HEALTH FOR ALL 2000
1. TRENDS IN POLICY DEVELOPMENT
The political structure has shown no significant change since the last evaluation. Jamaica is currently debating its constitution with involvement of the society at all levels. Since the second evaluation, the policies and political principles have been positively influenced through a reinforced commitment to the development of local health systems. The Ministry of Health has established a reform unit to oversee the implementation of the policies.
The economic situation, coupled with the shortage of skilled manpower, presents the main constraint to the improvement of policy development strategies for health for all. Policies related to the primary care rationalization have been considered and implemented to review the strategy for health for all. The rationalization seeks to restore credibility with emphasis on community participation and improved quality assurance programs.
It is significant that a government entity, the Bureau of Women’s Affairs (BWA), exists with responsibility for establishing a policy that has defined the need for women’s participation in development in addition to identifying the inequities affecting their status. In addition to BWA, there are non-government organizations that promote the subject of women in development and facilitate the process through lobbying and implementing projects. The Association of Women’s Organizations in Jamaica, (AWOJA) is the umbrella organization seeking the incorporation of gender in program planning by policy makers to ensure that women’s needs are addressed.
SECTION 2. TRENDS IN SOCIO-ECONOMIC DEVELOPMENT
2.1 Economic Trends
The Gross Domestic Product per capita was US$1,350 in 1994, while the growth of the economy averaged less than 1% (0.65%) per annum in 1994 and 1995. In 1995, using US$570 per year as cut-off, the World Bank quoted the poverty rate at 30% of the population, the rate being 70% in rural areas. There are no barriers to public health services as the country has a network of health centers and hospitals and payment barriers do not exist. Women have access to education and job opportunities, but the majority of the poor are women and children. Unemployment was around 16% in 1995, while in 1995, the unemployment rate was 10.8 for males and 27.5 for females.
2.2 Demographic trends
The population in Jamaica was near 2.5 million in 1995. The annual growth rate was 0.1-1.3% between 1985 and 1995, fluctuations being mainly due to migration. Total fertility rates, birth and death rates have remained constant, being 3.0 children per women and 23.2 births and 5.2 deaths per 1,000 population, respectively. Population structure changed little over the past 10 years, the pyramid still showing a large base. However, the trends are of decreasing proportion of those under 25 year age group, increases in the working age group (15 - 64 years) and increases in the elderly population. In 1982, 52.2% of the population was rural; by 1991, 50.4% was rural.
2.3 Social trends
Adult literacy rate was 75.7 in 1994; however, 31% of men are illiterate compared to 19% of women. The male/female enrollment is more or less evenly distributed at the pre-school and primary school. At the university, 63% of students enrolled are women.
2.4 Food supply and nutritional status.
Food supply increased over the past ten years. Per capita availability of energy also increased by approximately 100 kcal per day, mostly from increased fat. However, it is estimated that 30% of the population is nutritionally 'at-risk'. Assessment of mal-nutrition is determined from community surveys and monitoring of children 0-35 months attending health centers. Data from 1996 indicates that, although the situation had improved since 1993, 10.6% of children were born weighing less than 2,5000 g and 6.1%, 6.9% and 4.0% were 2 standard deviations below the median values of weight for age, height for age and weight for height. Anemia in pregnancy is monitored at government antenatal clinics. Approximately 15% of first visit antenatal women had hemoglobin levels less than 10g/100ml in 1996. Iodine deficiency disorders are not seen.
Malnutrition is controlled with specific food supplementation and broad-based food stamp programs. In 1994, the government launched the Baby-Friendly Hospital program aimed at increasing the prevalence of full breast-feeding. The prevalence among infants attending post-natal clinics was 50.4% in 1993 and 53.6% in 1996. Iron supplementation of pregnant women is no longer done due to affordability. The government is negotiating with local producers of cornmeal for iron fortification of that product. Jamaica has had a long history of salt iodination.
The epidemiological profile of the population has a relationship with its lifestyle, particularly in the urban population. It is not known what effect would the increased availability of processed foods have on nutritional status but the proportion of energy obtained from fat is on increase. The rate of teenage pregnancy declined, but the absolute numbers increased. A large share of disease is due to intentional and unintentional injuries, violence being at epidemic proportions with approximately 1,000 murders in 1996. Hypertension and diabetes account for a great share of the morbidity and mortality, in particular among smokers. A survey showed that 51% of people used tobacco in the previous month. In 1993, 79% of men and 41% of women reported drinking alcohol. Its consumption was identified as a factor in the increasing incidence of traffic accidents. Also in 1993, a lifestyle survey found that 37% of men and 10% of women aged 15-49 years had smoked marijuana. Cocaine was reportedly used by 2% of males and by less than 1% of women.
Specific projects aimed at lifestyle awareness and promotion of physical activity were developed in schools. There also seems to be a greater awareness and use of contraceptives, much of it resulting from promotion of condoms to reduce to risk of HIV infection. Regarding smoking, the Ministry of Health began to move aggressively by firstly declaring a no smoking policy in all its buildings. With regards to alcohol, the government introduced the breathalyzer in 1996, resulting in a significant number of arrests for driving under its influence.
3. HEALTH AND ENVIRONMENT
3.1 General protection of the environment
The Government established the National Resources Conservation Authority (NRCA) as the agency with responsibility for environmental management. Environment and Health policies are administered through this and the Environmental Control Division of the Ministry of Health. The Ministry of Health is responsible for developing policies, criteria, and guidelines related to policy development, planning and legislation formulation, environmental health information, risk assessment, pollution prevention and control, solid and hazardous waste management, water and waste water monitoring, food safety and hygiene and occupational health.
A review of studies conducted on the effects of air pollution in Jamaica formed the basis of draft interim ambient air quality standards. The outcome of analyses by the Environmental Control Division (ECD) of water quality data for each parish, was a decision to use appropriate technology for disinfection of water supply systems.
Due to inadequate treatment of waste, high concentrations of nutrients, including nitrates, have been detected in coastal waters, increasing stress on the marine environment. To remedy this problem, the National Water Commission has included sewage collection and treatment projects in its investment program, including projects in Kingston, Montego Bay, Ocho Rios and Negril.
Improper sewage treatment and disposal is the main contributor to pollution of Kingston Harbor and clearly it would mean that the infrastructure for sewage disposal needs improvement. There is a program design underway for clean-up of the Harbor, funded by the World Bank, International Development Agency and United Nations Environmental Program.
The problems associated with food protection include an insufficient national commitment; lack of coordination among the responsible agencies; deficiencies in the laws and regulations; problems of infrastructure; lack of information; limited participation in the preparation of international food standards (Codex Alimentarius) and difficulty in the acceptance and application thereof. To respond to these issues, PAHO provided support to strengthening and promoting improved operation of the networks of food-quality control laboratories, inspection services, epidemiological surveillance of food borne diseases and food legislation. The adoption of the Hazard Analysis Critical Control Points (HACCP) system is a rational and effective approach to food protection and is used as a supplement to current inspection procedures and quality control programs in the food industry.
3.2 Water Supply and Sanitation
There are 902 formal water supply systems producing an estimated 140 mgd. Over 80% of the population has access to piped water supply, while 12% receives untreated water of questionable quality and 7% do not receive water from the public supply network. While water from major supplies is chlorinated, some of the minor supplies distribute untreated water.
Waste water management consists of community systems present in the main urban centers, with 21% of the population being served by a sewerage system, 28% by individual septic tanks s, 50% use pit latrines and 1% has no sanitary facilities at their disposal. No sewerage systems exist in rural areas. There are 109 wastewater treatment plants. Due to inadequate treatment, wastes from the sewerage system and collections from cesspools are disposed of largely untreated.
As much as 50% of the solid waste generated in the country is attributed to the Kingston Metropolitan Area (KMA). Approximately 80% of the total waste is collected by private companies wholly owned by the government. The quality of their service has been deteriorating because of budgetary constraints. Special wastes such as medical waste, tires and hazardous wastes pose particular problems. The present system of incinerators for medical waste appears plagued by poor design, poor operation and inadequate and irregular maintenance. The implications for waste handlers and resource recovery systems are serious.
4. HEALTH RESOURCES
4.1 Human resources for health
There is a serious shortage and imbalance in the supply of trained health personnel for service in the private and public health systems. Vacancies include 68% of pharmacists, 30% of pharmacy technician; 60% of medical technologists; 45% of public health inspectors; 41% of registered nurses; 51% of registered midwifes; and, 39% of public health nurses. In 1994 the number of posts occupied represented only 68% of the cadre and a ratio of 1.5 per 10,000 population. Shifts in demography, epidemiology and health service organization have created the need for new categories of health workers; while at the same time, there is also a need for the rationalization and harmonization of training programs. A greater emphasis needs to be placed on the integration of health center and hospital care services and the introduction of new care and managerial modalities that will allow for better utilization of health personnel.
Curricula for the training of health professionals at the basic and higher levels were revised in the early 1970's to reflect the principles of primary health care. In-service education programs were provided to upgrade staff, and new categories were introduced such as the Family Nurse Practitioner, Mental Health Officer, Dental Nurse, Dental Auxiliary, Community Health Aides.
4.2 Financial Resources for Health
Government support for health services has been relatively consistent, with real per capita expenditure on health of US $25 for at least the past 5 years. The MOH is one of the better-financed public agencies in the government with 6.5% of the GDP. However, to achieve targets for health services delivery, it needs additional resources. A large part of the reform process entails the creation of alternative financing sources. Insufficient information exists on the private sector as there is little government control or regulation over it. In dissecting components of the national health expenditure, the largest elements are ambulatory care (70%), hospital care (20%) and drugs (10%). Health care expenditures are composed of private out-of-pocket (55%), public funds (32%), health insurance (8%) and other, including overseas funds (5%). Government appears highly dependent on external aid with regard to development of health services system.
4.3 Physical infrastructure
With economic difficulties and the introduction of structural adjustment there was a deterioration of physical infrastructure that impacted negatively on the delivery of care. The Government is investing approximately US$150 M to address this problem. The Ministry of Health also established a Maintenance Unit, improved the skills of technicians and repaired more than 70% of the non- functioning equipment. An information system has been put in place to support management of the unit. The Quality Assurance Committee and the senior directorate of the Ministry has the responsibility to manage the process of selection of technology.
The constraints faced are availability of resources to respond to the total need. Additionally, the issue of a policy on maintenance and its implementation is a priority.
4.4 Essential drugs and other supplies
The government has policies aimed at ensuring appropriateness of drug procurement and use. It developed a VEN (vital, essential & necessary) list of drugs, using international non-proprietary names, that is mandatory for procurement and use in the health services. Drug financing covers approximately 65-70% of demand, with fee collections covering the rest. There are adequate systems and procedures to monitor drug quality. The provision for essential drugs improved so that health facilities have adequate supplies of drugs. Remote facilities may be inadequately supplied because of other constraints such as staffing and transportation deficiencies. Other measures to improve drug availability include the removal of tax (15%) from over the counter drugs and of the common external tariff (15%) from drugs not produced in the CARICOM region in 1994. Tendering, procurement and distribution were all placed under the umbrella of the newly formed company, Health Corporation Limited (HCL), set up specifically to streamline these processes. The government also introduced the Drug for the Elderly Program that allows access to items for elderly with specific diseases namely, diabetes, hypertension, asthma, arthritis, and glaucoma, through both public and private pharmacies at highly subsidized prices. Vaccine supplies are adequate and are procured with assistance from the PAHO revolving fund.
4.5 International partnership for health
The bilateral and multilateral agencies established a framework that affords the agencies working in health to collaborate in focusing on various aspects of health. Additionally, this mechanism permits a more rational approach with the involvement of the Non Government Organizations. The constraint, however, is shown to be the diverse planning cycles that operate within this environment. Notwithstanding these differences, the international community has reinforced the importance of primary health care and with support for the poverty eradication program in which health is a major issue in seeking to attain some degree of equity. Most of the bilateral support has been directed towards institutional strengthening and programs for HIV/AIDS.
5. DEVELOPMENT OF THE HEALTH SYSTEM
5.1 Health policies and strategies
The health sector policy and plan exist to guide the activities of the Ministry of Health. The policies address the need for changing values, attitudes and practices; reforming the health sector; health promotion and illness prevention; environmental protection and promotion of sustainable development; and, access to diagnostic, curative and rehabilitative care. The strategies include health promotion; primary health care; community participation; intersectoral collaboration; and, decentralization.
5.2 Intersectoral cooperation
The organization of Government at the local level lends itself to intersectoral cooperation; however, the centralization of authority had precluded the establishment of any institutionalized mechanism to support cooperation. Through the reform of the health sector decentralization is a major appropriate mechanism by which cooperation would be more effective. The renewed focus on strengthening local government provides an opportunity for intersectoral cooperation.
5.3. Organization of the health system
The government began developing its primary health care system in the early 1970's. As a result it was able to deliver preventive and basic curative health care to approximately 95% of the population, thereby reducing the incidence and/or prevalence of most communicable diseases. However, organization of the health system was still highly centralized and this negatively affected efficiency of the local health center facilities. In the mid-eighties, rationalization began to reduce the number of hospitals and improve the efficiency of those remaining. Some hospitals offering the basic inpatient services were rationalized to provide mainly outpatient and maternity services. Yet, bed occupancy of 57% (1996) at the remaining hospitals of similar type, reflects under-utilization and inefficiencies at that level of care. On the other hand, those hospitals offering a higher level of service have recorded much higher levels in bed occupancy (approx.80%) as they struggle to deliver optimal health care in the face of chronic nursing staff shortages and inadequate infrastructure and equipment.
5.4 Managerial Process
Significant changes in the managerial process are the recruitment of CEOs for major hospitals, improvement in cost recovery for hospital services and the widespread execution of a variety of management training programs to strengthen management capacity for decentralization. Technical assistance is being given to the Ministry of Health in several areas under the broad objective of health sector reform. This includes decentralization, policy formulation, quality assurance, alternative financing, management information systems, facilities maintenance, legislative development and legal framework. The head office will function more in a regulatory capacity for the entire health sector, public and private, and more management responsibilities for public services will be given to four regional authorities, parish level and institutional managers. It is hoped that decentralization will lead to greater community involvement with regard to the development, management and sustained use of public services.
5.5 Health information system
Currently, the Health information system includes (a) epidemiological surveillance with special emphasis on notifiable diseases and diseases of national interest; (b) health center information system that reports health status and health center activities mainly in the areas of maternal and child health, family planning and curative services; and (c) hospital information system that reports hospital activities and utilization in terms of management of diseases and injuries, and mortality. Information is used for program planning and to monitor progress A problem is the lack of linkages between the information systems and lack of information about the environment.
5.6 Community action
The government understands the benefit from community action in health and established mechanisms to effect them. Community health aides have been employed and are responsible for health education and monitoring of health status in communities. In addition, intersectoral committees were formed to identify health needs and meet these needs accordingly. These are non-governmental but the government has representation on them. These committees implement income-generating activities, thereby assisting in development. The training of community leaders is crucial to the continuity of these health committees.
5.7 Emergency Preparedness
There have been no significant changes with regard to natural and man-made disasters. The last natural disaster in Jamaica was Hurricane Gilbert in 1988. However, there is a well developed and organized emergency and disaster preparedness, response and mitigation program. The Ministry of Health, Division of Emergency Medical Services, and the Office of Disaster Preparedness and Emergency Management (ODP), a statutory body, are largely responsible for leading disaster mitigation, preparedness and response activities. Organizations, committees, plans and simulation exercises are well managed and coordinated.
With PAHO support, the University of West Indies public health program provides training in disaster management and the Geology department conducts research and education. Community-based disaster coordinators are active in the country, as are private voluntary organizations. Schools of engineering and architecture, and the building industry, will incorporate disaster mitigation into their disciplines. Public education programs on disaster are being developed.
6. HEALTH SERVICES
6.1 Health education and promotion
The Health Promotion Charter for the Caribbean is the framework for health education and promotion strategies. Strategies consider that people depend on actions taken by individuals and communities to modify crucial ecological and behavioral factors and to provide efficient and effective systems of health care. They include: formulating healthy public policy; reorienting services; empowering communities to achieve well-being; creating supportive environments; developing personal health skills; and, building alliances with special emphasis on the media.
The Ministry of Health is committed to the concept of health promotion and the prevention of illness. Its objective is to empower individuals to take responsibility for their own health, that of their family and the community. The strategies are to: coordinate activities and cooperate with interest groups in promoting healthy lifestyle; implement counseling services for developing wholesome healthy habits; use innovative, culturally acceptable approaches in promotional programs; and, revitalize/establish health committees to foster community participation.
Health education focuses on family life, nutrition, sexuality, general safety, conflict resolution, environmental protection, STD/HIV prevention. The Bureau of Health Education is the unit within the Ministry of Health, responsible for health education and promotion in terms of planning, implementing, evaluating and coordinating health education and participation programs in the country. However, under the Health Sector Reform, the Bureau will form part of the Division of Disease Prevention and Health Promotion.
6.2 Maternal and Child Health/Family Planning (family and reproductive health).
Studies showed that 27-40% of women had an illness during pregnancy, delivery or puerperium, their causes being STD, hypertension, eclampsia and postpartum hemorrhage. Complications of pregnancy are the leading causes of admissions to public hospitals. Public health facilities provide care for most pregnant women. In 1996, two-thirds of women were attended by trained personnel at public facilities, with 21.5% of the visits during the first trimester of pregnancy. Private sector provides 60% of ambulatory health care. However, over 90% of deliveries were attended by public sector health personnel. The level of teenage pregnancy is at 24.6%.
In the public services, 69.5% of the postnatal women accepted a family planning method in 1996 and 6.9% of the total population of women of childbearing age were new acceptors. The 1993 contraceptive prevalence survey estimated contraceptive use at 48% of women in childbearing age. There is high, but irregular condom use, which is promoted for STD/HIV prevention.
Training of staff in ORT, refresher courses for midwives; increased number of schools with child health education; partnership with the private sector in family planning; updates for nursery and basic school teachers in CDD/ARI, immunization and breast-feeding; review of MCH manuals and policies have taken place to influence maternal and child health/family planning.
The immunization coverage for all vaccine-preventable diseases remained over 90%. There had been no reported cases of polio for 13 years and the country was certified free from polio in 1994. There has been no measles since 1990. Effective surveillance systems for both acute flaccid paralysis and measles are in place. Although the coverage for diphtheria, tetanus and pertussis is high, 9 and 13 cases of tetanus and 9 and 22 cases of pertussis were reported in 1995 and 1996. All cases of tetanus occurred in the adult population. With the antenatal coverage of tetanus toxoid of 83%, the last reported case of neonatal tetanus was in 1994.
Hepatitis B vaccine is given to health workers and contacts of confirmed cases. However, consideration is being given to include this and Hemophilus influenza B vaccine into the routine immunization schedule, the main constraint being their cost.
As a result of increased rubella activity, MMR vaccine was introduced into the regular schedules in 1995. MMR is given between 12-23 months of age. Twenty-four cases of congenital rubella have been identified in 1996. A survey to determine the level of rubella antibodies in the population between 5 to 35 years is being considered prior to a mass rubella campaign.
6.4 Prevention and control of locally endemic diseases
The Epidemiology Unit of the Ministry of Health has an active surveillance system to monitor and control endemic diseases namely dengue, typhoid, gastroenteritis and STD/HIV. The infrastructure improved with laboratory facilities at national and regional levels, increase in the number of contact investigators, decentralization of testing to all parishes and health centers.
The budget of the vector control program was reduced in the 1980's but steps have been taken to revive it. There is a mosquito laboratory that tests for malaria and identifies mosquito specimens island-wide. The program monitors air and seaports to detect Aedes aegypti. Regionally, there are vector control staff who are responsible for coordinating control programs within their regions.
6.5 Treatment of common diseases and injuries
To reduce the severity of acute respiratory infection, otitis media, diarrhea, diabetes mellitus and hypertension, several protocols on their management were made available at the health center level. Training was given to the community health worker who should provide support in the community. The ability of the public sector to respond to emergencies was improved with the implementation of an emergency medical service and at the same time the casualty departments of some hospitals were reorganized to deal more effectively with emergencies such as injuries.
7. TRENDS IN HEALTH STATUS
7.1 Life expectancy
Life expectancy at birth, estimated from national population projections in 1996, was 75.5 years for both sexes; being 73.2 years for males and 77.8 years for females for the period 1995-2000.
Official statistics grossly under-estimate infant mortality. Studies estimated the under-registration at 27% in 1980 and 75% in 1993. A survey estimated infant mortality at 24 deaths per 1000 live births. The majority of deaths occurred during the neonatal period. The 1986-87 perinatal mortality survey found that the main causes of perinatal mortality were intrapartum asphyxia (44%) and immaturity (19%). The death rate of children 1-4 years is 1.2 per 1000.
Maternal mortality was estimated at 82.2 per 100,000 live births in 1993-95 compared with 100.3 in 1981-83. The main causes are gestational hypertension and hemorrhage, thromboembolisms and genital tract trauma & sepsis.
In 1991, malignant neoplasms, heart disease and cerebrovascular disease were the leading causes of death. However, major under-reporting exists for sudden/violent deaths in the system. In 1991 there were 36 registered deaths for homicides, manslaughter and suicides, but police reported approximately 700 such cases. Based on police statistics for 1991, accidents, violence and poisoning accounted for over 1000 deaths and should therefore rank as the fifth leading cause of death. These are the leading cause in people 15-44 years. In 1995, there were 367 motor vehicular fatalities. Approximately 32% of them were pedestrians. The number of homicides and suicides have increased from 731 cases in 1993 to 863 in 1995, approximately 80% being males.
With the exception of STD/AIDS and diarrheal diseases, global target diseases do not represent a major cause of morbidity in Jamaica. Levels of DMFT are extremely low ie.1.08 at 12 years, there are no new cases of leprosy and the only cases of malaria are imported. Communicable diseases of concern are tuberculosis, typhoid, congenital rubella syndrome, dengue, gastroenteritis, and STD/HIV. There were 121 confirmed cases of TB in 1996, the highest since 1991, 12 of them co-infected with HIV, and there were 14 deaths giving a case fatality rate of 11.6%. As a result of a rubella outbreak in 1995, there were 24 cases of congenital rubella syndrome in 1996. Major improvements in the prevalence and severity of diarrheal diseases have resulted from oral rehydration therapy, but not in its incidence. Rotavirus still is the main cause.
STDs including AIDS are major problems. Over the past 10 years, there has been an increase in the incidence of ophthalmia neonatorum and the STD continue to spread, particularly among the high risk groups such as female and male prostitutes, migrant farm workers, homosexuals, bisexuals, drug addicts and informal commercial importers. In 1996 there were 527 new cases of AIDS, bringing the cumulative total to 2060, of whom 1148 have died – a case-fatality rate of 55.7%. Sixty-two percent of the cases were males and 38% females, and the main mode of spread was heterosexual transmission. In attempts to controlling the spread, condom distribution increased from 2 million in 1985 to 10 million in 1995. However, 77% of males having sexual intercourse with a non-regular partner reported using a condom. More women are abstaining, while men appear to have reduced the number of multiple relationships.
It is estimated that there are approximately 20,000 blind persons (1% of the population) in Jamaica. The main causes are non-preventable cataracts and glaucoma. To some extent, eye care services are integrated into basic services, but eye care has not had high priority.
Using the established rates for schizophrenia (1%) and depression (5%) within a population, the number of schizophrenic and depressed persons in Jamaica is estimated at 23,890 and 119,430 respectively. Among patients seen by the community mental health services, the common diagnosis were schizophrenia (50%), depression (20%), substance abuse (10%) neurosis (7%) and organic psychosis (5%). Mental health services are not integrated and this contributes to ineffectiveness in the use of resources and, at times, poor management of the patient. The service is limited in range and experiences shortages of trained manpower.
8. OUTLOOK FOR THE FUTURE
The basic objectives of the government are improving efficiency while ensuring equity of access to health care. To achieve this, strategies include: a) health promotion and disease prevention; b) maintenance of health status though integration of services to facilitate diagnostic, curative and rehabilitative care to decrease morbidity and mortality with specific emphasis on adolescents, aged, disabled, substance abusers and children; and, c) management of the health sector.
The Ministry of developed a national corporate plan and budget for the period 1996-1999 with specific policies, objectives and program & activities for meeting its overall goal. Strategies are:
1. Ensuring equity for health.
2. Strengthening health promotion and protection by of the reorganization of central level to create a Division of Disease Prevention and Health Promotion.
3. Strengthening the health sector by: I) identifying the appropriate private/public involvement in the delivery of care, ii) development of a customer-centered approach to patient care, iii) restoration of hospitals with high usage, iv) management training, v) information systems development, vi) development of emergency medical services, vii) health legislation program to inform decisions within the health sector, viii) national health insurance, ix) decentralization and privatization, x) quality assurance through manual preparation and training.
Manpower development must be given priority in the area of policy issues; education and training with links with local universities; management & productivity; and the appropriate manpower mix for hospitals and health centers.
4. Developing and strengthening specific health programs must be done through integration into ambulatory care service delivery. Ministry of Health must develop programs in the area of care and protection of children, and prevention and control of drug abuse, while strengthening existing programs in maternal and child health, immunization, family planning, STD/HIV/AIDS prevention and control, environment, accidents and violence and chronic diseases. A number of strategies for strengthening diagnostic and treatment capabilities are needed.
5. The strategies identified for developing and using appropriate technology include the strengthening of the maintenance unit, appropriate training of users of the technology and quality assurance.
6. International partnership in health will be strengthened through donor-country committees.