to sensitise high-level decision-makers in the
social and economic development sectors to the rationale
of intersectoral actions for health for human resources
development.
(4)
Seminars for political and public representatives on the
health-for-e.il goal.
(5)
Timely and regular channels- of communication between
sectors as also within the ministry of health on the
intersectoral aspects of health problems and health
effects.
(6)
Studies and publications of reports on priority health
problems and intersectoral actions, to encourage joint
sectoral programme development.
(7)
Short-term
action-research
at
the
district
and
peripheral levels to test practical meth , .s of field
assessment and actions for health.
(3)
Prompt dissemination of research results end inculcation
of
research
information-seeking
behaviour
in
administrators.
(9)
Use
of
simple
indicators
to
monitor
intersectoral
actions
for
health
by
the
communities
and
local
government bodies.
SEA/HSD/106
Page JO
Annex
OPTIONS' FOR THE USE OF EXISTING MECHANISMS AND METHODOLOGIES
FOR IMPLEMENTING INTERSECTORAL ACTION FOR HEALTH
1,
All teles must emanate from prograinmes
2.
Mechanisms required by health sector to:
(a)
(b)
(c)
3.
. Need for focal point for intersectoral action for health (IAH) with
responsibility and accountability
‘Ceil’ or section or wing within the planning commission
4.
5.
analyse sub-activities
identify action point
ensure coordination
*
Need for qualitative Improvement in the capability of personnel
6.
Network
7.
Planning units to be strengthened - multisectoral vision
8.
Sensitise top decision-makers and provide information (cell)
9.
Cell to deal with sector-specific analysis and recommendations
10.
Involve -core administrative
ministry of home
’
,
11.
Change in attitudes of ministry of health personnel
12.
Training of health staff in development programmes
13.
Tag health to other priority developmeat/economic programmes.
DOC ID 0U07w (TP/1986)
AD OOOlw
sector,
i.e.,
ministry
of
interior/
•
e.g.
SECTORAL ACTION CAUSING
HEALTH PROBLEMS/HEALTH HAZARDS
IRR1GATION/DAMS
FACTORIES/INDUSTRIES
PESTICIDES
DEVELO PM ENT
FISHERIES
EXISTING MECHANISMS
Central level:
•
planning commission/ministries
NHDC/NHDN
HFA COMMITTEE
NESDB
HEALTH
SECTOR
ACTIONS TO
HEALiH
PROBLEMS
OVERCOME
----
HEALTH
PROBLEMS
1
COORDINATING MINISTRY
I AH
MINISTRY
OF HEALTH
OTHER LEVELS:
TOTAL
OTHER
I AH
ACTIONS TO
PROMOTE HEALTH
SECTORAL ACTIONS
REDUCING HEALTH PROBLEMS
AND HEALTH HAZARDS
STATE COORDINATING COMMITTEE
) INTERDISTRICT COUNCIL
BLOCK,''TOWNSHIP LEVEL) MEDIATE
(LOCAL)
VILLAGE PANCHAYAT
e.g.
food a nutrition
occupational health
SEA/HSD/106
Page 11
DRUG CONTROL
HEALTH PROMOTION
WATER AND SANITATION
HOUSING
AGRICULTURE
EDUCATION
ENVIRONMENT
OTHER SECTORS
I AH
HEALTH
SECTOR
HEALTH
POLICIES
STRATEGIES
IAH - Intersectoral Action-for Health
Page 12
l SECTOR
POLICIES
STRATEGIES
.SEA/HSD/1O6
POLITICAL COMMITMENT TO
HUMAN DEVELOPMENT /
EQUITY DISTRIBUTION
Com H
; PROBLEMS
PRIMARY HEALTH CARE
Based or. the analyses of human resource development for primary health '
care offered in previous chapters, we may now attempt to summarize the major
problems found in six sL-utry—countries and the desk review.
Not every
problem, of course, is found in every country; but if a problem or issue has
been identified in two or more countries it has been considered worth
reporting.
These observations will be presented in three groupings: health
human resources development, primary health care delivery, and under-lying
issues.
It should be clear that all problems are inter-related.
~6-rr—Itevelopaent of Human Resources for Health
To avoid repetition and to sharpen this presentation, the problems of
human resource development for health will be presented mainly under
generalized concepts, rather than, separately for eacli—per-souhel .category:
-CL)—-Inadequate Numbers and Ratios of Conventional Personnel. Most
developingS»untrle's-4i&ve.inadequate supplies of"physicians, • professional
nurses, sanitarians, dentists, ^ligrmaaists. some types of technicians and
other conventional categories of personnel to meet their health needs. While
various adjustments ~ such as training many assistant nurses or community
health workers (see below) - are necessary, a minimal supply <;£ fully-trained
physicians, sanitarians, arid ethers d-S—still essential for the effective
'ope-sariiip. of a health.care system provlrH’ng-jwiwrr?""hcaith"care.
In some- -■
countries, where the supply of doctors is adequate, relative shortages of
nurses and other personnel result in the inefficient use of medical time.
(2) Inappropriate Training of Conventional Personnel.
The education and
training of physicians,.nurses and other conventional personnel in developing
•-countrLee—e-re—based largely on teaching models drawn from industrialized
countries.
The emphasis—ie c-n laboratory ’scicseas^-AliwicaL specialisation.
and high technology.
It is weak on the basic requirements of^pritsary health
care such as prevention - ^tisoual and environmental - and the psycho-social
aspects of family health problems, so important in. FHC. Some use may be made
of field training in a conajunity setting, but seldom enough' and often nona.
—Seme medical schools are greatly overcrowded, reducing the quality of
teaching, and teachers are technologically, rather than socially, oriented;
this applies to the education of nurses and sanitarians as much as to
physicians. Little if any use is made of social scientists in the
educational programmes.
(3) Lack of Health Human Resource Planning. For health personnel trained in
universities there is seldom communication with health authorities or
national planning bodies on the needs.
Even for personnel categories trained
in a Ministry of Health, there may be poor communication between the branches
responsible for training and those using the personnel.
The lack of planning
applies to both the numbers turned out and the content of their education.
Nurses or assistant nurses trained in hospitals, .for example, may be quite
unprepared tor functions they are later expected to perform .tn community
health centres.
/...
.
(4) Lack of Comiaunity Health Workers. In response to many health human
“esource problems, new types of multi-purpose community health workers (CHW)
have been produced, with varying levels of training.
Some highly developed
countries have also done this to meet health needs in rural areas, where
doctors were lacking.
In most developing countries, however, the numbers of
these CHWs trained have to date been below the needs.
There have been
difficulties in finding suitable teachers, in devaloping appropriate teaching
materials.. and in recruiting qualified, students.
Moreover, the educational content in these ptcgr:
has sometimes been highly technical and clinical,
rather than social and preventive. As a result, the later performance of
CH’ds may be largely confined to treating'the sick rather than promoting
community health and welfare.
(5) Inadequate Teamwork and Supervision. AU of the countries reviewed o.n
this study, and most developing countries generally, provide primary health
care through teams of personnel working in organised frameworks.
The
effective functioning of such systems, however, requires an understanding of
the meaning and practice of teamwork.
It also requires that team leaders are
capable of leadership and effective (not dictatorial) supervision.
Such
qualifications seem to be rare in the countries studied.
Basic education in medicine, nursing, pharmacy, etc. seldom has'the time
or resources to teach the requirements for teamwork and supervision. As a
result this ordinarily becomes a task for in-service training and continuing
education. Even such education, however, appears to be lacking or
unsuccessful in the countries studied.
Teamwork requires sensitivity to
personal relationships and supervision requires organizational knowledge and
skills;
such matters are not easily taught in a classroom but are learned
best in a field practice setting.
(6) Lack of Continuing Education,
Effective teamwork, and leadership are not
the only subjects for which continuing education, can be useful.
For.good
performance of all health care functions, clinical as well as social,
education should be a lifetime process.
Systematic arrangements for periodic
continuing education are important but seldom found in developing countries.
Its lack may also help to explain the poor morale among many health workers.
(7) Lack of j»h Pc
Frcbleus iu teamwork and general work
performance are often due to lack of any clear explicit statement of the
tasks expected from each member of the health team. Absence of job
descriptions leads to confusion and uncertainty in the relationships among
personnel in. a health facility.
It also contributes to inappropriate
training.
Both the teacher and the student require a clear understanding of
future job functions.
Such job descriptions should be prepared by health
authorities responsible for programmes, and they should be updated
periodically with experience..
(8)
Ztbsencfe of Relations with Traditional Healers.
In most of the
developing countries studied, traditional practitioners and traditional birth
attendants (TBAs) play a large part in the primary health care of the
people.
Yet - with some exceptions for TBAs and in one country for general
healers ~ the policy in the countries r. vi ......e is .v.^nore these personnel
and hope that provision of modern health services will lead eventually to
their disappearance.
The soundest policy toward traditional healers may be
subject to debate, but Ministries of Health that simply ignore their
existence are missing an opportunity to exert Influence on the nature ti£
health services used by millions of people.
(?) Low Motivation of Pertonnel. Permeating many of the health manpower
problems reviewed above are the attitrdaa and motivation of health
personnel. These attributes may ’be Initially acquired during basic training,
but they are shaped, by many subsequent experiences. Ml too often one
encounters health professionals, ^particularly^physicians, who rush to
complete their tasks in a health centre in order so maximize the time they
have for private practice.
Others undertake post-graduate studies abroad and
do not return to their home country; this "brain drain” means a serious loss
of health manpower investment 'by many developing countries.
The. issue of personnel motivation is, of course., complicated, and it is
caused by many econoraic, social and psychological factors that are not-easily
influenced.
No simple course or. training can impart a socially responsible
motivation in any doctor, -pharmacist or nurse. 'But many policies may : have an
influence on motivation,.as will be explored in the next chaptar.
6.2
Problems in the
*
Functioning Of Primary Health Care
It is re’cognized that it is somewhat artificial to separate the
considerations of health human resource development in the last section from
the overall primary care system; however, this section will attempt to
address the problems in the functioning of programmes on a somewhat 'broader
(1) Poor Working and Living Conditions. The.greatest need for primary
health care programmes in developing countries is in rural areas, and life
there offers few Of the amenities to which staff trained in urban centres are
accustomed. While most countries are devising strategies to make rural
health work and rural life more attractive to such personnel, work in many
rural health centres remains difficult; the physical structure is-often
deteriorated, and may lack properly functioning heat, water and electricity.
When .personal housing is provided for staff, it may be modest and -in'poor
condition; schools for dependents of personnel from urban areas are usually
below the standards to. which they are accustomed. A particular need in most
countries is housing for young unmarried female staff such as nurse-midwives
whose posting to areas other than the home village may be culturally
unacceptable without appropriate housing.
These are, of course, problems
inherent in rurality, but they must be recognized as requiring various
compensatory measures.
(2) Inadequate. Salaries and Incentives. Among the -greatest obstacles to
organizing adequate PHC programmes is -the low level of salaries paid -to all
levels of staff. The typically low public service salaries are undoubtedly
responsible for short periods of public employment and high turnover.
Physician; salaries are a particular problem, insofar as - unlike most other
personnel ~ doctors have an alternative option to engage in private
practice.
There may sometimes be financial awards for meritorious service,
but they are net very large.
*•
Remuneration for con. unity health workers presents special problems.
Ordinarily, countries do not want to pay CilWs official salaries.
They are
sometimes regarded as "volunteers", and may receive only compensation for
their work expenses.
In reality, these small amounts may be the only
monetary income of the CHW, and therefore are significant for thair stability
in the PHC work.
Governments differ on this policy question and
international agencies tend to be reluctant to finance such personnel
expenditures, but experience has shown that' reliance on 'volunteerism” is
unrealistic for sustained health activities (as against one-time compaigns in
village clean-up, immunization, etc.).
(3) Weak Health System Management. The above problems concern the
management of a health care system, but there are other more fundamental
difficulties.
In all the study countries, responsibilities in the Ministries
of Health (and other ministries) are highly centralized.
Even when MOH
officials function at a provincial or district level, they have usually been •
appointed by central authorities and often must get approval from the top for
almost anything involving the expenditure of money. This policy causes
delays, inefficiencies and irritations.
Proper management also requires a
flow of information on the operation of health programmes - information on
patients seen, services provided, problems encountered, etc.
Seldom do such
information systems function efficiently.
Sometimes there are printed forms
to be used, but they are not filled out.
In some higher-level offices
receiving such forms, they pile up and are not analysed.
Official personnel policies, another aspect of management, may be
counter-productive.
In one of the study-countries, any physician doing
clinical work is paid more than a physician whose main duties are
administrative.
Thus a Provincial Health Officer receives a lower salary
than a fresh young medical graduate treating patients.
The problems of
inadequate training in teamwork and supervision are further obstacles to good
management, discussed above. Another impediment to supervision ie simply the
frequent inadequacy of communication (if telephones do not work) and
transportation (if vehicles are not available).
The isolated health worker
is often left with little or no supervision or consultation.
(4) Problems with Equipment and Supplies.
Operational equipment and
adequate supplies can be crucial in a PHC programme, and yet they are often
lacking in health facilities.
The supply of drugs, and vaccines is
particularly important, but - depending often on Imports from abroad - they
may simply be unavailable.
Even when available in a central depot, the
logistical process of getting them out to rural units may break down, causing
serious delays.
Recurrent costs of drugs are a chronic problem. Vehicles
may be available, but without fuel.
Refrigerators, important for storing
vaccines, may not work for lack of spare parte; personnel with the necessary
skills may not be available to maintain equipment in working order.
(5)
Meagre Community Participation.
One of the weakest aspects of the PHC
programmes in the six study-countries relates to the involvement of the
community. While a village or municipality may contribute land or money for
establishing a health centre and even labour for its construction, local
people rarely are involved in deciding priorities for health unit operation.’
In some countries local Health Councils are established to represent
community people in programme admini'scrai.ivn, but - sometimes after initial
enthusiasm - they seldom meet and do not function, Co-operative work by
local people is essential in improvement of water supplies and sanitation,
but this usually requires mobilization and guidance by sanitarians, which is
often lacking. Campaigns against snails or other disease vectors can be
carried out by community groups, with proper technical leadership and
inter-sectoral co-operation, but this Isas not been observed In the country
studies.
(6) Weak Intersectoral Co-operation. While it is widely recognized that
health depends on far more than health services, implementation of this
concept has proven difficult. At the local, provincial and central levels,
health personnel are often overburdened with their own work. Opportunities
to improve environmental sanitation through association with agricultural and
public works personnel are. not exploited.
Seldom does the PHC nurse have the
authority to gain access to children in the schools.
Even within a Ministry
of Health, theoretically committed to primary health care Integration at the
local level, local operation of specialized vertical programmes in such
fields as malaria control or family planning often continues.
(7) ’Weak Preventive Orientation. While curative health services are an
essential responsibility of health personnel, much too often preventive and
health promotive activities are overlooked both in training personnel, and In
the functioning of the health post. Overworked staff, under pressure from
rhe community to provide curative services, may have little time or energy to
devote to prevention activities, even where their training has included it.
Moreover, prevention is an overall orieutaf.ion rather than a discrete set of
activities which is needed at all levels, from CHWs to doctors.
1
(8) Low Utilization
As a ’result of the many problems
summarized above, both in health manpower development and in the functioning
of PHC programmes, it is not surprising that taany community people seem to
have relatively low regard for the
PHC
*
services pf health centres or other
local health units.
Analysis of utilization rates in countries studied shows
them to be very low, by comparison with other programmes in the same country
(such .as health insurance schemes), with health care utilization rates in
other countries, with the capacities of the health facility staffs, or with
obvious evidence of health needs.
In spite of (or perhaps because of) the low rates of utilization of PHC
services, the data suggest that-hospital out-patient departments are heavily
ased and overcrowded. Clients with ailments which could be handled at the
health post, by-pass it and go to a hospital where they are aware that they
«?ill see a Specialist rather thap a general medical practitioner, non-medical
community health worker (or perhaps neither of these types of personnel) at
the health poet. In some countries there in evidence that phyaicsano aro
offering private medical services, even in rufal areas, Cor which Indi,vidualy
and families are paying personally. Alternatively, patients consult 0
traditional healer or a private physician,
(9) 01 sense,
Waste. "Hie ultimate coat of all the inefficiencies and
other problems reviewed is persistent dincass and death, excessive birth
rates and unnecessary waste in the use of resources. Children and adults do
not receive preventive and/or treatment eorvlces that could avert disease or
• cure it; instead they get seriously sick and may die, Wo set the evidence
of this in the high infant mortality rates and the relatively low llfo
expectancies of all six of the study-countries.
c
>
Waste is easy to demonstrate. The low utill.•«».tIon of VHU resources
means that those resources are not. fully utilized. In countries with serious
shortage^ of personnel ~ according to widely aeceptcd standards ~ one seas
doctors, nurses, and others aittlng around and waiting for patients who do
not come. The money paid for their salaries is wasted and, more important,
the capability of these personnel to serve people Is squandered,
6.3 Underlying Issues
All of the problems in health manpower development and primary health
care functions may, in a deeper sense, be regarded as symptoms of certain
- underlying issues. >Exploration of these basic social issues in depth la
impossible here, but they may be, identified briefly.
(1) ina^equats Health Funds in the National B'y'gct . t Where total figures
were available in the’ntudy countries,’ the' ituufa allocated to the Ministry of
Health have been only n very small percentage of the national government
budget. They usually amount to lens than 5 percent for both recurrent and
capital costa, and. in at least two of the nix study-countries this figure has
been declining in recent years. This reflects, of course, low government
priorities.
W l>ow Ragard for Primary Health fare. Comprehensive health aervlses
include a’wide range ol -technical activities for the diagnosis, treatment,
and rehabilitation of diseased persons, as wall as for prevention and health
promotion. The complex technologies found in hospitals have a dramatic
quality not seen in the day-to-day tasks of health m/tlmenance.
Primary
health care, therefore, tende to be appreciated by many people at much lees
than its true value. These attitudes are unfortunately reflected in the
budgetary allotments of Ministries of Health,
There are, of course, health expenditures by ministries other than the
Ministry of Health, but the MOH in the major source of public support for PHC
furnished to the general population. 1’ec, analysis of M0H expenditures
nearly always shows the lion's chare of fund® - usually over 50 percent - to
go to the support of hospitals and reflect an urban omphaeie rather than a
rural one. Primary health care tends to occupy a very important place in the
declared priorities of health authorities, but not in the way that th»
available funds are actually allocated and spent,
/...
(3) The Prt vgte Health Care Market t Private household expenditure
*
for
healtK^arvTccs Tfa^rno’t bden quantified in many developing countries, but
where they have been
*
they have usually been found to be large " larger
indeed than overall governiaent health expenditure. In one of the study
countries where this question has been investigated, private health
expenditures were found to t ’count for -some 60 percent of the total,
A
large share of ow pereonn] expend
tw»
*
goes for primary health, care,
including private physicians, traditional healers and self“prescribed
drugs.
These expenditures result not only in serious inequities, but also
in serious Inefficiencies, They mean inequities because the services go to
those with most wonoy to spend, rather than to those In greatest need. They
mean inefficiencies, because the lack of .planning and organisation in the
private medical market is inevitably wasteful, Private incentives even mean
that patients may be given services that are unjustified and unnaeessary
because- they yield a fee to the provider,
>
»
W> External Support ^<>r Health, In the next Chapter we will examine in
more detai'FThe procasa eT^external support for health, One fundamental
question involved is the leva! of resources which developed countries are
prepared to make, available to developing countries.; on a global level this
is lees than 0,5 percent and health expenditures are only a very small
percentage of,this. Even if the inefficiencies noted previously did net
exist, the Impact of external health support on the developing opuntrlee
would be small. Inefficiencies and lack e£ co-ordination unfortunately make
the impact even- smaller,
(pi Political Commltiaeat. Probably moat fundamental of all the leeues that
lie beneath problems’ In "&P/FHC la the political w.(it of each nation for the
advancement of its peopls'e health, Since WHO was founded in. 1946 and
especially clneo the Alma Ata Cunferenee of 1978, declarations about health
a? e "basic human right" and about ths goal of "health for all" have been
made by health leaders in every country. But there is a vast difference
between declarations and actions taken to Implement. them, The gap between
these two lg determined by fclie degree of political coamlt-eent to health in a
country. This, in turn, if. influenced by countless different forces in e'aeh
national society,
6.4
Health Project Evaluation
*rxxD<wr.«^«ar?-c:si
csr^
‘fc:r’i.,iKuc:»r».'^:»^.'A^-xer=seCTXX.xic£i
The evaluation of projects In primary health oare, as In any other
cross-sectoral, fflultl-diacipllnary field, is inherently difficult. Ah
regards the problems outlined In title study, each problem hats its
explanations, and pointing a .finger of blame at any one international or
national organisation does not usually serve to right the situation. By Ito
nature, national development in health and every other sector i.e a
complicated process, hound to Involve delays. Perhaps the most Important
lecfion is that, with very limited resourceo, goals must not be too ambitious,
and tlme-’schodulea should anticipate the probability of delays, Otherwise
both national and International staff can become frustrated and demoralised,
The ultimata evaluation of a health project must depend on its impacts
ou the health of the people, la there evidence that the fictlvj^aagefc.^bo
project have made ehaa haaithlor? le there a reduction
morbidity vr. an improvement 1» the capability of people to wa«k -and function
in aeeiety? In there
*
evidence of iaproved nutritional statue in children?
Ar© there lower mpg ef parasitic infestation? These are, of course, very
difficult to measure «•■ even g& straightforward an intis® sa the infant
monallty rate in.« deHtiod gsograhiP &»'©«• Evon if an objaetlv© improvement
in acme such measure can * 8 demonstrated, 16 can seldom ba concluded that the
change hee ba»n dua s>Meiv m the p©!^ under study, and not also to other
related social and environmental eii’Ci.wrsncne, Moreover, the slightest real
change in the health status of « population usually takes years to
demons,reto5
Bvnluacif'fs of aativ'lfeioa in the field of human resource development, is
particularly diflieu.lt. One may assess what -students have learned in a
course, through oKnffiinatlona^ But the crucial •question is what effect does
the course have on the graduates
*
eubaeQuent perform
*
• -e« Determining thia,
in relation to other influnncns an performance, is not go easy.
In the fee© of such difficulties in evaluating health imposts or
outeomegs most health and social scientists must beastiafled with mere
aodesfe criteria for aasesanient, Is there improved "coverage" of a ’
population, for ajcampie, with personnel providing primary health care? Are
they accessible more, equitably than In the past? Can it be shown that, a
project, has reeultafj if, g higher rate of utilisation of certain services by
the people? Bush measui'emente of the "process" of health nape are easier to
aafe@i and yet again there are difficulties, ’’Baseline data" on aondltlens
before the project must be available, and often they ore not, Also, ana must
still '^a the queatlOB of whether any changes identified oan.be attributed
to tba project, Perhaps the. mer-u paena.qe of ti®R In a country brings changes
in the health behaviour of people, with of without any apeelfle intervention
Ebi s on international- project may provide, there ate comparative reaeareh
designs that can overcome these difficulties, but It- la eoetly to carry the®.
out and they.must be carefully planned in advance,
Il la amaii woudet, therefore, that many atteapis at evaluation.ef
health projects, international and national, continue to be too descriptive
and Impressionistic, One observe»i events and talks with th© personnel
involved. Are they BSEiutled with what has.been happening? is there
evidence that people (patients) arc pleased with the service? What problems
»• physical, behavioural, social *» have haen eweountfired? Hava plana been
frustrated and, if bo, how meh has been duo to defeets in the planning or to
events beyond anyane’e control? After a reasonable time has passed, to what
extent do the realities of a programs earsaspend to the original plan?
Respite all the difficulties, evaluation of health projects muse be
sttripled, Primary health care iu agpeeially diffleu.lt to evaluatej becaus
*
it cfifiompaaeee so many uctlvitlea, In general, if the object of study can b*
narrowed dawti, pueceaefiul evaluation
more likely. Th© performance of
specified imunisations, the ehildblrths oacurrlog under hygienie conditions,
the hcuBoholde aeefeRalble to safe water, the proportion of sehool children
with eigne of Malnutrition, the percentage of*' women of ehlld“tearlTtg age
accepting family planning methods, the rate of malaria parasites detectable
in blood 6®eura ■= such MameKuints are mu uh more feasible than "primary
health •
collect
interpr.
system
evaluat'
advancei
ire" as a whole.
Yet each of these specific criteria requires the
>n of information 'nd its recording.
The findings must also be
:ed against s background of knowledge about the total health care
md, indeed, the overall environment} in which an activity is being
1.
In the long run, such efforts have always been necessary for the
mt of health sciences and health services.
fcrrt H
- S'
RECOMMENDATIONS FOR STRENGTHENING HUMAN
RESOURCE DEVELOPMENT FOR PRIMARY HEALTH
CARE THROUGH EXTERNAL SUPPORT
Solution of the prc’lems or reduction of the difficulties reviewed in
the last chapter obviously oust depend .on national actions and actions
suitable to the conditions in each country. Externally-financed technical
co-operation is obviously not appropriate for all problems.
International
agencies may help by supporting such actions or sometimes by suggesting
strategies that have been effective in other countries.
It must be
emphasized that internationally-funded projects or activities are effective
only insofar, as they support national objectives.
In this chapter some recommendations are made on human resource
development for health and the functioning of primary care systems.
While
they are presented in a roughly logical sequence, the rank, order of the
proposals, however, should net be interpreted as implying any recommended
priorities. Decisions on first-level or second-level priorities will
obviously vary in different countries, and at different times in the same
country. Priority ratings for the development of primary health care
necessarily depend on considerations of resources, deficiencies, historical
experiences and political, factors in each national.health system.
*
7
Development of Human Resource for Health
Act'.^ns needed to improve health human resource development should
correspond to. the, nrcble^g. 1 font * ** •-■■4 • . •y-w-r’-'-l'ii’s here roughly parallel__________
the. problems Identified in Chapter VI.
However the most appropriate
international strategy will vary with the category of health personnel and
the country involved.
(1)
Increasing the Supply of Health. Personnel,
in countries with a low
supply of doctors, the training of "community health, workers" deserves higher
priority than the formation or expansion of medical schools.
Still a certain
minimum number of doctors are needed for the proper operation of a national
health care system,
qualified women snouxa be admitted to medical schools on
the same basis as meh.
International agencies can provide consultants,
fellowships, equipment, teaching materials, etc. to help establish or enlarge
medical schools.
The training of nurses, midwives, pharmacists, sanitarians and other
basic types of health personnel can usually be undertaken within the normal
resources of hospitals but it 1g important to develop hospital-based training
schools which make use of community settings for teaching students about the
social and preventive aspects of PHC.
The training of sanitarians in
adequate numbers is especially urgent, but it is made'difficult by the lack
of qualified teachers.
Because this work usually pays very low salaries, the
most competent sanitarians often leave government for private employment or
change to other occupations. External support can provide incentives
(including salary supplementation) to teachers, effective teaching materials
and housing for students.
The schools may be multi-disciplinary
institutions, where laboratory technicians, pharmacy assistants and others
are taught - with common instruction in basic biology and chemistry.
L
(?)
Improving the Social Content; and Methode of Health Training. The
possible role of international agencies for improvement of the social and
community content of health training is substantial.
In all six
study-countries, no deficiency in J?HC personnel training is more general than
Che weak place of community field experience or social science instruction in
the preparation of students. Education on the purely technical aspects of
medicine, nursing, midwifery and sanitation may be very well provided, but
the social, behavivu.al
«aviroasi«ntal aspects of primary health care are
almost ignored or, more often, taught only superficially and Ineffectively.
In medical education, there are several ways by which the policies might
be improved. ©apartments of Community Medicine (sometimes "preventive and
social medicine") are typically small and weak. They require enlargement and
further training of their faculties. Secondly, every medical student should
have a social exposure to community health work in a rural as well as an
urban area - experience at least equivalent in depth and breadth to that
received in hospitals on surgery or other clinical subjects.
Thirdly, dll
clinical faculty should be required to teach the social aspects of their
subjects ■* e.g. teaching paediatricians the social aspects of child health,
the social aspects of communicable disease, etc. (If faculty members in these
clinical departments are incapable of teaching such subjects, they should
either learn them or invite others to teach them.)
Teaching methods in most professional health schools have not caught up
with modern pedagogical knowledge.
Formal lectures are delivered on
classical subjects, without regard to their impact on students' learning or
understanding. Much education can be made more effective by teaching
teachers how to teach, and helping teachers design courses that enable
students to solve problems in the real world,
('wuO offers a major advisory
programme on this matter.)
Equivalent changes should be promoted in schools of nursing, sanitation,
etc. In fact, the establishment of field training areas could well serve the
training needs of all the PHC health disciplines.
In several countries, such
field training areas have been established, but they are inadequately staffed
or used only by certain schools. The field training areas, in different
parts of a country, cc^ulc be subject to change, but should have the same
importance as that now held by hospitals, As part, of the field training,
students could participate in household surveys on various health problems,
which would contribute not only to their education, but also to research on
medical/social/environmental problems.
(3) Encouragement of Health Human Resource Planning. Technical co-operation
can serve as the catalyst to bring together Ministries of Health, Ministries
of Education and universities to adjust training programmes to the needs of
the health services.
It can also give advice on how to quantify existing
health human resources (often quite different from the names on official
“registers") and to make reasonable estimates of future needs. Joint
councils of health and educational authorities can be very useful for health
human resource planning which should, of course, be carried out as part of
the planning of overall health systems.
(4)
Effective Training of Community health Workers. The training of new
types of multi-purpose auxiliary health workers has helped to make PHC
accessible to rural populations in many countries,, but aspects of the concept
remain to be clarified. Objective assessment of the situation by national
and international experts can lead to sound policies for an effective
schedule of training, training of trainere, proper teaching methods, scope of
functions, relationships with other health personnel, proper supervision,
continuing education, etc. Both women and men should become trained for this
work, preferably
coming ii&ii filial communities; however, even
these CHWs may lack community orientation in’’their work, and need additional
training. Finally, very brief training of village "health communicators” or
"health promoters" is needed to acquaint people with the availability of PHC
units and advise on simple elements of hygiene.
(5)
-n~service and Continuing Education. The systematic provision of
continuing education, according to a practical periodic schedule, is needed
by all health personnel.
This requires careful planning and administration,
physical facilities where teaching can be done and participants housed, as
well as proper teachers and teaching materials.
The "field training areas"
recommended above to enrich the community content of basic health personnel
education, can serve also as the sites for continuing education.
In-service
training, often needed at the beginning of employment in a health post, is a
good way for new health workers to learn about teamwork. Acquiring teamwork
skills and attitudes can. be facilitated by regular meetings of health centre
staffs to discuss cases and general problems,
(6) Effective Relations with Traditional Healers. While some traditional
healers are highly entrepreneurial and concerned with personal gain, others probably more frequently among traditional birth attendants - welcome new
knowledge about methods of treating and preventing disease.
The formal
health system, including external technical co-operation, can learn to
collaborate with and teach traditional healers, so that they provide
beneficial PHC services.
Regular but short courses can be given to
traditional healers for this purpose, a practice that has been most often
done with TBAs.
7.2
Functioning of Primary Health Care
After health personnel are trained, conditions need to be created
whereby their work can be well done and effective.
Physical settings have an
influence on the feelings and attitudes of both patients and health workers
and attention should be given to the work setting and the social environment
around it.
(1) Improved Working Conditions. To some extent, attractive working *
conditions are a matter of physical structure and its maintenance.
The
health post, examining room, laboratory, waiting areas, equipment, pharmacy
and its essential drug supply, water and sanitation arrangements should all
be as orderly and well maintained as possible.
The same applies to personal
housing provided for staff members. Technical co-operation can help on such
matters, even though physical measures alone are never enough.
(2) Setter Salaries and Incentivesr Salary levels in moat countries have
certain uniformities among different ministries, so that changing them in the
Ministry of Health or any other single Ministry is usually difficult.
It
should be possible, however, within the boundaries of a MOH, to re-arrange
the levels payable to different kinds of health personnel.
If primary
health care is to be truly accorded high priority, this should be reflected
in higher salaries paid to its providers.
Increments for continuing service
and seniority should also be designed tc encourage continuity.
Several countries among those studied have mandated periods of public
service (usually rural) for all or most new medical graduates.
In one
country, students with higher scholastic records escape this obligation and
may directly enter specialty training - an unfortunate'policy since it makes
those serving in rural posts feel "punished" and "second class".
Mandatory
rural service is a way of the student's paying back society for a
socially-financed professional education, and it should be required equally
of all graduates.
In fact, greater rewards and incentives should be built
into these programmes, so that young doctors work at optimum levels. A
system of periodic reporting and review should be feasible.
It is also
important to support the young graduate with proper supervision and to
provide her or him with opportunities for consultation.
Incentives through rewards for meritorious service are also feasible for
all health personnel.
Financial increments can be combined with honour,
recognition and opportunities for further training.
If such rewards go to
perhaps 10 per cent of health workers per year, the costs need not be very
high.
Financial support for such policies might even be explored by
international agencies, as has been done by philanthropic foundations in the
past, in order to test the value of an idea.
Regarding community health workers, although the prevailing policy in
many countries is to pay theta no salaries, this ^Slicy should be more
flexible. When CHWs carry crucial responsibilities for PHC, both national
and international agencies should not hesitate to pay theta amounts beyond the
compensation for their working expenses.
Such expenditure would be only
minor in the overall health sector budget and would go a long way toward
alleviating the sense of disillusionment and high drop-out rate among CHWs.
Other strategies for elevating salaries are being tried.
Small charges
to patients for drugs can go into a "revolving fund" for purchase of further
drugs, and paying small salary increments. Where community participation is
mobilized, this can include the organization of a health co-operative, to
which all local families contribute small periodic sums for supplementing
staff salaries and improvements in the health facility. Where the financial
benefit increases the diligence and devotion cf health unit staff, the payoff
to the community in better service is apparent.
(3)
Efficient Health System Management.
One of the most concrete and
definite ways that PMC programmes can be improved is by strengthening the
managerial process in national health care systems.
Strengthening is needed
at all levels, but especially at provincial and local levels.
Providing supervision is essential, and this ability does not belong
intuitively to every person in a supervisory capacity.
For professional
personnel, supervision, administration and planning — the essentials of
teamwork — can be trained at graduate level such as a School of Public
Health, as discussed more fully below.
Proper management Includes mechanisms for producing, transmitting,'
organizing, and using information.
Information systems are essential to
progrannne evaluation as well as day-to-day management. Without a reliable
flow of information on morbidity/mortality, use of human resources, and
provision of services to people, evaluation essential for programme planning
is very difficult to carry out.
Other management essentials include
logistics for assuring drugs and other supplies, maintenance of equipment and
vehicles, and records on personnel schedules and on all financial matters.
At the community level management has an important role to play in achieving
effective integration of health programmes . As noted earlier, certain
vertical activities (e.g. family planning) may persist in a country for
historical reasons, but every effort should be made to integrate these with
overall PHC programmes as soon and as efficiently as possible.
To do all these managerial tasks efficiently requires special training.
A medical head of a health centre team should not be expected to carry all
these responsibilities, in addition to community health and clinical duties.
The training of “Health Care Managers" is a realistic solution, for which
external support could be highly valuable. An appropriate locale for such
training would be a School of Public Health.
(4) Active Community Involvement. Rarely is there a community in a
developing country that spontaneously develops the initiative to launch a
programme for primary care. A dramatic event, such as an epidemic, may
stimulate action, but ordinarily action must be promoted by the health
workers themselves.
Chapter VI notes the typically limited performance of
sanitarians, doctors, and nurses in this regard, and little should be
expected unless modifications are made in their training.
In public health affairs, the personnel with training specifically
oriented to community organizations are "Health Educators".
Their skills with
posters and talks and audio-visual presentations are generally known, but
much more important is their ability - when properly trained - to communicate
with the natural leadership and understand the prevailing attitudes of local
people, so as to mobilize community action.
This concept of health education
might be better described as "community health organization". All PHC
programmes should have trained Health Educators of this type, not at every
local facility, but at a district or provincial level from which every local
area can be reached.
The work of the Health Educator should be of two types:
first, to
orient all health personnel in the PHC programme (especially field workers
and their supervisors) on the concepts and methods of health education, and
second, to work directly with community leaders and local people in the
attempt to demonstrate the value of community participation.
The training of
Health Educators, like Health Care Managers, should be at a School of Public
Health.
(5) .Strong Inter-sectoral .Coy-operation. Organizing health benefits
achievable through schools, agricu11ureV~and other sectors is a task mainly
for PHC team leadership. This would include leadership at local health
centres, as well as leadership at district and provincial levels.
Obviously
inter-ministerial health,, .councils at the national level can be most helpful
of all, but they are often more difficult to achieve and,.J.f. established, to
keep active. Proper training arid continuing education of PHC leaders is
required for this objective.
7.3
Schools of Pubixc Health or Health DeyeJLogment 'institutes
References have been made above to the need for a School of Public
Health available to each country for training PHC leaders, Health Care
Managers, Health Educators, and others.
In recent years, some countries have
designated such schools as “Health Development Institutes".
The terms
School of Public Health" and “Health Develcpmei.' Institute" are treated as
synonymous in this section.
In three of the six countries studied, some such
school or institute existed, but for various historical reasons it was not
playing its potential and appropriate role.
Almost every country has a school of medicine, or several of these, not
only to train physicians but also to provide leadership role for medical
science and service in the country. However schools of medicine, it must be
recognized, are inevitably oriented to the treatment of disease in the
individual patient. Their educational—programmes^are built on basic sciences
of anatomy, pathology, biochemistry, physiology, etC'Z—and'-their~curricula
culminate in internal medicine, surgery-, paediatrics, obstetrics, gynecology,
ophthalmology, neuro-psychiatry, etc. Aside from the classroom, their places
of learning are the laboratory and the hospital ward.
The goals and methods of public health and of primary care, as now
understood, are-very different. Their orientation <s "<'!? .* --patients but to communities »<j
i-heir tasks are mainly
preventiva, .and-curative only in an organizational sense.
The basic sciences
of public health are not anatomy, etc. but sociology, economics, political
science, statistics, nutritional science, sanitary engineering, management,
ecology, etc.
The culmination, of their curricula is in disciplines relevant
to the population: epidemiology, community health education, public health
planning, health care management, applied nutrition, environmental
management, health information systems, and so on.
Their major places of
learning are in communities, rural and urban.
In such settings, and. in the
study of such disciplines, requirements for good primary health care
programmes - like teamwork, supervision, motivation, etc. - should be learned
naturally without necessarily labelling them as such.
Health Development Institutes must be multi-disciplinary not only in the
subjects they teach, but also in the students they admit and the personnel
they turn out. The need for training Health Educators and Health Care
Managers in such schools has been discussed earlier.
In addition, teachers
and leaders in nursing, midwifery, environmental sanitation, nutrition,
health information (statistics), communicable disease control (epidemiology)
and other fields should be trained. Perhaps most important, general Medical
Officers of Health should study in the School or Institute for at least one
year.' With such education, one may expect that national,, provincial and
district leaders in public health -and primary care will acquire not only the
necessary technical^knowledge, but also the motivation and inspiration to
provide effective leadership to all other personnel.
Like a school of mediiine, every country should have access to a
national or regional Health Development: Institute, not only to train urgently
needed categories of personnel, but also to provide general status and
inspiration to the whole field of advancing the health qf populations.
The
average doctor and nurse should, of course, also have some appreciation of■
public health (or "community medicine", as it may be called, or perhaps
"preventive and social medicine"), but departments teaching this field are
invariably of very minor importance in medical schools - inevitably dominated
by the laboratory sciences and clinical disciplines. Public health is
usually regarded by both faculty and. students as a diversion from the central
purpose of medical education - the diagnosis and treatment of the individual
patient. Countless attempts to strengthen departments of public health in
medical schools have been unsuccessful. Other attempts to inject a "social
point of view" in each of the clinical disciplines have had moderate success
in a handful — perhaps in one per cent — of the world's medical schools.
The strategy, therefore, should be to develop firmly grounded Health
Development Institutes accessible to or in ail countries.
They should be
university-based, but as medical and nursing schools are linked to hospitals,
these Institutes should be linked to Ministries of Health or major provincial
Departments of Health.
Academic degrees might be awarded for certain
programmes of study, but not necessarily for all.
The Institutes should not
only train personnel, but should do research on the problems of the health
care system, and provide consultation and leadership.
Development of the
faculty and resources for such institutions in developing countries would
take time, but such development would be an extremely useful objective for
external international support.
7.4
Co-ordination of External Technical Co-operation for Health
Co-ordination of international technical co-operation, both multilateral
and bilateral, has been discussed in Chapter V.
It was clear that
co-ordination is necessary, not so much to prevent overlap in particular
geographic areas, as to provide technical co-operation that corresponds to
the priorities of the recipient country rather than to those of the external
agencies. Almost any developing country welcomes financial support for any
reasonable purpose;
the needs are so great in every sector.
But the most
effective support is naturally that which co-incides with the overall
planning strategy and priorities of the country.
To achieve this,
co-ordination should be improved, on three levels.
(1) Within national governments, general planning units or similar
bodies with overall responsibilities should co-ordinate technical
co-operation activities for health from all sources.
Likewise, Ministries of
Health should contain a unit responsible for monitoring, co-ordinating and
■ 'T-"-'i'K'
evaluating technical co-operation coming to any part of the Ministry. Every
effort should be made to assure the consistency of any externally financed
project with the basic policies of the government.
(2) Within the health sector proper, WHO assists the government in
co-ordinating technical co-operation activities and its input should be
requested early in the planning process for both the health sector and those
in other sectors which have implications for health. WHO may also formulate
health proposals for support by other international agencies.
These roles
may be played most effectively when there is a WHO Programme Co-ordinator
(WPG) in the country, although governments also have access to the
appropriate Regional Office.
(3) Among United Nations agencies, the United Nations Resident
Co-ordinator ie the designated official responsible for co-ordination.
Because of his or her place in the structure of the United Nations and the.
arrangement whereby the United Nations Resident Co-ordinator is normally the
Resident Representative of UNDP, he or she maintains relationships with all
U.N. specialized agencies and all ministries of national governments.
This
endows UNDP with special responsibility with regard to the inter-sectoral
aspects of primary health care.
For example, the International Drinking
Water Supply and Sanitation Decade Is one area in which there is need for a
high degree of co-ordination across a wide spectrum. Resident Co-ordinators
need also to be aware of health activities from non-tradltional sources such
as multilateral development banks, which may have their own technical as well
as financial resources.
Co-ordination of UN system activities with those of other international
organizations, such as bilateral and non-governmental ones, is especially
difficult since they do not share with UNDP the continuous contact involved
in being. Executing Agency for UNDP's programme. However, the Resident
Co-ordinator should seek to promote communication among them and the U.N.
family of organizations and WHO should do the same among the various
international agencies concerned with the health sector. Exchange of
information 'can be beneficial for every source of technical co-operation to a
country, and can help to avoid duplication or discord on various technical
matters.
7•5
Health and Development
This study has focused on primary health care and how it may be
strengthened, in particular by human resource development.
It has been
evident throughout that primary health care is more than a component of the
health care system, but is rather a reorientation of that entire system and
the personnel in it.
Health care systems, it should be explicitly
emphasized, are a basic part of development; the attainment and maintenance
of good health in populations should not be seen as simply personal and
humanitarian goals.
They contribute to overall national development in at
least two important ways.
The first and more obvious, is that healthy people are better workers,
better students, better parents, better citizens and so on. Good health
contributes to productivity, community welfare, family life, culture and.
4
hopefully, peace. The second and x.ess obvious, is that the health sector is,'
i» fact, one of the most amenable of the taaay sectors cf society requiring
change for achieving speedier national developments unlike land ownership,
housing, industrial production or foreign policy, it does not touch the deep
roots of the basic power ctructure in a nation. Although some changes' in
health care may be subject to debate, they are not controversial in the seas.e
of significant changes in other sectors.
This is why so many developed
countries have benefitted from major reforms in their health care systems,
without social upheavals.
Important reforms and improvements in health care
systems, including PEC, can be made with relative ease politically, for a
relatively small price economically, and with large payoffs. The benefit"
cost ratio of improved health services is high, especially in developing
countries where the main diseases are so readily preventable. The benefits
cen. be high both economically and politically, because every family is
concerned with disease and health every year or even every day.
Tackling the "underlying issues’’’ that explain the problems of HRE/PHC,
as summarised in Chapter VI, need not, therefore, be so weighty a task as
might at first appear.
The social forces that can lead to political
commitment for health include all sorts of population groupings - farmer's
associations, labour unions, women’s leagues, religious groups “ for whose
members health usually has deep personal meaning.
If the political
commitment to work toward "health for all" can he achieved, the other
strategies should be implementable without great difficulty.
It is quite
feasible to mobilize the. large expenditures, already boihS made in the
private sector, for the public sector of health, ’ll: has to a significant
extent already been'done in the many countries ~ developed and developing ~
with social security programmes for health service.
If this can be done, an
increase in the health sector’s share of total governmental expenditures and
in the PHC share of health expenditures, should be implementable in
relatively short order.
Thus attainment of “health for all” in a country can demonstrate
concretely and dramatically the benefits of planning, community efforts, and
social change, for everyone to see.
The primary health care orientation of
an effective health care system brings benefits even closer to the field of
observation of every family.
Such achievements In health can encourage
equivalent actions for social reform in the many other sectors contributing
to national development.
£.g>v1 H 5
*
—
WHO Regional Office For South-East Asia
NEW DELHI
SEA/HSD/H2
PRIMARY HEALTH CARE
NETWORKS
— Report of an Intercountry Consultative Meeting
WHO Project !CP PHC 8CG
JJHDP P.-ojccl FtAS/8t/0I7
CONTENTS
Page
1.
INTRODUCTION
1
2.
OBJECTIVES
2
ORGANIZATION OF THE CONSULTATION
3
3.1
Achievement of the Second Phase (1985-1986)
of the Intercountry Project Primary Health
Care Promotion and Development (ICP PHC C06)
Country Reports on Present Status of Primary
Health Care Development
Sustaining and Further Developing National end
Regional Collaborative Networks of Institutions
for Primary Health Care
Intensification of Action Programmes for
Primary Health Care
13
4.
CONCLUSIONS
2G
5.
RECOMMENDATIONS
2I
5.1
5.2
Strengthening of Primary Health Care Networks
Intensification of Primary Health Care
(Project ICP PHC 009) and Development
of District Health System
21
CLOSING SESSION
23
3.2
3.3
3.4
6.
j
8
1?
21
ANNEXES
1.
2.
3.
4.
5.
List of Participants
Agenda
P rogr amtne
Reports of Group Discussions
Flow Chart
25
30
31
, 34
48
1,
INTRODUCTION
An Intercountry Consultative Meeting on Primary Health Care
Networks was held in SEARQ, New Delhi; Iron 12 to 16 January
1S87. Fourteen participants from seven countries attended
the meeting, including two participants from Iran. Ms J.
Haslett, Assistant Resident Representative, United Nations
Development Programme, New Delhi, also attended. Dr • D,H;
Regmi (Nepal) and Dr N.T. Cooray (Sri Lanka) were eleeted'is.s
Chairman and Rapporteur respectively. The list of partici
pants is given in Annex 1.
The meeting was inaugurated by Dr Chaiyan K» Ssnyakora,
Director, Programme Management, on behalf of Dr " Ko Ko,
Regional Director. He welcomed the participants from the
Member Countries of the Region and also from Iran who
responded to the .invitation to offer their advice and
guidance on the important subject of intensification of
primary health care. He said that this meeting would not
only review what the countries had achieved through various
activities
implemented
under
the
intercountry
project
'Primary Health Care Promotion and Development
*
(WHO ICP PiiC
006/UND? RAS/81/027) in the past few. years, but also
determine what further practical initiatives should he
pursued through the successor project, 'Intensification <«£
Action Programmes for Primary Health Care’ (WHO iCP ESC
009/UNDP RAS/86/C76), in .the next few years. In. his address,
he mentioned that the time was ripe to start building up the
health system in defined, manageable units, such ar- for
districts, and to target for health for all starting with.
the intensification of the priority elements of primary
health.care, and progressively adding more elements and srora
districts. He wanted the meeting to draw up a regional plasr
of implementation for the project, which had country pla.ts-.
of action as a crucial component. While appreciating thecomplexity of.such an action- the Actino Reoio«
t
*
wi rector
2
felt that the inputs should be made available through the
regional project on intensification o£ FHC and utilized as
part of national and external, inputs in support of the
strategies for health development in selected district's. He
hoped that important outputs from. this project would not
only have a measurable impact on health programme and health
care in the district but would also provide useful practical
experience in the organization, development and management
of district health infrastructure based on the principles of
primary health care.
The agenda and the programme of the meeting, as adopted,
are given in Annexes 2 and 3 respectively.
2.
OBJECTIVES
The objectives of the meeting were:
(1)
To review the implementation of the plan of
action developed in the intercountry meeting
in
January/February
1985
with
special
reference to referral support, intersectoral
action, management development and promotion
of innovative approaches;
(2)
To review the status of national and regional
collaborative primary health care networks in
and amongst the Member States for sharing
information, expertise and resources;
(3)
To make recommendations for sustaining and
further developing national
and
regional
primary health care networks in the Region,
and
_
(4)
To develop a general plan’ of operation for
intensification of the action programme for
primary health care, particularly inmunizatidn, diarrhoeal diseases, acute respiratory
infections and essential drugs and vaccines
and other essential elements
of
primary
health care within the overall development
structure at district and peripheral levels.
1
3
3.
ORGANIZATION OF THE CONSULTATION
The consultation was conducted through plenary sessions and
group discussions as follows:
3.1
Achievement of the Second Phase (1985-3936}
of the Intercountry Project Prinssy Health
Care Preaction and Developnent (ICT PHC 006)
The project Primary Health Care Promotion and Development
(WHO. TCP PHC 006/UNDP RAS/81/027), funded by the United
Nations. Development Programme (UNDP) and executed by the
World
Health
Organization
(WHO)
commenced
as
an
interregional project in August 1982 with the following
development objectives:
- Strengthening primary health care programmes
with emphasis on participation and organization,
infrastructure development and intersectoral sod
intrasectoral coordination..
- Strengthening the inputs of. existing health
manpower in primary health care development and
implementation.
- Establishing regional and
interregional TCOC
networks in primary health care for rural and
urban populations.
The project was jointly avauiatefl ny UNUr and rftu.' ra
August 1985 and the second phase of the project extended
until December 1986.
The achievements of the second phaae
(1985-86) of the project in relstion to its seven ■ vacation
!
*
objectives are presented as follows:
' ;
t
...
i
Operational Objective 1
To promote and strengthen both national an-1
regioril
collaborative networks ct PHC institutions for sharing
resources, information and experiences in primary tazalth
care development.
'
i
i
,
4
Achievements
An essential ground work for a functional PKC network had
been laid with the designation of national focal points,
establishment of ■ two regional primary health care informa
tion resource centres (PIRCs), compilation of guidelines for
PHC networks in the South-East Asia Regon and with linkages
act up with Health Literature and Information Service
(SELLIS) and Health Service Research (HSR) networks and with
ESCAP-POPIN. An additional contribution is the lead given by
the PHC network in the coordination of the work of the
above-mentioned national networks.
Objective 2
To promote intersectoral action level
care development at implementation.
for
primary
health
Achievements
A meeting on intersectoral action for health was conducted
in SEARO from 28 October to 1 November 1985. Following the
recommendations of this meeting, there was development of
country plans and initiation of activities in Bangladesh,
Burma, Indonesia, Nepal, Sri Lanka and Thailand. Overall,
there was deeper understanding of the rationale of intersectoral collaboration in health development in the Region.
The progress was reviewed at a Task Force Meeting (sponsored
by WHO headquarters) held in SEARO from 13 to 17 October
1986. The results of country activities supported under the
project would be of considerable significance.
Objective 3
To strengthen referral support to primary health care
Achievements
A meeting on referral support for primary health care was
held in SEARO from 20 to 2 3 August 1985 and. ns a follow-up
country plans for improving the existing referral system had
been set up and activities initiated in Bangladesh, Bhutan
Burma, India, Mongolia and Sri Lanka for rapid -jialysis at
existing referral systems and identification of gaps ir.
referral services. Following Chis analysis, a workshop or
referral support for PHC was conducted in SEARC from 13 t.
22 August 1986 to review past experiences and implement
further action.
>
Objective 4
■ .
. 1
*
.
To develop health manpower at intermediate and peripheral
levels for the implementation and monitoring of primary
health care.
,
I
Achievements
Several
activities
took
place . in
the
Region
underit the
project. Management training and development of middle-l^evel
managers
were
initiated
in
Bangladesh,
Burma,
Indie,
Indonesia, Nepal, Sri Lanka and-Thailand.
j
Objective 5
•
!
|
To promote improvement in the management of primary health
care progransse through operation research
studies/ ant
utilization of research results.
Achievements
The project led to enhanced awareness of the relevancy of
health systems research (HSR) in the resolution of probleiE
in health service delivery. Two important concepts were
introduced: Problenr-Oriented Research Information Seekic^
Behaviour
(PORIS)
and
F isearch
Information
Display;
Utilization Promotion (RIDUP) , and. three major, problem areawere selected for detailed study in India.
Objective b
To promote innovations in primary health care implementation-
6
■■chicvejscnte
The project helped to sustain interest and further stimulate
Innovative approaches to PHC in the Region. Studies were
.nitiated in Burma, Indonesia aad Thailand.
Objective 7
To promote the development of urban primary health care in
selected countries of the Region.
Achievements
Pilot studies were initiated sod supported rn Indonesia,
Thai land, Burma.and India for the development of: urban- PHC
models.
Overview of the achievements of the Project IIP PSC 0C6
The contribution of the project was directed mainly to
reinforcing tHe organizational prir.ciules < :d upgrading of
support systems essential in Che vyerstioa of health systems
based on PLtC. The project had further streng rhened other PHC
activities that were Cakir; pier? i" the courtrirs. Referral
support to PHC vts. also being rtreng.'h .nad in Nepal. Activi
ties of the project have thus beta .. nts iu tae process for
HFA/2G00
complementing
other
activities
of
national
govarnareota and WHO. '.he contributions of the project to
national health de.elopnent in tb^ Htsoer Countries of the
Region were directed mainly to reinforcing the organizational
principles and upgrading of support systems essential in the
operation of health systems based on PHC. I ‘e evaluation of
netior.al strategies for health for all -und- .‘taken by Member
Countries during ’.984 as part cf the globt
evaluation has
shown progress in health development, lies tii coverage has
improved. There have been significant red:» tiers in infant
and maternal mortality. Life expectancy
at
birth has
recorded increases.
There has bevss a reallocation of
resources to the rural health sector, tt-r.-z
is an increase
in the deployment of health personae^ kra rural areas and
greater emphasis ca their training and: o:.icacacion. Local
—i
Kc inc; -<
*r
irttwr
*
A4mcrr
’.-xr.—
"Ho
-CiPcitie
II
1
outputs of activities under each project objective clearly
indicate
several
inter-related developments
which have
contributed to strengthening national health systems.
Tha focus of activities in intersectoral action was
mainly directed towards ensuring a deeper understanding of
the underlying rationale of such collaboration between the
health sector and other related sectors and the integration
of health development into the mainstream of national
socio-economic development. In referral systems support,
national activities concentrated on the critical role of
referral, especially at the first referral level, and
sustaining confidence in the PHC system. National plans of
action were directed to th< orientation of infrastructure
facilities, adoption of referral procedures and guidelines,
orientation arid training of staff, logistice and coossunicaticns
support.
National
nd
regional
PHC
information
networks were significant contributions by the project.
Their particular significance related to
the
specific
function of bridging the gap in regard to the non
availability of PHC information, especially ir. management.
The focus of training of middle-level health manzger
strengthened, the system at the operational ?.evel as did
other activities, such as referral systems support and
intersectoral action. Thia converge to decentralized levels
of administration and is in line with decent ral last lot? of
development administration in the area of ires Lth research,
activities rfe-tasing to promotion of research a; ' utilixato on
of research results benefit from infartaataos: f.-eafera-'.-jd by
the information net;.i-A,k& «t . option-'} t s>r?.d msg osiat bevs Ass.
Research, iofonwitiro- would also, reach «• widi’ea : -?/i’sns.W:p- cns
potential users tbrovp+s the networks. ■ ? eoret .isatier.-s Cferst
health re-^wsccir msatee-rs ~.e he.s.Itu. <iewtgmets. .s^ac.1-:-1 ? y t-c
areas a£ tafee cat
y»t, health. pla.T,
urbar-. rrlA, c-’. . i'W’-ns': :h.sjl o-c.ti.cxtkr-fst.-f-nscisyt, f
receiver' g?.»net ax.ee
Cr-tx-.■
kx» PVl, co«»'— a b-tcasi
<ssi
*
--.'.til;?
and -»ne Kctc
ai>tt
*
tx- ala»o«t *
1.6
rtesw.
, astibcuty cif tht
project. Tbcfi
cl s^acia;. sigt.-yf.-i.cttea Si£
an.-it point to thst
• -i
/.-ik.'-'e
tt
local cosui B im’s aft:l
r-.'n.-?, ST-sfeasi's
sawielsp
ac.op~vih.le and
• .•.Sfw’feth'-'’- ttes.5ii.kuiSfi.--~
to-i
-bt-r- appro.:-..
Actuc;. i’.rv-f:
'th-.- ~i.-f>X£cK.
■
ttw urb.:<a
h-A.-.; h<ov: i'l.e-1 frc»n
..-Kdierta-w
i— i.c.te-cs
<r
*
tor .i:E
ioslfotwWti-va: ’•. ■tct'.rS; .
ketwers. v
ss’.^t-AHt aed hveSs r ■
~Uta •‘cu-kivs.
p-tov
■=> ^‘l,n - -
8
information, experiences and expertise available through the
networks.
The activities of the project provided catalytic inputs
to strengthen
the health infrastructure
and
taake
it
operational in the delivery of the elements of PHC to the
community. A well-established infrastructure of manpower,
physical facilities, technological and financial resources,
rationally organized and efficiently managed is essential
for the effective delivery of care and the demonstration of
tangible outcomes. A significant pointer that emerges from
these activities is the feasibility to directing efforts for
the efficient delivery of elements of
in a managed,2
and defined unit of administration, such as a district. The
infrastructure built up in the countries of the Region as an
integral part of the health system woui" bo the vehicle for
the delivery of an integrated package of services to the
coununity. This will enable all aspects of the system to be
fully tested and lead to the identification of critical
factors that make the system effective and efficient in the
delivery of
services.
A district
health
system with
decentralized management is also a vehic ,e for incorporating
the real experience gained through studies and activities in
referral
systems
development,
intersectoral
action,
middle-level management and other areas.
3.2
Country Reports on Present Status of
Primary Health Care Development
Presentations
were
made
by
participants
front
India,
Indonesia, Maldives Nepal,
Sri Lanka and Thailand. A
presentation by ths participant from Iran was also made.
From the country reports presented, it vas appari
that in the last few. years, promotion of PHC and its
development in the Eegiort h.-ta been reoriented to health
infrastructure
services,
increased manpower and
larger
population coverage- But as- SF8 enthusiasts, participants
were concerned about cbe. pace o(r progress and its impact on
the health status ct the people,
particularly in. the
Region's poorer section e!F the pcjnslaticr..
The presertaticas. also ttrarie it clear that though the
*
Conrwrie
l»u»4 - r C5./'r —r ovr.r art i1
rot—nos. different
w-nhor
9
socio-economic conditions, different health systems end, in
a way, even different levels of health development, they had
many common features in PHC development. Health services
infrastructure development, training of middle—level managers
and
the
training
and
appointment
of
peripheral-level
workers, made health services more accessible to the
population.
Certain PHC principles, though inadequately developed,
had taken firm roots like the need for intersectoral colla
boration and a referral mechanism, the need to focus on the
underserved and the need to innovate and he more readily
acceptable and used by the people.
The achievements of the project IC? PHC 006 were more
in some countries than in oth< rs. Achievements in some of
the project objectives were recognized as being directly
attributable to the project's inputs. As concurrent PK-7
projects, operating in the countries - some supported by WHO,
some by other agencies, have similar objectives - it became
difficult co separate the achievements of the project per
se, especially in the- bread areas of management, ir-wQ-rmation
networks .and HSR. There is also this very irsp.orCera’x - fact
that while programmes and studies h%v.5> been l.'ssAC&esit ast> the
respective countries under the project, mary of Efegee ace
still ongoing and. it wilt be a while; before- tifr&ir zaav-lts
are known. The refemr®! systems project., n-rbjsr
tbsi
PORTS studies, arid. .etc Evi tries tc initiate- wrt-h: -*& bss Ser
intersectoral actios axe- yet to be nsSess.«c».
While- achieve me nits *
£
the pre-j-tet may rrrt always ba
measurable, t:ve- project bsei c<®rced-.rly beex. -a
'
catalyzing fortttc in tht. £&&ton th-.wwgh the mjr?- -.- crtiwiittixar.
and progra’mriffcS euc-i'?- fe§ rR-j. prirjeet. .2. a;u--mair>- c!: t'Vt
country prusxee-’t-stiKttss^ b» uhjjpcciSp-IIUimesi
!
('!}■ BES »*t-tvpc5u:>r.ij <. T.r-...-■=
®.znetwerks of
iis ®ax<t CAaattvy »in> cr.o, Sj-cte -m •--'tt'Sst t>„t
their functicr. is yet ta iS<
Tint awt--.•.-tCRittcy
networks '-.Pki-lso
j-sst. t>ie<
ii’ht-?... "Oe- Td-p-ntiCtcation and- scn'-fn^-ch-’ntiBS
*.
c.2’ r,-»l
cs-imS
goj—“s x.i-t'S
further attaclion. Tmcre is a
ec '.‘-.sse a
ermtmeit
among
K.>t i'cea-S
cocm''
.>
fWFTs?
•Ath.vcbu
so- •
fee
inst itut ion:v
cai8--er t'ft-Sl ir-B'-vnidft.i.tlts.. Xha: ciho^-'-'ls
st
’.0
cominunic-.'icio-.> and funding rust be streamlined. Information
networking in countries was working satisfactorily but it
.’Ceded Co include private and nongovernmental organizations.
The two ?Hu information resource centres at NIHFW, New
?elhi, and^at ATC/?HC, Bangkok needed tc have ::>ore contact
with all national focal points in rhe network.
(2j Intersectoral Action. The principle of
inter
sector si action is well accepted at the national level in
each country but it remained difficult to operationalize
lute.sectura’ actions. At the ceraauuity level, fewer people
closely involved in development cart work together end ensure
intersectoral coordination. In some countries, micro—level
planning and decentralization with delegation of authority
to the lower level is showing successful coordination.
Examples are in. working through the progra aes for Quality
of Lite campaign through NES08 in Thcilw,.- , Basic Minimum.
Seeds i.-. India, and Integrated Family Health Care Package in
Indonesia>
(o> Referral Systems. “vereness of •.•efe.rrrH system
has been increased and effort :las been made co strengthen
the health services infrastructure co provide referral
support tc PHC. The implementation of the referral system
faces many difficulties and the bypassing phenomenon is not
uncommon. Small-scale- studie? on effective referral system
are going on in six countries.
medical
education,
however,
this
bed
been
generally
disappointin’.
Improvement
of
management
training
for
medical students would remain a challenge although cols
challenge was being met in some countries.
(5) Operational
Research.
Operational
research
is
generally weak in the Region but awareness about the benefits
of this important back-up for ?KC has increased with the
studies on situation analysis etc. where priority areas that
need research have been identified. Following this awareness,
-,c more research proposals have been submitted end supported by
the project ICF PHC 006.
(6) Innovations.
Most
innovations were related to
areas where some amount of development had already occurred.
For example, in the training and use □ * ’peripheral-level
workers, and health mnsjesent, certain countries had. r.lco
attempted innovations in other areas-, such as logistics.,,
resfJrrc owbi i >.■ ■ r ion ;;r>d <;*
I. ■: e 1‘o-cbitol.ogy <
■
(7) !«rbn;.< FiiC.
A number
of
projects
are und
tr
*
implementation In
Indi.;, Ind nesis,
Thailand,.. J’s
Indonesia., ; !■■» study seeks to r • - j.uicn >•.’•’
l-’x^lop-.v ■ -t ard.
implementation o£ th
*-.
Integra.- ' t-.kagi1 of
'rvlcr.r r'l.ou^h
community paicicir. a'< -..n.
I t,; -.reraii
scztive
■thdevelopment of a mod I fi r <rrb-’
fee I ;••.» covntr;'
The study m ir.di-A relate
*
• the city of .orebor
fiis
the objective of «eve:.;-pic.. a.
u. i-ity--or..■:sited nos•re«ch;
smoag h’.iltb persyn>« I. Gr-;-re• .as .6 I..; ’*
!-' pen.-'
Sand rise study ia ir.
'
■;
. ■.*
<CAteo'..-h posts, cover;>i?, 25 CO? ?. .■
tva
t
' I -.c-
. . . <a .£
.wot i
o.
accivi ■; i -e fteng >o ;
ef Cvct ir-g the u> ■ •
i'
the M»lv»r« or t
hesl-h
Lu
id'
-
ty
13
The reports of the gtoup discussions are giver, in /tones
6 end the output hco been incorporated in the section on
corsclu».s.OES and: reconoendstions.
3.4
Entensificeticn of Action Frogtsssaea
for Friwary Seslth Cere
(1)
H<?A ieadnrship
As a prelude to r.tie panel discussion on intensification, the
HFA leadership concept vse- introduced. Health for all tveana
striving for equity ssin social justice and thus narrowing
down gaps between the wnpe-veri shed ssajoritry /rod the privi
leged nirtor/xy. It. therefore, cacuxot be pursued, let alone
achieved, without a strong. 1: adership. Such a leadership
needs Co be in the people off influence and prestige, people
who are flexible and creative «nd> those who cst
*
choose iJ
*s>
place and tice of interventions decisively.
*•
ft critical mass of HFA leaders is necessary cȣ only in
terns of th® aioiswa mraber of such Aecders- bat rasra
importantly in having such leaders dispersed ic. strategic
and influential. sector® of policy making. Teas the critics!
mass of SPA le-sdcro should be drawn not only frota Cha hcais-X
sector but also fro® other sectors: education, aprionicure,
local development,
political
parties,
interest groups,
nongovernmental organisation?' and rxsay ether
Soehsu of
people's rapresentsricoo.
A cbessit<n«sK to the HFA. goa.i:. supported Sy social.
moral
and
intellectual
cossuitEesTt,
is
ars
esrsesrtSal
prerequisite.
In reality, the experience hat? been: Cl? There: is■■. s
lack of continuity of policies and plans, dee tc fxatpeent.
change'? in political asd on) ' *
y
making eev-irenrrte—r
There i.:i
limited ■■:<•.
..'.vi <-.:x
< kes.i:--wotKeru nr the o-.’crall socin—ec-<T>T.ic devtelcp^aat prior?.:?r.-
ire inclined to apply conventional cechnofdgicsl solutions
to major health problems, which, even chough technically
sound, are not always feasible due to political, cultural,
social and financial practice; {5} Health workers have
limited capacity to translate key socio-economic policies
into health policies; (ft) Articulated political will to
formulate and implement policies is not always translated
into strategies ocd actions, and (7) Health professionals
have little influence in the policy-making process in their
countries.
Considering chat HF?. leadership development
is A
complex and difficult process, it is also imperative that
those with the poterstisl for Leadership are brought together
to realise their collective strength. it it also necessary
to sustain the processes by building network■: of individuals
and institution
*
whose resources could be harnessed to
develop leaders and sustain the critical sass.
Cl.>
?aael diacuasions
A panel discussion. fcllesed with presentation of five topics
related to iratensificatians of primary health cars.
Why
ssstecsif icstice.?. The cctccep: '.a.'i ctcel for operational
trained health managers at the district level with central
planning and technical support was essential for adaptation
and • implementation
of
the
national
health
policy.
Decentralization may be a political issue and has tn be
viewed
within
the
constitutional
and
administrative
structures of countries.
What to intensify aa& how?. Primary health care is defined
as essential health care to the entire population, it
includes at least eight elements.
Within this operational fran.eworh, it is proposed
"intensify" seme elements without bandoning the others.
Selection of elements to eonc ntrate upon depends on:
(1)
capacity of health infrastructure to deliver
the programme element;
(2)
epidemiological evidence of magnitude of the
health problem relating to the chosen element
of PHC;
,
(3)
feasibility of available resources
needs for intensification; and
(4)
cost advantage and
significant impact.
possibility
of
to match
showing
Intensification would require that in the process:
(1)
full use is made of Che health infrastructure
to deliver prograncne elements;
(2)
coordination and synergism is maximized with
other related programmes, e.g., between EPI
and MCH, and between CDD and nutrition;
(3)
health facilities are utilized to the fullest
extent, and restructured as needed;
(4)
realistic targets for programme delivery are
set and achieved:
16
(5)
the community is involved find the support of
other sectors ensured;
(6)
training in clinical and managerial skills is
provided to health workers;
(7)
adequate waterisl
established;
(8)
availability of manpower, physical, financial
and material resources are to be examined,
and reorganized to match what is needed to
intensify the chosen elements of PHC„ This
nay call for alternative mixes o', manpower,
reallocation of tasks and respoc ibilities,
development of skills and work resc -eo_iing;
(9)
. local level detailed planning (micro-planning)
will be an important step for organizing and
managing
the
resources,
implementing
activities, monitoring and evaluation; and
(10)
an appropriate information system that will
support both epidemiological intelligence and
raanegeria. needs.
and
logistic
support
is
District planning. If PHC is to succeed, improvement in
district planning activities is crucial. Five processes are
important in district planning, namely, analysis' of the
present situation, establishment of priorities,
setting
objective
and
targets,
monitoring
and
control,
and
evaluation.
Health service research for district health system. Health
service/systea
research
(HSR)
and
its
scope
towards
improving the health of the people was defined and its
importance in the understanding of community participation,
technological options and alternative interventions within
resource constraints. HSR is multidisciplinary, culture- and
country-specific. It involves both health and other sectors.
HSR mechanisms require institutional base, close involvement
of decision makers,
utilization of available
research
potential and its results in irapleir.entatic i, ttocit
r.g *d
evaluation of programmes. The developmcnl of HSE' in ’.c
South-East Asia Region was referred to- Even though
A/1C3
strongly focuses on health systems research, on tsMe
this has not been too successful. An important r:.. son ;<
this is that it is generally a one-time activity with Ir.k
of continuity.
Participants
contributed
to the
panel discussion
*
Attention was brought to the fact that district-leveladministrations differ i,t countries.
(3)
intensification of. PMC and introduction
of Project ICP PHC 009
UNDP and WHO agreed in princip e co launch the new projec
ICP PHC 009 Intensification of Primary Health Care. Th
project will begin in 1987 a: i last three years for te;
present.
It will
be
financed by
the United Natiac r
Development Programme (USDP) and executed by WBO/SEARO. ihe
project aims at intensifying and accelerating the ?HC acicn
programme, especially irnaunizat ion, control of diarrheal
diseases, acute respiratory infections and essential d-jgs
through the health infrastructure. The project addresses the
disadvantaged
and
vulnerable
population
groups
in
well-defined geographical areas and aims at showin; a
measurable impact.
(4)
Plan of Operation of Project ICP ?RC 009
The activities necessary
for the output
of
the aiie
immediate objectives of the project will be started witt' si
comprehensive health system survey followed by a national':
workshop for developing a detailed country plan of action,
including training, management, logistics and supplies, sad
other activities related to inter. -ificstion.
The project
intends
to
intensify
national
adtton
programmes for PRC in selected districts/arcas cotael
--renting
*
activities and inputs of the ongoing programmes. ijorc
districts any be added in future. Practical experience in
the setting of comprehensive district health systems und^c a
decentralized management integrating the delivery o' health
~ro-?xo
’ I ••.'.th r-.rc through hee l th 5.nf restructure icd
»1 :s-;t ■sectors ”ill be highly relevant for
.•- ,< uin,. <-.her ;iotri:ts and ob’-ir clarcnts 'if primary
■’t
:a—J- t’.-.i , rcrressi'.cly exp
it"; Cfca coverage. At
naciono? ver: shop. a country werk plan : ill be prepared
• '-..ailing the ac:iviv’.sr.
The project
will
have
the
(1)
Approaches to cetivities,
its objectives,
training
prograrzes
anc
health
sys terrs
research, er.hanceaent ai c^rautiity i avolvemcnt
and
intersectoral
ccllabc-.-ation
through
established
and
innovative
sschaniams,
determination
o£
specific
bar'ats
for
services aftd coverage, and establ shinent of
sound
epidemiological
surveilb ncr
and
information
system
for
monitc ing
end
rnansgement;
(2)
Evaluation, in 1989; with a seco'd compre
hensive survey. An important content of the
evaluation
will
be
the
dsscr pt ion
of
managerial processes development ard lessons
derived
for
the
future
development
of
district health systems, and
(3)
Measurement of the performance of the project
in terms of achieving output? for inznunization coverage, access to ORS,
access to
treatment for ARI, and, finally, adequate
provision of essential drugs and vaccines.
It will also review the managerial processes, training
programmes, physical facilities, logistics, epidemiological
and, information system. The health status of the district ■
population will be assessed.
>
(5)
Decentralized Henagenent System
The rationale for a decentralized management system lor PHC
implement at ion was presented. As one ~.f the objectives of
the project ICC PIIC 009 was
to assist
participating
countries in developing decentralized managerial processes,
the objectives, activities and responsibi1ities of a district
health management system were spelt out ss also the L.ctu.'\
influencing its operation, such as political caa;;\ .lents.
confidence or the ccrtmunity, support from central adri..ist
tion and motivation and training of district chiefs r.ri
district health officers.
It was also stated chat decentralized
cautgerear
referred to intermediate levels of administrative unit
within national systems which were adequately represented b
all other sectors of development co promote intersectcra
action for health and referrer Co 33 ’district
*
in chi
presentation. In order co take it effective, delegation of
powers and responsibilities to -he District Health Officers
to plan, mobilize and utilize 1 anpower, financial, teertuological and material resources fo. intensification of the
action prograsames in coordinated and integrated manner was;
stressed. Supportive and functional' linkages between the'
District
Health Office
and
central,
intermediate
and
peripheral
levels
of
administration,
ncagovernmencal
organizations, cotssunity action groups and people were
essential and required to be defined.
Decentralization was not an entirely new concept in the
Region. It had beer, tried out successfully in some countries
and its value in the areas of eoaasutiicy involve sent act
participation and coordination of health—related sectors it
P11C was recognized. It was also pointed out that C.-ttre couli
be no uniform decentralized management system to pply for
ail the countries of the Region as national systc-.s in the
different countries differed politically, economically a.ic
administratively.
(6)
District Health Systems Survey Guidelines
The document on District Health Systems Survey GuideiineS
The guiding 'pri.'ciplel(SEA/PHC/Meet.17/5) was presence
for developing a survey protc 20I Co be used at tb»
pre-project
phase
was
circul; ted
and
ezplaicacdl
Th;
objective of the survey is co sa-e 3 ccasorebeosiye
of the situation, and review existing jxanag-eriaa prreesi
.
*
and to review PHC structure in vaxi«t>s ■>. cownttP'•'. S&c
conduct of the survey and its expected "outcome w» s~:3t~
provided along with the survey protocol.
j.
0
It was clear that the guidelines provided would be used
as au outline and full survey protocols developed at the
country level after the selection of district(s) for iraplersnting the intensified PHC project.
Group discussions followed these presentations first on
decentralized management systems and district health systess
survey -guidelines, and then on initiating activities to
implement Che project ICP PHC G09 focusing, on two activi
ties: national workshops co develop plans of action for
intensification and conduct of pre-project surveys. Group
reports are given in Annex 4. With respect co initiating
activities
for
implement Ing
the
project,
the
groups
suggested that instead of starting with the aseiinfe surveys
as depicted in the flow chart of aetivitii > (Annex 5), a
national workshop be first convened tc plan ai-J. select the
district (s'
for implementation followed by a
district
workshop where a rote detailed plan of actio, and activities
would be set cut.
4.
COHCHJSIOSS
The implementation of the project ‘Priraary Health Care
Promotion and Development (WHO 1C? PHC 005/i.'»D<? 8AS/81/SJ27)
made
significant
contributions
to
the
proswtian
and
development of primary health care io the Member Countries
of the WHO Scuch-Sast Asia Region (KrlO/SEAR}. Strategies for
intersectoral action on health, establiahwent of referral
mechanisms, strengthening of middle-leva! managers training,
development of Problem Oriented Research Information Seeking
Behaviour (FOHIS), etc. have provided country experiences tc
further strengthen both national and regional networks of
primary health care- These achievements nave lad to further
initiatives in
development through the successor project
5 inter.sif icat io-n of Action Programmes for ?ri®iary HealthCare’ (WHO ICF PRC (W9/HSDP RAS/86/076} '..ftich will be
planned ana impleoarited in the Member Countries of WifC/SSAS
frost 1987. This project aims at intensify irg nn-c thus
cccelerat
the progressive expansion ci prj-very health
care is the S>gfcn to enable ti:e cvttntris, co tealire “its
social {td^al cf ???>
*■
xv'lO-
5.
REC0KESK2ATIOHS
5.1
Strengthening of Primary Health Care Kctworks
(I) Regional and national focal points for pritiary
health
care
networks
existed
but
did
not
function
satisfactorily. These required to be strengthened chiefly by
increasing the awareness of their tasks and functions and
establishing functional linkages with satellite nodes in the
network. Financial and technical<support may be provided to
regional and national focal points, if necessary,
for
manpower development and application of systems approach.
(2) Mechanisms to dissensi: ate information between and
among
rhe regional and naticlai
focal
points may be
strengthened. Valid inforraotior m ./ ba made available, to.
decision-makers,
administrators,
providers
of
healtjt
services, other related sectors and cxcmnunities.
1
(3) Sharing
of
experience
asong
the
different'i
countries and even among the different districts and
villages within a country would improve cooperncion and
strengthen the functioning of the primary health care
network.
In
this context,
technical
cooperation artcng
developing countries (TCDC) and technical cooperation among
developing districts/villages (TCDD/TCDV) any be predated..
5.2
Intensification of Primary nee’th Care
(Project TCP PRC 00$) and Development
of District Health System
(1)
In «l.- preparatory phase for icplemea£ati..ra of trie
project i-CP FHC 039, each country may select a dafir.s.v
geographical Rrea/district( a) for the intensifies
:
*
ton cf
national primary health care action progranrses. The selected
district! si way neither be the best not the worst buX
average in (he context cf the cue tryss health' >it<jas.sew sc.i
its health iefrestructure. It may be s- manages::ie waiu wxte
at lease first referral health r: ci.lxti.es and with evidenceof activities with other sectors hat lends to inters-?ccoza.l.
collaboration -..d cowaunicy participation.
;.2) .-he
l.?-nc nt scion of t.-e project ’’"''re'-.s if . .edsev..
of Aci.vor; .’rcvtTOiS for Primary health Csra€
fy.y-:".
00^/ilfiky?'
*
375
rray begin with the yondiict
c i
2
».
national workshop with the participation of national focal
pointe for primary health care, expand’d progranne on
ianonization, diarrhoeal diseases control, acute respiratory
infections control, essential drugs and vaccines and other
relevant programmes. This workshop may prepare a detailed
country work plan for the intensification of primary health
care in the selected district's). Additionally, it may
recommend mechanisms for strengthening acd making core
effective the national focal points for primary health care
and its linkages with the different satellite nodes in the
national primary health cere network.
(3) Districts selected say have the possibility co
experiment
with
innovative
managerial
precesses,
and
district
health officers
may
be
del gated
authority
coarmeneurate
with
their
responsibilities
in
planning,
personnel management, budgetary and financial control, all
of this in support of intensification and within the
framework of a national health policy.
(4) Decentralized management is important and feasible
for the intensification of primary health care activities at
the intermediate level of the administrative structure, such
as districts, io the countries of the Region. Each country
n>ey identify its policy guidelines within the framework of
its national policies for the decentralization of district
health managenent which stay view decentralization in its
proper perspective as a management tool for efficient and
effective implementation of national health programmes.
(5/ A survey proceed may be developed
in each
country, based on the guidelines discussed at the consul
tation meeting, and be used as an instrument to make a
comprehensive analysis of (a) the health situation, (b) Che
existing health infrastructure and its managerial processes,
and (c) eventually evaluate the progress and impact in the
selected district! s). The survey instrument stay therefore
include both process and impact indicators. It may be used
to establish baseline information in the selected cistriccts)
following the national workshop and subsequently to measure
the progress and impact of primary health care intensifica
tion in tne defined area/district!s).
(6) District-level workshops may be conducted
by
district health orcar.izat ions with suoport from the national
level. These workshops may develop d strict
ns a...
activities and identify requirements for training tri t»cb
resources.
{7} Training activities, including the trcling cf
officials responsible fcr the intensified print Jy bealCo
care approach at the district level, may be undertaken.
Training nodules as developed by WHO/SEARC asy 'c..t
adapted as needed to suit conditions and needs in each
■■
country. These E-sy be field-te; ted by a designated agency or
~~
institution and steps to operationalize training nodules in ;. ~
close consultation with cone, rned district officials <ray-.;
also be undertaken.
X’
WHO any provide support
.or training, cutrses- as.1
production o
training materials. The organization ssay also j._jc
provide support for drugs, medicines, equipment and otlfier
j
supplies necessary for implementation and icanagerrent of the
*
project IGP PHC 009.
* - tl
(8) Functional and s .;p> ..rtive linkages within the
district health office and ; "’tween the district health - £
office and rhe ministry of hat ’ th, district administration,
other sectors in the district, ...ore peripheral units asd the
community are desirable. There linkages may be in the areas . S
of technical support,
support for planning
resources,
_T.
logistics,
and management,
coordination
and
cosaucityr. ;f.
involvement.
~
(9) Each country may periodically review t>;e progressiveof issplementation cf the project IGP EaC S09 activities.
5
*’■ •
ۥ.
tXOSISG SESSI0W
~
Dr Chaiyan K. Sanyakorn, Dire -.tor, "rograra.ee JJanageicent, ■' _
delivered the closing address on behalf of Dr U Ko K-j., ' —
Regional Director.
He stated that primary -:ealth cere iateiislf scat Ion .
should be regarded ns s priority prograssse for" achfadSag
HFA/2000 and assured Hemi?er Countries that they ' douje;
receive all possibl-! support from SEARS in the pla;v.-,lag aad.
implementation of the project IC? PHC 0-09..
.
Or. behalf of the participants, Dr (Mrs, Suniti Acherya
of Nepal, thanked SEARO for organizing the meeting, which,
she felt, had helped participants to look at the promotion
and developinant of PHC as a whole and not just as
intensification of one element, as ia the past. This had
far-reaching implications, especially in the understanding
of the importance of improved managerial processes and
decentralized
management,
intersectoral
collaboration,
innovations, etc. The background materia' provided to the
participants and the presentations made at the meeting had
been most useful towards enhancing this understanding and
thus moving forward cowards attaining the health goals in
the countries.
The Chairman endorsed Dr Acharya's conrents. He closed
the meeting after conveying his thanks to the participants,
UNDP and WHO/&EABG.
Annex I
LIST CF PARTICIPANTS
EASTERS HEDITERHAKEAK REGION
Iran
i
Dr Abalfath Laraeei
Deputy Under Secretary of Htilth Affairs
Ministry of Health and Medicel-Education
Islamic Republic of Iran
’Tehran
Dr S arsed Hohacsaadi
Deputy Managing Director of Health Affairs
Ministry of Health ead Medical Education
Islamic Republic of Iran
Tehran
*
SOUTH-EAST ASIA aSGIOS
India
Dr G.K. «'i shwakarsa
Uirector-GeweraI of Health Services
Government of India
!>ew Delhi
Prof Sown st h Roy
Director
National Institute ci Haa-ttfs atw£ Fafiiy Wclfa
Getvemaasi of IciSiia
idonesia —
Dr Suyono Yahya
Director-General of Gos-sunity Health
Ministry of Health
Republic of Indonesia
Jakarta
Dr Suwarna
Director
Directorate of Health Centre Development
Ministry of Health
Republic of Indonesia
Jakarta
Maid ives
Dr Abdul Sesad Abdullah
Director-General of Health Services
Ministry of Health
Republic of Maldives
Male
Mrs Amirrath Rasheeda
Director
Allied Health Services Training Centre
Ministry of Health
Republic of Maldives
Male
Dr D.N. Regmi
Senior Public Health Administrator
Ministry of Health
His Majesty's Govemz^nt of Nepal
Kathmandu
Dr (Mrs) Suniti Acharya
Chief. Expanded Prograraae on Immunization
Ministry of Health
Hie Majesty's Government of Nepal
Kath^an-i-:
Ministry u£ i'.sjltb
Dc-iccratic S
C.-J.cmoo
':c i£ Sri Larka
Dr f.7. Cot^
Director
National. Irstitute ci .-r-.__.i Sciences
Democratic Sctiali.t ..tpuelii of S i Lcnha
Kalntars
Thailead
Dr Dhatchai Mcngkandi
Deputy Permanent Secretary
Ministry of Public health
Royal Govertcneat of Thailand.
Bangkok
Dr Prakrom Vuthipongse
Director
Office of the Primary Health Care
Ministry of Public Health
Royal Government o£ Thailand
Bangkok
UNDP
Ms J. Haslett
Assistant Resident Representative (Progransaing)
New Delhi
WHO SEARO
Resource persons
Dr 3.A. Jayaweera
Director. Research and Family Health
1 i
3
"’.aaource parsons (coned)
Dr Utco
Safe!
Director, Health Promotion and Protection
Dr D.3. Bisht
Director, Prograrnne Coordination and Inforaation
Dr R. Pararajasegaraut
Regional Zidviser in Prevention of Blindness
Dr N.W. Vidyasagara
Regional Adviser in Maternal ar.d Child
’ea.’.th
Mr C.R. Krishnamurthi
Health For All Officer
Dr R.J. Kinr-Farley
Medical Officer, Expanded Programme on Icsnunization
Dr R.S. Tsirkin
Medical Officer, Health Laboratory Technology
Dr V, Oddo
Medical Officer, Acute Respiratory Infections
Hr A. Besa
Sanitary Engineer
Mr S. Perry
Technical Officer, Diarrhoeal Diseases Control
Dr Soon Young Yoon
Social Scientist, Research Prenotion and Development
Secretariat
Dr N.K. Shah
Director, Prevention and Control of Diseases
Dr H. Zakir Husain
Senior Public Health Administrator (Primary Health Care)
Dr Sombhong Kutranon
29
Secretariat (coned)
Dr Daw Yin Mys
Regional Adviser in Health Statistics
Dr S.A. Orr.eszyna
Programme Management Officer
Dr P. AbeyStocn
Medical Officer, Medical kJdu lotion
Dr 5.C. Ghosal
WHO Consultant, IGF ?HG 309
Dr (Ms) Saroj Jlia
WHO Consultant, IC? PHC 006
Mr D.P. Karwah
Administrative Assistant
Mr R. Rajagopalan
Senior Administrative Secretary
Mr 8. Microo
Administrative Secretary
Annex 2
AGENDA
1.
Evaluate
the
achievements
of
the
second
phase
(1985-1986) of the intercountry project 'Primary Health
Care Promotion and Development1 (TCP PHC 006).
2.
Review
the
present
status
of
development
and
functioning of national and regional collaborative
networks of- institutions for primary healt h care.
3.
Recoaciend ways and means of sustaining and further
developing national and regional collaborative networks
of institutions for primary health care.
4.
Consider , the
general plan of
operation
for
the
intercountry
project
’Intensification
of
Action
Programmes for Primary Health Care'
(WHO fCP PHC
009/UNDP RAS/86/076).
31
AsfflsrK 3
Monday., »2 January 29:37
0830-0930 hours
negiatretion
0930-1000 hours
Inaugural session
.. \
- lnauguretj.cn ty the Ag» Eegjouai
Streeter
- 1streduction of participants
■'
— N’OTninstion
nE
Ciusanastj,
’Zice-Chairisacs assi Sapporceur
- AiMwancesects
I
— Group phatagE3B&,
/
1330— !???■ beers-
i
Setsfxork
*- objectives
asr-5
sieeLiag
— A.’optiau 'f th?
■■•-■£
/
AgenSi:
Ftiv-.Msse
Monday? 12 Janncgy 1987 (contd)
1400-1700 hours
Agenda item 2
Country reports on present status
of development and' functioning of
ncticsal and regional collabora
tive networks of institutions for
primary health care
Tueaday, 13 -Xesuary 198z
0900—1G33 hours
Agenda itea 2 (ccnc-dl
11GO-123Q hours
Agenda itesa 3
Ways and steens of Sustaining and
further
developing
national
and
regional collaborative networks of
institutions for primary health care
- Guidelines
for
discussions
presented by T
*r
(Hal S«roj Jhs,
followed by Groups A and B discussions
1400—1700 hours
Group discussions Ccontinuedi
preparation of report
Wednesday, la- January 19S?
agenda ixe» <*
0900-1030 hours
Paeei discussions on;
and
Anftei: £
REPORTS OF GROUP DISCUSSIONS
1.
wpyr> and Mean
*
of Sustaining and Further Developing
Hntional and Regions! Collaborative Metwjxks of
Institutions for Priiaary Health Care — Agenda item 3
Group W Ch&ir«an : ?>r Suycno Yahya
5s4t it p r: r £ a • j T
*
£j £■ r- J- -}'f -j^ci V. • f p ■{ r.<, r? v © *>
The ,<vo«m> !-<»’•><ti--. o-l-'tiny Pt!C tjet«<»vs.& at
atu': tf ji ’.'tff: levels. i.-. recogr;ted the r.?.ed tor t'ltC
irc-il points in ’"hi? count
,
*
le- to act;j. the hen i r.h-f cr-all
*
gv.--»
Tc v-ss, hovever . f.-lr ;i:st t’u« national focal points
Cl}
did not function satisfactorily o>ein|
to ignorance of their
rr-!“S (tusks .><i fv-.ict ions; sod lack of awareness of
c.:;.sti: p.
. ncd- c-. “h«>3e nodes should be identified
ni -: 'iwsde f-'-.'.C: rooc-.l '
fcppM't tesources.
(Zl
«.u order to courdinete activities between the
regional an
l
*
naticna-. foccl pciuce,
there is need
to
ic s-.-ttfy f set ir -.s snd tesks of t .'th focal points. The
iiijitt' nns
•- - ■ ;hs of regii?’; i f sesi points should first be
1f r .'-cd from the
po. .cs or • isw. Ths- functions'
n :c tasli- >', r.c’.ifial f.cctl pole: s should th :i be identifiec
IseEwci
' h............
' :■■
'.
-:■■:.■ • : thee cr est'-i’ished-.
13) Tl.r- .'; •■>
”-’C i.:'- n •. i.c
ul'-'ti,. . nch country
*«•z'we«
r< wation.il Prk ■'■ •■st
: d <'•".•?■•.'• rtry node-? hss tc
r-s establish.-!. Tn>
*
rd?. •_.l
1
c-:.s'
npdes
.-.ws«t ha clecdy l-f: -d.
(a)
Member
Countries
should - conduct
natio-'. 1
workchops for strengthening national i
,:i
points and "establishing linkages with t e
regions! focal point.
The national workshop will .also identity the
nation.’’! focal points, theix PllC aecondrty
nodes, regional focal point in terns of
institutional structure, function and tasks
and the mechanism of linkages n.-:ong regional
and national local points.
carry
the
Stibn i » .**e
rhe
natjonai
not tonal
. mechanise
focal
responsibi1iti *s
tmining
or fellowships.
’orkshop
should be a
serenethen!ng
(5)
or otner
workshop. Th»s workshop
die nations
verkshoo
c orrej? in i cat! on
(?) Othei. ways to st.-^zks ui.trr
***
among I<embe r Cou n cries:
regional
focal
propr jr.-;’’: .
As-iflA-
poinx’.
A.. s
• ,.
voov s
nn<i
I
(c)
Exchange programmes in the Region.
(d)
Country projects.
(e)
Technical
cooperation
among
villages (TCDV): Expansion of
intercountry training.
developing
PHC through
Multicentre
studies
in
Member
Countries
concerning
essential
elements
of
?HC,
manpower
development,
appropriate
technologies and systems development.
(g)
Primary
health
care
information
resource
centres (PIRCs) should play an ac.ive role in
the dissemination cf relevant infc •m?' ion.
(8) The group requests Member Countries to avoid the
past experience of sending different persons to attend
different meetings of the same project.
(9)
Ocher recommendations:
(a)
Countries must recognize the same institutions
as the focal point for PHC network.
(b)
Follow-up
action must
be
instituted
strengthen national focal points.
<c)
Workshops/meetings must be held to share
ideas» identify the strengths and weaknesses
and.
co
help
replicatesome
innovative
developments.
Cdj
The products of 1CP PRC 0C6 s>.;::.id be user! as.
frcse.’i£r-L ds.ta- to fa.eili.tate. th- implemejrtstticKi c-£ 1C? E"HC
to
Group ’£•' — Chs-imaa t’Fssrfr Sonra-tth Btajt
- Rapporttr.r: ilr Snwascra-
(1) The- discus siasss of ■•’•.to i’:Ctnoun cry meeting have
brought up> the rut-cd to. ’iwt •■> fresh look -ft: the nation;..!
fetal poiivts. exist in,.t £u tire- ty-atr^ S3'> the need tc identify
appropriate
national
focal
points
(HFP),
prefera\y
institutions rather than individuals, who would link w:h
other institutions in PHC operating in the country, e..,
training and education institutions,
research council,
health service organizations, nongovernmental and volant
y
*
organizations and community organizations at periphe il
levels, and also function as an information centre.
(2) The informat ion centre would collect informalott
for use and disseminate it to different levels in be country system: decision makers, administrators, provides of health
services
not
forgetting
the
community
nd
nongovernmental organizations (NG3s) and to the rejioial
primary health care information resource centres (PIRCs).
(3) Both NFPs and Pills will need financial sup>rt
and guidelines for functioning and for the developoen of
manpower and systems approach through training, if necessry.
(4) Training will relate Co all activities in *
rear to NF? functioning as an information centre — collect on,
storage,
retrieval
and
dissemination
of
informst.tn,
repackaging of information for target groups, and alao 'o»
to
document
projects,
screen and market
infonzatin.
Training can be arranged at the regional level or at he
country level where resources are available.
(5) Type of information to be collecteo and dissni-nated includes progress reports of programmes, researnes,;
field and community studies, success sad failrre sports
in the eight elements cf ?HC and their sopportive strateies.'
(6) Wherever possible, HFTs fee Kinfonsatiora, FlXISi
and HSR networks must he combined tt® sraiidi implies tic ofj
efforts and confusion of chzto.nel®.
1
(7) The role awdi fwtHEticc: e>£ splits. ESC .-.itstswrrftx *ba
e
tc
be strengthened and isa-l’e teuo-.n t& ctw c^nmr.-txy ici u&icli t is.
located as also to all thec.f tlae
ffo-’.-tvies.
33
2.
Decentralized Management System and District Health
Survey Guidelines - Agenda items 4.3 and 4.4
Group 'A
*
- Chairmen : Dr (Mrs) Suniti Acharya
- Rapporteur: Mrs Aminath Rasheeda
Decentralised ManegeMent Systen
(1) Feasibility
tnanegeaent syste®:
(a)
of
decentralized
There .is a felt seed tor the
of the existing B®! programme.
Jc
I...'1
'I!£?.
district
health T/
ntensification
Z,
’r’V
39
(3) Factors which will help to impro e distrie -level
manpgetnent:
and
(a)
Delegate
bilit”.
(b)
Provide resources ar.d atmosphere:
Technical:
(c)
authority
relevant
reepc:
■-
Pre-service training
in-service training
improve coiapetency:
Hanagerisl skills < id leadership
(d.)
Provide information, [ >1’ '.y plan and guidance.
..
(4) Powers and rceponsibi iitiec that can be delegated.
co the district health office:
•
(a)
Local—level training
(b)
Financial accooutchil
(c)
Personnel manage rent
(a)
Utilising the
uaximm ber.ot it -
fo
the
(e)
Powercand
rerposslbiliticc
have
couutry-oj'Mc.ific s-.d rt Levant to the au'
to iraplCTieac tue pca£rsss.cs.
be
jrrty
(5)
Factors that infbxanc: district 'fetcitb nss»B®enw'it
(a)
fb)
(c)
(d)
(e)
(f)
(g>
(h)
( i)
i »1
Political
Econcmic
Administrative-, e.g.» Segirea
auttorsnev
Level of commitment.
Taboos and ett: tare
Geographical ropngrap f
•
Logistics and aup^acfc
■.
Commoni.cntier, usd tea:
Leadership, skill s cs.. e&ipasciitrp <ssff braUQ& '- am
Inefficiency acxi »edr-'.:aa»isrm
y
Li . ile
ce'-r-jitsunt
resources
i*
40
(k)
Lack of trained manpower
(1)
Lack
of
readily
available
retrospect and prospective
(ra)
Lack of coordination and cooperation.
information,
(6) Functional and supportive linkages are necessary
for decentralized health management within and between the
district health office and other related sectors.. Efforts
should be made to ensure that health development is an
integral part of the overall develcprent system at the
district level.
rz
District Health Systems Survey
The group did not feel the necessity for the survey protocol
as provided in the guidelines. However, it was felt that a
general survey is more applicable at present due to time
constraints and other factors. A general survey collecting
baseline data on the following should be conducted:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
Acute respiratory infections (A ?I)
Control of diarrhoeal diseasea (CDD)
Expanded programme on immunization (EPI)
Essential drugs
Management aspects
Technology used, e.g., ORS, in the control of CDD
Community perception of the programme
This will also help to evaluate the programme.
Group 'B' - Chairman : Prof Sccmath Roy
— Rapporteur: Dr Abdul Sanad Abdullah
(1) The
need
for
decentralized
management
was
recognized as important and feasible for the identification
of PHC
implementation at
intermediate
levels
of
the
administrative structure in the countries of the Region.
Intermediate levels refer to those levels away from the
centre and which constitute a civil administrative unit with
representatives of health and health—related sectors. They
n
oloovc
rafor
Vzx
rliofrirrc
41
Decentralization is sesn in the context of decentralized
management of health in a district system within the
existing
national
system
and
not
with
decentralized
administration which is beyond the purview of this group.
(2) Decentralization should be viewed in its proper
perspective, viz., as a managerial tool for efficient and
effective implementation of national health programmes. [
While the concept or decentralization and management is;
accepted, the degree of its decentralization will vary in;
different countries ' according to the ' strengths of the ’
decentralized units and the existing lines of administration.
Planning and implementation as well as budgeting and
financial management at the district level may vary from
country to country and from one situation to another,'
depending on the political set-up, socio-economic sicuatsion,
managerial
capabilities,
etc. 1 Decentralization
wotild,
therefore, need to be adapted to suit the given situation.
There can be no uniform decentralized management system that
can apply to the Region as a whole.
(3) Districts or other such integrated units selected
for the intensification of ?HC prograoraes should have freedom
to experiment with newer concepts in managerial processes,
for delegation of authority and responsibilities to the
district health offices in planning policies, personnel
management, greater .control over budget allocations and
finances and greater involvement in support of activities,
such as guidance in programme matters, drug procurement and
equipment usage.
■
(4) Aspects of decentralization relevant
- effectiviS
delivery of PHC are in Che areas of carrying out situational'
analysis,
problem identification, • preparation of sound
implementation
plans,
setting
targets,
monitoring
end.
evaluation,
intersectoral action,
resource mobilizaticc,
community participation and innovations.
(5) The role of the district health office is critical
to the success of the decentralized managesienC ■
Motivation,
confidence
and
capabilities
in
heafctb
development ate expected from its chief and the health trenrrt
(6)
Supportive
training
activities
in
maan, •a-.nern?1
42
Training activities should also be directed to other
officials in the district system who will collaborate in the
intensified PHC approach.
(7) Functional and supportive linkages within the
district health office and between the district health
office and the Ministry of Health, district administration,
other sectors in the 'district
,
*
more peripheral units and.
the community will be in the areas of technical support,
support for planning, resources, logistics and management,
coordination and cocsnunity involvement.
(8) A situational analysis carried out at the start of
the project is an important management tool for planning,
progratEming and monitoring. Also, when carried out at the end
of three years when the life of the project is over, it is
useful for evaluation, when analysing the health situation,
considering the small size of the population and the
inaccuracy er non-availability of information, the various
indicators
suggested
(infant
mortality
rate,
maternal
mortality rate and life expectancy) may not be appropriate.
More importance should be given to process indicators
instead.
(9) A survey protocol would be developed at the
country level that would serve as an instrument to make a
comprehensive analysis of the situation, to review existing
managerial processes, and to review the PHC set-up. This
instrument may be developed on the basis of the guidelines
— - r-- ■* - J
—
t-tuz i t *.• —' a o.- •
A
e. —
z« *v rl .»
.««■>
r*z>«a
n1
o
*
It
rna Kt"
necessarily be simple. The survey should be carried out end
' processed 'in the
shortest
possible time
for
problem
identification,
target-setting
and
monitoring.
Process
indicators must be included, specially in the areas to be
intensified, and special attention must be paid to the
■survey for collecting relevant data from the underserved
vulnerable groups.
43
3.
Initiating laplersentation of the Project
ICP PHC 009 - Agenda items 4.1 and 4.2
Group ’A’ - Chai naan : Dr Suyono Yayha
- Rapporteur: £>r M.T. Cooray
Country Level Actions
Each country should identify policy guidelines for the
decentralization of the district management health system
emphasizing on expanded programme on immunization (EFI),
control of diarrhoeal diseases (CDD), essential drugs ano
vaccines (EDV), acute respiratory infections (ARI), etc.
This would be followed by a national workshop at which a
district will be selected. Project TCP PHC 009 will be
introduced with:
(1)
planning for collection of baseline data;
(2)
preparing a plan of action xfor implementation,
and
(3)
strengthening of PHC network and identifica
tion of focal points at n'stional and district
levels.
This will be followed by the baseline survey. At the same
time, the group recosmeuda that a three-day workshop be
conducted in the selected district to inform the e’.jtrict
level health and health-related sectors about the proposed
inputs’and activities of the project.
The district-level workshop will
identify existing
resources and requirements for new or additional resources,
including supplies and equipment. Training needs related to
activities, such as E?i, AM, diarrhoeal diseases, drug
management, epidemiology, management training, etc., will be
identified. The district-level workshop will also develop
the district plan and activities.
The district health
workshop will be conducted by the District Health Officer,
with resources
from the national
level. The district
workshop should identify the elements to be included in the
project. This would be based on the baseline survey. The
work plan should then be developed in terras of EPI, ARI,
CDD,
EDV,
managerial
training
needs,
development
of
integrated
training
modules,
supplies
and
logistics,
deployment
of
manpower,
conraunity
participation,
intersectoral coordination and any other district specific
needs. The work plan should identify government inputs and
required UNDP inputs The work plan should also include ar.
yearly budget within guidelines and limits set, as stated in
the project document.
Action for the WRO Regional Office
(1) The Regional Office should send
an
coomunication to the countries on the following:
official-
- Intercountry consultation of January 193?
- Request ' commencement
mended by the meeting
of
activities
as
-
recom
- Request WRs> to identify focal points and follow
up action with a responsible person in the WR’s
Office.
(2)
Assistance for training courses
(3)e'Provision of training modules, when necessary.
(4)
modules.
Developing,
translating and
printing
of
training
1988-1989
/
(1)
Implementation - January 1988
(21
?• id-term review at the district level - July 1938
(3) National workshop to assess results 6f projects
with aview to replication in other districts - January 1989
(4)
1989.
Regional
workshop
(before
UNDP
review)
-
March
45
SCHEDULE OF ACTIVITIES
Activities
1987
JFMAMJJASOHD
1. Preparatory phase
including project
'formulation at
country .level
!2. National workshop
3. Baseline survey
‘4. Preparation of
district workshop
n
.5. District workshop
16. Ordering of supplies
and equipment
Development of
integrated
training modules
(a) technical
(b) management
18.printing training
^■□dules
'9. Conducting training
• Group *
5 ’ - Chairman : Prof Soisaath Roy
— Rapporteur: Dr Abdul Saead Abdullah
‘The group discussed activities related to the plan tsf
^operation of project LCP PHC 009 after a careful review of
46
(1) The pier, of operation for the intensification of
PHC will be discussed at a national workshop to be convened
by the focal points appointed by the governments and
participated by key administrators and experts of the
intensification areas. At this workshop, what to intensify,
how and where will be decided.
(2) The national workshop will be convened as soon as
government concurrence to the project
is obtained by
WHO/SEARO.
(3) Saseline
surveys
needed
for
management
end
monitoring will be conducted as soon as the district or any
other manageable area is selected. In the selection of the
district it will be remembered that activities will be
targeted to the underserved and vulnerable populations. The
survey will be conducted using existing manpower and
resources in countries and made as simple as possible.
(4) In the plan of operation, focus will be on the
implementation of district management in the four areas of
intensification and to develop a replicable model in the
country for further activities and projects.
(5) The terminology used in Che project document,
e.g.,
'children',
'paediatric
group',
etc.,
will
be
clarified at
the country
level
keeping
in mind
the
vulnerable age groups needing attention.
(6) The training modules to be used will be developed
by WHO/SEARO and sent to Member Countries where these will
be further developed and adapted to serve the countries'
project activities and then field-tested. This will be
undertaken by an appropriate institution who will develop
steps to operationalize it in consultation with the selected
district officials.
(7) Support
following areas:
for
supplies
will
be
needed
At the management level -
Word processors and computer
Photocopying and cyclostyling facilities
in
the
47
At. the implementation level -
Vaccines and drugs
Cold chain equipment
Diagnostic and laboratory equipment
Production plants for ORS etc.
*
Transportation: Bicycle, mopeds, etc.
(8) Different countries would experience time delays
<|L.' different degrees in implementing the project depending
oW the existing bureaucratic structures. As soon as a clear
activity plan is submitted to WHO/SEARO, funds should be
released.
■
(9)
Some
seed
rbooa
money may
f-ho
made
be
rx£
chart-
I.
available
A~ ti XX.
-T"XA »
■
*
for
the
Annex 5
00
FLOW CHART
Cow H 5 A —* 8
WHO Regional Office For South-East Asia
NEW DELHI
f~SEA/HSD/97
12
SWOEBG OF
March 1986
SYSTEM
FOR PRIMARY l^ffiCARE
^Report of a Consultation
«iun o
• ieo ouzt nnc,
IIN'P Prntmrl RAS 781/027
CONTENTS
Psge
SUMMARY
1.
REFERRAL SYSTEM IN PRIMARY HEALTH G’AE A CONCEPTUAL FRAMEWORK
1
2.
NEED FCS. REFERRAL SUPPORT SYSTEM
2
3.
DIMENSIONS OF A REFERRAL SYSTEM TO SUPPORT.
PRIMARY HEALTH CARE
3
4.
REQUISITES OF A REFEESAL SYSTEM
6
5.
FP.ASES’CRK FJX SAPID t-MYSIS .'c THE
BEFEEPAL S7PT5RT pdk '-araaTT EV.Tri CARF
9
FRB?O>S»SS c.:K ACEiaS 8ESESFXE
15
f>.
lit
SUMMARY
The Thirty-seventh session of the Regional Committee held In
1984 had stressed the imiortance of a sound referral system
in providing meaningful support to primary health care.
Following this, the subject was again discussed in greater
detail at the Intercountry Meeting for Primary Health Care
Networks in January/February 1985.
'
The present consultation was called as a follow-up of
the recommendations of the above intercountry meeting and as
a first step towards supporting action programmes in the
countries with the following objectives:
(1)
To discuss and arrive at a consensus on the
conceptual framework at a comprehensive
referral system in support of primary health
care (SEA/PHC/Meet.11/7);
(2)
To review the framework for the rapid
analysis of referral support to primary
health care (SEA/?HC/Meet.ll/8);
C?)
To exchange .‘n-'orsatlc-, on the '■.■'sting
referral system 1.-’ Itidiv. dual countries, and
(4)
To develop country acLii .. research plans on
selected aspects of the referral system to
support primary health cere.
The Director,
Health Systems Infrastructure,
WHO
Regional
Office
for
South-East
Asia,
welcomed
the
participants to the Consultation. He explained that since
the International Conference on Primary Health Care and the
Alma-Ata Declaration, efforts towards primary health care
development have taken a quantum leap, but at the same time
there have been apprehensions that primary health care would
become second-rate health care for the 'have nots'. It has
After thorough informal discussions on the conceptual
framework of a comprehensive referral system in support of
primary health care, certain terms were redefined in the
context of the situation existing in the Member States and
some other modifications suggested in the background paper
prepared for the Consultation.
On the basis of the framework for the development of an
action plan, each of the participating countries developed
an action research plan proposal with specific objectives
and a tentative calendar of activities. These plans are
included in the report.
vi
ri-
&
ro
.
&
SU
&
p
rs
H’
1$FEpMl S^TEffJlM ^IMAf^f Sl$/1-H CARE
*1
J»
A CONCEPTUAL FRAMEWORK
Definition
Tn general terras a referral 13 d fined so a process by which
reference
is mode
of
matters
requiring
decision
or
settlement or consideration to some authority, within the
scope given to such authority. This definition implies that
the level/pcrson to whom the reference is made (i) is higher
in level; (11) Is more knowledgeable; and (ill) has the
authority. It further implies that the level making the
reference
has
neither
the
knowledge,
competence
or
facilities, nor the authority to take a decision on the
problem referred.
In the background of health for all, wh a a health
problem or a patient requires care which
xceeds the
capacity or the competence of the home or commur.. ty or first
health facility levels of primary health care, bringing the
problem or patient to the attention of mere skilled
personnel and more adequate facilities to bear on different
problems or illness, is called referral (see Report of
Informal Planning Meeting, 25-29 June 1984, SHS/HQ).
The 'Glossary of Terms' used in the Kealth-for-All
Series Nos.l-R, defines referral as a turning for support or
referring patients to an appropriate facility, institution
or specialist at the next more central level in the health
system, such as a health centre or hospital. They in turn
can refer problems and patients to successive levels in the
health organization.
In the light of these definitions, a simplified meaning
of referral can be "Referral is a process to seek solution
or support to the problem from a person/institution having
competence and facilities to do so". However,
in a
governmental system it also implies that the person to whom
the problem is referred has also the authority not only to
suggest a solution, but also support its application.
2.
NEED FOR REFERRAL SUPPORT SYSTEM
In any organization the available competence and facilities
vary at different levels. Similarly, the different levels
are
vested
with
varying
degrees
of
authority
and
responsibilitiea considered adequate to disch. rge their
functions. However, occasloae/probless do aris- al: each
level, where they need the support of pereons/l stitutions
who have the required competence and facilities to find a
solution to a given problem. The referral system r.eets the
requirements of r.uch situations.
In
the
field
of
health,
professionals
with
progressively higher training and competence who can give
specialized care or support over' a wide range, islng sore
advanced technology that can be offered at peripheral
levels, are available at referral-level hospitals. The
district health offices similarly are better equipped to
solve various types of problems th t may -rise
home, in
the cocsunlty or at the first health .level. Thus the
referral system helps in the efficient de. ivexy of urinary
health care cervices and in securing ruopl 's faith in the
primary health care approach.
In rhe health system at present pr /ailing in many^countrles, an individual is free to se. . treatEieat for —
his/her ailments with any institution at ar level. There is
also a deep-rooted impression that one g< s better advice
and treatment at higher-level health Insti Xlons. In order
to create faith among individuals and the coeraunity in the
primary health care approach, they have tc be assured that
in case the services of higher-level :nstitutions are
needed, such services would be made available to them on a
priority and preferential basis through referrals. A health
system based on primary health care cannot be developed and
cannot function without support from the first referral
level ensured through a well organized system.
-
3.
.. DIMENSIONS OP A SEFES! AL SYSTEM TO SUPPCZT
PRIMARY HEALTH CASE
A referral aystea should be able to deal with referrals
related to any of the ess ntial elements of prloary health
care frea any level of prl ary health care in respect of any
of the supporting infrastrvsture (Figure 1).
figure t.
* COHCtPHyt tMfl CF A CC«Flgl«»5>VE
gfFffgM. SWTC3 S» SBWOff Cf f«C
.10 SVeAS
This SsMtttf <si Elecr-ui
*
of fUC
Th® referral system should -fee organized to support the
essential- eicaeKts o£ ptls^iry health care, which ictiude cr.
least, causation ecttc:Tmi--z prevailin'? he<h prohJcxs acd
the netted oi psevettting ar.i caat-rolliBg thasi pyocctioa of
food supply ess proper suiritiao; an
nvpply <:■£ ns£s
wafer afld ftaoia essAtsCltaj asferotl ana f-hliJ ca.v
laalrJlng fts&y plaasifigf fiaJohutlPi wgufcai as^ov
def&rtiMS ^laoaeosi prevaaffofl s&f sszi?a4 yf iwsljty
•ataifc 44«easMj izdatcess al en$s> ;j>-?.?-^-. 3.. 4 .;?5ufL-oj
,?ts& the prswlslss ©1 assestial dry^3>
the S-evals si PU&
Prissry health eafe ssy be
?t »s. - Jny^ js?
it) »Jsse level "• whleh refers cp a »9t?ge^i4 as
a
ya??: is ar-> ss^et-^y. ?5t ily r^r‘^r~.
a?e
fst hee- 'b
at fhia level. ?e&Pie t-rs-3 t?)a
s§ well os esssunlfy ysftezs
£ vavloss
Made fcteraa
*:
vlti? tif 'a»4 are
dlreerly inveiveJ i» se?vi;^s al . is level.<?Ki555<t7 level " aefl’^tlee at 4-1? lavsl
easeere the health sf the
«9®j?twlfy
aad Feaulta ssssaa fatlileltw anj jeist
by e gr©3?
eer§?^i
fiealth fMlilty ievel - aesss gi-ste
tessityf-lcaa whish ar?
having
prefgaslopal health aeraannei
sue er.sere eMseate sf ptlaar? tsalth r?re
^'health j>Fafgesifisa will
»MW1V?S, ha.aj.fh pg.c
aaalpcgafa art ether tralse^ tetri'ls veft(e~§
»■?© afe is the sfatg health §s^^?s).- The
issgifyplpr.p pjn by vpiunf-ayy PFgafiltstieffS
S/“:1 the private seeta? also prsv} ’e prisffry
health ears laeilltlea aah tan h- iffeitwiei
Is the sy.atp.? proyi^ they have fwffetiyeal
ilidsagee with other levels si primary health
cere..
OHrSeSf
(4)
ii
piFSt Fgfffeial level =
tfels la she r
level la she health afgeslreftsa r-.. ■
the Prelaw eFlfllag sf eey <?f the 1 •' .
tS/es levels sas he referase fog sslas’.z
ffts £!
*.$&
Feje-fsl level serves «w arses *
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fi?f«rj31»r ?fe ellsleel FS 'S ‘ i
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well as sfcfsjaSFS Iva
vtissttes
biased '9 ?eF§553?i ?Fe>SPJ-;sj?3? .F^7SF55,fef-llUlee;. ?^«i8ssai» sepsilee essr
iavpJ-e.-
^eas^TSgfiire- fe?
!•? s^s gfe
*
»?fewv feaU?}
?!®£&eas el.Ce£$v
all levels,! aef£=‘l.rf a’,:?p,?,:'t; '§ eleEaseg ere .?ss
effsessiel.- ?r>e§e
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l^s£g^g& wan
(ir lB.f.9~~Cjr?3
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47} SssfiRffllfy parfle^sEles.-
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6
Other Levels -of the Referral Syetes'
These are:
(1)
(2)
Intereediate or secondary level
Tertiary level
Types of P-eferral
The types which say be referred from one level cf the FHC
areg to another resy be grouped broadly «iS •
(1) Clinical
(patient
care,
investigation,
diagnosis,
after-care) and
which
includes
treated it
and
(2) Health programme (referrals concern cd with
prcblens relating tc public health programmes)
Twc—zay Cora’mication
Referral should not be considered as a one-way traffic from
the periphery to more central levels. The dynamics of
interaction among various referral levels requires a two-way
communication.
inward flow cf prcbleua related co
progrartBes and treatment of patients;
health
•
outward flow of information with respect to
the patients and problems referred, feedback
from analyses cf reports, policy decisions,
new ideas end new technologies, etc.
4.
REQUISITES CF A REF3ERAL SYSTEK
Procedures
There should be clear-cut procedures in regard to when and
where the referral is to be made, indicating clearly, while
raking the referral, why the referral is being made.
Safeguards mist be built into the system to ensure that the
referral system is not misused for ’passing the buck.’ and
thus overloading the referral level with finding solutions
to problems which c< a be tackled at the local level itself
Steps should be tak< a to ensure that all persona ccicerne.
are well aware of th', referral procedures.
Resources
The level referred a should not only have the coroatenc.and expertise to fin a solution to the problem refernd but
should also be vest- d with the administrative author try tc
implement whatever is decided upon.
Referral Chcnnale
The referrals can be made from nd to any level of he
syettn (Figure Z). it as? be related either to a clinical or
an
administrative
probier.
Wh. le
there
are
ssrrtiy
well-defined channels for administrative referrals, It ?'
uot so in the case of clinical referrals. The usual ateffti
of referrals is to follow the organizational channels. I».
has
its
advantages.
However,
such
a
rigid
systm/
particularly in clinical referrals is not only ?.unneees ary
but may be harmful too. For instance, in tbeVease c! a
severe head injury it Is no
•se going to the fls'.
referral-level hospl '1 thr •.ugh the first health facl It’
level • knowing full
veil that the facilities for ,ts
treatment are not .■ railabi ? at the latter. 4s cmch, ir
clinical referrals
’.e referral paint must ba decided is.
ssch case according > need md no rigid procedure choulcbe
laid down. For the a oo’-h o[ ration of the clinical mferal
system, each aervica le.el i st be fully kncwledgeaole thut
the competence and fucf.lftif available at different lev-Jj,
so that the referral car. be ade to the appropriate level 1
the first instance. Any delx in clinical referrals aav Iasi
to disccutentnent with the services and ultimately pxxpl.nay lose faith in the pritu y health care approach. At thi
sane time, the pressures an temptations to refer ary cst-t,
on considerations other- tin actual need cuet be resisted
The clinical referrals must >perate on the principle of "t>
everyone according to hls/he ■ needs and to pene cn dhsarad'’
All levels of service delivery oust know the coupetAtce of
personnel and facilities available at different: levels So'
the diagnosis and treatment of patients, so that tha.cjrsx.
may be referred to the appropriate level fn the first
instance itself. A "referral slip/card” should be used. wbj.i
I no. bVia. «l_{.n4z>a1
ro
*
eoFz>v
1a
oJtrfTio
ol 1
Figure 2
Fig:: e 2. CHA'I.'J? S OF C&WJNICAHC?! BETWEEN
DIFFERENT LEVELS OF THE REFERRAL SYSTEM
-
HEAL !! CARE LEVELS
PRIMARY HEALTH CAR!
'
s.
euxbeoss. .70.. r-WS./iWiZS is of thz i.-rcasi.
Cn.njXiT 1'IZ. i>iCX!StX iiEftSSI. CZE3
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Sa. zefatr..-/. £>-?-..n ?s s. £c.taj1 uactuKiisn to dc&l .’'.th' Os
r.rfferraXi. free.
le“?i i.i'i cbosishc of a*r.
',lw
<
aul-aytter/o ( 5
>•.persons, equiprsnt,
c.) ’~>
cch.iovs cl■ : ;■
to tic prohltzs usfcsrc-i. ft .<
different •'<•••;
r.-r'Sl o-jj-ctzatic: ol or f'"retie il
iinkagec .;..■. r,..f
ten razxous x-velr :7
the ueJivet/ of health cer-ir.e ♦ .
Hcture’cf f yKOifela Rvcsxrnli
In ths light of the <?cf. ■. ,7J no: rafczrrJ.s, the arene >f.
referrals will ■i.it ;-5 or. tip i.e
*- '*. fzor which .'.he r?5em’.
J.e node, but brccdly coyer:
J
,•
x
Ci) Zatient :.. l j
(2) *J>.£nCennnc<
.
of
act
(3) Training
(4) Evaluation
(5) Rseearch
v£
(6?< Inter-re'’’-r.ocrc
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CrJ.tjrie ft.r Lixf.:'
*
rr-r j?1 tva'.-n
and iidnaiws-T' S’-C~3
The referral systea is
at tc Ctrl uith ztfer. 1 pvoblas
and not nanjgeuenn pzehlcc.3.. S.e£&rtal prshlea: are thwe
silica cannot :.-j desl-: a', the referring *.sval -ritLx.a
Ciicposition. 8L-d. .fl“C'..VonS, wi
S' .> ■-•JOJ.ir''. VZCblcr<5 'll.
thoiis wtrch sbculd i.tzsc".;.y
e hcndlxed ?t 7'-’.e p.»—-».
leva?.,
but
carxoi:
te
ta. kle4
ci
account
of
'er?
non—avsiluiility cf tie
y at a p^ztie^lar cctienc.
for evijoplc, a reticr.t7n lefer -.1 to s rafcrr.'.ol, heepf
::r
blocaxaiiinatiui.’
fc.r 1 tie
rate.site \accav?:., f;-.
aier jseops nt '-.ha fl-jt h"« th facility ievsl (
ttiaith cent’.-:, hsa-.'cb unit,. . Lr-jscscty, ete.b i
*
ajc. .-.1
workiui’ ordor. Thio ir. p~..a'.7 -. cir.ti.rctr.C prehlat 2 - *.h
a referral p.eb'sm, and should i>i; ttl.cii earc ox by i.".; 'ivy:-.
10
hospital for X-ray, because X-ray facilities arj- not planned
to be available at the first health facility'level, is a
referral problem and should be taken care of by the referral
system.
By
their very nature
referral problems
are
permanent, while management problems are temporary.
Framework for Rapid Analysis
The general approach for rapid analysis suggested in the
framework' is a problex-oriented cue. in the first step the
present situation is described. In the second step, each
country selects a "preferred" item of referral and works out
an Ideal referral syptem for the seme. In the third step,
the ideal referral system worked out is compared with what
is existing in the country to identify the gaps for
preparing an action plan.
Step 1
Describe the referral system in your country with reference
to the following items:
Political and adstinistrative structure in the country
What are the administrative dlviai r.s?
-
What are the levels of govezamer.t'
What are their relationship
sector at different levels?
to
the
I -.alth
What system of decision-making exists a
community level?
the
Cosponents of the health systes
What important organisations, or groups
ere
there in the country providing health care
besides the ministry of health?
What activities- outside the health sector have
significant effects on health, either positive
or negative?
ti
I
Organizational structure of the health services
•
-
What ia the organizational structure of the
ministry of health and its suoordiuate levels
of management?
—
What types of health care are provided at each
level?
-
How are health programmes itroiemented?
Operational management of the referral eystex
(Describe separately for clinical referrals and
programmes referrals as appropriate)
(1)
Procedures
Does a formal referral system exist at present
for
patier.te/health
prograde
problem?
DencrJ.be.
Is it a two-way systen or only for ’transfer’
of cases or problems?
Are all levels of the referral system awcre of
the existence of such a s stem (if it exists?)
Dees the system ."How for
according
to
the
n ids
patients/problens?
|
i
'level- jumping *
cf
individual
Are any procedures laid '’own for making the
referrals, e.g., referral slips/referral cards?
Does the referring level know the information
to be provided while raaki g the referrals?
\■ •
Are the times and dates fixed known' at every
level for sending the referrals, so that the
services are made available without waiting?
Or do facilities exist so that the patient - can
be attended to at any time?
.
V/ f
12
(2)
(3)
-
Foss the sy;tcs provide for attending to the
referrals at the referring levels also (e.g.,
visit by doctor to the hone and cocsunity
level or by specialists, t’o the ?HC level?)
. -
Is there aay organizational or rdnlnietrailve
arrangement
for referral
institutions
to
attend to referral cases on a priority and
. ■ preferential basis?
, -
Has the referral level any accountability for
attending to the referrals?
Manpower
-
What staff are available at each level
programing technical eanagesient tasks?
for
—
Are staffing levels adequate and are
descriptions and responsibilities clear?
job
-
Are mechanises for' handling personnel matters
working satisfactorily?
Training
-
Are. health personnel adequately trained to
function appropriately at th 2 level they are
posted?
— Are adequate and relevant training materials
Including manuals and handbooks available?
(4)
Superviclon
-
Are health personnel at various levels being
regularly supervised?
—
How. much on-the-spot
training,
>n-aervlce
training or continuing education is given as
oart of supervisory support?
\
5)
Supply, logistics ar 4 maintenance
-
Are
transport
facilities
adequate for pstj mts?
and
available
~ Are ccEtunicatiot facilities available betreen
different levels to seek morn information and
guidance for sc iding ths pstieats to tte
referral levels?
(6)
(7)
(8)
-
Are storage facilities adequate?
-
la eqelprant adequate?
-
Are
facilities
and
equipment
transport) adequately csitw.nlned.'
(including
f.
r
Intia and date?—sectoral coordination
-
Are health activities in genUrr1 - and referral
activities in particular being coordinated
with other health agencies- other ntnistritfs
and private and traditional practitioners and
other systems?
-
Is there any effci :ive co rdination?
—
Are
there
structure
coordinating the war’- of'
cd
trechaniats
.1 sectors?
for
Coraunlty participation
-
What fors of cotmauaity oartlcipatlon exists
for health activities
x general and for
referral activities in per icuiar?
-
Are these activities effec .ive?
\.
.
Monitoring and Evaluation-
-
Is there any mechanism, to assess the- load' strA
tvop nf rpfArral
txb
rt-1 frrrl bt-
is any assesrrcent being made of the patients’
ss.tisfcctioa with the referral services?
(9)
•
Resources (teeltaical/fltsncial)
Are the facilities era the coEpetenee
personnel at every level standardisei
- identify the type of services av; liable
each level?
-
of
to
at
—
Are ail the levels aware of the feci titles and
services
available
to
ensure
that
the
referrals are made st tire appropriate level?
Step 2
Describe your •preferred
*
headings as in Step 1.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
referral
system under the
Procedures
Manpower
Training
Supervision
Supply, logistics and maintenance
Intra and inter—sectofal ceardinat .on
Consunity participation
Monitoring and evaluation
Resources
Step 3
(1)
Identify at least five or core prcblent
relating to the operational Eancjeseut of
the existing referral system in year country
(as judged by the gap between the present
situation and your preferred situation).
(2)
List the first five problems
priority.
ir<
order
of
sene
6.
PROPOSALS FOR. ACTION RESEARCH
■BANGLADESH '
Action Plan Frartw-erk
TOPIC: Scheers for Patients Referral
SITUATION ANALYSIS
Present Situation
-
The process cf pabitnes referral ie not given
due importance as a system activity.
-
Patient referral is < nee rather' perfunctorily
without much sense cc- responsibility^ on the
part of the referring, level.
-
No effort ie made to find 'out what happens to
the patient once the referral is-made.
-
Manv a time the referral is dene verbally-•
The referring level is not aware of
advices given to the pniieht on disposal.
-
the.
-
There is no scope for .monitoring or evai -ating
the referrals ends.
-
Referral as a process -a nut uniform' <tal- is
not equally familiar to heath. inatitutiers at
.each level.
».•>
—
There'ie.no scope for research.
ifeede identified
— There must be a fonroJ schema for tka referral
cf catiente both: at tic ref erring. Level (El'SC?
as veil as at the J IC, the first referrallevel.
-
Some documentation
tc be done Loth aS-.i-ltsEy
arid UHC levels that ci x be used for. mcnitc r’rjsg
Patients referred isust carry sone referral
documents in the shape of fc "ss/carda which
give t’rea a sense of bel-ongi'i, to the system
and aleo of security that .they will b~ Inched
after at the referral level (UH ).
Each level (H?WC, UHC, .etc.)
.1 the referral
systcn oust be clear about its ro’e in the
referral process.
PLANHIHG
—
Objective: To develop end field test a patient
referral syates at KFSC - the first health
facility level.
-
Area of L-^ylecenf’ti-—i: 6 HFHCs ccrpriF.1ng 2
UHCs of J . district.
—
Serpurges; Detailed budgets will be preferred.
—
Detailed plan of at tier.: As annexed.
-
indicators of assesgrent;
Number of referral requests rece ring st -vices
Hueber cf KFWEs actively parti' Coating (first
•health care facility)
Hctnber of UKCs participating (fl
level)
Number
of
satisfaction
patient
follow-
t ? ferrsl '
ups
howir.’
INPLElSNTATiCN
—
Calendar of work; As annexed.
-
Staff training and field work; As proviled in
the action plan.
Itoaitryins
Reporting
Six ■mcatiilj- ticaitorinj;
FeeibeeX: Continuing
3VALUATIOH
Evaluation plan
Record analysis
Sample survey
Indicators of success: *.s
noted under Planning^
SAtM&Sll
PLAN OF ACTION AND CALENDAR OF WORK SEPTEMBER 1985-AUGUST 1986
CALENDAR OF WORK (ACTIVITIES)
I
1.
Preparation of PP and approval
2.
Situation analysis
3.
Selection of UHCs and HFWCs constituting
the sample size for field research size
for field research and determining the
scope of services with (the referral
scheme
A,
Designing of referral cards
5.
Selecting format for basic patient
document at HFWC and record and report
forms at UHC
6.
Training and nr’ent’>tfnn
r^nrr’ng
level staff on proposed referral scheme
jointly with local commity leaders
(six workshops of 3-days each with
about 30 participants)
7,
Trial run of activities Nos.3 and A
(one day) at five places
1 GOO
6 000 '
8,
Finalization and printing of Nos,4,& 5
activities
9,
Implementation of referral systems
10,
Provision of inputs in the development
of referral levels
11.
Feed-back consultation between staffs
of referring and referral
12,
Selection of indicators
NOV
CALENDAR OF WORK (ACTIVITIES)
or assessment
13.
Evaluation
1R,
Publication of ,ooorrs
15.
Presentation in national meeting
TOTAL:
20 000
ATT,.?'! 2-7
:.a
Fvi ?A2-.?:ir f.S.3
A VCSitJ. kH?3!2AL SVel^l
dec -- C£«7J Ufifeecira
To lnvv.>jyse i fostsal referral syk>tes for pstie.at -?s-e
at oil levels ol radical care
Sbort-tezz Objacti'.-as
(1)
to asseec, vith the aid of
nzorsatioa
available, the vEstar atd typer • c referral
likely to be ssda free ?7?JL I.FHC) to the Fill.
(district hospital?;
(2)
to ctudy the type of services I zovlJod at
FH5L (fHC) and ZSL (district hospl:al);
(3)
to develop a raforral card £c..: v.s at ?lr?L
(2HC) and FIX (district hoBoitel); nd
(4)
to assess the tcf.-rzai load at 5i.i» to vrozk
out the rcqitircs&at oz □?tpc1:=;'. logistic
support
srul
tzslnera
rr.r’.Xi. id. fcr the
rezerrrl syctcr to to f'.'-H.’ .jw’itiorzil
(after iGtrodusticn of raf-iLcl
dtes >'or replaceufitict.
z;-o primary heolth cfttrea vd.ru - a.-l'
the ofeele dlalrict (etcut 13?3Cs>.
Ho: Xaiiltij
of
to
Xctt ’<1 <■£ K.:u3t&z.ln?
JC..«;, -2.it-. tre cctt. tt?.0E soaitezing by 3 il tri irAl, a
i-UKXtct.v;1 ■sppv-ats&l :roul-i Ve carried
ta aoEson the
■’f-C'-i -u
the p-eject and suggest a. iillcatiouo if
Sval-.-. rlcr.-: w.ld be done i.ouctisc in July 19E'
y'^1.3
*»
I
SorJ.eoriug hr~ .ix
: ■.•<-■ Id be- deci'.-’d after a detailed . ■idy of
st sitvxtlin..
<
A^a.cr
(«} CcatinHc---.’"
' fan
so(rac)
IiG
1‘V «•HlOttt'u
trader ~' ->5.w
<7:>
■LLX.-'livg ?9Fi.
’■
" r.-- <c-fl "4i?XZ ?ti to F2L
:5 iL.-’cr. o’" tvf. • of c--esc
»
r.^K
l'.s £:> cp: T^^rl-’stc. r
Btralc;
' . xi , r :-e7k’ctBcaca.
Id..- ■_ - "1.rr. 5vn ex b-'-txcv' -kc
•
if'-nrte t- -cLv.! <> ■• ve
AGSsiGI
(bi Aaprai.'al
‘TAMAf-ER.
vx.3
,:;hs
■SMf
t.J
HO
TCClju
- P«j«j"ct •: chart ex refarmia- ’?•>. ?.f robleca noj.vec'Zuaoqlv.xd
- Aaj’ ctl r feed, iufcruzticu -
TAEIt
■ ■-
•
••
— Extendi g guidance
- Uodixic itlon in approach ?.a r •_ - cec^
U:OIA
1.
Collection of information from
FHFL and FRL the number and nature
of cases referred and the number of
cases and their nature treated at
First Referral Level from that
particular FHFL (PHC)
2.
J dent! fl cat inn of the niwber of
cases from 1 above the number of
cases and their
would
really need rep-ral on the basis
of service faciutic.s available at
FHPI
3.
!,
Development of procedures for
referrals
Preparation of guidelines for the
use at FHFL antf FRL Indicating tow
to make and how to deal with
referrals
DEC
CALENDAR PF WOKK
CALENDAR OF WORK
11.
Study of the service facilities
available at FHFL and FRL,
standardize.them.and circulate
them for the information of FHFL
and FRL
Preparation and circulation to the
public, information material about
the functioning and advantages of
referral system
Preparation and pre-testing of the
referral card
Introduction of referral cards ror
use
1
111.
1V.
V,
,
A,
Monitoring
Study-' of the services provided to
referrals by FRL
1.
Logistic support
1.
identification of the logistic
.. ’ supports-needed for
mth
referrals effectively
A
■
.................... 1
i1*1 3'.
.
*
1 i.u'.i'W jij'w.
CQH&i
AMfc J3X\T KS7im
Msia £bje<?i4v<?
?f tzpi&va
©?& sr,d ;?fi>l eUait espeet sf pseteBt e&f
*
>~gfe?^aia is s aelestetf §a as to gala esspSFleare ia the
■tevetepaeaz oi e eaffiprehs&slv.'- gsfezzal §ystes>
•
* r. '
i
^adlssesF itBs Waia ^Jee^lve
\ ■
.95® §esvi<?£j aK pfes^t aa^ fils®? ®se ps&f
->
iaAiaatoFB fa? S^=s^s€gi-v&,
(J.)
A FBfe??31 3y^S<23
fee??? ^asuffl&ss&i
<2?
Ail
(3)
lhe 88i3®u?l?7 sill els© fee »eli-iaf©She syefeo
W)
lk(in>& ea?a fe? fea?l§6 ?3 will i?e lapsed
-SF
Wfi-3.
‘
teaiffc
p^fessissala
is
she
»r-i-g§tJ.«B/s'?i?sfis/.?lffl9i$ Jaist twapteai t 11 fee
f BRlllaS Ki.tfe
gys! '&
il sf
S«Ko« Conpor.cntc
Sub-cbjec.ives
1.
Procedures
To icprcve kccwleje of health
professionals and community on
referral, systess
2.
Manpower
To icprcve ccasnet.ncy of
health professionals at
bti gade/scaonboispital/sfsrak
joint hospital
3.
Zact?J.tiee/
script ant
To Isprcve facilities, psrti.-"
cularly st the brigade, faldshet
eta.ti.oa ea£ scsr-t hcspltal
4,
LcgistJcs
i ncl siding
ecsacnicetlca
To iisprovto/ e'Z sip ecffTKiy.ication
facilities;
(s) Radlt- cossurlcsrfoo
(b) Telephone ccrssunlcatfow
(c) Transport
5,
tfoaf.toeiag and
Evaluat .'c-n
To chcaia ccss-sn - di»r,3,'.s ding
by ‘-11 aiiSi'fs on : jferrsl.
nystsffc by revlesrtrt *
hc
reezot
project
Activities
Responsibility
Hue Schedule
1(a) Preparation of handbooka
on referrals
Dr Rolsodma
Ministry of
Health
Nov. 1935
(b) Wider distribution to all
health professionals
Dt Dularasureng
Aloak Health
actor
Dec. 1965
S.No.
X.
' ‘
--
(c) Health education lu the
community
2(a) Update and revise job
descriptions ’’
(c) Continuing education
courses to staff to
update and upgrade
their knowledge
-
4 000
To date
Ministry o(f
Health
(b) Define required compe
tencies of staff and
facilities at each level
/
Resources Remarks
( US *
)
Nov. 1935
4 000
Jan. 1986
Feb-Mar. 1986
•
•• -
(d) Study tours
Jap. 1986
►
-- —---I
(concluded)
5.No.'
Activities
•3 .
Responsibility
Time Schedule
Resources Remarks
( US t)
To upgrade Brigade
Feldsher stations at
Somon hospitals in
the project area in
accordance with Che
defined (standard)
competency of staff
and facilities
HOH/AHD
Feb 1986
10 000 ■”
4(a) To establish a radio
communication network
between the Brigade
Feldsher Stations/
Somon Hospltal/Almak
Joint Hospital
HOH/AHD
3
! dn
i SO.
■7 7;
Feb-Mar
S3H-8 000
;pod
1986
Oi)
lb) To strengthen transport
facilities at Brigade
Feldsher Stations
(motorcycles)
Apr-May
1986
(c) To provide ambulance
service at Somon Hospital
for outreach services
Aor-May
1986
To organize National
Workshop
it '
isiaq
'/V 'JOS
5S S’
?; aq.q.
v’. <7 t? 3
MOH
---------------—,)>-------------------------------- ------------
Aug 1986
1S e , MC
4 —sdcrf—•—
2$
. SRI LANKA
A PROJECT TO STRENGTHEN THE EXISTING PROCESS
FOR REFERRAL AT THE PRIMARY HEALTH CARE LEVEL
IN A SELECTED DIVISION IN SRI LANKA
Situation AualysiB
1.
The FHW is crucial for the delivery of all PHC services;
—
—
about 2 500 in the island
18 months' in-service and field training
1 per 3 GOO population
operate from an Instit ition: GHC
first health facility
each has support of 2C volunteers and
Mandalas
Graisodaya
i
2.
Currently, referral is done by: FHW
FHM
PHI
AMP
FHW
PHN
PHI
AMP
- chiefly MCH
- Informal, optimal
- no records/documents/registration
- no feed-back
- limited scope
- chiefly communicable diseases control and
environmental sanitation
- ambulatory patient care
Planning
1.
Objectives
Main:
Sub
objectives
Strengthen the quality of existing referral
service of PHC worker
1. 1
improve
prestlge/credibility/utilization
service of PHC worker
of
1.2
use as a method to upgrade/maintaln
skills and levels pf. competence of
PHC worker
1.3
provide an additional tool to improve
supervision/monitorlng of PHC worker
1.4
identify
and
priority referral
1.5
increase community acceptance of PHC
worker
1.6
make referral more cost effective
1.7
control and screen case load
1.8
improve quality of service
at referred institution
1.9
provide
additional
method
for
monitoring
and
evaluating
health
services
1.10
provide design of a referral
for National Health Service
provide
improved
provided
system
Ares of Implementation
AGA Division
Beliatta
75 000 population, 5u sq. miles
FHW
-
20
PHN
-
4
PHI
-
6
AMP
-
3
Bari Hospl 11
20 GHC
4 Central Dispensaries
1 Divisional Health Centre
-
1 Provincial Hospital
Major Health Problem
;
*
-
-
Nutritional
Helminths
EPI coverage
C.astro-lntestinaI
Acute respirator’/
Malaria
Oral health
Environmental sanitation
Foot! Hygiene
STD
Alcoholism
Health education
Plan of Work
1.
2.
3.
5.
6.
7.
8.
9.
10.
let approval of Ministry
Arrange meeting with concerned staff to explain
project
Arrange meeting with wtamodaya Mandalas and other
village leaders
Assessment to establish base-line workload sampling
Design and prepare required documents
Training workshops:
indicators
- use of persons
record keeping
fol 1 OW-'lp
Kun for three months and review
Prepare manual for referral
Workshop to discuss and evaluate system
Commence modified system and implement for 6/8
months
Evaluation
With respect to:
1.
PHC worker
- work load
-■ job satisfaction
Improved competence
Improv?.' . ’latiousnip with community
- receipt of feed-back
2.
Cotrsunity
3.
Referral Institution
.-
4.
patient satisfaction
perception of PHC worker by Gramodaya Mandalas
work load
appropriateness of referral
feed-back
Supervision
—
quality of services rendered
coirplaints
perception cf system
33
TENTATIVE TIME FRAME FOR IMPLEMENTATION
MONTHS
DETAILED PLANNING:
- following approval and discussions
- objectives better defined
- mobilization personnel and material
- review time-fratae
- cost.
■
- write up project for submission
C-cm h-5a
WHO Regional Office For Sout i-East Asia
NEW DELHI
[ sea/h‘</95 j
PRIMARY HEALTH CARE
INFORMATION NETWORK
— Report of a Meeting on Cieorin ?~House Activities
*S2
OmaSSSCEHB!
1
saosnsEs sssjEcx
2
GEJECi .C'iE-i
<$
SS3ECE3BE ®®
4
■"^snaBsTB^iri®® ~
"■■' ■ •■••.'-
■ ------------------- 5
■ MEEEODOI.'JCr ■
6
■EVSMfASim
11
iii
ix*«;; grviTi.
?.;>■. privity ruil'h case approach has b.-.-ea considered itc::’;
suitsole for achieving the goal of health for all by 2O‘J0
Friasry health care requires the coordinated efforts ef
•suiti-E 13Cip.l5ne.ry groups la order to ensure inWa-aectorni
and intersectorc 1 linkages and cooperation fox promoting
effective health care delivery. These is an urgent nee4 for
the peeper planning,- organisation and fjarucgctsent si’ resources
available for the activities connected with prisary health
care. For the successful iwplesentation of these pre.gratrar.es,
adequate information Is required at 'different levels of its-'.
operation.
I
In this connection, a review of the existing,., national
<-d International lafcxaation services reveals ’Shat the
subject ’PrinBiy health care’ <?HC) has not loess given
adequate coverage so far. The different components of
primary health care and the various supportis,;: activities
required for its successful iaplesseutat ■ on have not betui
clearly defined or focused earlier. Ths type oj documents/
literature produced on primary health care r.-ci the data
generated on its activities are in many ways different iron
the other routine information on health
thus. there
are currently great gaps in the availability -te well as
accessibility of information on priest? he.vlth
..ts-i it.'*
related areas.
Further, whatever inforaation La .r --d.iubu. in .rssbi-r ■
Countries of the Region in various for.ae 3uch as field;
experience, success and failure stories, new jMthodologlr-.and innovative approaches' for primary health care, -oven Chitis not readily accessible for sharing with onk snothej- in
the Region. This requires to be consolidated and disseaincto'.
for the mutual benefit of policy-aakera, health 'sijtoinfstrstors and programme personnel concerned with primaiy health
care activities•’
• '•
2
This concern was duly recognised, expressed and shared
by representatives of Heater Countries of the Region during
the recent deliberations of the luf.ercountvy tolerance oa
Primary Health Care held In the URO South-Ea.?-. As;.-. Regional
Office, New Delhi, in January/February 1985.
The conference recoaaetided tlx development :.£ aeter-..•ch
systems with clearing house ectivie'e?: for prc";oticg uad
sharing inforoatlou oa prl&aty health care.
PROPOSED PROJECT
It le proposed co establish a WHO South-East Asia Regional
Priaary Health Care Inforcation Systec. consisting of y net
work of primary health care national focal point.'. <'•>!?;,) in
the countries of the HUO Scuth-E&at Asia legion, supported by
two priisary healthcare information resoxtree ceustad ;?IRCs>..
Scope and Coverage
Geographical scope. The geographical scope of the PKG
laforuation network System will be the WHO Soutb-i-'nsc Asli
Region, covering all the 11 Meaner countries. ?or the purpose
of collection of information, other countries and inter-,’.t/cnal orgcnisatlon's outside this region . >-j
l
*
nine bo
covered through appropriate linkages.
Subject scope. The overall scope of the subject areas to
be covered for this system will include all the assent'-?.!
components oi sad toe relevant supportive acclviti ::■ covered
by priaary health care. The following eight major areas 5
_______:____ rjirctesxx.health..cere. .identified, .hy-WHO,. will be taken i
account for the collection, selection, processing and
dissemination of information:
(1)
Education of the people concerning prevailing
health problems and methods of preventing
end controlling them;
(2)
Promotion
nutrition;
(3)
Adequate supply
sanitation;
of
food
of
supply
safe
and
water
and
proper
b/isic
3
(4)
Maternal and child health care and
family
planning;
asajor
(5)
Zsajunieation
diseases;
ii'i
Prevention and control of
diseases;
(7)
Appropriate treatment of coiamou diseases and
injuries; and
(8)
Provision of essential drugs.
against
the
infectious
locally anaemic
For the auccoaaful impleaentation ox primary health
care,
various supporting
activities
ere meat - vltaX
*
Therefore, inforoation related to the following supportive s
activities pertaining to primary health care would also font ’
a part of the scope of coverage.
Cl)
Involvement of people and community parti
cipation;
,
(2)
Involvement of the managerial process;
(3)
Development and application of appropriate
technology for health care delivery;
(4)
Bioaedicul and health services research,
including research on innovative approaches-
(5)
Health manpower development;
(6)
Development
resources;
and
mobilization
of
financial
'
(7)
Intraand inter—sectoral
collaboration; and
(8)
Development of an effective referral system.
linkages
and
•>
To facilitate the
collection and processing ■ > of r
appropriate information,
a detailed
list
of
subject
descriptors will be developed by the two PIR.Cs.
4
OBJXCTITO?
l.varftll
The overall objective of the 8EAR JiiC Ztsxcs -stiaft iSeSfewrfr
System will be to improve the availability tex'. *
ctas®fhiliei
of inforsation on priioary health cs.ra ant yrcaot® lt<
exchange through ayatecatic awl regnl&r collection, asoffxgg,
retrieval and dlsaa&instior, as the national -i
*s£
rs^icna;
levels.
Specific
These will he:
~
To improve the availability bas ixccoaibility
of InfcnsatlcE on primary health caw in ths;
fleabor Countries
for
the
promotion aad
strengthening of iiesltb cars;
-
To stimulate exchange of information on primary
health care smo-g the Menber Countries,
-
To identify, collect, process and diaesainata
interaction on prinary health cere geurnted
ir Member Countries;
-
To make inventories of priaery
inrortBation;
-
To bring cut publications (news bulletins,
etc.) for channeling info station on primary
health care.;
health
csre.
To establish linkages with other infottta'cion
networks such, as HSR~KBT.tZS and" £SCA£—TCP1K
(papulation Information); and
-
4.
To develop mechanises for supplying copies of
docu'aects to actual users on a regular basis
ae well as on dener.d.
STRUCTURE AH2 FUNCTIONS
The South-East Asia Regional ??.C Information Network Systcn
will consist of a network of national focal points for PNC
.-i"- : r.doraatioa &';.-rce Centres, which
ig House functions. The *o PIE.Cs Kill
.
■.
. tut:: of Heal th and F sail ly
■
c.-'cni, India, an5 at the ASEAN Training
k- e
>.■ •.
?; iru.■/ Huai".;. Care 'Development (ATC> ?HC),
£u;:;
rd
• • T'.'o two PfRCs
also function SB
v.:■ •» . £;,•>.•:;
■ -or their r- >p<-five countries. The
t 11 isos and inkage with the HELUS
l-.'-.rthe respective countries. Linkages
wirn other aetuorkfl such as F.SCAF-POPIN will also be
1
■.
.
NFPb ic< the Member Countries will establish
< th other network, points such as HELUS anc HSF.
fee.-' joints to form s national PHC information
This report will provide Information to the
? users. I./ormatfor: not readily available in the
viil be- obtained from the :’IHCe.
PlBCi’- will, ih addition to having contact wltr. the
'"."i'r . hove linkage with international organizations and
.
networks trithiu «r.i outside '.he r.ugiou ftn
ill : ■•.ing it.<< collection cf inforriation. In collsibot tlon
. ■ -eal points these resource centres will ■r........
-s- ct.--.
of holdings of Lltersturo. Period.'call the
' -i.
jl; .n-.-i.nate infortaation io national focal points
.md tn other users.
NETiKWK OPERATIONS ’
1?.' national PHC information network will be responsible for
ie identific.-,tlon and collection of relevant ir •ormation/
docnmaaVi tn rhe country aYyi will 'process,
-tore "nc
•iisssminate them to users.
The PIHCs wills
(1)
develop necessary procedures and guidelines
to help the national PHC information network
to collect documents and leforaation and
process then;
(2)
identify and
and documents
collect
relevant
information
6.
(a)
already processed and available, in the
Member countries particularly in other
network svate^s such as HE1.11S-HSR and
POPIN;
(b)
in the librnr Lte.'docusentation centr-s
attached or linked so n.?' . -pal foc-.x
points of the S3AE Pi’C . ife • ttion
Network System;
(c)
froii inst it-.Clone! source;
.he Neov.-r
Countries which ace not nart of any of
the health-related ietfc;—-S3
network;; ■■
(d)
free the national ind -.•••fiional i-.etwork.-;
of other '"S! Regions;
(3)
process the information and
nts th--;
collected to g« eral . . ; :■ :i n products
su. > as news b--jletiu= end d!Tv fortes on
primary health cer>?;
(4)
disseminate infenatf
information net rorl
thr
products: a-cd
(5)
provide informatic
and
l«
.
national ?HC
the 1 ifortoal ton
senta <
request.
METHODOLOGY
Info •tuition Sources
Info-nation on priucry health care is bring and will bo
gene ’ed from verdous sources. The PIXCe '..'.ill Identify
thet- sources in. each country with the help of the NFP in
the countries concerned. The PIRCs will also take into
account other national ano international aoutccs likely to
produce Inf creation on primary health care. The iudivi-luu.
organizations will fall into the following categories;
(1)
P.esearch and training institutions lr. health
related areas;
(2)
Management Institutes;
7
(3)
Goveriwtnt
relevaut co health
•’~Y<■',apswt - l-ott. -lit' in and out-’ide the
health sector;
(4)
Relevant dtpartj of Uufversifies;
(S'
Voli.i-.sc ir;
rca.'onsi.’ :<
and ■; -that re-tted activities;
(6)
Centres coordinating
programmes; and
(7)
Emin
primary
for
health
health
care
professionals la the area of health.
Document Types
The Information on prinary health care can be produced in
differ :>r kinds of doeumer.ee and tn different formats. Foe
PSRCs will mainly concentrate on rhe collection of the
fc.’.lowl-f types c-f. documents containing information relevant
to primary health care.
( l)
draining manuals;
(2)
Educational aids;
(3)
Journal articles;
(4)
Reports' on technical, research, admtnictralive and operational, aspects;
(5)
Fugitive literature; and
(6)
Other relevant material. •
Hech.-.niea for Collection of Information
Role of ?!?F In collection. Each NFP for primary health care
in Kar-ber Countries will actively collect information frc>:i
his/her countcy in collaboration and coordination with the
already established HELLIS~HSR information network.
The NFP/PHC will coordinate with the
PIR.Cs ’ inidentifying information sources in the country, providing
8
information or
pr.s -.
organized within ti-_: .-■■.•■■
important documents
i
successful experler.cr
r I e.i, in the Regie .
information and icr 2-. . .■
.
.. . •
.
.->•
,
•
... < i
Role of PxRCa in coilectir.u.
documents from the
C■
.
national organicatio.'.s and ;let
*-WO South-East ? si-’. R. ? ■.
... _■■■.:
following :.-ajor str■
.
.
L .
b.:lr;g
;.f
...
■ .
.?•■: «r
with
i
■-. ..
.s'. .-.-or. ccnev
:.j-j.:. ’ .t-iid? r
on .
.hr
<■
-•
. ■
the i "
;>:to
(1}
Scanning of lir.erai.ure
to identify t’w Infor
primary health care;
(2)
Regular contact . ...L
.-i.i :
for a continuous fl. >l o£ inf .'.rent
*
(3)
Monitoring
of
cu *•.••
•
interna. ;ona;
-.
> -.r:
relevant isjfocozf io. ;
.
•:■....ices
>, c.
ior idfu
i'ylng
<■-)
! on ‘
of
■
. .. - ..■ elated
■ ■ .
and outsf-ic ’-iiO/SEARj
(5}
Obtaining
documenta
diesemination; and
(6)
Preparing a nailing list cf pro'iucers wd
consumers of
the SEAR PKC
- tian
det'eork Syate.n, in collaboration Hltli .■ a,
-■ _
yithir
frs«a
?s
for.
Processing end Storing in PIRCs and the Ns:focal
Phi Network Libraxler./DccunentEt Ser. Centre;.
The processing and Bl aring cf docuaents and Lr.f.
t ton cn
primary health care invedves the
fol lowing important
*
activities
These sctv.'it'"s are to be done in the PTRCe and
the librariaB/docucen: atioa centres of the national i'HC
■information network:
Claaslfieitics. The rfoeuss^cts on primary health care will
be classified to briafi together related items and arreagtixg
than in e. helpful s&quaoca for retrieval. fhe oocnzents
relating to primary health cstm Kill be merged with other
docuaants available in the idbrai- las/docueentat. .on centres
of the PKC information network. io separate sequence be
isstatatoed. Khctcver clessiflcatic a scheme la folio-wed by
thsa iibrariea/dococMrttation centres in. the nets -*k
•..’ill be
used for the dwasenta on priasxy health care.
Cataloguing. ftocissente classified will be catalogued in
order to prepare catalogue cards for the main catalogue cf
the
host
llbrary/docuseotat.ion centre.
Uniformity
in
cataloguing practice is essential for cumulating primary
health ears infomation at the regional and global levels.
Ac.glo~A,?.erican
cataloguing
Rules-II
(AAC3.-I1)
provide
procedures adequately for the type of documents eu-umerl?ted
in Sect.oxi 6.2. These rules are followed in a majority ctf
the Member Countrioa as well ’as for HELUS network
libraries. Therefore, AaCR-II rules' will ba followed.
fndorlag.
Various thesaurus and subject headings arc
available for indexing the literature. The most' contn aly
used tools at international level are Medical Subject
headings (HeSH) and POP.Gf thesaurus. MeSB is already being
used in HELUS network not only for clinical subjects but
•llso iu areas such as Health Services Research Therefore,
HaSH will be used for documents on primary t.?alth tare.
Suitable terns will be used for documents on pr .-laty health
care. Suitable teens will also be used iron FOPI‘: tbese-irus,
if they are not found in MeSH.
Storing. The documents on PHC collected by the PIRC
nd
the libraries/documentation centres of the national ■ PHU,
information network will be stereo along with the documents
of the host institute. This would involve storing different
documenta in different'collections such as book collection;
report collection; reprint collection. However, .the access
to these documents will be through the card catalogue er a
printed index that may be brought out from tine to time.
Through indexing, it will be ensured that documents and
information on primary health - care are accessed -froa^ a
single source.
’ * ’ s
io
The ator&ge of inforaatic-n *1X1 iss swaosl initially
*
£»
case any of the PIRGs ox iihi^.^/dochArtucaiCicn 'ceatr«o of
the national PHC iufotaatlon -sotwerk use eooputJH
**
’’he
pritaary health cere inforsastioa will font part of s5s&
database.
f
Disamsinstion of Infora»riori
Tbw National PHC information network ...ill supply s»h&teves
docuBeate/inforoation ate available with
to ssasre on
*
request
Whatever io not available with thw-. will be
requested fro® PIRCs. The PlSCa will procaae the K»C
information and will dltseninate it - to all the national
focal points ana end-ueere in countries of the Regies. The
following channels of disoealnaticn 5rt.ll ba uaehs
Hewa bulletin. A quarterly news bullrtiti co primary health
care which will consist oft
(1)
Write-ups on inpertant 1
(2)
Listing of documenta,
(3)
Prograsna activities and field •arpeslcacen;
(4)
Significant success aac faliura atcti.es
about priaary health care activities;
(5)
lafortation on training progwnaes; and
(6)
Relevant research findings.
I ■-xastlon on demand. The PIRCa will provide infortantion
on detsand to any of the NFPs in the Header Countries. The
following types of information will be provided on denands
(1)
(2)
(3)
Bibliographical
Directory type
Statistical
The PIRCs will provide referral services tor information
not readily available with then.
11
Supply of copf.ee of documents, Copleo of docuneBts either
Hated in the newsletter or identified by the NFP aaA its
ucera will be supplied by the PIRCs. Th-jy will include copies
of journal arr.icleo,fugitive literature or technical reports.
7.
EVALUATION
It is necessary to envisage and plan la advance about the
toolu and Indicators for evaluating the progress of
activities and development of the clearing house- The task
cis- evaluation would be directly linked with the (1} overall
objectives of the proposed clearing house, and <ii) with tan
specified activities in a given tise-fraass and available
resources • The detailed nctivities listed J.n Section 5 would
facilitate the aonitoeing and evaluation of the clearing’
houaa. However, the following evaluation cjieck-liat or siaplf
*
indicator
arc suggested for the purpose of evaluation.
Evaluation check-list:
<1>
Fulfilment of the general objectives of cl
*
<ritg house:
-
Pilling up of gaps of FHC intoraatiou.
extent
to soae extent
;
-
Efforts yet to be started in that direction
-
Gaps filled for PHC Inforaatiou:
-
only in terse ot availability
-
in teroaa of avaLiability aa well .■»
-
availability and accessibility
adequate to aone extent
a largo
•aes.tbi.iity
(fully
'•
adequate
still cannot ba ascertained
(2)
Training/orientation:
-
Orlented/tralned the people (profeasionala) who were
to manage the clearing house.
1
- Orient-pd the lustitutionaJ. tepresetitabi.ve® os -.te
liaison Kr.n nanaging the .'•ufotsaticu in idwti? f.:-d
national focal point
(3)
Starting of Inventory
Type of inventories prepared:
(4)
Manpower invents;: ies
Health aervl'-ta organization and infract rue Lure
Progrsame inventoried
Researches
Appropriate technology
Training ac-pecta
Identification or producera/acurcee ox informations
-
List of iuatltutions/individual
addresses available
-
Institutions
contacted
and
briefed
about
objectives or requirements
-
Information starting cooing/flowing in the suggeated
formats'
professionals
Type of
the
information being
received
Institutlons/lndividual profess.!onais
- progrsxzee reporting
or
the
from
_
- research findings
- documents/ reports
(5)
....
Identification of consunerc for fHC inforfflatiou:
-
Yet to be started
-
Identified consumers:
_____
Regional mailing list(s) of consumers of infortrnicion
in collaboration with NFPs primary health cave
developed:
EatablLshssent
networks:
7 rt
Linkages
with
be Seva]oped_____
*
o£
other
lnforaar.lt
, .
fe.rt.’al'.j' developed
•
_
__
Fully ieveloped
(through taeetiags and vieita)
(through correspondence)
Status of exchange "of
cares
information on primary health
-
(Has) some exchange begun?
—
Exchange between the clearing-bousos
-
Between and aaiong focal points
.
Statue of the news bulletins
-
(Has) the work, started
—
(Is) the
*
EHC information available for bringing out
newsletter
_
- Regularly
- Intermittently
- (How many) news bulletins
have been issued
- Any other observation
__________________
_____
_________________________
Status of the feedback:
-
(Has there been any demand for PHC information from
any institution/individual professional?) \
- None so far
- Fox bibliography alone
- For document reprint
___
- For data on certain aspecta of PHC
- Any other viz > case studies
- Training health personnel
'____ __
________ ,
____________
sere/axe tfte asexH; c£ PHC inforuatiicst:
- Mecicel dsetoxs amS health personae!__________ _
— Setfe'grapt-exs
statisticians__________ ____ _____
— Extfi'ssfcis witlcrs
____
- Afatiiss raters _______ __________________________ _____
- Planners__ _______________ .________________________ __
— ethers _ ____________________________________________
So far as the setheJelogy ef evssisaticCT of pr-sgress of
clearirg fexjs^ er Its Activities are ctraceised, this east be
periaiic or st tha etsd of the project. Teels will he sicple
sasr-strsttwr&jt cherir-lists swi~oi!>Ssr¥»Kf<ia
Position: 3735 (2 views)