~ 0 ' - E M / M G / 7

January 1985

MANAGERIAL PROCESS FOR NATIONAG HEALTH DEVELOPMENT

Report o f an Intercountry Workshop

Damascus, Syrian Arab Republic, 15-25 September 1984

(Meeting reference: WHO-EM/INT.W~(P.MFNHD/~)

CDITORIU MOTE

The issue of this document does not constitute formal publication.

The manuscript has only been modified to the entent necessary fqr proper COmprehenslOn. Tl)e vlgws expressed, however, dq not necessarily reflect the official policy of the World Heglth Organization.

The designations employed and the presentation of the material in this document do not inply the expression of any opinion whatsostver on the part of the sgcretariat of the Organization concerning the lesal statys of any country. territory, city or area or of its authorities, or concerning the delimitatiqn of its fr~rttiers or bsundaries.

TABLE OF CONTENTS

LNTKOUULI'LUN ................................................ I OBJECTIVES O F THE WORKSHOP ................................. 2

........ ORGANTZATION OF THE WORKSHOP AND THE METHOD OF WORK 3

..................... PROGRAMME O F WORK AND WORKING SCHEDULE 5

PARTICIPANTS .............................................. 5

........ ....................... LAtJOUAQE OF TlIC WON<SIIOP .... 5

............................. INAIJGURAL CEREMONY (SESSION I) 5

......................... INTRODUCTION T O MPNHD ( S E S S I O N 11) 5

..................... PROBLEM-BASED METHODOLOGY (SESSION 11) 6

.................... HEALTH POLICY FOFMJLATION ( S E S S I O N 111) 6

TNPORMATTON SUPPORT FOR MPNHD (SESSION I V ) ................. 8

MECHANISMS FOR ENSURING CONTINUITY I N THE ............................. MANAGERIAL PROCESS ( S E S S I O N V) 10

. . . . . . INTRODUCTION TO BROAD HEALTH P R O G P M T N C (SFSSTON VT) 12

14 . PROGRAMME BUDGETING : ALLOCATION OF HEALTH RESOURCES .............................................. ( S E S S I O N VII) 15

15 . FORMULATION OF NATIONAL PLAN OF ACTION FOR HEALTH FOR ALL (SESSION VIII) .. ......................................... 1 7

. .......................... 16 DETAILED PROGRAMMING (SESSION IX) 20

17 . PROGRAMFEZ IMPLEMENTATION : PROGRAMME OPERATION AND .................................... INTEGRATION (SESSION X) 2 1

18 . MONITORING AND EVALUATION OF NATIONAL STRATEGIES FOR HF,AT.TU FOR AT.1. (SESSION XI) ................................ 22

19 . NATIONAL. ACTION T O STRENGTHEN MPNHD AND USE OF TCDC MECHANISMS I N SUPPORT O F THE APPLICATION OF MPNHD (SESSION XII) ............................................. 2 3

. ...*.......... 20 WHO TECHNICAL COOPERATION I N SUPPORT OF HPNHMID 25

........................................ . 2 1 EVALUATION EXERCISE 26

.................................... 22 . CLOSURE OF THE WORKSHOP 29

................................ ANNEX I L I S T OF PARTICIPANTS 31

................................... ANNEX I1 PROGRAMME OF WORK 35

........ ANNEX P I 1 qUESTIONNAIRE FOR EVALUATION OF THE WORKSHOP 40

WHO-EM/MG/ 7 WHO-EM/ INT . MP . MJ?NHD/ 3 page 1

1. INTRODUCTION

The Intercountry Workshop on the Managerial Process for National Health

Development held in Damascus, Syrian Arab Kepublic, trom 15 - 25 September 1981 was hosted by the Government of Syria in collaboration with the World Health

Organization. Regional Office for the Eastern Mediterranean Region.

This Workshop was one of several that have been organized in this Region

over the last two years for senior health officals from the countries of the Region, in support of the formulation and implelpentation of national strategy

for Health For All. The Inaugural Session was attended by Hi$ Excellency the

Minister of Health of the Syrian Arab Republic and officials representing the

Ministry of Healch, other ministries of the Government, Parliament, universities

educational and research institutions from Damascus.

The participants of this Workshop were addressed by His Excellency

Dr Ghasoub El ~ifai, Minister of Health of fhq Syrian Arab Republic on bchnlf

of the Host Government and Dr C. Vukmanovic, Regponsible Officer for the Manager-

ial Process for National Health Development, WHO read the message on behalf of

Dr Hussein A. Gezairy. Regional Director for the Eastern Mediterranean Region,

wishing all participants successful deliberations during this important Workshop.

Dr Nazmy Falouh. Assistant Minister of Health of the Syrian Arab Republic

was elected Chairman of the Workshop and Dr I. A1 Khawashky, Regional Adviser,

Organization of Health Care Services. Eastern Mediterranean Region, as Rapporteur.

The Workshop was attended by 21 participants from 7 countries of the Keglon

and WHO staff from the Eastern Mediterranean Region.

The aim of t h i s Workshop was t o c o l l e c t i v e l y l ea rn and exchange experiences

on the concepts, p r inc ip le s , methods and procedures of an in t eg ra ted Managerial

Process f o r National Health Development and i t s maln component p a r t s , and ro pro-

mote fu r the r understanding and increase capab i l i ty of the p a r t i c i p a n t s t o iden t i fy ,

understand and dofine soc ia l . ~ o l i t i c a l . economic, organizat ional , t echn ica l and

adminis t ra t ive i ssues , problems and cons t r a in t s when applying the process t o the

formulation and implementation of na t iona l s t r a t e g i e s and plans of a c t i o n f o r

Health For A l l .

1t is e x p e c t e d t h a t t h i s Tntercountry Workshop on the Managerial Process f o r

National Health Development w i l l s t imula te na t iona l ac t ion so t h a t s imi l a r work-

shops w i l l be organized n a t i o n a l l y , f o r na t iona l leadership f o r h e a l t h development

represent ing hea l th and other sec to r s of government a s well a s in t e res t ed groups

and communities, a s an en t ry point f o r fu r the r developing and strengthening na t iona l

n ~ a ~ ~ a g e r i a l c a p a b i l i t i e s i n support of national hea l th systems based on Primary

Health Care and f o r the ac t ions required t o support na t iona l s t r a t e g i e ~ and plans

of ac t ion f o r Health For A l l .

2. OBJECTIVES OF THE WORKSHOP

2.1. General Objectives

The general ob jec t ives were t o ~ r o m o t e f u r r h e r development of an in t eg ra ted

managerial process f o r na t iona l hea l th development and t o exchange experiences on

i t s use i n the p a r t i c i p a t i n g coun t r i e s , with a view t o ensuring i t s proper applica-

t i o n i n support of the formulation and implementation uf r ta~iolzal strategies and

plans of ac t ion f o r Health For A l l by the Year 2000.

2.2. Spec i f i c Objectives of the Workshop

I n the l i g h t of using MPNHD a s a c r i t i c a l t o o l f o r the formul4tion and imple-

mentation of na t iona l s t r a t e g i e s f o r Health For A l l by the Year 2000, the s p e c i f i c

ob jec t ives of the Workshop were:

(a) To analyse the accumulated experience in MPNW, the current developments

and accomplishments, and to share experiences about important social,

economic, political, technical, organizational and ar l c u i a i s ~ ~ d ~ i v r issues,

problems and constraints pertaining to the process when used in support

of Health for All.

(b) To practice the application of MPNHD and its various components in support

of the formulation and implementation of strategies for Health For All.

(c) TO review the current methodology in use for MPNW and to promote the

development of national guidelines for the integrated managerial process

for national health development.

(d) To stimulate countries to produce operational plans for systematic monitor-

ing and evaluation of national strategies and plans of action for Health

for All as a part of the application of the managerial process.

(e) To idencity ways of using Tecl8~~icdl Cuuprrdtiuu L r t w r r i l Devrlvping

Countries (TCDC) mechanisms to strengthen countries' capacities for

applying the managerial process.

3 . ORGANIZATION OF THE WORI<SHOP AND THE MT:THOD OF WORK

The Workshop was organized in 12 sessions and 1 1 exercises reflecting all major

components of the Managerial Process for National Health Development and its use in

support of formulation and implementation of national strategies and plans of action

for Ural th For A 1 1 .

The work proceeded in plenaries and working groups. There were no formal lec-

tures during the Workshop. The organization of the Workshop was therefore planned

to allow maximum flexibility for group interactions, sharing experiences among parti-

cipants on the important items under diccusoion andputtinginto practice the knowledge

acquired individually during preparation for various sessions and collectively in

group dynamics in working groups were held every morning and some afternoons with the

grouD dynamics in working groups and in plenaries. Sessions in the form of plenaries

and working groups were held every morning and some afternoons with the purpose of

e n p s s i n e i l l1 p a r t i c i p a n t s in collective work on the proposed sessions and it related

exercises.

For each new session, there was an initial plenary which was used by workshop

moderators for briefing working groups on the objectives of that particular session

and exercises scheduled in response to thc objectives, and to give participants a

sense of direction on the group work as well as to raise questions for clarification.

The work then proceeded in working group, heavily relying on active participation of

all participants and their contributions to the work of the groups, sharing their

experiences from their own countries, thus facilitating the process of learning from

each other, and making comparisons US Lllr lessons learned, allowing for generalobser-

vations as a part of various country experience.

The outcome of working groups1 discussions was reported in summing-up plenaries

for each session. A rapporteur from each working group, appointed in turn, supportedby

~hrchdirnldn of irs working group, was requested to present a group solution to the

assigned task of each group . Following the presentations from working groups, there

was general discussions in plenary. Finally, where appropriate, the moderator of the

session summarized the main outcome of the session: concepts, principles, methods,

techniques, processes, and solutions recommended during the discussion.

m non-structured time some afternoons and in the evenings, participants were assigned to reading the background documentation and preparing themselves for the

work of the following day.

The role of moderators was to structure discussions during plenary sessions and

working groups and to keep the workshop proceedings within the framework of the accep-

ted proeramrn~ o f w n r k , ensuring that the objectives of the Workchop wcrc achicvcd.

Each working group was also observed by the moderators and feedback was provided on

the various dimensions of the group dynamics. This was considered necessary to develop

sensitivity on the part of each participant on how to lead working groups in an effec-

tive and efficient manner. The Chairman and the Rapporteur from the working groups

Y.IPYP s 1 ~ n provided h i n t s an methqds oE mabins affective prcscntationo. At the end

of the Workshop an evaluation of the outcome of the Workshop was conducted by all

participants. (Annex 111).

WHO-EM/NG/7 WHO-EM/ INT .WI(P .PPNIID / 3 Page 5

4 . PROCRAFVTR O F F O R K ANT) IJORKTNC, SCFlF,TIIlT.F

The detailed programme of work is provided in Annex I T .

5. PARTICIPANTS

21 participants and 5 observers from the Ministry of Health of the Government

of the Syrian Arab Republic attended the Workshop. There were 14 participants from

seven countries from the Eastern Mediterranean Region and 7 participants from the

R ~ ~ i n n a l O f f i r e , WPCs and field staff. (Annex T )

6. LANGUAGE OF THE WORKSHOF

The working language of the Workshop was English. A concerted effort was made

to allow, the host participants to speak in Arabic to facilitate their maximum parti-

cipation. Fcllow Arabic-cpenking participants then provided English trnnolation to

the rest of the Group. The Regional Office has already extended the offer to support

simultaneous translation; however, due to unavoidable circumstances, the host country

was unable to locate suitable resource persons.

7. TVAUGUFAL CEFWIONY (SESSION I)

The Inaugural Session took place in Al-Cham Hotel Damascus at 10.00 a.m.

On Saturday, 15 September 1984, the Opening Address was given by His Excellency

Dr Ghasoub El Bifai, Ministry of Health of the Syrian Arab Republic and

Dr C. Vukmanovic, Responsible Officer of the Managerial Process for National Health

Development, WHO Geneva read the Message to partlclpants on behaLk ot

Dr Bussein A. Gezairy, Regional Director for the Eastern Mediterranean Region. The

Inaugural Session was followed by the Introduction of participants, adoption of

Workshop objectives and Workshop procedures.

An overall introduction to the Managerial Process for National Wealth Develop-

ment and its use for the formulation and impl~mcntatinn nf natinnal s t r a t e g i e s for

Health For All was given followed by explanation of methodology and terminology in

use for the Managerial Process.

9. PROBLEM-BASED METHODOLOGY (SESSION 11)

A brief overview was provided concerning the use of problem-based methodology

in training leaders and managers in the process of MPNHD. It was emphasized that

cases/problems relevant to country situations would be used to illustrate the applic-

catinn nf rnnceptr. covered in the harkgronnd readingp drrrine the plenary and working

groups.

10. HEALTH POLICY FORMULATION (SESSION 111)

This session covered content, agents,processes andmechanisms required to ensure

that thc dcvclopment and control of national health policiee, ~trntegieo and plans of

action for Health For All are being formulated as integral parts of policy-making

mechanisms concerned with socio-economic development at the highest government level.

The three working groups were consequently asked to review and share experience

among participants on the important steps being taken in their own countries to

~rdnalatr policies for Health For All into national reality. (See Exercise 1).

There were nine specific issues addressed in working groups' exercises and the

synthesis of their findings were reflected in plenary discussion. The following

points were particularly raised in this discussion :

( I ) ~t was stated that all countries represented in rhe Workshop have ascertained

initial political commitment to Health For All through Government declaration

or announcement of this Policy by the Presidents of countries. It was however

realized that major efforts are required to translate their initial commitment

into reality.

(2) The need to produce specific legislative acts to enact National Policies for

Health For All and to ensure that Primary Health Care priorities are reflected

in these policies rhrough appropriare incersectoral coordination and cooperation

was particularly emphasized.

(3) Systematic analysis and asscssrncnt of cxiating oocio-cconomic policica nnd

health ~olicies are required in all countries to ensure that health systems

are developed as an integral part of the overall social and economic develop-

ment.

( 4 ) While in all participating countries some forms of mechanisms for providing

political support to the development and implementation of national strategy

for Health For All and coordination of activities within health sectors, with

other sectors and with communities have been initiated, it was, however, em-

phasized that these mechanisms have not yet fully acted as collective bodies on

a permanent basis. They meet occasionally and there are many probleins rela-

ted to sustaining membership, promoting secretarial and securing financial

support and deVelOplng adequate mechanisms for the monitoring and implementa-

tion of their agreed actions and recommendations.

( 5 ) It was for example stated that the systematic review and analysis of the

extent of existing coverage of Primary Health Care by health and health-related

sectors such as agriculture, education, industry, environment, housing, etc

are urgently needed to formulate more sound and realistic policies concerning

tho crnpe . quantitative and qualitative coverage of ~o~ulation groups, progres-

sively, as required.

( 6 ) Reviewing various national experiencbs it was stated that for example in many

instances only few institutions outside the Ministry of Health were fully infor-

med or havc participated in reviewing policies for Health For All and Primary

Health Care. Many sectors in the Government are not being made fully part of

national action for HFAI2000 and Primary Health Care. Educational institutions

have not been properly engaged in Health For All and Primary Health Care acti-

vities. Interested groups, people and cornunities are not sufficiently acting

as equal yarLners i l l N d ~ i u l ~ d l Health Developme~~t rrocesses.

The Workshop therefore strongly recornends that promotional activities at

national level for Health For All and Primary Health Care be intensified first and

foremost within the health sector, among variouskindsof health personnel, health

and health educational institurions. InLensive promotional activities are further

required at the highest policy levels in the government to help translate initial

political commitment for HFA12000 into national reality. Further promotion is also

required with the ministries of Planning, Budget, ducati ion, Agriculture and other

s e c t o r s r e l a t e d t o H e a l t h . Massive promot iona l a c t i v i t i e s f o r o b t a i n i n g t o t a l

commitment of p e o p l e and communities f o r HFA/2000 and Primary Wealth Care a r e

r e q u i r e d :

- The Workshop unanimously concluded t h a t w i t h o u t o b t a i n i n g t o t a l p o l i t i -

c a l commitment f o r H e a l t h For A l l and commitment of v a r i o u s s e c t o r s ,

i n t e r e s t groups and people and communities f o r n a t i o n a l a c t i o n s towards

H ~ A / 2 0 0 0 and Primary H e a l t h Care, p l a n s and programmes b e i n g formula ted

th rough t h e a p p l i c a t i o n of MPNHD w i l l remain on paper .

- F u r t h e r , t h e Workshop recommended t h a t i n most of t h e c o u n t r i e s , r e o r i e n t a -

t i o n o t e x i s t i n g e d u c a t r o n a l i n s t l t u t l o n s and e d u c a t i o n a l programmes a r e

r e q u i r e d t o match t h e i r n a t i o n a l p o l i c i e s f o r H e a l t h For A l l .

- ~ u l i ~ i e s LU d e v e l u p ~ l d ~ i u ~ i d l 11eal~11 ~ l ~ a ~ ~ p ~ w e r plans LO a c h i e v e rhe s t r a t e g y

f o r H e a l t h For A l l a r e r e q u i r e d i n most of t h e c o u n t r i e s .

- it was s t a t e d t h a t in many countries, policics for generation and alloca-

t i o n of h e a l t h r e s o u r c e s t o p r i o r i t i e s b e i n g de te rmined i n t h e n a t i o n a l

p l a n s of a c t i o n f o r Hea l th F o r A l l , a r e r e q u i r e d .

I J . INFORMATION SUPPORT FOR MPNRD (SESSION IV) , .

T h i s ~ u p i c was discussed in p l e n a r y s e s s i o n ( s e e E x e r c i s e 2 ) . The d i s c u s -

s i o n i n d i c a t e d v a r i o u s ways i n which i n f o r m a t i o n s u p p o r t t o Managerial Process

i s b e i n g o r g a n i z e d and o b t a i n e d i n c o u n t r i e s . I n some c o u n t r i e s H e a l t h Informa-

t i o n Support i s g e n e r a t e d from medica l r e c o r d s and e x i s t i n g r e p o r t s f rom h e a l t h

c e n t r e s , h o s p i t a l s and o t h e r t y p e s of h e a l t h c a r e f a c i l i t i e s , w h i l e i n o t h e r s

v e r y o f t e n s p e c i a l s u r v e y s a r e conducted i n a d d i t i o n t o p a r t i a l r e p o r t i n g from

h e a l t h c e n t r e s and h e a l t h i n s t i t u t i o n s .

Many problems were c o n s i d e r e d a s b e i n g common t o t h e m a j o r i t y of c o u n t r i e s :

P a r t i a l coverage of d a t a g e n e r a t i o n and c o l l e c t i o n ; incomplete and poor d a t a

r e g i s t r a t i o n . Numerous d a t a t h a t have been c o l l e c t e d have never been p r o c e s s e d

n o r r e l e v a n t i n f o r m a t i o n g e n e r a t e d . I n a d d i t i o n t o i n a d e q u a t e coverage of i n f o r -

mation g e n e r a t i o n i n t e r m s o f E~neraphiral a r e a $ 2nd certain population groups,

mentionwasmade of i n a d e q u a t e coverage concern ing t y p e s of i n f o r m a t i o n c o l l e c t e d .

Problems of i n a d e q u a t e communication and d i a l o g u e b e t w e e n u s e r s of i n f o r m a t i o n and t h o s e

that produce the information were mentioned. In the ministries of health and

health administration at intermediate and local level analytical potentials for

making use of available informat~on are Lim~ted. Many examples were cited in

the discussion of inadequate dialogue between various sectors of the government

and poor utilization of exisring information in sectors other than Health for

health development planning purposes.

The Workshop concluded that radical measures for improvement of national

health information support to facilitate decision-making in all relevant components

of the Managorial Process fnr Natinnal Health Development are required. The

following recormnendations were made:

1. A national committee, group or similar mechanism on inter-sectoral and inter-

disciplinary bases, representing both producers and users of health informa-

tion from Health, Education, Agriculture, Planning, Finance and other minis-

tries of the government, should be formed. Representatives from institutes

of public health, medical schools or the schools of public health and the

management training institntinnri, r e q ~ n r r h institutions. social insurance

authorities where they exist, representatives of interest groups and of non-

governmental organizations and other kinds not mentioned above should be in-

cluded in the work of the committee or the group. The task of the committee

or group should be that of designing a national health information support

system to the Managerial Process for National Health Development as a part of

health system design for the country.

2. The need for setting-up national councils for developing andlor strengthening

national health information support to decision-making process within MPNHD

was agreed upon.

3. Guidelines for national health information support to MPNHD should provide

c o m n national definitions, classifications, nomenclature, statistical

standards and statistical methodology.

4 . It was recommended that a national committee group or similar body identi-

fied under (1) above should be charged with the responsibiliry of formula~ing

national indicators for identifying changes in the health situations in the

WHO-EM/MG/7 WHO-EMIINT .WKP .FTPNHD/3 page 10

country and therefore to support monitoring and evaluation of the progress

made in implementing national strategy for Health For All. To facilitate

the task of formulating national indicators use should be made of GMO publi-

cation entit1ed"Development of Indicators for Monitoring progress towards

Health For All by the Year 2000" (Health For All Series No. 3. Geneva. 1981).

5. Need was identified to organize systematic training on a continuous basis,

both for producers and users of information on the subject of information

support to decision-making as a part of continuous training activities being

conducted within MPNHD.

12. MECHANISMS FOR ENSURING CONTINUITY IN THE MANAGERIAL PROCESS (SESSION V)

The Manarerial Process for National Health Development should be a continuous

process, the continuity of which should he ensured and maintained through political,

legislative and technical support as well as intra- and inter-sectoral coordination

and collaboration of various national sectors providing health or health-related

services. The Community plays an important role in this respect through awareness

of it+ need< and ttndersranding of its ohligations towards health rare q e r v i ~ e ~ .

This topic was discussed in plenary session (See Exercise 3) after relevant

introductory remarks.

In discussing this topic, it became evident that lack in continuity in the

Managerial Process for National Health Development is one of the most alarming

common constraints for such development. Many factors were seentohinderthis conti-

nuity. At national level, these include political instability; unpredicted econo-

mic recessions; lack of follow-up mechanisms at national, intermediate, institu-

tional and community levels; proper sense of accountability and means of its

assurance. At the level of health sectors, however, the main constraints lie in

the lack of or inadequate intra-sectoral co-ordination between different divisions

of health care provision; inadequate exchange of information within the same health

sector and between this sector and other national providers of health-related

services, professional rivalry and cmpctition and thc administrative and

technical indifference between planners, managers and implementation, monitoring,

controlling and supervising as well as evaluation bodies.

WHO-EM/MG/ 7 WHO-EM/XNT.WW.WNHU/J page 11

The participants shared their specific experiences in this respect. A number

of problems were highlighted concerning barriers in building the continuity at the

national, institutional and community levels. Based upon this discussion, the

following recommendations were made :

National Level:

( 1 ) AIthougll national health councils with multi-sectoral membership have been

established in some participating countries, yet these bodies have limited

themselves mostly to perfunctory advisory roles, and on an irregular basis

when urgent needs a v i s e . These bodies ~ ~ t . d to h~ l e g i s . l a r i v e l y and admini-

stratively strengthened to ensure their continuous role in support to plan-

ning, follow-up and coordinating activities regarding formulation and implem-

entation of national health policy and programs at natiopal, intermediate

and local levels.

(2) National councils should also assume the monitoring and evaluation role to

ensure continuity in the application of Managerial Process for National Health

Development.

Institutional 'Level:

(1) A proper role for the national institutions (universities, professional

schools, medical and health associations and public bodies) within the context

of a particular social system needs r o bc developed. However , it: i a essential

that such institutions are involved in all levels of the HFA strategies. More

specifically, technical expertise should be tapped from professional institu-

tions as advisers/consultants to the national council or similar body as well

as the ministries of health and other ministries. This will ensure their

posicive role in irnplemenracion of plans of action of rhese s~raregies.

(2) Active multi-disciplinary technical groups or committees need to be gstab-

lished to develop programme6 based on Primary Health Care on an ongoing basis,

and they need to be connected with the national health council or similar

bodies. The role of these committees should also be to conduct research and

feasibility studies relevant to Primary Health Care implementation in a

multi-sectoral capacity.

WHO-EM/MG/ 7 WHO-EM/ INT . WKP . MPNHD/ 3 page 12

Community Level:

( 1 ) In order to build continuity in the Managerial Process for National Health

Development, the role of the community, through appropriately planned program-

mes of health promotion and education, should be expanded from an advisory

capacity to a partnership in f o r m ~ ~ l a t i n p , anrl implementation of programmes

as well as in monitoring and evaluation.

( 2 ) A concerted effort is needed to prepare communities in differentiating real

needs versus "wants" by the technical as well as political bodies.

13. INTROlOnUCTION TO BROAD HEALTH I'ROGRAMMING (SESSION VI)

Five sessions (2 plenaries and 3 working group exercises) were organized to

provide the participants an opportunity to review and p r n r t i q ~ Rrnad Health Progam-

ming for the formulation of national strategy for Health for All. Specific exerci-

ses in the working groups covered situation analysis, problem definition and set-

ting priorities, objective setting, strategy and programme formulation.

During the plenary sess ion, a stago w a s set to help onnlyse

information on health problems and to determine health development strategies by

undertaking feasibility analysis of alternative courses of action. Following is

the summary of small group deliberations on this subject.

Situation hnnlyaio

1. Most of the participants agreed that the situation analysis in their countries

focusses on disease-oriented problems. Socio-economic problems still continue

to escape the scrutiny needed by health development planners in most of the

countries during the process of situation analysis;

2 , The actual process of situation analysis isgenerally being carried out prima-

rily by the ministries of health with some support from the Ministry of Plan-

ning and thus relying heavily on morbidity and mortality information and

health resources data. Representatives of the orher ministries (Agriculture,

Industry, Education) are rarely involved in either providing information and

or in reviewing available data relevant to health development. Thus, a col-

lective effort is needed to systematically analyse :

WHO-EMIMGI 7 WHO-EM/INT . WKP .MPNW/3 page 13

Socio-economic and development policies

Health policy

Socio-economic situation

Demographic situation

Epidemiological situation and health status of the poptllztinn

Health resources situation

Health services situation

Situation of housing, food and nutrition

Environmental situation

3. All the Groups agreed that very little is being done to formulate long-term

Plans of Action for Health for A11 and to anticipate (forecast) needs for

national health development. Such forecasting is needed to prepare f n r the

expected as well as unexpected events due to projected socio-economic growth

as well as to cope with turbulent national and global economics. Most of the

countries are concentrating on short-term planning for national health develop-

ment.

4 . Most of the participants pointed out that a comprehensive data analysis requi-

res trained manpower available to planning groups and committees charged with

the planning and management responsibilities for national health development.

Problem Definition

5. As regards the problem definition stage, there was a consensus that malnutri-

tion, diarrhoea1 diseases, malaria, and road accidents were the highest priori-

ty problems in countries represented in this Workshop.

Following criteria were considered by all groups in identifying these priori-

ties:

- loss of economic productivity - social consequences - mortality - morbidity - available resources - projected health development services.

WHO-EM/MG/ 7 I+IO-EII/ INT . IJKP . MPNnn/ 3 page 1 4

Objectives and t a r g e t s e t t i n g

6 . Each Group provided s p e c i f i c statements of general ob jec t ives , t a r g e t s , and

ind ica to r s f o r the problems se l ec ted above. It was, however, s t r e s s e d t h a t

s p e c i a l considera t ians a r e needed i n def in ing hea l th improvement ob jec t ives .

~ h e s e includc thc extent o f coverage of population a t r i s k on short- termand

long-termbases, s p e c i a l a t t e n t i o n topromotive andpreventive a spec t s , p o l i t i c a l

and s o c i a l a c c e p t a b i l i t y a e w e l l a s t echn ica l f e a s i b i l i t y . From the examples c i t e d

above, i t wasclear t h a t a l l t h e p a r t i c i p a n t s w e r e a h l e t o formulate general and

s p e c i f i c ob jec t ives , t a r g e t s and ind ica to r s . A need was f e l t t o t rain and

inform o L 1 l t . r ~ iirvolvrd i n planning groups as well as t echn ica l committees.

S t ra tegy formulation

7 . Strategy formulation f o r the object ives i d e n t i f i e d by the working groups

provided r i c h i l l u s t r a t i o n s of the app l i ca t ion of c r i t e r i a l i s t e d i n the

background reading macerials (PLPAHD 8 1.3 , rr . 48-49) .

8 . Effect ive s t r a t e g y formulation i s a l s o contingent upon coordination wi th in

the hea l th sec to r as well as with o ther sec to r s . The working groups high-

l igh ted the problems prevalent wi th in the hea l th sec to r about the lack of

coordination and s t r e s sed the need t h a t the hea l th sec to r has t o demonstrate

f i r s t by r e a l ac t ions , how mechanisms of coordinat ion have been e f f e c t i v e l y

displayed wi th in h e a l t h sec to r i f we a r e t o win the support of o the r sec to r s .

Programme formulation

During the programme planniqg phase, a number of observat ions , and suggestions

were p resen tedby tbe working groups based on t h e i r individual experience from t h e i r

own countr ies . These included:

9 . A d i s t i n c t i o n t o be made concerning t h e service programme and t h e development

p r o g r a m i n order t o ensure appropr ia te a l l o c a t i o n of resource$. This wpuld

enable the development of a s t r a t e g i c approach i n carrying out the ove ra l l

hea l th improvement ob jec t ives f o r a p a r t i c u l a r problem.

10. Health programme planning and formulation must ensure both v e r t i c a l and

hor i zon ta l coordination.

WHO-EMIMGI 7 WHO-EMfINT.WKP.MPNHDf3 page 15

1 1 . Lack of technical support In areas of health development continues to be a major

problem in the countries of the participants. Professionally competent manpower

is needed at all echelons of health and various sectors to carry out planning.

implementation and evaluation of programmes being proposed to support HFA stra-

tegies.

preparation for Broad Programing:

12. Discussion had indicated that many countripe have so far made limited and insuf-

ficient efforts to undertake broad programming for the systematic formulation of

national strategies for Health for All, due to lack of clear terms of reference

from the highest decision-making establishment in the countries. It was strongly

recommended that in asfiigning this task, attentian ehould be paid to the fol-

lowing:

- Equal partnership in assuming responsibility among health and health-related

sectors;

- Involvement of decision-makers and political groups;

- Time frame for completing the task;

- Criteria ror moni~oring and evaluarion of the proposed work to support

HFA ;

- Clear indication of mechanisms required for reporting the outcome of the

proposed work.

1 4 . PROR- BUDGETING: ALLOCATION OF HEALTH RESOURCES (SESSION V I I )

The availability of resources could he the backbone for attaining any priority

health programe objectives. These resources should be clearly identified quantita-

tively, functionally, and qualitatively for the achievement of each of these objec-

tive separately, and should be considered in the light of the available information

and the present utilization of such resources in relation to stated objectives and

the extent of service delivered to the communities in question.

This topic was projected for discussion by the plenary after introducing the

most salient features to be regarded in connection with it (see Exercise 7) .

WHO-EM/MG/7 WHO-EM/INT . W K P .MPNHD/3 page 16

It was stated during discussion that broad health programming and programme

budgeting are interlinked and part of the formulation process of health strategy.

However, it was clearly revealed that there is an overall deficiency in the situa-

tional analysis and programming capabilities in the health sector in most of the

partlclpatlng countries to implement health development scraregies racner chan co

develop vertical specialized services. Similarly, there seem to be equal deficien-

cies in countries concerning their capabilities for the economic analysis of propo-

sed strategies during broad programing and the assessment of cost benefits, This

is of vital importance for proper allocations of financial, manpower and other re-

sources within the realities of availability and the possrbrlrty of readjustment

according to proposed objectives. The discussion had stressed the importance of

rlning thorotleh and romprehensivebroad programming which might be the only method

of persuading politicians, decision-makers and finance providers of the feasibility

of health programmes and the practicality of attaining their objectives within

proposed durations. Alternative objectives should always be prepared for possible

achievement from the same suggested resources for the consideration of politicians

and decision-rnokcrs within thc framework of the same health programme.

Specific experiences of the participants were presented and discussed. Problems

and constraints that hinder proper judgement of resources and consequent allocation

were highlighted. The synthesis of these and the possible means of solution were

the following:

1. Decision-makers should have good feasible explanations about the preferred

pattern of allocations in terms of the expected outcome within a health prog-

ramme. This necessitates proper programme analysis in both horizontal and

vertical directions, and reasonable comparison between costs and benefjts.

2. Resource allocation should seriously consider the available political, social

and economic realities and should make space for possible unforeseen economic

and other consrraints, dud pldu L V L f e - v ~ i e n ~ d t i ~ ~ ~ aild ~r-adjustment according

to such potential circumstances.

WHO-EM/MG/~ WHO-EMIINT. WKP .MPNHD/3 page 17

3 . Alternative objectives wlthln the same framework ot the programme and the

availability of resources should be kept ready for consideration by

decisionlnakers.

4 . Allocations of resources should be mainly directed towards budgeting of

programmes in support of politically determined objectives of the entire

health system, rather than specific health services.

5. All types of national resources should be identified clearly and practically

to decision-makers. The means of generation and timely utilization and

possible adjustment towards their availability should also be clarified.

6. Discussion of the main constraints that hinder feasible allocations of re-

sources and subsequent attainment of objectives revealed the following conclu-

sions that neccssitatc immediate attention: - Deficiency of programing capabilities for efficient programme budget

projection at high ministerial level; - Rigidity of systems of employment and resource readjustment at the level

of the ministries and lack of or improper understanding of the finance-

controlling bodies, or their i n L r r l r r r ~ z ~ r i r t r l i r r ~ ~ i u r l s opposing t h e prog

ramme objectives.

- Difficulty in attaining objectives of programmes within pr~posed durations

due to all above-mentioned reasons, and the resultant effect on politicians

as to the feasibility of the whole health programme.

A national master Plan of Action for Health for All should be the result

of broad programing and realistic priority health program budgeting dependent

on allocation of available as well as expected resources. This master plan which

constitutes one of the components of the National Plan of socio-economic develop-

ment and presumably formulated by health authorities in collaboration with national

planning bodies and sectors dealing with health-related problems should be consi-

dered as a working document to be proposed to Government for their consideration

and approval. Once accepted by the Government, this document is meant to provide

long-term political guidance on countries' prlorltles wlthin a realistic framework

of economic feasibility and resources' availability for the development of a coun-

try health system h a s ~ d on primary health care.

5RlO-E11/MG/ 7 VHO-EM/INT.WW.WNHD/~ page 18

This master Flan of Action is subdivided into several medium-term programmes

where goals are translated into detailed ubjecLivrs and specific targetg. To

implement the medium-term programmes, short-term actions are taken (yearly plan),

these actions are directed towards the targets, and their effectiveness and quantifi-

cation aremeasured by accepted indicators to ensure progress related to the medium-

term programme and in conformity with the master Flan of Action.

All these plans are not supposed to be static, as they might be subject to

changes or modification$ governed by economic, political, technical and other consi-

derations and circumstances and should be guided by frequent evaluation of activities

performed in terms of programmes.

There was a plenary discussion of this topic by rhe participants (see Exercise8).

rl-py all a ~ r e e d and understood during the discussion that far a national Plan

of Action to be forrnulatqd, the fqllowing components have to be considered and

included:

- Policies to be followed

- Objectives and related targets to be attained

- Political, social, economic, administrative and technological processes

required

- Ptiority health problems ta be identified

- Main actions agreed by all concerned sectors

- Manpower required

- Rrnad allnratinn of resn i l r res

- Organizational responsibilities for programe implementation, m~nitoring

and successive evaluation.

Nevertheless, it was quite evident from discussions among participants that

practically none of their countries have properly formulated a national master Plan

of Action for Health for All. This was mainly attributed to the prevailing political

as well as economic uncertainty. However, medium-term (5-6 years) plans or program-

mes have been formulated in this direction in most o f the participating countries.

WHO-EM/MG/7 WHO-EM/INT.WW.MPNHD/3 page 19

Unfortunately, very often these medium-term plans and programmes fell short of the

achievement of their objectives and targets due to constraints related to the quan-

titative and qualitative deficiencres in many of the afore-mentioned components of

plans of action. Such being the case, most of the'activities within the available

health systems of the participating countries are directed on a yearly plan hasis

governed by the allocated budgetary health allocations and mainly aimed at dealing

with any presently eminent health problem.

The participants showed great concern about this alarming situation. They

discussed possible avenues of solutions, the synthesis of which could be included

in the following:

1. strengthening of the managerial capabilities within ministries of health at

the central level to ensure comprehensive formulation and coordination in the

implementation of the master Plan of Action for Health for All with all its

related components.

2 . Increase the managerial abilities of technical people concerned with the health

of the population In different sectors ot the Government. Consequently, they

should act as catalysts to enable the achievement of targets and objectives of

any formulated plan of action at various levels.

3 . Plans of Actions for other health-related activities in ministries other than

Ministry of Health should be formulated in synchronization and harmony with the

national master Plan of Action of Health for All.

4 . Encouragement of the e~tablishment of health management institutions, at the

national or regional level through national actions and international collabora-

tion. These institutions should be directed towards the development of high- as

well as mid-level t~ralLll ruanagers .

WHO-Enl/Mti/7 ma-EM/INT.WKP.MPNHD/~ page 20

16. DETAILED PROGRAMMING (SESSION 1x1

Exercise 9 --- This process consists of the detailed formulation of a country-wide programe

that coincides with tllr oLjac~ivrs and LargeKs Of Cne national master Plan of Action

for the ultimate improvement of health care delivery systems. This detailed program-

ming is ideally undertaken at the regional or provincial level to enable the review

of the local implication of the programme activities and facilitate its implementa-

tion.

The working Group discussed the subject (Exercise 9) and the following observa-

tions were made in this respect:

1. It was pointed out that none of the participating countries have to this

moment carried out detailed programming at the peripheral level. The major

reason cited was the lack of trained personnel capable of undertaking this

task. It seems that most of the trained personnel, if ever available, are

concentrated at the central level. The need for detailed programming at the

central level was perceived only when requested by political or technical in-

ternational agencies and is r~sually rond~lrted through their assistancc.

2 . In order to gain maximum benefit of detailed programming at the peripheral

level, it was recommended that a manager with full-time responsibility he

designated, who must ensure the involvement of related technical and adminis-

trative sectors and cornunity members. It was further recommended that clear

terms of reference be prepared and the team beenlightenedthrough intensive

briefing and frequent interchange of information and experiences with the

central planning units.

3. A further analysis of the implication of the national master Plan of Action

at the peripheral level enables planners to ensure the conformity of the

regional activities with that of the plan. This may allow the planners

and implementers to test the feasibility of the programme and its possible

adjustment.

WHO-EM/NG/~ WHO-EMlINT.WKP.MPNHDl3 page 21

4 . Uetailed programing at the perrpheral level allows the setting of the local

objectives and targets to deal with the specific local health priorities.

Furthermore, the reconnition of possible obstacles and constraints, in re-

source availability and traditional barriers,could be more striking aqd a

more practical programme of activities can be delineated accordingly.

5 . Detailed programming at the peripheral level allows for adaptation of pre-

vailing or existing health systems to theemerging socio-economic development,

wlthln the avarlable local resources.

17. PROCRAMME TNPTRMENTATTON: PROGRAMME OPERATTON ANT) TNTRCRATKON (SESSION X)

Exercise 10

Progrannne implementation conducted whether centrally or peripherally requires

detailed programming which has been previously endorsedby the appropriate multi-

sectoral authorities concerned. This allows t h e prnermmne managers to make use of

the available resources for the benefit of the population to be served. There are

three essential phases for programme implementation, namely starting up procedures,

day-to-day operation of activities and services as well as monitoring.

Participants were challenged with this exfrcioe (Excrcisc 10) to make cements

and observation on the unique attributes needed to provide the know-how and the

leadership needed to demystify implementation of programmes. Their recommendations

were as follows:

1 . Programme manager must attend to prevalent and projected population problems,

and should be able to re-orient his team to the strategy of HFA/2000. He

must be able to adjust the operational details to the existing realities of

the cornunity and its resources. inastimulatinerather than reactive attitude.

2. Very few examples of genuine active community involvement in the implementa-

tion of PHC at the peripheral level were available among the participating

countries. It was recommended that, to be more effective, community involve-

ment should start at the level of planning and then continue up the implemen-

tation as well as monitoring phases.

WHO-EM/MG/~ WHO-EM/INT.WKP.MPNHD/3 page 22

3. To acquire better inter-programme and inter-sectoral co-ordination, it

was emphasized that the current health manpower and logistic support has

to he re-oriented to perform a multi-purpose health development role at

the peripheral community level.

4. It was reiterated that the implementation of the PHC concept should never

be pursued as a vertical programme. This would minimize duplication of

scarce resources, discourage building of proffs~ionol cmpircs and provide

the consumer access to integrated health services.

5. Management of resources during implementation (available fundq, manpower.

constructions, etc.) needs continuous manipulation according to availabili-

ty.

6 . Problems confronted during implementation could be in the form of lack of

motivation of personnel, lack of facilities and, more critically, lack of

orientation towards PHC strategy.

18 . MONITORING AND EVALUATZON OF NATIONAL STRATEGIES FOR HEALTH FOR ALL (SESSION X I )

Exercise 11 Evaluation is the constructive systematic method of learning from experience

to improve current activities and promote better planning for future action accord-

i n c l y . T h i s rnmprises critical and sincerely realistic analysis of various aspccts

of programme activities and the impact of its implementation on the overall socio-

economic development in relation to its acceptability, cost-efficiency and effec-

tiveness. Evaluation is not meant only for programmes and their activities. It

should reflect on the whole managerial process for national health development.

This topic was reviewed among the working groups where discussions revealed

that most countries, if not all, have not yet developed an evaluation

mechanism as defined in the managerial process. Hence, they were unable to progress

in the proper and right direction of formulating strategies and policies for HFA12000.

M o s ~ counlrirb: have a centralized system of feed-back from periphery to central

bodies which is not fully analysed nor utilized as it mainly originates from

hospitals and health centres without reflection of the real health status of the

population.

The participants appear to he familiar with the evaluation components as

outlined in HFA Series No. 6. However, application of these components seems

locking in their national managerial system.

The participants recommended the following:

1 . Indicators for the evaluation process need to he developed during the pro-

gramming phase at central as well as peripheral level.

2 . Emphasis he laid on developing competent technical personnel to carry out

the evaluation process.

3. Evaluation should he performed by natlonal multl-sectoral comttees with

special terms of reference to systematically review every component of MPNHD.

Sub-committees of the same composition should be established at the periphery.

4 . Sincerity and facing of realities have to be the guiding principles in the

evaluation process so that the evaluation results in the improvement of the

programmes.

5 . Mobilization of resources and collection of adequate information about the

availability'of these resources, their distribution and future development,

are essential for effective evaluation.

6 . Evaluation should be performed through the mechanisms of self-evaluation,

regional then central evaluation, multi-sectoral evaluation as well as

joint national-international rcvicw and cvaluation missions.

7. The WHO common framework and format for evaluation of HFA Strategy are recom-

mended to be used and seriously rnncidered a s eltideliner for the partipipa-

ting countries in their national process of evaluation.

19. NATIONAL ACTION TO STRJ3NQTIICN Ml'NlID AND USE OF TCDC NECIIANISMS I N SUPPORT OF THE APPLICATION OF MPNHD (SESSION XII)

T h c participants of thc vorlrohop rcvicvcd the poooible avenues for etrenghten-

ing MPNHD on a national basis and the use of technical collaboration of developing

countries in that respect. This was discussed in a plenary sessiop and the following

was recomended:

WHO-EM/MG/7 WHO-EM/INT .WKP .MPNHD/ 3 page 24

1 , Continuous and persistent efforts should be directed towards the national

policy-making bodies to whom the needs and requirements as regards the health

situation are clearly projected. This should he performed along with means

of concomitant translation of the national initial commitment to HFA strateey

iuLv rrdliLy i ~ r Llrr SVLIII of legislarive enforcement, health infrastructure

development, strengthening of planning units and mechanisms of inter and

intra-sectoral co-ordination as a continuous process under the leadership of

a highly authorized and prestigious national body.

2. Thorough assessment of the existing managerial process and capabilities.

This should he follpwed by intensive efforts to build national managerial

capabilities in the right direction at various levels of health services

and healrh-relaced sectors, and other health-interested groups and comunities.

This should include managerial staff support of technical ministries and

managerial re-orientation of their existine. technical staff towards MPNHD-

3 . Ministries of health should pursue a continuous dialogue and deploy inter-

sectoral partnership with other ministries responsible for health-related

problems.

4. Ministries of health should study, then enforce the necessary administrative

and technical changes required in support of HFA strategy, possibly through

continuous briefing of all health personnel at all levels and dissemination

or inCur~naLivn concerning nacional healch policy, programmes and then objec-

tives and targets, to health professionals as well as other offjcials and

politicians in the community to create coordination and understanding and to

initiate a constructive dialogue between different sections within the Ministry

of Health and with other related sectors in that respect. A legislatively

supported multi-sectoral national council rather than a vertical department

within the Elinistry of Health for PHC could be the answer to this question.

5. Training should be pursued at the natronal as well as the regional level

for the strengthening of MPNHD. This should be directed towards:

- training of the trainers

- development of health development planners in all health-related sectors

WHO-EM/MG/ 7 WHO-EM/INT.WW.HPNHD/3 page 25

- orientation of representatives of interested groups and communities

- organization of provincial seminars and workshops in MPNHD involving all

health and health-related sectors and communities

- appropriate development of learning material through national experts and

by rranslaring seLb of WHO publi~d~ions celd~ed ro MPNHD inco cbe nacfonal

language

- establishment or strengthening of national institutions for health development

and TCDC to develop critical masses of health development specialists. This

should be supported by national health research institutions and the continu-

ous initiation ot lnter-reaction between all these in~titutzonsco ensure the

integrated reconstruction Of existing health systems to achieve the goal

of HFA through the PHC concept, and to develop national guidelines for its

achievement

- organizing national multisectoral workshops on MPNHD.

6. Governments, and ministries of health should use the common framework and

format of WHO for evaluating the strategy for HFA/2000, as an entry point to

draw the attention of all national institutions and decision-makers to realize

the need for further strengthening of MPNHD.

20. WHO TECHNICAL CWPERATION I N SUPPORT OF MPNHD

The participants discussed the possible avenues of WHO technical coopera-

tion in support of MPNHD in their countries. Their recommendations were as

follows:

1. Establishment of a regional centre for the development of managerial capa-

bilities in support of MPNHD

2. Assistance to qountrirs in rs~dblisl~t~~r~~~ uC ~ u ~ i u r ~ l i ~ l s t i t u t i o n s Lor train-

ing in the managerial process at all levels.

3 . Support national seminars for MPNHD and continue regional workshops in this

respect.

4 . WHO should play a catalytic role in coordination between international and

bilateral agencies in support of HFA strategy and the development ot national

managerial processes.

WHO-EM/NG/~ 14130-EY/INT. WKP . MPNHDI3 page 26

5. WRCs in the countries of the Region should be given more chance and be challenged

to play promotive and supportive roles in the development of natipnal managerial

process.

6. Supporting fellowships ts develop health development specialists.

7 . WHO approach to H F h sfrntcgy ehould be concomitantly directed to ather sectors

of national authorities concerned with health.

8, Encouragement and support to visiting seminars and case studies, between covntries

of the Region to exchange experiences as regards field application of the stra-

tegy of HFA.

9. More concenrracion should be given by WHO to the most cornon areas of weakness

in the Region as evidenced by the course of the evaluation process.

10. To ensure total country commitment for HFA strategy and PHC, the Regional Office

should include other government sectors dealing with healtb matters in its

related activities,

1 1 . All ~olitical regional meetings and councils as well as existing political

and technicalorganizations should be used to promote HFA strategy.

1 7 T h e Roeinnal Offire mieht ronsider a meeting at highest level of envernment

sectors related to health problems, where the most important issues and problems

in pursuing HFA strategy are displayed before of a11 parties concerned for

collective and coordinated solution.

2 1. EVALUATION EXERCISE

The evaluation of the Workshop entailed participants ascertaining their views

on the educational experiences provided during the workshop as well as on determining

future training needs for their respective countries in the Managerial Process f ~ r

National Health Development. Out of 22 participants, 18 completed the questionnaire.

The analysis of their responses are as follows:

The maiority of the participants strongly agreed that the objectives gf the work-

shop were adhered to and that they would strengthen their efforts to implement na-

tional strategies for Health for Ail. Fo\~rteen out of eighteen part.icipants rated

their overall experience of this workshop as excelleaf. Theparticipants considered

the organization and themethods usedextremely useful in learning the concepts, principles

WHO-EMIMGI 7 WHO-W/INT.WKP.MPNHD/3 page 27

procedures and methodologies discussed during the workshop. Most of the partici-

pants found the interchange in working groups and plenary very productive in terms

of learning from each others' expericncos in the Region.

The following Table of selected items support the above.

Table 1: Views about objectives and methodology (No. 18)

Wurkshop Experiences Strongly Agree Disagree Strongly No Agree Disagree Opinion

1. Objectives supported efforts 15 3 - - - to implement national HFA stra- tegies

2. Objectives increased my capacity 10 8 as plannerladministrator

3. Overall organization consistent 10 7 w i t h objectives

4. Background reading useful 14 2

5. Plenary sessions helped 12 6 crystalize issue

6. Working groups allowed 9 8 discussion and inter-change

7. Tasks accomplished during 5 1 1 the workshop

Participants were asked to identify the components of MPNHD which were fairly

developed in their country as well as those which needed further development, Their responses revealed that formulation of policies and broad programing have been fairly

well attended to but evaluation of development strategies and detailed pr~graming

in some cases require immediate attention (See Tables 2 & 3 ) .

Table 2: FNHD Components fairly well developed in countries represented

Components

1. Formulation of National HealLh ~olicies

2. Broad Programing

3. Programme Budgeting

WHO-FM/MG/~ WHO-EM/ INT .WKP MPNHDI 3 page 28

Table 2 (Cont'd)

Components

4. Master Plan of Action

5. Detailed programing

6. lmplemencatio~~

7. Evaluation

8. ~e-programing

9. Information support

( 1 = extremely well developed)

(6 = least developed)

Table 3: MPNHD components, which require immediate attention

1. Formulation of National Health Policies

2. Broad programming

3. Programme Budgeting

i. Master Plan of Action

5. Detailed Programing

6. ~m~lementation

7. Evaluation

8. ~e-programing

9. ~nformation support

( 1 = immediate attention)

(5 = needed in the future)

Ranking

4

4

5

5

6

5

The par~icipdr~ts selected the following 3 actions fo support MPNHD in their

countries in order of priority:

1 Dcvcloping national Buidelin~s Fnr MPNHn

2- Organizing a national workshop on MPNHD with a multi-sect~ral composition

3- Provided a briefing paper to higher policy-makers and decision-makers.

WHO-EM/MG/7 IrlllO-EM/INT . WKP .MPNHD/3 page 29

In terms of WHO support, the participants identified the following in

terms of priority:

1- Strengthening planning units within ministry of health

2- Mobilization of national institution to re-orient their programmes to HFA

strategies

3- Re-orienting national training institutions.

22. CLOSIRF OF THE WORKSHOP

The Workshop was closed by Dr Nazmi Fallouh, Vice-Minister of Health of

the Syria- Arab Republic on behalf of H.E. The Minister of Health of the hoot

country. He expressed his appreciation and satisfaction with the dynamics

developed through the Workshop and in its outcome. He also hoped that this will

lead to initiation of similar activities at the national level of all participa-

ting countries for the development and strengthening of MPNHD and its use in

support oE strategy of I1rA.

Dr C. Vukmanovic thanked the Government of Syria and H.E. the Minister

of Health for providing all the necessary assistance to make this workshop

a success. He also thanked the participants for their efforts and collective

engagemem in che accivicies of the Workshop which resulted in such an instruc-

tive and informative outcome.

Several participants have also expressed their appreciation and thanks

to the Government of Syria and to WHO for organizing this Workshop and allowing

them accessibility to its collective learning on MPNHD.

AFGHANISTAN

CYPRUS

DEMOCRATIC YEMEN

page 31

ANNEX I

D r A l i Ahmad Omar Pres ident of Cadre Department Ministry of Publ ic Health Kabul - D r Abdul Quadir Awa Vice-President, In t e rna t iona l

Rela t ions Department Ministry of Publ ic Health Kabul

could not p a r t i c i p a t e

M r J a f f e r Jooman Director-General Planning and S t a t i s t i c s Ministry of Publ ic Health Aden -- Mr Abdul Aziz Assakaf Director , Division of Medium

Level Health Cadres Ministry of Pub l i c Health Adcn -

DJIBOUTI Could not p a r t i c i p a t e

IRAN, ISLAMIC REPUBLIC OF D r Bijan Sadrizadeh Director-General Family Health Department M i n i s L r y oT BralLh Teheran -- D r Ayoub Espander Health S p e c i a l i s t Ministry of Health Teheran

WHO-EM/MG/ 7 I~O-EM/INT. NKP .MPNHD/~ page 32

LEBANON Mr A f i f Ballot~z Administrative Chief (Health Projects) Ministry of Public Health Beirut --

Mr Georges Maalouf Hospital Administration Ministry of Health and Social Affairs Bcirut --

LIBYAN ARAB JAMAHIRIYA

SOMALIA

SYRIAN ARAB REPUBLIC

Mr Habib Esmail Tamer Director-General of Health Manpower Developmgnt

Secretariat of Health Tripoli - .-7 Mr Yassin Farah Ismail Director of Planning Department ninistry of Health Mogadishu -- Dr Ahmed Sherif Abhas Responsible Officer for Coordination with International Agencies

Ministry of Health Mogadishu

* Dr Nazmy Falouh Assistant Minister of Health Ministry of Health Damascus

Dr Mustafa A1 Ba'ath Assistant Minister of Health Ministry of Health Damascus

Dr Walid A1 Haj Hussein Director International Relations Minigtry nf HealPh Damascus

*~lso Chairman of National Preparatory Committee.

OBSERVERS FROM HOST COUNTRY

Dr Khaled Mardini Director of MCH Centres Ministry of Ilealth

Dr Hesham Burhani

Dr Asaad Istewany

Director, School Health Ministry of Education

Director of Planning Ministry of Health

Dr M. Yassin Muftah Director ot Preventive Services Ministry of Health

OBSERVER FROM AN INTERNATIONAL ORGANIZATION

Dr R. Nahas UNFPA Representative Syrian Arab Republic

WHO STAFF PARTICIPATING

Dr M . I. A1 Khawashky Regtonal Adviser, Eastern Mediterranean Region Organization of Health Care Sewices

Dr M.A. Khalil Regional Adviser, Eastern Mediterranean Region Occupational Health

Regional Adviser, Eastern Mediterranean Region Nutrition

Dr J. Jirous WHO Representative and Kabul, Afghanistan Programme Coordinator

Dr A.M. Rahmani WHO Representative and Beirut, Lebanon Programme Coordinator

Dr Chang Hua Chuang WHO Malariologist Riyad, Saudi Arabia

Dr Sayed Ali Hussein \&ID Medical Officer, Damascus, Oral Health Syrian Arah Repuhlir

lJHO SECRETARIAT

Dr Q. Vukmanpvic Responsible Of ficen. WHO, Geneva Wanneerial Prnces. f p ~

National Health Development

Dr Abdul klahid Sajid k110 Conssltant Director. Office of Fducacional Developmcnt:, Unive~sity of Texas Mdical Branch. Galveston. Texas, USA.

Ms A.N. Hemfa Conference Off ifer Eastern Mediterranean Region

Miss Vona Zaki Secaetayy Eastern Mediterranean Region

WHO-EM/MG/ 7 WHO-EM/ INT . WP . MPNHbl3 page 35

ANNEX II

Lrlter~ountry Workskco~ on Managerial Process for National Health Development Damascns, Syrian Arab Republic, 15-L5 bcptember 1984

PROGRAMME, OF WORK

Date/ Type of Time Session

Subject Recommended Reading

10.00 Plenary Session 1 - Opening of the Workshop

- Intrdduction of Participants Organization of the Workshop Workshop Objectives and Workshop Procedures Session 2 - ?nTmtk@Xion to MPNHD %anagerial Process for concepts, Principles, Methods Natronal Hcalth Development and Procedures. ?lain ( "HFA" Series No. 5) Components of the Process

- Methodoloqy in uve for MPNHD wHO/EMRO Technical - Use of terminology within Publication No. 3 ; MPNHP Introducing a Managerial

Process for National Health DeveLopment Draft Glossary of terms used in ''HFA" Ser ies , N o s , 1-8

- Problem-based learning in MPNHD

11.45 ~nltial Session 3 Plenary Introduction to Formularlon Global S t ~ d ~ ~ g y for

of National Health Policies Health for All ("HFA" Series, No. 3) pp. 31-49) MPNHD Guiding P r l ~ l c i p l r s ("HFA" Series, No. 5 pp. 18-21)

1 3 - 0 0 Working Exercise ; : Health Policy Groups Formulation Process :

Actors, Mechanisms, Content

14.30 Lunch

kfternoor~ : Free for discussions and preparation for t h e following day

i m o - ~ r f / r f ~ / 7 WHO-EN/INT.WKP,MPNHD/~ page 36

ate/ Type of Subject Recommended Time Session Reading

Sunday - 16/9/84

0.8.30 Summing-up plenary fpr Session 3

Plenary

10.30 Pause

10.45 Plenary

National Health Policies

Session 4 Introduction to Information MPNHD Guidinq s n p p r t for MPNHD

Session 5 ~c&hanisms for ensuring continuity in the managerial process

Princiales (IiFA Series, No.5, pp. 57-60)

MPNHD Guiding principles (HF4 Series No.5, pages 14-17)

13.30 Lunch

Afternoon : Free for di$cussiops and preparation forfollowing day.

Monday - 17/9/84

08.30 Initial Session 6 Plenary Introduction to Broad MPNHD Guiding

Health Programming Principles (HFA Series No. 5) Broad Programming as a part of MPNHD (MPNHD/Bl. 3 )

Working grm,ps

Exercise 4 : idem situation AsseSsment, Problem defiqitlon and setting Priorities

Visit to the National Health lnstltute follgwed by Lunulr gjven by the Ministry of Health

Afternoon t Free for dlscusgions and preparation for the folkowing day.

WHO-EM/MG/ 7 WHO-EM/INT.WKP.MPNHD/3 page 37

D ~ L S / Typeof Subject Recommended Time Session reading

Tuesday

1a/9/84

08.30 Working Groups

ID. 45 Working Groups

Session 6 (Con't) " Exercise 4 (Cont'd)

Pause

Exercise 5 : Setting Broad programming as Health nhjertiveq and part of MPNHD Strategy Selection (MPNHD/81.3)

13.30 ~unch

Afternoon : A tour of r)amaSCU$ organized by the Ministry sf Health

Wednesday

19/9/84

08.30 Working Groups

Exercise 6 : Strategy idem selection and broad health programme formulation

10.30 Pause

10.45 Summing-up plenary for Session 6

Broad Health Programming Broad Programming as a part of MPNHD (MPNHD/~~.~)

13.30 Lunch

16.00 summinn-up Plenarv for

Broad Health Programming idem

Session 6 (Cont ' d )

dinner

Date/ Type o f Subject Recommended Time Session Reading

Session 7 : Programme Programs Budget~pg as a Budgeting, ~llocatiuq pasr o f MPNHU of Health Resources. (MNHHD/84.2)

10.45 plenary Session 8 Introduction to National ' MPNHP Guid$ng Principles Master Plan of action fox (HFA Series No. 5 Wealth for All p.p. 34-35

13.30 Lunch '

Afternoon : Visit to Bmra Roman Amphitheatre

Friday

2 1/9/84 Non-working day

Saturday

22/9 /84

08.30 Initial plenary

Session 9

Introduction ta Detailed Programming

Detailed Programming as part of MPNHD (MPNHD/81.4)

4.45 Working Exercise 9 : Detailed Groups ~rd~rarnme Formulation

10.30 Pause

- Visit to Rural HeaAth Centre

16.30 Working Session 10 : Groups 'programme Implementation Programme Implementat~on

as a part of MPNHP ( M P N H I J / ~ ~ .51

19-00 Closure

WHO-EM/MGI7 WHO-EMIINT ,WKP .MPNHD/3 page 39

Date/ rype of Subject Recommended Time Session Readlng

Sunday 23/9/84

08.30 Summing-up Detailed Programming idem Plenary for and Programe Implementation Sessions 9 4 10

10.45 Initla1 Session 11; Plenary Introduction to Monitoring

and Evaluation of MPNHD and its use In Support of Health for All

Working groups Exercise 11 : Monitoring

and Evaluation

13.30 Lunch

16.00 Working groups Monitoring and Evaluation (Con'd)

10.00 Closure

Health Programme Evaluation : Guiding Principles (HFA Series No. 6)

Monday 2 4 / 9 / 8 4

08.30 Summing-qp plenary for session 9

10.30 Pause

10.45 Plenary Session

12.04 plenary Session

13.00 plenary Session

14.00 ~lepary Session

Monitoring and Evaluation Health Programme of MPNHD Evaluation :

Guiding Principles (HFA Series NO. 6)

Session 12 National Action to Strengthen MPNHD and Use of TCDC Mechanism in support of the applicatign of MPNHD

WHO Techpical Cooperation in support of MPNHD

Evaluation of Workshop

Consideration of Draft Report

closing session

'JHO-EM/~IC,/7 TJHo-EF~/ INT . IJKP. I.PiWD/ 3 !,age 40

ANNEX TTT

WHO-EM/MG/7 WU-EMfLN'l .WKY .Mk'NHU/3 page 41

IJHO-EM/MG / 7 WHO-Bf/ INT. IGP .IfPMHD/3 page 4 2

15. Circle the component(s) of MPNHD which is/are fairly well developed

and applied within the health system of your country :

q. The formulation QE national h e a l t h oolicies, comprising goals,

priorities, ang main directions towards priority goals, that are

suited to the social needs and ecnnarnlc conditions sf the country and

forp part of national ~ o a i a l and cconomic dcvclopmcrlC policies,

b. Broad Proqramminq - the translat~on of these policies, through --- various stages of planning, i n t a strategies to achieve clearly

stated objectives and, wherever possible, specific targets;

c. PrQqramme budgeting - the preferential allocation of health resovrces for the implementation of these strategies;

d. The Master Plan of Action resulting from broad programming and

programme budgeting and indicating the strategies to be followed and

the main lines Q £ action to be taken in the health and other sectors

to implement these strategies;

e. Detailed progxamminq - the conversion of strategies and plans of action into detailed programmes that specify objectives and targets,

and the technology, manpower, infrastructure, financial resources, and

time required for their implementation through a unified health system;

f . Implomentatios - the translation of detailed programmes into action so that they come into operation as integral parts of the health system;

the day-to-day management of pxogrammes and the services and institutions

for delivering them, and the continuing follow-up of activities to ensure

that they are proceedinq as planned and are on schedule.

g. Evaluation of developmental health strategies and operationaJ. programmes

ror tnelr ~mplementac~o~, In order progressively to xmprove their

effectiveness and impact and increase their efficiency.

WHO EM/MG/~ WHOLEM/ INT , WKP .MPNHD/3 page 43

h. Rcprogrqmming, ae necessary, w i t h a v i e w to improvinq the master

Plan of Action or some of its components, or preparing new ones as

required, as part of a continuous managerial process for national

health development.

i Support, In the form of relevant and sensitive information, for

all these components at all stages.

16. Circle the component(s) of MPNHD which is/are least developed and

require immediate attention :

a. The formulation of natlonal neaitn pollcles, comprising goals,

priorities, and main directions towards priority goals, that

are suited to the social needs and economic condit~ons of the

counfry and form part of nat~onal social and economic developmenf

policies;

b. Broad Programming - the translation of these policies, through

various stages of planning, into strategies to achieve clearly

stated objectives and, wherever possible, specific targets;

c, P r o r j r a m m e Budgeting - the preferential allocation of health resources for the implementation of these strategies;

d. The master Plan of Act~on resultlng from broad progranu~iny ard

programme budgeting and indicating the strategies to be followed

and the main lines of action to be taken in the health and other

sectors to implement these strategies;

e. Detailed prcgramming thc convorcion of strategies and plans

of action into detailed programmes that spec~fy objectives and

targets and the technology, manpower, infrastructure, financial

resources, and time required for their implementation through

a unified health system;

f, Imp~ementation - the translation of detailed programmes into action so that they come into operation as integral parts of the health

system; the day-to-day management of proqrammcs and the services and

institutions for delivering them, and the continuing follow-up of

activities to ensure that they are proceeding as planned and are on

gchedule.

g, Evaluation of developmental health strategies and operational

yxuyrdumu fyx their iruplernentation, In order progressively to

improve their effectiveness and impact and increase their efficiency;

h. Reprogramming, as necessary, w i t h n v i e w to i m p r o v i n g the m a s t e r

plan of Action or some of its components, or preparing new ones as

required, as part of a continuous manageriaL process for national

health development;

i. Support, in the form of relevant and sensitive information, for a l l

these c o m p a i ~ e n t s at all states.

L7. Based upon your participation in this Workshop, select future

action(s1 neeaea EO supporc m e appllcatlon ot MPNHD and its use for

st;rategies for Health for All in your country. Please write your

ot-der of priority (c= highest priority - 2 = moderate priority - 3 = LOW, priority) in the right hand column.

Priority Order

a. Organizing a nakional workshop Conference

and ~r/sominar to discuss i s s u e s and problems

related to further promotion and application

of MPNHD in support of national strategy

for H e a l e n for ALL with mu~tl-sectorai

participation.

b. Developing national guidelines for the

integrated Managerial Process for National

Health Development.

WHO-EMIINT.WKP.WNHD/~ page 45

1 7 . (ront'n) Priarity Order

c. Provide a briefing paper to higher policy

and decision-making authorities on the need

for developing and strengthening national

maneserial qapabilities in support of

national strategy for Health for All.

d. Seek support in my country and from WHO - to translate in my own national language

WHO publications on "MPNHD Guiding Principles"

e. Initiate a systematrc monztoring in my

country of the Managerial Process for

National Health Development and its use

in support of natianal strategy for

Health for All.

f. Others - 18. Based upon your experiences in this Workshop, identify the

pstential area of promotional, political and technical support

needed from WHO L L ~ ia ip lrnlr11L MPNHD i r l yoqs country. Please

~~itayour order of priority (1 - 2 - &@rate priority - 3 = low priority) in the right hand column.

a. A thorough assessment of the existing MPNHD

and i t s use for strategy for Health For All

b. strengthening planning unlts within Ministry - of Health

c. Mobilizing national institutions to

re~rient their programmes towards HFA

Strategy.

Priority Order

d. Rearient national Graining institutions - and organize training programmes to strengthen

the technical competence of health system

basecf un Primary Iiealth C P ~ C .

a. Others

19, Any overall cgments :

2 0 . On a sc&? of 1 - 5 how waq14 you rate your overall experience

within this Workshop

1 ?,

I 1 -t,. - 5 r'"' 1

poor excellent