HEALTH FOR ALL BY THE YEAR 2000 AND HEALTH FOR ALL LEADERSHIP INFORMATION MATERIAL
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WHO/HLD/87.4
ORIGINAL: ENGLISH
HEALTH FOR ALL
LEADERSHIP
INFORMATION MATERIAL
WORLD HEALTH ORGANIZATION
HFA Leadership/IM.2
International Conference
on Primary Health Care
Alma-Ata 1978
The International Conference on Primary Health Care was held from 6-12 September
1978 in Alma-Ata, capital of the Kazakh Soviet Socialist Republic. The Conference was
attended by delegations from 134 governments and by representatives of 67 United
Nations Organizations, specialized agencies and non-governmental organizations in
official relations with WHO and UNICEF. The Conference was jointly organized and
sponsored by the World Health Organization and the United Nations Children’s Fund and
was preceded by a number of national, regional and inter-regional meetings on primary
health care, held throughout the world in 1977 and 1978.
Objectives of the Conference:
(i)
to promote the concept of primary health care in all countries;
(ii)
to exchange experience and information on the development of primary health care
within the framework of comprehensive national health systems and services;
(iii)
to evaluate the present health and health care situation throughout the world as it
relates to, and can be improved by, primary health care;
(iv)
to define the principles of primary health care as well as the operational means of
overcoming practical problems in the development of primary health care;
(v)
to define the role of governments, national, and international organizations in
technical cooperation and support for the development of primary health care; and
(yi) to formulate recommendations for the development of primary health care
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The Conference declared that the health status of hundreds of
millions of people in the world today was unacceptable; and it called
for a new approach to health and health care, to close the gap
between the “haves" and “have-nots”, achieve more equitable distri
bution of health resources, and attain a level of health for all the
citizens of the world that would permit them to lead a socially and
economically productive life.
The International Conference on Primary Health Care therefore
called for urgent and effective national and international action to
develop and implement primary health care throughout the world and
particularly in developing countries in a spirit of technical cooperation
and in keeping with a New International Economic Order. It urged
governments, WHO and UNICEF, and other international organiza
tions, as well as multilateral and bilateral agencies, non-governmen
tal organizations, funding agencies, all health workers and the whole
world community to support national and international commitment to
primary health care and to channel increased technical and financial
support to it, particularly in developing countries. The Conference
called on all the aforementioned to collaborate in introducing, devel
oping and maintaining primary health care in accordance with the
spirit and content of this Declaration.
The Declaration of Alma-Ata
The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth
day of September in the year Nineteen hundred and seventy-eight, expressing the need
for urgent action by all governments, all health and development workers, and the world
community to protect and promote the health of all the people of the world, hereby makes
the following Declaration:
I
The Conference strongly reaffirms that health, which is a state of complete physical,
mental and social wellbeing, and not merely the absence of disease or infirmity, is a
fundamental human right and that the attainment of the highest possible level of health
is a most important world-wide social goal whose realization requires the action of many
other social and economic sectors in addition to the health sector.
II
The existing gross inequality in the health status of the people particularly between
developed and developing countries as well as within countries is politically, socially and
economically unacceptable and is, therefore, of common concern to all countries.
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International Conference on Primary Health Care — Alma-Ata 1978
HI
Economic and social development, based on a New International Economic Order, is of
basic importance to the fullest attainment of health for all and to the reduction of the gap
between the health status of the developing and developed countries. The promotion and
protection of the health of the people is essential to sustained economic and social
development and contributes to a better quality of life and to world peace.
IV
The people have the right and duty to participate individually and collectively in the
planning and implementation of their health care.
V
Governments have a responsibility for the health of their people which can be fulfilled
only by the provision of adequate health and social measures. A main social target of
governments, international organizations and the whole world community in the coming
decades should be the attainment by all peoples of the world by the year 2000 of a level
of health that will permit them to lead a socially and economically productive life.
Primary health care is the key to attaining this target as part of development in the spirit
of social justice.
VI
Primary health care is essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community and country can afford to maintain at every stage of their development in the
spirit of self-reliance and self-determination. It forms an integral part both of the
country’s health system, of which it is the central function and main focus, and of the
overall social and economic development of the community. It is the first level of contact
of individuals, the family and community with the national health system bringing health
care as close as possible to where people live and work, and constitutes the first clement
of a continuing health care process.
VII
Primary Health Care...
1.
reflects and evolves from the economic conditions and socio-cultural and political
characteristics of the country and its communities and is based on the application of the
relevant results of social, biomedical and health services research and public health
experience;
2.
addresses the main health problems in the community, providing promotive, preven
tive, curative and rehabilitative services accordingly;
3.
includes at least: education concerning prevailing health problems and the methods of
preventing and controlling them; promotion of food supply and proper nutrition; an
adequate supply of safe water and basic sanitation; maternal and child health care,
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including family planning; immunization against the major infectious diseases;
prevention and control of locally endemic diseases; appropriate treatment of common
diseases and injuries; and provision of essential drugs;
4.
involves, in addition to the health sector, all related sectors and aspects of national and
community development, in particular agriculture, animal husbandry, food, industry,
education, housing, public works, communications and other sectors; and demands the
coordinated efforts of all those sectors;
5.
requires and promotes maximum community and individual self-reliance and partici
pation in the planning, organization, operation and control of primary health care,
making fullest use of local, national and other available resources; and to this end
develops through appropriate education the ability of communities to participate;
6.
should be sustained by integrated, functional and mutually supportive referral systems,
leading to the progressive improvement of comprehensive health care for all, and
giving priority to those most in need;
7.
relies, at local and referral levels, on health workers, including physicians, nurses,
midwives, auxiliaries and community workers as applicable, as well as traditional
practitioners as needed, suitably trained socially and technically to work as a health
team and to respond to the expressed health needs of the community.
VIII
All governments should formulate national policies, strategies and plans of action to
launch and sustain primary health care as part of a comprehensive national health system
and in coordination with other sectors. To this end, it will be necessary to exercise
political will, to mobilize the country’s resources and to use available external resources
rationally.
IX
All countries should cooperate in a spirit of partnership and service to ensure primary
health care for all people since the attainment of health by people in any one country
directly concerns and benefits every other country. In this context the joint WHO/
UNICEF report on primary health care constitutes a solid basis for the further develop
ment and operation of primary health care throughout the world.
X
An acceptable level of health for all the people of the world by the year 2000 can be
attained through a fuller and better use of the world’s resources, a considerable part of
which is now spent on armaments and military conflicts. A genuine policy of independ
ence, peace, ddtente and disarmament could and should release additional resources that
could well be devoted to peaceful aims and in particular to the acceleration of social and
economic development of which primary health care, as an essential part, should be
allotted its proper share.
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International Conference on Primary Health Care — Alma-Ata 1978
In 1979, the Thirty-second World Health Assembly endorsed the Report and Declaration
of the International Conference on Primary Health Care and launched the Global
Strategy for Health for All by the Year 2000. The Assembly also invited the Member
States of WHO to formulate their national policies, strategies and plans of action for
attaining this goal and to act collectively in formulating regional and global strategies.
Since 1979, Primary Health Care has been firmly implanted in the world political scene.
There is international agreement on the adoption of a worldwide primary health care
policy and strategy with the goal of making essential health care available to all people
of the world.
Leadership internationally and nationally is now required to sustain support to countries
in accelerating the process of primary health care, maintaining its momentum and
cooperating in overcoming obstacles.
References
1.
2.
3.
Alma-Ata 1978 Primary Health Care - WHO/UNICEF, “Health for All" Series, No. 1
Formulating strategies for health for all by the year 2000, WHO, Geneva, 1979. "Health for All" Series, No.2
Global Strategy for Health for All by the Year 2000, WHO, Geneva, 1981 “Health for All” series, No.3.
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Health for All and Leadership
Health for All by the Year 2000 — A Vision of the Future
The goal of Health for All by the Year 2000 is a vision founded on social equity; on the
urgent need to reduce the gross inequality in the health status of people in the world, in
developed and developing countries, and within countries. It is a vision based on the
principle that health and development are closely interlinked. It is a vision whose range
of view encompasses fundamental change — in the way health is perceived, promoted,
protected, and delivered.
And these changes, which represent a fundamental shift in values, include:
• change in how people, individually, take greater responsibility for the protection
and promotion of their health;
• change in the way people participate collectively in health, organizing them
selves into action groups and enhancing self-reliance;
• change in the perception and value systems of the health providers — in which
the health professionals have to be socially concerned, de-mystify health,
involve people, empower them so that they may assume greater responsibility
for their own health. They also have to broaden their understanding of health, no
longer confined mainly to medical care or traditionally-defined preventive
health care services.
• change in the organization and administration of the health system, going
beyond the physical design involving redefinition of objectives of the principal
institutions, reallocation of responsibilities and even of the power structure;
getting health closer to the people by decentralizing and delegating authority, by
revolutionizing the health care delivery system, emphasizing bottom-up plan
ning and forging linkages, and by bringing other health-related sectors into
closer alliance;
• finally, change in the attitudes and perception of policy makers in which health
has to be seen and pursued as an integral part of development emphasizing a
greater concern for social equity, bolstered by the courage to choose health care
systems which are affordable, which give preferential attention to the under
privileged and vulnerable, and which provide rational means for deploying
resources.
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Values
By “values” we mean the fundamental principles or ideas that people stand by or prize,
the reasons and beliefs which empower people and enable them to work continually
towards a particular goal. Values influence, in a profound way, people’s behaviour. They
make up the inspiration or belief system that is the driving force which gives people their
energy, enthusiasm and motivation from within. When values are shared, they enable
people to work together.
The perspective of Health For All assigns new values to health. “Health” is no longer just
the availability or the access to health services but rather a state of personal well-being
going beyond the absence of medical problems. It means promoting healthy life styles and
ameliorating the environment in which we live; preventing illness, accidents and
disability with all the means at our disposal; and providing care and cure to all using
relevant technology. “For all” means that health is to be brought within reach of everyone.
It emphasizes equity, social justice and cooperation.
Central to these new values is that health is a fundamental human right and a worldwide
social goal; it is an integral part of development; and, people have a right and the duty to
participate individually and collectively in the planning and implementation of their
health care and thus they must be encouraged and prepared to become self-reliant.
Leadership and “Health for All”
Leadership is essential to new values in society, particularly values that are concerned
with social progression. The goal of Health for All is concerned with such new values.
And strong leaders who are value driven are necessary, to help people and systems
undergo significant change. Not just good managers or executors, but strong leaders.
New sets of questions need to be raised concerning social responsibilities and also the
directions and quality of health care.
Those in leadership positions in health, in the health-related sectors and in the community
will need to play a crucial role in meeting the challenges ahead. Their leadership qualities
will be marked by a concern for social justice; compassion for the under-privileged;
dedication to the growth of self-reliance; commitment; ability to communicate; courage
to take risks and make bold decisions; and faith in people’s capabilities. These have
emerged as the crucial leadership qualities for Health for All.
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Health for All and Leadership
Leadership is vital for the wide articulation of change and the consistent initiation of the
processes and activities by which change can be brought about. Some of the assumptions
about the “leadership tasks" related to the changes needed for HFA are:
Leaders should be fully informed about Health for All, and the
strategies for its achievement and be able to communicate it to
others',
They should be able to identify central issues affecting implem
entation of their national strategies;
They should be able to specify their own personal role in
resolving those issues which fall within the scope of their
responsibilities;
They should be able to define strategic actionsto resolve these
issues;
They should be able to initiate the process of change required
and create networks of support for the implementation of
change;
They should be able to involve and mobilize others, enable
them by infusing a sense of purpose, commitment and a focus
of action;
They should be able to identify and support the development of
leadership.
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Snformation Package
for Health for All
Leadership Development
This folder contains short papers on the following subjects:
1.
Evolution of Primary Health Care
2.
International Conference on Primary Health Care, Alma Ata 1978
3.
Meaning of Health for All
4.
Prerequisites for “Good Health”
5.
Partners in Health
6.
Organization of Health Systems Based on Primary Health Care
7.
Community Participation
8.
Resources for Health
9.
The Managerial Process
10.
Measuring Progress Towards the Goal of Health for All by the
Year 2000
11.
Collaboration with Non-Governmental O anizations in imple
menting the Global Strategy for Health foi All
12.
The Role of Universities in the Strategies for Health for All
The papers contain, in a non-technical language, brief information about Health for All
and Primary Health Care, with emphasis on the process and main issues concerned. Each
of the papers also contains a suggested list for further reading. The papers are intended
for anyone interested in Health for All but they have been specifically aimed at persons
participating in workshops, colloquia or seminars on Leadership in health. Their purpose
is to clarify the basic ideas and concepts contained in the Health for All policy and strategy
so that they may be applied as suitable to specific needs and situations.
The contents of this package will be updated periodically and completed with new
additions relevant to the evolving circumstances in health. Comments and suggestions
both on content and presentations, as well as on other health issues for which similar
papers would be useful are most welcome and should be sent to:
Dr. S. Khanna
Director, Health for All Strategy Coordination
World Health Organization
1211 Geneva 27
Switzerland
HFA Leadership/IM.1
Evolution of
Primary Health Care
Primary health care has become a widely disseminated concept, but many people are still
unclear as to its current meaning. When the term “primary health care” is used to refer
to a wide variety of situations, many substantially different from the context of the agreed
definition, confusion can result both within countries and internationally. Lack of
understanding of the concept has even led to resistance in some circles.
How did the Primary Health care concept evolve?
The primary health care concept emerged from a series of ideas which evolved gradually
with the re-examination of existing approaches to health care and the assimilation of new
experiences.
As early as 1951, when the efforts of many developing countries were centred on
specialized mass campaigns forthe eradication of diseases, the Director-General of WHO
observed that these efforts would have only temporary results unless they were followed
by the establishment of permanent health services in rural areas to deal with the day-today work in the control and prevention of disease and the promotion of health.1 True,
there were some successes, like the reduction of yaws, the control of malaria in some areas
and, later, the eradication of smallpox; but many debilitating and killing diseases like
tuberculosis, gastro-enteritis, measles, etc., continued to prevail.
Disenchantment with traditional approaches
The enthusiastic application of new knowledge and technology did not always achieve
the results expected, and this became evident as more vertical programmes were
implemented - less successfully. And people became disillusioned with the part that
medical care and services played in improving their health.
Health and Development interlinked
Parallelly, during the 1960’s and early 1970’s there was increased understanding that the
causes of poor health were not primarily the common diseases but rather low health status
which is a product of the prevailing socio-economic conditions; political structures and
philosophies; nutrition and the environment. Thus, the links between health and
development became clearer and led to further questioning of the purpose, relevance and
social significance of health care within the broader context of social and economic
development.
1 WHO Offical Records, No. 38, 1952, page 2.
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It was then realized that the world’s priority health problems required a fresh look and new
approaches for their solution. Clearly this did not imply just injecting more technical
knowledge.
Need for a new Approach
Rather it meant that fundamental changes were needed in the way health was perceived,
promoted, protected and provided. And that such changes also had to take into account
peoples’ perceptions, values and altitudes towards health besides being able to adapt to
their evolving circumstances. What this required was sustained motivation and commit
ment on the part of those who had the political and economic power to introduce such
change.
Emerging Experience
The emerging experiences of a number of developing countries which had initiated new
approaches to meeting the health needs of their people further confirmed this conviction.
In countries which achieved considerable success in their nationwide endeavours, a
strong political will was evident; health had been given a high priority in the
government’s general development programme, and a fundamental decision had been
taken to bring about substantial changes instead of looking for solutions within the
existing system.
Enterprise and leadership characterized the successful experiences in limited areas of
some countries; and in all cases, the leading role of a dedicated person could be clearly
discerned. In most cases, changes led to major shifts of emphasis in the health services:
from a curative to a curative-preventive approach,from urban to rural populations, from
the privileged to the underprivileged, and from vertical mass campaigns to a system of
integrated health services forming a component ofoverall social and economic develop
ment.
The Basic Health Services Approach
On the basis of this evidence, during the early 1970’s \he Basic Health Services Approach
was conceptualized. Itfocused on increasing access and availability of health services
to the rural populations ofdeveloping countries. Case studies of national health systems
in a few countries namely: Bangladesh, China, Cuba, Tanzania, Venezuela, Yuogoslavia,
India, Niger and Nigeria helped to formulate a series of approaches that could be
implemented to meet the basic health needs of people of the developing countries.
Two relevant international publications
*
were released in 1975 by the WHO, as attempts
to publicize information about such policies and the countries in which they were being
put into effect.
• 1 Djukanovic and Mach ,1975, Alternative Approaches to meeting basic health needs in developing countries
- A joint WHO/UNICEF study - WHO 1975.
2. Newell, Health by the People. WHO 1975
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Evolution of Primary Health Care
The Primary Health Care Philosophy
The concept of Basic Health Services paved the way for Primary Health Care which, at
first, was essentially an expansion of the ideas contained therein, i.e., accessibility,
availability, acceptability, affordability and appropriateness of health services. This
earlier narrow concept ofPHC was later broadened to encompass a philosophy which
went much further than the simple provision offirst contact health services.
The Conference on Primary Health Care in Alma Ata in 1978 gave the PHC Philosophy
a Political dimension with five underlying principles:
• Equitable distribution
• Community involvement
• Focus on prevention
• Appropriate technology
• Multisectoral approach
This political philosophy has dominated discussions about PHC since the late 1970’s, and
it is distinguished from the original narrow definition ofPHC by being referred to as the
Primary Health Care Approach
The Primary Health Care Approach
The meaning of the five basic principles which provide the framework of the primary
health care approach can be summarized as:
Equitable distribution
Health services must be more equally accessible, not neglecting rural and isolated
population or peri-urban dwellers.
Community involvement
Active participation by the community in their own health decisions is essential.
Focus on Prevention
Preventive and promotive services rather than curative services should be the central
focus of health care.
Appropriate Technology
The methods and materials used in the health system should be socially acceptable and
relevant.
Multisectoral Approach
Health must be seen as only part of total care; nutrition, education, water supplies and
shelter are also essential minimum requirements to well-being.
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A new course of Action for Health
The Primary Health Care (PHC) approach thus constitutes a. qualitative break with the
past, a new course of action for health. Far from being just the addition of yet another layer
to the health service - at the bottom, in the communities, using community resources PHC implies a reordering of priorities that should permeate all levels and sectors
concerned with the promotion of health. Such a reordering has, above all, three main
implications.
Implications of the Primary Health Care Approach
First, in terms of understanding health problems, the PHC approach stresses that health
promotion involves a set of issues much wider than those which health services have
conventionally tried to tackle. Therefore the PHC approach is qualitatively different. It
involves political action and the efforts of many sectors other than health.
Second, the PHC approach emphasizes the use of certain policies to translate that
understanding into practice. These policies include other relevant socio-economic issues
which develop a framework for intersectoral action; they emphasize the need for an
integrated approach to health care within the health service itself; they encourage a
progressive shift from centralized planning and decision-making to decentralization and
active involvement of people in health matters.
Thirdly, the PHC approach calls for shifts in the allocation of resources to give greater
emphasis to the preventive and promotive health activities and to the underserved and
disadvantaged population groups.
It should be clearly understood that it is the primary health
care approach which is being promoted internationally as
the key to attaining the goal of health for all by the year
2000. The approach advocates that health care be
brought as close as possible to where people live and
work. It stresses that primary health care be an integral
part both of the country’s health system, of which it is the
central function and main focus, and of the overall social
and economic development of the community. It there
fore requires a strong political will and support at both
national and community levels reinforced by a firm na
tional strategy.
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Evolution of Primary Health Care
Therefore, the following questions posed by the Director-General of W.H.O., Dr Halfdan
Mahler at the opening ceremony of the International Conference on Primary Health Care
held in Alma-Ata in September 1978 are still valid for the health leadership today.
1.
Are you ready to address yourselves seriously to the existing gap between the
health “haves” and the health “have-nots” and to adopt concrete measures to
reduce it?
2.
Are you ready to ensure the proper planning and implementation of primary
health care in coordinated efforts with other relevant sectors, in order to promote
health as an indispensable contribution to the improvement of the quality of life
of every individual, family and community as part of overall socioeconomic
development?
3.
Are you ready to make preferential allocations of health resources to the social
periphery as an absolute priority?
4.
Are you ready to mobilize and enlighten individuals, families and communities
in order to ensure their full identification with primary health care, their
participation in its planning and management and their contribution to its
application?
5.
Are you ready to introduce the reforms required to ensure the availability of
relevant manpower and technology, sufficient to cover the whole country with ■
primary health care within the next two decades at a cost you can afford?
6.
Are you ready to introduce, if necessary, radical changes in the existing health
delivery system so that it properly supports primary health care as the overriding
health priority?
7.
Are you ready to fight the political and technical battles required to overcome any
social and economic obstacles and professional resistance to the universal
introduction of primary health care?
8.
Are you ready to make unequivocal political commitments to adopt primary
health care and to mobilize international solidarity to attain the objective of
health for all by the year 2000?
Note
The following references may be consulted on the above subject.
Alternative Approaches to meeting basic health needs in developing countries.
A joint UNICEF/WHO Study, WHO 1975
2. Alma-Ata 1978. Primary Health Care, UNICEF/WHO, 1978
3. National Decision-making for Primary Health Care, A Study by the UNICEF/WHO Joint
Committee on Health Policy, WHO 1981
1.
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Meaning ©if Healilh for Ail
The road to Health for Ail
International discussion in the 1950s emphasized the social aspects of health and disease.
In many countries programmes of social and community medicine were developed to
incorporate a series of public health and social hygiene measures. But the links with social
and health policy were not very strong. It was more a question of an expanded view of
public health.
Dissatisfaction with health care systems
In 1972-73 a WHO study on the development of health services concluded that there was
widespread dissatisfaction among people with their health care systems, which were
failing dismally to cope with primary health problems in countries at all stages of
development.
Developed countries
In some developed countries health care systems had become and are still today
extremely complex enterprises being run on a gigantic scale and at a staggering cost. But
despite their expensive and impressive infrastructure and highly specialized technolo
gies, the emerging health problems of people were not being solved. The principal reason
for litis discrepancy is that these new health problems require a completely new approach
to health which emphasizes individual self-reliance and commitment to good health.
Developing countries
At the same time, most developing countries which were also often newly independent,
still faced major problems with the control of infectious diseases, the provision of safe
water and basic sanitation services, the provision of care during pregnancy and delivery
and the elevation of the standard of living to a minimum acceptable level.
In the rural areas and the rapidly expanding urban areas millions of people still remained
without access to essential health care and lifesaving measures.
The above mentioned WHO study led to a continuing discussion of how health care
systems should evolve and how WHO could best support couniries struggling to improve
lheir systems.
International concern
The overriding concern of the international community and the WHO governing bodies
was that the world wasfaced with a magnitude ofsevere butpreventable health problems,
and at the same time with an inadequate and intolerably inequitable distribution of
resources for health. Moreover, the majority of the world’s people did not benefit from
the health and medical solutions that existed.
HFA Leadership
Expressing the ideas that were dominating the international discus
sion during the 1960s and the early 1970s the World Health Assembly
decided in a groundbreaking resolution in 1977 that “the main social
targets of governments and WHO in the coming decades should be the
attainment of all citizens of the world by the year 2000 of a level of
health that will permit them to lead a socially and economically
productive life.” With the adoption of this resolution the Health-forAll movement was born, and a slogan was created.
Internationa! Health Policy
The central issue of this international health policy was the provision of health/or all,
emphasizing solidarity in the use of resources for health; equity in the development of
possibilities for health and human justice in all parts of the world. Equity and solidarity
do not concern only medical care but also health promotion, and disease prevention. This
requires a forward-looking strategy, a prospective approach to balance the customary
retroactive tradition in medicine.
The perspective of the Year 2000 was introduced to provide orientation for achieving the
goal and to underline the urgency for future oriented action. The turn of a century has
always appealed to people’s imagination, because it stands out as a landmark in the
counting of time. And a deadline was needed as a target date for the evaluation of
progress. In 1977, when the movement was bom, the year 2000 was still far enough ahead
to give time for action, and close enough to start immediately and work diligently.
The Meaning of Health for All
To some people Health for All is yet another slogan. Of course, Health for All is a slogan,
but not an empty one. It is a short, striking and imaginative set of words which, given the
right context, serves as a rallying point for concerted social action within and between
countries, a public relations watchword that fires people’s imagination, a quick reference
to a complicated set of activities and a list of specific health targets. It is an expression
of the cry for social justice from all those who suffer inequity in health. It is intended to
draw attention to the importance of health, to a serious search for new ways of solving the
problems of health, and to help mobilize all available resources for health.
Health for All does not mean that as of the year 2000 we shall all be free of disease and
disability and eventually die in a “state of health” at the end of our biological life span.
“Health for all” means that health is to be brought within reach of everyone in a given
country including the remotest parts of the country, and the poorest members of society.
And by “health” is meant not just the availability of health services but a personal well
being and a state of health that enables a person to lead a socially and economically
productive life. “Health for all” implies the removal of the obstacles to health - that is to
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Meaning of Health for AU
say, the elimination of malnutrition, ignorance, contaminated drinking water, and
unhygenic housing - quite as much as it means finding solutions to problems such as a lack
of doctors, hospital beds, drugs and vaccines.
The Strategy for Health for All
The achievement ofthe health-for-all goal callsfor dramatic changes, a social revolution
in health development. It aims at changing the mentality of people, influencing the
structure of health systems, and reorienting the way in which health professionals are
working. To bring about these changes, the HFA movement had to be activated, and the
slogan had to be given practical content through the development of a strategy.
The Alma-Ata Conference in 1978 set down the principles of Primary Heath Care.
Through consultations within countries, regions and at the global level, a Global Strategy
for Health for All by tine Year 2000 was developed. That strategy defines the broad lines
of action to be undertaken at policy and operational levels, nationally and internationally,
both in the health sector and in other social and economic sectors. For the first time, a
global strategy had been formulated not at a top level international conference but
painstakingly built from country level upwards. Once the general principles for action
were agreed, the work of developing indicators for monitoring and evaluation was set in
motion; and countries started detailing their plans of action and their lists of activities.
The global strategy is necessarily rather general as it has to be based on the lowest
common denominator; the specific targets set and activities suggested in the strategy have
to be such that they can be reached by all Member States within a reasonable period of
time. It is based on the following fundamental principles.
Fundamental Principles
• Health is a fundamental human right and a worldwide social goal.
• The existing gross inequality in the health status is of common concern to all
countries and must be drastically reduced.
• People have the right and the duty to participate individually and collectively in
the planning and implementation of their health care.
• Governments have a responsibility for the health of their people.
• Countries must become self-reliant in health matters.
• Health is an integral part of overall development. Energy generated by improved
health should be channelled into sustaining development.
• Better use must be made of the world’s resources to promote health and
development, and thus help to promote world peace.
In fulfillment of the above principles concerted efforts have had to be made to develop
health systems based on primary health care.
3
HFA Leadership
These ideas provided some guidance for the development of national health care systems.
However, since health needs vary considerably between the six regions of WHO, each
region has developed its own specific strategies.
Is Health for All progressing?
Most Member States of WHO have formulated national HFA strategies and are now at
varying stages of implementation. The first evaluation report was presented to the World
Health Assembly in May 1986. This report shows that the new concepts of health and the
new approaches to reach them have gained worldwide acceptance and that a high level
of political commitment has been achieved. The progress reports from countries show
not only great successes, but also many problems to be solved and obstacles to be
overcome. Twenty years ago it would have been inconceivable for nations to admit that
there were such problems and obstacles. That these problems are now publicly presented
and seriously discussed shows that Health for All has taken roots and is starting to have
its effects.
Paradoxically, until now the developed countries are among those who have most
benefitted from the health for all concept because of their capacity to use the information
and the ideas generated through WHO. But a start has been made in most developing
countries, and Health for All has proved to be a slogan that has helped set free the social
energies needed for health development.
National, regional and local actions
In many countries national, regional and local meetings involving all ministries con
cerned as well as health professions and representatives of the people have discussed
health for all. Specific national policies for health for all have been developed. In Europe,
a set of regional targets has been agreed upon, and the target document translated into
several languages. Top international health journals are seriously debating health for all.
National health information systems are being revamped to suit the new types of targets.
Where do we go from here?
It is recognized that Health for All has successfully taken off. Commitment and strong
leadership are now necessary to sustain the progress made so far and to further accelerate
the process of implementation of national strategies so that by the year 2000 countries can
provide Primary Health Care to all their people. Only then will the principles of equity
and social justice be reflected as the true meaning of Health For All.
References
1.
2.
Mahler, Halfdan. The meaning of "health for all by the year 2000".
World Health Forum 2(1): 5-22 (1981)
Formulating Strategies for Health for All by the Year 2000, WHO, Geneva, 1979.
“Health for All" Series, No. 2
3.
Global Strategy for Health for All by the Year 2000, WHO, Geneva 1981,
"Health for All" Series, No. 3
4
HFA Lsadership/IM.4
Prerequisites for “Goad Health”
Universal Consensus
The achievement of Health for All by the year 2000 involves setting into motion a process
for which a number of prerequisites are essential. At the outset it has been necessary to
create a broad consensus among people of all nations that it is an objective that should,
can and will be attained by the year 2000. Much will have to be done to improve the
delivery of health care, for example, in maternal and child care including family planning,
immunization, prevention and control of locally endemic diseases, appropriate treatment
of common diseases and provision of essential drugs. However, such improvements will
not be enough unless certain fundamental conditions are met.
Peace and Social Justice
Without peace and social justice, and without providing each and all with a useful role
in society and an adequate income, there cannot be health for all for the people, no real
growth and no social development. The main responsibility for attaining those objectives
lies outside the health sector. This responsibility must be fully recognized at all levels of
policy-making in countries so that priorities in overall national development take into
account the need to strengthen those aspects of life that are prerequisite for health. Given
the magnitude of the task of attaining health for all, strong political will and the
mobilization ofpublic support arefundamental prerequisitesfor launching the necessary
action.
Freedom from Fear of War
War is the most serious of all threats to health. The devastation that a war entails in terms
of people killed, wounded and permanently disabled is difficult to imagine. But peace
is not just the absence of war. It is also a positive sense of wellbeing and security for
people of all countries, implying the opportunity to freely determine their own destiny and
fully exploit their human potential.
It assumes the possibility of all nations actively participating on a basis of equality and
in a true spirit of solidarity and reciprocity in the development of a more satisfying world
for all people.
It is not only war itself that presents health problems, but also the fear of war. The
increasing international tension in recent years has raised this level of apprehension to a
point that severely hampers the opportunities for all people of the world to work together
in harmony for a better future. Therefore, the international community should make
every effort to end wars and to remove the threat of war.
HFA Leadership
There are some things that the health sector can do that fit its basic role and that can help
to reduce international tension. Each national health sector should take responsibilityfor
creating a better understanding ofwhat wars really mean for health, and thus strengthen
the motivation for peace. By analysing objectively the extent of human destruction,
suffering and disability that a war would entail in their country, by giving a realistic
analysis of how little its health services would be able to do to treat the civilian and
military casualties, and by making these facts known and understood by politicians and
the general public, the health sector could help to encourage a more active search for ways
of preventing war.
Equal Opportunity for All
In the commitment of the Member States to Health for All lies a fundamental principle
of social policy: all human beings have an equal right to health. That right will be ensured
by providing all the people of the world with an equal opportunity to develop health to
the fullest and to maintain it. This principle has two aspects: equity among nations and
equity among the people within each country.
The wide disparities in health status between the developed countries and the large
majority of developing countries as reflected in their profiles of ill-health, mortality,
sickness and age and social groups most at risk show the links of affluence and poverty
to health. In developing countries, the predominant risks arc closely associated with
condi tions of poverty: insufficient food and nutrition, poor social and physical infrastruc
ture for satisfying basic minimum needs and lack of knowledge to cope with problems
of ill-health. In such a situation, problems of survival acquire the greatest urgency, since
the very young are most exposed to health risks.
While inequality exists at the global level, the health disparities arc even more serious
within countries, particularly in the developing countries, the most visible gap being
between urban and rural populations. This reflects how health related resources are
distributed within the countries, including access to health services, education and
income-earning opportunities.
Usually the people in urban areas are better off than in remote rural areas. They are often
better served with basic services including health. However^the people who have to live
in slums and shanty towns, with their disorderly expansion, are deprived of a healthy
environment. Those living in peri-urban slums tend to have the poor health profile of
deprived rural areas.
The health status of women and the disparities in health between genders is often a critical
indication of health equity in a society. In a number of developing countries, problems
of health are exceptionally severe for women.
The facts and experiences presented above call for explicit policies and strategies to
reduce inequities in health. There is no simple way to tackle the cumulative health
hazards and thus reduce morbidity and mortality.
2
Prerequisites for "Good Health”
The health sector can contribute by identifying the disparities in health, together with the
vu nerable groups that are involved, and by placing these in their different socio
economic contexts.
One driving force in this work is active community participation, as well as a greater
awareness in society of existing health hazards and ways of reducing them by individual
and community actions.
Secure Work and a Useful Role in Society
Secure work and a useful role in society have always been fundamental human needs.
Unemployment and underemployment take a human and social toll on individuals, their
families and communities that is also damaging to health. Also, to these problems there
are no easy answers, particularly as the economic prospects are uncertain. And the
countries which need most to reduce unemployment and underemployment and to
improve the health of the people have the least amount of resources allocated for these
tasks. Employment policies, including responses to the economic recession by training
of young people, should provide people with an opportunity for choosing satisfying social
and economic activities while maintaining living standards and fulfilling social and
family roles.
Research efforts should be devoted to finding new ways of redistributing work and work
opportunities as economic and industrial patterns change. The political challenge is to
find acceptable means ofpromoting this development. The health sector has to pursue
the optimal strategies in which available resources produce the most equitable health
outcome. The constraints themselves provide the opportunity for reinforcing two major
reorientations in health policy which were emphasized in the Alma-Ata Declaration.
First, this means a further strengthening of preventive health and the primary health care
approach. Second, health strategics would have to pay greater attention to intersectoral
linkages. In addition, adjustment resources should be mobilized where and when
appropriate in close collaboration with aid donors and international agencies.
Political Will and Public Support
Given the magnitude of these tasks, strong political will and the mobilization of public
support is essential for launching the necessary Health for All action. The ministries of
health orother authorities responsible forpromoting and sustaining health policies should
take a strong line in ensuring the clear commitment of the country as a whole to the
objective of health for all. This is in conformity with Resolution 34/58 of the United
Nations General Assembly, Resolution WHA30.43, calling on countries to develop their
national strategies for health for all and take the necessary steps to ensure their
implementation. The process of mobilizing support should preferably be set in motion
by political decisions taken at the highest level and confirmed in all sectors throughout
the country. This should be in all sectors with an impact on health, acknowledging that
safeguarding the people’s health is an overriding concern in their own particular field
as well.
3
HFA Leadership
The European Example
A Common Regional Health Policy
The countries of the European Region of WHO agreed on a common health policy in
1980. The strategy called for a fundamental change in countries’health development and
outlined four main areas of concern: lifestyles and health; risk factors affecting health and
the environment; reorientation of the health care system itself; and, finally, the political,
management, technological, manpower, research and other support necessary to bring
about the desired changes in those areas. Calling for a basic change in countries’ health
policies, the strategy urged that much higher priority be given to health promotion and
disease prevention; that not merely the health services but all sectors with an impact on
health should take positive steps to maintain and improve it; that much more stress should
be laid on the role that individuals, families and communities can play in health
development; and that primary health care should be the major approach used to bring
about these changes. The strategy also called for the formulation of specific regional
targets to support its implementation.
Targets and Indicators
These events represented a landmark in health development among the European
peoples. Never before had the countries of the Region agreed to adopt a single health
policy as a common basis for subsequent development, both in individual Member States
and in the Region as a whole. The 33 countries of the Region went even further, urging
Member States to review their health developments and bring their health policies and
programming in line with the health for all strategy.
Targets for the region were developed through the active participation of national health
and social institutions, in consultation with their health authorities. In spite of the great
differences in socio-economic development, in health status and in political orientation,
a common set of 39 targets was agreed upon and adopted in 1984. While not legally
binding on individual countries, they are intended to help them at their own national
targets, reflecting their specific needs, priorities and values.
Specific indicators were then developed for each of the targets, and texts with problem
statements and suggested solutions were prepared. This was published as a regional
publication (1), which has been translated into several national languages and has resulted
in widespread debate on national health development in European countries, and already
in the adoption of national health for all strategies and plans in some.
Reference
1. Targets for health for all, WHO Regional Office for Europe, Copenhagen, 1985
4
HFA Leadership/IM.5
Partners in Health
Equity is the unifying theme of a policy for Intersectoral action for
health. The main policy priorities, whether they are related to the
quality of life, problems of survival in developing countries, or disease
patterns in urban industrialized societies, concern the disparities
between and within countries. They also reflect on how reduction of
these disparities can improve the health of vulnerable groups.
The equity-oriented approach in the health sector has been firmly
based in primary health care both in terms of objectives of coverage
and priorities in health care. The implications of this equity-oriented
approach for national development strategy and sectoral policies
stresses that equity in health cannot be achieved by the health sector
in isolation. Linkages are needed with other sectors that control and
influence factors that determine health; such as agriculture, food and
nutrition, education and information, environment and physical infra
structure. The health sector must cooperate in the management of
these factors for the promotion of health.
Many of these relationships have already been recognized and, in a
few instances, used successfully in pursuitof health-promoting goals
in widely varying political systems. However, there is a need for more
initiative by the health sector in enhancing intersectoral collaboration,
and for greater response by the other relevant sectors.
Health and Development
Improvements in the health status of a population cannot be achieved simply by
expanding and developing the health services. More than ever before policy-makers and
planners are recognizing that a country’s health forms part of an integrated process of
development. The linkage between health and development has been amply demon
strated by both the experience ofdeveloped countries and the improvement in the quality
of life in several low income countries. In developed countries, the communicable
diseases, which were the principal causes of mortality, were controlled before major
discoveries for their cure and treatment were made. The health gains were mainly due
to better living conditions, which reflected improvements in nutritional status, sanitation
HFA Leadership
and health behaviour. In low income countries, health development is increasingly
becoming part of a strategy aiming at satisfying the basic needs of the population by
giving the poor access to resources and economic opportunities, raising educational
levels, ensuring availability and distribution of food, improving the status of women, and
providing the basic infrastructure of transportation and other public amenities.
Partners in Health
There is awareness in the world today that the health sector cannot do it alone. Partners
in health are needed. Many other ministries, services, institutions, government and non
government organizations, and all levels of administration down to the community and
the family must become involved in health. So the drive towards the goal of Health for
All by the year 2000 can only be inspired and fuelled by concerted interaction of all
relevant partners namely: agriculture, food and nutrition, education, culture, informa
tion and life patterns, water and sanitation, habitat and industry.
Agriculture, Food and Nutrition, and Health
Agricultural policies, products and processes are major determinants of people’s health
in both developed and developing countries. More than two thirds of the people in
developing countries derive their livelihood from agriculture. Most of their working time
is spent in agriculture, and most of their income on food.
The processes of agricultural development affect health in diverse ways. By increasing
food output these processes improve the nutritional status of both farmers and consumers
in rural and urban areas. On the other hand, raising output may create new health hazards,
or exacerbate existing ones. Yet agricultural policies can improve health, by taking into
account health implications of the agricultural methods and by providing food supplies
which can ensure a balanced diet for the population.
Generally, agricultural planners collaborate readily in the elimination of known, existing,
and clearly visible health risks. However, there are health risks which are not readily
detectable, and require specialized analysis. In the absence of this, agricultural technolo
gies may be selected (e.g. in the area of pesticide use, irrigation systems, farm storage,
and the use of labour—especially work overload of women), which can produce serious
health hazards and contribute to the deterioration of the health and nutritional status in the
region. It is within the framework of these interrelationships that the health and
agricultural sectors need to work together.
Education, Culture, Information and Life Patterns
In view ofthe decisive role that the education sector has to play in the promotion ofhealth
and the urgent need to improve the health of vulnerable groups, much greater attention
should be focused on the expansion of educational programmes aimed at these groups,
the strengthening of their quality and the inclusion of education relating to health.
2
Partners in Health
Formal and Non-formal Education
Formal education provides an excellent platform for creating and nurturing those
activities which lead to human development. Providing teachers and students with
opportunities to learn about health and health-related matters can contribute to the
achievement of better health for the whole nation. Non-formal educational programmes
such as functional literacy, adult education and parents’ education have had particular
success in improving quality of life.
Nevertheless, more efforts need to be given to targeting such programmes towards health
issues of direct relevance to the individual, the family and the community.
Female Education
The vital role of female education in accelerating the decline in mortality means that
communities with high adult female illiteracy are most vulnerable and at greatest health
risk. The prevailing situation requires that a much greater effort be made to impart
functional literacy and non-formal education. Such programmes should address concrete
life situations of illiterate women, the efficiency of their household and resource
management in conditions of scarcity, their work, whether on farms or elsewhere, and
their skills for family care.
University Education
The health link in university education has different dimensions. Institutions of higher
learning provide a country with professionals, some of whom will be destined to become
health leaders and promote scientific knowledge on health. Training of professionals
who will work in sectors whose activities will directly influence health should include an
adequate level of awareness of, and competence in, health matters.
Cultural Factors
Health programmes also need to take in account cultural factors, which include deeplyheld notions about basic health matters such as food, pregnancy, childbirth, diseases and
hygiene. In both developed and developing countries, people, especially the youth, are
increasingly exposed to problems of addictions, which comprise drugs, alcohol and
smoking. Preventive strategies need to involve education, information and value
formation.
The Role of the Media
The media can create public awareness about health issues and foster community
involvement by reflecting public opinion, encouraging dialogue and facilitating feedback
from the community. Media can influence policy-makers about health development, and
publicize relevant information for wider use.
In many instances, media help set social norms and lifestyles which are relevant to health.
It is vitally important, therefore, that the media and the health sectors are forging a
partnership.
3
HFA Leadership
Environment, Water and Sanitation
Ministries or agencies concerned with housing, public works, urban and regional
planning and environmental protection all have important roles to play in helping to
improve people’s health status — especially the health status of the poorer and
disadvantaged groups. In all actions to improve shelter, health and environment, the
special needs of women in their triple role as income earners, household managers and
child rearers must be recognized.
Habitat and industry
The lack of infrastructure and services as well as poor quality of housing in the majority
of settlements in rural areas, small urban centres and on the fringes of laige fast growing
cities relate to a high prevalence of diseases. The effects on health of the lack of basic
services and poor quality housing must be identified and acted on by health, housing and
public works agencies. Virtually all endeavours to increase production imply changes in
the environment. The qualitative deterioration and quantitative depletion of resources,
including the capacity of the environment to absorb wastes, and their negative health
impacts, tend to be disregarded. There is a need, therefore, for dialogue between all
parties involved, so that appropriate modifications arc made in time and negative health
impacts avoided. In most nations, intersectoral action has already contributed to the
protection of the health of workers through occupational health programmes in which the
state, employers and trade unions each play a role. However, there is abundant evidence
to show that many people, including women and children, work without that protection
in an environment that can seriously be detrimental to their health.
Legislation and regulation with respect to housing, air, water and food quality, infra
structure provision, workplace and health protection, should be reviewed and improved,
where and when necessary, with the aim to reduce the most serious threats to people’s
health status, especially to disadvantaged groups.
Involving the Community
Community participation has been identified as an important means of overcoming
sectoral barriers. It is the community and its involvement that best motivate collaboration
between sectors; through the community, health goals can be linked to and reinforce
other goals of wellbeing. This has been repeatedly demonstrated in community level
projects that have incorporated health in multisectoral programmes, whether in the field
of nutrition, water supply and sanitation, or education. Community participation is the
means by which additional resources available within the community are mobilized for
health. It may not be easy to motivate the community to participate or to sustain such
participation. Support is needed from community level workers and all sectors to
promote and develop self reliant community level organizations that can form the base
of an institutional framework. Another dimension of community involvement is the
participation of non-governmental organizations active in health or health-related issues.
4
Partners In Health
Collaboration with Non-Governmental Organizations
People in all walks of life, including individuals, families, communities, non-governmen
tal organizations, and other associations of people concerned, should become involved
in action for Health for All. Partnership is the most important element in the Global
Strategy. Non-govemmental organizations (NGOs) as representatives of groups of
people have a long tradition of providing health care. Where the principle ofpartnership
has been accepted, governments have recognized that NGOs are indispensable allies
because they supplement government resources with publicly raised money and volun
teer staff.
Non-governmental organizations are close to the people, responsive to their needs, and
able to act quickly. They can operate cost-effectively, because they use their limitedfunds
moreforfield work and lessfor overheads. Non-govemmental organizations usually are
innovative and flexible, not inhibited by rigid programming.
NGO’s and Governments
While worldwide voluntary action for health is considerable in volume and magnitude,
it is mostly ad hoc, often unrelated to national health strategies, plans or programmes, and
invariably uncoordinated. Few NGOs relate to each other or to the government’s
programmes, and this results in a lack of concerted action which could have a real impact
on health problems. There is an urgent need for governments to share responsibilities
with NGOs so as to benefit from their experience and expertise, to draw lessons from their
innovative experiences and to support them in their work. There is a similar need for
NGOs to show better understanding of national plans and priorities, to be good partners
in the larger task of implementing Health for All strategies and to use their natural strength
of closeness to the community to help stimulate the development movement amongst the
people. The partnership approach demands that governments be willing to support
NGOs through allocation of resources and to consult them in formulating plans and
programmes. This collaboration between partners is most likely to succeed if there is
open two-way communication. Tofacilitate such a dialogue, mechanisms of consultation
can be created.
References
1.
2.
3.
Intersectoral Action for Health, World Health Organization, Geneva, 1986.
Inequalities in health and health care, The Nordic School of Public Health, Gothenburg, Sweden,
NHV-Report 1985:5
Intersectoral linkages and health development, WHO Offset Publication No.83, WHO, Geneva, 1984
4 Collaboration with non-governmental organizations in implementing the global strategy for health for all,
Report of the Technical Discussions, (WHO document A38/Technical Discussions/4)
5
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HFA Leadership/IM. 10
Measuring Progress Towards
the Goal of Health for Ail
by the Year 2000
■
"Health for All” by its very definition is not just one single,
quantifiable entity for all people. It means many different things
to different people, reflecting their sense of the concept as it
echoes in their own consciousness. It is therefore necessary
to illustrate to those concerned in different situations that they
are making progress towards reaching a level of health that is
the highest achievable in their particular circumstances.
Monitoring and Evaluation
It is necessary to introduce a systematic monitoring and evaluation process as part of
national strategiesfor healthfor all. Whatever the precise nature of the process, it should
include: monitoring progress in carrying out the measures decided upon, the efficiency
with which these measures are being carried out, and the assessment of their effectiveness
and impact on the health and socioeconomic development of the people. In applying this
process, indicators that help to measure changes directly or indirectly are needed.
Indicators
Four broad categories of indicators are considered of value to countries in monitoring
and evaluation of their national strategies.These include:
a)
Health policy indicators to measure trends and changes in political commit
ment for HFA resource allocation, degree of equity of distribution of resources,
community involvement, degree of decentralization in decision making and
organizational framework, and managerial process.
b)
Indicators of the provision of health care to measure progress in availability,
accessibility and use of health care services and quality of care. These have to
be related to the specific types of services that the national health strategy aims
at providing.
1
HFA Leadership
c)
Health status indicators to measure changes and trends in health status of the
population.
d)
Social and economic indicators to measure demographic and economic
trends, income distribution, education, housing and food availability.
As part of their process of evaluation, countries are expected to select indicators that are
appropriate to their individual social, economic and health situation. Indicators selected
should be able to measure change towards attaining the objectives and reaching the
corresponding targets. They also have to be closely related to the means available for
data collection and processing and should be gathered as an intrinsic part of the system
for delivering health care.
Information Support
Many countries still lack reliable information support for measuring their progress
towards health for all. Often the information is collected at various levels but it is not
systematically processed, analyzed and used. Most countries do have many potential
sources of data which are capable of providing the information required for monitoring
and evaluation of their national strategics, such as: vital events registers, population and
housing censuses, routine health service records, epidemiological surveillance data,
sample surveys and disease registers. However, lack of coordinating mechanisms in the
collection and processing of information by different sectors not only makes the process
uniquely difficult, it severely limits knowledge as to what information is available or even
to duplication of efforts. Above all, a positive attitude and a genuine desire, particularly
at the policy and decision making level to measure progress towards health for all are
basic requisites.
Making Use of Information
Information should be perceived as a toolfor decision making and policy reorientation.
The available information needs to be converted and presented in such a way that it can
be used by policy and decision makers, by managers and by the community to learn what
progress is being made, to identify areas where changes are needed, and to specify
actions that must be taken to bring about such changes. In this way, monitoring and
evaluation will promote learning from experience, and using the lessons learnt, will
improve both current activities and future planning, and will guide the allocation of
human andfinancial resources in order to achieve equity in health the essence of the goal
of health for all.
Global Indicators
It is understood that countries will select indicators that are most relevant to assessing
national progress of their national strategies for health for all. When endorsing the Global
Strategy for Health for All (1981), countries also agreed to cooperate in assessing
progress being made collectively in regions and globally towards attaining the goal of
2
Measuring Progress Towards the Goal of Health for All by the Year 2000
health for all. For this purpose, a short list of global indicators were selected. These
constitute a minimal list so that all countries may be in a position to use them. Since
average global values of indicators have little meaning, monitoring and evaluation at the
global level will be based on the number of countries in which these indicators comply
with pre-determined values.
The following list of 12 global indicators was adopted by the Thirty-fourth World Health
Assembly in 1981.
The number of countries in which:
Health Policy Indicators
1.
Health for all has received endorsement as policy at the highest official level;
2.
Mechanisms for involving people in the implementation of strategies have
been formed or strengthened, and are actually functioning;
3.
At least 5% of the gross national product is spent on health;
4.
A reasonable percentage of the national health expenditure is devoted to local
health care;
5.
Resources are equitably distributed
6.
Well-defined strategies for health for all, accompanied by explicit resource
allocations, whose needs for external resources are receiving sustained support
from more affluent countries.
Indicators of Provision of Health Care
7.
Primary health care is available to the whole population, with at least the
following:
• safe water in the home or within 15 minutes’ walking distance, and adequate
sanitary facilities in the home or immediate vicinity;
• immunization against diphtheria, tetanus, whooping cough, measles, polio
myelitis and tuberculosis;
• local health care, including availability of at least 20 essential drugs, within
one hour’s walk or travel;
• trained personnel for attending pregnancy and childbirth, and caring for
children up to at least one year of age.
Health Status Indicators
8.
The nutrition status of children is adequate, in that:
• at least 90% of newborn infants have a birth weight of at least 2500g;
• at least 90% of children have a weight for age that corresponds to reference
values given in Annex 1 to Development of Indicators for Monitoring
Progress towards Health for All by the Year 2000.'
’ Health for All Series No.4
3
HFA Leadership
9.
10.
The infant mortality rate for all identifiable subgroups is below 50 per 1000
live-births.
Life expectancy at birth is over 60 years.
Social and Economic Indicators
11.
The adult literacy rate for both men and women exceeds 70%.
12 The gross national product per head exceeds US$ 500.
Some Pertinent Questions
In measuring progress towards health for all, active involvement of all authorities
involved in the national strategy is crucial. For HFA leadership this implies an informed
awareness of: the health needs and priorities; a knowledge of the process involved in
application of appropriate health development measures; and an objective appraisal of
issues and difficulties in implementing the process, thus raising the critical and pertinent
questions aimed at providing adequate indices of effectiveness. Furthermore, commit
ment to resolve these through corrective action is final proof of the usefulness of any
monitoring and evaluation effort.
Thus, leadership in health at different levels must raise a number of questions pertinent
to the national situations. Some examples of these questions are:
1.
In which aspects do the national health policies require revisions and/or further
clarification or strengthening?
2.
Is there sufficient evidence of commitment to the national health strategy at the
political level; the technical and managerial level; the community level?
3.
What actions have been taken to slrcngthcn/oricnt the health system towards
primary health care? Have these led to desired results in terms of improving
availability of health care to the people and/or improving distribution and use
of the health resources?
4.
What policies of other sectors are contributing (negatively or positively) to
health development?
5.
What measures have been taken to increase people’s understanding of their
health problems and for involving them in health activities? What have been
the main stumbling blocks?
6.
Has progress towards an equitable distribution of health manpower been
achieved in urban and rural areas? What have been the main obstacles?
7.
What initiatives have been taken to improve the economic support for the
strategy? Are these proving adequate?
8.
What progress has been made in improving availability of health services?
4
Measuring Progress Towards the Goal of Health for All by the Year 2000
9.
What is the infant mortality rate? Have there been any changes over the past
10 years?
10.
What progress has been made in improving literacy among women?
Pertinent questions should be asked in order to determine the reasons for not achieving
acceptable progress and targets and to determine what corrective actions are proposed.
Progress towards the goal of health for all should be measured
by the communities, by health and public administrators, and
by national policy/decision makers. An active and constructive
dialogue among all groups concerned is crucial for identifying
progress or lack of progress and seeking participatory meas
ures towards accelerated progress.
Note
The following WHO references may be consulted on the above subject:
1.
Global Strategy for Health for All by the Year 2000, (1981), “Health for All" Series, No.3, pages 73-76
2.
Development of Indicators for Monitoring Progress towards Health for All by the Year 2000, (1981), "Health
for All" Series, No.4
3.
4.
Health Programme Evaluation - Guiding Principles, (1981), “Health for All" Series, No. 6.
Managerial Process for National Health Development - Guiding Principles, (1981), “Health for All" Series,
No.5, pages 50-55
5
HFA Leadership/IM.6
Organization ©f Health
Systems Based on
Primary Health Care
In fulfilment of the Strategy of Health for All by the Year 2000,
concerted efforts have to be made to reorient and develop
health systems of which primary health care is the central
function and main focus.
Health Systems Based on Primary Health Care
The health system can be broadly defined as the coherent whole of many interrelated
component parts, both sectoral and intersectoral, as well as the community itself, which
produces a combined effect on the health of the population. Action taken within any one
component affects the action to be taken within the others. The ideal may be to have a
unified health system encompassing promotive, preventive, curative and rehabilitative
measures, and care of the extremely disabled and incurable. Whether unified or not, a
health system should consist of coordinated parts extending to the home, the workplace,
the school and the community.
Structural Organization of the Health System
The health system is usually oiganized in levels. Primary health care pays particular
attention to the point of initial contact between members of the community and the health
services. Properly conceived, the notion of levels implies a regionalized system within
which the highest priority is given to primary health care at the local level. Prevention,
health promotion and the care of common problems should constitute the main line of
action. More expensive and specialized needs should be referred to higher (district,
regional or national) levels. Il is at the local level that health care will be the most effective
within the contextofthe area’s needs and limitations, duly recognizing the users of health
systems as social beings in a particular environment.
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HFA Leadership
Outreach
A health system based on primary health care should particularly be concerned with
ensuring that such care is readily available to all, with appropriate support at the
intermediate and national levels, as well as more specialized referral services when
required. Thus a well-balanced system will provide specialized skills as extension of the
essential health services available to all in need. Rather than waiting passively for
problems to appear in the emergency or ambulatory services (the “come-and-gct-it”
approach), the health system should actively reach out to the whole population to promote
health and prevent illness as well as to treat problems when they do appear.
Essential Characteristics of the Health System
Any particular health system embodies the characteristics of the country in which it
operates. Among the approximately 160 sovereign countries of the world there are, of
course, no two exactly alike. Therefore no universal blueprint can be composed for
countries. The following principles have been defined as applicable to all health systems
based on primary health care:
• The system should encompass the entire population on a basis ofcquality and
responsibility.
• It should include components from the health sector and from other sectors
whose interrelated actions contribute to health.
■ Primary health care, consisting of at least the essential elements included in
the Declaration of Alma-Ata, should be delivered at the first point of contact
between individuals and the health system.
• The other levels of the health system should support the first contact level of
primary health care to permit it to provide these essential elements on a
continuing basis.
• At intermediate levels more complex problems should be dealt with, more
skilled and specialized care as well as logistic support should be provided, and
more highly trained staff should provide continuing training to primary health
care workers, as well as guidance to communities and community health
workers on practical problems arising in connection with all aspects of pri
mary health care.
• The central level should coordinate all parts of the system, and provide
planning and management expertise, highly specialized care, teaching for
specialized staff, the staffing of such institutions as central laboratories, and
central logistic and financial support.
2
Organization of Health Systems Based on Primary Health Care
Administrative Levels
The Individual or the Family
The primary health care approach has broadened the concept of the health system to
include not only health facilities but also communities and families as important agents
of health. The most basic unit is, therefore, the individual or the family.
The Community
Effective primary health care action at the level of community demands a well organized
community. Whether derived from traditional patterns or from local, political or other
groups some clear structure is essential. Where a community is without any clear
structure, such a structure may need to be developed before further steps can be taken. It
should also be noted that a community need not always be defined geographically, but can
also stand for a group of people with some common interest. Particularly in urban and
periurban areas, where the sense of geographical community may be weak, social, ethnic
or religious communities may provide appropriate starting points for primary health care.
The Community Health Worker
The community health worker can be considered as the next level of the health system
after the community itself. This term is used to refer to workers whose special
characteristic is that they are administratively responsible to the community rather than
the health service and should be selected by the community from among its own members.
The Basic Health Service Unit
The next level may be called the basic health service unit — a term that covers health
centres and their satellite clinics and outreach units, dispensaries, ambulatory clinics, and
similar facilities staffed by full-time health workers.
The First Referral Level
Beyond the basic health service units is the intermediate or first referral level (generally
a district), which usually has a clearly defined local responsibility for the planning and
management of all health activities within its particular area. This level is the main focus
of concern, since it is usually the most peripheral level capable of providing wide-ranging
technical and administrative support for primary health care.
Referral System
Effective mechanisms for referral should be developed. The scope of referral has been
broadened over the years and includes both the problems of communities as well as those
of individuals requiring medical care. The main principle of proper functioning is that
the first referral level is not overloaded with problems that could be dealt with by primary
health care in the community, thus patients and problems are referred back to those who
3
Organization of Health Systems Based on Primary Health Care
number of these areas and groups. Yet other nations will provide a complete range of
health programmes to the total population, progressively improving quality. Countries
concentrating on a limited number of programmes at the outset, such as malaria control,
immunization, or diarrhoeal disease control, should deliver them through the general
health infrastructure, thus strengthening it and acting as a spearhead for the progressive
delivery of a wider range of primary health care activities through it.
Intersectoral Support and Involvement
To develop health systems and to change them where and when required, countries will
have to take into account first, that the support of individuals and communities, political
and social leaders, as well as health workers is mobilized. Primary health care demands
a greater opportunity for local participation in decision-making. Therefore, ways will
have to be devised for involving the communities in the process of reorientation of the
health system. Then action will have to be taken in other sectors, and the responsible
authorities will have to be motivated for collaboration.
Coordination
Furthermore, greater coordination will be needed to see that the available resources are
used to meet the priority needs of primary health care. The logistic system will have to
be improved, health manpower will have to be planned, trained and deployed; and appro
priate health care facilities will have to be planned for, designed, constructed and
equipped so that they are readily available, accessible and acceptable to all the population;
and health technology will have to be selected that is scientifically sound, adaptable to
various local circumstances and maintainable with resources the country can afford.
References
1.
Health System support for Primary Health Care, Public Health Papers No.80,
WHO, Geneva, 1984
2.
Research for the reorientation of national health systems, Technical Report Series No.625,
WHO, Geneva, 1978
3.
Alma-Ata 1978 Primary Health Care, "Health for AH" series,
WHO, Geneva 1978
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HFA Leadership/IM.7
Community Involvement
The Concept of Community Involvement
Community involvement is central to all aspects of human development of which health
is but one. Although the nature of community involvement variesfrom society to society,
it is essentially a process by which people strive to better themselves and seek legitimacy
for their actions. People have the right to participate and this right is not a newly
discovered feature of society but one which has recently received renewed recognition
as a central value of all human activity. Various formal movements and approaches have
emerged since the last three decades emphasising the concept and techniques of self help.
In some countries the whole development thrust is based on participatory principles
where emphasis is on people’s own ability to act, to change and control their environment.
Self-reliance is the term used to indicate that people cannot be developed or educated.
They must develop and educate themselves through a process of thinking, problem
solving and acting.
During the last two decades it became obvious that people’s participation is not only
beneficial but essential in the pursuit of better health objectives. Participation is often
synonymous with cooperation as people involve themselves in activities which include
disease eradication programmes, mass health education campaigns, construction of
health facilities or donation of financial and material resources.
The term “awareness of health” is used to imply that at all levels of health from global
through to community level, awareness is the first critical step towards the goal of HFA.
From awareness emanates commitment, and commitment can lead to action. But this
process is a complex one and involves, inter alia, the feeling of concern or relevance on
the part of the individual for a particular problem or symptom. Conflicting and mitigating
factors such as timing, availability of resources, ability to make changes or take action etc.
also come into play.
At the Alma Ata Conference in 1978 Community Participation was described not as an
optional extra but as an essential component of PHC. “Participation is not only
desirable, it is a social, economic and technical necessity". The implications were clear:
without underestimating the overall responsibility of governments for the health of their
people, individuals, families and communities were asked to assume greater responsibil
ity for their own health and welfare. Individual and collective participation was
described as a ‘right and a duty'.
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HFA Leadership
Definition of Community Involvement
The term ‘community involvement’ in health is a process in which
partnership is established between government and local communi
ties in planning and implementation of health activities. It aims at
building local self-reliance and gaining social control over primary
health care infrastructure and technology.
Successful Community Involvement
Such a definition, however, is not globally applicable and different countries have taken
the concept of community involvement and sought to adapt it to their own particular
circumstances. More importantly, the concept of community involvement has begun to
be put into practice within a wide range of countries and health systems and is beginning
to provide concrete evidence of how this practice works and what issues it raises. Among
the factors which affect its success are:
■ the need to see involvement of community in health as a development process and not
a one-time activity or a utilization device for extending the coverage of public health
services;
• the understanding that community involvement in health must build upon the existing
mechanisms for wider community participation;
• the need to examine the term 'community' and recognize that different groups of people
may get involved on a different basis.
Government Support
For effective community involvement, governments need to give their full support to the
concept and its practice. However, the role of the government is not to use the community
to impose its view or legitimize its actions, but rather to use involvement as a mechanism
through which the ideas and concrete suggestions of local people can be brought to
influence the policy and functioning of health services. Political leaders and health
professionals need always to be open and responsive to dialogue with local people in
order to facilitate their involvement. Specifically:
• Involvement needs to be continually interpreted in different contexts so that the form
it takes can be relevant to each context.
• Great attention needs to be paid to existing political and cultural traditions in local
communities and to their potential use as the basis for involving the community, rather
than importing external structures.
2
Community Involvement
• Similarly, governments should both encourage local communities to assume the
necessary responsibilities and empower them adequately to undertake this involve
ment.
• Scientific and other technical infoimation provided by government and health profes
sionals must be pertinent to the community’s wishes and expressed in a manner
intelligible to local people. Only then can local communities accept and fully identify
with the proposals being put forward.
The “Community”
The process of involving community in health must begin with a deep understanding of
the ‘community’ element, its characteristics and the nature of its contacts with the health
services. The responses and capabilities of the community are the central issues.
In general terms the kinds of action required revolve around the twin needs to study and
determine the potential for involvement at the community level and to develop the
mechanisms to facilitate this involvement.
Local level involvement is, in fact, a widespread characteristic of most communities and
should form the basis of further action. For example:
° The study of the characteristics of the community should not be only anthropological
in nature but should also examine the political and cultural factors which influence
involvement. The responses and potential effects ofthe involvement ofdifferent groups
should be examined, as well as the influence and control that some groups have over
others.
• Strengthening of community-based organizations is a key aspect. Strong community
organizations and the delegation of authority to such organizations can effectively
facilitate community involvement.
• Countries should mobilize their communities to broaden the base ofinvolvement so that
the whole range ofhealth care issues, e.g., housing, sanitation, water supply, nutrition
etc. are covered.
• There should be a clear and understandable division of responsibilities between the
community and the health systemfor different aspects ofhealth care. It is important that
both sides understand their specific responsibilities and that an effective dialogue is
established to determine this division.
• It must not be seen as a one-way process in which the health services determine the
policy, deliver the goods and then seek the communities’ involvement. The basis of
community involvement have to be established from the very beginning. It might be
useful to establish a set of principles to govern the exchanges between health services
and community organizations.
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HFA Leadership
Support Mechanisms
Successful involvement of the community cannot emerge and develop without the
support of appropriate mechanisms at different levels. Such mechanisms operate at both
national and local community levels. Experience to date suggests that, in the first
instance, political commitment is essential, as this provides the basic impulse to such
issues as decentralization and inter-sectoral coordination which are fundamental
support mechanisms of the process of involving the community. Where successful
involvement has occured, it has done so with the assistance of a whole range of
organizations, e.g., local organizations, NGOs, etc., which have helped the process to
emerge. The main issues concerning support mechanisms are summarized as follows:
• In developing support mechanisms emphasis should be placed on the existing infra
structure. At the local level, community-based organizations provide the basic infra
structure.
• Intersectoral coordination at the local level is important. Although there is widespread
awareness of this, in fact, little intersectoral coordination actually takes place when
policy decisions are made or resources allocated at the community level.
• A common problem is that of logistics support. The health system often has limited
means to reach communities and similarly, appropriate technologies are not available
in adequate supplies. Lack of such support reduces the chances of success.
• It is also evident that administrative decentralization is critical. Much has been written
and said about decentralization, but it remains largely unimplemented and local
communities continue to lack the decision-making authority which is crucial to their
involvement.
• In many countries vital support mechanismsfor community health activities have been
provided by NGOs. The NGOs, and cooperation between government and NGOs have
had considerable effect upon health services, particularly in remote underserved areas.
• Similarly, mass campaigns can be successful in mobilizing widespread support for
health programmes. Such campaigns are particularly effective in promoting commu
nity involvement where community-based organizations already exist to carry on the
activities.
• Professional Medical Organizations are also a very useful support. In more developed
countries, such organizations have helped promote positive attitudes towards commu
nity involvement among the professional health workers.
Education and Training
Since community involvement in health is an ongoing and evolving process, it is
important to educate and train people in content and methodology. Clarifying the
principles underlying the concept ofcommunity involvement is a basic way of ‘increasing
people’s faith' in the idea and promoting positive attitudes towards its acceptance.
Because this implies a radical change from much conventional medical practice, educa
tion and training are indispensable to create a favourable climate for this change. And
these activities should become an integral part of all health training.
4
Community Involvement
• A persistent issue is the balance in training. Health service training concentrates
overwhelmingly on medical aspects, whereas involving communities in health demands
different areas of knowledge. There is a need, therefore, to balance the content of staff
training, particularly at the community level, so that health workers are better prepared
to promote community involvement.
Methodological Problems
Given that community involvement is a relatively new concern there arc several
methodological problems which confront health services. The most pertinent issues
which have to be resolved arc:
a)
the rigid professionalism of health services and the corresponding reluctance to
produce the staff and develop the skills required;
the reluctance ofprofessional health staff to involve the community in the decision
b)
making process;
c)
the monopoly of health knowledge by health service staff and the ensuing lack of
practical flexibility and innovation in solving local problems.
A key element in community involvement is the community health worker (CHW). The
notion of a local-level health worker as the pivotal force in the community is crucial, but
there is still much debate as to the exact role and skills required by the CHW. This aspect
needs to be further examined by the countries.
Conclusion
Community involvement in health is still very much at an experimental stage in most
countries and therefore there is little substantial experience which can, as yet, serve as
example. However, as an essential component of the Primary Health Care Approach, it
is expanding in many parts of the world. Also, a number of lines of action have been
identified in order to promote the concept of community involvement as a mechanism for
self-reliant socio-economic development using health as an entry point. Among them arc:
• improving intersectoral collaboration at the local level, with health as an integral part
of community development activities;
■> renewing efforts to motivate local people in the area of health so as to ensure their
willingness to become actively involved;
• placing emphasis on the training of Community Health Workers as key mobilizers of
the community;
• developing the organizational base within local communities which is a prerequisite for
their active involvement in health activities.
References
WHO Community Involvement in Health Systems for Primary Health Care, SHS/83.6.
WHO Community Involvement for Health Development Report of the Interregional Meeting, Brioni, Yugoslavia,
9-14 June 1985. SHS/85.8.
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HFA Leadership/IM.8
Resources for Health
I
Health for All Strategy, through Primary Health Care icalls for a
dramatic shift in health resources towards a more equitable distribu
tion in countries. This requires “strong political commitment (will and
support) at both national and community level reinforced by a firm
national strategy”
(WHO-UNICEF 1978).
Implications of the Economic Climate for Health for All
While there is a great deal of agreement about the underlying principles of the HFA
approach, there are many political, planning and managerial difficulties involved in
creating this shift in resource distribution. In fact, the world economic recession has had
important implications for adjustment policies which governments have had to adopt in
order to keep a reasonable balance between economic growth and social development.
This has not been easy for the poorest countries of the world many of which have
experienced severe reductions in their health budgets at a time when additional resources
are required to sustain and build national health systems based on primary health care to
meet the priority health needs of all their people, especially the underprivileged and
vulnerable groups.
Some countries have made substantial efforts to promote socioeconomic development,
especially in the areas of food production, water supply and education. The benefits
however, have sometimes been less significant than expected because of factors such as
political instability, financial crisis, fluctuating exchange rates, natural disasters and high
population growth. Nevertheless, the first evaluation of the Global Strategy for Health
for All in 1986 has shown that governments have begun to invest in health services,
especially through the expansion of health facilities and manpower development. But
new capital investments have also increased the burden of recurrent expenditures in the
health budgets. At a time when additional resources are required to strengthen health
system infrastructure so as to extend primary health care such expenditures appear
difficult to fund.
Efficiency and Cost Benefits vs Equitable Distribution
Moreover, in many countries aspects such as the impact of available health care as well
as concerns with efficiency and cost benefits are being balanced against more equitable
distribution of health-related resources in order to bring care to the underserved. The
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HFA Leadership
danger of this balancing act is that concern with equity can give way to concern for "cost
containment" which can mean reduction in social expendituresfor those who need them
most. The manner in which the health goal is incorporated into the overall strategy as a
goal for development also affects the allocation of resources and in turn, the issue of
equity which is the fundamental principle of Health for All.
Lack of Political Determination
But external factors cannot be entirely blamed for the underachievement in health. Marty
governments have not yet seriously taken up the strategic actions required to generate
and mobilize all possible resources for health. Very few countries have attempted to
make an estimate of the magnitude of resources required for their national HFA strategies.
Altogether very few new initiatives have been undertaken to mobilize resources inter
nally which can have national impact. Few countries have been able to reallocate their
existing health budgets preferentially to primary health care. Inefficient use of existing
health resources persists; effective actions to reduce waste or to improve cost effective
ness have been too few to have a substantial positive impact on the resource situation. And
the health sector remains a weak partner in influencing socio-economic development
policies or in mobilizing effective supportfrom other related sectorsfor health activities.
These problems need to be discussed among health development leaders. A greater
understanding of resource issues and a better identification of alternative options for
action are essential to accelerate the implementation of Health for All strategies.
Options for Financing HFA
How to finance health plans and how to make best use of resources have both become
critical issues in the attainment of Health for All. In the long run, the search for additional
and new resources, particularly domestic resources, and making the most efficient use of
all that is available offer the best options for financing HFA. Improved financial planning
and management and bold administrative and organizational measures are also required.
The strengthening of national capability, especially that of the Ministries of Health or
equivalent bodies, in developing and implementing policies based on sound economic
analysis and strong financial management are a prerequisite to effective national action.
Traditionally, Health has not been accorded a strong position in the hierachy between
ministries. In the competition for resources, the Health Ministry usually has lower status
than others. Finance and Planning Ministries need to be convinced that primary health
care is the right strategy to meet basic needs of people and promote socioeconomic
development so that resources for health may be consequently expanded and existing
resources allocation patterns changed
In order to effect a national change in resource allocation, national and local leaders can
promote policy-making mechanisms to progressively correct imbalance in the maldis
tribution of resources.
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Resources for Health
Government Responsibility
At the national level political agreement on the magnitude and the type of government
responsibility in health financing should be reached Most of the costs in training,
transport, supervision, evaluation, equipment, spare-parts, building of referral centres
and wages of health professionals should be met by governments. Special attention has
to be paid for support services to primary health care which are expensive, such as
transport for supervision and logistics, and which are too often underweighted. Commu
nities also may bear part of the financial burden and make small payments for some
services.
Economic Strategies
After identifying government responsibilities the subsequent political step is to determine
appropriate mechanisms to mobilize additional resources. Several options for economic
strategies could be considered by health leaders from the political point of view:
• reducing the rates of hospital investment for the benefit of the operating budget;
• reducing the growth of additional hospital expenditures by improving their
efficiency (including reduction of waste, e.g. drugs) and making additional
resources available for primary health care support services from existing health
resources;
• developing new cost-sharing mechanisms (social security schemes, community
participation, etc.);
• exploring the use of non-govemmental institutions from profit and non profit
making sectors; and
• mobilizing external funds from international aid agencies or private voluntary
organizations.
Each of these possible solutions presents serious political implications which have to be
carefully analyzed, not only in the short-term but in the long-term as well.
Political implications are not limited to national levels. At the regional, district or even
village levels, there may be conflicts between various groups or classes (including health
professionals) which could impede the development of Health for All plans by allocating
scarce resources to a limited number of people.
Clarifying the values, expectations, administration and organization, that justify such
radical changes in the distribution of resources, is extremely difficult.
Planning Difficulties
Even if there is a political commitment to allocate more resources for the health benefit
of the greatest number of people, elaborating or developing a national resource plan
which includes community involvement, and consequently community resources, is the
next challenge.
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HFA Leadership
A New Planning Approach
“Bottom-up” resource planning could help health leaders to know of local conditions.
These are defined not only by disease patterns, but also by the perception of needs, ability
and willingness to participate and pay for services, modes of work, religious-cultural and
social norms, etc. On the basis of such information, which requires a new planning
approach, it is possible for health leaders to develop their resource plans more appropri
ately.
The following issues could be considered:
• Obtaining and maintaining a full picture of the existing sources of finances in the
health sector and their distribution.
• Costing alternative patterns of health care delivery systems, for example: insti
tution-based and community-based systems, in order to determine which pattern
or which mix of complementary patterns, will be the most socially and economi
cally advantageous to all people in the long-term.
• Ensuring the economic feasibility and sustainability of long-term health plans to
achieve Health for All.
• Determining the total recurrent costs implications for all past and new capital
investment schemes.
• Articulating the criteria that can be used in establishing various financing
options, within the overall perspective of equity and effectiveness. On the basis
of this planning exercise, budgeting could be more adequately worked out.
Budgets need to be formulated by geographical areas, by level of care and on a
per capita basis. The review of year-to-year budgeting can then be used
progressively to create resource shifts that are acceptable and feasible and to
monitor whether or not the actual expenditures are reflecting the planned
expenditure projections for Health for All.
It should be pointed out that in order to develop long-term planned strategies it is often
necessary to undertake some legislative action, e.g. in the area of new health personnel
categories, essential drug supply, new cost-sharing mechanisms, etc. which also involves
health leaders.
Managerial Difficulties
Resource planning remains a paper practice if plans arc not put into effect. In the final
analysis, the success of primary health care depends on effective management and
organization. Community activities may succeed or fail, depending on the support and
supervision received from the back-up health services. The same is true for each level
of the health system.
Health leaders, politically committed towards Health for All, and guided by a long-term
resource plan have also to be involved in the management of resources. Areas for main
concern and emphasis could be the following:
• improving the efficiency of existing services at all levels, especially support
services to Primary Health Care;
4
Resources for Health
• ensuring the preferential allocation of resources to the most vulnerable groups
through an appropriate balance between preventive and curative approaches,
primary health care facilities and hospitals, and rural and urban services;
• examining alternatives to improve the cost-effectiveness of health services,
including the use of appropriate technologies and manpower mixes;
■ developing mechanisms for cost-control and cost-containment, and considering
ways of reducing all waste in the use of health resources; and
• defining indicators of resource allocation which could be used to monitor actual
resource shifts year-by-ycar in comparison with the planned projections.
Conclusions
The Health for All Strategy implies a shift in the pattern of resource allocation and
distribution for the benefit of disadvantaged groups. But resource allocation policies
have to consider not only what goes into health care hut also to other determinants of
health such as education, environment andfood, with due considerations to principles of
equity.
The issue should not only be where the money is going to come from to pay for health care,
but more importantly what broad policy framework is needed to expand the economic
support for health for all. This support must come from individuals, families, communi
ties, the private sector, non-governmental sectors and, of course, governmental sources.
The issue is not just how many more resources are required and how to mobilize them,
but also how can the existing available resources be used more efficiently and produc
tively.
Achieving health for all will require sacrifices. The mechanisms and methods used to
finance and support services will continue to be imperfect. The task offinding long term
solutions is difficult but must be faced if the health offuture generations is not to be
jeopardized.
References
Economic Support for National Health for All Strategies. Background Document World Health Organization,
Fortieth World Health Assembly, Geneva May 1987. A/40<Technical Discussions/2..
National Decision-Making for Primary Health Care. A Study by UNICEF/WHO, Geneva 1981.
Guidelines for Costing Primary Health Care Development Geneva, (WHO Document, SHS/84.3).
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A
The Managerial Process
The Need for a Managerial Process
The World Health Organization, in fulfilment of its function as the coordinating authority
in international health work, is playing an important role in providing a common
framework to formulate policies, strategies and plans of action for Health for All by the
year 2000. This role includes promoting worldwide understanding that Health for All by
the year 2000 is feasible, and facilitating the coordinated development of strategies to
reach the target. To this end, WHO will ensure the availability of relevant and valid
information, support technical cooperation among countries, and provide technical and
managerial support to national efforts. However, even though the broad goal and the key
to reaching it have been identified, a managerial process has to be applied by each
individual country in order toformulate and implement the strategyfor reaching the goal
in a manner that is adapted to the country's own health situation and resources, social
and economic conditions, and political and administrative mechanisms. It is clear that
Health for All is to be attained within countries.
Formulation of National Policies, Strategies and Plans of Action
First and foremost countries themselves should formulate their policies, strategies and
plans of action which should be directed at solving national problems. Moreover,
specific national targets should be formulated and quantified. And what is equally
important, political commitment to and support for the health for all goals will have to be
mobilized. Without such commitment and support, national policies and strategies for
Health for All will not be translated into action.
Naturally, national policies, strategies and plans of action will vary widely according to
the aspirations and capabilities of countries. To begin with, “Health for All” may be
interpreted differently by each country in the light of its cultural, social, economic and
political-administrative characteristics, health status and morbidity patterns of its popu
lation and state of development of its health system.
National Targets and Approaches
V
;
In the process ofsetting national targets, countries may vary greatly in their interpreta
tion of what is an acceptable level of health. In addition, while attempting to promote
health for all, widely different approaches could be used, such as providing, on the one
hand, the full range of services required, starting with those in greatest need and
progressively reaching the whole population, or at the other extreme, providing limited
services to the total population from beginning and progressively extending the range of
these services. Periods of economic scarcity and the changing economic circumstances
of nations will determine and influence the “context” in which the managerial process has
to be carried out.
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The Managerial Process
The managerial process is a continuous process of national
planning and programming. It includes policy formulation and
the definition of priorities. It involves the preparation of pro
grammes to give effect to these priorities, the preferential
allocation of budgets, and the integration of the different
programmes within the overall health system. It also deals with
the implementation of strategies and plans of action, the
programmes, services and institutions for delivering them, as
well as with their monitoring and evaluation with a view to
modifying existing plans to prepare new ones as required, as
part of a continuous cycle. Finally, it outlines the information
required through the process.
There are many possible entry points to the whole process. In all cases, it has to be realised
that the way to Health for All is not a simple one, but that, if the various issues involved
arc dealt with adequately, whatever the entry point, the attainment of this goal by the year
2000 is realisticfor many countries.
Some Common Components of Managerial Processes
Most countries already have some form of managerial process for national health
development. Although these processes differ widely across countries, certain common
components or stages can be identified. These stages define the structure of the
managerial process.
Formulation of National Health Policies
A national health policy is an expression of the goals for improving the health situation,
the priorities among these goals, and the main directions for attaining them. Each country
will have to develop its health policies as part of overall socio-economic development
policies and in the light of its own problems and possibilities. Whatever the process, each
country has to specify its health goals and priorities following the identification and
careful analysis of its health problems and socio-economic capacity to deal with them.
In the light of this analysis, it will be able to indicate the main directions for attaining these
goals.
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The Managerial Process
Broad Programming
A national strategy, which should be based on the national health policy, includes the
broad lines of action required in all sectors involved to give effect to that policy. The
development of a national strategy can he considered as the selection and subsequent
formulation of broad health programmes. A health programme is generally understood
as a series of interrelated actions aimed at attaining a defined policy such as the
improvement of child health or the provision of safe drinking water. Each country-wide
programme should include targets, quantified if possible, as well as the organization,
manpower, technology, facilities, equipment, drugs and supplies required, cost estimate
and financial plan, a rough time table of action, means of monitoring and evaluation and
ways of ensuring appropriate correlation among all of the above.
Programme Budgeting
For any strategy to be viable, it is essential to make resources available for priority
activities where and when they are needed. The process for doing so is called in many
countries “programme budgeting", i.e., making sure that budgets are available to attain
the programme objective. Without this, plans are merely dreams on paper. Budgeting
is a means of ensuring that programme decisions become budget decisions. Actually,
programme budgeting has to begin during policy formulation, and particularly during the
phase of broad programming, once priorities are known. These priorities will have to
compete for resources not only among themselves, but also with the existing programmes
and institutions in the health system, as well as with other sectors. Therefore it is crucial
to make rough calculations of the budgetary consequences early in the process ensuring
at least that additional resources are allocated to defined priorities, since it is rarely
possible to reduce resources available for ongoing activities in the health services.
Establishment of a National Plan of Action
When broad programming has been completed, including the programme budgeting
outlined above, the national plan of action can be prepared in a document summarizing
the product of the programming process. A national plan of action is a broad
intersectoral master planfor attaining the national health goals through implementation
of the strategy. It indicates what has to be done, who has to do it, during what timeframe
and with what resources. It is a framework leading to more detailed programming and
budgeting, implementation and evaluation.
Detailed Programming
When the government has approved the master plan of action, the different items have to
be specified in such detail that the programme can be implemented. Detailedprogramme
formulation generates the working documents for individual programmes, providing
essential indications for setting these programmes in action and later operating them.
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Implementation
On the basis of these documents, programmes have to be brought to life and by doing so,
implementation is set in motion.
However, unforeseen circumstances and problems may arise that necessitate revision of
the plan of action. Orientation to action and flexibility will, thus, be needed. The
resources needed for all programme activities should be secured in the right places at the
right time so that programmes can be implemented successfully. Like finance, manpower
is a key resource. Whatever has been planned and set in motion has to be managed on a
day-to-day basis.
Monitoring
Throughout implementation, the way resources are used and activities carried out must
be monitored. Monitoring is the day-to-day follow-up of activities during their implem
entation to ensure that they are proceeding as planned and are on schedule. 11 keeps track
of ongoing activities, milestones achieved, personnel matters, supplies and equipment,
and money spent in relation to budgets allocated. Reliable information on these matters
must, therefore, be provided by those performing the activities. Monitoring makes it
possible to identify deviations so that activities can be put back on the right track.
Evaluation
Evaluation is a part of the managerial process for national health development. It should
be based on information gained from monitoring the implementation of the policies,
strategies and plans of action. Evaluation has to be built into the entire managerial
process for national health development and has to be applied periodically. It therefore
has to be carried out throughout the planning and implementation ofprogrammes and
the operation of services and institutions for delivering them so that their effectiveness
in terms of improvement of the health status of the population and their socio-economic
impact can be assessed. Reprogramming may have to be initiated in response to the
results of evaluation.
Information Support
The decision-making process, involving all relevant components of the managerial
process for national health development outlined above requires relevant information.
This information may come from routine statistics, but it may be necessary also to carry
out special or ad hoc surveys for data collection.
National governments may find it useful to develop or strengthen their national informa
tion systems so as to ensure the timely availability of the right kind of information.
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The Managerial Process
Administrative Reform
The strengthening and adaptation of administrative structures and systems at all levels
and in all sectors, not only the health sector, may be required including intersectoral
coordination between health and other related sectors. To achieve such coordination,
countries may wish to review their administrative systems to ensure that coordination can
take place at the central, intermediate and local levels. As part of this review, they may
wish to assess the degree to which they need to strengthen local and intermediate levels
of the national administration, by delegating responsibility and authority to the commu
nity and intermediate levels as appropriate, and by providing sufficient manpower and
resources. In some countries it may be necessary to provide incentives to manpower for
service at the peripheral levels, especially in remote and neglected areas. Governments
may find it also useful to involve non-govemment organizations in the managerial
process and to create appropriate mechanisms of consultation for that purpose.
Training in Health Management
Training considerations are some of the most important elements in the planning of a
national development strategy. Appropriate training in health planning and manage
ment at all levels is urgently needed to prepare and sustain the capabilities ofmanpower
to formulate and implement national policies, strategies and plans of action
The health sector in general and the health administration in particular has problems in
attracting managers of high competence and skill.
Where health administration is dominated by physicians in decision-making positions,
management often suffers from lack of skills in administration, finance and management.
In spite of general agreement of the importance of middle level management, there is a
great deficiency of trained middle level workers who arc able to design workable local
plans and implement them.
The issues above indicate the importance of training all categories of health personnel and
particularly doctors in management skills.
References
Managerial Process for National Health Development—Guiding Principles, Health for All Series, No. 5, WHO,
Geneva 1981.
Health Programme Evaluation — Guiding Principles, Health for All Series No. 6, WHO, Geneva, 1981.
Broad Programming as part of the managerial process for national health development — Guiding Principles,
MPNHD/81.3, WHO, Geneva, December 1981.
Detailed Programming as part of the managerial process for national health development — Guiding principles,
MPNHD/81.4, WHO. Geneva, December 1981.
Programme Implementation as part of the managerial process for national health development — Guiding
principles, MPNHD/81 5, WHO, Geneva, December 1981.
Programme Budgeting as part of the managerial process for national health development—Guiding principles,
MPNHD/84.2, Geneva, August 1984
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Collaboration with
Non-governmental Organizations
in implementing the Global
Strategy for Health for Ail
The Need for Partnership
There is growing recognition that partnership between governments and non-govern
mental organizations is an inescapable necessity for the attainment of Health for All by
the year 2000. It is also felt that the time is opportune for intensifying such partnership,
based on mutual understanding, identification of appropriate roles, complementarity of
actions, mutual learning by doing and full-fledged cooperation. The World Health
Organization is promoting, fostering and strengthening such partnership.
Voluntary Action and Health
Historically, voluntary organizations were based on the human impulse to help other
human beings in need and to reduce suffering. This fundamental human trait has
expressed itself universally in social measures, in philanthropy, in science - particularly
medicine - and also in spontaneous initiatives undertaken by individuals or organized
groups.
The concept of helping the needy is alive and growing today but the emphasis has shifted.
The focus is now on promoting self-help and assisting individuals and communities to
become self-reliant to achieve a better quality of life. Political systems, culture, religion,
literacy, and economic factors, all have an influence on the growth of voluntary groups
and their activities.
Expansion of NGOs
This century has witnessed the origin and growth of literally thousands of self-care and
self-help groups in communities, organized national voluntary bodies, societies and
other private associations, professional groups and, on the global level, international
nongovernmental organizations, with overall objectives of promoting and fostering
health
A necessary condition for sustaining this human energy is the governments' willingness
to share responsibilities with people and people’s involvement in government-initiated
development activities.
HFA Leadership
Many national NGOs have international affiliates who provide them with professional,
material or financial resources, usually for specified health programmes such as the
control of leprosy, the prevention of blindness, the acceptance of family planning or
training in nursing and child care. Many of these international bodies provide a direct link
with WHO with which they have a special formal relationship. Because of these
affiliations, International NGOs are an important element in the promotion of the global
Health for All concept through their role in advocacy, mobilization of expertise,
education and health development. Individually they can raise and channel much needed
funds for the promotion of Primary Health Care.
Collaboration between WHO and NGOs
Over the years, WHO’s collaboration with NGOs has greatly expanded, covering a wide
range of health interests. There are now over 130 international nongovernmental
organizations in official relations with WHO and, NGOIWHO collaborative activities
relate to all aspects ofprimary health care. They range from dissemination of informa
tion through NGO networks and data collection in support of specific activities, to the
preparation of manuals, organization of training courses for all categories of health
workers, collaboration in specific health programmes such as control of tuberculosis,
leprosy, cancer, cardiovascular diseases, mental health, environmental health, oral
health, clinical laboratory and radiological technology, and health education.
Since the adoption of the Global Strategy for Health for All by the Year 2000,
collaboration with NGOs has assumed a new urgency and meaning. It has become clear
that the this sector has crucial contributions to make at the local, national, regional and
international levels.
Strengths and Assets of NGOs
The strengths and assets of nongovernmental organizations are summarized in the
following:
• many NGO’s are operational mainly or exclusively at the community level, and
as such are often more sensitive and responsive to the needs of the people,
especially the health needs of the more disadvantaged populations. Thus they
offer an organized means for interpreting popular needs to the often more distant
government, and can serve an advocacy role for necessary changes and initia
tives,
• they have the flexibility to experiment with innovative and alternative ap
proaches to solve health problems, often achieving cost-effective breakthroughs
which could provide new models for national planning,
• through the effective deployment ofmanpower resources, and with many varied
training programmes, NGOs can significantly contribute to national health
manpower development with particular emphasis on primary health care,
• and, with their simpler managerial structures, it is often possible for them to
operate with remarkable cost effectiveness for the increased benefit of the
ultimate beneficiary, the people,
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Collaboration with Non-governmental Organizations In
Implementing the Global Strategy for Health for All
• the many professional associations and organizations working for the prevention
and control of specific health problems offer possibilities for concrete technical
support to governmental training and service programmes. Many local or
national NGO’s represent the effective mobilization of women, youth, disabled
persons and other groups to support their own self-reliant efforts and thus play
a dynamic role in national development. Other NGOs are able to play a similar
role in supporting community level self-help and self-care groups. Even more
important are the groups which arise spontaneously at the grass-roots level in
response to local needs, promoting self-reliance and calling attention to inequi
ties and the maldistribution of resources.
Obstacles to Effective Collaboration with Governments
Internationally, NGOs have made their experience available to the global struggle to
improve health conditions working closely with WHO and other agencies on policies,
programmes, training, standards and public advocacy for the health for all strategy.
However, there are several problems and obstacles impeding effective collaboration
with Governments. The impediments vary from country to country. Some of them are
identified in the following:
Lack of Mutual Understanding
There is lack, of understanding by many governments of the resources which NGOs have
to offer. Much NGO work is not visible and there is sometimes mistrust of NGOs and their
intention. This is more evident where the financial and programmatic aspects of these
NGOs, both local and external, are not fully understood.
For their part, NGOs often fail to understand government policies, long-term responsi
bilities and development priorities. Some distrust the governments and do not fully
appreciate the need for a certain measure of accountability to the government. Often they
are impatient with bureaucratic constraints and thus avoid an open dialogue. Further
more, many NGOs fear a loss of identity and freedom of action, arising out of government
coordination efforts.
Certain NGOs find themselves diverging from the priority concerns of national policy
when they embark on rigid or preset programmes, or when they deal exclusively with
emergency actions. Such a “take it or leave it” approach is difficult for governments and
hinders operational partnership.
Lack of Resources
Scarce resources including money, trained personnel and managerial capacities on both
sides make close working relations difficult in many countries. Often procedural or
bureaucratic difficulties prevent a timely and strategic transfer of funds from govern
ments to an operational NGO, or from an NGO to a government programme, a support
that might give new life to a vital programme.
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Some NGO’s are even reluctant to be partners in a joint effort with other associations
working voluntarily in the health Held. There is therefore the question ofpartnership not
only between NGOs and governments, but also amongst NGOs themselves. In many
countries there are large numbers of organizations in the health field, many of them with
very' specific objectives. In many cases there is no available information on them and
governments are often unaware of their activities, their variety or even of their existence.
These problems have been solved in certain countries by an initiative on the part of the
NGOs in coming together collectively to approach government; in others, governments
have taken the initiative of calling together the representatives of a wide range of
organizations. However, for this process to be successful, a national health plan and a
strategy in which all can participate is essential.
Lack of Dialogue and Appropriate Mechanisms for Collaboration
Underlying the above, is the lack of appropriate mechanisms for encouraging dialogue
and joint collaboration between NGOs and governments. Differences in policy percep
tions, both apparent and real, often are difficult to resolve. NGOs expertise and
experience are not readily available for policy development, planning and evaluation of
national strategies. Competition among NGOs and the seeming competition between
NGOs and governments are not conducive to partnership.
Conclusion
The focus on any partnership in health and all the questions arising therefrom must bear
on one essential fact: the concern with people and the urgency of reducing human
suffering. Even though there are some difficulties in establishing collaboration between
governments and non governmental organizations, these are by far outweighed by the
numerous positive experiences which show that meaningful collaboration at all levels is
not only possible but actively sought. The energetic engagement of a whole range of
NGOs in the planning, execution, monitoring and evaluation of health action has led to
the development of appropriate mechanisms for collaboration at country level in many
parts of the world.
Therefore, in order to encourage andfacilitate the implementation ofHealth for All and
to make best use of the natural strength of the non-governmental sector, ways and means
must be continuously sought to overcome the difficulties and obstacles that still prevent
their full participation and collaboration in the process.
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Collaboration with Non-governmental Organizations in
Implementing the Global Strategy for Health for All
Forging better Partnership between Governments and NGOs
There are new opportunities to forge better partnership between NGOs, governments and
WHO. Steps need to be taken within countries to examine the present circumstances of
NGO activity and to see what must be done to strengthen collaboration at the national
level, and to intensify the alliances that are needed for effective cooperation at the village,
local and district levels. Regional and inter-country mechanisms which are now weak in
this area need to be developed in the spirit of technical cooperation among developing
countries and in the context ofregional strategies. Global and international coordination
in the extremely complex world of NGOs needs to be examined and work must begin on
exploring new modalities for cooperation among international NGOs in rationalizing
their goals and programmes, their technical cooperation with countries and in their
mobilization of resources to support Health for All strategies. It is now time to conceive
and launch a bold new global alliance of NGOs to mobilize and influence the flow and
direction of international resources for the implementation of Health for All Strategies.
References
Collaboration with Non-Governmental Organizations in Implementing the Global Strategy for Health for All,
Issues for Discussions, A38/Technical Discussions/1 Add.1, WHO, 1985.
Collaboration with Non-Governmental Organizations in Implementing the Global Strategy for Health for All,
Report of the Technical Discussions, A38/Technical Discussions/4 , WHO, 1985.
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e *
The Role of Universities in the
Strategies for Health for All
The Potential of Universities in Health for All
A broad range of institutions for higher education, referred to simply as universities
hereafter, stand out as potentially strong assets in the Health for All effort and its specific
challenges regarding health care and health manpower development. The historic
mission or purpose of universities, ie: assist through education with programmes in
professional manpower development; advance knowledge through research, both basic
and applied; and provide service through constant interaction with the community are
all highly suitable for improving the health ofpopulations. Universities can play crucial
roles in establishing effective systems for pursuing the health for all objectives. Their
academic and technical competence as well as their capacity to elicit cooperation of
relevant national and international institutions can be brought into bold relief for the
benefit of societies both within and between nations.
Health for All and Universities
- A Partnership of Opportunity
Some universities have already recognized that health is an important area of concern in
social justice and human development and they have therefore devised appropriate
mechanisms to make their inputs meaningful in the national and global efforts to promote
health. In doing this they have developed effective links between disciplines, and built
bridges between universities and governments on the one hand and universities and
society on the other. In reorienting their traditional education systems they have shifted
their priorities to community-oriented problems and given serious research attention to
areas of national development and world health.
Through these examples they have shown that Universities can contribute substantially
in reducing the burden of illness by improving the living conditions and broadening the
coverage of health care systems; by focussing on preventive actions; by formulating
health policies in the light of such concerns; and by being open to innovation. In research,
they can further reduce heavy burdens of illness by extending the field of health sciences
to its full extent - from the community to the patient’s bedside to the laboratory bench.
Moreover they can bring together new talent to find solutions to the complex issues in
human resource development and provide continuously improving answers to healthrelated problems.
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Network of Universities
Universities can involve the scientific and academic community more deeply in these
issues than it is now engaged. They can systematically link this community with
leadership groups in different countries. Universities can play a useful role in bringing
decision-makers together, across disciplines, sectors, and national boundaries to focus
on these problems and tofollow-up with ways to study, test, and disseminate ideas. They
can also explore ways to encourage the scientific and technical community to exercise
more leadership in moving technically-advanced nations towards solutions to problems
in human development.
Research and Action in Health and Behaviour
An importantfocus for research and action lies in the social, economic and behavioural
environments which influence the life of the community and in which decisions are made
about health care, for example infant and child care. Maternal education is a crucial
factor in reducing infant and child mortality. Maternal understanding and support for
health-promoting behaviour can be enhanced by basic literacy or health specific
education. There is great need to strengthen the knowledge in health and behaviour in
the developing world through research that is relevant to the characteristics of the
country, with special emphasis on ways in which public education could be effective in
fostering patterns of living that protect against major riskfactors. Of particular impor
tance is the clarification of the relationship between health and behaviour, with reference
to breast-feeding, nutrition, child care, sanitation, water use and family planning. What
is fundamentally needed is a greater awareness within the scientific community of the
opportunities that exist, because even a modest shift of attention to such problems could
yield major benefits. Universities can play the role of catalyst and conveners in bringing
the world’s attention to these needs and opportunities.
Some developing countries have made much progress in education, health, family
planning, and nutrition. Other countries have accomplished much less. It is important
to sort out these experiences and to learn lessons about the underlying factors and general
principles which contributed to their success or failure. Universities can seek effective
ways to get the nature and sources of such progress better understood, to identify
particular models which have potentialfor application elsewhere and on a larger scale,
and to develop clearer understanding ofhow such lessons might be absorbed and applied
by other countries.
Internationally Coordinated Research
In the late sixties it became clear that there was an urgent need for increased research
efforts for better methods of prevention and treatment formany diseases especially in the
tropical countries. This has led to explosive developments in the research activities of the
World Health Organization. More than 500 university departments and many thousands
ofscientists are actively involved in internationally-coordinated research efforts on some
of the main health problems of the world. They cover the whole range from the most
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The Role of Universities in the Strategies for Health for All
sophisticated laboratory work and field research. The projects are not limited to
departments of medical faculties but also involve departments in the natural sciences,
social sciences, technology and industry. In addition to these research projects, institu
tion strengthening in developing countries is also an important long-term investment that
aims at establishing viable research units.
The Role of WHO in Research and its Application
A quite different question is the utilization and application of the new knowledge by
health authorities in a given country. This is where WHO has a leading role as catalyst
in the process. In various ways, WHO has stimulated the involvement of the academic
communities in research efforts. With the direction of a minute part of bilateral aid into
multilateral support of such activities, scientific progress and its health applications could
be considerably accelerated.
Involvement in Community Health Services
Leadership responsibility within the university for its involvement in community primary
health care service programmes has varied, but medical schools have been predominant.
They have until recently concentrated on providing hospital-based speciality care
services. The addition of new concepts of primary care service however, has now
broadened and extended the context ofservice to involve the total community health care
system. Schools of public health have often contributed to an understanding of
population-based concepts of health problems and health services as well as the academic
disciplines necessary to support research and education on these issues. Schools of
nursing can substantially contribute to these efforts, particularly given the increased
attention to community-oriented primary health care by nursing internationally.
Some examples of interaction in
Community-based health activities
Primary health care service involvement of the university commonly is multi-discipli
nary; the specific mix varies among institutions depending on specific requirements ofthe
community programme but usually includes some combination of service, teaching, and
research in local, community-based activities. Although schools of medicine, nursing,
public health and allied health professions predominate, schools of the other health
professions, the behavioural and social sciences, civil engineering, and public admini
stration also have participated. Examples include the following:
• technical assistance in planning, organizing, implementing, and evaluating the
community programme;
• continuing education for all health professionals in the programme, including the
development and operation of accessible, up-to-date information and materials
resource centres at field locations;
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• delivery of primary health care services at field locations by faculty preceptors
and students in clinical training;
• research in basic and applied clinical epidemiology for:
assessing community health needs, determining priorities in resource allocation,
setting interim goals, measuring progress, and evaluating programme effective
ness; assessment of cost effectiveness of alternate primary health care technolo
gies, and organizational arrangements for primary health care services delivery.
Obstacles to effective collaboration
While there is no doubt of the potential or importance of university contributions to
Healthfor All efforts, there are still obstacles that stand in the way. Some obstacles have
to do with the universities themselves. They are often seen as:
• trying to model themselves narrowly after established institutions,
• heavily focused on their traditional hospital-based, speciality-oriented, medical
activities and isolated from other health needs of society;
• bound by tradition and resistant to change
• assuming that community-oriented teaching and research will lower standards;
• compartmentalized so that collaboration between different parts of the university
is difficult;
• not closely related to their communities or regions, and having only a dim
perception of world health problems or opportunities;
• misunderstanding the concepts of academic freedom and autonomy in ways that
contribute to their isolation, rather than engaging creatively in societal problems
while retaining control of decisions on the nature of their involvement.
The concept of purpose and service
Perhaps more fundamental are the views of universities about their own purposes. Some
universities believe their purpose to be met by traditional education and research,
unrelated to urgent problems ofsociety; others believe it is imperative that the university
be integrally involved in clarifying societal problems and pursuing their solutions.
The concept of service also presents problems to universities, some seeing it as a drain
on resources and an infringement on academic flexibility; others as an essential route for
the university to effectively engage its research and educational capacities in problems
of broad importance.
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The Role of Universities In the Strategies for Health for All
Problems in relationships
There are also serious problems in relationships between the university and the health
services (referred to here as the Ministry of Health):
• The university and ministry usually have limited communication with one another,
• the university may not invite the ministry to advise on the training of its students,
despite the fact that many will be employed by the ministry;
• the ministry may not invite the university to participate in planning and policymaking, even though the universities have relevant competencies and resources;
• the university may not initiate and the ministry may have no interest in having the
university pursue health services research that could be important in ministry
decision-making;
• they both tend to have constricted views of the universities - about the kinds of
research and education universities should or could do; these restrictions tend to
limit the flexibility of response that the universities should have, and to miss
opportunities of considerable significance for health.
The concept of Health for All places aspirations for certain
developments on both ministries and universities - that there be
universal coverage with effective services, and that the com
munity be actively involved in the planning and provision and of
health services. But often neitherthe ministry northe university
knows how to proceed in practical ways towards fulfilling these
aspirations. Yet they could both benefit by collaborating with
one another in efforts to improve health. They need effective
structural mechanisms for interaction with each other in order
to do so.
The Prospect of Shifts in Relations Between
Universities and Governments
The reasons for the distant relationships between universities and ministries of health
have largely to do with attitudes and values of both sides. Changes in attitudes and
perceptions about the appropriateness of their interactions which would allow both sides
to use their ingenuity and resources to address the problems of health for all in mutually
supportive ways need to be brought about.
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