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Wld Hlth Org. techn. Rep. Ser., 1967, 350
WORLD HEALTH ORGANIZATION
TECHNICAL REPORT SERIES
No. 350
National Health Planning
in Developing Countries
Report of a
WHO Expert Committee
This report contains the collective views of
an international group of experts and does not necessarily
represent the decisions or the stated policy of the
World Health Organization.
GENEVA
1967
3SI?
The World Health Organization ( WHO) is one of the specialized agencies in relationship
with the United Nations. Through this organization, which came into being in 1948, the
public health and medical professions of more than 140 countries exchange their knowledge
and experience and collaborate in an effort to achieve the highest possible level of health
throughout the world. WHO is concerned primarily with problems that individual countries
or territories cannot solve with their own resources—for example, the eradication or control
of malaria, schistosomiasis, smallpox, and other communicable diseases, as well as some
cardiovascular diseases and cancer. Progress towards better health throughout the world
also demands international cooperation in many other activities : for example, setting up
international standards for biological substances, for pesticides and for pesticide spraying
equipment ; compiling an international pharmacopoeia ; drawing up and administering the
International Health Regulations ; revising the international lists of diseases and causes of
death ; assembling and disseminating epidemiological information ; recommending nonpro
prietary names for drugs ; and promoting the exchange of scientific knowledge. In many
parts of the world there is need for improvement in maternal and child health, nutrition,
nursing, mental health, dental health, social and occupational health, environmental health,
public health administration, professional education and training, and health education of
the public. Thus a large share of the Organization's resources is devoted to giving assis
tance and advice in these fields and to making available—often through publications—the
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© World Health Organization 1967
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ance with the provisions of Protocol 2 of the Universal Copyright Convention. Never
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do not imply the expression of any opinion whatsoever on the part of the DirectorGeneral ot the World Health Organization concerning the legal status of any country
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excepted, the names of proprietary products are distinguished by initial capital letters.
PRINTED IN SWITZERLAND
CONTENTS
Page
I.
2.
3.
4.
General background...................................................................................
5
1 .1
1 .2
1.3
1.4
Previous reports on planning........................................................
Technical discussions at the Eighteenth World Health Assembly
Regional seminars and meetings...................................................
Assistance to countries...................................................................
6
8
9
10
Characteristics of developing countries relevant to planning of
socio-economic development
.................
11
The organization of national health planning
13
3.1
The preparation of planning...........................................................
3.1.1 Indirect preparation
..........................................
3.1.2 Direct preparation...............................................................
13
13
16
3.2
Elaboration of the plan: planning methods.............................
3.2.1 The place of health in total development................
3.2.2 The total planning process.............................................
3.2.3 Application of the planning process to health
3.2.4 Choice of priorities in the health sector....................
3.2.5 The evolution of the health plan and medical manpower
3.2.6 Evaluation in national health planning....................
3.2.7 Revision of the plan and the process of continuous
planning.................................................................................
21
21
23
24
26
29
30
3.3
Training for planning.......................................................................
3.3.1 The need for training.......................................................
3.3.2 Personnel to be trained..................................................
3.3.3 Preparation of teachers ..................................................
3.3.4 Training courses . ..............................................................
3.3.5 The training institute......................................................
31
31
32
33
33
36
Future studies................................................................................................
37
. .
39
Annex. Short bibliography of national health planning methods
— 3 —
31
WHO EXPERT COMMITTEE
ON NATIONAL HEALTH PLANNING IN DEVELOPING COUNTRIES
Geneva, 27 September - 3 October 1966
Members :
Mr B. Abcl-Smith, Professor of Social Administration, London School of Eco
nomics and Political Science, London, England
Dr T. Bana, Director General, Public Health Service, Ministry of Health, Niamey,
N iger (Vice- Chairman)
Dr N. Espinosa, Head, Technical Department, National Health Service, Santiago,
Chile
Dr F. Rizk Hassan, Under-Secretary of State, Ministry of Public Health, Cairo, UAR
Dr H. E. Hilleboe, Professor of Public Health Practice, Columbia University, New
York, USA {Rapporteur)
Dr N. Jungalwalla, Additional Director-General of Health Services, Ministry of
Health, New Delhi, India {Chairman)
Dr G. A. Popov, Head of Public Health Planning Department, Ministry of Health
of the USSR, Moscow, USSR
Representative of the United Nations :
Mr H. Gille, Director, Division of Social Affairs, United Nations, Geneva
Secretariat :
Dr A. Leslie Banks, Professor of Human Ecology, University of Cambridge, England
{Consultant)
Dr A. Barkhuus, Chief Medical Officer, National Health Planning, WHO {Secretary)
Professor G. Destanne de Bernis, Faculty of Law and Economic Sciences, University
of Grenoble, France {Consultant)
Dr L. Kaprio, Director, Division of Public Health Services, WHO
Wld Hlth Org. techn. Rep. Ser., 1967, 350
NATIONAL HEALTH PLANNING
IN DEVELOPING COUNTRIES
Report of a WHO Expert Committee
A WHO Expert Committee on National Health Planning in Developing
Countries met in Geneva from 27 September to 3 October 1966. Dr P. Dorolle, Deputy Director-General, opened the meeting on behalf of the
Director-General and explained that the Committee’s task was to attempt
to answer four fundamental questions : when is a country ready to plan ?,
what machinery does it need for planning?, how is planning carried out?
and who are to be involved in it and what training do they require?
Dr N. Jungalwalla was elected Chairman, Dr T. Bana Vice-Chairman
and Dr H. E. Hilleboe Rapporteur.
1.
GENERAL BACKGROUND
Since 1951, four WHO Expert Committees on Public Health Admini
stration have been concerned largely with health planning. The technical
discussions at the Eighteenth World Health Assembly, held in 1965, also
were devoted to this subject.
Several meetings to discuss this subject have taken place under PAHO/
WHO sponsorship in the Americas. In addition, a WHO regional seminar
on national health planning was held in Manila, Philippines, in June 1964
and a WHO inter-regional seminar in Addis Ababa in October 1965. At
the latter, several national health planning projects undertaken by WHO
during the previous two years in certain African countries were considered.
Various aspects of the subject have also received intensive study in national
academic and research institutes and there is now an extensive literature.1
Governments in developing countries arc becoming increasingly aware
of the advantages of health planning at a national level and are therefore
anxious to utilize for this purpose techniques that take into account the
specific problems of their country. The task of advising on the prac
tical approaches to national health planning, as an integral part of socio
economic development, has therefore become urgent.
1 Bibliography on health planning (1965) Geneva, World Health Organization (unpub
lished document A18/Technical Discussions/5) ; sec also the Annex to this report.
— 5 —
6
1.1
NATIONAL HEALTH PLANNING
Previous reports on planning
The earlier WHO Expert Committees on Public Health Administration
were much preoccupied with the lack of system in the organization of
medical and health services. It will be useful first to examine briefly the
gist of their reports.
The first report1 dealt “ in a general way with some of the many impor
tant problems which are met with in health administration in different
countries ”. The committee agreed that the trend in the development of
health care made it necessary for doctors to assume more general admini
strative responsibility, and drew attention to the need for more detailed
study of the organization and of the mode of financing of health programmes
in different countries.
The committee stressed the importance of establishing a decentralized
administration effectively geared to the policy of the central authority and
considered that national health administrations should provide, for local
health departments, comprehensive planning, including medical legislation,
leadership and technical assistance in specialized fields.
The committee drew up a “ list of health provisions ” under two main
headings : one covering those services provided directly by health authorities
or jointly with other authorities and a second enumerating other services
that contribute to health. This list was revised and expanded to form
Annex 1 of the fourth report (see below).
The second1
2 and third34reports went in greater detail into the organiza
tion of health services at the local level. The second report concentrated
on the methodology of planning an integrated health programme for rural
areas and the third report dealt especially with urban areas.
The second report emphasized the important role that local planning
committees can play in stimulating local interest in planning. It was con
sidered that, although national health authorities are in general respon
sible for both health planning and co-ordination for the entire country,
the participation of intermediate and local authorities would be an asset.
The fourth report,11 like the first, dealt with general principles. It was
concerned with long-term planning at the national or federal level to ensure
that health services are developed “ in an orderly and efficient manner ”,
Faced with the difficulty of defining “ public health ”, the committee
adopted from the first report an amended form of Winslow’s definition.5*
1 Wld Hlth Org. teehn. Rep. Ser., 1952, 55.
- Wld Hlth Org. teehn. Rep. Ser., 1954, 83.
3 Wld Hlth Org. teehn. Rep. Ser., 1960, 194.
4 Wld Hlth Org. teehn. Rep. Ser., 1961, 215.
5 Winslow, C.-E. A. (1923) The evolution and significance of the modern public health
campaign. New Haven, p. 1.
REPORT OF A WHO EXPERT COMMITTEE
7
It then defined “ public health services” as all those personal and com
munity services, including medical care, directed towards the protection and
promotion of the health of the community. It agreed that, whatever the
social and economic system of the country, national health planning is an
essential part of national development and policy, and that it is the respon
sibility of public health administrators to convince governments of the
need to provide adequate funds for health services.
The committee felt that, in the establishment of priorities in health
work, emphasis should be placed on prevention ; on the provision of
services for people engaged in productive work and for mothers and chil
dren ; and on work that affects the health of the largest number of people
and contributes most to the improvement of the nutritional standard of
the population.
The committee recommended enlisting the full support of professional
organizations, especially those of doctors and nurses, and of the services
concerned with medical research, medical education and public health.
Attention was drawn to the need for the even distribution of health services
throughout urban and rural areas and for the discussion of plans with
other governmental and non-governmental organizations.
After the final decision has been reached on targets and objectives,
the central health authority should broadly allocate the services to be
planned to the different regional, local or individual health organizations
or institutions in the country, each of which should then prepare more
detailed programmes for each specific function needed to fulfil the objectives
of the plan. This would involve :
(a) establishment of the administrative organization needed to imple
ment the plan (including the different specific programmes) ;
(/>) recruitment, education and training of personnel ;
(c) estimation of requirements of medical supplies and equipment;
(r/) estimation of number and type of buildings needed ;
(<?) estimation of the cost of financing the plan in terms of both capital
and recurrent expenditure (ensuring, as far as possible, that funds are
available to meet recurring expenses) ;
(/) provision of a time-table for implementation of the plan by phases,
over a period of years.
These individual programmes would then be assembled and examined
by the central health authority and modified as necessary to harmonize
with the over-all health targets and objectives and to ensure a balanced
distribution of personnel and material resources, especially the financial
allocations approved by the relevant central authority.
The integrated over-all long-term national health plan could then be
circulated to the different health organizations to permit them to check
8
NATIONAL HEALTH PLANNING
the part that they are to play. This would afford another opportunity for
readjustment before the plan was presented to the legislative body for
discussion and approval.
The committee recommended that operational research in public health
be carried out in the quest for a more objective basis for planning, which
in most countries is still empirical. The research topics outlined by the
committee included health indicators, the methodology of anticipating
the impact of epidemic waves, time and motion studies, motivation in the
use or non-use of health services, standards for health laboratories and
services, the cost to the economy of disease and disability and the outlay
needed to reduce this cost. Pilot studies of these factors in the planning
of public health services at different levels of government administration
were recommended.
1.2
Technical discussions at the Eighteenth World Health Assembly
The increasing importance being attached to health planning may be
gauged from the fact that this formed the subject for the technical discus
sions at the Eighteenth World Health Assembly, held in May 1965. The
topic chosen reflected the growing interest in rational organization and
deployment of national resources for over-all economic and social develop
ment.
The report of these discussions 1 emphasized that the provision, training
and equitable distribution of personnel presented the greatest difficulties,
and that constant review was essential.
The following preconditions and prerequisite data for health planning
were generally accepted.
Preconditions
(1) An understanding of the government’s interest, aims and assessment of objec
tives in national socio-economic development and of its policy in respect of health plan
ning as one of its integral parts. Strategical decisions should be taken by the govern
ment, especially where a new system is being introduced.
(2) Enabling legislation for planning and subsequent implementation of the plan.
(3) A planning organization for over-all socio-economic planning at policy- and
decision-making level, and a health planning organization that is part of the former or
exists at the same level.
(4) Arrangements for co-ordination between all planning organizations and between
these organizations and the relevant government departments.
Prerequisite data
(1)
Demographic data—national, regional or provincial, and local.
1 Report of the technical discussions at the Eighteenth World Health Assembly : Health
planning (1965) Geneva, World Health Organization (unpublished document A18/
Technical Discussions/6 Rev. 1).
REPORT OF A WHO EXPERT COMMITTEE
9
(2) Vital and health statistics (crude and infant mortality rates, deaths by causes,
morbidity data, hospital admissions, etc.).
(3) An inventory of public and private health service institutions, including training
institutions, and a complete analysis by categories of health service manpower, whether
employed by the government or practising independently.
(4) Information on the current national economic background and general man
power position.
(5)
A statement of the financial allocations to the health services.
Some authorities would regard these as too restricted in scope and
would request the addition of the following :
(n) hospital morbidity and mortality data,
(b) the results of mass screening investigations into the prevalence of certain specified
or asymptomatic diseases and the physical fitness of certain vulnerable groups, data on
the growth of urbanization, and information on the extent of nomadism.
It was accepted as axiomatic that the national ministry of health (subject
only to cabinet approval) should be finally responsible for the health plan
and its implementation, but that there should be a continuous dialogue
between the politicians and health experts at the centre and the health
workers in the field.
The following specific recommendations for action by the World
Health Organization were made :
(i) Research
WHO should institute or support research into the establishment of
“ norms ” of provision for use in the planning of health services. Despite
the great need for quantifiable objectives the quality of the services should
be safeguarded.
(ii) Training
WHO should institute or support courses of training in health planning.
(iii) Planning procedures
WHO should provide guidelines in health planning with a view to
facilitating planning operations in developing countries.
1.3
Regional seminars and meetings
Inter-Regional Seminar on National Health Planning, Addis Ababa, Octo
ber 1965
The principal aim of this seminar was to utilize the experience gained
in integrated planning projects undertaken during the previous two years
by WHO in association with several African governments. Detailed health
plans for several countries in the WHO African Region, together with
10
NATIONAL HEALTH PLANNING
the comments of the officers chiefly concerned in their preparation, were
discussed.
Pan American Health Organization (PAHO)
PAHO participated in April 1959 in the second meeting of the Special
Committee of the Organization of American States (Committee of 21),
at which it was decided that health problems should be considered funda
mental in the planning of economic and social development. The third
meeting of the Committee of 21, in September 1960, from which sprang
the Act of Bogota, delineated the various components of well-being and
enumerated those aspects of individual and collective health that all the
countries of the American continent considered of great importance.
In February 1965, a working group met in Puerto Azul, Venezuela,
to analyse the work carried out in Latin America and, especially, the
application of the methodology developed by PAHO 1 in co-operation with
the Centre for Development Studies (CENDES) of the Central University
of Venezuela. The group recognized the important progress that had been
made and the usefulness of the methodology. It was noted that lack of
information and administrative deficiencies were limitations in its adequate
application but that the situation generally improved once planning was
initiated.
Regional Seminar on National Health Planning, Manila, June 1964
At this seminar,12 current practices and experiences in national health
planning in countries of the WHO Western Pacific Region were reviewed,
modern guidelines for national health planning were discussed and the
resources of countries and the means required by them to implement their
national health plans were assessed.
1.4
Assistance to countries
WHO has been assisting five African countries in national health plan
ning ; four of the plans are now in print 3 and the fifth (for Liberia) will
1 Pan American Health Organization, Study Group on Health Planning (1965)
Final report, Washington, D.C. (document PS/18).
2 WHO Regional Office for the Western Pacific (1964) Report on the First Regional
Seminar on National Health Planning, Manila, Philippines, 3-17 June 1964, Manila
(document WPRO/380/64).
3 Rdpubliquc du Gabon, Ministerc de la Sante publique ct de la Population (1965)
Plan quindecennal 1966-80 de Developpement des Services de Same, Libreville ; Rdpublique
du Mali, Ministerc de la SantiS publique et des Affaires socialcs (1966) Plan di’cennal
(/" juillet 1966 - 30 Join 1976} de Developpement des Services de Same, Bamako ; Rdpublique du Niger, Ministerc de la Santi publique (1964) Perspectives dicennales 1965-74
de Developpement des Services de Same, Niamey; Sierra Leone Government. Ministry
of Health (1965) National Health Plan 1965-75, Freetown.
REPORT OF A WHO EXPERT COMMITTEE
11
soon be available. The approach to planning in the five countries was
pragmatic and has been discussed fully in the preliminary report on the
Addis Ababa Seminar.1 The WHO Regional Office for the Eastern Mediter
ranean has assisted national planning projects in Somalia and Libya and
the WHO Regional Office for the Western Pacific is giving assistance
in Korea.
Through the agency of PAHO, many of the countries in the American
continent have been receiving guidance and assistance in national health
planning.
2.
CHARACTERISTICS OF DEVELOPING COUNTRIES
RELEVANT TO PLANNING OF SOCIO-ECONOMIC
DEVELOPMENT
Developing countries are characterized by three features that may be
present in various degrees according to their stage of development :
(1) Factors that limit or hamper communication between regions,
between sectors of activities or between social groups. In the health field
the consequences are :
(a) the difficulty of educating an illiterate population in health matters,
(Z>) the limited ability of the marketing structure to provide the popula
tion with supplies adequate to their needs,
(c) the outmoded agrarian structure, which impedes the production
of food.
(2) The uneven economic development (commodities produced at a low
productivity are paid for at less than their real value), which results in
production becoming directed towards exports and not towards food
supplies, with the result that standards of living arc so low that even the
more elementary health needs cannot be met.
(3) The presence of “ vicious circles ”, e.g., that of poor nutrition and
low productivity, which can be broken only through economic measures
that, by increasing food production, contribute to improved nutrition
and general health conditions.
The three fundamental components of any development policy imply
a close relationship between decisions in the health sector and those in
the economic sector ; they are :
1 WHO Inter-Regional Seminar on National Health Planning, Addis Ababa, Ethiopia,
11-12 October 1965, Interim report, Geneva (unpublished WHO document PA/66.5).
12
NATIONAL HEALTH PLANNING
(1) an increase of the accumulation rate ;1 the maximization of surplus
is achieved only by making a definite choice of the crops to be grown, and
this also determines the level of nutrition ; the mobilization of surplus
necessitates a reorganization of marketing structures and the establishment,
after consultation with public health specialists, of a list of commodities
to be placed at the population’s disposal;
(2) the distribution of accumulation between development consump
tion and investment, which cannot be undertaken without consultation
with health and educational administrators, who will take into considera
tion the principal needs of the country;
(3) industrialization, which will be successful only if measures are
taken to avoid a deterioration in living standards.
The Committee recognized certain fundamental principles that establish
the link between social and economic development and matters of health.
Economic and social sectors are inseparable, since (a) health is a means
of development, (/>) economic development is a means towards the attain
ment of health, and (c) health constitutes one of the objectives of economic
development. Thus, so far as health is concerned, there is an imperative
need for continuing discussion between economists and physicians at all
levels of responsibility and in all sectors of activity.
Because all developing countries have limited resources, choices among
competitive ends are inevitable and it is essential to consider all economic
measures that could improve health. At the same time, consideration
must be given to the factors that improve the productive capacity of men,
e.g., education and health, and the accumulation of “ things ” (e.g., ma
chinery, production plant) needed to increase productivity.
1 For the purposes of this report, the Committee adopted the following definitions:
Necessary consumption is the consumption needed to ensure the survival of the
population and the operation of the economy at its existing level.
Development consumption is the sum of those goods and services that are indis
pensable for ensuring the development of the economy, because they both represent
a rise in the level of satisfaction and are prerequisite for any increase in the productivity
of the labour force (e.g., education, health).
Surplus is the excess of production (individual or national) over the necessary con
sumption (individual or national).
Investment is the increase in the stock of “things” (machines, production plant,
etc.) at the disposal of the economy as a whole.
Accumulation is the sum of development consumption and of investment.
Rate of accumulation is the ratio of accumulation to the gross national product.
This quantity, other things being equal, determines the possibility of increasing the rate
of growth of the economy as a whole.
REPORT OF A WHO EXPERT COMMITTEE
13
3. THE ORGANIZATION
OF NATIONAL HEALTH PLANNING
The Committee recognized the necessity for a developing country to
begin national health planning as soon as possible, and noted that the
quality of planning would improve with experience. The Committee
identified two main steps : (a) the preparation of planning and (b) planning
itself. The rest of this report is concerned with these topics and with train
ing for planning.
3.1
The preparation of planning
There are two levels of preparation—indirect (often called the pre
planning stage) and direct (concerned with the organization of the machinery
for planning).
3.1.1
Indirect preparation
Indirect preparation will be considered under two sub-headings,
namely—the conditions of national health planning and the basic data
required.
3.1
. 1.1
Conditions of planning
In the first countries to become industrialized, three motives stood
out in the development of health services :
(a) the economic motive, based on the realization that workers whose
health was protected lived longer and produced more,
(6) the fear motive, e.g., fear of epidemic diseases, especially cholera,
(c) the altruistic motive—compassion for other men.
These same motives underlie health planning today.
National health planning is an integral part of general social and eco
nomic planning. It is a process that may vary from country to country
and even in the same country at different times. Some of the more im
portant conditions are as follows :
The government's interest in national socio-economic development plan
ning and in national health planning should be clearly indicated. However.
governments change and so may their interests. Nevertheless, it is essential
that the preparation of a national health plan is based on clear and sustained
directives given by the political authority. Such planning is complicated
14
NATIONAL HEALTH PLANNING
in many developing countries by the political instability of governments,
whereby both the planning and the execution of programmes are abruptly
and recurringly interrupted. The problem of obtaining continuity under
these circumstances remains unsolved.
Enabling legislation for planning and subsequent implementation of the
plan is desirable. Laws and regulations facilitate setting the planning
machinery in motion, but it is sometimes possible to proceed without
them.
A planning organization for over-all socio-economic planning at policy
level and decision-making level should co-ordinate and integrate sectoral
planning undertaken by groups that are in constant touch with the central
planning agency.
Administrative capacity is essential : it has been estimated that over 80 %
of the failures in socio-economic plans are due to administrative failure,
and that administrative systems of government in almost all developing
countries with limited resources are inadequate and must be strengthened
during the pre-planning period.
The basic difficulty is that few health administrators possess an adequate
knowledge of recent advances in public administration. New recruits to
public health work need formal training in administrative organization and
management. Senior health administration officers may need refresher
courses and education in decision-making and problem-solving. Lay
administrators can assist physicians to their mutual benefit, both in the
planning and in the execution of health programmes.
“ Planning ” includes the provision of professional personnel from the
political sciences as well as the medical sciences to give administrative
direction to comprehensive health programmes. Throughout the whole
planning process, from diagnosis to evaluation, there is room for a variety
of specialists, including those from the social sciences, to assist the health
team, both in planning and in implementation. This matter is discussed
in the section on training (section 3.3).
The health administrator is largely occupied with decision-making and
planning in his day-to-day tasks. He needs to know and apply a knowledge
of decision-making gained from the associated fields of public and business
administration. He needs to decentralize decision-making to the lowest
possible organizational levels, as a shared responsibility wherever competent
staff arc available. This does not just happen—it has to be planned.
Concentrated training courses in decision-making and planning should
be an integral part of national health planning. Much can be accomplished
in a course of several weeks if this initial exposure to experts in administra
tive practice is followed by shorter courses at regular intervals. Non
medical administrators should also take part in these courses.
REPORT OF A WHO EXPERT COMMITTEE
15
3.1.1.2 Basic data required for national health planning
When no data are available, or when the lack of accurate and complete
data is a serious problem, the collection of essential data will have to be
pursued simultaneously with planning, the plans being modified in the
light of the information that emerges. The basic information used for
health planning can be listed under the following headings :
(1) Indicators of resources
Money. Expenditure on health services analysed by items and by
sources of finance ;1
Manpower. Personnel of different categories used in the provision of
health services, including indices of utilization ; 2
Facilities. The number of hospital beds and other phsyical facilities,
plus equipment and supplies, in which health services are provided, includ
ing indices of utilization ;
Organization. The organization of the health services, indicating the
combined functions of different persons (the “ team ” concept) and the
availability of equipment and supplies.
(2)
Indices of health and disease
These indices include mortality, morbidity, disability rates and ratios,
and levels of health.
Some of the resources indices arc especially useful, c.g., hospital beds
per 1000 population, doctors per 100 000 population, cost per tuberculin
test in TB case-finding, or cost of health centres for a large rural republic.
Health indicators are useful but have to be used with caution, as, for
example, in comparing deaths from abortion per 1000 pregnancies in
Chile and in the USSR. In comparisons between countries, hidden variables
may invalidate the conclusions.
All countries need to collect the information set out under the first
heading (indicators of resources). Indices of utilization show that part of
the need for health services that is currently being met and the diseases
that arc currently receiving attention. Health planning need not await the
availability of precise information on indices of health. A broad indication
of the more prevalent diseases is suficient for the preparation of a health
plan and such a broad indication can normally be obtained by a study
of utilization statistics. This is not to deny that the more precise the infor
1 Abd-Smith, B. (1963) Paying for health services—a study of the costs and sources
of finance in six countries, Geneva, World Health Organization (Pubt. Hllh Pap., 11).
' World Health Statistics Annual 1962 : Volume III, Health Personnel and Hospital
Establishments (1966) Geneva, World Health Organization.
16
NATIONAL HEALTH PLANNING
mation on levels of health and the causes of ill-health available to health
planners, the better is the quality of the plan that can be developed.
In planning, different indices may be used for the different levels of
operation. For instance, the public health plan for a town or rural area
may take into account the number of hospitals and hospital beds, the
amount of capital construction, or the number of medical workers needed.
It may refer to specialized care provided for different groups of the popula
tion (e.g., children, women, industrial workers) and to preventive measures
(e.g., medical examinations, vaccinations).
From the highest level of the administration to the lowest, the indices
must be defined in precisely the same way. Some of the planning indices
may be standards.1
Further information on basic data for planning will be found in the
fourth report of the WHO Expert Committee on Public Health Administra
tion 1
2 and in the report of a WHO Study Group on Measurement of Levels
of Health.3
3.1.2 Direct preparation
There is now a fairly extensive literature on direct preparation (which
is concerned with the organization of the machinery for planning) 4 and it
is evident that the pattern of development and the machinery for socio
economic planning established in a country depend largely on its political,
social and economic institutions and its stage of development. It is beyond
the scope of this report to discuss the central planning organization in detail.
As already mentioned, it is essential that, in any country embarking
on national health planning, there should already exist some type of central
1 Public health standards are : the quantitative indices of the state of the environ
ment, health, epidemiological and medical care; hospital beds per number of popula
tion ; medical staff per number of population ; supply of drugs, equipment and transporta
tion; indices of the extent to which medical services are used (personnel, hospital beds,
equipment) ; size of hospital site, area of hospital premises; auxiliary premises and budg
etary appropriations for construction and maintenance of medical institutions.
2 Wld Hlth Org. techn. Rep. Ser., 1961, 215.
3 Wld Hlth Org. techn. Rep. Ser., 1957, 137.
1 The Committee recognized that the terminology of the administrative structure
varies from country to country. For the purpose of this report the Committee defined
the following terms :
The central planning authority is the body which, subject to the overriding authority
of the cabinet, is the one highest placed in the government in matters pertaining to socio
economic planning.
The central planning unit is the technical bureau in charge of the actual process of
planning and acts as the secretariat for the central planning authority.
The machinery for health planning within the ministry ot health is based generally
on two units :
The Ministry of Health planning committee and
The planning unit, which, inter alia, acts as the secretariat to the planning committee.
REPORT OF A WHO EXPERT COMMITTEE
17
planning authority responsible for the co-ordination of all planning activities.
In some cases the health and sanitary conditions of a country are of such
importance for its development that the minister of health should, when
ever possible, be a member of this planning authority. The central plan
ning authority is normally headed by the country’s chief executive and is
therefore in a strong position to have its decisions adopted by the full
Cabinet.
A central planning unit, in whatever form it has been established,
should act as the secretariat for the central planning authority. It is most
important to stress that the sectoral planning team (e.g., for health) and
the central national planning authority should achieve the greatest possible
degree of co-ordination.
3.1.2.1 The health planning process
The health planning process itself might be said to comprise a logical
series of steps, for example :
(1) assessment of the problem, including drawing up an inventory of
available resources ;
(2) formulation of the plan, i.e., definition of objectives and priorities,
together with the resources necessary for their attainment;
(3) discussion and acceptance of the plan by the political head on
behalf of the community ;
(4) implementation ;
(5) periodic evaluation of the plan’s effectiveness in fulfilling health
objectives.
The machinery for the above task (with the exception of implementa
tion) consists generally of two units : (1) a planning committee in the
ministry of health and (2) a planning unit that also acts as secretariat for
this committee.
3.1.2.2 The health planning committee
The technical tasks of the committee consist in (a) integrating projects
proposed by the operating organization into programmes for medium
term and short-term (including annual) periods, (b) submitting programmes
to, and defending them before, central planning and budgetary authorities,
(c) recommending policies and administrative and other measures required
in carrying out the programme and (cl) reviewing and evaluating the pro
gramme.
It may be helpful at this point to distinguish between “ projects ” and
“ comprehensive plans ”, for it is possible to initiate planning by way
of carefully prepared projects with limited objectives and full financial
support and later go on to the preparation of a comprehensive plan. The
18
NATIONAL HEALTH PLANNING
choice will often depend on the available expertise, the time factor and
the administrative machinery at hand.
3.1.2.3
The health planning unit
Although arrangements for planning at the higher levels are important,
especially in relation to co-ordination and finance, the detailed work will
be done within the planning unit. It is therefore essential to lay down
clearly its terms of reference from the outset. The concept of “ planning ”
is new to many people and the unit may find itself isolated and starved of
information as a result of misunderstanding and suspicion of its functions.
Moreover, planners have been known to exaggerate their importance,
with equally unfortunate results.
A strong “ sectoral ” team, meeting regularly, would do much to keep
the perspective right. Planning is a continuous process; someone must
have the responsibility for ensuring continuity. The preparation of a first
plan may require 12 to 18 months or even considerably longer. If the plan
consists, in effect, of a series of projects with set target dates and approved
expenditure and there is a good general administrative machinery within
the ministry of health, these projects can safely be handed over to the
responsible executive divisions, e.g., those for rural health services, hos
pitals, personnel or finance. The responsibilities of the planning unit can
then be limited to measuring progress, with a view to making subsequent
plans more realistic.
3.1.2.4
Staffing of the planning unit
Staffing of the planning unit may present considerable problems. Most
ministries of health in developing countries are seriously understaffed and
such staff as is available is already overburdened. Few medical personnel
have a knowledge of planning, and experience has shown that plans drawn
up by a visiting team, particularly if its members are unfamiliar with the
country and have spent only a few weeks there, may prove superficial and
unrealistic ; moreover, such teams do not assist in the building of a perma
nent organization. The nucleus of the planning unit must consist of local
personnel, though external advisers may be brought in to assist.
It is also becoming increasingly evident that the planning team should
include non-medical experts, either as permanent members or as readily
available consultants. A general administrator can provide expert knowl
edge of administrative organization and management. A statistician is
essential for checking and assessing data and an accountant for preparing
the cost analysis. Legal advice may also be desirable, to ensure that legis
lative authority exists to implement the plan or to draft amending legisla
tion where this is needed. The team should also benefit from the advice
of experts in economics, demography and sociology.
REPORT OF A WHO EXPERT COMMITTEE
19
There is also the question of adequate clerical assistance, for the plan
is built up on details ; reliable book-keeping, record-keeping and filing are
essential. So also are adequate facilities for preparing and duplicating
documents, since the unit serves as secretariat to the planning committee.
3.1.2.5
International aspects
The Committee recognized that WHO is under considerable pressure
to act quickly in providing advice on machinery for planning, including
the question of timing and the type of experts needed. Conditions vary
so markedly in different countries that a plan of action must be made by
someone on the spot. On the other hand, in developing countries trained
staff is often scarce and the few men of experience available are submerged
by their daily tasks. In many instances, therefore, only preliminary plan
ning by external experts is possible, but then there must also be national
counterparts.
The plan should be drawn up by the national staff with the advice of
planning consultants, since this will be important for its implementation.
Each country has its own problems and it is the responsibility of the officials
within the country to conduct the day-to-day administration of health
services. These responsibilities cannot devolve on external consultants
called in to prepare a national health plan. Before the planning experts
can begin their tasks they must know what has already been done. It is
important to identify the responsibilities and duties of all members of the
planning team and it should be noted that planning forms a part of admini
stration and cannot be separated from it.
In considering the qualifications required of the national staff, it must
be borne in mind that doctors undertaking planning should have wide
experience in the health services of their own and similar countries, as
well as a medical education and background that will inspire the confidence
of their colleagues.
3.1
.2.6 Co-ordination with other sectors
In several fields close co-operation with other ministries is essential.
Medical education and education in a number of specialties, such as sanitary
engineering, dentistry and nutrition, are often the concern of the ministry
of education or, possibly, of independent institutions. The ministry of
education may also have its own school health services and health teaching
facilities. Although the ministry of health usually supervises environ
mental sanitary installations, the provision of such installations is often
the responsibility of the ministry of public works. The ministry of health
has overlapping interests with the ministry of agriculture in nutrition and
veterinary public health, with the ministry of labour in occupational
hygiene, and so on.
20
NATIONAL HEALTH PLANNING
3.1.2.7 Prevailing patterns
Consideration of the planning machinery in various countries brings
out the need for a highly qualified staff and for making full use of existing
facilities, e.g., statistical departments, without duplicating them for plan
ning purposes. The ministry of health must play a salient part in co
ordination at all levels. Although in some countries it may be possible to
decentralize responsibilities, the extent to which this can be done must
again be determined by the framework of local government within the
country. A national health plan must take into account all health resources
within the country, including manpower and the money spent on medical
services, including the private sector.
The importance of communication between those responsible for the
preparation of the national health plan and the over-all socio-economic
planners cannot be overemphasized. As already mentioned, the WHO
Regional Office for the Americas has used local courses lasting from three
weeks to three months to acquaint senior officials and representatives
of professional organizations with the fundamental principles involved
in planning. Much resistance to planning, largely due to the lack of
a clear understanding of the basic principles, is thereby avoided and the
active participation of the important medical and paramedical organiza
tions is enlisted.
3.1.2.8 Responsibility for planning
Although the central planning authority is generally responsible for
the co-ordination of planning, it is accepted that the ministry of health
should be responsible for taking and keeping the initiative in the planning
of the health sector. In considering co-ordination at different levels in
the health field, it must be remembered that in many countries local selfgovernment units are at different stages of evolution and that in certain
technical fields their responsibilities in the field of health overlap those of
the central government.
There is, therefore, no alternative at present to action by the ministry
of health in evolving the over-all health plan and the ministry must be
accepted within the country as the body competent to do this.
3.1
.2.9 Co-ordination with the professions
With regard to co-ordination with professional organizations, it is again
not possible to generalize. In smaller countries informal methods may be
practicable, whereas in larger countries co-ordination may be achieved by
direct consultation by the ministry of health with representatives of each
body and by having representatives of the professional organizations on
the planning advisory committees.
REPORT OF A WHO EXPERT COMMITTEE
21
3.1.2.10 Community participation
Political leaders must be convinced that there is a need for planning.
The health expert can help the politician to understand, accept and actively
support health planning. When health plans have been prepared they
should be brought to the notice of the political leaders as quickly as possible
as the best way to meet the health needs of their constituents and to dis
tribute resources fairly. Health experts can use health education technique
to gain the confidence of politicians in health planning and to secure com
munity participation.
The successful implementation of a health plan rests upon the close
co-operation of the whole population of the country. It would therefore,
in theory, be desirable for representatives of the people to participate in
planning at the local as well as at the central level. In many developing
countries this is not practicable, since local systems of representation have
not always evolved and there are special difficulties where there is a high
degree of illiteracy. Health education for the community and, especially, for
schoolchildren will thus need to come into the curriculum of planning
training. There is particular need to adopt some of the principles and prac
tices of the behavioural sciences. Hope for the future may well rest in
teaching children concepts of health that will motivate them to protect
their own and their communities’ health when they become adults.
It will often be necessary for those in positions of responsibility at the
central level to assess the needs of the people and to provide for these needs
as far as possible within the plan. Where resources are limited it may be
desirable to acquaint the political leaders with possible alternatives, so that
they are fully aware of the range of priorities on which to build up the
expectations of the people. In this respect the medical profession, where
it is well organized, can help greatly, but in this matter, as in many others,
the final decision is a political one. Once the health plan has been prepared,
the over-all principles should be understood by the whole population ; the
success of the plan may well depend on this.
3.2
Elaboration of the plan : planning methods
3.2.1
The place of health in total development
It was pointed out in an earlier section of this report that any plan
for health services should be closely integrated with the plan for the whole
economy. Moreover, health skills are not only needed to plan health
services ; they are also needed to assist in the planning of other sectors
of the economy that have important health aspects. For example, the
provision of water supplies and of housing has important health aspects,
which need to be considered when plans are laid down. Similarly, there is
22
NATIONAL HEALTH PLANNING
be recognized when an agricultural policy is being developed. Thus, in
considering the discussion of health sendees that follows, it should be
appreciated that health planners have important contributions to make
outside the specialized field of health services with which this report is
principally concerned.
The battle against disease and the maintenance of high levels of health
are important in relation to the fulfilment of economic policy. Morbidity
affects both attendance at work and the quantity and quality of work
achieved. Deaths in early life involve not only human tragedies but also
a waste of social investment. Some of the economic effects of inadequate
health services can be measured and the provision of health services can
make important contributions to economic growth. However, not all
health services contribute to- economic objectives, nor should economic
output necessarily be the principal objective in the provision of health
services. Nevertheless, certain health services in certain economic circum
stances can play an important part in economic development.
It is of course generally recognized that the ultimate objective of all development
efforts is the improvement of the standard of living of the people. The inclusion of
social development objectives in over-all development objectives therefore implies the
setting of targets in terms of various indicators of levels of living such as per capita
food consumption, literacy ratios, life expectancy.1
It is because the purpose of health services is partly to provide a humani
tarian service that helps to maintain social cohesion and partly to assist
with economic growth that no simple formula can be evolved that lays
down the precise role health services should play in economic and social
development. Rivkin has stated2 that governments are under strong
pressure to allocate resources to social services and that the provision of
such services can put excessive strain on limited economic and manpower
resources.
In view of the difficulty of producing any “ scientific ” basis for deter
mining what proportion of national resources should be devoted to health
services, it is not surprising that empirical study has failed to show that
health spending is, in practice, determined by any clear criteria. Over the
last ten years, WHO has envolved a standard framework for national
health accountancy. Definitions have been developed and applied for
health expenditure, for its functional components and for different sources
of finance. It has been observed that, although countries with a higher
national income per head tend to spend a higher proportion of their
1 Economic Commission for Africa (1965) The concept and content of economic
and social planning, Geneva, World Health Organization (unpublished document NHP/
SEM./WP/10.65). p. 11.
Rivkin, A. (1963) The African presence in world affairs : national development and
its role in foreign policy, London, Free Press of Glencoe, p. US.
REPORT OF A WHO EXPERT COMMITTEE
23
resources on health services, a wide variation exists in the proportion so
spent, both among high-income and among low-income countries. Never
theless, no low-income country spends more than 4 % of its gross national
product on health services. If the private sector of health services is excluded
where it tends to benefit a very small proportion of the wealthier urban
population, no low-income country spends more than 2 !4 % of its gross
national product on health services ; most spend only 1-2 %. Low-income
countries tend not to charge for health services, whereas in some highincome countries most of the population have to pay the full cost of these
services.
The evidence does not suggest that the countries that have the greatest
need for health services spend the most on them. Nor do the different
methods of financing seem to determine what is spent on health. The
level of health spending seems to be determined more by the history of
each country than by more rational criteria. Thus, for example, even
such factors as the proportion of physicians among ministers or in the
legislature might have a significant influence on the level of health spending.
In low-income countries, the decision on the amount to be spent on health
services is, perhaps inevitably, a political one and in that (albeit limited)
sense can be said to represent the felt needs of the country.
Most health administrators have extremely limited resources; whereas
in developed countries the health authorities are provided with as much
as USS 74 a year per capita, in many developing countries less than
USS 2 is made available.
In view of the present difficulty of comparing the effects of measures
in the health field with those of measures in other sectors (e.g., education,
production), the Committee believes that further research is needed (a) on
the criteria for the distribution of resources between the health and other
sectors and (Z>) on the criteria for determining the allocation of resources
within the health sector.
3.2.2
The total planning process
The central planning authority lays down the broad guidelines for the
over-all social and economic plan of the country to cover all the sectors
of economic and social policy. Such guidelines include :
(1)
(2)
(3)
(4)
criteria for the determination of broad consumption objectives ;
policy objectives in the distribution of income ;
broad policy objectives to be fulfilled in each sector ;
a rough indication of the distribution of resources between sectors.
Within the framework of these various objectives, each sector (educa
tion, health, agriculture, fisheries, basic industries, consumption industries,
24
NATIONAL HEALTH PLANNING
transport, trade, etc.) prepares its own draft plan. Every sectoral plan
calls for:
(1) an accurate assessment (diagnosis) of the existing situation ;
(2) definition of the means recommended to improve the efficiency in
the operations of the sector;
(3) an estimate of personnel needs, category by category, together
with an indication of the facilities needed for staff training ;
(4) the costing of the various activities, project by project, taking into
account and listing separately : (a) capital expenditure (buildings, vehicles
and equipment) spent inside the country or spent on imported goods, and
(b) recurrent expenditure on personnel in each category and materials
bought in the country or imported ;
(5) a description of the expected results, in terms as concrete as pos
sible ;
(6) as accurate as possible an estimate of the expected economic
effects ; and
(7) recommendations for activities in other sectors ; for example, the
health planning unit may make recommendations about nutrition (including
crop rotation), health education in educational establishments and environ
mental health.
This draft sectoral plan is then forwarded to the central planning unit,
whose task is to determine whether it is possible to carry out the plan
as proposed, whether changes are required (and if so, what) and whether
the recommendations concerning other sectors can be put into effect.
Discussions then take place between each sectoral planning unit and the
central planning unit to determine what plans will be finally submitted
to the central planning authority.
After it has been approved by the political authority the final version
of the plan is sent back to each sector for implementation. During its
execution, it is essential to evaluate the achievements and compare them
with the objectives set. As a result any necessary modifications can be
introduced when the next plan is prepared.
3.2.3
Application of the planning process to health
The above principles will now be elaborated as they apply in practice
to the health sector. The first step of the health planning team is to obtain,
through the central planning unit, the general policy objectives laid down
for the whole economy that are relevant to health planning. Has a general
manpower policy been evolved and what account has so far been taken
of the need to train health personnel ? What are the broad objectives of
the plan for total investment and for total consumption, both governmental
REPORT OF A WHO EXPERT COMMITTEE
25
and in the private sector? What is the policy concerning the distribution
of income, which may affect the salaries of health personnel and the pos
sibility of certain sectors of the population purchasing health services ?
Are there any broad policy objectives laid down centrally for the health
sector, for early action against certain diseases or to provide health services
to support particular areas of economic growth ? How is the geographical
distribution of the population expected to change in the future ?
Most important of all is to produce, in consultation with the central
planning unit, a provisional estimate for health expenditure during the
planning period. Because of the time needed for staff training programmes
to yield a stock of trained manpower that can be deployed within the plan,
it may be advisable to plan for the developments to take place over a long
period, possibly as long as ten to twenty years.
In producing this estimate of future health expenditure, consideration
should be given to past and planned changes in the national income, to
trends in spending in other sectors of the government budget and to relative
priorities accorded to particular fields of development by the political
leadership.
Once an estimate of total health expenditure has been made, it must
then be related to the population projected for that year, bearing in mind
that the health plan will be one of the factors generating demographic
changes. After allocating a proportion of the budget to central and regional
services and to training, it is possible to calculate how much will be avail
able for organized health services per unit of population. After various
alternatives have been considered, it has to be decided how this budget
should be divided between in-patient and other medical care services and
preventive services of different types. In making these choices, considera
tion will be given to the disease pattern and changes in mortality and
morbidity and the possibility of altering this pattern by suitably deploying
available resources. Alternative budgets can then be prepared that envisage
the employment of different categories of staff with all the supporting
materials needed to enable them to work effectively. The various options
can be considered in a concrete, manageable form.
Planning within a given budget leads the planner to compare the value
of the work that can be expected of different grades of staff with the cost
of employing them (and of training them). Decisions need to be made
on both the preventive and the curative sectors of the plan, however much
the two sectors are ultimately to be integrated within the service finally
established.
In effect, quantity of service has to be weighed against quality of service
and in the process the probable demands of the population need to be
considered ; if these demands arc not all to be met, it is necessary to decide
how the limited funds arc to be allocated. If no decision is taken on this,
allocation (rationing) will be on the basis of “ first come first served ”.
26
NATIONAL HEALTH PLANNING
Rationing can be achieved by administrative decision (to give emphasis
to particular age-groups or type of disease) or by price (charging, for
example, for all curative services or for certain ones).
There are countries whose resources are so limited that it is necessary
to plan expeditiously to satisfy the most urgent unmet health needs with
whatever resources are available. After this phase of extemporization, it
becomes practicable, sooner or later, to take a longer and more systematic
view (covering a period of fifteen or twenty years) and to determine the
extent to which funds, manpower and other resources could become avail
able within that period for further development.
In other words, it is necessary to start with the minimum and deal first
with the most urgent.
In summary, therefore :
(a) a balance has to be struck between curative and preventive services
and within the former between in-patient and other services ;
(b) a decision has to be taken on whether certain diseases, age-groups
or occupational groups should be given priority ;
(c) the most economical instruments (staff plus supporting materials)
to secure the chosen objectives need to be selected, which involves making
decisions by balancing quality against quantity.
3.2.4
Choice of priorities in the health sector
In high-income countries with large stocks of trained manpower and
large economic resources that can be spent on health services, the problem
of choice is much easier to resolve than in low-income countries, where
economic and manpower resources are extremely limited. Thus it is pos
sible for high-income countries to adjust both the total allocation to the
health sector and its distribution among the various parts in accordance
with the need for health services as indicated by data on morbidity and
by the possibility of preventing disability and death in early life.
Many different ways of establishing priorities are used in different
parts of the world. Some countries prefer simply to state certain broad
principles, e.g., the need to give priority to preventive services, and leave
it to those who work in the health services at the local level to apply these
principles in practice. Other countries have attempted to evolve priorities
by the use of cost-benefit techniques, while recognizing that they are not
applicable throughout the whole health sector. Still others have identified
specific aims, such as the reduction of the infant mortality rate or the
eradication of particular diseases.
In health planning there is a great need for clear definitions in order
to avoid confusion. This is particularly true when dealing with the allimportant concept of estimating future needs. In this connexion the words
REPORT OF A WHO EXPERT COMMITTEE
27
“ forecast ”, “ projection ” and “ target ” are often used indiscriminately.
Harbison 1 stresses that a distinction between them is essential:
In the modern world, it is really impossible to predict what is going to happen in
particular countries or regions, regardless of the techniques which may be employed.
... Projections, of course, are different from forecasts. They express the logical con
sequences of assumed courses of action. They arc helpful in determining what needs to
be done if certain objectives are to be attained, or perhaps what will happen anyway if
certain objectives arc in fact achieved. Targets, on the other hand, arc operational
direction indicators based upon projections and reasonable judgements.
Harbison suggests that the methodology would be greatly improved
if both the concept of a “forecast” and the term itself were discarded,
and if analysts would indicate clearly when they are making projections
and when setting targets.
The purpose of target-setting is not to make a prediction of what will take place;
nor is it to make projections on the basis of limited assumptions of attainment of one
or two specific courses of development. Its purpose is rather to influence the future course
of development. A target indicates a direction for action. Its precise quantitative dimen
sion is far less important than its function of indicating the direction of activity for
achievement of specified goals.1
2
It is evident that without some kind of specific criterion it will be impos
sible to estimate future needs. Much important work in this field has been
carried out in the USSR. :
The public health plan is a combined, balanced plan, all the different parts of which
(the development of out-patient and polyclinical services, in-patient care, the training
of doctors and health workers, capital construction, medical research and so on) must
be maintained in the right proportions. A standard ratio of facilities to the population
—out-patient and polyclinical services, in-patient services, sanatoriums and health
resorts, sanitation and epidemiological services, etc.—is of great importance in planning
the development of the health services and also as an index of the standard of medical
services. This ratio is approved by the Ministry of Health of the USSR. It is based
cither on special scientific investigations or on the practical evaluation of existing medical
care services.3
Mortality and morbidity data and other factors may be used in many
different ways in selecting health priorities ; on close analysis, however,
these methods are often found to contain many common features. Thus,
there are many similarities between the principles underlying the different
formal methodologies of health planning used, for example, in the Socialist
1 Harbison, F. (1964) Human resource assessment. In : Economic and social aspects
of educational planning, Paris, UNESCO, pp. 122-123.
2 Harbison, F. (1964) op. cit., p. 125.
3 Popov, G. A. The planning of in-patient services in the USSR, Copenhagen, WHO
Regional Office for Europe (unpublished document EURO-137.2), p. 2.
28
NATIONAL HEALTH PLANNING
Republics of Eastern Europe, in India, and in the Latin American coun
tries. Detailed descriptions of these methodologies have been published
(see the Annex).
Two interesting developments in planning methodology occurred in the
USA in 1965 and 1966. One method, known as Planning-ProgrammingBudgeting, is now in use in all federal departments, including the Depart
ment of Health, Education and Welfare. The other, known as a Com
munity Self-Study Guide for Planning, was developed on an experimental
basis in 21 communities by the National Commission on Community
Health Services. These two methods might be of use to developing coun
tries seeking means to strengthen their planning.
The planning process could be greatly facilitated by the development
of clear concepts. What may eventually become a comprehensive meth
odology will also assist in determining the kind of empirical data that are
relevant, and can assist in preventing the collection of masses of facts and
figures that may not be relevant at all. The present dearth of statistical
data provides no excuse for failing to develop clearer concepts and more
systematic methods of analysis.
Though the means used to establish priorities are often hard to inter
pret, owing to the different meanings attached to the terms used in different
countries, there are, in fact, common features that underlie many systems
of health planning. Many countries, consciously or unconsciously, use
what may be broadly called economic principles to establish priorities.
The emphasis on prevention rather than cure is one such principle. The
cost of curative services for a disease can be saved if the incidence of that
disease can be reduced or if it can be totally eradicated. Secondly, the
common emphasis on saving the lives of younger people in whom there
has been considerable social investment and who still have major contribu
tions to make to production represents another choice. The choice of
diseases that can be prevented at relatively low cost rather than those that
can be prevented only at high cost is a third type of decision with an under
lying economic motive. The decision to provide somewhat better health
services in areas or for occupations where the loss of skilled manpower
or of working hours is of greater value to the economy is a fourth
example.
Many countries apply criteria of this kind, although expressing them
as principles of public health rather than principles of economics, whereas
others have been trying to introduce them by the conscious use of formal
economic tools. Although it is not always appropriate to use the same
formal systems of establishing priorities for all countries or cultures, the
Committee consider that the different systems need further study in order
to identify the common features and the differences in emphasis. Public
health administrators should learn to use more of the basic concepts and
techniques of economics, but health services should not be exclusively
REPORT OF A WHO EXPERT COMMITTEE
29
aimed at increasing production. They contribute to other aspects of human
welfare that are very real, however hard they may be to measure.
3.2.5
The evolution of the health plan and medical manpower
Once the pattern of health services for a unit of population has been
determined, the distribution of the total financial resources allocated to
these services for the planning period can be determined. At this stage
it needs to be decided whether health services should be distributed evenly
over the country or whether higher expenditure should be allocated to
particular areas—because the population is widely dispersed, or because
it is desired to give a higher standard of service to particular parts of the
economy that are critical for economic growth, or because of differing
expressed needs for health services. Any decisions of this kind will neces
sitate revising the inventory of services for the favoured and less favoured
areas. Moreover, the mechanism for establishing the pattern of distribu
tion between areas needs to be determined (central budget control, the
sponsorship of health insurance at growth points of the economy or the
development of health services on an occupational basis).
When the financial and manpower requirements of the health services
are known, the necessary staff training and capital construction programmes
need to be worked out and phased over the whole planning period. It is
at this stage that the capital construction programme must be checked
against the planned capacity of the building industry. Similarly, the man
power requirements need to be checked in the light of national educational
and manpower policy to determine whether the required number of persons
of the required educational levels can be obtained without damage to other
sectors of the national development plan. If undue demands are made on
the pool of educated personnel, then either the national educational pro
gramme must be expanded or the manpower requirements of the health
plan appropriately curtailed.
Population data arc important for a number of reasons. First, the
trends in the total population, its age structure and geographical distribu
tion and the rate of population growth affect the need for health services.
Secondly, an assessment of human resources is of prime importance for
national health planning to give a clear idea of prospective sources for the
development of medical, paramedical and auxiliary manpower. Thirdly,
the effects of health activities upon future population trends, as well as the
utilization of human resources, have to be taken into account. In other
words, medical manpower analysis cannot be divorced from the general
assessment of human resources. Essentially it necessitates a reasonably
comprehensive analysis of the existing situation, which is then used as a
baseline to estimate the long-term requirements over a period of perhaps
10 to 20 years. The literature on methods of making manpower inventories
30
NATIONAL HEALTH PLANNING
is considerable ; this subject was discussed at the United Nations Conference
on the Application of Science and Technology for the Benefit of the Less
Developed Areas, held in Geneva in 1963.1 The most difficult aspect of
manpower analysis is the determination of long-term requirements.
The Committee noted that the United Nations and its specialized
agencies were engaged in a review of international activities in the develop
ment and utilization of human resources, with a view to making proposals
for intensified concerted action in this important area.
When considering human resources in the smaller countries it is neces
sary to pay continuous attention to ways of obtaining medical manpower
from outside the country if insufficient is available internally. Moreover,
attention must be given to the problem of the emigration of medical man
power to other countries, including high-income countries.
This detailed consideration of long-term perspectives is needed to
establish staff-training and construction programmes for the first planning
period and to determine the amount of current expenditure during the same
period. Each year should represent a phased step towards the final objective.
Some countries decide to introduce the ultimate plan area by area as staff
emerge from training programmes ; thus the building programme is put
into effect in successive areas until the whole country is covered. Other
countries prefer to plan for each area to evolve gradually throughout the
whole planning period. The more drastic the changes being introduced
during this period, the greater are the attractions of proceeding on an areaby-area basis.
Only by looking far ahead—for a span of ten to twenty years—is it
possible to make training and capital construction programmes consistent
with long-term economic realities, insofar as these can be foreseen. Only
thus is it possible to avoid undesired differences in the resources devoted
to health services in different areas. Only thus is it possible to avoid training
staff who cannot be employed because the money is not available to pay
them. Health planning must be long-term planning to secure what can
be termed “ input consistency ”.
3.2.6
Evaluation in national health planning
The determination, as the first phase of national health planning, of
the extent and characteristics of health problems from an analysis of the
available data requires keen judgement. Evaluation is fundamental to
administrative control and indispensable for ensuring that continuous
planning is systematically based on experience gained. It measures the
degree to which objectives and targets are fulfilled and the quality of the
1 United Nations (1963) Science and technology for development, New York, Vol. 1,
p. 89; Vol. VI, p. 105; Vol. VII, p. 81.
REPORT OF A WHO EXPERT COMMITTEE
31
results attained. It measures the productivity of available resources in
achieving clearly defined objectives. It ascertains how much output or
cost effectiveness is achieved. It makes possible the reallocation of priorities
and of resources on the basis of changing health needs.
Although evaluation studies are still in a state of development, their
wider use should lead to a fuller appreciation of their potential contribution
to the continuous improvement in the efficiency of planning. Better methods
of evaluation are urgently needed, from complex systems analysis to simple
field studies performed by local health administrators. This kind of research
should be built into every national health plan so that it can be periodically
revitalized, in keeping with medical progress and advances in organiza
tional theory and practice. Local and regional health programmes should
serve as a permanent laboratory for evaluation studies in public health
practice.
3.2.7
Revision of the plan and the process of continuous planning
Once the first draft has been prepared and shown to be consistent with
economic limitations, manpower limitations and the capital construction
programme, the draft health plan should be presented once again to the
central planning unit responsible for the whole economy. The implications
of the plan in health terms and in economic terms should be clearly explained.
Once the planning unit has digested these implications it may feel justified
in amending its original policy directives or in revising the provisional
financial allocation. If one of these courses is adopted, it will be necessary
to revise the health plan, either completely or in part. Similarly, the presen
tation of the health plan may result in new directives or amended financial
allocations to other sectors of the national plan.
It cannot be overstressed that planning is a continuous process. Every
few years new plans will need to be prepared to take account of the progress
achieved, both in health and in other sectors of development.
3.3 Training for planning
3.3.1
The need for training
A problem to which the Committee gave special attention was the
experience and training required by staff concerned in national health
planning.
It is generally agreed that planning should not become a separate profes
sion within medicine. However, without training there can be no planning,
for doctors are not prepared for this work, either in the course of their
general medical education or as a part of their specialized public health
training.
32
NATIONAL health planning
Health “ planning ” and “ programming ” are not new to the public
health administrator, who has always had to develop “ plans ” to justify
financial support. What is new is the concept of “ planning” as a multi
disciplinary undertaking in which a number of different disciplines co
operate in organized teamwork, preparing a plan that is finally acceptable
to the government and will have financial and administrative support for
its implementation.
Since the final decisions in the allocation of funds in a steadily increasing
number of countries today are taken on the advice of planning bureaux
largely composed of persons with training in economics, it has become
increasingly important that communication be developed between eco
nomists and members of the health professions.
Practically all developing countries have begun to undertake national
socio-economic planning. It is therefore essential that senior public health
administrators be able technically to assist such governments in elaborating’
the “ health sector ” of these plans. Experience in the utilization of senior
personnel in several national health planning projects suggests that, if admin
istrators are to be able to assist governments in this way, they should receive
special training in certain fields as well as refresher training in others.
Training in planning should be a part of training in public health
administration. There is a need to train all types of supervisory personnel,
both medical and non-medical, in health departments. This will create an
understanding of the purpose and value of planning at all administrative
levels in health agencies—national, regional and local.
For health administrators to be able to compete successfully for national
resources with experts from other governmental agencies, they must aquire
knowledge and skills in planning comparable to that of their colleagues in
other sectors.
3.3.2 Personnel to be trained
It can be said, with some justification, that the planning process requires
trained staff at all levels, from those who collect and record data to the
senior officials whose task it is to prepare, co-ordinate and present the
final plans for approval and incorporation in the over-all national plans.
The latter are especially important, particularly in the formative stages of
national health planning, for without their guidance and leadership the
planning groups cannot function effectively.
General experience in the administration of public health and medical
services is therefore a first consideration. Where, for example, outside
help is called in to develop a national health plan, it is essential that there
should be national counterparts ; however, if the latter are to develop
the planning process, they will need instruction. Senior staff, for reasons
indicated below (section 3.3.4), may require only a relatively short course
REPORT OF A WHO EXPERT COMMITTEE
33
in the theory and practice of planning and in related subjects. Their sub
ordinates, those responsible for the day-to-day work, may be given prac
tical training in longer courses, designed to familiarize them with planning
requirements and procedures as applied to their own country.
The question was raised in the Committee whether a new class of
experts should be developed to take on the responsibilities of health plan
ning, i.e., lay administrators. It was the consensus of opinion that atten
tion should primarily be directed, particularly in developing countries, to
the training of medical administrators. As resources increase, lay adminis
trators can be recruited and trained ; long-term plans could well provide
for such training. Most developing countries will have no choice but to
train health administrators in planning and to refresh their knowledge and
skills periodically.
3.3.3 Preparation of teachers
Teaching and learning are interdependent. Accordingly, teachers must
be prepared for their teaching roles if the learners are to profit from the
teaching. This implies the careful selection and preparation of teachers
of planning. Modern teaching methods (e.g., programmed instruction,
audio-visual aids) and case studies taken from the developing countries
where the learners will return to work are essential. The report of the
WHO Expert Committee on Professional and Technical Education of
Medical and Auxiliary Personnel 1 provides information on this subject.
3.3.4
Training courses
The Committee discussed the appropriate length of training courses
and how this time should be allocated. It was concluded that no specific
time could be recommended ; some courses would be only a few weeks
long, whereas others, for top-level personnel and full-time specialists in
planning, might last as long as two years. However, few senior personnel
can be away from their posts for more than three months, and training
courses should be planned accordingly.
It is suggested that the disciplines in which either some further training,
with a possible change in emphasis, or a basic understanding of principles
is needed are :
statistics (health, vital, population and economic),
demography,
political science, including economics and government,
public administration,
cost accounting and budgeting.
1 Wld Hlth Org. techn. Rep. Ser., 1966, 337.
34
NATIONAL HEALTH PLANNING
It is not the intention that the planner should attempt to replace the
expert in any of these fields. However, if he is to get the best out of such
experts he must be able to talk their language.
Statistics
Anyone who has obtained a DPH or MPH has followed courses in
health and vital statistics. However, even if a certain familiarity with
statistics as used generally in public health is taken for granted, the tech
niques used in planning call for knowledge not generally obtained in
courses on public health. Thus, although part of the training in statistics
may be in the nature of a refresher course, an important part will be new
to most participants; this will include economic statistics, sampling as
used in planning, systems analysis and survey techniques, operational
research and cost-benefit analysis.
Demography
Demography will be a new field to most participants in training courses.
No planning is possible without a thorough understanding of population
problems. In some countries the lack of manpower is the important factor
limiting the pace of economic development. An understanding of popula
tion dynamics is essential to any planner. In the narrower field the health
planner will be concerned with the estimation of future manpower availa
bility—not only of medical manpower. He must be in a position to discuss
these problems intelligently with government officials, not only from the
ministry of health but also from the planning unit.
Political science, including economics and government
Instruction in political science is an urgent need for anybody dealing
with planning, and adequate time must be devoted to it. Since very few
economists are likely to become familiar with medical thinking, it is impor
tant to train medical administrators so that they can participate fully in
discussions with planning economists.
Public administration
Failures of socio-economic plans are often due to faulty administration.
The serious lack of middle-level workers in administration has to be taken
into consideration in most developing countries. Often plans are drawn
up that depend for their implementation on basic changes in administration
within a few years along lines followed in developed countries. The health
planner should co-operate closely with the public administrator at all
stages of planning, from pre-planning to execution. To make this possible
the health planner needs to understand the basic principles of adminis
tration. Training in public administration should cover the essentials of
federal government, state government, organization theory and admin
istrative management.
REPORT OF A WHO EXPERT COMMITTEE
35
Cost accounting and budgeting
It has been the general experience that in no field is the average public
health worker weaker than in cost accounting and budgeting. In most
developing countries methods of allocating funds and systems of account
ability and control are outmoded. In particular, health budgets are seldom
arranged in a manner that is useful for recording the resources devoted
to particular parts of the health programme. It is, of course, not intended
that the planner should be able to carry out cost accounting and budgeting
himself, but he should be familiar with modern techniques and thus be
able to appreciate meaningful subdivisions of health expenditure and
understand estimates of the financial resources that have previously been
made available or are likely to become available for the implementation
of health programmes during the planning period. The planner should
give particular attention to the principles underlying what is often called
performance budgeting. As these principles aim at relating planned and
incurred expenditure to the individual projects and activities, they can
provide indications for the more active use of budgeting in the planning
and evaluation processes than is usually possible with traditional budgeting
techniques.
After these basic studies, a course of instruction on the actual planning
process would follow. Each of the subjects taught would need to be dis
cussed in detail with lhe expert teaching it, especially in relation to the depth
and breadth of knowledge desirable and time that can be allotted. The
general pattern might, however, be along the following lines—health
planning machinery ; methods of health planning; evaluation studies and
research in public health practice.
It will be noticed that several disciplines, including psychology, anthropo
logy and sociology, have not been mentioned. An elementary knowledge
of these subjects would, of course, be extremely useful to any person
undertaking planning, particularly in a country other than his own, but
they should always form part of the background of any general public
health worker. Familiarity with sociological research methodology, as
well as a knowledge of the social studies related to health that have been
carried out in developing countries, would be very useful for health planners
and whenever possible should be included in training courses. If any
worthwhile attempt were to be made to teach the basic principles of these
subjects, additional time would have to be devoted to the course. A pos
sible solution would be to arrange a few well-prepared seminars, especially
for the more senior students.
The critical question in training personnel for work in planning in
developing countries is simply : What tasks are you preparing the person
to carry out? To answer this question, health administrators from the
countries concerned and those actually responsible for short-term and
long-term planning should be asked to participate in designing the cur
36
NATIONAL HEALTH PLANNING
riculum : the needs of Africa might be quite different from those of Latin
America.
One way to develop such curricula and carry out courses would be as
follows. First, a group consisting of a health administrator, an expert in
the subject under study, a curriculum specialist and an educational psycho
logist would determine exactly what task the student was being prepared
to carry out. In preparing the curriculum, the group would also review
existing courses in schools of public health and institutes of higher learning
and the relevant reports published by WHO. Subsequently, at least one
teaching and research centre might be set up in each geographical region,
preferably attached to a university that has a school of public health, or
to a department of public health in a medical school, a good department
of'political science, social science and education or an institution of equi
valent academic status ; it also possible to use suitable regional organiza
tions. Such a centre should be prepared to give follow-up and refresher
courses in outlying areas of the country or in other countries.
The curriculum should include instruction in the use of indices and
indicators in health planning, as discussed in section 3.1.1.2 (page 15) and
the discussion of well-prepared case-studies based on actual practice in
developing countries. The case-studies can be combined with the use of
field demonstration areas, located near the training centre. The main aim
is to obtain the student’s active participation and not just his passive
observation of health centre activities.
Actual plans can be used for teaching purposes and can be very effective
if the students can make evaluation studies and criticisms of the plans and
thereafter prepare new ones.
3.3.5
The training institute
Ideally, training should be undertaken in an area where the problems
are similar to those likely to be encountered by the student in his own
country. However, problems of urgency, cost and availability of skilled
and experienced teaching staff must be taken into account when consider
ing the practicability of establishing training centres.
The crux of the matter would appear to be the ready availability of
experts in the various fields, and this, in turn, involves the selection of
special university centres or public health institutes in which to hold the
courses of training. The fundamental principles of planning may be gen
erally applicable in any part of the world, but the urgent need is for knowl
edge that has an immediate practical application in the developing coun
tries.
Programmes of research are also required, much of which would, no
doubt, be research into various aspects of public health administration,
especially planning. Special problems requiring multi-disciplinary action
REPORT OF A WHO EXPERT COMMITTEE
37
for their solution may need to be referred to universities or equivalent
institutes. There is here a most fruitful field for inter-disciplinary co-opera
tion among various university faculties, including medicine, economics and
political science, agriculture, law, sociology and architecture.
Every training centre for planning should include research activities
as an integral part of its programme, since the best teachers are those who
enrich their teaching with the results of current research in their own and
allied disciplines.
Information is available 1 on the training facilities in the United Nations
Planning Institutes, especially at the three regional institutes—the African
Institute for Economic Development and Planning, the Asian Institute for
Economic Development and Planning, and the Latin American Institute
for Economic and Social Planning—as well as on the various UN-sponsored
institutes of public administration. There already exists close co-operation
between some of them and between UN and WHO.
Health administrators from developing countries should have access
to research workers in the training centres in their regions, to bring to
them problems urgently in need of solution. In turn, teachers should have
access to the health centres in the developing countries for research purposes.
This cross-fertilization would strengthen the work of both and accelerate
the application of new knowledge to improve the health of the people.
It will be necessary, however, to ensure that research techniques do
not outrun practical considerations. It will be a long time before complex
methods can be applied in most developing countries. At present they do
not need them, for their basic requirements are relatively simple. What
is required is clear, practical and authoritative planning to promote health
services, training and research within the compass of the over-all social
and economic circumstances of a given country.
4.
FUTURE STUDIES
The Committee, bearing in mind the importance of national health
planning in relation to over-all socio-economic development plans, empha
sizes the need :
(1) to continue to note trends in national socio-economic planning and
to collect and analyse systematically social, economic and health data
relevant to national health planning in developing countries in the various
geographical regions with a view to developing more meaningful health
and resource indicators ;
1 United Nations Economic and Social Council (1965) Relationships among planning
institutes: Report by the Secretary-General (unpublished document E/4035).
38
NATIONAL HEALTH PLANNING
(2) to pursue further the examination of the various aspects of the
inter-relationships between over-all national economic and social planning
and national health planning ;
(3) to utilize as a planning team medical administrators and non
medical administrators in order to advise governments on the best approach
to national health planning projects ;
(4) to study further the different methodologies for national health
planning as a means of improving planning in countries at different levels
of development;
(5) to develop a systematic approach to budgeting and cost-accounting
as an important part of national health planning and as an essential basis
for the choice of priorities ;
(6) to give consideration to the preparation of a practical manual on
national health planning, which should describe in detail how health
planning is carried out, indicating the minimum information essential for
health planning purposes and the way it can be obtained, assembled and
assessed ; it should also explain what is desirable but not essential; it
should illustrate with actual examples the uses of the information and
thus the advantages derived from the planning process ; finally, it should
show how plans can be evaluated over a period and suitably amended
and developed ;
(7) for member governments and other agencies to study the use of
different mechanisms of financing health services (such as health insurance)
and for establishing priorities in the allocation of health services in lowincome countries, with full consideration of the administrative problems ;
(8) to study and experiment with new ways of training economists in
the health aspects of national development and of training health planners
in the economic aspects of national planning, e.g., by field training of joint
teams;
•
(9) for the integration of accumulated experience through the periodic
review and assessment of the consultative planning process in the assistance
given to requesting countries in national health planning ;
(10) to develop regional centres, in conjunction with universities or
equivalent institutions, for training, research in methodology and consul
tative services to countries in the region ;
(11) to undertake studies of the possible usefulness in diagnosis and
treatment of the paramedical and auxiliary medical personnel employed
in many developing countries, so that recommendations can be made on
the educational level required of trainees and on the range and length of
training programmes.
REPORT OF A WHO EXPERT COMMITTEE
39
Annex
SHORT BIBLIOGRAPHY OF NATIONAL HEALTH
PLANNING METHODS
1.
Latin America
Duran, H. (1965) Health planning in the countries of Latin America. In : Canad.
J. publ. Hlth, 56, 271.
Durdn, H. (1966) Methodology for health planning in Latin America, Geneva,
World Health Organization (unpublished document NHP/INF/66.2).
Hall, T. L. (1966) Planning for health in Peru : New approaches to an old problem.
In : Amer. J. publ. Hhh, 56, 1296.
Pan American Health Organization (1965) Health planning : problems of concept
and method, Washington, D.C. (Scientific publication No. 111).
2. USSR
Bogatyrev, I. D. (1959) [Material referring to the establishment of standards for
the necessities of curative-prophylactic assistance to inhabitants of roMvzs.]
In : Zdravookhr. ross. Fed., No. 2, 32.
Popov, G. A. (1962) The planning of in-patient services in the USSR, Copenhagen,
WHO Regional Office for Europe (unpublished document EURO-137.2).
Popov, G. A. (1965) Some new techniques in public health planning, Geneva,
World Health Organization (unpublished document NHP/SEM./WP/8.65).
Popov, G. A. (1966) Some aspects of the use of norms and standards in studying
the efficiency of medical care, Copenhagen, WHO Regional Office for Europe
(unpublished document EURO-294.2/6).
Popov, G. A. (1966) Principles of public health planning in the USSR, Geneva,
World Health Organization (unpublished document NHP/INF/66.4).
Rozcnfcl’d, I. I. (1963) Planning and allocation of medical personnel in public
health services. In: Principles and methods of planning public health services:
Part IH, Jerusalem, Israel Program for Scientific Translations.
3. India
Government of India Planning Commission (1964) The planning process, Delhi,
Government of India.
Ministry of Health, Government of India (1962) Report of the Health Survey
and Planning Committee, 1959-61, Delhi, Government of India (in two
volumes).
40
NATIONAL HEALTH PLANNING
Paranjape, H. K. (1964) The Planning Commission : a descriptive account, Delhi,
Indian Institute of Public Administration.
4. General
Further information on the bibliography of this subject is given in Bibliography
on health planning (1965) Geneva, World Health Organization (unpublished
document A18/Technical Discussions/5).
WHO publications may be obtained, direct or through
booksellers, from :
ALGERIA
ARGENTINA
AUSTRALIA
AUSTRIA
BANGLADESH
BELGIUM
BRAZIL
BURMA
CANADA
CHINA
COLOMBIA
COSTA RICA
CYPRUS
CZECHO
SLOVAKIA
DENMARK
ECUADOR
EGYPT
EL SALVADOR
FIJI
FINLAND
FRANCE
GERMAN
DEMOCRATIC
REPUBLIC
GERMANY,
FEDERAL
REPUBLIC OF
GREECE
HAITI
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN
IRELAND
ISRAEL
ITALY
JAPAN
KENYA
KUWAIT
LAOS
LEBANON
LUXEMBOURG
MALAYSIA
MEXICO
SocidtS nationalc d’Edition et de Diffusion. 3 bd Zirout Youccf, Algiers.
Librcria de las Naciones, Coopcrativa Ltda, Alsina 500, Buenos Aires
— Editorial Sudamcricana S.A., Humberto 1° 545, Buenos Aires.
Mail Order Sales, Australian Government Publishing Service, P.O.
Box 84, Canberra A.C.T. 2600: or over the counter from Australian
Government Publications and Inquiry Centres at : 113 London Circuit,
Canberra City ; 347 Swanston Street. Melbourne ; 309 Pitt Street,
Sydney ; Mr. Newman House, 200 St. George’s Terrace, Perth ;
Industry House, 12 Pine Street, Adelaide; 156-162 Macquarie Street,
Hobart — Hunter Publications, 58a Gipps Street, Collingwood,
Vic. 3066.
Gerold & Co., I. Graben 31, Vienna 1.
WHO Representative, G.P.O. Box 250, Dacca 5.
Office international de Librairie, 30 avenue Marnix, Brussels.
Bibliotcca Regional de Mcdicina OMS/OPS, Unidad de Vcnta de
Publicaciones, Caixa Postal 20.381, Vila Clementino, 01000 SAo
Paulo — S.P.
see India, WHO Regional Office.
Information Canada Bookstore, 171 Slater Street, Ottawa, Ontario
KIA OS9 : Main Library, University of Calgary, Calgary, Alberta;
1683 Barrington Street, Halifax, N.S. B3J 1Z9 ; 640 Ste Catherine
West, Montreal. Quebec H3B 1B8; 221 Yonge Street, Toronto,
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393 Portage Avenue, Winnipeg, Manitoba R3B 2C6. Mail orders to
171 Slater Street, Ottawa, Ontario KIA OS9.
China National Publications Import Corporation, P.O. Box 88, Peking.
Distrilibros Ltd, Pio Alfonso Garcia. Carrera 4a, Nos 36-119, Carta
gena.
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MAM, P.O. Box 1674, Nicosia.
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Einar Munksgaard, Ltd, Norregadc 6, Copenhagen.
Librerla Cientffica S.A., P.O. Box 362, Luque 223, Guayaquil.
Nabaa El Fikr Bookshop, 55 Saad Zaghloul Street. Alexandria —
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Librerla Estudiantil, Edificio Comcrcial B No 3, Avenida Libertad,
San Salvador.
The WHO Representative, P.O. Box 113, Suva.
Akateeminen Kirjakauppa, Keskuskatu 2, Helsinki 10.
Librairie Arnette, 2 rue Casimir-Dclavignc, Paris 6°.
Buchhaus Leipzig, Postfach 140, 701 Leipzig.
Govi-Verlag GmbH. Ginnheimerslrasse 20, Postfach 5360, 6236
Eschborn — W. E. Saarbach, Postfach 1510, Follerstrasse 2, 5 Colo
gne 1 —Alex. Horn. Spiegclgasse 9. 62 Wiesbaden.
G. C. Eleftheroudakis S.A., Librairie internationale. rue Nikis 4,
Athens (T. 126).
Max Bouchercau, Librairie “A la Caravelle”, Boite postale 111-B,
Port-au-Prince.
Kultura, P.O.B. 149, Budapest 62 — Akademiai Kdnyvesbolt, Vaci
utca 22, Budapest V.
Snaebjorn Jonsson & Co., P.O. Box 1131, Hafnarstracti 9, Reykjavik.
WHO Regional Office for South-East Asia, World Health House,
Indroprastha Estate, Ring Road, New Delhi 1 — Oxford Book &
Stationery Co., Scindia House, New Delhi ; 17 Park Street, Cal
cutta 16 (Sub-agent).
sec India. WHO Regional Office.
Iranian Amalgamated Distribution Agency. 151 Khiaban Soraya. Tehe
ran.
The Stationery Office, Dublin.
Heiliger & Co.. 3 Nathan Strauss Street. Jerusalem.
Edizioni Minerva Medica, Corso Bramantc 83-85. Turin ; Via Lamarmora 3. Milan.
Maruzen Co. Ltd, P.O. Box 5050, Tokyo International, 100-31.
The Caxton Press Ltd, Head Office : Gathani House. Huddersfield
Road, P.O. Box 1742, Nairobi.
The Kuwait Bookshops Co. Ltd. Thunayan Al-Ghanem Bldg, P.O.
Box 2942. Kuwait.
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