Towards o 2 • OCTOBER 2000 Unity for Health · 2 TOWARDS UNITY FOR HEALTH, 0CTOBER 2000 role of...

TOWARDS UNITY FOR HEALTH, 0CTOBER 2000 ■ 1

COORDINATING CHANGES IN HEALTH SERVICES AND

HEALTH PROFESSIONS PRACTICE AND EDUCATION

TowardsUnity forHealth

No 2 • OCTOBER 2000WHO/EIP/OSD/NL/A/2000.2

3 Building synergies4 Educating to create unity in health:

an educational programme tosupport the TUFH project

5 Partnership towards unity for health:voices from the community

7 If I were a Minister of Health: theopportunity of “Towards Unity forHealth”

9 Towards unity for health – vision andviability

10 Sherbrooke-Estrie integratedcardiovascular health programme:a commitment for TUFH

11 A community cardiovascularprogramme in the Maastrichtregion: the relevance of TUFH

13 Public health in the United Kingdom:a nation striving for unity for health?

14 Family health: the cornerstone of ournational health organization faceschallenges

16 An alliance of health professionals:the best support to unity for health

17 Towards Unity for Health: The PhuketConsensus

18 Les sciences infirmières, un atoutpour créer l’unité dans le domaine dela santé

19 Diarydates20 Unity in health care practice: some

directions for change: a nursingperspective

22 Accrediting the capacity to meetsociety’s health care needs

23 Needed: a people-centred classifica-tion of health problems seen inprimary care

25 Towards unity for health throughmedical education curricularinnovations

27 Towards Unity for Health: anopportunity to engage our medicalschools in health research

29 Team effectiveness in achieving“Unity for Health”

30 Communication technology anddistance learning: more words thanaction

33 Facilitating information exchangeamong international health agencies,foundations and local initiativesthrough a common clearinghouse

34 Basic health services: why we arenot making greater progress

36 World directory of medical schools:Supplemental information

38 Addresses

What Sicily can gain fromand contribute to“Towards Unity for Health”Pina Frazzica, Center for Training and Research in PublicHealth, Caltanissetta, Sicily

The Sicilian context

Sicily is the most southern Italian region and is located in the center ofthe Mediterranean. It is an island of ancient cultures and populations,

of breathtaking landscapes, of colours and sunny weather.Its surface is 25 708 km2, with approximately 5.5 million people. The

Sicilian population aged over 65 keeps increasing, while Sicily remains oneof the few regions in Italy with a positive growth rate. The Sicilian popula-tion enjoy, in addition to their mild climate, the healthy Mediterraneandiet, which seems to foster their longevity despite the modest quality oftheir health services.

The Sicilian health systemThe Sicilian Regional Health System (SRHS)comprises nine local health organizations(LHO), 17 public hospital organizations (HO)and three university hospitals. There are alsoa number of private structures under contractto the SRHS, as well as a few purely privatedoctors and clinics.

LHOs are responsible for the managementof territorial health services and district hos-pitals (over 60 in Sicily) and for providing pri-mary care, including contracting generalpractitioners (GPs). HOs provide inpatient

Pina Frazzica continued page 2 ➤

2 ■ TOWARDS UNITY FOR HEALTH, 0CTOBER 2000

role of the latter in influencingpublic opinion.

● Social and health services andvoluntary associations.

This is only a partial list. In addi-tion, the information society de-mands care and services of highquality that are based on scientificevidence. Undertrained profes-sionals often cannot provide these.

Sicilian patients are known toundertake “voyages of hope” to-wards northern regions to haveaccess to better care. Those whocannot afford the economic as wellas the social costs accept what isavailable and hope for the best. Theresulting inequities provoke severedamage to the SRHS and to societyin general.

The need for changeIn the midst of all this, the SRHS hasrepeatedly been criticized by thepress and therefore the need forchange has became more evident.

The first step towards the“change” was the creation of a ma-jor training institution, Cefpas, theCenter for Training and Research inPublic Health, situated in the heartof Sicily, in the city of Caltanissetta.This is the only training institutionof its kind in Italybelonging to theg o v e r n m e n t a lhealth system.

Cefpas openedits doors in 1996,and despite a dif-ficult start it hasdeveloped train-ing activities ofhigh standards inpublic health andin clinical sci-ences. It has alsobecome one of the first schools ofpublic health in Europe to be certi-fied ISO 9000. Quality for Cefpas isthe organized and evident effort toproduce training and researchactivities based on effectiveness,efficiency, appropriateness, equity,scientific soundness, research, in-novation and courtesy.

Over 120 courses of quality arecarried out each year: they are in-novative in terms of approach,methodologies and instrumentsand train doctors side-by-side withnurses, veterinarians, psycholo-gists, etc. Cefpas was among thefirst institutions in Italy to offertraining activities on evidence-based medicine and is on its way tocreating a regional evidence centre.

TUFH and the Sicilian experienceThe basic principles of TUFH fitperfectly with the philosophy,mission and strategy of Cefpas.Cefpas will submit a TUFH project,which will start with the experiencegained through multiprofessionaltraining, which has been a majorundertaking for the Center and thebeginning of an attitudinal changeby health professionals.

Some of the initial resistancehas, over time, become less markedand doctors are no longer surprisedto sit next to veterinarians, nursesor social workers during their train-ing. The result was the establish-ment of a common experience andunderstanding and a growing re-spect for the different profession-als caring for population health.

The project that is being de-signed aims todevelop and testa model forbuilding TUFHmultisectoral al-liances at locallevel in progres-sive stages. Itstarts with themost naturals t a k e h o l d e r s ,that is, the LHOsand HOs, andproceeds to-

wards other relevant but less“traditional” health-related“actors”.

The Sicilian experience can con-tribute to those regions that, likeSicily itself, are caught between theindustrialized “North” and thedeveloping “South” and that

MOVING TOWARDS UNITY FOR HEALTH

specialized care, diagnostic serv-ices and outpatient care.

In Caltanissetta, a new faculty ofmedicine will soon become thefourth medical school in the regionand we hope to involve it in theTUFH project. Unfortunately,universities still dispense medicaleducation through outdated pro-grammes and methods. They con-tinue to graduate young doctors,most of whom will only inflate theconsistent unemployment list andwhose medical education is obso-lete within five years of graduation.

The SRHS has suffered frominappropriate investments byshort-lived governments, from mis-management of resources and frominsufficient attention paid to thedevelopment and motivation ofhealth personnel. Furthermore,very limited investments have beenmade with regard to health promo-tion programmes.

Heavily fragmented, clinicallyoriented with a poor health infor-mation system, the SRHS has beencharacterized by a lack of integra-tion among:

● The medical sector and othersectors, particularly the social,environmental health, labourand economic sectors—frompolicy-makers to implementers.

● Clinicians and GPs: they seem towork for different non-commu-nicating systems. This results induplication of effort, ineffectivepractices, inefficient use ofscarce resources and, ultimately,disservice to the population.

● Physicians and other personnel,particularly veterinarians, allworking in preventive care.

● Faculties of medicine and em-ployed graduates whose ongoingneed for applied training fails tobe met by the academic world.

● Health sector employers andsyndicates or professional asso-ciations.

● Medical-sector media and massmedia, despite the important

Sicily

Italy

continued page 3 ➤


EDITORIAL

➤ experience the problems of both.It is hoped that Sicily’s approachcan be applied by both. It can beparticularly useful to small coun-tries, given Sicily’s surface andpopulation.

Meanwhile, the TUFH experi-ence would pull Sicilian profession-als from health and related sectors

out of years of isolation and makethem part of a shared effort tosearch for global and sustainablesolutions, relevant also to their ownsituation. There will be importantlessons for all to learn from thisambitious yet timely endeavourthat is TUFH. Cefpas and the otherinterested stakeholders hope to

join the rest of the world in the im-plementation of this innovativeproject. ■

Dr Frazzica is Director General, Cefpas;Cittadella S. Elia; Via G. Mulé 1;93100 Caltanissetta, ITALY(Telephone: +39 0934 505208; Fax: +39 0934594310; E-mail: [email protected]).

Dr Charles Boelen

Building synergiesA s we rapidly learn so much

about so many things throughthe virtue of modern communica-tions technology, few significantevents of any kind seem to remainunnoticed. The world is indeed be-coming Marshall McLuhan’s globalvillage.

In principle, with the accumula-tion and fast dissemination ofknowledge we should be better pre-pared to understand how our soci-eties function, what makes theirdifferent constituting elementshold together and how they are or-ganized to attain their goals andpreserve their value systems. Aspartners in the health field, we aregiven unprecedented opportuni-ties not only to perform better inour specific areas of expertise, butalso to grasp how we fit—or shouldfit—into the giant jigsaw puzzlethat makes up a health system.

In acquiring a clearer vision ofthe complex web of influences onpeople’s health status, we may begiven to realize how relative ouractual contribution is, how it can beimproved, the nature of our limita-tions and—to put it positively—what new opportunities therewould be if we linked our efforts tothose of other partners who offerdifferent but complementary setsof skills and resources. A systems-minded culture seems to emerge,and with it a consciousness that wecan spur progress and shape soci-ety through new interactions andpartnerships.

Health policy-makers are awareof their dependence on policy-makers in other sectors of socio-economic development. Managersof health service organizations seekalliances with other groups toensure a continuum of services.Health professionals—specialistsand generalists alike—value team-work and readjusted roles for ex-pansion and sometimes for sheer

s u r v i v a l .Ac a d e m i cinstitutionswant tov a l i d a t et h e i rp ro d u c t s ,w h e t h e rthese aregraduatesor researchresults, bycontracting

with their users. Communities andconsumers move progressivelyfrom the status of passive demand-ers to that of active contributors.

While the state of interdepend-ency is well documented and theperformance of health systemsbetter assessed, a proportionaleffort must be made to reducedamage and lost opportunitiescaused by fragmentation in thewide array of activities generated byhealth partners and to create sus-tainable partnerships.

In my view, a new frontier forproductive health system develop-ment aiming at improved quality,

equity, relevance and cost-effec-tiveness of services lies in ourcapacity to create a common pur-pose and a synergy in action amongall principal stakeholders. This im-plies at least three conditions:

● First: mindsets and skills foraltruism and effective collabora-tion.

● Second: organizational patternsof health services delivery thatallow optimal use of skills andresources for coordination andintegration in action.

● Third: adequate policies andsupport to create necessary in-centives.

The “Towards Unity for Health”project is an endeavour in thisdirection. Through the various edu-cational, research and organiza-tional innovations that it entails, itis gaining momentum among pio-neers in professional associations,health professions educationalinstitutions and health servicesorganizations, all allied by a sharedvision and commitment to developthe best approaches to servepeople’s health. The march is long,but it is in motion. ■

Dr Charles Boelen, Coordinator of HumanResources for Health, WHO Department ofOrganization of Health Services Delivery, andExecutive Editor of this newsletter, contributesthis regular feature. He can be contacted asfollows: World Health Organization OSD/HRH;1211 Geneva 27, SWITZERLAND (Telephone:+41 22 791 2510; Fax: +41 22 791 4747;E-mail: [email protected]).



Educating to create unity in health: an educationalprogramme to support the TUFH projectCharles Boelen, World Health Organization, Geneva

tive and sustainable partner-ships;

● understand strengths and weak-nesses of each stakeholdergroup;

● advocate unity in health to vari-ous interest groups with targetedarguments and facts;

● design and conduct research anddevelopment to identify politi-cal, social and technical factorsenabling the implementation ofa TUFH field project:

● participate in policy formulationto improve the performance of a

health system,using lessonslearnt from fieldexperiences.

The educa-tional pro-gramme will bedesigned to

meet needsof spe-c i f i ct a r g e t

groups, suchas undergraduate and postgradu-ate students (medical schools,nursing schools, schools of public

Those involved in TUFH projectsmust acquire the knowledge

and skills needed to foster a coor-dinating and integrating approachtowards health services delivery,which the right educational pro-gramme can help provide.

But most educational pro-grammes in health service manage-ment or public health do notemphasize the causes and conse-quences of a fragmented healthsystem or how to reduce this frag-mentation. They also do not teachhow to encourage such stake-hold-ers as policy-makers, healthmanagers, health professions,academic institutions andcommunities to shareviews and commitment.

The TUFH AdvisoryCommittee proposes todevelop an educationalprogramme to help po-tential leaders of thekey stakeholdergroups do the follow-ing:

● become more aware of opportu-nities to improve health systemperformance through produc-

health) and representatives of thefive stakeholder groups mentionedin the “partnership pentagon”. Thelearning process would be adaptedto fit the expected outcomes in agiven target group. The proposedprogramme would cover four mod-ules (M):

● M1: Setting the stage (fragmen-tation in health systems and itsimplications)

● M2: Creating unity (needs andopportunities to create unity inhealth system reforms; organiza-tional patterns of services thatfoster integration)

● M3: Knowing the partners(strengths and limitations ofeach main stakeholder; strate-gies to make stakeholders moresocially accountable)

● M4: Partnership and leadership(negotiation and contracting;prime movers and enlarged col-laboration; creating a momen-tum and sustaining it; from fieldproject development to healthpolicy formulation).

A working group has been set upto design, develop and field-testthis educational programme. Thecurrent members of the group arePalitha Abeykoon, Ayité M.d’Almeida, Charles Boelen, MarioDal Poz, Charles Godue, PaulGrand’Maison, Richard Madeleyand Win May. The group will be en-larged to include educational ex-perts from different regions to helpdevelop the programme. ■

Dr Boelen is Coordinator of Human Resourcesfor Health, WHO Department of Organizationof Health Services Delivery, and ExecutiveEditor of this newsletter. He can be contactedas follows: World Health Organization OSD/HRH; 1211 Geneva 27, SWITZERLAND(Telephone: +41 22 791 2509; Fax: +41 22791 4747; E-mail: [email protected]).

TUFH Advisory CommitteeAn international advisory committee has been set up to advise on activities related to the“Towards Unity for Health” project. The committee is now composed of 30 membersrepresenting the five stakeholder groups: policy-makers, health managers, health profes-sionals, academic institutions and communities. It also includes WHO staff from theregional offices and headquarters.

The committee contributes to the following activities:

■ advocacy and strengthening of collaborative processes■ development of field projects in research and development■ development and adaptation of methodologies■ consultation with stakeholder groups■ production and exchange of information.

Members of the TUFH Advisory Commitee are selected on the basis of their capacity tocontribute to one or more of these activities, a fair geographical distribution and a bal-anced representation of the five stakeholder groups.

Two working groups have been constituted, one for TUFH field projects and one for theTUFH educational package.


PARTNERSHIP WITH THE COMMUNITY

Partnership towards unity for health:voices from the community

are elderly, or economically inactivefor other reasons. A high proportionof single parents and a significantpart of the local population dependsupon state support and on publicservices.

Despite, however, this socioeco-nomic and demographic profile, thetwo case-study areas have a historyof community activism that is im-portant in interpreting the studies.We may have lost some of our pastglory, but we have kept a vibrantpopulation. Liverpool has a longtradition of community organiza-tion. We have community councilsin many parts of the city, partner-ship areas, forums and much activ-ity from people who wish to havetheir voices heard and to make adifference to their lives.

[ T]he overall mortality rate inLiverpool is 26% worse than for Eng-land and Wales. The residents ofVauxhall and Everton on averagelive approximately eight years lessthan people living in our moreaffluent parts of the city …

❝ I began to be involved in things… because I didn’t like people whodidn’t know me to tell me what Ineeded—what my family needed. Iwas unhappy with the environmentand with the behaviour of people—paid workers and professionals inmy community. I felt that decisionswere being made behind closeddoors. I got involved in BECHAG[Breckfield and Everton Commu-nity Health Advisory Group] whenI asked to go to a meeting abouthealth in the area. I met the peopleinvolved, and I liked what I heard,and I felt relaxed and included. Ididn’t feel as if I wasn’t wanted.

Over a two-year period, peoplewere slowly leaving our local healthclinic in Everton Road. Our two

communities of Everton andBreckfield bonded more closely aswe became more aware that peoplewere leaving Everton Road Clinicthrough the back door. Eventuallyonly the receptionist, the conti-nence supplies, baby-milk distribu-tion and the dentist were left froma once-busy clinic. Trust was lostbetween the local community andprofessionals.

Then the community and paidworkers came to open meetingswith the Health Authority. Thissparked off the research that led tothe development of a joint groupfrom two communities … Evertonand Breckfield … Because of thesupport from our friends in Vaux-hall community we formed a strongbond there, too, and the three com-munities were brought together.

A five-year health plan was writtenwith the three communities withsupport from Save the Children. Anew GP surgery was establishedwhere, according to the HealthAuthority, we didn’t need it. Thisgrew really quickly. Two thousandpatients—which tells you we didneed it—have registered in the lasttwo years. This is because peoplelocally trusted those who had beeninvolved to make sure the new GPwas good at the job, valued people,and was community-friendly. Sixtyrecommendations were made tothe Health Authority, and all butone were accepted. Doors wereopened, and the community heldthe key.

❝ I would like to speak about GPrelationships … We did have a GP,but my own experience was that toget an appointment it was like anobstacle course: you’d have to plana strategy to get in. So thank God,two years down the road that hasnow gone. My new GP—I can go in,

Among the participants at theinternational conference “TowardsUnity for Health” in Phuket, Thailand,10–13 August 1999, were fivewomen,1 three of whom were volun-teers and residents of communities inNorth Liverpool, United Kingdom.They came to share their perspectiveon a situation captured in a casestudy soon to be published by WHOwith other case studies from aroundthe world.

As a result of partnership betweenthe Health Authority and communitymembers, a health clinic in Everton/Breckfield remained open and itsservices were expanded, and a newgeneral practice was set up inVauxhall, with two female physicianswhom community members helpedselect. The following is excerptedfrom a transcript of the presentationat the conference.

❝ Liverpool was a vibrant port, witha population of 370 000 in 1851[which reached a peak of 900 000 inthe 1990s] … The city, however, hasdeclined steadily in economic sig-nificance with its decline as a port.The docks no longer provide largenumbers of jobs, but [the port] hasmore tonnage than ever. The citypopulation has almost halved since1945. Much of this loss has been dueto slum clearance and rebuilding inouter suburbs. The young havemoved out, and … [the] people left

1 Lyn Barry, resident of Breckfield; MrsNancy Flanaghan, resident of Vauxhall;Annette James, Project Coordinator,First Years First, West Everton Commu-nity Council; Patsy Patterson, residentof West Everton; Christine Wall, DeputyChief Executive, Liverpool HealthAuthority. Please contact the Liverpoolteam through Ms Wall: Hamilton House,24 Pall Mall, Liverpool L3 6AL, UNITEDKINGDOM (Fax: +44 151 285 2357;E-mail: [email protected]).



I can sit, I can explain … and thatis, he listens. And we will speaktogether to the illnesses, the ail-ments and what have you. Accessto my GP is now fantastic. We havea team staff. Just phone up: youdon’t have to say why you wish tosee the doctor, and you’re justgiven access to your GP … “GP” tome now means “great partner-ship”. It’s not a doctor sitting there,and he has a patient: it’s a partner-ship.

❝ The Health Authority came on thescene, and they asked us what wewanted. And we said: “Female doc-tors”. We were lucky enough to gettwo doctors who work in partner-ship together. But we told them—orbefore that—we told the HealthAuthority that we wanted to inter-view the doctors ourselves, shortlistthem, and then choose what doctorswe wanted. One Health Authorityofficial swallowed his teeth andsaid: “That’s never been done be-fore.” So we said: “We’ll be the first”.We did. We saw 17 doctors, and wegot these two ladies: very good. Butbefore they started, we told them:“We’re a bit awkward in Vauxhall.We’re unique. So we’d rather thatyou went out as health workers for12 months and got to know the peo-ple of the area”. . . .

❝ … [W]hat should be happeningis the doctors should be coming outof their ivory towers and listeningto people. And don’t forget: there’smore of us than of you. And no one’slistening. And I think that WHO—the World Health Organization—should start introducing andinviting people from the grassrootsand maybe your eyes will beopened …

❝ Why work with local people?Because I believe it bases the de-velopment of services and policyfirmly in reality—in real life. Work-ing in this way can lead health pro-fessionals away from the narrowmedical model of illness and cureto struggle with a more social andholistic model of health, well-

being and quality of life. This alsoincludes the necessity to sharepower.

… Local communities are nothomogeneous. Adults and chil-dren within communities do notnaturally agree with each other.Working with local people overtime ensures that social responsi-bility within and between commu-nities and within and betweenagencies is taken into account. It’sa mistake for any organization tobelieve that they’re outside thestructures that they want tochange.

Working with local communitiescan be extractive, sapping energyand taking away the will forpeople to be involved in change:too many meetings, too littlepower shared, not enough re-sources, people giving of their owntime freely when they’re alreadystretched with day-to-day living.Or it can be empowering: valuinglocal adults and children, recog-nizing their strengths and skills,and building on those things forreal and sustainable change.

… I think we’ve heard today that itis time to invest in the determi-nants of health, well-being andquality of life, and not just of illnessand cure. There are many who callfor an epidemiology of health.

We have struggled within commu-nity health, social services andeducational organizations toassert the right of local people toparticipate fully in those thingsthat affect their health, well-beingand quality of life. Whilst mostpeople agree with community par-ticipation, what they really meanis community consultation. It’simportant recognizing that we’retalking about consultation wherethe power to take decisions lies …

❝ I’d like to talk about the reception-ists. First thing we did, we got rid ofthem. Because we had receptionists[who] were like dragons. And if yougot past them to the doctor, you were

lucky. Because they questioned yourhealth before you’d even got over thedoorstep. And not only were theyquestioning your health, buteveryone else standing there waslistening in, so everyone knew whatailment you had. No confiden-tiality.

And we were lucky in Vauxhall, be-cause we got [GBP] 300 000 from theHealth Authority, and we turned ourhealth centre around. And the firstthing we did, we made sure that thereceptionist was behind glass. Andalso that when people went up to thereceptionist, that no one else couldhear them … And our receptionists,the first thing they say is: “Welcome.How are you? Good morning.”Because if [they] don’t treat the pub-lic right, they’re out on their ear.Because after all, the public is keep-ing them in a job …

The same with the doctors. It didn’tmatter—the doctor thought thatbecause he was a doctor, that youhad to bow to him. And our biggestproblem in our area is getting theelderly people—and I’m in thatcategory myself—but the elderlypeople think that because you’re apriest or a teacher or a doctor, youknow everything. And that’s the waythey were brought up. So conse-quently when they went to the doc-tor, if the doctor said: “Stand in thecorner on your head”, they’d do it.Because he was a doctor …

But we were trying to teach thepeople to be different and to ques-tion health, and to say if you didn’tlike what was going on, question it.Ask. And it’s uphill, because it’s dif-ficult changing people who’ve beenused to that type of thing all theirlives …

❝ … [T]he reason why I get in-volved is because I don’t expectothers to come in and do it for me.I’ll do it with them. I have a family,and the only one who can changethe health in my area for my familyis myself and others like me …


POLICY

❝ … [B]reaking the rules meantthat at the Health Authority, in-stead of saying “it can’t be done”,we said “it will be done, and we’llfind ways of getting round it”. AndI think that’s the problem in thatwhen you’re within a system—anyhealth system—you’ve got peoplein the organization who say: “Wellthis is what the book says we cando, and as long as you fit into thoserules, then everything will be fine”.And I think what we have to do isto say: “The rules are only there asguidance”. And we have to findnew ways of actually applyingthose rules to what we want toachieve …

❝ … [W]hat I’m hoping for in thefuture, and what we’re going to fightfor, is some involvement withtrainee doctors from hospitals. Wewant these doctors to come out dur-ing their training, as part of theirtraining, to work in a community.And then when they are treatingpeople, it’ll come into their minds tosay, “Hang on, I know what way thisperson lives”. And they’ll treat themaccordingly …

❝ … [I]f you treat your staff in apoor way and they don’t feel confi-dent to do the job they’re paid to do,then they’re not going to be treat-ing people with respect and valu-ing them. So I think there’s a role fororganizations, as well, to look at theway that their staff are treated,wherever they are. Because whatyou’re wanting to do is to work withthose people so that they can, intheir turn, do the job that they’repaid to do. And one of those thingsis in a sort of servant role, servingthe community. And identifying theneeds with local people and thenworking with them for change … ■

If I were a Minister ofHealth: the opportunity of“Towards Unity for Health”Daniel G. Makuto, World Health Organization, Geneva

the development of other publicsector policies so that they interactto impact favourably on health. Tomeet this challenge, the Minister ofHealth would need to work closelywith all colleagues across the healthsector as well as those in health-related sectors.

This would call for the formationof consultative partnerships be-tween communities, civil society,health professionals and policy-makers from other sectors, bothpublic and private. This consulta-tive policy formulation processwould ensure broad ownership byall partners, which would be re-flected through coherence andcomprehensiveness in the develop-ment and implementation ofhealth programmes, as well as theorientation of services and care.

Although this approach has beenadvocated since the Alma-Ata con-ference in 1978, translating the con-cept into reality has remainedelusive. One reason for this is thatafter Alma-Ata the importance ofthe higher echelons of the healthsystem was underplayed in manyinstances, vis-à-vis that of the pri-mary level.

A division was thus created be-tween primary health care workersand other professionals in thehealth system. This compoundedthe many divisions that alreadyexisted in the health system (e.g.curative/preventive, private/pub-lic, etc.), which all militate againstcoherence, synergy and unity ofpurpose, compromising the effec-tiveness of the primary health careapproach.

A new initiative to heal the divi-sions was therefore required if PHC

Daniel G. Makuto

I f I were a Minister of Health Iwould be the chief policy-maker

for health in my country, and assuch it would be my role to ensurethat there was an equitable, well-functioning health system thatresponded to the population’slegitimate demands and moved mycountry nearer to the attainment ofHealth for All (HFA). To a large ex-tent, the health of the populationwould be determined by policiesmade in the health and other re-lated public sectors.

It is well known that publichealth sector policies shape con-temporary environments in com-munities, workplaces, schools andhomes and also determine issuessuch as agricultural and industrialproduction and access to educationand housing, together with a hostof other factors that all influencehealth as well as behavioural atti-tudes. They therefore have a directbearing on the environment, whichcan evoke illness or health in an in-dividual or community.

As a Minister of Health, mymajor challenge would be to de-velop health policy and influence


POLICY

was to remain an effective vehicletowards Health for All. This new ini-tiative would aim to see workersfrom all sectors involved in healthworking with unity of purpose.

It is against this background thatthe Towards Unity for Healthproject was conceived. Experiencewith TUFH would become very rel-evant to the work that a Minister ofHealth would want to accomplish,particularly the building of effectivepartnerships for health.

Therefore, as a Minister ofHealth I would draw on theseexperiences to establish effectiveconsultative partnerships withcommunities, health workers andpolicy-makers from other sectors.The TUFH approach would alsohelp to strengthen the country’sprimary health care strategythrough the elimination of frag-mentation among all players andthe creation of unity of purpose.

In order to move forward in thisarea, collaboration between thecountry and WHO/TUFH would beessential. Having secured this col-laboration, the first responsibilitywould be to sensitize colleaguesfrom the health and other sectorsto the concept and rationale of theTUFH. To achieve this, a high-levelnational intersectoral TUFH work-

shop would be organized, wherethe importance of health to devel-opment as well as the critical roleplayed by other sectors in healthwould be emphasized.

Next, to ensure that the healthsector would work with unity ofpurpose it would be essential tobring together the health profes-sionals to address the problem offragmentation in the health sector.This activity could take the form ofan in-depth meeting assemblingkey workers from the many divided

providers of care, i.e.

curative/preventive, private/publicand individual/community orien-tation. The meeting would addressfragmentation and aim to identifypolitical, organizational and scien-tific conditions that create unityand heal the divisions.

It would be understood that al-though healing the divides wouldtake time, it is critical for thesmooth and efficient running of thehealth sector as well as to enablethe health sector to coherentlyreach out to other sectors to buildrobust and sustainable partner-ships. As Minister of Health, tofacilitate a learning-by-doingapproach.

I would sponsor a TUFH projectin the country that initially could berestricted to a small area. As lessonsare learnt from the project through

a learning-by-doing approach,these would be documented with aview to applying them in expand-ing the TUFH approach to cover thewhole country as its effectiveness isdemonstrated and benefits accrue.

I would also see it as my re-sponsibility to advocate for TUFH.Given that ministers of health at the52nd World Health Assembly in1999 through resolution WHA52.23reaffirmed their commitment tothe objectives of the health for allstrategy—in particular the achieve-ment of equitable, affordable,accessible and sustainable healthcare systems based on primaryhealth care in all Member States—it is essential that countries bringtheir PHC strategies back oncourse, particularly with respect toforging more effective partnershipsfor health amongst all stakeholders,which is crucial for the success ofthe PHC approach. TUFH is a toolgeared to achieving this, and min-isters of health should therefore beadvocating the adoption of theTUFH approach by countries atvarious forums. They should alsoadvocate for networking and infor-mation-sharing on experienceswith TUFH among countries andregions.

If I were a Minister of Health, myadvocacy role would be backed bymy strong conviction that if coun-tries adopted TUFH principles andapplied them in the developmentof their health systems, PHC wouldbe back in its original place as en-dorsed by the World Health Organi-zation Member States, i.e. as theStrategy Towards the Attainment ofHealth for All. ■

Dr Makuto is Special Adviser, Office of theExecutive Director, Family and CommunityHealth, World Health Organization, Geneva,SWITZERLAND (Telephone: +41 22 791 2520;Fax: +41 22 791 4830; E-mail:[email protected]).


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how this challenge is perceived toaffect their personal status quo.Their logical and emotional wish tobe involved and to remain involvedwill need to be fostered.

Thus, it will not be sufficient topropagate the vision at the macro-scopic level alone. Concerted effortwill be needed to enable individu-als to accept and act upon thisadditional responsibility. So, forexample, educational institutionswill need tangible encouragementand support that enables them toequip their students—their futurefellow professionals—with thecapability to adapt themselves tochange and to participate in themanagement of change. The latterwill inevitably involve competencein interprofessional and inter-sectoral collaboration (Engel,2000). ■

References● Brundtland GH (1987) Ourcommon future. New York, UnitedNations.

● Engel CE (2000) Health profes-sions education for adapting tochange and for participating inmanaging change. Education forHealth, 19, 37–43.

● Ewan C (1985) Objectives formedical education: expectations ofsociety. Medical Education, 19, 101–112.

● Kamien M (1996) Responding tosociety’s needs: one criterion inevaluating the education of generalpractitioners. Education for Health,9, 147–153.

● McMichael et al. (1996) Climatechange and human health. Geneva,World Health Organization (unpub-lished document WHO/EHG/96.7).

● Prosser A (1985) Teaching andlearning social responsibility.

Canberra, Higher EducationResearch and Development inAustralasia.

● Smith GD (1996) Editorial:Income inequality and mortality:why are they related? BritishMedical Journal, 312:987–988.

● Virchow R (1847) in Porter R(1997) The greater benefit to man-kind: a medical history from antiq-uity to the present. London, HarperCollins.

● WHO Division of Development ofHuman Resources for Health (1991)Changing medical education: anagenda for action. Geneva, WorldHealth Organization.

● WHO Commission on Health andEnvironment (1992) Our planet, ourhealth. Geneva, World HealthOrganization.

● WHO (1996) World health report1996. Geneva, World Health Organi-zation.



Note from the Editor: Dr Engel is aspecialist in health professionseducation, with wide internationalexperience. His comments on the“Towards Unity for Health” ap-proach reflects the need for thestakeholders to apply strategies forchange. He can be reached as fol-lows: Centre for Higher EducationStudies, University of London, 55/59 Gordon Square, London WC1H0NT (Telephone: +44 20 7612 6363;Fax: +44 20 8977 2073; E-mail:[email protected]).

The vision is eminently worthy ofnational and international sup-

port. The translation of the visioninto reality will depend on activecollaboration by politicians, publicservants, financiers, employers andcommunity leaders, as well as bythe professionals and managers inthe health services—public andprivate. To this imposing array needto be added the scholars, research-ers, teachers, practitioners and ad-ministrators in the various sectorswhose activities affect social, eco-nomic and environmental well-being. Anthropologists, architects,engineers, lawyers, local govern-ment officers, psychologists andsociologists represent just a few ex-amples.

The viability and, indeed, thelong-term success of the vision willdepend on a realistic blend of themacroscopic with the microscopic.

The macroscopic vision is essen-tially the acceptance of an overrid-ing need for effective advocacy (e.g.Brundtland, 1987; Ewan, 1985;Kamien, 1996; McMichael et al.,1996; Prosser, 1995; Smith, 1996;Virchow, 1847; WHO, 1991; WHO,1992). This advocacy is concernedwith support for an integrated setof initiatives for the improvementand subsequent maintenance ofuniversal well-being. The continu-ing growth of the world’s popula-tion and the increasing proportionof individuals living at or belowsubsistence level indicate theenormity of the challenge for thisadvocacy (WHO, 1996, 1997, 1998).

The microscopic vision is that ofthe individuals who will be ex-pected to participate in this advo-cacy. Their vision will be intimatelyaffected by their individual circum-stances, their sense of satisfaction,security and success and, therefore,

Towards unity for health –vision and viabilityCharles Engel, London


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Paul Grand’Maison

Figure 1. Location of the Estrie Region withinQuebec and Canada

Sherbrooke-Estrie integrated cardiovascularhealth programme: a commitment for TUFHPaul Grand’Maison, Nicole Bolduc and Danielle St-Louis, Sherbrooke

istrative jurisdiction oversees allhealth care services and has iden-tified CVD as a regional healthpriority.

The programme targets twopopulations: all patients hospital-ized with an acute CV episode; andthe general population at risk ofdeveloping CVD. During its first 18months of implementation, theprogramme is giving priority to thefirst group of patients.

Creating the unityPopulation-based interventionsand patient-focused disease man-agement approaches are inter-twined in order to offer curative,rehabilitative and preventive careas well as health promotion/educa-tion. The use of community-basedresources, in interaction andcomplementarity with hospital re-sources, is prioritized. Standard-ized care protocols (including theprocess and content of informationexchange between all interveningindividuals and patients), usingdefined communication channelsthrough a comprehensive informa-tion exchange system, are currentlybeing implemented.

Information is available throughthe regional health authority

regarding popula-tion sociodemo-graphic data,health (morbidity,mortality, publichealth issues, risks,etc.) and the use ofresources and serv-ices (institutions,health profession-als, community re-sources, costs, etc.).Complemented bymore focused indi-cators, this infor-mation will be used

by stakeholders to monitor the pro-gramme and to make evidence-based decisions at individual andpopulational levels.

Furthermore, a project to estab-lish a comprehensive, computer-ized clinical chart system linkinginstitutions and practitioners in theregion has recently been launched.This should facilitate the integra-tion of services and promote con-tinuity of care, thus optimizing theuse of resources and serving as asupport for research initiatives.

All professionals are involved inpatient-centred interdisciplinaryteamwork. Recognition of indi-vidual contributions as well asimproved quality and continuity ofcare represent significant incen-tives for participation.

Although the programmeacknowledges the pivotal role offamily physicians who offer com-munity-based services, specialistphysicians are the central care pro-viders in acute-care situations.Clinical nurse specialists act as casemanagers and are responsible forthe coordination/integration ofpatient care and follow-up, inter-facing with both hospital and com-munity. Efficient communicationbetween all professional resourcesis thus a prerequisite.

In most industrialized countries,cardiovascular disease (CVD) is a

leading cause of mortality, morbid-ity, long-term incapacitation andhigh health care costs. The TUFHstrategy offers a highly relevant pa-tient-centred framework to im-prove a population’s cardiovascular(CV) health.

The programme described here,which is part of a larger endeavourto establish regional comprehen-sive and integrated programmeapproaches for complex and bur-densome health problems, hasadopted the TUFH strategy. It aimsto improve the physical and psy-chological well-being of peoplewith or at risk of CVD through acomprehensive and integratedhealth care delivery system thatendures complementarity betweenindividual and population health,optimal use of communityresources and empowerment ofpatients.

The Sherbrooke-Estrie healthadministrative region (Fig. 1) is a10 000-square-km region of 300 000inhabitants, with one tertiary-careacademic health centre, five com-munity hospitals and seven publicand numerous private communityclinics. The regional health admin-


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Figure 2. Organizational modeland partners

A community cardiovascularprogramme in the Maastrichtregion: the relevance of TUFHErik C. Ruland, Department of Public Health of the RegionalPublic Health Institute Maastricht; Gaby Ronda, JannekeHarting, Patricia van Assema, Patrick van Limpt, Jan van Reeand André Ament, Maastricht University; and Ton Gorgels andFrank Vermeer, University Hospital Maastricht

Leadership from a medical schoolThe Université de Sherbrooke Fac-ulty of Medicine, which offers bothmedicine and nursing pro-grammes, has committed itself toTUFH and is in the process of be-ing designated a WHO collaborat-ing centre with a specific focus onthe TUFH strategy. Conscious of itssocial accountability and togetherwith its affiliated health care insti-tutions, it promotes and supportsthe development of creative healthcare approaches more responsiveto population needs, whereby stu-dents can be better trained to meetthese needs in their future profes-sional practice. The present pro-gramme, coordinated by theFaculty’s major partner, theSherbrooke University Hospital,favours such an approach.

Fig. 2 represents the partnersinvolved at the strategic (generalorientations, policies, formal agree-ments of collaboration, etc), tacti-cal (development of tools,protocols, information exchangesystems, etc.) and operational(direct actions with patients) levels.The five groups of partners in-volved in the TUFH partnershippentagon can be identified in theorganizational model. All partnershave confirmed their long-termcommitment to the project, whichwill serve as a template for an inte-grated community approach appli-cable to other complex health careproblems.

The programme has identifiedseven major thrusts for develop-ment, evaluation and research thatembody the values of quality,equity, relevance and cost-effec-tiveness. They include: epidemio-logical studies, informationexchange (process and content),integration/coordination of care,clinical research, processes tooptimize hospital and community-based care, biopsychosocial reha-bilitation of patients, andprofessional roles and their devel-opment.

These evaluative research activi-ties will strive to ascertain the vari-

ous elements that facilitate orhinder the implementation of suchprogrammes. Lessons learnt will beused to replicate similar or im-proved clinical approaches forother health care problems and/orjurisdictions. Information obtainedwill be disseminated at local, na-tional and international levels. ■

Dr Grand’Maison is Vice-Doyen à lacommunauté and Secrétaire, Faculté demédecine, Université de Sherbrooke; 3001,12ème Avenue Nord; Sherbrooke, Québec,CANADA J1H 5N4 (Telephone: +1 819 5645204; Fax: +1 819 564 5378; E-mail:[email protected]). Nicole Bolducis a member of the Faculté de Médecine,Université de Sherbrooke and SherbrookeUniversity Hospital; Danielle St-Louis is atSherbrooke University Hospital.

Introduction

In most western countries the pre-vention of cardiovascular disease

(CVD) is a major concern. Dutchresearch has shown that for peoplewith only a primary education therisk of acquiring CVD is twice ashigh as for those with the highesteducation. The conclusion of anexpert meeting organized by the

Netherlands Heart Foundation in1994 was that a united approachcombining public health services,general practitioners and the hos-pital was needed to meet the needsof low socioeconomic status (LSES)groups and reduce fragmentationin the preventive health servicedelivery.

To meet this challenge, scien-


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tists, health professionals, politi-cians, health managers and com-munities in the Maastrichtregion united to create a newcomprehensive approach. The“Hartslag Limburg” (Dutch for“Heartbeat Limburg”) project,started in June 1998, integrates twoexisting strategies: a populationstrategy, aiming at all inhabitantsand specifically at LSES groups; anda high-risk strategy, focusing on in-dividuals. The Maastricht regionhas 180 000 inhabitants, 20 400 ofwhom live in four selected LSESareas in the city of Maastricht. Thehigh-risk strategy focuses on 2 700high-risk patients living through-out the region.

Population strategy: community-based health promotionThe main partners in the popula-tion strategy are: the city council ofMaastricht and four adjacent mu-nicipalities; the Regional PublicHealth Institute of Maastricht

(GGD); two community-develop-ment organizations; and the re-gional community health careorganization (please see figure).Collaboration is realized through 10local health committees, four ofwhich are located in LSES areas. Inline with the principles of commu-nity-based health promotion,many local organizations also par-ticipate in each committee. Thecommittees organize all kinds ofactivities that promote and facili-tate a health lifestyle, includingstopping smoking, eating lesssaturated fat and increasing one’sphysical activity.

High-risk strategy: individualcounseling of high-risk patientsThe main partners in the high-risk

strategy aregeneral practitioners, cardio-

logists, the GGD and MaastrichtUniversity, together with the uni-versity hospital. Crucial within thehigh-risk strategy is a new function:a specifically trained health advisor.Health advisors guide high-riskpatients in acquiring a healthierlifestyle and promote the use ofneighbourhood facilities such assports clubs. They have an overviewof ongoing community activities,and form a linchpin between thecommunity level and the medicallevel of Hartslag Limburg.

Scientific evaluationHartslag Limburg’s main aim is toreduce the incidence and preva-lence of CVD. An effective integra-tion of a population and a high-riskstrategy, with collaboration of allhealth care providers, is defined asan intermediate goal.

Scientific evaluation of theeffects and processes that lead tothe expected outcome, as well asevaluation of cost-effectiveness ofthe entire project, is carried outby Maastricht University and theNational Institute of Public

Health and Environment. Thefirst scientific conclusions are ex-pected to be published by 2003.

Relevance of the TUFH principlesCrucial to the development andimplementation of the project hasbeen the involvement of repre-sentatives from all five keystakeholders of the TUFH penta-gon, right from the beginning in1995, at both the operational leveland the policy level. The key ele-ments in convincing all partnersare the win-win conditions createdthrough collaboration with somany organizations (1). To meet allexpectations, it is of vital impor-tance to manage the operationallevel and communication betweenpartners, and to ensure a high de-gree of media exposure. HartslagLimburg, for instance, publishesthree newsletters, one for eachproject level: LSES areas, healthprofessionals and the generalpublic.

Main linkages are shown between the partners of Hartslag Limburg.This project unites 12 principal partners within the Maastricht region.


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Interim resultsSince the start of the project, morethan 200 local and regional activi-ties have been realized, includingfavourable changes in municipalhealth policies and increased mu-nicipal funding for the LSES areas.Collaboration between partners isgrowing towards structural organi-zational change as GGD, MaastrichtUniversity and the university hos-pital are on the verge of establish-ing a joint “Regional DevelopmentCentre for Public Health”. It is clearthat Hartslag Limburg, in realizingpartnerships between key stake-holders, acts as a catalyst towardsmore unity for health in theMaastricht region. ■

Reference1. Ruland E et al. “Hartslag

Limburg”: a united approach inpreventive care. Communitybased prevention of cardiovascu-lar disease integrated with a highrisk group approach in generalpractices and in the hospital.Maastricht, GGD-zzl, 1999.

Dr Ruland is a community health specialistand project manager of the Hartslag Limburgproject; Department of Public Health of theRegional Public Health Institute Maastricht(GGD-zzl); PO Box 3973; 6202 Maastricht,NETHERLANDS (Telephone: +31 43 382 1782;Fax: +31 43 382 1700; E-mail: [email protected]). Ms Ronda and Ms Harting areresearchers, and Dr van Assema is assistantprofessor; Department of Health Educationand Promotion, Faculty of Health Sciences,Maastricht University. Dr van Limpt is aresearcher and Professor van Ree is Chair ofthe Vocational Training Section; Departmentof General Practice, Faculty of Medicine,Maastricht University. Dr Gorgels andDr Vermeer are cardiologists; Department ofCardiology, University Hospital Maastricht.Dr Ament is with the Department of Health,Organization, Policy and Economics,Maastricht University. The authors may becontacted through Dr Ruland. The HartslagLimburg project is supported by theNetherlands Heart Foundation.

Public health in the UnitedKingdom: a nation striving forunity for health?Richard Madeley, Queen’s Medical Centre, Nottingham

lar. It believes that if the targets aremet, 300 000 untimely and unnec-essary deaths will have been pre-vented by 2010.

As in most western countries, thedeath rate from coronary heart dis-ease (CHD) in England fell by 38%between 1978 and the late 1990s,and that from stroke by 54% overthe same period. But the rate is stillmuch higher than in most other EUcountries—only two other coun-tries out of the 15 have worse rates.Furthermore, the death rates arevery uneven throughout the coun-try.

For example, the death rate fromCHD is:

● three times higher in Manches-ter than in the affluent Londonsuburb of Kingston and Rich-mond in people aged under 65

● 38% higher for men and 43%higher for women born in the In-dian subcontinent than in thepopulation as a whole

● three times higher among un-skilled men than among profes-sionals, with the gap wideningsharply in recent years.

The agenda of the governmentposes a challenge to those of uswith the job of educating healthprofessionals. It is much wider than

Richard Madeley

In July, 1999, the government ofthe United Kingdom published

its White paper on public health,entitled “Saving Lives—ourhealthier nation”. (1) In its intro-duction, the Prime Minister, TonyBlair, underlines its main principle,which is that although individuallifestyle choices do matter, there isa vital role for government in tack-ling those causes of ill-health thatare beyond the control of a singleperson. These include such issuesas poor housing, education, lowwages, unemployment and air pol-lution. In addition to support fromthe Prime Minister there is a state-ment signed by representatives ofthe Departments of Health, SocialSecurity, Home Office (Ministry ofthe Interior), Education andEmployment, Environment andTransport, Trade and Industry, andAgriculture, Fisheries and Food!

The document sets targets forthe improvement of the maincauses of premature death and ill-health in the United Kingdom.These are as follows.

By the year 2010:● Cancer: to reduce the death rate

in people under the age of 75 byat least a fifth

● Coronary heart disease andstroke: to reduce the death ratein people under the age of 75 byat least two-fifths

● Accidents: to reduce the deathrate by at least a fifth and that ofserious injury by a tenth

● Mental illness: to reduce thedeath rate from suicide and un-determined injury by at least afifth.

The objective of the governmentis to improve the health of everyonebut that of the worst-off in particu-


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teaching about such traditional riskfactors as hypertension, cigarettesmoking, exercise and cholesteroland fibrinogen levels, important asthey are. Fortunately, scientificallyrigorous research is now comingonstream that quantifies some ofthose factors that are beyond thecontrol of the individual.

For example, the study of public-sector workers in England known as“Whitehall 2” (2) compares the in-cidence and prevalence of CHD inrelation to job stress and the degreeof control an individual has overhis/her job. Job content was ana-lysed both by the workforce itselfand by specialist personnel manag-ers. There was a high degree of cor-relation between their opinions.The results showed that those injobs with a low level of control were50% likelier to develop CHD thanthose with a high degree, evenafter making allowance for tradi-tional risk factors.

In my personal experience, it hasbeen relatively easy to get medicaland nursing students to acceptthese findings and the relationshipbetween health and stress in gen-eral. I often find that they acceptmore easily than older profession-als that some of the so-called “life-style choices” are sometimes notsuch a free choice as is claimed. Forexample, they understand the dif-ficulty of resisting peer pressure insuch issues as cigarette smoking,sex and alcohol abuse.

The project “Understanding dis-ease epidemiology” is undertakenduring the second year of the un-dergraduate medical and nursingdegree courses. A mixed group ofboth courses is introduced to apatient suffering from heart dis-ease. The students take a historyfrom the patient about the clinicalfeatures of the disease, and how ithas affected his/her family. Theyalso explore whether the diseasecould have been prevented andwhether the patient had been atincreased risk.

They discuss the wider implica-tions of the patient’s situation,

including those social factors thatare relevant. These have recentlybeen highlighted by a joint publi-cation produced by the WHO Re-gional Office for Europe and theUniversity of London entitled Thesolid facts: social determinants ofhealth. (3) I think students acceptthese ideas because, when they arediscussed in the context of a real,live patient, their relevance is moreobvious to them than if given in theform of a traditional lecture.

It is a very interesting time to beworking in public health in theUnited Kingdom, and the princi-ples of the WHO programme “To-wards unity for health” are highlyrelevant to our everyday work. ■

References1. Saving lives: our healthier nation.

UK Government White Paper, Cm

4386. London, The StationeryOffice Ltd., July 1999. Website:<http://www.ohn.gov.uk>.

2. Bosma H et al. Low job controland risk of coronary heart diseasein Whitehall II prospective cohortstudy. British Medical Journal,1997, 314:558–565.

3. Wilkinson R, Marmot M, eds. Thesolid facts: social determinants ofhealth. Copenhagen, WorldHealth Organization RegionalOffice for Europe, and London,International Centre for Healthand Society, University of Lon-don, 1998.

Dr Madeley is Professor of Public Health,University of Nottingham Medical School,Queen’s Medical Centre, Nottingham NG72UH, United Kingdom (telephone: +44(0)115970 9305; fax: +44(0)115 970 9316; E-mail:[email protected]).

Family health: the cornerstone ofour national health organizationfaces challengesMilton Menezes da Costa Neto, Ministry of Health, Brasilia

B razil in the last decades hasmade important progress in the

health field, particularly by meansof the National Health System(Sistema Único de Saúde, SUS)regulated by the Brazilian Constitu-tion of 1988 and related laws. Ourhealth system is intended to bebased on universal access anddecentralization, as well as oncommunity participation.

Translating a law into effectivechanges that are consistent withthe primary health care philosophyhas been a major challenge for thesystem. Starting in 1994, the Brazil-ian Ministry of Health has thereforedeveloped a new model of healthcare delivery based on the familyhealth strategy.

Objectives of the new family healthstrategyThe family health strategy proposesa new dynamic approach for struc-turing the primary health servicesas well as for establishing a new re-lationship with the community andwith several levels of the health sec-tor, with the following objectives:

● to recognize health as a citizen-ship right, humanizing thehealth practices and seeking theuser’s satisfaction through aclose relationship with healthprofessionals;

● to provide universal coveragethat is comprehensive, egalitar-ian, continuous and above all,resolute—and that ensures highquality for the population in thehealth unit and at home. The


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services must meet the people’sneeds, with the family in itssocial context as the nucleus;

● to identify the risk factors towhich the population is exposed,as well as to intervene appropri-ately;

● to establish partnershipsthrough participating in actionsinvolving different sectors;

● to stimulate community organi-zation with a view to effectiveexercise of social control.

The strategy is accomplishedstarting from the primary healthunits. Each unit must organize ateam composed of at least one phy-sician, one nurse, one nursingassistant and four to six communityhealth workers.

By July 2000, the Family HealthProgramme had placed 8906 teamsin primary health units in 2829cities all over the country, servingmore than 30 million Brazilians.The goal for the year 2002 is to havemore than 20 000 teams workingaccording to the new strategy, serv-ing around 80 million people. Thisdemonstrates the clear politicaldecision to replace the formermodel by the model of familyhealth.

Human resources requirementsBut the organization of this systemrequires a proper human resourcesdevelopment plan. Health person-nel are trained and acquire theknowledge they need in order tounderstand the various health de-terminants that are of a physical,mental or social nature, as well asindividual or collective. They areintended to focus more on healththan on disease, and to adopt aninterdisciplinary practice pattern.

For this purpose, the Ministry ofHealth has supported the develop-ment of regional training centresfor the Family Health Programme,co-managed by universities andhealth services. More than 50 uni-versities are now involved in thisprocess all over the country. Theuniversities as well as health serv-ices participate in service deliveryand educational programmes.

Health personnel in primaryhealth units divide their work be-tween individual and community-health activities, with particularemphasis on the biological and so-cial parameters regulating familyhealth. They are expected to iden-tify and prevent risk factors anddevelop a comprehensive plan ofwork for a given population.

The implementation of such aplan requires a system view and acapacity to mobilize all availableresources in a given area and con-vince various health partners toshare a common purpose. Thisapproach is consistent with theWHO “Towards Unity for Health”approach.

Brazil, with its new health policyfounded on family health, is provid-ing a new opportunity to imple-ment the primary health carestrategy and respond to priorityhealth needs of individuals andsociety at large. ■

Dr Menezes da Costa Neto is a generalpractitioner and professor of general practiceand Advisor, Basic Health Care Department,Ministry of Health, Esplanada dos Ministérios,Bloco “G”, 6 andar, CEP 70 058-900; Brasilia,DG; BRAZIL (Email: [email protected]).

Extracts from: Primary healthcare 21: everybody’s business.Report of an internationalmeeting to celebrate 20 yearsafter Alma-Ata, Almaty,Kazakhstan, 27–28 November1998.

Geneva, World Health Organization,2000 (unpublished document WHO/EIP/OSD/00.7; available on requestfrom Department of Organization ofHealth Services Delivery, WorldHealth Organization, 1211 Geneva27, Switzerland).

“PHC models have been imple-mented, mostly as demonstrationsat local levels. However, it appearsthat few have been absorbed intothe fabric of the health system.”(page 22)

“A road map ought to offer to de-velop, together with practitioners,new systems and tools for prob-lem identification, priority settingand strategy development. It willalso require consideration ofmechanisms to include in healthplanning contributions from othersectors and from communitiesserved. A case in point is TowardsUnity for Health, a WHO-spon-sored network of health managers,health professionals and academ-ics.” (page 24)


HEALTH PROFESSIONS

An alliance of health professionals:the best support to unity for healthNurses, pharmacists and physicians unite globally for improved healthJudith A Oulton, International Council of Nurses, Geneva; Delon Human, World MedicalAssociation, Ferney-Voltaire; and Ton Hoek, International Pharmaceutical Federation,The Hague

techniques, community assess-ment and community diagnosis.

Delivering better health care topeople demands that health profes-sionals with diverse training andskills pool resources and expertise.The rapid increase in scientificknowledge, health information andmedical technology make it impos-sible for any one professional groupto master all the knowledge andabilities that would allow for high-quality care. Sharing competencesand perspectives can improve theoutcomes and cost-effectiveness ofcare. The synergy created whenhealth care professionals work incollaboration, instead of along par-allel tracks, benefits the patient andthe health care system.

Many models for unity towardshealth fulfil the purpose of joiningforces to attain a common goal. Wemust accept that partnershiprequires a willingness to shareresponsibilities as well as risks andgains. It is a relationship or socialcontract based on mutual trust andrespect. Unity in health can alsobring together alliances involvingthe public and private sectors, in-dustry, universities, professionalassociations, health care agencies,traditional and lay practitionersand communities.

HPA activitiesIn creating theHealth ProfessionsAlliance, nurses,doctors and phar-macists will be tack-ling key issues suchas health resourcesplanning, humanrights, tobacco ad-

diction and the integrity of healthprofessionals, to name just a few. Infact, effective joint action hasalready been undertaken by ICN,FIP and WMA.

● The three founding organiza-tions have made joint interven-tions during WHO meetings onthe active involvement of healthprofessionals in planning healthcare systems, the eradication ofpoverty, and debt relief. HPA wasalso active in discussions onplanning for long-term care andin support of the framework fortobacco control.

● ICN, FIP and WMA teamed up tomake a proposal to the 53rdCommission on Human Rights,requesting a special UN Rappor-teur to monitor and ensure theindependence and safety ofhealth professionals in providinghealth care to all people. This, inpart, led to the establishment ofa special UN Rapporteur for hu-man rights defenders.

Looking to the futureThe present and future require newways of working. We must learn tounderstand teams—their perform-

In May of this year, the interna-tional organizations representing

the world’s pharmacists, nurses andphysicians took a bold step towardsunity for health. The InternationalCouncil of Nurses (ICN), the Inter-national Pharmaceutical Associa-tion (FIP) and the World MedicalAssociation (WMA) launched theHealth Professions Alliance (HPA),aimed at improving health care de-livery. The HPA will benefit citizensand health policy-makers world-wide by strengthening collabora-tion among these core members ofthe health care team.

How will the Health ProfessionsAlliance support unity for health?ICN, FIP and WMA believe that thisholistic approach will reduce

fragmentation inhealth servicedelivery, whichcan be causedby divisions be-tween the vari-ous health careproviders. Mo-bilizing physi-cians, nurses

and pharmaciststo work more

effectively together will also con-tribute to coordinating changes inhealth professionpractice and educa-tion. Such unity forhealth should en-courage “training andlearning together towork together”, withcommon educationin selected areas suchas communicationand interviewing


ance capacities, theirstrengths and limita-tions. To be able tomeet health needs inthis constantlychanging world, weneed five-star profes-sionals who can takeon different roleswithin a health carecorps.

Today’s successful teams, work-ing with a unity of purpose, under-stand and accept that the group ismore than the sum of its parts. Part-ners complement each other’s skillsand acknowledge shared ones,reaching out to work with others invarious arrangements and condi-tions.

In a future that will be more ame-nable to shared and overlappingcompetences, it is important toaccept that different situations re-quire different roles. Health profes-sionals no doubt do this easily intheir social lives, but are still quiteprotective of “turf” at work. Thegoal of the Health Professions Alli-ance is to build on our combinedstrengths, uniting towards betterhealth through strategic alliancesand collaborative practice models.

HPA’s own strategic develop-ment will involve both proactivework on specific initiatives and re-sponsive action to issues as theyunfold. The proactive work will in-clude:

● Joint advocacy on selectedhealth issues

● Health human resources plan-ning, to ensure right numberswith right qualifications

● Joint environmental scanningand trend monitoring in healthcare

● Ethical issues● Joint guidelines in selected areas:

e.g. ethical issues in centralizeddatabase, the health team, etc.

● Equity and access to health care● Tobacco control initiatives● Strengthening health profes-

sionals’ role as healthy trendset-ters. ■

HEALTH PROFESSIONS

The InternationalCouncil of Nurses is afederation of 122 na-tional nurses’ associa-tions representing themillions of nursesworldwide. Operated bynurses for nurses since1899, ICN is the inter-national voice of nurs-ing and works to ensurequality care for all andsound health policiesglobally.

The International Pharmaceutical Fed-eration is a worldwide federation of na-tional pharmaceutical associations andhas as its mission to represent and servepharmacy and pharmaceutical sciencesaround the globe. FIP sees its principalrole as one of education and developmentof the practice and science of pharmacy.

The World Medical Association is a globalfederation of national medical associa-tions, representing the millions of physi-cians worldwide. Acting on behalf ofphysicians and patients, the WMA en-deavours to achieve the highest possiblestandards of medical science, education,ethics and health care for all people.

Dr Oulton is Chief Executive Officer, Interna-tional Council of Nurses, 3, place JeanMarteau; 1201 Geneva, SWITZERLAND(Telephone: +41 22 908 0100; Fax: +41 22908 0101); Dr Human is Chief ExecutiveOfficer, World Medical Association, PO Box63, 01212 Ferney-Voltaire Cedex, FRANCE(Telephone: +33 450 40 7575; Fax: +33 45040 5937; E-mail: [email protected]); and Dr Hoekis General Secretary, International Pharma-ceutical Federation, PO Box 84200, 2508 TheHague, NETHERLANDS (Telephone: +31 70302 1970; Fax: +31 70 302 1999).

Towards Unity for Health:The Phuket ConsensusBackground

The participants in the interna-tional “Towards Unity for

Health” Conference in Phuket,Thailand, on this day of 13 August1999 present this statement ofConsensus to serve as a foundationfor the development of partner-ships to promote health for allpeople worldwide.

This Consensus is grounded inthe fundamental principles out-lined in the United Nations Univer-sal Declaration of Human Rights,resolution 1997/71 of the UnitedNations Commission on HumanRights; the Declaration of Alma Ata;and the World Health Organiza-tion’s Global Strategy for Healthfor All, derived from resolutionWHA30.43 (1977) of the WorldHealth Assembly and the WorldHealth Organization’s definition ofhealth. In addition, the Consensushas imbedded within it the notionsof health-related human rightsfound in the codes of professionalethics and conduct and patients’rights promulgated by many pro-fessions in many nations.

We agree that:

● The health of individuals andfamilies reflects the health of thecommunities and environments inwhich they live, work and play.● Each person has the right tohealthy environments and equita-ble, humane and ethical healthservices.● The good of individuals, commu-nities and the environment must berespected and considered in allmatters relating to health.● Policies and practices that affecthealth must be evidence-based,rational and sustainable and mustaim at achieving both individualand societal good.● Effective partnerships betweenindividuals and communities andall sectors—private, public, profes-sional and voluntary—are essentialto creating and sustaining effectivehealth interventions and pro-grammes.● Global society must ensure ad-equate resources for the health ofall its members.● Responsibility and accountabil-


HEALTH PROFESSIONS

Les sciences infirmières, un atout pour créerl’unité dans le domaine de la santéSuzanne Kérouac, Université de Montréal

ity for health, particularly that ofthe most vulnerable, are shared byall partners across all sectors.

Recommendations forAction AgendaThe following agenda for action isproposed. Implementation of thisagenda will depend on a funda-mental reorientation of the educa-tion, training and continued

development of thewide range ofstakeholders inhealth.● Synthesise andpromote theTUFH Consen-sus.● Identify the key

determinants ofpartnerships that im-

pinge on health.● Create mechanisms for develop-ing the new skills needed for com-munity alliances: cross-sectoralconsensus-building, communityengagement, leadership training,management and resource devel-opment and deployment.● Develop shared knowledge andinformation systems for appraisingpartnerships and benchmarkingthe outcomes and impacts of TUFHprojects.

● Engage civil society, the publicand private sectors and communityleadership in the TUFH partnershipmovement.● Ensure support for TUFH by allstakeholders.● Ensure adequate resources toprovide appropriate technical as-sistance, demonstration projects,research and evaluation of sustain-able TUFH partnerships.● Develop, disseminate and imple-ment a strategic plan to advanceexpand a sustainable collaboratingTUFH network.

The World Health Organization,as the world’s key agency in inter-national health, should take thelead in developing and promotingthis Consensus. A resolution shouldbe drafted for adoption by theWorld Health Assembly to giveeffect to the implementation ofUnity for Health. ■

SummaryIn order to respond to increasingpublic expectations, more and morenurses are educated at the baccalau-reate, master’s and doctoral level.Consequently, many nurses now havethe knowledge and skills necessary toimplement changes and improve thequality of health care. Universitygraduates can also use research andother sources of information toanticipate needs in public health.More than ever, nurses are ready tocollaborate with other specialists, inorder to remodel health care pro-grammes and meet new challenges.

Contrairement à la plupart desautres professionnels de la

santé, les infirmières ne sepréoccupent pas uniquement dutraitement de la maladie. En effet,grâce à leurs nombreuses interven-tions en milieux clinique etcommunautaire, elles contribuentégalement à la promotion et aumaintien de la santé, à la pré-vention de la maladie ainsi qu’à laréadaptation des personnesatteintes de déficiences.

Depuis toujours, les infirmièresentretiennent une relation privilé-giée avec les gens et leur famille.Pour cette raison, elles occupentune place stratégique dans les équi-pes de soins, et ce, dans plusieurscontextes : centres hospitaliers, ré-seaux communautaires, soins de

première ligne, santé publique,soins à domicile et santé scolaire.Vu leur rôle clé, les infirmières agis-sent très souvent à titre de pivotentre les différents professionnelsdu milieu de la santé.

Anticiper les besoinsDans la plupart des pays du monde,le système de santé connaît unevéritable métamorphose. L’évolu-tion des connaissances sur la santéet la maladie, le vieillissement de lapopulation ainsi que les progrèsréalisés dans le domaine des tech-nologies médicales entraînent unetransformation radicale des soins etservices. Les demandes du publicsont grandes et on s’attend à ce quele personnel infirmier contribue àla santé par ses connaissances, ses


attitudes et ses habiletés spécifi-ques.

Afin de répondre aux besoinsgrandissants de la population, laFaculté des sciences infirmières del’Université de Montréal a choisid’accorder une importance touteparticulière à la recherche et au dé-veloppement. Les thèmes de re-cherche privilégiés par notreFaculté comprennent, entre autres,le soulagement de la douleur, lessoins aux personnes âgées et auxgroupes vulnérables, le soutien à lafamille et aux proches, l’influence

des déterminants sociaux sur lasanté ainsi que la promotion de lasanté dans divers milieux notam-ment en milieu pluriethnique.

Tout en tenant compte des pré-occupations des décideurs, nosprofesseurs et étudiants aux cyclessupérieurs tentent d’identifier et decaractériser les besoins en matièrede santé. Les résultats de leurs re-cherches sont couramment utilisésdans les prises de décision. Par con-séquent, nos chercheurs contri-buent à une meilleure organisationdes modes de gestion traditionnels.

Par ailleurs, la recherche univer-sitaire nous permet d’offrir des en-seignements à la fine pointe desconnaissances et des tendancesdans les pratiques de soins. Au bac-calauréat, nos étudiants sont expo-sés à la rigueur du processus derecherche et de l’analyse critique.On leur enseigne notamment à dis-

Diarydates✍ ✍ ✍TUFH regional consultation in Europe30 NOVEMBER–1 DECEMBER 2000, BARCELONA, SPAINThe intention is to explore mutual support between TUFH and primary health care andthe development of field projects in Europe. For more information, please contact DrJaime Gofin, Director, Community Oriented Primary Care Teaching Programs;Department of Social Medicine; Hadassah School of Public Health and CommunityMedicine; Hebrew University; POB 12272; Jerusalem 91120, ISRAEL(Telephone: +972 2 6777119; Fax: +972 2 6431086; E-mail: [email protected]).

✍ ✍ ✍Other TUFH regional consultationsAFRICA: NOVEMBER 2000, HARARE, ZIMBABWE (TO BE CONFIRMED)Convened by the WHO Regional Office for Africa. For more information, please contactDr B. Touré, Regional Adviser, National Health Systems, WHO Regional Office forAfrica, PO Box BE 773, Harare, ZIMBABWE (Fax: +263 4 790146).

EASTERN MEDITERRANEAN: FIRST QUARTER OF 2001Convened by the WHO Regional Office for the Eastern Mediterranean. For moreinformation, please contact Dr H. Sheilch, WHO Regional Office for the EasternMediterranean, WHO Post Office, Abdul Razzak Al Sanhouri Street, opposite Children’sLibrary, Nasr City, Cairo 11371, EGYPT (Telephone: +202 670 2535;Fax: +202 670 2492/2494).

SOUTH-EAST ASIA: FIRST QUARTER OF 2001Convened by the WHO Regional Office for South-East Asia. For more information,please contact Dr Palitha Abeykoon, WHO Regional Office for South-East Asia, WorldHealth House, Indraprastha Estate, Mahatma Gandhi Road, New Delhi, INDIA(Telephone: +91 11 331 7804/7823; Fax: +91 11 332 7972;E-mail: [email protected]).

✍ ✍ ✍Community-oriented education for health professionals infrancophone countriesAPRIL 2001, OUAGADOUGOU, BURKINA FASOOrganized by the International Conference of Deans of French-Speaking MedicalSchools. For more information, please contact Professor A. Gouazé, Doyen de laFaculté de Médecine; 2bis, boulevard Tonnellé, 37032 Tours Cedex, FRANCE(Telephone: +33 47 37 66 73; Fax: +33 47 36 62 12).

✍ ✍ ✍Family medicine and “Towards Unity for Health”MAY 2001, DURBAN, SOUTH AFRICAThis international conference is co-organized by WONCA and WHO. For moreinformation, please contact Dr Ilse Hellemann, Executive Member at Large, WONCA,Kastelfeldgasse 14, 8010 Graz, AUSTRIA (Telephone: +43 316 82 61 17;Fax: +43 316 82 61 17 20; E-mail: [email protected]).

✍ ✍ ✍Universities and health of the disadvantaged in AfricaSECOND QUARTER OF 2001, NAIROBI, KENYAThis meeting is being co-organized by the Tropical Institute for Community Health(TICH) and WHO as part of the UNI-SOL project (a WHO/UNESCO project: “Universitiesin Solidarity for Health of the Disadvantaged”). For more information, please contactDr D. Kaseje, CISS International, PO Box 73860, Nairobi, KENYA (Fax: +254 2 711918).

MO MO

Suzanne Kérouac



HEALTH PROFESSIONS

cuter, à questionner et à interpré-ter des articles scientifiques.

Grâce à cette formation, les in-firmières bachelières développentune polyvalence remarquable.Qu’elles travaillent en milieu clini-que ou communautaire, elles fontpreuve de créativité, d’autonomieet d’une capacité d’adaptation horsdu commun. Maîtrisant à la fois lesconcepts scientifiques, cliniques etles aspects psychosociaux liés à lasanté et à la maladie, elles appor-tent une contribution essentielle ausoin des personnes et des famillesainsi qu’au développement et àl’évolution des soins de santé.

Travailler en interdisciplinaritéGrâce à leur formation de hautniveau et à leur expérience en re-cherche et développement, les in-firmières bachelières sont plus quejamais aptes à échanger avec leurspartenaires du domaine de la santé.Leur participation au dialogue en-tre les scientifiques et les décideursest devenue essentielle. En effet, lacomplexité des besoins et des soinsde santé pose des défis qu’aucuneprofession ne peut espérer releverà elle seule. Plus que jamais, il estnécessaire pour les différents pro-fessionnels de la santé de travaillerensemble, en vue d’offrir des soinsqui répondent aux besoins de lapopulation.

D’emblée, les professionnels detoutes les disciplines s’entendentsur le but commun recherché : lasanté. Toutefois, même si l’objectifultime est le même, les approcheset les visions de chacun diffèrentsensiblement. Alors que lesmédecins, particulièrement lesspécialistes, accordent la prioritéau traitement, l’approche desinfirmières est davantage orientéevers la personne et l’intégralité dela vie humaine.

Très longtemps, la professiond’infirmière a été perçue comme leprolongement des services que lesmédecins rendaient à la popula-tion. Accompagner le malade ou lemourant semblait moins presti-gieux que de sauver une vie. Peu à

peu toutefois, cette perception setransforme.

Si l’on veut faire face auxnouveaux défis, toutes les profes-sions liées à la santé devront êtrereconnues et valorisées. L’autoritédevra être partagée entre toutes lespersonnes soignantes, de façonefficace, souple et dynamique. Lesforces et les habiletés de chacunpourront alors être utilisées à bonescient.

En premier lieu, la collaborationentre les professionnels se fondesur le principe d’équité, soit la re-connaissance de l’égalité dechaque discipline. En second lieu,elle s’appuie sur le principe deparité, soit la reconnaissance de ladifférence entre chaque discipline.

Mais avant tout, la collaborationrepose sur le respect des uns enversles autres.

Le travail en interdisciplinaritéoffre un potentiel de croissance etd’enrichissement inouï à tous lesprofessionnels du milieu. Enreconnaissant l’excellence dans lapratique de nos collègues de toutesles disciplines, nous pourrons bâtirensemble, à de moindres coûts, unpartenariat solide qui sera garantde la qualité des soins et servicesaux personnes. ■

Dr Kérouac est Doyenne, Faculté des sciencesinfirmières, Université de Montréal, C.P. 6128,succursale Centre-ville, Montréal, QuébecH3C 3J7, CANADA (Telephone: +1 514 3432306; Fax: +1 514 343 2306; E-mail:[email protected]).

Unity in health care practice:some directions for changeA nursing perspectiveMarjorie Gott, Leicester

Forces for change in health sys-tems include the shift to ambu-

latory care, technological innova-tion, cost containment and healthdevelopment. In addition, forecast-ers such as Craig (1) predict that“wellness” will be the service thepublic wants in the next decade,and that nurse practitioners andcommunity physicians will leadthis service. So the goal in thefuture is to deliver more and bettercommunity-based health services,collaboratively and cost-effectively.

New attitudes towards collabo-ration are needed. The 20th centurywas notable for turf wars betweenhealth professionals. It is time tolook at what nurses and doctors areable to do, make better use ofunderused skills and develop newroles and responsibilities.

Nursing, in particular has beenan underused and undervalued

service. Yet innovative nursingpractice is occurring that, if repli-cated, could change the mode ofhealth care delivery, increasingeffectiveness and efficiency.

This belief was the guiding prin-ciple for an international collabo-rative project consisting of dialoguewith senior nurses in three coun-tries: Australia, the UK and the USA.Nurses in each country were askedto describe case studies of “goodpractice” that were internationallyrelevant, capable of replication andthat indicated skill areas to be de-veloped. The project is now pub-lished. (2) It is hoped that it willstimulate debate between healthcare professionals, principallynurses, doctors and health policy-makers.

FindingsIn Australia: It was found that rural


FIVE-STAR PRACTITIONERS

nurses have extended their role towork as the primary, sometimes theonly, carer in remote communities:New needs-led curricula have beendeveloped and the government andkey stakeholders (nurses, doctorsand others) have worked togetherto legislate for an advanced role fornurse practitioners in South Aus-tralia.

In the UK: It was found thatnurse practitioners are makingmajor differences (access, work,cost) to the delivery of primaryhealth care (PHC) services and, ina rural community, a nurse-ledminor-injuries unit is providing aservice to a rural community thatmight not otherwise be available.

In the USA: It was found thatnurse practitioners are acting associal and business entrepreneursto provide new services to bothunderserved and affluent commu-nities, and that medical and nurseeducators are developing multi-disciplinary teams to build com-munity/campus partnerships forhealth (i.e. the Health ProfessionsSchools in Service to the NationProgram).

The clinical environment ischanging rapidly; this was evidentin all three countries. Nurses, withphysician support, are extendingand advancing their practice in linewith new needs and opportunities.Several trends are evident:

● Better teamworking: In the UK,doctors believed that with callmanagement by nurses they wereseeing much less acute minor ill-ness episodes, that some surgerieswere lighter, and they were manag-ing more complex cases. Doctorsalso believed that PHC workerswere making greater use of eachothers’ expertise.

This finding was also describedin the work of an Australian ruralgeneral practice nurse after a new(nurse/doctor jointly designed anddelivered) course of preparation forher role. Two nurses in the practicewill soon have completed thecourse. There is now no perceivedneed to recruit additional general

practitioners.● Better care management by use

of protocols: The use of common,jointly (nurse/ doctor) developedprotocols to manage care incidentsseems critical to success. Workingtogether on a problem builds own-ership of the solutions arrived at.Interdisciplinary care recognizesand uses the different skills of teammembers, but the margins of careand responsibility are blurred andshared. Depending upon the issueand the context, protocols are aslikely to be devised by nurses as bydoctors or other team workers.

● Better response to communityneeds: In the UK, Australia and theUSA the success of the extendedrole of the nurse in meeting theneeds of communities is evident.For most patients who attend arural UK nurse-led emergency careservice it is believed to be a moreappropriate form of service deliv-ery than high-cost doctor-led A&Ecare. In addition, the model devel-oped to serve small rural commu-nities has now been adapted andadopted as appropriate to reform oflarge inner-city A&E services.

In addition to better skill mix andreduced cost, there is a broader is-sue here: that of access to healthand illness services that would notbe provided if it were not for nurses.Rural nurses in remote areas of Aus-tralia serve the community by pro-viding a full range of nursing andhealth services, which no otherprofessionals will provide: In theUSA nurses deliver an extendedrange of services to previouslyunderserved (poor) rural commu-nities in the southern States.

Accreditation, credentialing andstandards of careNurses would be more cost-effec-tive if their practice were not lim-ited by law (lack of sufficientprescribing and admitting privi-leges in the UK) or unchecked mar-ket forces (growth of managedhealth care organizations in theUSA). There is also a threat tostandards. The findings here, across

countries, are of great concern.They have to do with lack of formalrecognition of new nursing rolesand practices and therefore withinconsistent, unregulated prepara-tion and continuing education op-portunities. It is hoped that themajor importance placed oncredentialing by the InternationalCouncil of Nurses, reported by DrAffara (3), will soon be adopted asan international priority.

SummaryFor much of the last century thenursing contribution to health carewas hardly visible. Part of the roleof the nurse in the future will be toeducate other health service deci-sion-makers about the value ofnursing and the contribution nurs-ing can make to the health andwell-being of society. They can dothis by showcasing good health carepractice that is truly collaborative.If doctors and nurses jointly design,deliver and monitor services theimpact on the health and illnessexperiences of the communitiesthey serve can be significantly im-proved. ■

References1. Craig A. Visions of primary care.

(Internet communication of 1999at web site http://www.newhealthnetwork.co.uk).

2. Gott M. Nursing practice, policyand change. Oxford, RadcliffeMedical Press, 2000.

3. Affara FA. Credentialing for thehealth professions: an interna-tional nursing perspective.Geneva, World Health Organiza-tion. Towards Unity for Health,No. 1, April 2000: 36–37 (unpub-lished document WHO/EIP/OSD/NL/A/2000.1; available onrequest from Department ofOrganization of Health ServicesDelivery, World Health Organiza-tion, 1211 Geneva 27, Switzer-land).

Dr Gott is Director of Gott Associates; 5 FernCrescent, Groby, Leicester, UK LE6 0BF(Telephone/Fax: +0116 287 6943; E-mail:[email protected]).


ACCREDITATION

Accrediting the capacity to meetsociety’s health care needsChallenges to institutions and professionsWilliam E. Jacott, Joint Commission on Accreditation of Healthcare Organizations, Minneapolis

Commission on Accreditationof Healthcare Organizations(JCAHO), I am convinced that theprocess of accreditation has madea positive difference in health care.The JCAHO was established in 1951by leading American health careprofessional organizations andsince then has served the publicinterest and leveraged ongoing im-provements in patient safety andhealth care quality by awarding ac-creditation only to those organiza-tions that meet its state-of-the-artstandards.

While the process initiallyfocused on hospitals, JCAHO’s ac-creditation services have expandedto include managed care healthplans, medical laboratories, homecare, behavioural health care,ambulatory care, long-term careand assisted living organizations.The historical strength of theJCAHO is its ability to convene pro-fessional experts and leaders to de-velop standards, accreditationprocedures and policy positionsthat have broad credibility. Thatcredibility is reflected in the reli-ance placed on JCAHO accredita-tion by government regulatoryagencies, private and public sectorpurchasers of health care, financial

markets and the public.Supporting JCAHO’s mission to

improve the quality of health careworldwide is a subsidiary, the JointCommission Resources, Inc. (JCR).JCR supports the provision of edu-cation, publications, technicalassistance and international ac-creditation and has provided prod-ucts and services (represented bythe name Joint Commission Inter-national, or JCI) to more than 40countries around the world. Nota-bly, in 1999, JCI published interna-tional health care standardsdeveloped by a 16-member taskforce representing six major worldregions. Those standards set uni-form, achievable expectations forhospital structures, processes andoutcomes.

Traditionally, the evaluation ofhealth care organizations hasfocused on their compliance withprocess standards rather than ontheir health care outcomes.Currently, however, the JCAHO isintegrating performance measures,including outcomes, into evalua-tion.

Each accredited organizationenrolls in a performance measure-ment system of its choice, whichcollects and analyses data from theorganization and reports the analy-sis to the JCAHO. The JCAHO is nowidentifying nationally standardizedperformance measures that can beembedded in every measurementsystem so that the performancedata will be comparable acrosssimilar health care organizationsregardless of the measurement sys-tem chosen.

Challenges aheadLooking ahead, our profession—and the health care organizationsWilliam E. Jacott

Good health is a fundamentalright of society. All people de-

serve competent and safe healthcare, and one way to assure this isthrough the accreditation of healthcare organizations.

Accreditation is a statementabout the performance of a healthcare organization, based on anevaluation of its compliance withevidence-based and consensus-based standards. These standardsaddress patient care (i.e. their as-sessment, their treatment and theprotection of their rights) as well asorganizational processes such asthe management of human re-sources, information and quality.Notably, the accreditation processcan be designed to accommodatespecific legal, religious and culturalfactors within a country.

Trust for improvementA key component of the accredita-tion process is the on-site visit, dur-ing which surveyors (physicians,nurses, administrators) evaluate anorganization’s adherence to stand-ards by interviewing patients, clini-cians and the organization’s leadersand staff. Patient care is observed,medical records are reviewed andpolicies and procedures are exam-ined.

With these measures, the level ofcompliance with each standard isscored and the scores aggregatedfor groups of related standards.Based on the aggregate scores, thelevel of accreditation is determinedand recommendations for im-provement are made. For theorganization to retain its accredita-tion, such improvements must bemade within a specified period.

As chairman of the Board ofCommissioners for the Joint


ACCREDITATION

Needed: a people-centred classification ofhealth problems seen in primary careNiels Bentzen, Medisinsk teknisk forskningssenter, Trondheim

we belong to—face several chal-lenges with respect to accredita-tion. First, we need to make theaccreditation process relevantwhile delivering value to institu-tions. That is, we must demonstratethat the processes of pre-surveypreparation, self assessment andon-site evaluation can result inmore positive health care out-comes. The question remains:When institutions and/or healthcare professionals are evaluatedthrough an accreditation process,does it make a difference in howcare is delivered?

We are moving from anecdotalresponses to that question to amore evidence-based response.With our increasing ability to col-lect and analyse data from the re-porting of serious adverse events,we are making an impact on out-comes. The best example of this isthe removal of intravenous potas-sium chloride (KCl) from United

States hospital nursing stations,allowing only pharmacies to dis-pense it. As a result, in the last yearthere has not been a single deathfrom improper administration ofKCl.

Another important challenge isto establish that accreditation sat-isfies the need for public account-ability. This means the processmust be cost-effective and success-ful in eliminating medical errors—a real and serious problemworldwide.

Outcomes must be measuredand demonstrate improvement inhealth care delivery, all within thecontext of appropriate public dis-closure. The public wants andneeds this information to make de-cisions about health care institu-tions and/or professionals. Thisdisclosure varies greatly from coun-try to country and often becomesinterwoven with the complicatedissues of liability, marketing of

services and data privacy or confi-dentiality.

In summary, I believe the proc-ess of accreditation is responding tothe needs of society. Although thereare many complexities to over-come, all countries in the worldneed to be involved in the develop-ment and implementation of avalid accreditation system. Onlythen will our public be assured of acompetent and safe health caresystem.

I wish to acknowledge DennisO’Leary, Paul Schyve and KarenTimmons (all of the JCAHO) fortheir assistance with this article. ■

Dr Jacott is Head, Department of FamilyPractice and Community Health, University ofMinnesota Medical School and Chair, Board ofCommissioners, Joint Commission onAccreditation of Healthcare Organizations;Mayo Mail Code 381;420 Delaware Street SE;Minneapolis, MN 55455, USA (Telephone: +1612 624-2622; Fax: +1 612 626-3619; E-mail:[email protected]).

CLASSIFICATION

Classifying health issuesdifferently

In primary care, patients presentwith their symptoms very early in

a disease process, often before it ispossible to make a diagnosis. Thesymptom is then the only sensibleway to label the encounter. Some-times the symptom is the begin-ning of an acute disease episode,and sometimes it signals the startof a chronic disease episode. Symp-toms may evolve over time, butusually a pathophysiological proc-ess can eventually be identified anda diagnosis made.

The patient may have only oneencounter and not call again for thesame problem. He or she may or

may not receive a treatment beforethe nature of the problem is under-stood. What makes the symptomdisappear—reassurance, time, na-ture’s own healing power or thetreatment—nobody will ever know.In another situation, the generalpractitioner/family physician—GP/FP—and the patient will overtime get a better understanding ofthe disease from which the patientsuffers.

If the GP/FPs want to communi-cate about their patients, they mustbe able to talk the same language.This means they must call the samehealth problem by the same name.In order to reflect the effect on thepatient, the “language” must be

able to describe the patient’s feel-ings and social and psychologicalsituation, as well as a possible di-agnosis. Such a classification mustfollow established criteria. Only ifit covers these aspects is it patient-centred.

A classification system must suitthe purpose for which it is de-signed. In primary care it must beable to classify episodes of healthproblems, whether on a symptomlevel or on a pathophysiologicallevel. An episode-based classifica-tion system must describe the de-velopment of the health problemover time, thus capturing the fullclinical episode and the process ofreaching a final diagnosis.


FAMILY PRACTICE

The ICD-10 systemThe ICD-10 (the tenth version ofthe International Classification ofDiseases) is intended to classify dis-eases and is an “endpoint” classifi-cation, useful in hospitals. It isdisease-centred, detailed and con-tains all possible diagnoses seen inhospitals, many of which are rarely,if ever, encountered in general/family practice or in primary caresettings.

The ICD-10 system was not de-veloped to record the frequent rea-sons for encounter with the GP/FP,and lacks specificity for commonconditions. The ICD-10 classifica-tion cannot record processes orepisodes. It was not designed torecord the early development ofsymptoms or describe the status ofnormal well-being.

The ICD-10 system is usedmainly to classify diagnoses madeby specialists in a hospital to whichpatients are referred for diagnosticrefinement and treatment. It is fartoo detailed for use in general/family practice. There is evidencethat in countries with a well-devel-oped primary health care system itsuse results in many classificationerrors, rendering such “informa-tion” of doubtful value. In primaryhealth care settings in developingcountries, the problem of validitybecomes even greater.

In primary care, ICD-10’s valid-ity (the extent to which the GP/FPscoding conveys the reality of thepatient), reliability (the extent towhich the classification will providethe same result in a similar encoun-ter in the future) and objectivity(the extent to which all GP/FPsagree on the same codes for thesame health problem) are very low.The application of ICD-10 in primarycare can be compared to using a tapemeasure in centimetres and millime-tres to measure the distance to themoon! It doesn’t make sense.

ICPC-2ICPC-2, or International Classifica-tion of Primary Care, second edi-tion, is a system designed to

capture health problems inpatients consulting their GP/FP. Itis constructed for this use. It hasmutually exclusive classes, and in-clusion/exclusion criteria, whichmakes it easy to use with a highdegree of validity, reliability andobjectivity. In our opinion, it is thebest classification choice in pri-mary care at present.

Using ICPC-2 makes it possibleto describe the reality of primarycare more clearly, allowing it to beused for comparative statisticalanalysis and research as well asteaching and learning. It can cap-ture the patient’s reason for en-counter, the process of care and adiagnosis, which sometimes is asymptom diagnosis and sometimesa more comprehensive diagnosis.

ICPC-2 reflects the reality of gen-eral/family practice, where certainproblems are seen frequently andaddressed in broad terms, amena-ble to treatment or referral forrefined diagnosis, specialized treat-ment and follow-up. It also accom-modates the classification ofindividuals suffering no disease.ICPC-2 is episode-based,and thus well suited toclassify the beginning of adisease as well as its dif-ferent stages and the fol-low-up of the patient overtime.

Let’s take cough as anexample. This is one ofthe most frequent reasonsfor encounter in general/family practice in theWestern world. Most

patients with this symptom areseen only once, and “cough” is therelevant diagnostic label for thisconsultation. Some patients con-tinue to cough, and consult again.

The result of these follow-upconsultations may be that in somepatients the cough is due to allergy,pneumonia or acute or chronicbronchitis. The GP/FP has to recordfor months or even years before he/she sees a patient with lung cancer,whose reason for encounter also iscough. The picture is quite differ-ent when cough is recorded in ahospital and linked to a specificdiagnosis. Therefore a unique clas-sification system can be inappro-priate.

ICD-10 to ICPC-2: conversion orcommunication betweenclassificationsIn primary care it is important thatwe have one language, but we mustalso be able to communicate withthe rest of the health care sector,despite the fact that our diseasepanorama is only partly overlap-ping.

It is therefore important thathealth problems classified withICPC-2 also can be described withICD-10, so that different aspects orstages of the patient’s health prob-lem are well described. But sincethe two classifications are meant toclassify different things bygeneralists and specialists with avery different frame of reference,full equivalence will be elusive.While efforts at conversion can bemade with relative success, it is im-portant to remember that ICPC-2 is

Niels Bentzen


ACADEMIC INSTITUTIONS

a patient-centred, episode-basedclassification, and ICD-10 is a dis-ease-centred, endpoint classifica-tion.

ConclusionThere is no right or wrong classifi-cation system. ICD-10 and ICPC-2are designed for different purposesand are best suited for the purposesthey were designed for. Health pro-fessionals should understand therespective value of both ICPC-2 andICD-10, for a more holistic ap-proach to health and diseases ofindividuals and society at large.

It is our hope that ICPC-2 will beused as an ordering principle forclassifying symptoms and healthproblems in primary care and thatICD-10 will be used as a comple-mentary and refined disease clas-sification, which will ensure thatGP/FPs can also classify rare dis-eases when they meet them in theirpractice.

A good conversion betweenICPC-2 and ICD-10 towards unityfor health for patients and notonly for their diseases! This is whatthe WONCA International Classifi-cation Committee will worktowards. ■

Further reading1. ICPC-2 International Classification

of Primary Care, second edition.Prepared by the International Clas-sification Committee of WONCA.Oxford, Oxford University Press,1998.

2. Okkes IM et al. ICPC-2-E. The elec-tronic version of ICPC-2. Differ-ences with the printed version andthe consequences. Family Practice2000, 17:101–106.

See also: (http://www.ulb.ac.be/esp/wicc) for references and the elec-tronic version of ICPC-2-E.

Dr Bentzen is chairman of the InternationalClassification Committee of the WorldOrganization of Family Doctors (WONCA) anda professor in the Department of CommunityMedicine and General Practice; Medisinskteknisk forskningssenter; N-7489 Trondheim,NORWAY (Telephone: +47 7359 8876;Fax: +47 7359 7577; E-mail:[email protected]).

Towards unity for health throughmedical education curricularinnovationsLeslie J. Sandlow and Joseph W. York, University ofIllinois College of Medicine, Chicago

curricula. This term should not beconfused with primary care as it isusually understood.

Generalism refers to an empha-sis on the whole patient, withmeaningful participation in care bythe patient, family and community.Generalism is as applicable to thesubspecialty surgeon as to the fam-ily practitioner. It is demonstratedby professionalism and continuousdevelopment of skills and knowl-edge throughout the career of thephysician.

For the academic institution,developing a generalist curriculummeans emphasizing a number ofcompetences:

Basic and clinical sciences: A corecompetence for all physicians is afirm comprehension of how thehuman body functions in bothhealth and disease. A good fund ofknowledge in this area prepares aphysician to make good decisionsabout prevention, treatment andthe appropriateness of differentprotocols. It can help physiciansunderstand the interactions oftreatments on different systems inthe body. It enhances communica-tion of the mechanisms of healthand disease to patients and stu-dents.

Disease prevention and health promo-tion: Physicians must be well-grounded in the concepts ofpreventive medicine and mainte-nance of good health, and must beable to effectively communicatethese to patients. In some cases,this means prevention of primarydisease. For patients with chronicconditions, however, the physicianmust also understand how to mini-mize the secondary pathologies

Towards Unity for Health seeks toprovide better health care by re-

ducing fragmentation in healthcare delivery and encouraging part-nership among the variousstakeholders in the health care sys-tem. A primary emphasis in this aswell as many health care reform ini-tiatives is improving the overallhealth of a given population. Phy-sicians today are being asked to ex-pand their capabilities in a numberof new dimensions:

● Continue to be the health advo-cate for the individual patientwhile providing for the healthcare needs of the community.

● Treat disease while teaching pre-ventive care and health promo-tion.

● Provide longitudinal care to theindividual and family, whilemaking use of subspecialties andother health care professionalservices.

● Provide the best care possibleusing the latest technologies andprotocols while keeping costsunder control.

Academic institutions are amajor stakeholder in the Unity forHealth partnership. They face thechallenge of developing curriculathat prepare health care profes-sionals to meet these new de-mands. This paper describes anumber of curricular initiatives andconsiders how they relate to theconcept of Unity for Health.

The generalist curriculumOne way in which academic insti-tutions can balance the needs ofthe various stakeholders in thehealth care system is by applyingthe principle of generalism to their



that emerge from diseases such asdiabetes. Topics such as epidemi-ology and public health contributeto the fund of knowledge that thephysician needs for practising pre-ventive medicine.

Humanism and biopsychosocial knowl-edge: Beyond the clinical skills andtechnology, a physician must un-derstand what it means “to be hu-man”. How people react to newsabout their health and how theythink about their bodies are ques-tions that the medical humanitiesseek to answer. The generalist phy-sician must also understand how apatient’s mental state can affecthealth outcomes. A generalist cur-riculum should include insightsinto humanism and psychology, toenable the physician to treat the“whole” patient.

Management and clinical decision-making: Physicians can address theneed to provide cost-effective carethrough the concept of evidence-based medicine, which is the use ofpertinent, searchable questions tomeet medical information needs.Evidence-based medicine providesthe tools to make a critical appraisalof literature to predict whether acourse of treatment will be effec-tive, while making appropriate useof limited resources. Trainingstudents to use “best evidence” inevaluating alternative courses oftreatment equips them to functionin a cost-conscious environment.

Social and community contexts ofhealth care: Generalism seeks to re-late the patient to the communityand vice-versa. It encourages cul-tural competence, the ability of pro-fessionals to not only understandthe complexities of a patient’sheritage, but make use of it to thepatient’s benefit.

A number of medical schoolshave addressed these needs in apractical manner by establishinglongitudinal primary care experi-ences with community preceptors.These programmes, which some-times continue through all fouryears of school, help introduce stu-dents to issues of epidemiology,preventive care, culture and hu-manism. The student can interactwith public health workers, socialworkers, community nurses, den-tists and other health care profes-sionals in the community, to gainan appreciation of the benefits ofteamwork.

Longitudinal primary care pro-grammes, community clinics andother similar programmesstrengthen linkages between theacademic institution and the com-munity it serves in several ways:The faculty become more aware ofthe problems of the community;the community benefits from thehigh quality of care, and studentsorient to the community and ulti-mately serve it as professionals.

Professional behaviour: Regardless ofchanges in the health care environ-ment, the practice of medicinecontinues to be a profession char-acterized by qualities of altruism,accountability, humanism and ex-cellence. These qualities are time-less and are not dependent on anypractice or academic environment.The formal curriculum should in-clude exposure to the history ofmedicine, its heroes, and the cul-ture in which the physician prac-tises. The informal curriculumbecomes important here, also, byproviding role models for studentsand feedback to students on theirown professional qualities.

Lifelong learning: Physicians con-tinue to learn throughout their pro-fessional careers. This processbegins on the first day of medicalschool and doesn’t stop until retire-ment.

The generalist curriculum instilsin students a discipline of knowl-edge acquisition that continues aslifelong learning. Students mustlearn to recognize and tolerate am-biguity and uncertainty and thelimits of their own knowledge base,and develop a discipline of inquiryto further their understanding ofmedical concepts. Academic insti-tutions must also encourage con-tinuous professional developmentthrough programmes that meet theneeds of medical professionalsthroughout their careers.

Relating generalism to Unity forHealthGeneralism addresses many of theneeds and expectations of the Unityfor Health concept. It encouragesphysicians to treat the communityas well as the individual and buildrelationships with the other healthcare professionals who also con-tribute to individual and popula-tion health.

The emphases on disease pre-vention and health promotion andcritical evaluation of treatmentprotocols make the generalist phy-sician a partner with the healthmanager. As a team, they jointlyensure that limited resources areput to the best use in caring for theJoseph W. York

Leslie J. Sandlow



patient and community.Continual professional develop-

ment links the health care practi-tioner with the academicinstitution as a resource for learn-ing and growing professionally.Finally, an emphasis on communitybrings academic institutions intopartnership with policy-makers asboth seek ways of applying limitedresources to the demands of a pub-lic for safe and effective health care.

ConclusionIntroducing concepts of generalisminto the medical school curriculumanswers the call for a greater senseof social accountability for aca-demic institutions as they develophealth care professionals who treatthe individual as well as the com-munity, display humanistic quali-ties, and use scarce resources in acost-effective manner. The skillsand attitudes that the students takefrom their education helps themrelate better as health care provid-ers and work with the otherstakeholders in the Unity for Healthpartnership. Finally, the profes-sional emphasis prepares healthcare professionals who can adapt tonew and different health caresystems that may emerge in thefuture. ■

References● The generalist physician taskforce. AAMC policy on thegeneralist physician. AcademicMedicine, 1993, 68(1):1–6.

Dr Sandlow is Senior Associate Dean forEducational Affairs for the University ofIllinois at Chicago College of Medicine, andProfessor and Head of the Department ofMedical Education; and Mr York is a Lecturerand Assistant to the Head for the Departmentof Medical Education at the University ofIllinois College of Medicine. Both authors canbe reached at 808 South Wood Street, MC591, Chicago, Illinois 60612, USA(Telephone: +312-996-3590; E-mail:[email protected]; [email protected]).

Towards Unity for HealthAn opportunity to engageour medical schools inhealth researchChaloem Varavithya, Thammasat University, PhathumThanee, THAILAND

Medical teachers are overloadedwith educational activities andclinical duties. The average time forresearch is less than eight hours perweek. Research topics are toonarrow in their scope. Training inresearch methodology must bestrengthened.

Research funding comes fromthe university, the National Re-search Foundation and foreigncountries or international agencies.It is largely inadequate. Supportfrom policy-makers and politiciansis modest, due to severe budgetarycompetition and lack of clear poli-cies.

Medical education researchResearch in medical education re-search has lower status and prior-ity than health research. Althoughabout 400 research topics in medi-cal education can be found in theliterature since 1978, this does notreflect an appropriate coverage ofneeds in this area.

Clear directions must be set toimprove the relevance of researchefforts. We consider that the WHO“five-star doctor”, with the at-

Where are we?

The mandate of medical schoolsor faculties of medicine in Thai-

land includes undergraduate, post-graduate and specialty training,continuing education, research,social advocacy and medical serv-ices. The main goal of medicalschools is to produce doctors to suitthe country’s needs. Medicalschools have also been working aspartners with university hospitalsand other health service systems toensure that the quality of healthcare, cost-effectiveness, relevanceto community needs and equitycontribute to health system devel-opment. Research in both healthand medical education are consid-ered important to support thesemissions.

Health researchThe term health research coversclinical research, biomedical/labo-ratory research and public healthresearch. Data collected by theNational Research Council showthat clinical research and biomedi-cal/laboratory research account70% of the total health research ex-penditure. Public research has beenrelatively neglected. A recent studyidentified several obstacles toprogress of health research in Thai-land.

Despite their noteworthy re-search capabilities, several facultiesof medicine, especially new ones,face problems such as inadequatefacilities, lack of technical and sup-port staff, inappropriate equip-ment and inadequate vital supplies,and unstable budgetary support.

Chaloem Varavithya



tributes of care provider, decision-maker, communicator, communityleader and manager, is a good ref-erence point to guide educationleaders in conducting research toimprove the curriculum and learn-ing processes to prepare a “doctorfor the community”.

Medical schools as prime moversThe main goal of health research isto improve the performance ofhealth care delivery systems. Toaccomplish this goal, research re-sults should be used by concernedorganizations—such as the Minis-try of Public Health, educational in-stitutes, etc.

One of the main recommenda-tions from WHO’s “Towards Unityfor Health” international confer-ence (Phuket, Thailand, August

1999) is to createpartnerships amongkey stakeholders, asillustrated by the“Partnership Penta-gon”. The medicalschool as a repre-sentative academicinstitution shouldtake a leadershiprole in implement-ing such a recom-mendation.

As previouslymentioned, medicalschools in Thailandor other developingcountries should

use their potential to make a greatercontribution to health systems im-provement. In Thailand, medicalschools are engaged in partner-ships. Medical schools and theirfaculty work with internationalorganizations such as UNDP, WHO,ADB, UNHCR, etc.

Government organizations suchas the National Research Council,the Thailand Research Fund andthe National Health Research Insti-tutes have reviewed policies to sup-port and monitor health research inline with the spirit of the TUFHinternational conference.

The Thai Medical School Con-sortium, composed of deans andother education leaders, alsopromotes and supports medicaleducation research and health re-search.

The “Partnership Pentagon”, adiagram symbolizing the TUFHproject, provides a challengingvision for medical schools. Theattached diagram reflects how it fitsthe national Thai situation.

In my view, most medicalschools in Thailand are capable offorming such a partnership withother important partners in thehealth system. The diagram de-scribes the linkages among fivestakeholders.

The medical school can be acatalyst for such a partnership, asit can win over other partners inraising the important researchquestions, conducting the researchand providing appropriate answersfor the adaptation of the nationalhealth system to the needs of Thaisociety. ■

Sources consulted● Essential national health researchand priority setting: lessons learned.Geneva, Council on Health Re-search for Development document97.3.

● The ENHR handbook. Geneva,Council on Health Research forDevelopment document 2000.4.

● Health research: essential link toequity in development. New York,Oxford University Press, 1990.

● Strategic plan for health research,Thailand 1999. Bangkok, MedicalScience Committee of the NationalResearch Council and WHO Thai-land country office, 1999.

● Essential National Health Re-search Asian Regional Network,College of Public Health,Chulalongkorn University AsianRegional ENHR Network Focal Point(1999–2000). Bangkok, 2000.

Dr Chaloem Varavithya is a professor in theFaculty of Medicine, Thammasat University,Klong Luang, Phathum Thanee 12121,THAILAND (Telephone: +662 926-9794;Fax: +662 926 9795; E-mail:[email protected]).

The “Partnership Pentagon”

The partnership diagram modified from the Partnership Pentagon

HEALTHSERVICESBASED ONPEOPLE’S

NEEDS



Team effectiveness in achieving“Unity for Health”Arie Rotem and Sally Nathan, University of New South Wales, Sydney

which he or she views the worldand can stand in the way of thedevelopment of collective goals.Operating with ill-defined and con-flicting goals acts as a significantbarrier to effective partnerships.

To formulate common goals, anopportunity must exist for partici-pants to explore their assumptions,define their needs and state thegoals as they see them. Charting theforces in the system from withinand external to theteam can as-sist the devel-opment of acommon un-derstandingof what eachparticipantis respond-ing to andf a c i l i t a t ethe nego-tiation ofd i f f e r -ences. Theteam mustalso go be-yond a gen-eral goal to specifically articulateobjectives that will focus their en-ergy.

In the early stages of a researchpartnership between the School ofMedical Education and a businessunit within the local Area HealthService, differences in desired out-comes and assumptions about ajoint research project were re-vealed. The assumptions abouthow and for what purpose theproject was to proceed were basedon largely operational concernsabout service improvement for thebusiness unit, and more on under-standing, documenting and pub-lishing about an under-researchedphenomenon for the academic

institution. While these objectiveswere not in direct opposition andcould all be achieved, checking as-sumptions and negotiating sharedgoals as the partnership evolvedensured that the direction andscope of the project were refinedaccordingly.

When problems arise or differ-ences in assumptions are revealed,it is essential that the vision theorganizations have together is re-

affirmed. Agreement onthe vision can helpclarify and solveproblems andkeep the partner-ship focused onoutcomes.

Role definitionConflict and con-fusion about rolesand responsibili-ties is common in

partnerships.The roles andresponsibili-ties of teamm e m b e r s

should draw on individualstrengths so that each team mem-ber can complement and supportthe others.

Flexibility in the role each mem-ber plays is also often necessary totake account of shifting expecta-tions and external pressures. Re-sponsibility for team functions mayshift from member to member indifferent situations according totasks and the resources and exper-tise on offer.

In negotiating roles and respon-sibilities, team members need to beprepared to articulate what theywant and what they can provide.Highlighting areas of agreement onroles is a good place to start.

T erms such as “partnership”,“intersectoral collaboration”

and “alliances” have become com-monplace in the public health lit-erature, but much is still to be learntabout how to turn this vision ofworking together for health fromrhetoric into reality.

Partnerships by their very naturebring together a diverse set ofactors, including policy-makers,health managers, health profes-sionals, community groups andacademic institutions. Thesestakeholders represent different in-terests and values that guide theirperceptions and responses. Theyoperate in an arena of forces thatare often conflicting and pulling indifferent directions but rarelyachieving agreement and stable re-lations. Against this constraint,which is a product of complexityand wide participation of differentcommunities of interest, we need tolearn better how to work as teams.

Working as a team requires rec-ognition, tolerance and indeed re-spect for diversity, but at the sametime willingness to pull togetheraround common goals, performingcomplementary roles and adheringto an agreed method of work.

Focusing effort through commongoalsFrom our experience, one of thereal challenges of partnershipapproaches is being able to buildconsensus about goals and objec-tives. Goals need to be formulatedwith reference to the needs and re-sources of the team members. Theprocess of goal-setting is thereforeoften political rather than purelyobjective.

Each participant’s unique values,orientation, standards and vestedinterests represent the lens through


FAMILY PRACTICE

Procedures and processesThe right balance needs to bestruck when establishing proce-dures and processes to guide thepartnership in achieving effectivecommunication and creative prob-lem-solving and to make decisions.Too little structure can result inconfusion about responsibilitiesand loss of clarity about goals. Toomuch structure can stifle creativityand block discussion.

Changes in the broader contextRecent research investigating therole of the nongovernment sectorin health, undertaken by research-ers in the School of Medical Educa-tion, has highlighted importantcharacteristics of nongovern-mental organizations (NGOs) thatboth enable and require them towork together with diverse sectorsto achieve outcomes. The researchfound that NGOs, which are oftenlimited in both their financial andhuman resources, depend on part-nerships to achieve results: theywork together out of necessity.

In contrast, other stakeholders inthe health sector, including policy-makers, health managers, healthprofessionals and academic insti-tutions, may aspire, but not alwaysperceive a need, to work together.(1) In reality, a number of incentivesmay direct these groups away fromforming partnerships and insteadtowards protecting their ownsectoral interests.

Changes in the broader contextin which organizations operate canmean the difference between ashort-term partnership and a sus-tainable long-term commitment towork together. External incentivesare what make partnerships anecessity. For example, the incen-tives in public health education andresearch funding in Australia arebecoming increasingly focused onfostering partnerships instead oftriggering unnecessary competi-tion that pulls institutions apart. Inthe Pacific, health ministers are sig-natories to a series of agreementscommitting their countries to be-

coming Healthy Islands. (2)Difficulties with interpersonal

relations and pressure from exter-nal forces are often inevitable, butill-defined goals, unclear roles andinappropriate procedures willhamper coordinated effort. Thereare no magic pills for effectiveteamwork; some problems will onlybe resolved over time. However, byfocusing efforts on the establish-ment of common goals, clear rolesand responsibilities and appropri-ate procedures, conflict can beminimized and the positive rela-tionships needed for effectiveteamwork can be fostered. ■

References1. Harris, E et al. Working together:

intersectoral action for health.Canberra, Commonwealth ofAustralia, AGPS, 1995.

2. Ritchie J, Nathan S, Mehaffey A.Capacity building for interna-tional health gains. NSW PublicHealth Bulletin, 2000, 11(3):24–26.

Dr Rotem is Professor and Head, School ofMedical Education, Faculty of Medicine,University of New South Wales, Sydney NSW2052, AUSTRALIA (Telephone: +61 2 93852506; Fax: +61 2 9385 1526; E-mail:[email protected]).Ms Nathan is an Associate Lecturer at thesame institution, address and fax number(Telephone: +61 2 9385 1061; E-mail:[email protected]).

Finland

Communication technology anddistance learning: more wordsthan actionPertti Kekki, University of Helsinki

The development of informationand communication technology

was very rapid during the last dec-ade. However, the possibilities cre-ated by this in the field of educationand training to a large extent stillremain underused. We wish to con-firm the vast opportunities offeredby communication technology indistance education of health per-sonnel and document it with ourexperience.

Our experienceSince 1994 the Department of Gen-eral Practice and Primary HealthCare at the University of Helsinki, aWHO Collaborating Centre, has of-fered two programmes focusing onthe development of the quality ofhealth care and management skills.Both can be taken part-time, andthese and many of our othercourses are available through theInternet.

We collaborate with universitiesin North America and Europe, withWHO and with the National HealthScience Library in Helsinki, whichenthusiastically applies the newinformation technology. Our teach-ing materials are on the Internet. Toget there, the student needs a usercode and a password.

In 1998/1999 we collaboratedwith a branch of the Nokia Corpo-ration and the Helsinki TelephoneCompany. This activity, called the



Pertti Kekki

PublicationsThe publications listed below arerecommended as particularly relevant tothe “Towards Unity for Health” initiativeand to coordinating changes in healthservices and health professions practiceand education. Some of them can beobtained free of charge.

Due to the limited supply and for thesake of better dissemination, WHO willgive preference to filling requests for itspublications from heads of institutions,organizations and programmes, with theexpectation that they will be madeaccessible and available to large groupsof readers.

■ World directory of medical schools.Seventh edition. Geneva, World HealthOrganization (available for sale in spring 2000from Department of Marketing and Dissemi-nation, World Health Organization, 1211Geneva 27, Switzerland).

■ Improving the social responsiveness ofmedical schools: Proceedings of the 1998Educational Commission for Foreign MedicalGraduates/World Health OrganizationInvitational Conference, Barcelona,12–14 March 1998. Academic MedicineSupplement, August 1999. Available fromAssociation of American Medical Colleges,2450 N Street, N.W., Washington, DC 20037,USA.

■ Physician funding and health caresystems: an international perspective.Summary of the conference hosted by theWorld Health Organization (WHO), WorldOrganization of Family Doctors (WONCA)and Royal College of General Practitioners(RCGP), 12–13 December 1997, St John’sCollege, Cambridge. London, RCGP, 1999.Available from RCGP, 14 Princes Gate, Hydepark, London, SW7 1PU, UK.

■ Making medical practice and medicaleducation more relevant to people’s needs:The contribution of the family doctor. Reportof the WHO-WONCA (World Organization ofFamily Doctors) conference 6–8 November1994, London, Ontario, Canada. Geneva andHong Kong, 1995, in Chinese, English,Portuguese, Russian and Spanish. Availableon request from Department of Organizationof Health Services Delivery, World HealthOrganization, 1211 Geneva 27, Switzerlandand World Organization of Family Doctors,Locked Bag 11, Collins Street East PostOffice, Melbourne Victoria 80, Australia.


TUFH in FrenchAn international network of francophone institutions and organizations has beencreated with a secretariat based in Moncton, New Brunswick, Canada, with thesupport of the government of Canada and WHO. This network supports the TUFHproject: “Towards Unity for Health” in French is “Vers l’Unité pour la Santé”, andTUFH is VUPS. For more information on this network, its international board andprogramme of activities, please contact Dr Aurel Schofield, Coordonnateur de laFormation médicale francophone du Nouveau-Brunswick and Vice-Doyen Adjointpour le Nouveau-Brunswick, Faculté de Médecine, Université de Sherbrooke, 667rue Champlain, Suite 101, Dieppe, Nouveau-Brunswick, CANADA E1A 1P6(Fax: +1 506 862 4179; E-mail: [email protected]). ■

the world with end-to-end digital connectiv-ity).

The financial sup-port to develop ourprogramme has comemainly from tuitionfees for our trainingactivities. Despitespeeches and good in-tentions, it seems to bedifficult to find fund-

ing for this kind of real and concreteactivity, at least in Finland.

Attitudes of education pro-gramme designers towards thetechnology could be changed bygiving opportunities to use it, to re-lieve any apprehension. However, itis fair to say that study through theInternet and assistance to learnersrequire some adjustments—notfrom an engineering or technicalpoint of view, but rather to encour-age teachers and learners to acceptinteracting through a different me-dium to acquire new knowledgeand skills.

The benefits of high-tech dis-tance education overwhelm theobstacles, particularly in avoidingabsence from the workplace. Thisnew delivery mode offers consider-able flexibility for adaptation to avariety of health professionals’needs. ■

Dr Kekki is Professor and Head, Departmentof General Practice and Primary Health Care,University of Helsinki; Mannerheimintie 172;00300 Helsinki, FINLAND (Telephone: +358 9191 27411; Telephone/Fax: +358 9 19127536; E-mail: [email protected]; URL:www.yle.helsinki.fi).

CATRED (Computer-assisted telematicremote education anddevelopment ofprimary health care)has now become ourroutine.

About 10 of our col-laborating healthcentre organizationsin southern Finlandpurchased desktopequipment, which facilitates vide-oconference with us, either point-to-point or multipoint. Theseconnections are regularly used forvocational training in general prac-tice, as many of our trainees andtrainers are in health centres andhospitals outside Helsinki; for con-tinuing education of health centrepersonnel; and for joint researchand development activities withthe health centres.

In spring 1999 the Department,together with five health centre or-ganizations, started a two-yearquality-development activity onprevention and treatment ofischaemic heart disease. About 50GPs and nurses participate. Thisproject will cover about 1000 pa-tients belonging to risk groups.

Most of the contacts between theDepartment and the health centrestaff take place through video-con-ference. For videoconference weuse both a room system and a desk-top system, and presently ISDN (In-tegrated Services Digital Network,a system of digital telephone con-nections that enables data to betransmitted simultaneously across


PUBLICATIONS

Dear Reader,

Towards Unity For Health: Coordinating Changes in Health Services andHealth Professions Practice and Education is the World Health Organizationnewsletter that succeeds Changing Medical Education and Medical Practice,which was published from June 1992 through December 1998.

This new newsletter reflects an enlarged scope, consistent with WHO’spolicy for developing new alliances and partnerships among educationalinstitutions, health professions, health managers, policy-makers andcommunities to ensure sustainable improvement of quality, equity,relevance and cost-effectiveness in health interventions. Topics relative tohealth professions education and practice will continue to be addressed,along with other issues in health services development and healthsystem changes.

If you wish to continue receiving this newsletter, please complete and returnthe form below:

World Health OrganizationAttention: Mrs. S. Bernasconi, OSD1211 Geneva 27SWITZERLAND

or let us know by fax: +41 22 791 4747 or E-mail: <[email protected]>.Please note that Towards Unity for Health will also be available in both .pdfand text-only formats from the WHO Web site: <http://www.who.int>.

I hope this new WHO newsletter will be as well received as ChangingMedical Education and Medical Practice, and that through topics of sharedinterest, collaborative links will be strengthened worldwide.

Yours sincerely,

Dr Charles BoelenEditor-in-Chief, Towards Unity for Health

Please note: The newsletter Towards Unity for Health will systematically besent to all WHO Representatives, WHO regional offices and WHO collaborat-ing centres and to international NGOs in official relations with WHO. Theserecipients therefore need not confirm their wish to continue receiving thenewsletter. ■

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✁For your urgent attention, please

■ Tuberculosis control and medical schools.Report of a workshop convened by the WorldHealth Organization, 29-31 October 1997,Rome, Italy. Geneva, World Health Organiza-tion, 1998 (unpublished document WHO/TB/98.236; available on request from Departmentof Organization of Health Services Delivery,World Health Organization, 1211 Geneva 27,Switzerland).

■ Pelc I, Cassiers L (eds). La faculté demédecine et le médecin praticien du XXIèmesiècle. Journées d’Etudes internationales.Organisée par l’Organisation mondial de laSanté et la Conférence internationale desDoyens, 9–12 avril 1996, Bruxelles.Bruxelles, Fondation pour l’Etude et laPrévention des Maladies de Civilisation, 1998.

■ Doctors for Health. A WHO global strategyfor changing medical education and medicalpractice for health for all. Geneva, WorldHealth Organization, 1996 (unpublisheddocument WHO/HRH/96.1, in Chinese,English, French and Spanish; available onrequest from Department of Organization ofHealth Services Delivery, World HealthOrganization, 1211 Geneva 27, Switzerland).

■ Boelen C, Heck J. Defining and measuringthe social accountability of medical schools.Geneva, World Health Organization, 1995, inEnglish, French, Spanish (unpublisheddocument WHO/HRH/95.7; available onrequest from Department of Organization ofHealth Services Delivery, World HealthOrganization, 1211 Geneva 27, Switzerland).

■ Towards Unity for Health. Working paper.Geneva, World Health Organization (availablein English and French, and soon in Chineseand Spanish, from Department of Organizationof Health Services Delivery, World HealthOrganization, 1211 Geneva 27, Switzerland).

Coming soon■ Towards Unity for Health. Monograph ofcase studies. Geneva, World Health Organiza-tion (available in 2000 from Department ofOrganization of Health Services Delivery,World Health Organization, 1211 Geneva 27,Switzerland).

■ Blumenthal D, Boelen C, eds. Universitiesand the health of the disadvantaged. Geneva,World Health Organization (unpublisheddocument WHO/EIP/OSD/2000.10; for moreinformation, please contact Mrs M. Palluel,Department of Organization of Health ServicesDelivery, World Health Organization, 1211Geneva 27, Switzerland). ■


INTERNATIONAL NETWORKING

political will and otherrealities. Small stepscan tempt rather thanalienate potential col-laborators.

Considerable effortis expended on devel-oping new organiza-tions to addressmyriad health prob-lems at an interna-tional level. It is expensive to buildsuch organizations and to fund in-ternational meetings to presenttheir findings. Such efforts mayunwittingly duplicate existingprogrammes and innovations.

The problem is that the vastmajority of these programmes andinnovations are not known outsidea particular institution, small com-munity or local circle. How caninternational health organizationsand foundations interested inTUFH goals tap into this vast butoften hidden experience, recognizesynergies and better coordinatetheir efforts?

First, we must realize that singleinstitutions, international initia-tives and NGOs haven’t the re-sources to develop and evaluate allneeded innovations relevant toTUFH goals. Second, while collabo-ration and dissemination of suc-cessful innovations relevant to awide international audience arecritical needs, such collaborationacross organizations and dissemi-nation of successful innovationshave not been prominent compo-nents in the funding of organiza-tional efforts. Thus, the return oninvestment in international organi-zations’ innovations is less than

optimal in improving globalhealth.

Of greater concern, funding

and dissemination ofinnovations relevantto TUFH are in dangerof disproportionatelyfavoring innovatorsfrom industrialized,E n g l i s h - s p e a k i n gcountries whereaccess to fundingstreams, travel oppor-tunities, publication

venues and other vehicles for dis-semination are more readily avail-able.

One strategy for overcomingbarriers to formal collaborationwhile reducing disparities in accessto support and outcomes of rel-evant, global innovations is toestablish a user-friendly, central-ized information clearinghouse.The clearinghouse would collectfrom organizations, institutionsand funded initiatives aspects oftheir innovations relevant to TUFH,such as the following:

● problems addressed● strategies employed● outcomes achieved● materials to be shared with

others (deliverables)● source of funding● contact persons.

How would the innovations becategorized and disseminated? Onepossibility would be the creation ofa taxonomy of innovations basedon such domains as:

● Improving health policies● Improving community health● Improving health services● Improving the educational

process.

Each domain could offer a seriesof health-related elements. For ex-ample, under “Improving commu-

Facilitating information exchange amonginternational health agencies, foundations andlocal initiatives through a common clearinghouseArthur Kaufman, University of New Mexico, Albuquerque

Several years ago, noting the frag-mented state of primary care in

the United States, the U.S. NationalInstitute of Medicine recom-mended the formation of a public/private, non-profit primary careconsortium of professional socie-ties, private foundations, govern-ment agencies, health careorganizations and representativesof the public. The Institute sur-mised that competition betweenstakeholders detracted from thewhole, while coordination offereda more profitable outcome for allparties.

Despite the rationality of thisrecommendation, the goal of anintegrated primary care system inthe United States remains elusive.Issues of turf and competition be-tween professional primary caregroups remain a stumbling block toneeded consortium-building.

“Towards Unity for Health” simi-larly calls for coordination of vari-ous health-related stakeholders,but on a grander scale involving abroader set of stakeholders. It islikely to have greater success thanthe U.S. effort by avoiding the pit-falls of being too prescriptive as tohow collaboration should occur.The development of a roadmap to-wards TUFH goals should grow outof local experience, resources,

Arthur Kaufman


INTERNATIONAL NETWORKING

nity health”, elements might in-clude:

● Basing clinical programmesupon priority communityhealth needs

● Assuring universal access toprimary care

● Increasing literacy rates in thecommunity

● Increasing rates of secondaryschool graduation.

Each organization, foundation,institution or local programme thatsubmitted information and mate-rials to the clearinghouse wouldperiodically update its information.The information could be dissemi-nated by written materials, in local,regional or international work-

shops and over the Internet via aWebsite. Use of the Internet is grow-ing rapidly as a preferred means ofinternational communication. E-mail communication is ofteneasier, quicker and cheaper thanmail, fax or telephone. A TUFHClearinghouse Website is being de-veloped under a collaborative ar-rangement with The Network:Community Partnerships forHealth through Innovative Educa-tion, Service and Research, anongovernmental organization inofficial relations with WHO. Theclearinghouse Website would allowaccess to and dissemination of in-novations relevant to any interestedindividual, community, pro-gramme or organization.

What is now needed is a meansof ensuring that the elements in thetaxonomy are relevant to potentialusers and that the technology re-duces and does not exacerbate dis-parities in accessing informationbetween individuals in industrial-ized versus developing countries.We will soon be field-testing theclearinghouse concept in its vari-ous forms. ■

Dr Kaufman is Professor and Chair, Depart-ment of Family and Community Medicine,University of New Mexico, and SecretaryGeneral of The Network: CommunityPartnerships for Health through InnovativeEducation, Service and Research; 2400Tucker, N.E.; Albuquerque, New Mexico87131, USA (telephone: +505 272 2165;fax +505 272 8045; e-mail:[email protected]).

Basic health servicesWhy we are not making greater progressV.R. Pandurangi, Commonwealth Association for Mental Handicapand Development Disabilities, Sheffield

The new millennium is an idealopportunity not only to lookto the future but also to reflect

on the achievements in health ofthe closing decades of the past mil-lennium. To be sure, there havebeen major gains in health all overthe world: many more people areliving longer, healthier lives, andmany more communities now haveaccess to basic health care. But howgood is this basic health care? Whyis the quality of care so often lack-ing for so many people, and why arewe not making greater progress inthis vital area?

Fragmentation and divisionThe most glaring barrier to progressseems to me to be the persistentfragmentation and division at alllevels of health service delivery: thebarriers between medicine andpublic health, between preventive

and curative services, betweengeneralists and specialists. Morerecently, this is manifest in the di-vide between private and publicsector interests, and between theeconomic and social approach tohealth care. The conflict betweenthese last two approaches can onlybe a barrier to performance of anyhealth care service.

In addition to these critical di-vides in health care, the continuinglack of communication and coop-eration between health personneltraining, health practice and healthresearch at national level only ac-centuates these obstacles.

Poor coordination and cooperationIt is a sad fact that the keystakeholders responsible for pro-viding basic health care simply donot cooperate sufficiently witheach other, each working largely in

isolation. There must be muchcloser partnership between govern-ments, academic institutions,health professional associationsand health providers in the com-munity if any improvement is to bemade in basic health care. Minis-tries of health, education and fi-nance all must work together muchmore closely in countries, with thepriority interests of the communityat heart. There must be much morecommitment to cooperation andless attention paid to individual ter-ritorial interests.

Even at international level, theUnited Nations organizations witha mandate in population andhealth, such as the World HealthOrganization, the United NationsPopulation Fund, UNICEF andeven the World Bank, all must co-operate more closely, seeking toidentify areas where joint activities


and common goals could make areal difference to the health, welfareand development of people.

Failures of the medical professionFrom the beginning, the basic ten-ets of the medical profession wereits ethics, humane values and prin-ciples of humanitarianism. Recentadvances in science and medicaltechnology and in the globalizationand privatization of health carehave meant that commercial inter-ests are now a significant factor,

with a parallel shift from humanevalues and ethical considerations.Costs and financing, instead of thewelfare of the individual and thecommunity, now seem to dominatehealth care policies and practices.

This tendency towards commer-cialization of health care is accen-tuated by the loss of power, prestigeand resources available to the gov-ernment or the public sector, and aparallel rise in the power and influ-ence of commercial or private sec-tor interests. There should not be abottom-line profit motive in healthcare, nor in education or any othersocial service: this can result onlyin a lowering of standards and a lossof equity. Inevitably the poorest inthe community, those who lack theability to pay, will suffer the most.

Shortages of human resourcesfor healthThe growing impact of cost-effec-tive policies and practices in health

QUALITY ASSURANCE IN EDUCATION

services can only have a negativeeffect on the low level of remunera-tion and prestige attached to healthpersonnel working in basic healthcare services all over the world.There is already an acute shortageof trained human resources in pri-mary health care and a persistentshortage of opportunities for high-quality education and re-trainingfor public health workers. How canwe see any significant improve-ment in basic health care in the fu-ture?

Social accountability andunity for healthTo make any kind of progress in thedelivery of basic health care to thecommunity, the key stakeholdersresponsible for health servicesmust accept greater responsibilityfor and accountability to their com-munities. The priority health careneeds of both individuals and soci-ety must remain the focus for ac-tion: how to achieve a balancebetween quality of care and equityof access, while managing overallcost-effectiveness and relevance ofhealth services to the needs of thecommunity.

It is clear that social accountabil-ity must be emphasized as one ofthe basic principles of both healthscience education and health carepractice. Achieving a balance be-tween these diverse elements inhealth care is the only way to bringabout any improvement in basichealth services. There must begreater unity and cooperation be-tween all the players responsible:this means policy-makers, health

managers, health professionals,academic institutions and commu-nities.

The role of nongovernmentalorganizationsNongovernmental organizations,both at country and internationallevel, can play an important role inraising awareness, in promotinginnovative policies and practicesand in bringing the differentstakeholders together. NGOs canplay a vital role in bringing togethergovernment ministries, commu-nity care providers, health trainersand practitioners, as well as keystaff in United Nations agenciessuch as the World Health Organiza-tion and NGOs working close to thegrassroots in countries and com-munities. This is what is meant byUnity for Health.

The Commonwealth Associationfor Mental Handicap and Develop-ment Disabilities (CAMHADD), anNGO in official relations with WHO,will organize jointly with WHO aconsultative workshop on partner-ship towards unity for health inBangalore, India, from 19 to 22 No-vember 2001, with the aim ofachieving greater social account-ability in health. Details of thisworkshop, which is co-sponsoredby the Rajiv Gandhi University ofHealth Sciences in Bangalore andby the Commonwealth Founda-tion, can be obtained from the au-thor. ■

Dr Pandurangi is Founder, Emeritus SecretaryGeneral and International Coordinator ofCAMHADD, 36-A Osberton Place, Sheffield UKS11 8XL (Telephone/Fax: +44 114 2682695).

V.R. Pandurangi

Now on the World Wide Web

Fact sheets on HIV/AIDS for nurses and midwives (WHO document WHO/IP/OSD/2000.5) are now available from the Web: <http://www.who.int/evidence>.

The product of a partnership of the International Council of Nurses, the WorldHealth Organization and the Joint United Nations Programme on HIV/AIDS, thesematerials were designed to be easily adapted to local circumstances. Thoughconceived primarily for nurses and midwives, they will be useful for other healthworkers and for other professionals such as teachers, pharmacists and commu-nity workers. ■


MEDICAL SCHOOL UPDATES

World directory of medical schoolsSupplemental informationWHO received the following in

formation on medical schoolsfrom the governments of its Mem-ber States after the deadline for in-clusion in the seventh edition of theWorld directory of medical schools,published in May 2000:

Cook IslandsInstruction began on 2 September 1999at:

James Cook School of MedicineSouth Seas UniversityRarotongaCook Islands

Costa RicaInstruction began in January 1997 at:

School of Medicine and SurgeryUniversidad HispanoamericanaBarrio Aranjuez100m North and 300m East of the Hos-

pital Calderón GuardiaP.O. Box 408-1002San José

GhanaInstruction began in September 1999 at:

St Luke School of MedicineCape Coast

GuyanaInstruction began in January 2000 at:

American International School ofMedicne

P.O. Box 101728301 Camp StreetCummingsburgGeorgetown

IndiaThe Government of India has asked WHOto list the two following schools:

Patliputra Medical CollegeVinoba Bhave UniversityDhanbadBihar(affiliated to Ranchi University up to

1992)

Jawahar Medical Foundation’s ACPMMedical College

North Maharashtra UniversityDhule

MongoliaInstruction has begun at the followingschools:

Darkhan-Uul Medical CollegeDarkhan

Gobi-Altai Medical CollegeGobi-Altai Aimak

Ulaanbaatar Medical CollegeP.O. Box 188Ulaanbaatar 26

MontserratThe following school no longer operateson Montserrat (information dated 7December 1999):

School of MedicineAmerican University of the CaribbeanPlymouth

Netherlands AntillesInstruction began in April 1999 at:

University of Sint Eustatius School ofMedicine

P.O. Box 73OranjestadSt Eustatius

Instruction began in January 2000 at:Saint James School of MedicineBonaire

Permanent relocation of following medi-cal school (from Montserrat):

School of MedicineAmerican University of the CaribbeanSt Maarten

NiueInstruction began in August 1999 at:

“Lord Liverpool University”George Washington School of Medicine

PakistanThe following school has been provision-ally recognized by the Pakistan Medical andDental Council for a period of two yearsfrom 7 July 1999:

Hamdard College of MedicineNorth NazimabadKarachi

Maharashtra(affiliated to Poona University until No-

vember 1994; has been affiliated toNorth Maharashtra University,Jalgaon, since November 1995 forsecond batch of students academicyear 1991–1992)

Award of MBBS degree recognized byMedical Council of India as from 31 March2000 from:

Government Medical CollegeSaurashtra UniversityRajkotGujarat

Change of name of university: The Univer-sity of Health Sciences, Vijayawada, AndraPradesh, changed its name to NTR Uni-versity of Health Sciences, Vijayawada, asfrom 2 February 1998. This change ofaffiliation applies to the 10 medical schoolsin Andra Pradesh listed on pages 154–56of the seventh edition of the directory.

Due to the change of name of the city ofBombay to Mumbai (Maharashtra), Bom-bay University changed its name to Uni-versity of Mumbai on 4 September 1996.This change of name applies to the sevenmedical schools affiliated to it (pages 167–170 of the seventh edition of the directory).

ItalyInstruction began in 1993 at:

Libera Università Campus Bio-Medicodi Roma

Rome

MalaysiaInstruction has begun at:

Kulliyyah PerubatanUniversiti Islam Antarabangsa Malay-

siaP.O. Box 14125710 KuantanPahang

Micronesia (Federated States of)Instruction began in March 1999 at:

School of MedicinePacific Basin UniversityPohnpei


MEDICAL SCHOOL UPDATES

PhilippinesInstruction has begun at:

College of MedicineUniversity of Northern PhilippinesViganIlocos Sur

Saint Kitts and NevisInstruction began in April 2000 at:

Windsor University Medical SchoolFortlandsBasseterreSaint Kitts

Saint LuciaIn accordance with instructions from theGovernment, the following school wasomitted from the seventh edition (althoughit was listed in the sixth edition). The Gov-ernment subsequently asked WHO to listit again:

School of MedicineSpartan Health Sciences UniversityP.O. Box 324Vieux FortSaint Lucia

SenegalInstruction began on 25 February 2000 at:

St Christopher’s College of MedicineDakar

SeychellesInstruction began on 23 June 2000 at:

University of Seychelles—AmericanInstitute of Medicine

P.O. Box 1103Victoria

TurkeyInstruction began in 1998 at:

Faculty of MedicineBaskent UniversityFevzi çakmak Caddesi10 Solkak N% 45Bahçelievler06490 Ankara

Readers are reminded that WHOhas no authority to grant any formof recognition or accreditation toschools of medicine or other train-ing institutions. Such a procedureremains the exclusive prerogativeof the national government con-cerned. WHO limits itself to pub-lishing information on medicalschools that has been provided orconfirmed by the governments ofits Member States.

The seventh edition of WHO’s

World directory of medical schools(xiv + 441 pages, ISBN 92 4 1500107, WHO order number 1157268)contains information on 1641medical schools in 157 countries.The directory sells for CHF 45.00 orUSD 40.50; the price in developingcountries is CHF 31.50. Addressesof national WHO distributors canbe requested by electronic mailfrom <[email protected]> orcan be found on the WHO pub-lications Web pages: <http://www.who.int/dsa/>.

For information on specific

HACER QUE LA PRATICA MEDICA Y LA EDUCACION MEDICASEAN MAS ADECUADAS A LAS NECESIDADES DE LA GENTE:LA CONTRIBUCION DEL MEDICO DE FAMILIA. EL REPORTEDE PROGRESO DE OMS – WONCA 1995 – 1998 Y EL PLANDE ACCION OMS – WONCA 1998–2001

Traducción de Making medical practice and educationmore relevant to people’s needs: the contribution of thefamily doctor. The WHO – WONCA 1995 – 1998 progressreport and the WHO – WONCA 1998–2001 action plan.La traducción al español de este documento ha sido realizada por la DoctoraMarta Alarcón, MD, Miami, Florida, USA, con la asistencia del Doctor DonWedemeyer, MD, Miami, Florida, USA. El contenido ha sido revisado por elDoctor Wesley Schmidt, MD, Asunción, Paraguay, y el Doctor Warren Heffron,MD, Albuquerque, New Mexico, USA.

Para preguntas sobre la edición traducida al español, favor ponerse encontacto con la Doctora Marta Alarcón o el Doctor Don Wedemeyer por correoelectrónico: [email protected].

This document was translated into Spanish by Marta Alarcón, MD, Miami,Florida, USA, with assistance from Don Wedemeyer, MD, Miami, Florida, USA.The content was reviewed by Wesley Schmidt, MD, Asunción, Paraguay, andWarren Heffron, MD, Albuquerque, New Mexico, USA.

For questions concerning this Spanish translation, please contact Dr MartaAlarcón or Dr Don Wedemeyer by e-mail: [email protected]. ■

schools, please see the followingURLs:

● <http://whqlibdoc.who.int/publications/WDMS/WDMS_A-C.pdf>

● <http://whqlibdoc.who.int/publications/WDMS/WDMS_D-I.pdf>

● <http://whqlibdoc.who.int/publications/WDMS/WDMS_J-P.pdf>

● <http://whqlibdoc.who.int/publications/WDMS/WDMS_R-Z.pdf> ■

Accreditation for social accountability

More and more, health services organizations, educational institutions andthe health professions are being called on to show how they respond to

society’s priority health concerns. The WHO project “Accreditation for SocialAccountability of Medical Schools” is intended to support and promote effortsin this domain. For more information, please contact the TUFH newsletter. ■


■ WHO headquartersWorld Health Organization

1211 Geneva 27, Switzerland(Telegraph: UNISANTE GENEVA;Telex: 415 416;Telephone: +(022) 791 21 11;Fax: +(022) 791 31 11)

■ WHO regional officesWHO Regional Office for Africa

Temporary address:Parirenyatwa Hospital; P.O. BoxBE 773; Harare, Zimbabwe(Telephone: +(001) 407 733 9244;Fax: +(001) 407 726 5062)

WHO Regional Office for the Americas/Pan American Sanitary Bureau

525-23rd Street, N.W.;Washington, D.C. 20037; USA(Telegraph: OFSANPANWASHINGTON;Telex: 248338;Telephone: +(1 202) 974 3000;Fax: +(1 202) 974 3663)

WHO Regional Office for the EasternMediterranean

P.O. Box 1517; Alexandria 21511, Egypt(Telegraph: UNISANTE ALEXANDRIA;Telex: 54028 or 54684;Telephone: +(203) 48 202 23;Fax: +(203) 48 38 916)

WHO Regional Office for Europe8, Scherfigsvej; DK-2100 Copenhagen(Telegraph: UNISANTE COPENHAGEN;Telex: 15348 or 15390;Telephone: +(45) 3917 1717;Fax: +(45) 3917 1818)

WHO Regional Office for South-EastAsia

World Health House; IndraprasthaEstate; Mahatma Gandhi Road; NewDelhi 110002, India(Telegraph: WHO NEW DELHI;Telex: 3165095 or 3165031;Telephone: +(91) 11 331 7804;Fax: +(91) 11 332 7972)

WHO Regional Office for the WesternPacific

P.O. Box 2932; 1099 Manila, Philippines(Telegraph: UNISANTE MANILA;Telex: 27652;Telephone: +(632) 528 8001;Fax: +(632) 521 1036)

■ WHO regional training centreWHO Regional Training Centre forHealth Development

School of Medical Education;University of New South Wales;Sydney 2052, Australia(Telephone: +(612) 9 385 2500;Fax: +(612) 9 385 1526;E-mail: [email protected])

■ WHO collaborating centres inhuman resources development

Centre collaborateur de l’OMS pour laRecherche en matière deDéveloppement des Ressourceshumaines pour la Santé

Faculté des Sciences de la Santé;Université nationale de la République duBénin; B.P. 188; Cotonou, Benin(Telephone: +(229) 300 001;Fax: +(229) 301 288)

WHO Collaborating Centre forEducation and Medical Practice

Faculdade de Medicina; UniversidadeFederal de Minas Gerais; CP 100; BeloHorizonte, Minas Gerais 30.130-100,Brazil (Telephone: +(55 31) 239 7167;Fax: +(55 31) 273 4985)

WHO Collaborating Centre in MedicalEducation and Practice

Centro de Ciências da Saúde;Universidade Estadual de Londrina; Cx.Postal 6001; CEP 86051; Londrina,Paraná, Brazil(Telex: +(55 432) 268;Telephone: +(55 432) 21 2000;Fax: +(55 432) 27 6932)

WHO Collaborating Center for HealthManpower Development

Centre for International Health;McMaster University;1200 Main Street West; Hamilton,Ontario, Canada L8N 3Z5(Telex: 21618347;Telephone: +(1905) 525 9140, ext.22033; Fax: +(1905) 525 1445)

WHO Collaborating Centre for MedicalEducation and Practice

Facultad de Medicina; Universidade dela Frontera; Montt 112 - Casilla 54-D;Temuco, Chile(Telephone: +(56 45) 212108Fax: +(56 45) 212108)

WHO Collaborating Centre forDevelopment of Human Resources forHealth

Faculty of Medicine; Suez CanalUniversity; Ismailia, Egypt(Telex: 63297 scufm un;Telephone: +(20 64) 328 935;Fax: +(20 64) 229 982)

WHO Collaborating Centre for theDevelopment of Human Resources forHealth and for Primary Health Care

Department of General Practice andPrimary Health Care; University ofHelsinki; Mannerheimintie 172; 00300Helsinki, Finland(Telephone: +(3589) 191 27411;Fax: +(3589) 191 27536;E-mail: [email protected];URL: http://www.yle.helsinki.fi)

Centre collaborateur de l’OMS pour leDéveloppement des Ressourceshumaines pour la Santé

Département de Pédagogie desSciences de la Santé; U.F.R. sur laSanté, Médecine et Biologie humaine deBobigny; 74, rue Marcel Cachin; 93012Bobigny CEDEX, France(Telephone: +(3311) 48 38 76 40, ext.224 / (3311) 48 38 76 41;Fax: +(3311) 48 38 77 77)

Centre collaborateur de l’OMS pour leDéveloppement des Ressourceshumaines

Fondation Mérieux, Centre desPensières; 55, avenue d’Annecy;74290 Veyrier-du-Lac, France(Telephone: +(33) 50 64 80 80;Fax: +(33) 50 60 19 71)

WHO Collaborating Centre forEducational Development of Medicaland Health Personnel

Educational Development Centre;Shaheed Beheshti University of MedicalSciences and Health Services; Teheran,Islamic Republic of Iran(Telephone: +(98) 21 293 211;Fax: +(98) 21 294 228)

WHO Collaborating Centre for Problem-based Learning in Health ProfessionsEducation

International Health ManagementCentre; Istituto Superiore di Sanitá;Viale Regina Elena 299; I-00161 Rome;Italy(Telephone: +(396) 4938 7294;Fax: +(396) 4938 7295)

WHO Collaborating Centre for Trainingof Health Professionals

Department of Training in Public Healthand Bioethics; Istituto Superiore diStudi Sanitari, Largo del l’Artide 11,Rome, Italy-00144

WHO Collaborating Centre for Problem-Based/Problem-Solving Approaches toEducation and Practice in Public Health

Faculty of Health Sciences;Moi University; PO Box 4606;Eldoret 0321, Kenya(Telex: moivarsity 35047;Telephone: +(254 321) 33059, 32781/2/3; Fax: +(254 321) 33041)

Centro Colaborador de la OrganizacionMundial de la Salud para la Formaciónde Recursos Humanos

Facultad de Medicina; UniversidadNacional Autónoma de México; Edificio“B” Primer Piso; Apartado Postal 70-443; México, DF 04510, Mexico(Telephone: +(52 5) 616 1162;623 2401/2402;Fax: +(52 5) 616 1616;E-mail: [email protected])

ADDRESSES


WHO Collaborating Centre for HealthManpower Development

Office for International Relations;Faculty of Medicine; RijksuniversiteitLimburg; Postbus 616; 6200 MDMaastricht, Netherlands(Telex: 56880 fg rl nl;Telephone: +(3143) 881 520;Fax: +(3143) 670 708)

WHO Collaborating Centre for Researchin Health Manpower Development;Community-Based Educational Systems(COBES) Programme

Faculty of Health Sciences; University ofIlorin; PMB 1515; Ilorin, Nigeria(Telex: 33144 unilon ng;Telephone: +(23431) 221 844)

WHO Collaborating Centre for Researchand Training in EducationalDevelopment of Health Personnel

Department of Medical Education(DME), College of Physicians andSurgeons, 7th Central Street, DefenceHousing Authority, Karachi 75500,Pakistan(Telephone: +(92 21) 588 7111/588 3285; Fax: +(92 21) 589 3062)

WHO Collaborating Centre for Qualityof Care

Medical University of Southern Africa,Box 203 Medunsa 0204,Republic of South Africa(Telex: 32 0580 sa;Telephone: +(27 12) 529 4669;Fax: +(27 12) 560 0274)

WHO Collaborating Centre for HealthCare Professionals Development

Institut d'Estudis de la Salut; Balmes132–136; 08010 Barcelona; Spain(Telephone: +(3493) 238 6900;Fax: +(3493) 238 6910;E-mail: [email protected];Web: http://www.iesalut.es)

WHO Collaborating Centre for Researchand Training in EducationalDevelopment

Educational Development Centre;Faculty of Medicine; University ofGezira; P.O. Box 20; Wad Medani;Sudan

WHO Collaborating Centre for MedicalEducation

Faculty of Medicine; ChulalongkornUniversity; Rama IV Road; Bangkok10330; Thailand(Telephone: +(662) 252 7859;Fax: +(662) 254 1931)

Centre collaborateur de l’OMS pour laRecherche et la Formation en matièrede Développement de la Formation desPersonnels de Santé

Centre National de Formation

ADDRESSES

Pédagogique des Cadres de la Santé;67, boulevard Hedi Saidi; Bab Saadoun;Tunis 1005, Tunisia

WHO Collaborating Centre for PrimaryHealth Care/Public Health Education

School of Public Health; Loma LindaUniversity; Loma Linda 92350;California; USA

WHO Collaborating Centre for Leader-ship Development for Health for All

School of Public Health; University ofHawaii; 1960 East-West Road;Honolulu; Hawaii 96822; USA(Telephone: +(1808) 956 7486;Fax: +(1808) 956 5286)

WHO Collaborating Centre forEducational Development of HealthProfessionals and Health Care Systems

Department of Medical Education(M/C 591); University of Illinois Collegeof Medicine at Chicago; Box 6998;Chicago, Illinois 60680, USA(Telephone: +(1312) 996 3590;Fax: +(1312) 413 2048)

WHO Collaborating Centre forEducational Development of HealthProfessionals and Health Care Systems

University of Illinois College of Medicineat Rockford; 1601 Parkview Avenue;Rockford, Illinois 61107-1897, USA(Telephone: +(1815) 395 5600;Fax: +(1815) 395 5887;E-mail: [email protected] [email protected])

WHO Collaborating Centre forPostgraduate Public Health Educationand Research

School of Hygiene and Public Health;Johns Hopkins University;615 North Wolfe Street; Baltimore,Maryland 21205-2179, USA(Telephone: +(1410) 955 3540;Fax: +(1410) 955 0121)

WHO Collaborating Centre for theDissemination of Community-oriented,Problem-based Learning

Primary Care Curriculum; SocialMedicine Program; Department ofFamily and Community Medicine;School of Medicine; University of NewMexico; 2400 Tucker Avenue, NE;Albuquerque; New Mexico 87131-5241,USA(Telex: 660 461;Telephone: +(1505) 277 2165;Fax: +(1505) 277 0657)

WHO Collaborating Centre forInternational Health

University of Texas Medical Branch atGalveston; 1.142 Bethel Hall; 301University Boulevard; Galveston, Texas

77555-0862, USA(Telex: 765603;Telephone: +(1409) 772 0870;Fax: +(1409) 772 0875)

■ Nongovernmental organizationsin official relations with WHO ineducational development

Conférence internationale des Doyensdes Facultés de Médecine d’Expressionfrançaise

(Monsieur le Professeur Pierre Farah,Président); Doyen de la Faculté deMédecine; Université St.-Joseph; B.P.11-5076, Beirut, Lebanon (Telephone:+(961) 1 614 004; Fax: +(961) 1 614054; E-mail: [email protected])

International Federation of MedicalStudents’ Associations

IFMSA General Secretariat; c/o WorldMedical Association; B.P. 63; 01212Ferney-Voltaire, France (Telephone: +33450 40 4759; Fax: +33 450 40 5937;E-mail: [email protected]; URL: http://www.ifmsa.org)

The Network: Community Partnershipsfor Health through InnovativeEducation, Service and Research

(Coordinating Secretary:Mrs P. Vluggen); P.O. Box 616; NL-6200 MD Maastricht (Telex: 56880;(Telephone: +(31 43) 388 1522/1524;Fax: +(31 43) 367 0708;E-mail: [email protected] Wide Web: http://www.unimaas.nl/~network/welcome.htm)

World Federation for Medical Education(Dr Hans Karle, President);Faculty of Health Sciences;University of Copenhagen;The Panum Institute; Blegdamsvej 3;2200 Copenhagen N, Denmark(Telephone: +(45) 35 32 70 68;Fax: +(45) 32 32 70 70;E-mail: [email protected])

World Medical AssociationDr Delon Human, Chief ExecutiveOfficer, WMA Secretariat; B.P. 63;01212 Ferney-Voltaire, France(Telephone: +33 450 40 7575; Fax: +33450 40 5937; E-mail: [email protected])

World Organization of Family Doctors(WONCA)

(Dr W.E. Fabb, Chief Executive Officer);World Organization of Family Doctors;Locked Bag 11; Collins Street East PostOffice; Melbourne Victoria 8003,AUSTRALIA(Telephone: +(61) 3 9650 0235;Fax: +(61) 3 9650 0236;E-mail: [email protected])

Towards UnityFor HealthThe newsletter Towards Unity for Health isissued in April and October by the WorldHealth Organization, Geneva, Switzerland. Itaims to provide a forum for reflection oninitiatives worldwide to foster coordinatedchanges in health services organization andhealth professions practice and education. Itis also intended to help create a climate ofsolidarity among health authorities,academics, health professionals andrepresentatives of the community toencourage more appropriate approaches topursuing relevance, quality, cost-effectiveness and equity in health services.

© World Health Organization, October 2000

This document is not a formal publication ofthe World Health Organization (WHO), andall rights are reserved by the Organization.The document may, however, be freelyreviewed, abstracted, reproduced ortranslated, in part or in whole, but not forsale or for use in conjunction withcommercial purposes.

The views expressed in documents bynamed authors are solely the responsibilityof those authors.

The designations employed and thepresentation of material on maps in thisdocument do not imply the expression ofany opinion whatsoever on the part of theWorld Health Organization concerning thelegal status of any country, territory, city orarea or of its authorities, or concerning thedelimitation of its frontiers or boundaries.Dotted lines represent approximate borderlines for which there may not yet be fullagreement.

Comments are invited from individuals andinstitutions interested in health systemsdevelopment and health services delivery.Contributions of short articles (less than 800words long) are particularly welcome. Pleaseaddress comments and contributions to:

Dr Charles Boelen,Department of Organization of HealthServices Delivery (OSD);World Health Organization,1211 Geneva 27, SWITZERLAND(telephone: +41 22 791 2510;fax: +41 22 791 4747;e-mail: [email protected]).

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