In1977, the Thirtieth World Health Assembly (WHA) adapted the revolutionary Health for All (HFA) strategy. The members of the WHA decided that the main social target of Governments and the World Health Organisation (WHO) in the coming decades should be, “to achieve a more equitable distribution of health resources and the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life” (WHA, 1977). Thereafter in 1978, a joint WHO-UNICEF conference in Alma-Ata, Kazakhstan took place, where Ministers of Health from throughout the world agreed on a major statement and declared Primary Health Care (PHC) as the key to attaining this target (WHO, 1978).
The call for HFA was, and remains fundamentally, a call for social justice, universal access and intersectorial action. As Green (1994, p. 7) points out, “health is viewed by some as a right, analogous to justice or political freedom”. At the time of the Alma- Ata declaration, Bennett (1979, p. 513 quoted in MacPherson, 1982, p. 111) expressed a very optimistic view as he stated, “primary health care is the outcome of collective human conscience – a recent awareness that there has been inequality in the distribution of health which is a human right”.
Two decades after the Alma-Ata declaration, the implementation of PHC strategies in less developed countries (LDCs) has come far short of the set target. Today, WHO (1997a, p. 6) acknowledges that, “Millions of people still do not have access to certain elements of primary health care and, in many places, effective primary health care services do not exist. While health infrastructure has physically expanded in the past
20 years, actual provision of care has been limited…”.
Why do millions of people still lack access to certain elements of primary health care?
The answer lies in the fact that HFA strategies are collectivist ideals, whereas health policies in less developed countries are influenced by an anti-collectivist world climate. Multinational companies, the World Bank, the World Health Organisation and donor agencies have had considerable effect on health policies all over the world. Especially in less developed countries, through their political power and control of external funds, foreign donors have a clear influence over policy decisions (Green, 1994; Walt, 1996 and Koivusalo & Ollila, 1997). However, we also have to recognise that policy adoption or transfer under pressure from aid agencies, such as the World Bank, often reflects surface imitation and very little real commitment. For example, Cook and Kirkpatrick (1988) argue that in developing countries, policy measure to adapt the market-based approaches often simply reflect the policy-maker’s judgement as to the token measures needed to ensure the inflow of foreign assistance.
In the late 1970s and early 1980s, at the time of the adaptation of the HFA strategy, Keynesian-welfarist ideologies shifted towards Anti-collectivist ideas. Furthermore, the long boom of the post-war period ended in a global recession and less foreign aid money was available. At the same time, the World Bank decided to begin direct lending for health services. This move was justified on the grounds that the Bank could provide valuable support to health policy development and get the opportunity for dialogue on population issues (World Bank, 1980). As Koivusalo & Ollila (1997, p. 114) argue, “the HFA initiative and the Alma-Ata declaration were to suffer, right from the
beginning, from lack of resources and from competing viewpoints on health policies”.
The Situation of Primary Health Care (PHC) Laboratory Services
Why do laboratory services belong to the “certain elements of primary health care” to which millions of people still do not have access?
In 1976, the World Health Assembly adapted resolution 29.74 requesting WHO to develop a programme of health technology relating to primary health care and rural development as part of the overall primary health care programme (WHA, 1976). This effort was further strengthened in 1979 by the resolution 32.16 (WHA, 1979). This resolution urged member-states to give due attention to the development of health laboratory technology for the use in health laboratories in less developed countries, particularly in support of PHC.
Following these resolutions, WHO prepared a standard manual of basic techniques for a health laboratory geared towards the needs of PHC laboratories in LDCs (WHO, 1980). Furthermore, WHO expanded and increased its technical support to less developed countries to establish and strengthen PHC laboratory services at the various levels of the health care system. By the mid 1980s some countries such as Indonesia, Malaysia, Nepal, Morocco, Sudan, Kenya and Cameroon, established health laboratories in peripheral health centres.
Today, in the majority of less developed countries, laboratory services at the intermediate and peripheral level are limited, poorly managed and lack qualified personnel. Three main reasons for this development may be pointed out:
First, there is generally an urban bias in the resources distribution in developing
countries. The urban bias applies to both facilities and health manpower. For example, the 1998 World Health Report states that, “in Africa, many countries made the development of infrastructure the focus of their health policy, but ……hospitals continue to consume the largest share of the health budget, sometimes at the expense of health centres” (WHO, 1998, p. 150).
Second, shortly after the Alma Ata conference, international health policies shifted from the comprehensive PHC approach, to a more selective approach with emphasis on disease-oriented programmes (Koivusalo & Ollila, 1997, Vaughan et al., 1995). The disease-oriented programmes were seen by some as more cost-effective, as quantitative success indicators were more readily available. This selective approach still prevails today, e.g., sexually transmitted diseases (STD) and tuberculosis.
Third, a tendency to allocate limited resources to sectors where professional pressure is strongest, i.e., doctors and nurses; and where needs are perceived most pressing, i.e., mother and child health (MCH) and population control programmes.
To support the above statements further, I (the author) would like to give the example of Jordan. Through World Bank provided loans, Jordan has an excellent coverage of health centres all over the Kingdom. During inspection visits to more than
24 health centres, mainly in the Karak and East Amman region, I (the author) (Mallapaty, 1996) observed that:
- Laboratory facilities and equipment were available at all health centres;
- Many laboratories were understaffed;
- Laboratory personnel lacked basic skills;
- Work processes were not documented; and
- Supply management was flaw.
Similar observations were made in the African Medical and Research Foundation’s (AMREF) laboratory programme in Kenya. Carter (1992) states that there was clearly a need to provide more intensive refresher training in basic techniques to laboratory staff. In an effort to ensure equitable access to comprehensive, quality health care, basic and reliable diagnostic laboratory services must be included at all levels. Failure to do so will hamper the attainment of several of the original eight primary health care goals.
- Appropriate treatment of common diseases;
- Prevention and control of locally endemic diseases;
- Maternal and child health;
- Identifying, preventing and controlling of prevailing health
When taking into account the poor prospects of growth in health sector resources, high population growth rates and new health problems, governments have to reassess their resources allocation and health planning strategies to meet the needs of the entire population, and especially the disadvantaged segments of the population. New and innovative approaches to health care management are needed to meet the challenges of the 21st Century.
The new concept of essential public health functions (EPHFs) is one major component for developing sustainable health care systems. Public health functions are considered essential if they are cost-effective and vital for maintaining and improving health.
According to the HFA policy paper, countries at all levels of development should be encouraged and supported to provide these public health services to at least a minimum standard (WHO, 1997a).
Public health laboratory services were identified as an essential public health function (WHO, 1997b). In a recent article about WHO’s laboratory programme, Dr. Heuck (1998) highlights WHO’s achievement and regional efforts, especially in the quality assurance programme. Programmes complimented by training on laboratory management, reagent production, equipment maintenance and good laboratory practice. He points out that modern laboratory technology is costly, requires high technical skills and is almost solely produced in industrialised countries and sees this as a hindrance of technology transfer to developing countries. Heuck (1998, p. 70) further notes, “This partially explains the relatively slow evolution of laboratory services in most of the developing countries”.
While I (the author) agree with Dr. Heuck’s assessment of the current situation concerning modern laboratory technology, I believe, a more holistic, technical support for laboratory services in developing countries is required, besides better information exchange on technology production. World health advocates need to provide leadership and guide national health authorities towards an organisation-wide approach to quality transformation.
Since the early 1980s, the most enduring management theory in the industrialised countries has been total quality management (TQM). TQM does not limit itself to standard setting and quality control only; it is concerned with all aspects of the organisational management, concentrating on the processes as well as the product and
making user satisfaction a priority. As Johnson (1993) points out, while TQM is a top- down approach, it makes “customer satisfaction” its top priority and incorporates the philosophy of “kaizen”, continuous improvement.
How can this business-oriented approach be applied to the public health sector in less developed countries?
The key to success in TQM is leadership and clear commitment from the top. Dr. Edward Deming, one of the quality gurus has developed 14 points that highlight what is necessary for businesses to prosper and be competitive (Deming, 1990). Johnson (1993) gives an updated version that highlights leadership and training as requirements for the quality revolution and points out that Deming’s statements can be applied to any organisation.