Health is an important component of long-term socioeconomic development. It is clearly recognized that the improvement of health as a social development activity has a humane value in itself independent of other economic or political considerations. At the same time, there is definitely a relationship between improved health and economic productivity since health contributes to the formation and preservation of human capital. Health is required to maintain and improve the productivity of the work force and to make it possible for the pre-work population to take efficient advantage of the investment in educational facilities required for their later performance in life.
To bring about measurable improvement in health will require substantial internal investments in addition to the amounts already being expended for health. Additional investments will also be needed from abroad for application to strategic opportunities. Any effort on the part of an external institution to contribute to the improvement of health conditions in the region must take into consideration the wide differences among countries with respect to health indicators, internal organization for meeting health problems, the level of health planning and the disparities in the allocation of health facilities between urban and rural areas.
A careful search must be undertaken to identify the priority opportunities which will maximize the contribution of external agencies to the improved planning and increased efficiency in the use of existing financial and human resources as well as expand rationally overall investments allocated to the field of health.
The Bank recognizes that measures to improve the health of the region will contribute to the attainment of economic and social progress. The Bank will consider proposals in the field of health which show promise of yielding the greatest health benefits by reducing the widest spread health problems of the region. Such projects should emphasize preventive health measures, should form part of an acceptable national health plan, and should conform generally with accepted Bank financial criteria.
1. GENERAL REQUIREMENTS. All proposed projects, especially those for countries whose circumstances require preferential consideration, must be closely related to national health planning efforts and:
a) Form part of the existing or contemplated national health plan following generally the guidelines established by the Pan-American Health Organization, and must be identified as indispensable to the fulfillment of such a plan. If this plan does not exist it should be contemplated for early initiation. Such a plan should be integrated with the national development plan.
b) Emphasize preventive health measures. As contrasted with developed countries, developing countries are characterized by a shorter life span, and higher mortality and morbidity rates from diseases which lend themselves to eradication, or sharp reduction. As a country develops to a higher economic level, the eradicable and reducible diseases are substituted by non-reducible diseases. The former categories lend themselves markedly to preventive measures whose "cost per life saved" is much lower than that of the non-reducible diseases, which are characteristic of advanced countries. Projects should thus emphasize control and reduction of such eradicable and reducible diseases.
2. PROGRAM EMPHASIS. The limited financial resources available for a health program requires that the Bank differentiate among countries so that investments will be directed to the solution of the broadest public health problems. Consequently, it will be necessary to apply certain indicators which will reveal within reasonable ranges of accuracy the health "profile" of the individual countries, the pattern of health measures being undertaken, the projection of needs, and the levels of efficiency in the use of resources. It should then be possible to indicate generally those countries whose overall situation is satisfactory or unsatisfactory.
Despite the fact that serious disparities in health conditions may exist within countries whose overall situation is satisfactory, the major emphasis of the Bank's program in the field of health must be placed in those countries generally in an unsatisfactory situation. This does not mean that the Bank cannot entertain a more favorable condition, but these proposals should be limited primarily to those which produce benefits of demonstrated regional significance, or the solution of specific problems related to industrialization, such as industrial health and safety. Centers for training in health planning, in public health practice, and for research in techniques which are of a region-wide consequence, should be included among these exemptions, as should investment in the production of low cost equipment and materials of widespread applicability in public health, especially for use in countries in the poorer health category.
3. PROGRAM NEEDS. While the Bank places its program emphasis on those countries which are in a generally unsatisfactory health condition, the fields of health activities which require priority attention include the following:
a) To provide basic health services for the slums of urban centers, as well as rural areas;
b) For assistance to establish and expand maternal/child health care;
c) To make available potable water and facilities for disposal of wastes as well as other environmental improvements;
d) To control and reduce eradicable and reducible disease in specific geographic areas;
e) To achieve a well balanced ratio between professional and auxiliary medical personnel and the population;
f) To improve the management and planning of existing health facilities and services as part of an integrated national health program;
g) For preinvestment in health planning and assistance in project preparation;
h) For assistance to establish and implement national nutritional policies;
i) For health and hygienic education.
In general, the Bank will identify loans and technical cooperation projects in areas which have not received proper attention and inhibit the sector's balanced development. Similarly, the Bank will avoid certain types of developmental activities in health which may have been given undue emphasis in terms of total national development.
4. COUNTRY CHARACTERISTICS. For the purpose of identifying the present stage of health development, the countries of Latin America can be roughly divided in three groups. (See Annex I for the current list of countries in each category.) Each of these groups of countries have different priority requirements for international loan and technical cooperation. Annex I describes briefly certain aspects of specific country priorities by groups or categories of countries. It should be noted, however, that each individual project proposal should be judged on its merits and the descriptions represent only rough categories of priority for activities in each group of countries.
In meeting the above mentioned regional program needs, the following are some of the specialized fields of activity.
1. HEALTH ASPECTS OF RURAL DEVELOPMENT
a) GENERAL POLICY. From the public health point of view, the following are basic health services which are indispensable to project, develop, and recuperate health through which the rural population can raise its standard of living and increase its capacity to work:
It should be considered that rural health services cannot be complete and self-sufficient since it would be uneconomical and financially impossible to provide complete and specialized medical services in widely scattered and sparsely populated communities. Rural health services need to be part of a regional system of health services in which urban, suburban, as well as rural areas are adequately grouped within the same region. The various categories of health services responsible for the well-being of the community in a particular region include: regional hospitals, local hospitals, urban and suburban health centers, health posts and dispensaries, or rural health stations.
b) EVALUATION CRITERIA FOR THE ESTABLISHMENT OF RURAL HEALTH CENTERS AND POSTS
2. CONSTRUCTION OR EXPANSION AND MODERNIZATION OF HOSPITALS
a) GENERAL POLICY. The optimum utilization of human and physical resources for health purposes requires the coordination and integration of services which hospitals can provide. Consequently, hospitals and other integrated medical facilities are the basic infrastructure of modern health services. Although oriented towards the provisions of curative and rehabilitation services, hospitals can develop programs of health promotion and morbidity prevention as well. Hospitals have a basic role to play in the developing community through the coordination of the professional and administrative activities within defined geographic, economic and political areas.
The effective use of health resources is best achieve through a regional system of health units. Within the regional health system, the university and general hospitals constitute important focal points of medical services, training and research. The university hospital is the basic element of the regional health system since it combines all three activities.
Proposals for hospital construction should be supported only if the proposed hospitals are major components of an integrated national health program, or comprise an essential element of a medical education program designed to produce professional and auxiliary personnel required for the implementation of a national health plan. Especially to be avoided are proposals for construction of facilities of a prestige nature, or of a level of sophistication beyond the demonstrated needs of a public health program related primarily to the preventive health aspect of a national health plan.
In the absence of a national health plan, the country requesting a Bank loan must supply sufficient information to permit an accurate diagnosis of the principal health problems and to establish priorities in the use of investment resources.
The Bank will consider proposals for the following types of hospitals: Central General Hospital, Regional General Hospital, University General Hospital, General Municipal Hospital, Combined Health Centers and Hygiene Centers.
When justified on the basis of priorities with the national health plan the Bank may consider proposals for other hospitals. However, specialized hospitals which only benefit a limited number of people within the population as a whole may only be included in the project if inanced with national resources.
b) EVALUATION CRITERIA
3. POTABLE WATER SUPPLY AND SEWERAGE PROGRAMS. The Bank will continue to receive loan requests for potable water supplies and sewage facilities in urban and rural areas. Water borne diseases, together with diseases spread through improper waste disposal practices, comprise the greatest source of mortality and morbidity within the category of reducible diseases, especially in poorer countries. Such proposals should be evaluated in reference to national health plans to a greater extent than in the past.
See section OP-745 which covers general policy and evaluation criteria for potable water and sewerage programs.
4. PHARMACEUTICAL, BIOLOGICAL, NUTRITION AND MEDICAL EQUIPMENT INDUSTRIES
a) GENERAL POLICY. The importation of drugs, biological preparations, nutritional and other medical supplies and equipment represents a substantial drain in foreign currency of many Latin American countries, especially the smaller ones.
Adequate human nutrition is not only essential for the full development of the potential of the population but it also allows better productivity per individual. An overall lack of protein, in terms of quantity and quality and availability at a price compatible with minimum earnings, is the major cause of malnutrition in the region.
Commercial development projects related to low-cost protein resources are divided into tow major types: i) the production and distribution of scientifically proved low-cost protein-rich foods (such as Incaparina), or ii) the production of protein concentrates (cottonseed flour, soy, marine protein concentrate, etc.) for use in such food products. Either or both may be required in order to secure the optimum distribution of such foods in the interest of health in any given country. The basic objective of such projects is to introduce a nutritionally useful product having a sufficiently low price and the consumer acceptability to assure volume of sales and institutional use which will result in a reasonable return to the industry involved, while at the same time making a significant addition to the consumption of good quality protein.
There are three major factors bearing on consideration of the manufacture drugs and pharmaceutical products. The first concern is for the quality of preparations, all of which must meet well-recognized standards. For the majority of vaccine, anti-toxin, and therapeutic substances, these standards are spelled out in a series of technical WHO publications. The second concern is for an adequate quantity of the preparations to meet the needs of the market, be it country-wide, or regional. This will require market surveys. Finally, there is concern for maintaining the cost of such preparations at a level which on the one hand will make the manufacturing of these items economically feasible, and on the other will assure that the price will be commensurate with the ability of the consumer to pay for and use the preparations.
Proposals for the support of projects in this field will be entertained if such projects can be demonstrated to be economically efficient and especially if they will find a market extending beyond an individual country.
b) EVALUATION CRITERIA FOR NUTRITIONAL INDUSTRIES
c) EVALUATION CRITERIA FOR PHARMACEUTICAL, BIOLOGICAL AND MEDICAL EQUIPMENT INDUSTRIES
5. HEALTH MANPOWER, EDUCATION AND TRAINING
a) GENERAL POLICY: Health services, like education or industry, require a large capital outlay before they can be properly delivered. This is especially true of the advancement of complex medical and sanitary sciences.
However, this investment is not restricted to building and equipment for the provision of services such as hospitals or surgical instruments. It must also include capital outlay for the training and education of medical personnel.
It is estimated that 60 percent of the cost of public health services is for personnel. Shortage and uneven geographic distribution in all levels of health personnel limit the effective implementation of existing health plans, and the efficient use of available physical facilities.
An unsatisfactory as the current situation is, merely to maintain the current level of health services over the coming years will require dramatically expanded training facilities.
The Bank will entertain proposals for the support of new or expanded training facilities only if such facilities are accorded a high priority within the national health plan
The program should be oriented to solve the major health problems of the country with greater emphasis on preventive health. Where national authorities so desire, such a program might include the consideration of demographic trends and family planning.
The Bank will be especially interested in education training facilities which will serve as a regional or subregional need.
b) EVALUATION CRITERIA
Health Manpower Studies. Much general information is already available on the existing supply of physicians, nurses, auxiliaries and other health personnel in Latin America. To undertake effective planning, however, it is necessary to collect specific information of available health resources (both personnel and facilities) and health services utilization by the population in order to diagnose the health manpower situation.
This data will reveal more sharply the imbalances or inequities. It will also permit calculation of the rate of health service expenditures as a share of "gross national product" which is important for overall national socioeconomic planning and study of long term trends.
Decisions concerning health investments, however, need not always await completion of the comprehensive type of health manpower study outlined above. Such decisions can be made on the basis of information available from the Pan-American Health Organization from currently existing sources.
Selection of Countries. Given the scarcity of Bank resources in relation to country health needs it is suggested that the following criteria be applied in arriving at priority selection of countries:
i. Health Manpower Supply. The top criterion should be the current availability of health personnel. As a simple index of this, it is suggested that one use the ration of physicians to population, that is, the number of graduate physicians in the country per 10,000 population. The Latin American countries may be rank-ordered by this measurement.
ii. Medically Attended Deaths. In all Latin American countries there are thousands of deaths registered without final attendance by any physician. The proportion of these non-medically attended deaths is a figure readily available. While the complete failure to even register certain deaths which have no physician in attendance, would lead to underestimating this proportion, it is probably more reliable than mortality rates for any specific diagnosis. It is recommended that this proportion be used as an index of a country's need for health manpower. The rate will obviously be higher in countries where a given supply of physicians is more unevenly distributed between cities and rural areas. Thus, a high proportion of deaths registered without medical attendance would signify a greater need for health manpower and warrant higher priority for financial assistance.
iii. National Health Planning. Preference should be given to countries that have demonstrated serious, overall, national planning of health services. In such countries, any given investment in health manpower production is likely to produce more effective results in health service improvements.
iv. Coordination among agencies: Is there evidence of serious and effective coordination of multiple health agencies at the national and local levels? What are the relationships among the Ministry of Health, Social Security Programs, "beneficencia" societies, and other entities? Is there any pooling of personnel, facilities or equipment?
v. Organized vs. private spending: Of all the expenditures for health services in the country, what proportion is estimated to be spent through one or another type of organized program, as against purely private spending? A greater proportion of "social spending" gives greater confidence in the realization of planning objectives.
vi. Health in the national budget: Considering the overall amount of the national governmental budget, what proportion is allocated to health services? This calculation must count health moneys spent by agencies other than the Ministry of Health (especially Social Security agencies). In federated countries, account must also be taken of moneys spent by the states, as well as the national government. A higher relative allocation for health service reflects greater appreciation of this human need in the public authority structure, and would warrant greater confidence in manpower investments.
vii. Deliberate personnel distribution policies: All countries show a unbalanced distribution of personnel between cities and rural areas; the severity of this disparity may be determined largely by the accidents of geography or history. The critical is whether deliberate steps have been taken to improve the situation, such as mandatory periods of rural service for new medical graduates, or hardship posts, construction of decent housing for rural health personnel or the like.
viii. The Population. The amount of a loan to a country should be expected to bear some proportion to the country's population, since the tasks of providing health manpower are obviously greater if there are more people to be served.
ix. International Training Centers. Beyond the above four criteria for investing in a country, if there is reason to believe that a specific medical institution can serve as a training center for personnel from a group of countries, this factor should be given weight. Investment in such a training center can pay dividends of manpower development in several countries.
Specific Manpower Programs. The second dimension for decision-making on investment is the type of program to be aided in the countries selected. In this sphere, one must constantly keep in mind the relation of health manpower program to the overall task of providing health services and the relation of health services to overall social and economic planning. Accordingly, the following criteria are suggested:
i. Teaching Health Centers in Urban Slums. Virtually every Latin American city is surrounded by a belt of slums. These settlements represent one important aspect of the process of urbanization which, in all parts of the world, has accompanied industrialization. The need for health services in these slum populations is very great; at the same time, the opportunities for health manpower training among them are also very great.
Medical, nursing and related education has for centuries been concentrated in large hospitals, where the student sees patients who are critically sick. But prevention-oriented and socially-concerned medical education should focus on the patient in his home or, at any rate, not yet sick enough to be in a hospital bed. Such education can be best offered in a health center.
Priority attention should be accorded to the construction of teaching health centers in the urban slums, which are physically close to most medical schools in the large Latin American cities. Such centers should be equipped as specialized poly-clinics; they should, of course, be functionally related to hospitals, though not necessarily physically united. The administrative management of these centers ought to be assigned to departments of Social and Preventive Medicine in the medical schools, with the active participation, of course, of all the clinical departments.
The training of health manpower in such teaching centers should include nurses, technicians, social workers, dentists, etc. as well as physicians.
ii. Regional Hospitals. Medical resources are traditionally concentrated in the capital cities of Latin America, and the secondary provincial towns are relatively neglected. A high priority, therefore, should go to development of health training centers in the secondary cities. In some of these, the existence of a university has already stimulated establishment of a medical school. In nearly all of them, however, the geography and transportation flow make feasible a regional hospital. In such hospitals, young medical graduates as well as other personnel can receive training after completion of formal schooling. Such hospitals also are logical centers for post-graduate education of physicians and others who completed their training many years before. The development of excellence in regional hospitals, moreover can help to correct the basic unbalanced distribution of health personnel through out a nation.
iii. Schools for Health Service Auxiliaries. Even with expanded and improved education of physicians, one of the most basic needs in Latin America is for middle level health manpower. There is a great shortage of trained professional nurses throughout Latin America but a greater problem is the way that they function, in relation to the use of nursing auxiliaries who have had much less education.
The well trained professional nurse, with primary and secondary school education, followed by three years of hospital training, is engaged typically in large city hospitals, where she is handmaiden to the physician and continuously under his supervision. She is taught never to make diagnosis nor to give therapy, except on a doctor's orders. On the other hand, the nursing auxiliary, with only primary school education followed sometimes (not always) by a brief course (often three to six months) of hospital training, is engaged in rural health posts; here, she is alone most of the time and supervised only from a distance. Yet she is expected to treat the sick who come to the health post. Crude as it may be, she is essentially making diagnosis and giving therapy, which would never be permitted for the physician's professional nurse counterpart who has had much more training.
The solution would be to substantially upgrade the education of nursing auxiliaries. The level of training now required of professional nurses could be offered for the personnel who are expected to fill the health posts in the villages or the health centers in the towns and cities. Exactly how the Bank might support such schools for middle level health manpower requires further thought. However, more than physical buildings and teaching equipment are needed.
iv. Central Teaching Hospitals. Every country, and indeed every region within a large country, needs a center of excellence to set standards and inspire the health professional world. Therefore, great teaching medical centers are important. Such centers, however, may be able to attract financial support within a nation and as a rule loan proposals for such facilities should be placed at a lower level of priority.
If capital loans are made for the improvement of such central teaching facilities, they should be conditional on a wide definition of educational purpose in the center. Thus, these training facilities might be thought as "centers for the health sciences" rather than solely as medical centers for training physicians. In them, programs for education of all classes of health personnel could be offered.
v. Student Learning Aides. All of the priority actions recommended above are in the sphere of improved training of health manpower, quantitatively or qualitatively. To render all these actions more effective, the student could be helped to learn through provision of up-to-date textbooks in his native language. Likewise, he could be helped to purchase basic equipment for study, like microscopes and opthamoscopes. These books and instruments are often very expensive and sometimes not available in the country at any price. A program of assistance in this sphere could help to enrich all professional health education in Latin America, including that for auxiliary or middle level personnel.
6. HEALTH ELEMENTS IN ECONOMICAL AND SOCIAL DEVELOPMENT ACTIVITIES
a) GENERAL POLICY. Experience gained in the formulation of development plans and projects in many countries in Latin America during recent years has demonstrated the necessity of intersectoral cooperation. The successful execution of development projects depends heavily upon the quantity and quality of the available human resources which are affected by environmental health conditions. Thus, there is a health element to consider in most project activities at both the preinvestment and project execution stages.
It is important to note that potable water and sewerage projects are those which have the most direct impact on environmental and personal health, complementary investments can insure that these projects have a maximum impact on the health of the area they serve.
At the preinvestment stage of project development the inclusion of a health expert in the survey can guarantee that environmental and personal health factors influencing the success of the project will be given adequate attention. Adverse health factors in the environment can easily influence the feasibility of a project and conversely the project may have adverse effects on environmental health which can jeopardize its success over a period of time. Many instances can be cited in which the success of large scale development projects have been less than optimum through neglect of important health factors. Of special concern in large scale industrial development projects should be worker health and safety measures.
b) EVALUATION CRITERIA
The project should take into account, when relevant, the present and foreseeable future epidemiologic and other health problems of the region, with special reference to human settlement, industrial, and agricultural activities.
With respect to agricultural development projects, an assessment of regional food policies, nutritional requirements of the project population, zoonoses and aftosa problems and the potential contribution of the project to the nutrition of the local and the general population may be required to insure the success of the project.
Regional development projects must include a modicum of rural health services both preventive and curative to achieve balanced development, since these projects are usually multisectorial in nature involving agriculture, commodity marketing, small industry, communications, housing and community development.
7. PREINVESTMENT STUDIES
a) GENERAL POLICY. The Bank's support for preinvestment studies should include studies in the field of health where needed; special concern should be exercised to assure that preinvestment loans to planning agencies should include provisions for health planning. Similarly, preinvestment support should be encouraged for health planning and the development of feasibility studies within the agencies in the health field. An important aspect of health planning which could be supported through preinvestment studies is that of projecting professional, technical and auxiliary personnel needs required for carrying out a national health program.
b) EVALUATION CRITERIA
Health Planning and Policy-Making:
i. Studies designed to assist in the planning of basic preventative health services for the majority of the population deserve priority consideration.
ii. Special attention should be given to studies aimed at establishing national or regional, as opposed to imported, standards and norms of service applicable to the local social and economic situation.
iii. Priority should be accorded to those studies which deal primarily with the health needs most adverse to development and which can be satisfied at minimum cost.
iv. The subsectorial activity to be studied should form a significant part of the present health expenditures or represent a serious deficiency in the demand for services.
v. The studies should indicate the desirable balance between environmental and personal services.
vi. Health preinvestment studies which support the dynamic or "leading" economic sectors should be given priority consideration.
vii. The studies should be closely related to the priorities and guidelines established in the national health plan.
viii. Any recommendations resulting from preinvestment studies should include technical alternatives, especially the cost and returns of these alternatives.
ix. Health preinvestment studies in urban areas should be closely coordinated with urban development planning.
x. Macroanalytical studies in urban areas should be closely coordinated with urban development planning.
xi. Studies of such vertical programs as malaria and smallpox eradication and rural water problems may be necessary and can contribute towards the formulation of national health plans and programs.
xii. Intersectorial studies designed to improve the formulation of national or regional food and agricultural policies may be found essential to raise the nutritional level of the population.
xiii. Preinvestment studies of the local potential for the manufacturing or processing of pharmaceutical preparation, medical supplies and equipment may be needed to formulate effective policies in these areas.
Health Administration, Coordination and Financing:
i. Preinvestment studies designed to improve the administration and management of health services have a high priority in some countries and may require support.
ii. Studies of medical care should give consideration to the regional decentralization of services within a system of central and regional hospitals, clinics and health centers related to both urban and rural areas.
iii. Attention should be given to studies designed to improve the coordination of social security, armed forces, government and other health services in order to improve the efficiency with which existing health resources are being used.
iv. The financing of national health services as well as specific programs and projects may require study and support.
As in the case of Bank loans in other fields, projects proposed in the field of health should satisfy the normal criteria of the Bank but special attention should be given to the following financial criteria:
* The operational policies of the Inter-American Development Bank are intended to provide operational guidance to staff in assisting the Bank's borrowing member countries. Over the course of the Bank's more than 40 years of operations, the approach to developing operational policies has taken various forms, ranging from the preparation of detailed guidelines to broad statements of principle and intent. Many policies have not been updated since they were originally issued, and a few reflect emphases and approaches of earlier years which have been superseded by specific mandates of the Bank's Governors, the most recent being the Eighth Replenishment mandates of 1994.
In accordance with the Bank's information disclosure policy, the Bank is making all of its operational policies available to the public through the Public Information Center. Users please note that the Bank's operational policies are under a process of continuous review. This review process includes preparation of best practice papers summarizing experience at the Bank and other similar institutions, and sector strategy papers.
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