(wp)kro/icp/kpn/ooi-e english oily · 2015-09-27 · relional collaboration a.odl the participatidi...
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(WP)KRO/ICP/KPN/OOI-E ENGLISH OILY
REPOllT
KEETING OP HEALTH !WIAGEKENT DEVELOPMENT NETWOIUt PACILITATOllS IN THE SOUTH PACIPIC
Convened by the
REGIONAL OPPICE POll THE WESTEllN PACIPIC
OP THE
WOlLD HEALTH OIl.GANIZATION
Apia, Sa.,a
11 - 20 Kay 1988
"'HOI WP
1.
2.
3.
4.
5.
CONTENTS
SUKlWtY .. " " " " " " " " " " " " " " " " " " " " " " " " .. " " " .. " " " " " " " " " " " " " " " " " " " "
PUlPOSE " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " .. " .. " .... " " .. " " ORGANIZATION " " " ...... " .... " " .. " " .. " " " .. " " .... " " " " ...... " " ...... " .... " " ..........
3.1 3.2 3.3
Location and participants .. " " " ...... " .. " . " " " .. " " " " " " ........ " .. Outline " " ...... " " " " " .... " " .. " " " " " " " " " .... " " " " .. " .. " " .. " .... " .......... Method of work " " " " .. " .. ,. " " " " " ...... " " " .... " .. " .... " " " .. " " " " " " .. "
OUTCOKB " " " " " .. " " " " .... " " " " .. " " " " " " " " " " " " " " " " " " " .. " " " " " " " " " " .. " "
4.1 District health systeas based on pr1aary health care ••••••.••••••••.•.•.••.••••••••••
4.2 4.3
Operational planning at district level .... " " " .. " " " " .... " .. Net~rk plan of work " " " " .. " " " " " " .. " " " " " " .. " .. " " .. " " ,. .... " " "
EVALUATION " .. " " " " " .. " " " ...... " " .... " .. " .. " " . " " " " " " .. " " .. " .. " " " " .. " .... " .. ANNEXES
ANNEX 1 LIST OF PARTICIPANTS AND FACILITATORS .. " " .. " " .. " ..
ANNEX 2 KEETING PIOGRAHKE .... "" .. """ .. "" .. "" .. " .... " .... " .. """,, .. ,,
ANNEX 3 COUNTRY REPORT: TONGA DISCUSSION PAPER " " " " " " " ..................... .
ANNEX 4 THB ROLE OF HOSPITALS AT THE FIRST REFBRRAL LEVEL ...............................
1
3
3
3 4 4
5
5 7 8
10
11
15
19
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1. S~Y
In 1982, a joint WHO/UMDP mi88ion conducted a fea8ibility Itudy on how to improve health 8ervice .ahalement in the South Pacific. The mission confiraed that there were aajor Veskne8ae8 in the manalement of countries visited and recoaaended a aajor effort to develop aanalerial and planniDi capabilitiea at the national level with a provision for relional collaboration a.oDl the participatiDi countries.
The relional collaboration that evolved from thi8 aanalement aa8e8ament became known as the Health Kan8leaent Developaent Betwork of the South Pacific. The network approach to aanalement development aimed at involviDi national 8taff in the review of policie8 and procedure8 affectiDi their operation8. Such involvement was desilned to enhance the analytical and aanalerial capabilities of national ataff and to lead to the desiln of improved health manasement.
The network was composed of national facilitators, consultants, WHO and the Relional Teacher Trainins Centre, Sydney. The Regional Teacher TrainiDi Centre waa responsible for trainiDi and monitoriDi the development of the national faCilitators.
A sroup of middle-level msnalers from South Pacific countries who had the common losl of iaprovins the health of the people in their respective countries composed the relional health manalement development network facilitators. All the facilitators hold key positions, and consequently, were able to a aake 8ilnificant impact on health development activitie8 in their countri8s.
One of the main activitie8 of the facilitators was to orlanize and conduct national workshops. These workshops provided the opportunity for national partiCipants to review and propose recoaaendations for prioritymanalement problems.
WHO provided the facilitators with specific training materials, al well as the opportunity to learn and exercise skills on new management facilitation. The annual meetiDi of facilitators provided an opportunity for the network participants to review recent experiences, learn new skills and prepare country activity plans.
This was the fourth meetiDi of network facilitators. It bronsht tOlether eilht of the exiBtiDi facilitators and three new ones.
First, the sroup con8idered in some depth the relearch on district health system8 and the role of hospital8 at the first referral level. The research reviewed had been undertaken by the Institute of Rospital· Services (IRS), Seoul, in collaboration with WHO. Dr YOUDI Shoo Shin, Director of IRS, pre8ented a conceptual model and preliminary findiDis of the aajor survey concerniDi district level health care.
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Second, the facilitators applied the model to a simulated district-level situation. They analysed a case study of an underdeveloped rural district and prepared an operational plan to address priority requirements with due consideration to resources and constraints. The plan included provision for strengthening the infrastructure, adainistrative procedures, technical eupport and staff capabilities.
Third, the facilitators used their co .. on experience in planning for district health developaent to identify the aaJor coaponents of an operational plan and tha major stepa in its formulatton. Alternative methoda for planning were considered. Attention was siven to methods for lathering information, for setting priorities, for allocating resources and for involving key decision-aakers in the process.
fourth, the facilitators considered how they could help others, primarily district health teams, to plan. Throush role-play and rehearsal they experimented with various facilitator techniques. Beyond improvement of presentation skills, the facilitators considered ways to involve the district offiCials, to impress upon the officials the importance of planning as a tool for aanaleaent and to reduce the fear that planning will become a means for control by central authorities and functionaries.
finally, the facilitators suaaarized the ideas and concepts learnt and reported briefly on their plan for future network activities in their respective countries.
Throushout the workahop, various manalement and educational exercises were used to explore the facilitators' attitudes and to practise important skills. The facilitatora reviewed and discussed, for example, their communication styles, their approach to problem solving and decision making, and their stratelies of laininl personal power and influence. The facilitators also practised skills in reviewinl and previewing sessions, report writing and presentation.
The Iroup considered the meeting to be very beneficial to their further developaent and Ireatly appreciated the financial support provided by DANIDA for holding the meeting.
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2, 'U1POSI
Objectives
The aeeting was designed to provide the South Pacific Health Kanage.ent Developaent Network facilitatora with the opportunity to share experiencea, acquire new knowledge and strengthen facilitation skills. Specifically, the .eeting enabled the facilitators to:
(1) review network activities and aasess the outcoaes obtained during the period 1987-1988;
(2) review a conceptual fr .. ework for describing health .anage.ent functions at the district level;
(3) identify a process for foraulating operational plans at the district level;
(4) reinforce skills in facilitsting operational planning process to their own situation;
(5) ensure that facilitstors can apply the planning process to their own situation; and
(6) adopt a plan of work for the next period of Network activities.
3. ORGANIZATION
3.1 Location and participants
The aeeting was held in the Vi/Apia's Office, Saaoa, froa 11 to 20 Hay 1988. The aeeting vas efficiently adainistered by staff froa the Vi/Apia's Office. Dr Arie lotea, Director, WHO Regional Training Centre for Health Developaent, Sydney, and Hr M.J. Anderson, WHO, Kanila, aerved as .eeting facilitatora, assisted by Dr Young Sao Shin, Deputy Director, Institute of Hospital Services, Seoul, as a te.porary adviser to the .eeting.
Bight out of the original nine facilitators plus three nev network faCilitators attended the .eeting. The nev facilitators were froa Fiji, Kiribati and Samoa. A colleague fro. Papua Nev Guinea slso attended the aeeting. (See Annex 1 for a coaplete list of participants.)
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3.2 Outline
The programae for the meeting ~onsisted of three parts:
(1) Understanding a ~on~eptual .odel for des~ribing the distri~t health system;
(2) Learning to initiate operational planning at distri~t level;
(3) Preparing ~ountry a~tivity plans for the 1988/89 period.
Host of the fa~ilitators, in one way or another, are devoting a signifi~ant amount of time and energy to a~tivities dire~tly related to manas •• ent development at the distri~t level. Therefore, the first three days of the meeting involved dis~uasions on the distri~t health system. A regional WHO ~oaparative study on hospital at first referral level' was used as the vehi~le for these learning sessions.
The se~ond topi~ of the programme - how to tea~h operational planning at distri~t level - involved four days of:
(1) preparing spe~ifi~ materials for district level activities; aod
(2) learning new facilitation skills.
The final day of the meeting was devoted to .. king an outline of a network plan of work for the reaainder of the 1988-1989 period.
A detailed programme for the meeting is included in Annex 2.
3.3 Method of work
The meeting began with each of the facilitators reviewing their a~tivities sin~e the last meeting and reflecting on what they had learnt from these activities. This also provided the new facilitators with an opportunity to be~oae more faailiar with the role of a facilitator. A report from Tonga (Annex 3) describes the type of information useful for this dis~ussion.
The sessions on understanding the district health system were conducted by Dr Shin. The sessions were priaarily presentations of the regional research project on district health systems. Time was allocsted for the facilitstors to refle~t on the sppropriateness and relevance to their respective ~ountries of the proje~t's ~onclusions.
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The ae.ting'. aa1n purpo.e vae to aaaiat the facilitatota lh theif efforts to promote operational planning at diatrict level. This was aeco.pliahed through a proce.s of cloae interaction between the facilitatora and participanta, with .oat of the aeeting ti.e being spent in saall groups preparing and teating ways to approach people in a district to promote operational planning.
The facilitators kept the ainutes of the aeeting and managed most of the sessions.
4. OUTCOME
4.1 District health syateaa baaed on primary health care
The district health eystem is becoming one of the aain themes of management development activitiea. The initial step taken by WPRO to add to the knowledge and information available on thia subject vas to ask the Institute of Hospital Services, Seoul, Republic of EDrea, to conduct a regional comparative study on the role of hospitals at the first referral level. This study dealt with only one aspect of the district health systee, namely the provider side of the picture.
The purpose of having this item on the agenda was to introduce the facilitators to some current thinking on diatrict health systems and to obtain feedback froe them'bn the relevance of the study's reaults.
The research project has produced a model vhich illustrates how resources, knowledge and technology coae together for the purpose of directing and providing services. This is typically referred to as a provider model. With the model, it is possible to build an analytical framework which will describe the performance of a district in management teraa.
The develop •• nt and usea of tha model and analytical fra.ework were presented to the facilitstors for their review and aasassment. Annex 4 is a summary of the materiala presented. Katerial illustrating the reaults of the study for each country was alao repreaented in the meeting.
The facilitators, in general, agreed that the model provided a valid overall picture of the current role of hoapitals at the first referral level. They also concurred with .ost of the analytical descriptions generated by the project's questionnaires.
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The group brought up the important paint that the model - aa it ia currently deacribed - appeared to over-e~haaize the delivery aide of the diatrict health ayste. picture. This was an accurate asaeaament, and it waa agreed that the next phase of aodel development should integrate the co.aunity with the delivery of health care.
It waa also recognized by the aroup that if the questionnaire which waa uaed to collect the data for the analytical framework wae to be made more accurate. Some queatione would probably have to be apecific to the country concerned.
Each meaber thought that the reaulta from this exercise could be used to make aanagement 8Odification. to correct the probleas that had been identified.
The following concluaions were reached for each country:
4.1.1 Papua New Guinea
The district health syatem model could be applied to the provincisl level of health servica.
4.1.2 Solo8On 1alanda
The model was sstisfactory and could be applied to the provincial level.
4.1.3 Fiji
The aodel was found applicable to the sub-diviaion level. A few sdjuatments to reflect the adalnistrative set-up in Fiji were required.
4.1.4 Western Samoa
The results indicsted that the queationnaires for Sa8O •• ay not have been properly caapleted. Samoa agreed that the model could be applied by dividing Samoa into the two health districta of Upolu and Savaii.
4.1.5 Cook Ialanda, Kiribati and 'alau
The model did not apply very well to theae countries. Kiribati felt that the aodel had to be aodified alightly to fit the local aituation. In aeneral, the Cook Islands, Kiribati and Palau, as a whole, alght sach be taken aa a district. Therefore, the model aight work, but the questionnaire would require adjustments to reflect the special definition of a district.
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4.1.' tonaa
At preaent, tonga haa six health diatricts, and four of thea could coae under this model with soa. ~ariations. Because of the heavy centralization of authority at national level, the model could not be applied directly to the Tonga context without soae modifications.
4.2 Operational planning at diatrict level
4.2.1 Allocation of resources and efforts
In the discussion of recoaaendations for district level developaent based on s simulated situation, the facilitators differed in the aaount of resources they would have to allocate to various areas. For example, there was a range from 51 to 451 of total allocation for curstive services. Similarly, there was a range of 151 to 501 in the allocation to preventive services.
The average allocation by the group as a whole was:
(1) Infrsstructure 181 (2) Research 161 (3) Community involvement 151 (4) Preventive 271 (5) Curative 251
The discusaion revealed differencea in values, perceptions, interpretation of problems and beliefs about appropriate interventions. These differences in a relatively homogeneous group highlighted ths importance of involving the coaaunity and professional group in the planning procesa.
4.2.2 Approacbss to planning and decision-asking
Theories of planning were reviewed briefly. The rational-linear approach was contrasted with incramentaliaa and political proceaaes. The purpOae of this discussion was to prevent a aimpliatic orientation towards planning. Rationality is relative to a particular aet of values. Purthermore, there are limits and constraints (ttae, money, skills, availability of information, etc.), wbich prevent reconsideration of all aspects of a situation before a decision is .. de. The increaental aodel conSiders new decisions as modifications of previous decisions. It allows fine tuning or adJustaent to fit new conditions but not necesaarily a coaplete new analysis. the influence of political forces was also discussed st soae length. the concept of strategic planning and aanaseaent was siven much attention. It was asreed that management should help people create or accept a "Vision," a general direction which suides detailed aims and objectives. In the absence of a ca.aon vision it is difficult to develop team effort, to coordinate action, to secure coaaltment, to enable autonomy and delesation.
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4.2.3 Levela of plannins
Tbe facilitators noted that stratesic plannina tends to take place at tbe central level. The district level may contribute but is pri .. rily responsible for implementation. At the seme ti.e it was considered essential that officials st the district level understand the national policy and shsre tbe vision.
Kajor differences between the levels include:
Central
locus on policy Analyse major trends Allocate resources Lons-term freae Abstract Deal with options
4.3 Network plan of work
Peripheral
locus on implementation Analyse local conditions Utili.e resources Short-term freae Concrete Deal with sivens
The results of this week provided substantial reinforcement for tbe facilitators since tbe network's priority was to support their efforts to institutionalize operational plannina at tbs district level in their respective countries.
Each facilitator provided a brief su.-ary of what tbey perceived as the current status of operational plannina in their country.
4.3.1 Tonsa
Tonaa was currently developins district health plana based on their national healtb plan. A national operational plan is beina developed for the period 1990-1995.
4.3.2 liji
Supervision would be s priority development concern. Network activities had to be cancelled owins to politicsl chanaes; however, it anticipated that the three proposed worksbops could now be scheduled. Personnel .anaseaent and supervision were a priority concern.
4.3.3 !!!!!
Belau, to date, hss been able to use network 8upport very effectively. No plannina at the national level has been done. Belau continues to place e~basi8 on strensthenina individual skills.
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Kiribati has a national op.rationa1 plan which wa. a product of their ov.ra11 national p1annins proc.ss. The .~hasis for the n.xt plannins psriod would be on .upervision and aanaa ... nt workshops.
4.3.5 ~
Th. utilization of h.a1th r.sourc •• at district 1.ve1 is eff.ctiv., aainly because of the underutili.ation of inpatient s.rvic.s. Consequ.nt1y, it ne.ds not only an operational plan hut also specific int.rventions at district 1.v.1, which invo1v. ca..unity and service interrelationships.
4.3.6 Soloaon Islands
Plans ar. beins carried out for strensthenins operational effectiveness at provincial laval. Network support is n.eded at both national and provincial lev.ls.
4.3.7 Cook Islsnds
N.twork-supported activities have s1snificantly contributed to the success and improvements in curr.nt aanagement support practices. Network activities would continue to support staff development especially at health centre snd outer islands levelS.
4.3.8 Papua New Guinea
The country is not recognized as a foraal member of the South Pacific network; however, there is a high potential for shsrins in the area of .. nagement developm.nt through inforaation support activities.
A new activity waa preaented to the facilitstora as an additional tool for support ins th.ir work, na.ely health syste.s research. Kost of the group agreed with this proposal and are nov aware of this additional area of support.
The fundins aituation waa reviewed with .aphasia on the relationship of UNDP proJ.ct (RAS/86/065: Strategies for priaary health care developm.nt) to the current network prioriti.s. It was agreed that there was complete coapatibility between th.se two issues, and that all effort a would be made to maximi •• the i~act of the UNDP reaourc.a.
The facilitators agreed to review tbeir detal1ed n.twork activity plana for 1988-1989 and to forward the. to the WHO a.glonal Office aa soon as possib1 ••
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4.3.4 Kiribati
Kiribati has a nationsl operational plan which was a product of their overall nationsl plannins process. The e~hasis for the next plannins period would be on supervision and .. nageaent workshops.
4.3.5 Saaoa
The utilization of health resources at district level i8 effective, .. in11 because of the underutilization of inpatient services. ConBequent11, it needs not on11 an operational plan but also specific interventions at district level, which involve coaaunity and service interrelationships.
4.3.6 Solomon IslandS
Plans are beins carried out for strensthenins operational effectiveness at provincial level. Network support is needed at both national and provincial levels.
4.3.7 Cook Islands
Network-aupported activitiea have aignificantly contributed to the aucceas and improvements in current .. nagement support practicea. Network activities would continue to support staff development especial11 at health centre and outer islands levels.
4.3.8 Papua New Guinea
The country ia not recognized as a foraal meaber of the South Pacific network; however, there is a high potential for sharins in the area of aanageaent development through information support activitiea.
A new activity was preaented to the facilitatora aa an additional tool for aupportins their work, namely health aystema research. Koat of the group agreed with this propoaal and are now aware of this additional area of support.
The fundins situation was reviewed with eaphasis on the relationship of UNDP project (RAS/86/065: Strategiea for primary health care developaent) to the current network priorities. It was agreed that there was coaplete coapatibility between these two iSBues, and that all efforts would be aade to aaxiaize the iapact of the UNDP resourcea.
The facilitatora agreed to review their detailed network activit1 plans for 1988-1989 and to forward thea to the WHO aegional Office aa aoon aa poasible.
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LIST OF PARTICIPANTS AND FACILITATOIlS
COOK ISLANDS
FIJI
KIRIBATI
1. PARTICIPANTS
Hs Natalie Short Chief Public Health Nurse Hinistry of Health Public Health Division P.O. Box 109 Rarotoya Phone 29110 Ext. 24
Hr Sayed Khaiyum Head of Health Education Unit Hinistry of Health P.O. Box 2223 Government Buildings Suva Phone 387 855
Hr S.N. Reddy Acting Administrative Officer Hin1stry of Health P.O. Box 2223 Governaent Buildings Suva PiiOiie 387 855
Hs Herevai Vesikula Senior Health Sister Hinistry for Health Suva Health Office Box 30 Rodve 11 Road .§!!.!! Phone 314 988
He lloUa THo Chief Nursing Officer Hinistry of Health and Faa1ly Planning P.O. Box 268 Bikenibeu Tarawa
Annex 1
MICRONESIA, FEDERATED STATES
(not in attendance)
REPUBLIC OF PALAU
SOLOKON ISLANDS
(not in attendance)
TONGA
WESTERN SAMOA
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Mr Isamu Abrahaa Office of the Chief Division of Health Services lCDlonia Pohnpei, E.C.I. 96941
Ms Joanna M. Polloi Continuing Education Coordinator Bureau of Health Services P.O. Box 100 lCDror Phone 813
Hr Jemuel Dick Laumalefo Principal Nursing Officer Ministry of Health & Medical Services P.O. Box 349 Honiara Phone 23600 Ext. 303/328
Mr Albert Punifimana Nursing Officer Ministry of Health & Medical Services P.O. Box 349 Honiara
Mr Busby S. Kautoke Senior Assistant Secretary for Health Kinistry of Health Nuku'alofa Phone 21-200
Mr Sione Wolfgram Health Planning Officer Ministry of Health Vaiola Hospital P.O. Box 59 Nuku'alofa Phone 21-200
Dr S. John Ah Ching Chief Division of PubliC Health Health Departaent Private Bag ~ Phone 21212
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Ms Beverly Hellosoe Principal, Post Basic Nursing Health Depart.ent Private Bag A2!.! Phone 21212
2. FACILItATORS
Kr M.J. Anderson Manage.ent and Research Support Officer WHO Regional Office for the Western Pacific Manila
Dr Arie Rote. Director the WHO Regional training Centre for Health Developaent University of New South Wales P.O. Box 1 Kensinlton, NSW 2033 Australia
3. tBKPORARY ADVISER
Dr Young Sao Shin Deputy Director
MnM 1
Institute of Hoapital Services Seoul National University Hospital 28, Yunkeun-dong, Chongno-ku ~1l0 Republic of Korea
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ANNKX 2
SOUTH PACIFIC HEALTH MANAGEKENT DEVELOPMENT NETWORK FOURTH FACILITATORS KEETING
West.~n Samoa
11-20 MAy 1988
HEETING PROGRAHHE
Wednesday. 11 Hay 1988 (a.m.)
PRESENTATION:
Discussion:
South Pacific Health Hanasement Development Netwo~k
Int~oduction to meet ins G~eetin8 of new facilitators Activities of facilitators since last meetins
What have we learned about the health development process in our country.
What are ou~ needs as facilitators and as a netwo~k.
Wednesday. Thu~8day. F~iday, 11 - 13 Hay 1988
PRESENTATION: District heslth systems
District health system approach to health system development.
Results of the comparative study on district health systems in the South Pacific.
Discussion
A district health system model based on the followins manaseaent roles:
• technical support activities * adm1nist~ative support activities • education and t~ainin&
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Annex 2
- An analyt1cal fraaework for assessing d1str1ct health system developm.nt.
- How can we use the dietr1ct health system approach to auld. 1aplem.ntat10n of new UNDP project.
Monday. 16 Kay 1988
PRESENTATION: Making decisions and the process of planning
- Changing concepte of health
Strateg1c and operational plann1ng
The l18its of rational and linear models of planning
Planning at the district level
Discuesion
- The place of health among the other important soc1al objective ••
- What dec1sions are made about health services at the district level, by whom and through what process.
Activity
- With reference to an 1mportant health policy, conaider:
* It8 relationship with other policies • How it was foraulated and by whoa * What infor88tion wa8 or should have been considared in
formulating the policy
Tueeday, 17 Kay 1988
PRESENTATION: Strategic planning at the district level
- Gainina insi,ht 1nto directione that should be pur8ued.
Preparing and 8ecuring momentum to schieve desired direct10ne.
Activity
With reference to a typical d1str1ct level situation:
Bxamine env1roDaental future trends (3-5 yeara), 1dentify constraints, threats and opportunit1es.
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_ Asaess ths present orssni&ational and huaan reaources capabilitie., identify weaknesse., atrenatha, unique features and advantases.
Eatablish a list of emersins issues to meet your expectations of the future (includina manasement aystems, ataff capabilitiea and comaunity involvement).
_ Determine major atratesie. for dealing with the requirements.
Wednesday, 18 Kay 1988
PRESENTATION; From atrategiea to operational planning
* Interpreting policies and stratesic decisions.
* Planning as an impetus for team development.
* The components of a good plan.
Activity
With reference to an important .trategy, prepare an operational plan indicating'
* priority issues * clear-end objectives * activity steps and operations • aequence of activities * start and coapletion time for each activity * identification of who is responaible * identification of key resources
Thursday, 19 Kay 1988
PRESENTATION AND DISCUSSION; Facilitation of action learning
* The assumptions * The role of facilitators
Activity
With reference to strategic and operational planning at the district level, consider what you will do end how to support district level planning activities.
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Annex 2
Friday, 20 Hay 19S8
Discusaion
Plana of work for tbe next period of the network operation with particular reference to the facilitation of operational plannins at the diatrict level.
Conclusion and evaluation of the workshop.
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ANNEX 3
COUNTRY RKPORT' TONGA
DISCUSSION PAPER
i. Stimulation and improving follow-up on workshop propoaals
Hany important proposals from workshops held in Tonga in the past under thia project have been successfully followed up, such a.'
(a) Project docuaent for the refurbishing and upgrading of the Central Pharaacy and Medical Store Building haa been drawn up and approved by the Ministry of Health end the Gov.rnaent of Tonga, and is now awaiting finalization of financial sourc. for its impl.aentation.
This proposal came up from the Nationel Workshop on Hanagement of Druss Supplies.
(b) The prOsr .... of the local trainins of Assistant Pharaacist Grad. II is now half way with its first sroup of trainees. This prosraaae was proposed by the National Workshop on Hanasement of Druss Supplies.
(c) The revival of the Ministry of Health Druss Coaaittee.
(d) The identification of lack of planning skills which led to the joint Workshop/Trainins Course on operational health planning.
There were still a lot of important proposals from past manasement workshops under this project that have not been iaplemented due to several reasons. Exaaples of some of these important propoaals are as follows:
The National Workshop on Supervision recommended that appropriate actions should be taken to remedy the conflicts between the public health nurses and the newly introduced catesory of health officers. These two etaff catesorie. op.rate the health centres. Up to now, there has not been any succesaful work coapleted on this propossl.
It was recommended that a manual for health centre manas ... nt should be prepared to au ide the health work.rs in the health centree. This proposal had not been iaple .. nted.
It was recosnized that .ome of the key problema in the proper iaplementation and follow-up of past workshop proposals were due to the following:
Annex 3
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Difficulties in documenting the workshops reports.
Lack of organized mechanism for this important function of follow-up of workshops' proposals.
To remedy the above problems. the following recommendations were made:
(1) Workshop reports. A simple set format for workshop reports should be desianed. The report should be brief and cover basically the essential workshop procedures, results and proposals. Some fund should also be allocated from the workshop budget for the preparation of the report.
The report should serve an important function in the stimulation and follow-up of workshop proposals.
(2) Follow-up mechsn1sm. It was proposed that national facilitators should be made responsible for this follow-up function. They should form themselves into a task force or subCOmmittee, and relevant officials would be coopted from time to time.
In the case of Tonga, the task force would operate on an ad hoc way and would be responsible to bringing the workshop proposals to the attention of the relevant heads of divisions, Director of Health, HHD, Technical SubCommittee, National Health Development Committee or any other authorities. They would be responsible for the proper proposal, implementation and follow-up of workshop recommendations. They would also be responsible for putting the proposals into operational term for implementation.
2. Involvement of senior officials
In terms of obtaining the cooperation and participation of senior officials. Tonga has not faced many problems of any significance. Owing to their functions and workload in the Ministry of Health, the two national facilitators had been influential and successful. The Senior Assistant Secretary is the Head of the Administration Division, and the Health Planning Officer is the Head of the new Planning and Information Division.
The problems faced were on the work load which were expected from the netional facilitators and would increase in the near future. It was reCOmmended that a third national facilitator be established. There were eeveral key senior officials qualified for this task that could be recruited. This would facilitate sharing of the activities according to the responsibilities of the two facilitators.
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Anne" 3
3. Review of protocol on supervision and community involvement
The present protocol was geared to national issues on staff supervision. Community involvement was not included. The functions of supervision frequently listed in the past workshope bad more to do with the overall national "personnel .. nasement". The protocol has been too wide, and participants often spend more of their time formulatins cr1t1c1.ms of top offic1als 1n the Hin1stry and av01dins doinS the improvement. themselve.. It had often caused proble .. w1th1n the H1niatry.
It was recommended that the protocol for supervision should be restr1cted more into supportive supervision and at district level. It was also recomaended that prior to the commencement of the workshop, outside facilitator and/or consultant should work on the identification of key problematic issues to be covered during the workshop.
The work covered task analysis and analysis of district policies, system, procedures and activities. Hore emphasis should be made on supportive supervisory skills. The aspects of district operational planning should be separated from the protocol on aupportive supervision.
In the case of district level, plannini should be modified for development of district operational health plannins and based on national operational health plan.
Community inVOlvement could be incorporated as part of the protocol for supportive supervision or as a separate one. It was important for it to be geared towards the utilization of the important potential of the Community orsanizations especially the villase health committees.
4. Plan for promotion and involvement of UNDP project
The followins manasement activities under the UNDP project were requested by the Government:
(a> District workshops (4) on supportive supervision; (b> Workahop on health financial manasemsnt; and (c) Reorientation of the orsanization of the public health ayatea
towards primary health care.
These actiVities were orisinally scheduled to be impleaented froa April to Novamber 1988. The National Health Development Committee bad directed to reschedule all workshops, includins these actiVities. The reachedulins of these activities would depend on the availability of funds from WHO.
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Annex 3
The follow1nl activities were identified and would later be submitted to the Ministry of Health for consideration and for later subaisaion to WHO.
(a) aeview of pri.ary health care (b) District operational planning
The following activities were new areas that were realized to be important. being submitted for consideration and would be included under the UNDP project or some other source:
(a) Project planning (b) Establishment of COSt centres (c) Stimulation of village health committees
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ANNBX 4
THE ROLE OF HOSPITALS AT THE PIRST REPEIBAL LEVEL
1. Background
A WHO Expert Committee on th~ Role of Hospitals at the First Referral Level met in Geneva from 9 to 17 December 1985. The Co.-ittee reviewed a aequence of issues and problems relating to the roles of hospitals at the first referral level in support of primary health care. The Committee identified aome fundamental issues that stood in the way of closer integration of hospitals with local health systems based on primary health care, and it examined approaches to tackling them.
The WHO Regional Office for the Western Pac1fic recognized the importance of the issues raised to the Committee and decided to conduct a study to determine the appropriate role of hospitals at the first referral level in Member States in pursuit of health for all by the year 2000. Accord1ngly, the Institute of Hoepital Services (IKS). Seoul National University, and a WHO collaborating centre for hospital administration. were asked to conduct a study entitled "The Role of Hospitals at the First Referral Level for Attaining HPA" for 24 months, from 1986 to 1987.
2. Objectives
The three major objectives of the study were defined as follows:
(1) To investigate the existing role of hospitals at the first referral level in support of primary health care and other health-related activities;
(2) To investigate the characteristics of district health systems and national characteristics which may be pertinent to understanding the existing role of hospitals at the first referral level; and
(3) to analyse the ways in which these characteristics influence the role of hospitals at the first referral level.
3. Data COllection
The data for this study were collected by:
(1) Taking data already published by WPRO and other institutions which explained the current status of health care services in Member States.
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Annex 4
(2) Gathering data which were not available in ready-made form but were essential in understanding the existing role of hospitals at the first referral level in Member States by means of survey forms and/or field visits.
Sensitive to the dangers of this broad study on Member States of great differences, IUS decided to conduct a survey in three stages, i.e. preliminary, pilot and full-scale surveys. The preliminary survey collected information on the administrative structure of governments and the organization and management of both national and district health systems. The full-scale survey form was designed to reflect the insights gained from the results of the preliminary survey. It was revised after obtaining the results of the pilot survey from selected Member States in order to test the applicability of the survey form.
In addition, the research team conducted field visits to Member States in order to supplement the survey data with other types of essential information needed to be collected through more direct means.
4. Participants (Member States)
Out of the 35 Member States, 20 responded to the full-scale survey. They were: American Samoa, Australia, China, Cook Islands, Fiji, Japan, Kiribati, Laos, Malaysia, Pederated States of Micronesia, New Zealand, Papua New Guinea, the Ph1lippines, the Republic of Korea, Samoa, S1ngapore, Solomon Islands, Tonga, Tuvalu and Viet Nam.
5. Conceptual models
5.1 Why models
To organize the results of the study in a way that would allow the research team to develop an overall picture of the current role of hospitals at the first referral level in support of primary health care although revealing the diversity that exists among the Member States.
The models should not only be broad enough to be relevant to the health care systems of all the Member States, but also specific enough to serve as a normative model illustrating the kinds of roles of UFRL in support of primary health care.
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Annex 4
5.2 Definition of terminologies used in the models
PHC complex describes the followina four levels of health care activity:
the fam1ly and home; the community; the commun1ty health worker; and the basic health service unit.
HFRL describes the next level of health care facility to which PHC complex can immediately refer all kinds of problems and at the same time the facility at the most oraanizat1onal and technoloa1cal level that is capable of provid1na wide ranaina technical and administrative support for PHC complex.
It performs three roles in support of the PHC complex, such as:
technical support: administrative support activities; and education and training.
Cons1derina the current situation in Member States, the term "Hospital at the First Referral Level/District Health Office" (HFRL/DHO) was used instead of "Hospital at the Pirst Referral Level" (HFRL).
District is the geoaraphical or administrative boundary within which the HPRL/DHO performs support1ve roles for the PHC complex.
It encompasses the levels of the PHC complex and HPRL/DHO.
Annex 4
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SUBMODEL 1 - CONCEPTUAL MODELS OF OKS
(The roles of KFRL/DHO in support of PMC complex)
HfRW'OItO
PHC Complex
IlAne Healtl1 '-__ .~,,",-U'!!..!l!HJ;. __ CcU\wuty Health wocker f..--- .-
CO ... unlty 1---------
F...,l1 Y and Ho,",
R. 1: technical support
R .,. adm~nistrative: support
R ): ed.uco.tion &. trClinln"
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SUBMOOEL II - BASIC STRUCTURE OF OHS
HeALth
.'ct.ivities
t ~-~~-::':~':.:I-~ .------------4: HaMqeual I I Process I
CoaDWlJ,tV artlC:lpa~10
Three components:
'-------..1
Human and physical resources
Economic support
.Inc:ersecto£ CoU"borati
Organization - the structure through which the managerial process transforms the health resources into health activities
Three conditions:
Intersectoral collaboration
Community participation
Progra.me coordination - a general indicator of the operational efficiency of the managerial process
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Annex 4
SUBMODEL III - DKS AND THE PRODUC'rION OF THE ROLES OF HFRL/DHO IN
SUPPORT OF PHC
1--1 I 1
1 'He I !CoophJ
1 I 1 1 L __ !
Rl TeCnnlc~l S~PPQtt
R2 A~.lQltt[atlY. Support R) Education' T[.lnln~ M "an.~.'lal Process Cl 0',4n1%at10n c1 HUllan' 'hysl~al Resou CO!ll cl £~Qno.LC: ,Suppa't
lntot"!IIeC'co[al
Colla boration
COlillunity
part1.Clpf,tlOn
Combination of Submodel I and Submodel II
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Annex 4
SUBMODEL IV - THREE ANALYTICAL ASPECTS IN MEASURING THE EXISTING ROLES OF HFRL/DHO IN SUPPORT OF PHC
Scap. of • ~, "e~iviti----,
I.e.; lntarsectoral collAboration
C.P •• Co •• unl.tv Pact.lClpation
p.e .• PlOCl' •••• Cootdinacion
At.lthotlCy
i.e . .,J...
"FaL/OIIO
PHe Complex
1" C.I.
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Annex 4
6. Analytical framework
1. TECHN leAL SUPPORT
FT
scopQ.
",.8.
SU. C! .
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Annex 4
II. ADMINISTRATIVE SUPPORT
T.G{.
scope
FT. f" S.H.
SCO p4L
S.!.. fc:".8.
SM. C.l.
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Annex 4
III. TRAINING AND EDUCATION
d.u&lop........t:
f,1, ,.S,/1,
sc: .. pa.
S1: 1<,8,
CI,