Fifth Report on the World Health Situation 1969 -1972

OFFICIAL RECORDS OF THE WORLD HEALTH ORGANIZATION No. 225

FIFTH REPORT ON THE WORLD HEALTH SITUATION 1969 -1972

WORLD HEALTH ORGANIZATION GENEVA

1975 NOTE

In May 1970 the Twenty -third World Health Assembly, after discussing the Fourth Report on the World Health Situation,' invited Members to provide information for a fifth report, covering the period 1969 -1972, and requested the Director -General to prepare this Fifth Report for the Twenty -seventh World Health Assembly. 2 In May 1974 the Twenty- seventh World Health Assembly discussed and noted the Fifth Report, thanked Members and Associate Members for their assistance in providing material, and requested them to submit any further information or amendments they wished to include. In the same resolution it requested the Executive Board to consider at its fifty -fifth session the question of rationalizing the collection and summarizing of information on the health situation in the various countries.Pending the recommendations of the Board, the Director - General should continue his preliminary work on preparation of a sixth report, in which Member States were urged to take an active part. He was further requested to present a progress report to a subsequent World Health Assembly. 2 Part I of this volume, the General Survey, contains an analytical review, under broad subject headings, of certain aspects of the reports received from Member States and Associate Members.The reports themselves, with the additions and amendments submitted by the governments, are reproduced in Part II.

1 Published as WHO Official Records, No. 192, 1971. 2 Resolution WHA23.24. 3 Resolution WHA27.60.

ISBN 92 4 160225 2

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

PRINTED IN SWITZERLAND CONTENTS

Page

Preface VII

PART I - GENERAL SURVEY

Chapter 1.Introduction 3

Chapter 2.Demography, mortality, and morbidity 5

Demography 5 Mortality 8 Morbidity 11 Cardiovascular and cerebrovascular diseases 13 Cancer 13 Mental diseases 13 Tuberculosis 14 Malnutrition 15 Smallpox 15 Cholera 16 Malaria 17 Other parasitic diseases 17 Venereal diseases 17 Dental lesions 18

Chapter 3.Economic development and the organization of health services 19

Chapter 4.Factors influencing the development of health plans 23

Chapter 5.Health establishments 25

The main organizational problems 25 Financing 26 Administration and management 28 Basic health services 29

Chapter 6.Family health 32 - III - Page

Chapter 7.Health personnel 34

Education 34 Distribution and migration 35 Auxiliary personnel 36

Chapter 8.Protection and improvement of the environment 38

Chapter 9.Health planning 40

Chapter 10.Public health and medical research 44

Public health research 46 Clinical research 48

PART II - REVIEW BY COUNTRY AND TERRITORY

Page Page African Region Region of the Americas (continued)

Burundi 53 Venezuela 123 Central African Republic 54 Congo 56 Antigua 125 Guinea -Bissau 57 Belize 126 Liberia 58 British Virgin Islands 128 Madagascar 60 Falkland Islands (Malvinas) 130 Mali 62 French Guiana 130 Niger 63 Martinique 131 Nigeria 64 Montserrat 132 Senegal 66 St Kitts, Nevis and Anguilla 133 Upper Volta 67 St Lucia 135 Surinam 136 Angola 68 Turks and Caicos Islands 138 Cape Verde Islands 69 Comoro Archipelago 70 South -East Asia Region Sao Tomé and Principe 71 Spanish Sahara 72 India 141 Mongolia 145 Sri Lanka 147 Region of the Americas Thailand 150 Argentina 77 European Region Bahamas 79 Barbados 80 Austria 159 Bolivia 83 Belgium 161 Canada 86 Bulgaria 165 Chile 91 Czechoslovakia 167 Colombia 94 Denmark 172 Cuba 96 Finland 175 Dominican Republic 100 France 179 El Salvador 102 German Democratic Republic 183 Grenada 104 Hungary 187 Guatemala 106 Iceland 191 Guyana 108 Ireland 192 -- Haiti 110 Italy 196 Mexico 111 Monaco 198 Panama 113 Netherlands 198 Paraguay 115 Norway 200 Peru 118 Poland 203 Uruguay 121 Portugal 207 - IV - Page Page European Region (continued) Eastern Mediterranean Region (continued) Romania 209 Syrian Arab Republic 266 Spain 211 Tunisia 268 Sweden 213

Switzerland 217 French Territory of the Afars and the Issas . 270 Turkey 219 Union of Soviet Socialist Republics 222 United Kingdom of Great Britain and Northern Western Pacific Region Ireland 226 275 Yugoslavia 234 Australia Japan 278 Gibraltar 235 Khmer Republic 279 Laos 281 Malaysia 283 Eastern Mediterranean Region New Zealand 288 Philippines 292 Bahrain 239 Republic of Viet -Nam 295 Cyprus 240 Singapore 297 Democratic Yemen 242 Western Samoa 300 Egypt 244 Iran 246 British Solomon Islands Protectorate 303 Iraq 249 Brunei 306 Israel 251 Gilbert and Ellice Islands 307 Jordan 255 Hong Kong 309 Kuwait 256 Macao 312 Libyan Arab Republic 257 New Caledonia and Dependencies 313 Pakistan 260 Niue 314 Qatar 261 Portuguese Timor 315 Sudan 263 Wallis and Futuna 316

Index to countries and territories 319

Currencies 321

-V-

PREFACE

THE First Report on the World Health Situation published by WHO took as its starting point the year 1954. Subsequent reports have been published at intervals of four years, and the present report continues the story up to 1972. Thus, the five reports taken together span an interval of almost two decades. The Introduction to Part I of the present report makes some comparisons between the five reports, singling out salient features of each. It is clear that, although the progress made in some sectors has led to a certain change in emphasis, in most Member States the fundamental problems that confronted health administrations in 1954 -1956 have not yet been solved. It is as true today as it was twenty years ago that environmental health measures are of paramount importance in reducing morbidity and mortality in the developing countries and that the problem of raising environmental health standards is linked indissolubly with that of overall socioeconomic development. For example, despite all the efforts that have been made, community water supply and waste disposal services remain grossly inadequate in most developing countries, and often they are nonexistent. Under these circumstances, it is not surprising that parasitic infections and many other communicable diseases still exact a heavy toll. This is not, however, the whole story. Highly effective vaccines against a number of communicable diseases have become available during the last twenty years, yet there are large parts of the world where they have as yet made little impact.This is mainly because of insufficient financial and manpower resources and organizational shortcomings.That these difficulties can be overcome is demonstrated by the spectacular success of the smallpox eradication programme and we are hoping to apply the lessons learned in this programme to other diseases for which vaccines are available, provided that sufficient voluntary contributions are forthcoming to fund our expanded programme on childhood immunization. The control of many parasitic diseases is hampered by lack of knowledge of host parasite relationships and other biological characteristics of parasites.Sophisticated techniques are available today for the study of these questions, but they are not at present being applied. We are hoping to remedy this deficiency through the establishment in the developing countries themselves of a network of research and training centres linked to a central research institute possessing modern equipment and staffed by a multidisciplinary team of highly qualified specialists. Some of the health problems discussed in the present report seem likely to be aggravated rather than relieved in the coming years. One of these is malnutrition. As the report points out, food supplies are influenced by economic and technical factors that are mostly beyond the control of health administrations. The current world economic and energy crisis will inevitably put a brake on food production and force up prices. On the other hand, the demand will be increased by the continued upward trend in the world population. But there is still much that can be done to rationalize food distribution, to encourage the use of unconventional foods, and to look for cheaper alternatives to the more expensive foods. WHO is cooperating with FAO, UNICEF, and other international organizations to find the most effective ways of helping countries to solve these problems. In the developed countries, the health services, which twenty years ago looked forward to the future with equanimity if not euphoria, are now facing increasing problems. These have been brought about by the high costs of modern diagnostic techniques and methods of treatment and by the effects of inflation on the costs of providing health care in general.This is forcing governments to question the whole concept of the luxury health service. Some countries have already taken steps to try to reduce the expenditure on modern drugs and services, but there is little doubt that more drastic measures will be needed in the future and that the more complicated and expensive hospital procedures will have to be reserved for carefully selected cases. On the manpower side, increasing consideration is being given to the use of medical assistants and other health auxiliaries wherever the services of more highly trained -VII - personnel are not indispensable. This is, of course, a solution that has long been envisaged to solve the acute shortageoftrained manpower in the developing countries and is now receiving renewed impetus. The problems that I have briefly referred to here are among the highest priorities that emerge when one surveys the world health scene today, though there are all too many other pressing needs. I have also hinted at a fewofthe remedies that we have in mind. These I have discussed morefullyin my Introduction to The Work of WHO, 1974. In the compilation of this Fifth Report on the World Health Situation, some difficulties were experienced because not all Member States were able to supply the information requested. I appreciate that the collection of the data needed to reply to the questionnaire may place a heavy strain on health administrations. This problem was discussed during the Twenty- seventh World Health Assembly and, in response to a recommendation made by that Assembly, a study has been instituted on ways of rationalizing the collection and summarizing of information on the health situation in the various countries and on the advisability of issuing the reports at less frequent intervals in future.

Director- General Part I

GENERAL SURVEY

CHAPTER 1

INTRODUCTION

Two decades have passed since the start of the chronic degenerative diseases and geriatrics.In the period covered by the First Report on the World Second Report, the analysis of these sectoral activities Health Situation. The first, second, third and fourth gave way to an assessment of the overall situation reports underlined the salient facts and basic concerns regarding the major causes of social diseases.This about the state of health in Member States during the important change was probably the outcome of delib- periods 1954 -1956, 1957 -1960, 1961 -1964 and 1965 - erations during the period 1957 -1960 on the integra- 1968.1 The statistical data and the main problems pres- tion of sectoral services and on the need to find a more ented in these reports were derived from the replies general solution to concrete problems. to questionnaires distributed by WHO during the year The organization of health services at the national preceding the preparation of each report, as well level as well as at intermediate and local levels was as from information gathered by the technical units at already mentioned in the First Report, as was the headquarters, by the regional offices, and by WHO future role of financial systems derived from the con- representatives, sometimes through consultants recruit- cept of social insurance. The subsequent reports laid ed for specific projects.Some of the statistical data still more stress on the organization of health services, on demographic growth and the economy were taken on their planning, and on the role of social insurance. from documents published by the United Nations and A large number of countries gained their indepen- by the other specialized agencies. Using this mass of dence in the period 1957 -1964, and they felt the need documentation an attempt was made to present as to reform the systems that had previously been imposed precise a picture as possible of the world health situa- upon them by the colonial powers even though they tion and to pick out the most serious and most urgent did not always have the resources to do so. problems confronting national health authorities. Starting with the Second Report, special consider- However, the four earlier reports by no means fol- ation was given to research in medicine and public lowed a stereotyped form of presentation.Admit- health. tedly each of them contains data on the major public The Third Report devoted several pages to the phe- health problems, which essentially are the communi- nomenon of growing demographic pressure, which was cable diseases and environmental pollution.At the causing anxiety among all intergovernmental organiza- same time, however, they highlight different aspects tions and in the most seriously threatened countries. of health policy according to the period covered. Population growth is not in itself a public health prob- The First Report reviews the climatic, geographic, lem, although WHO has even been accused of aggrava- democratic, cultural, and economic data that affect ting it through assistance with the successful control of public health. These general data are not repeated in infant and general mortality.However, the inter- subsequent reports since the conclusions, some of governmental organizations realized that the quantita- which are qualitative, remain valid for a long time. tive development of activities such as public health, However, the analysis of the functions of the various agriculture, and education was being nullified by the health sectors reflects the concepts prevalent during a population increase in many developing countries. period when the health authorities were building up Economic growth, which was the hope of the decade specialist services, with a large degree of autonomy, 1960 -1970, sometimes reached high annual levels.It to cover such fields as curative care, maternal and frequently, and to varying degrees, made it possible childhealth, mental health,occupational health, to set up more institutions, to engage more staff, and health education, dental health, nutrition, veterinary to devote more funds to health programmes. How- health services, environmental health, the control of ever, if the absolute figures for those factors are related communicable diseases, and finally the problems of to a rapidly expanding population, the result is zero growth. What will happen if economic growth slows 1 WHO Official Records, No. 94, 1959; No. 122, 1963; No. 155, down or becomes stabilized in future years, while 1967; and No. 192, 1971. demographic growth continues unchecked ? - 3 -- 4 FIFTH REPORT ON THE WORLD HEALTH SITUATION

The Third Report devoted a new chapter to expen- naire for this Report indicate a spectacular reduction diture on health services.This initiative reflects the in communicable diseases, which have fallen far behind concern of economists and health authorities in the some of the chronic degenerative diseases, it is because face of the increasing cost of health activities, not only their financial resources and their improved legislative in absolute terms but also -which is more serious - and administrative apparatus have enabled those as a proportion of the gross national product.The countries to apply specific techniques. 1969 report of the Canadian Task Force on Costs of Moreover, there are several examples to show that Health Services illustrated it for Canada (see Part II). the relations between economic development and the This concern was generally predominant in the Fourth social sector are more complex than was imagined Report, where the study was extended to include the 10 years ago. The strengthening of the public health problems of social and economic development that services is not an automatic consequence of economic influence the financing of health activities. The Report growth. In the absence of social legislation there is a also stressed the important decisions concerning health risk that rapid industrial and commercial development legislation and the organization of health services that will accentuate the disparities in living and health were taken during the period 1965 -1968. standardsthat exist between different population These last two aspects -on the one hand, economic groups. The aim of such legislation is to facilitate and social development and its consequences for the the fair redistribution of national income by complex development of health care, and, on the other hand, mechanisms, the most effective of which are: some legislation and administration on health, social secu- system of balancing ministerial budgets; wage and rity, and welfare services -constitute important prob- salary adjustments; price control; rates of income tax lems in the period 1969 -1972, which is covered by this and other taxes; and social security organizations. Fifth Report.Itis not that the traditional prob- The improvement of the standard of health of the lems of public health, communicable disease control population as a whole requires the construction of a and environmental sanitation, have been solved -far legislative framework, with financial components, to from it.But techniques and organizational principles cover the entire social sector of which public health is have now a rational basis in experience gained over an important part. about 20 years. If the health services in some countries On account of these considerations, which have have not succeeded as quickly as was hoped in eradi- emerged clearly during the last decade and have been cating malaria and smallpox and in reducing the inci- the subject of statements by experts on political econ- dence of tuberculosis, this is not always because they omy and committees convened by the United Nations were uncertain about the techniques to be used, but and the specialized agencies, it seems justifiable in this basically because they encountered two major obsta- Fifth Report to give more weight to financial problems cles: financial constraints and the weakness of their and to legislative and administrative structure by administrative structure. For example, WHO received defining the place of-health among social programmes. very few requests for emergency assistance in 1972 This does not mean that the traditional and concrete from countries affected by cholera, since these coun- problems confronting national health administrators tries have acquired the necessary knowledge and con- are neglected. They are dealt with in the usual way, fidence to organize the control of that disease. Set- and, so as not to confuse the reader, the order of pre- backs are attributable not so much to errors in method sentation of the various chapters and sections in the as to impediments in financing and manpower. If replies Fifth Report conforms in broad outline to that in the from a number of developed countries to the question- four earlier reports. CHAPTER 2

DEMOGRAPHY, MORTALITY, AND MORBIDITY

Demography tality, increased life expectancy, and mitigation of the consequences of major natural disasters (famines, The world population continues to increase, but the epidemics, floods, and earthquakes) by more effective growth rate varies greatly from country to country relief measures and transport. and from region to region. The main causes of this The impact of population growth on the age struc- are well known: high birth rates, falls in infant mor- ture of populations is revealed by an analysis of general

GRAPH 1.PERCENTAGE DISTRIBUTION OF POPULATIONS BY CRUDE MORTALITY RATE IN THE WHO REGIONS (1970 or latest available data)

Percentage of population to Total 100 which the population 80 calculation (millions) 60 AFRICA applies 40 99.9 234.6 20 o 80

60 AMERICAS - 40 100.0 509.5 20 o 80 60 SOUTH -EAST ASIA _ 40 99.9 761.0 20 0 80 60 EUROPE _ 40 100.0 769.7 20 o /!%%//r,r,:;:%: 80 60 EASTERN MEDITERRANEAN 40 90.7 284.7 20 o 80 60 WESTERN PACIFIC 40 99.8 1049.0 20 0 80 WORLD 60 40 99.2 3608.5 20 o 4 6 8 10 12 14 16 .18 20 22 24 26 28 30 Crude mortality rate (per thousand population) IMO 40190 - 5 - 6 FIFTH REPORT ON THE WORLD HEALTH SITUATION mortality rates.In the least developed countries the rate. The distribution of the countries in the African general mortality rate, where it is known, is still high Region shows the existence of two subregions. The (above 18 -20 per thousand). In the developing coun- histogram for the Americas is more homogeneous tries where the health services can reach a high pro- since it relates to a group of developed countries and portion of the population the general mortality rate countries that are less developed but have a young drops rapidly and may fall below five per thousand. population. The countries of South -East Asia are at a In the developed countries it rises again to about fairly comparable stage of development.The histo- 10 per thousand because of the growing number of gram for Europe tapers off at rather high mean values people over 65 -those who have reached or who exceed because of the large proportion of old people.The the average life expectancy. This situation is illustrated countries of the Eastern Mediterranean Region have in graphs 1, 2 and 3. reached varying levels of development, which explains the heterogeneous nature of the graph.Finally, the Graph 1 shows the distribution of the populations histogram for the Western Pacific is influenced by the of the six WHO regions according to crude mortality rate for the vast population of the People's Republic

GRAPH 2.PERCENTAGE DISTRIBUTION OF POPULATIONS BY MEAN LIFE EXPECTANCY AT BIRTH IN THE WHO REGIONS (1970 or latest available data)

Percentage of population to Total 100 which the population calculation (millions) 80 AFRICA applies 60 99.5 234.6 40 20 0 80 AMERICAS 60 72.1 509.5 40 20 0

80 SOUTH -EAST ASIA 60 27.5 721.0 40 20 0 80 EUROPE 60 99.6 769.7 40 20 0

80 EASTERN MEDITERRANEAN 60 98.6 284.7 40 20 0 80 WESTERN PACIFIC 60 92.3 1049.0 40 20 0 80 WORLD 60 78.3 3608.5 40 20 o 25 30 35 40 45 50 55 60 65 70 75 Mean life expectancy (years) DEMOGRAPHY, MORTALITY, AND MORBIDITY 7 of China. For the world as a whole three peaks are The Eastern Mediterranean and Western Pacific Re- shown: the first at 6 -9 per thousand, corresponding gions are similar to each other; however, the former to countries with a young population and fairly devel- has an earlier, secondary peak for its least developed opedhealthservices,thesecondat14 -17per countries whereas the later, secondary peak in the thousand for many developing countries, and the Western Pacific Region corresponds to the most de- third at 22 -25 per thousand for countries where the veloped countries : Australia, New Zealand, and Japan. health system does not yet serve a high proportion of Africa alone constitutes a third category, with the the population. The developed countries are situated lowest life expectancy. For the world as a whole the between the first two peaks. distribution reflects the classical difference between Graph 2 also reveals three types of country according developed and developing countries. to life expectancy. The Region of the Americas and The figures for South -East Asia should be inter- Europe have the highest life expectancy but in the preted with caution as they are based on a sample of Americas there is an earlier, secondary peak for the only 27.5 %. developing countries of Central and South America. Graph 3 shows the percentage distribution of demo-

GRAPH 3.PERCENTAGE DISTRIBUTION OF POPULATIONS BY DEMOGRAPHIC GROWTH RATES IN THE WHO REGIONS (1970 or latest available data)

Percentage of population to Total which the population 100 calculation (millions) 80 AFRICA applies 60 87.0 234.6 40 20 0 //f'f4,:w. 80 AMERICAS 60 99.5 509.5 40 20 0 80 SOUTH -EAST ASIA 60 99.9 761.0 40 20 o 80 - EUROPE 60 - 100.0 769.7 40 - 20 - 171/1715,.,,.....1 o 80 - EASTERN MEDITERRANEAN 60 - 7 98.2 284.7 40 - 20-

0 ' 80 - WESTERN PACIFIC 60 - 100.0 1049,0 40 - 20 - %//f/Sf.j %///i..,,>i o 80 - WORLD 60 - 98.9 3608.5 40 - r 20 - ,,// 0 //ii/ii 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5 Demographic growth rate ( %) WHO 40194 8 FIFTH REPORT ON THE WORLD HEALTH SITUATION graphic growth rates in the WHO regions. The general The analysis by country covers too short a period rate for Africa is slightly lower than the rates for the and includes too many uncertainties to be published. Americas and South -East Asia because the level of Nevertheless, it does indicate that the European coun- general mortality offsets the high birth rate.In the tries are homogeneous in that they all have rates below Americas, the two peaks distinguish the two sub- 1.2 %. Rates for the countries of the Western Pacific continents. The pattern for the world as a whole again Region vary from 1.4 % to 3.2 %. The Americas show reflects the difference between the developed and devel- a wider divergence, with rates ranging from 1 % to oping countries. 3.4 %. The Eastern Mediterranean has the widest, The information that can be derived from these with rates varying from 1 % to 4.2 %. It is noticeable three graphs is limited because several WHO regions that some small and comparatively isolated territories are heterogeneous with regard to levels of health and where the health and family planning services can of economic development. It would be useful to make reach the great majority of the population show a a detailed analysis of the differences in mortality rapid decrease in the demographic growth rate.This between urban and rural populations and between dif- might justify more decentralized action by the family ferent socioeconomic groups. Such studies are needed health services in order to obtain clearer results with to identify the vulnerable groups to which planners small population groups. should give priority.France, the United Kingdom, and the United States of America are conducting Mortality statistical studies of this kind, mainly with occupational groups.Such studies could profitably be extended Mortality rates by cause of death are known pre- to socioeconomic groups in developing countries, dis- cisely only in countries with well- organized registration tinguishing between subsistence farmers, cash -crop services and where a high proportion of deaths are farmers, workers in the tertiary sector (banks, insur- established by physicians capable of determining the ance, hotels, administrations), and manual workers. causes in accordance with the international classifi- The differences between the mortality rates for the cation and filling in correctly the standard certificate regions are more stable than was believed between recommended by WHO. Moreover, the list of causes 1950 and 1960.At that time it was hoped that the of death is sometimes shortened, several causes being developing countries would fairly quickly close the grouped under the same heading. For these reasons gap separating them from the developed countries. it is premature to attempt comparisons between coun- This view has to be modified in the light of more recent tries on the basis of the data that appear in Part II of figures. It seems that after the rapid drop in mortality this report. observed between 1950 and 1960 a "consolidation" An attempt has therefore been made to present period is needed and that a further decline in mortality these data in a new way, so as to give an impression, will depend on conditions largely beyond the control not of the absolute number of deaths by cause, but of of the health sector. the classification by order of importance of causes of Itis impossible to determine the trend in the death that governments could draw up and use to guide demographic growth rate over so short a period as their health action programme.Graph 5 has been 1969 -1972. The figures supplied by the countries do not prepared by the following method: deaths by cause seem to show any general tendency towards a lower notified by governments for 1971 or 1972 have been rate. This impression is confirmed by the calculation added up for each WHO region (data for Africa were of the annual growth rate based on data published in not available) and ranked in order of importance; a the United Nations Demographic Yearbook, 1971. histogram was made for each main cause, the ranking The following table shows the development of this of that cause in the region being indicated by its posi- rate by five -year periods from 1950 to 1970 in the tion on a scale marked from 1 to 20. For example, the different geographic areas of the world (see also cardiovascular diseases are responsible for more deaths Graph 4). than any other cause in the Region of the Americas and in Europe; those regions are therefore highest 1950- 1955- 1960- 1965- 1955 1960 1965 1970 (ranking 1) in the "heart diseases" graph. However, these diseases occupy only the second place in the Eastern Mediterranean and third place in South -East World 1.82 1.98 2.05 2.08 Asia and the Western Pacific Regions. Malignant neo- Africa 2.21 2.40 2.44 2.70 plasms are not the principal cause of death in any 1.93 1.87 1.51 1.31 North America region but they take second place in the Americas and Latin America 2.96 2.90 3.09 3.01 Asia 1.95 2.12 2.28 2.54 Europe. This graph also shows the universal nature of Europe, including USSR 1.12 1.16 1.16 0.86 some causes of death, such as obstetric and perinatal Oceania 2.40 2.41 2.15 2.17 accidents. These causes appear between the eighth and DEMOGRAPHY, MORTALITY, AND MORBIDITY 9

GRAPH 4. MEAN ANNUAL DEMOGRAPHIC GROWTH RATES BY GEOGRAPHIC REGION IN FIVE -YEAR PERIODS, 1950 -1970

LATIN AMERICA

ASIA OCEANIA

NORTH AMERICA

EUROPE, including USSR

WHO 40196 fourth positions, and are therefore of worldwide im- cations of causes of death are illustrated by the fact portance. The successful treatment of tuberculosis in that the diagnosis "symptoms and ill- defined condi- Europe is shown by the fact that the disease has been tions" occupies first place in three regions.Europe relegated to thirteenth place, whereas it occupies fourth sets a good example by relegating this confession of place in South -East Asia.Influenza is regarded as a imprecise diagnosis to seventh place. main cause of death in only two regions, which brings It must be repeated that the graph does not express out the importance of a more standard definition at the absolute figures -for example, two causes occupying worldwide level.Finally, the shortcomings of notifi- third and fourth places in a region may be separated io FIFTH REPORT ON THE WORLD HEALTH SITUATION

GRAPH 5.RANKING OF 16 CAUSES OF DEATH IN FIVE WHO REGIONS (1971 or 1972)

DYSENTERY AND TUBERCULOSIS MALIGNANT NEOPLASMS DIABETES ENTERITIS (B5 -6) (B 19) (B 21) (B3 -4) 4 6 8 10 12 14 16 18 20

AVITAMINOSES CEREBROVASCULAR MALNUTRITION HEART DISEASES DISEASE INFLUENZA (8 22 ) (B27 -29) ( B 30 ) (B31)

4 6 8 10 12 14 16 18 20

CIRRHOSIS OF PNEUMONIA BRONCHITIS THE LIVER NEPHRITIS (B 32) (B 33) (B 37) (B 38) oc2 4 6 8 10 12 14 16 18 20

OBSTETRIC AND SYMPTOMS AND PERINATAL ACCIDENTS ILL - DEFINED CONDITIONS ACCIDENTS SUICIDE (B41 -44) (B 45) (BE 47- 48) (BE 49 ) 2 4 6 8 10 12 14 16 18 20 A BC D E F uNO 40193

A= Africa B= Americas C= South East AsiaD = EuropeE= Eastern MediterraneanF= Western Pacific DEMOGRAPHY, MORTALITY, AND MORBIDITY 11

either by a considerable difference or merely by a few The data used here are derived from information units -but it does have the merit of drawing the atten- supplied to WHO by governments and used for pre- tion of governments, grouped by WHO region, to the paring the World Health Statistics Annual.On the priority to be assigned to the leading causes of death. basis of these data, which are also reproduced in Part II, Communicable diseases, with the exception of tuber- Graph 6 has been prepared by the same method as culosis and influenza, have not been taken into account Graph 5, with the inclusion of the African Region. as causes of death. The reason for this is that the lists However, some changes have been made: typhoid and communicated by governments rarely mention the paratyphoid fevers have been grouped together, as have common infectious diseases as causes of death, since bacillary and amoebic dysentery and enteritis.Small- the underlying cause is not often given. Thus measles pox and cholera have not been taken into consideration. or whooping -cough rarely appear as causes of death, The graph covers the following populations, in since the death of the infected child is most frequently thousands, by region, in1971or1972: attributed to the terminal bronchopneumonia. The graph is based on the following numbers of Africa 41780 Americas 137469 deaths by region in1971 1972: or South -East Asia 46337 Europe 343570 Africa (not available) Eastern Mediterranean 89530 Americas 871795 Western Pacific 89426 South -East Asia . . . , 227290 Europe 2865244 Total 748112 Eastern Mediterranean . 60363 Western Pacific 372836 The differences between countries in the lists of Total 4397528 diseases subject to compulsory notification, combined with the fact that more than half the countries failed Clearly the ranking of causes for Europe is more to reply to the questionnaire for this report, make it likely to be correct than that for the Eastern Mediter- impracticable to base a picture of morbidity in the ranean, where only a minority of countries provided world as a whole on these replies. an analysis of causes of death. For the world as a whole Nevertheless, the position occupied by each of the the ranking of causes of death would obviously be 21diseases in the ranking list in order of importance influenced by the weight of the European figures and by region reflects the priority that national health is therefore not given in the graph. authorities in each region might assign to those diseases This presentation has many faults but it is hoped in their programmes. The graph shows the universal that it will encourage governments to improve their nature of some diseases, such as tuberculosis, whooping - health statistics by showing them that such statistics cough, infectious hepatitis, and gonorrhoea, which can be used for determining the major priorities for occupy high positions in all the regions. Other diseases, health action at the country, regional and worldwide such as trachoma, trypanosomiasis, schistosomiasis, level. rabies, typhus, and relapsing fever, are notified or present in only a few regions.Finally, there are dis- Morbidity eases which, although present in all regions, do not have high priority anywhere; examples are diphtheria, General morbidity statistics are either very incom- leprosy, and poliomyelitis.Graph 6 brings out the plete or nonexistent in most countries. The morbidity anomalies in the notification of diseases that are clearly statistics for hospital patients vary in value. They are universal, such as meningococcal infections, influenza, fairly satisfactory when the diagnosis is made on the and measles, none of which has been reported from patient's discharge, less reliable when the diagnosis is South -East Asia. made on admission; they ignore the private sector and The21communicable diseases and 16 leading causes reflect only morbidity that has led to admission to a of death selected for preparing Graphs 5 and 6 are public hospital bed, not general morbidity.Finally, by no means representative of general morbidity. the figures recorded depend to a great extent on the Moreover, there are many countries, or areas of coun- number of hospital beds.In countries where prac- tries, where diseases that do not appear in the above tically all requests for hospitalization are met, the sta- analysis take first priority.Onchocerciasis, which tistics have a definite value and can be used to guide affects more than half the inhabitants of the African planning. On the other hand, where the hospital bed savannas, and filarial infections, which cause disabling potential is notoriously inadequate the criteria for oedemas among 30 % of certain population groups in admission are based more on the severity of the case India, Sri Lanka, and Polynesia, represent the leading than on the nature or curability of the disease. health hazard for those living in the affected areas and 12 FIFTH REPORT ON THE WORLD HEALTH SITUATION

GRAPH 6. RANKING OF 21 NOTIFIED DISEASES IN THE SIX WHO REGIONS (1971or1972)

TYPHOID AND DYSENTERIES AND PARATYPHOID FEVER ENTERITIS TUBERCULOSIS LEPROSY (A2.3) ) A4-5 ) (A6 -10) (A 14) 2 4 6 8 10 12 14 16 18 20 22 STREPTOCOCCAL MENINGOCOCCAL DIPHTHERIA WHOOPING COUGH SORE THROAT AND INFECTION (A 15) (A 161 SCARLET FEVER (A 19) (A 17) 4 6 8 10 12 14 16 18 20 22

POLIOMYELITIS INFECTIOUS HEPATITIS (A 22) (A26)

4 6 8 10 A= Africa 12 B= Americas 14 16 C=South -East Asia 18 20 D= Europe 22 %%A E= Eastern MALARIA TRYPANOSOMIASIS RELAPSING FEVER SYPHILIS Mediterranean (A 31) (A 35) F= Western z 2 Pacific 4 6 8 10 12 14 16 18 20 22

WHO 40200

GONOCOCCAL SCHISTOSOMIASIS INFLUENZA TRACHOMA INFECTIONS (A 90) (076.077) (A 38) (A39)

6 8 10 12 14 16 18 20 22 A BC D E F A B C D EF DEMOGRAPHY, MORTALITY, AND MORBIDITY 13

the first priority for the health services that serve them. diagnosis on the measurement of blood pressure, blood Although schistosomiasis appears in Graph 6, its cholesterol, and comparative body weight, and on the position does not reflect the hazard it presents for some interpretation of the electrocardiogram and of indi- populations living alongside canals and watercourses vidual habits with regard to diet, tobacco and alcohol infested by the snail vectors. consumption, and physical activity. It is expected that These comments were called for in order to stress efforts to advise on diet and the way of life, coupled- the gaps in the available information. The above ana- if necessary -with drug treatment of hypertension, lysis has two main objectives: to make it possible to will exert a positive effect in the prevention of cardio- direct country and WHO programmes towards the vascular complications. priority diseases, and to encourage the health services It may therefore be hoped that community pro- of countries to assess the causes of death and morbidity grammes can be applied to the most vulnerable groups: more accurately. men aged35 -65and women aged45 -65with at least Some of the leading causes of death and most fre- two risk factors should be kept under regular surveil- quently notified diseases, which have the most striking lance, and should receive therapy to control their socioeconomic consequences and which WHO and hypertension. Primary prevention, however, should be governments have made special efforts to control, are started early in life. discussed individually below.

Cancer Cardiovascular and cerebrovascular diseases Research aimed at a better understanding of the The major part of this group of severe diseases with factors liable to produce cancer has developed in great serious social consequences is due to atherosclerosis, variety, both in countries, some of which have shoul- a disturbance in biochemical mechanisms probably dered substantial financial burdens for such research, at the cellular and molecular level.Arterial hyper- and at the international level.It would be unfair to tension, the result of disturbed regulation of blood compare the scope of these efforts with the modest pressure, is another prominent causative factor of results that have been obtained, since many studies heart and vessel disease; its importance stems from its will have to be carried out on a large number of sub- high rates of occurrence. The cardiovascular compli- jects over many years before they bear fruit.It is also cations of rheumatic fever and of various infections, hoped that progress in basic research will be recognized though in general regressing as a result of treatment as a prerequisite for advances in cancer control. The and rising standards of living, still present important impressive efforts in the fields of early detection, health problems in many countries. surgery, radiotherapy, chemotherapy, hormonal ther- Basic research has not yet clarified the mechanisms apy, and immunology must continue. of atherosclerosis and of essential hypertension. Fun- At present the methods of treatment are generally damental laboratory research is being conducted in combined, which means that treatment has to be many countries; also, studies of entire populations carried out by a multidisciplinary team.Cures and using methods of active and not merely descriptive long -term remission are becoming more frequent, and epidemiology are being carried out in practically all the period1969 -1972was associated with improvements parts of the world. These investigations are also being in diagnostic and therapeutic methods and with the extended to children, in whom the precursors of athe- establishment of more clearly defined procedures. rosclerosis are expected to be detected at an early stage. In recent years, working hypotheses have converged towards practical approaches to a better definition of Mental diseases risk factors and earlier diagnosis, and it is hoped that effective prevention of the major cardiovascular dis- Mental health is referred to on many occasions in the eases will result. country reports in Part II.Apart from the mental The principal risk factors are: high levels of choles- diseases and disorders associated with various patho- terol and other fats in the blood, indicating a disorder genic factors, there is a psychiatric component in of lipid metabolism; high blood pressure; cigarette criminality, delinquency, the education of children and smoking and alcoholism; and diabetes.Though the adolescents, traffic and occupational accidents, the presence of a single risk factor does not constitute medical and occupational rehabilitation of the handi- immediate danger, the risk increases exponentially if capped and the disabled, the abuse of narcotics and several factors are associated. other drugs, alcoholism, and certain group phenomena. This viewpoint governs the planning of population The governments of the developed countries spend surveys, health education of the public, and the training substantial amounts on mental health services -one- of health personnel. It makes it possible to base early third of the public health budget in the United States 14 FIFTH REPORT ON THE WORLD HEALTH SITUATION of America is absorbed by this sector -while the devel- the role of the psychiatrist is to teach, to advise, to oping countries have only very limited facilities for manage, and of course to treat the most difficult cases. looking after their mental patients. In many cases these The psychiatric team must obtain the cooperation of facilities consist of a single hospital with a few hundred general practitioners and in some cases of community or thousand beds for accommodating patients regarded leaders such as teachers, priests, and, where appro- as dangerous to society, and there are insufficient staff priate, traditional healers. to look after them, prepare them for discharge and This broad reform has repercussions on the teaching reintegrate them into society. The situation is clearly of physicians and auxiliaries and on the health educa- shown in the replies by countries to the questionnaire tion of the public. Considerable efforts need to be made and from statistics on the utilization of such services in these areas since, apart from the developed countries compiled by some countries and by WHO. where medical students still receive too little teaching The period 1969 -1972 saw the appearance of new in psychiatry, there are countries where half the schools trends and the strengthening of ones already existing of medicine provide no psychiatric training at all for in previous years. A large number of surveys have their students. shown that the prevalence of psychoses is roughly New drugs and other forms of therapy capable of comparable from one country to another. The pre- changing the behaviour of patients and preventing valence of severe psychiatric cases is about 1 %, and acute epileptic attacks; new techniques in medical shows little variation. The treatment of mental patients teaching; a deeper knowledge of the etiology and epi- is no longer based solely on hospitalization, which is demiology of mental diseases and the accompanying justified nowadays only for the most acute or severe neurochemical and physiological phenomena; and the cases -patients who are best treated by new forms of development of the theory of the organization of therapy such as protected workshops, psychotherapy, mental health services and public health services in and psychotropic drugs.The general hospital may general: these are the elements that have made it therefore include a psychiatric service and should have possible to advance the concept of mental health in a team of specialist staff to deal with mental cases and a specific direction. to assist with cases that may occur in other depart- This has many implications that affect all countries. ments, such as the obstetrics department for psychiatric There are areas on the fringe of psychiatry, i.e., psy- disorders accompany the chological problems, that psychiatry can help to solve. ments of medicine and surgery for suicide cases, the An example is the behaviour of migrant populations tuberculosis department for tuberculous mental pa- experiencing cultural changes. Economic forces, not tients, and the dermatology department for patients to mention political events, nowadays affect millions with pellagra or leprosy.The psychiatric hospital of people who move suddenly from country to town, services are supplemented by a network of institutions from farming by archaic techniques to jobs in industry, providing outpatient care -mental health clinics, day from one country to another, from a village hut to a hospitals, night sanatoria, protected workshops -and shanty town, from an individual house to a shared domiciliary care. The result is a rapid decrease in the dwelling, and who are immersed in an unfamiliar ethnic number of beds in traditional psychiatric hospitals. and cultural environment. It has by no means been A potential of 1 -3 beds per thousand inhabitants is proved that such stresses lead to psychoses, but it is regarded in some quarters as reasonable, and one per obvious that they can seriously disturb behaviour and 10 000 as a minimum, not counting the institutions for cause disorders, driving people to dissociate themselves people with moderate or severe mental deficiency, for from the community and indulge in aggressive and the criminal and insane, and for the senile insane, who delinquent behaviour. Mental health services have a pose problems that for planning purposes are now considerable part to play here. considered separately. The trend towards integration is predominant, not only within the mental health services but also within the general public health serv- Tuberculosis ices.Although the network of mental health institutions providing outpatient care is much more effective, Between 1969 and 1972 the tuberculosis control pro- it certainly requires more staff and probably more grammes in the developed countriescontinued to make money, despite the savings from the reduction in the progress, but at a different pace. The mostreliable and number of hospital beds. most simple statistical index of the magnitudeof the Auxiliaries or assistants are playing an increasing tuberculosis problem is the annual rate of risk of tuber- role in the psychiatric team.There are not enough culosis infection.In several developed countries the physicians specializing in psychiatry to deal with all rate reached 0.5 % between 1969 and 1972,dropping contacts.Moreover, it seems that this is not always by about 10 % each year; it is thus halved every 5-6 necessary.In the developing countries, particularly, years.However, a considerable proportion of devel- DEMOGRAPHY, MORTALITY, AND MORBIDITY 15 oped countries have not yet reduced this risk to less to measure.Moreover, although malnutrition has than 0.5 %.In these countries the fall in the rate is serious repercussions on health, the solution of the slower and seems to be between 2.5 % and 7.5 problem does not depend only on the health authorities annually.It will therefore take them much longer to but requires a broad multisectoral approach.The halve their risk rate.In some developing countries production of food of adequate quantity and quality, where the annual risk rate is higher than 2 %, it has and its consumption and biological uses, depend on remained constant for 10 years.Unless BCG vacci- a large number of socioeconomic and technological nation is intensified and other measures are put into factors. effect, the gap between the developed and developing National mortality statistics rarely mention under - countries will widen, as in other fields. nutrition as a cause of death.The Inter- American In the developing countries the prevalence and inci- Investigation of Mortality in Childhood, conducted in dence of tuberculosis are still very high, and the data 18 widely differing areas of the Americas and sponsored are extremely poor.The fact that tuberculosis has by the Pan American Health Organization, indicated dropped in the ranking order of diseases and causes that malnutrition was the underlying cause of death in of death does not mean that its economic and social children under 5 years in 7 % of cases and an associated importance has decreased accordingly.Tuberculosis cause in 46.2 % of cases.' A recent analysis of data patients still represent a heavy social and economic from 101 community surveys in 59 countries indicates burden for a community. that at least 100 million children under 5 years are Two further indices regarded as most reliable for suffering from moderate to severe types of protein - measuring the magnitude of the tuberculosis problem calorie malnutrition in the developing countries, which are the prevalence of individuals with Mycobacterium might deprive them of their full physical and mental tuberculosis in their sputum who can be detected by potentialities. Xerophthalmia, endemic goitre and direct microscopy examination, and the prevalence of cretinism, and nutritional anaemia are other examples tuberculosis infection by age group. From the latter of the widespread ravages caused by malnutrition, not rate, if measured repeatedly, the annual risk of infec- only in the form of high mortality but through human tion can be calculated. It is hoped that further research suffering and lowering of the quality of life of those will disclose epidemiological parameters that could be who escape death. used to quantify the relationship between the infection Malnutrition has become even more important to- risk and the risk of developing disease subsequently day, and will remain very important for years to come, (in terms of frequency, time interval, age dependence, owing to rapid deterioration in the food and nutrition etc.). status of a vast segment of world population. There Prevalence of infection by age group can be used for has been a reversal of the trend towards nutritional planning BCG vaccination campaigns for the most improvement in the developing countries associated vulnerable groups.These campaigns have become with a general decline in the quality of life, the conse- more effective since freeze -dried vaccine came into quences of which will have to be faced by the health general use.But preventive measures are not alone services of the affected countries.All these factors sufficient: the treatment of patients is the other require- demand a new dimension of innovative action. ment for reducing transmission. It has been shown that chemotherapy is effective provided that it is carried Smallpox out in accordance with the standard schedule. Trials made by the Tuberculosis Chemotherapy Centres in The period 1969 -1972 will go down in history as marking an offensive that may lead to final victory over Madras and Prague, by the International Union against Tuberculosis, and by the British Medical Research smallpox by the end of 1975.Since April 1971, the Council in East Africa are decisive in this respect: date of the last case notified in Brazil, the American hemisphere has been regarded as free from this age -old within one year the sputum of patients becomes nega- scourge. The offensive was made possible by cooper- tive in 85 -95 % of cases. The annual cost per case in ation between countries, which have adopted a com- 1970 was estimated at US $14 for the drugs administered daily, and between $7.60 and $22.76 for the mon approach based on scientific practices and con- intermittent treatment depending on the combinations cepts. These are: of drugs used. - the use of the forked needle, whose superiority over the vaccinostyle and injector was shown in 1968; Malnutrition ' See PUFFER, R. R. and SERRANO, C. V. Patterns of mortality Malnutrition is one of those problems that are of in childhood, Pan American Health Organization, Washington, undeniable qualitative importance but are very difficult 1973 (PAHO Scientific Publication, No. 262). 16 FIFTH REPORT ON THE WORLD HEALTH SITUATION

--- the concentration of efforts on vulnerable groups, of complete eradicationisreached as soon asis those never successfully vaccinated and all communities hoped. in which a focus is discovered; - the establishment of a system ofcontinuous and Cholera active surveillance using all available means and con- Between 1969 and 1972 cholera continued to be a stant reconnaissance to locate new foci, which are then serious hazard for Asia and Africa and a threat for subjected to intensive community vaccination. Europe.As in the preceding years, the number of notified cases varied considerably according to time Changes in the number of smallpox cases are difficult and place. After the lull in 1967 and 1968 a progressive to determine precisely, because of continuous improve- tendency manifested itself in 1969, together with a ment in the completeness of notifications.It was substantial territorial expansion, and cholera once estimated in 1967 that only 5 % of cases were notified, again became a major public health problem.The but by 1971 the proportion was estimated to be 20 -25 %. 1970 -1971 epidemics affected many new countries and Thus, from 1967 to 1971 the real number of cases may territories; 171 329 cases, including 102 083 in Asia be considered to have fallen from 2.5 million to 200 000. and 69 125 in Africa, were notified in 1971 alone.In In 1973 the number of cases notified was double the 1972 a new plateau was reached: no new territory was figure for 1972, but this increase may have resulted invaded and the number of notified cases dropped to from a still further improvement in notifications. 81 166, although that isstill a substantial increase A more reliable measure would seem to be a count over 1969.Moreover, the disease tends to establish of countries and their administrative subdivisions itself in the countries it invades and to become endemic, where cases occur. During the period 1967 -1972 the especially in Africa, where little is known about the number of countries where smallpox was endemic situation. dropped from 30 to seven.In 1973, 116 647 notified The countries at present free from the disease should cases, representing 87 % of the world total, occurred be divided into two groups. Some countries, generally in communities with a total population of only 275.5 with a low level of economic development, are recep- million. tive to cholera because the conditions for its spread are Smallpox foci have disappeared from West Africa, latent there, i.e., a high proportion of the population South America, and Indonesia. The disease was still has no access to safe water or to proper excreta rife in Bangladesh, Botswana, Ethiopia, India, Nepal, disposal facilities.However, the risk of invasion by Pakistan, and the Sudan in 1972. It remains a constant the cholera vibrio remains low since these countries are threat for all countries, but there is good reason to not affected by the major migratory movements from believe that a permanent warning system and vigilance the infected areas; Latin America is one such case. by national health authorities would make it possible The other countries, which generally are economically to seal off and extinguish foci due to imported cases developed, are vulnerable because they are visited by in a short time.It is appropriate to highlight the a large number of travellers from the endemic zones. interest taken in smallpox eradication by most govern- However, their comprehensive water supply and sewage ment health services and the determination that is disposal, systems enable them to seal off foci as soon being shown in all countries where the disease is still as they appear.It should be added that these latter endemic. Through this determination, the worldwide countries have facilities for rapid diagnosis, an early eradication of smallpox seems feasible by 1975 if warning system, and epidemiological teams who trace social and economic conflicts do not thwart the action contacts and treat them adequately and swiftly. programme of the health services. Member States of WHO have acquired the know- Research has continued to determine if there could ledge and confidence needed to control cholera them- be reservoirs of the virus that might be responsible for selves, and WHO has received few requests for emer- the reappearance of smallpox in areas where trans- gency assistance.Vaccination, the effectiveness of mission from man to man, the only proven mechanism, which is controversial, enjoys only limited confidence, has been interrupted. None has been found. Research and some countries have successfully controlled the on monkeypox has shown it to be no problem although disease solely by the temporary isolation of suspected some human beings are susceptible to it. Since nomad- groups and the control of water and foodstuffs, com- ism, the geographic isolation of some human combined with education of the public. Cholera vaccination munities, and the intensification of trade increase the ceased to be compulsory in international health con- difficulties of identifying all cases and maintain the trols as from 1 January 1974. The disease no longer danger that foci will persist, the WHO warning system arouses the same terror as in former times because, of and the vigilance of national services will remain indis- advances in therapy, but the lethality rates, generally pensable, probably until after 1980, even if the objective 7 -10 %, are still high in remote areas. In some countries,. DEMOGRAPHY, MORTALITY, AND MORBIDITY 17

warfare and economic regression have favoured the for consolidation are prematurely restricted malaria appearance of epidemics.Bangladeshi refugees in immediately stages a counter -offensive.In several India have been severely affected, since they account zones it has been necessary to return to the attack for 51 000 of the 71 386 cases notified by India. How- phase.In South -East Asia malaria is resisting, espe- ever, the epidemic in Indonesia, with 23 555 cases in cially in a few large cities. Sri Lanka is an unfortunate 1971 as against about 6140 in 1970 and 627 in 1969, example of the consequences of too early an interrup- does not seem to be related to social or economic tion of surveillance.The countries of the Eastern upheavals.Africa proved particularly receptive in Mediterranean present a variety of situations ranging 1970 -1971 in certain limited areas where the infection from apparently complete eradication to a high level rate (80 -115 per thousand) was much higher than the of endemicity.The countries of the Western Pacific figures generally observed in Asia (2 -20 per thousand). seem determinedtocarry on long -term control The proportion of severe cases and the fatality rate measures. were also higher, at least at the start of epidemics. Nothing has happened to change the view that Other parasitic diseases cholera is still a threat for communities with a low socioeconomic level and high population density. The slowness of the progress made in schistoso- Drinking -water supply, proper sewage disposal, and miasis control results from the chronic nature of the health education remain in principle the three pillars infection in man and also the difficulty of allocating of the control of this disease.However, vaccination adequate credits for more or less limited districts in the should not be abandoned until these three conditions countries Affected. It is well known that there has been are fully achieved. The quality of some vaccines could a recrudescence of the disease following the creation be improved. The addition of aluminium hydroxide of an increasing number of artificial lakes, such as seems to prolong immunity.Research on a cholera Volta Lake in Ghana, Lake Nasser in Egypt, Kainji toxoid is not complete. Lake in Nigeria, and the Euphrates dam in Syria. Surveillance, rapid warning, more widespread use In the case of onchocerciasis also the long duration of rehydration treatment, and vaccination remain the of the disease, which renders those affected liable to available weapons against epidemic outbreaks in the transmit Onchocerca volvulus through the intermediary developing countries.These concepts are perfectly of the blackfly over a period of 15 years, and the fact understood by the countries, but the solution of the that the infected territories cut across national bound- water supply problem requires such enormous efforts aries, make it difficult to carry on a successful cam- that the eradication of cholera may take many years. paign. A major international control programme is Vaccination will continue for a long time, especially if under way to meet these difficulties in the Volta River laboratories are able to produce more reliable and Basin area, the main focus, which includes no fewer effective vaccines or toxoids. than seven countries. Like so many other diseases, filariasis affects the populations of the unplanned suburbs of large towns, Malaria apart from the endemicity that reigns over huge rural The efforts made by the governments of countries areas. where malaria has been a major obstacle to 'development have borne fruit, since it is estimated that at the Venereal diseases end of 1972 nearly 40 % of the population previously exposed to infection had been liberated from this The incidence of the venereal diseases continues to scourge, and that about 25 % ran a lesser risk of con- be high in most countries. Variations from country to tracting the disease. The remainder, rather more than country seem to be considerable, but it is difficult to a quarter of the people at risk, can sometimes be given assess what proportion of cases are notified as com- antimalarial drugs. pared with those treated by general practitioners and Nevertheless, progress remains slow and uneven. those even treating themselves using drugs sold without The African continent poses the most serious challenge prescription.It became clear during the period 1969- because of the dispersion of the population in its huge 1972 that the efforts of the health services and the forests and savannas.Thirty per cent of consultations effectiveness of treatment were not attenuating the in health centres and 10 % of admissions to hospital danger caused by changes in the behaviour of adoles- are motivated by malaria, and it is possible that the cents and young adults, immigrant workers, and toll exacted by the biological combination of haema- certain other social groups. tozoon and anopheline is as many as a million child It should be recognized, moreover, that advances in deaths per year.In Central and South America real means of diagnosis and treatment have, on the one advances have been made, but when financial resources hand, shown that an increasing number of cases of 18 FIFTH REPORT ON THE WORLD HEALTH SITUATION genital infection are not caused by the specific organ- workers in certain industries. Authorities have at their isms, gonococci or treponemes, and, on the other, disposal a number of means for developing dental reduced considerably the risk of serious late compli- health services, but two major areas of development cations without, however, abolishing them. are fluoridation of drinking -water and the training of auxiliaries. Dental lesions In many countries a large proportion of dental Lesions of the masticatory system are very wide- services are provided in the private sector. However, spread and affect the great majority of people. When efficient and effective delivery of public dental health they involve most of the teeth, whether in the form of services, including private practice, relies on rational caries or of periodontal degeneration, they cause real provision of facilities and removal of the financial disability and consequently create a considerable barrier to obtaining those services.The former may demand for care on the part of the population. include polyclinics, health centres, clinics in schools The health authorities are therefore obliged to organ- and industrial centres, and group practice. The finan- ize dental services, although the demand itself is often cial barriers may be removed or reduced by health very small compared with actual needs as revealed by insurance or social security systems. the extremely high morbidity.In their replies to the The information available is too fragmentary to questionnaire for this Report countries mentioned the serve as a basis for compiling a general table showing numbers of staff engaged in dental health services, the situation in a sufficient proportion of WHO with some specific comments on groups regarded as Member States, but this is an important problem that vulnerable -namely, children, pregnant women, and will become more urgent in the future. CHAPTER 3

ECONOMIC DEVELOPMENT AND THE ORGANIZATION OF HEALTH SERVICES

Economic development leading to an increase in emerge and grow in all market economy countries gross national product (GNP) at constant prices undergoing rapid and substantial development. continued in most countries, the mean rate being 5.12 The proportion of their family consumption budget per year from 1960 to 1970 in the developed countries that households spend on a private basis for health is with a market economy. However, because of popu- definitely increasing, even in countries where social lation growth, the mean rate per capita was lower and security schemes cover almost all the population and came to 4.0 % in the same countries. There are consid- most of the medical care expenses. erable variations between the different nations; thus Bearing in mind that both government expenditure the Libyan Arab Republic recorded an annual growth (including compulsory social insurance) and household rate of 25.1 % from 1962 to 1969, while in Japan the expenditure on health are increasing in relation to figure was 10.9 % from 1960 to 1970. Uruguay is among GNP it is not surprising that their total, representing the countries with a slow rate of development, the all health expenditure, is increasing still more rapidly. figure being 1.0 % from 1960 to 1970, giving a negative It seems, in fact, that health expenditure between 1950 per capita rate of -0.3 %. and 1955 represented about 4 % of GNP.It is now The priority given in most market economy countries 6 -8 % in most of the developed countries, and certain to economic development has led social planners (parti- forecasts predict that 10 % will be reached between cularly health planners) to fear that their sector will be 1980 and 1990. neglected or held back.There has been no lack of Such a total, consisting of two parts, one public and studies and warnings to remind economists that the the other private, the dividing line between which is productivity of a population is linked to its health vague because of transfers for which social security is level, but this argument is only fully effective in periods essentially responsible, is therefore of distinct economic of full employment.Unfortunately, unemployment importance. Health manpower, which may exceed 1 and underemployment are widespread in most of the of the total population and 3 -4 % of the working developing countries, and industry, which is as yet population, receives wages and pays taxes. What some little developed, runs no risk of shortage of unskilled call the "health industry" absorbed more than 60 000 manpower. In regard to agriculture, which remains million dollars in 1971 in the United States of America the chief activity of many countries, the situation is and 4000 million in Canada. In those countries this more complex since the manpower requirements are "industry" employs 5 % of the working population. seasonal. The building and equipping of hospitals count as Nevertheless, it would seem that economic develop- investments and gross fixed capital formation. Hospital ment has encouraged the expansion of the health construction (continually more expensive) may be services in two ways. On the one hand, public health regretted by public health experts whose preventive services have for the most part received increasing programmes are jeopardized, but it benefits the build- sums from governments or -when itexists -from ing trade as well as the mechanical and electrical indus- social insurance, whose budget is closely linked to the tries. The budgets for the running of health establish- national product through the contributions of the wage ments principally belong to the commercial sector, even earners. On the other hand, economic development of in the case of public institutions. the market economy type rapidly increases the resour- Consequently itis not surprising that economic ces of that part of the population participating therein, development can, under some conditions, compromise as well as employees and managers in the very rapidly the preventive medicine sector by encouraging the growing tertiary sector (banks, insurance, hotels, ad- growth of a private commercial sector.It may even ministrations). In the Republic of Korea, for example, happen that public health institutions, especially hos- the wages of industrial employees increased faster than pitals, are converted into establishments admitting an the cost of living from 1966 to 1969. The existence of increasing number of paying patients, and limit corre- this privileged population group leads to the appear- spondingly the places for indigent patients, who remain ance of a private commercial sector, which is found to the majority in the developing countries. This pheno- - 19- 20 FIFTH REPORT ON THE WORLD HEALTH SITUATION menon is clearly shown in the WHO Executive Board's my firms.This class encourages the development of organizational study on methods of promoting the private medical practice and of clinics for paying pa- development of basic health services : tients run by newly trained physicians whose moderate official salaries do not encourage them to work full ...in many countries the `private' sector is the domi- time in the public health services. nant one... This may apply especially to the developing world. It could be thought of as an advantage, - The share of the ministry of health budget absorbed as the government need not face the direct expend- by the hospitals increases with the construction and iture... The dangers inherent in this state of affairs entry into service of new hospitals, the most expensive are not fully appreciated.' of which are often built as part of foreign aid programmes.The ministry then considers imposing a Coordination between the public and private sectors hospital day price for patients with some financial It does not neces- is consequently an essential step. means. In the absence of hospital legislation concerning sarily imply direct control of private establishments by public and private hospitals the situation becomes the health authorities when a social insurance system confused.At this stage the largest commercial and has been installed, for through the approval ( "accredit- industrial firms begin to take over the medical ex- ation" in the United States of America) of the social penses of their staff so as to retain the technicians and security funds, the granting of which is a condition of administrators they have trained.In practice, this their participation in the expenses incurred by their amounts to the setting up of mutual health insurance insurees, the health authorities can bring about an societies that are not bound by any general regulations. improvement in the quality of the care given in private Moreover, these firms may enter into contracts, pref- establishments and an element of competition that is erably with private hospitals, and the public hospitals This shows once again the likely to be beneficial. draw hardly any benefit from the new sources of funds. capital importance of the elaboration of social legislation as soon as economic development starts to gain - The developing countries with a market economy momentum. thus find themselves following a path that leads either In the light of the situation that has been analysed to the gradual breakdown of the public health system in reports by WHO consultants during recent years or to the institution of compulsory social insurance in many developing countries, the steps followed by funds whose budget is shared between employers and the individual medical care systems can be traced: employees, possibly with government subsidies.This - At the outset the free health care system prevails. is a healthy development if the government organizes Only a very small part of the population -the richest it in good time by promulgating social laws and by -can obtain high quality care either abroad or in the laying the foundations for a rational organization of rare establishments managed by foreigners. The great public and private health services and mutual benefit majority of the population, essentially rural, has only societies, which should gradually merge to give a difficult access to urban hospitals because of poor limited number of social security schemes. This pro- communications, the inadequate number of beds, and cess makes it possible to defray the increasing costs of the lack of qualified staff. individual medical care without a proportional increase in state participation. The latter may even be decreased, - The exploitation of natural resources begun in the releasing credits for more intensive prevention cam- past by foreign concerns continues within the frame- paigns. During this step only wage earners and their work of bilateral cooperation. It is accompanied by an dependants are covered. Contributions are paid prin- improvement in communications. The spread of cipally by the employers, whether these are private preventive health services leads to a greater awareness firms or state undertakings, or by the government itself of disease and motivates an increasing demand by the for its officials. The coverage of independent artisans population for treatment. A growing part of the health may depend on their voluntary participation for some budget is absorbed by the public hospitals. time. As regards rural workers, they may be covered - The progress of economic development and the by agricultural cooperatives that are subject to effec- creation of industries lead to the appearance of a tive government supervision. Indigent families remain Iarge tertiary sector that recruits employees of a cer- the responsibility of the public authorities. tain intellectual level inculcated by the national education system.Between the rich property- owning This system applies to both the public and the private classes and the class comprising workmen, artisans, sector and is consequently compatible with private and peasants a third class appears, consisting of govern- medical practice. Most developing countries, whether ment officials and employees of private market econo- in Latin America, western Asia, eastern Asia, or certain parts of Africa, are following patterns of this

' WHO Officials Records, No. 206, 1973, p. 108. kind. ECONOMIC DEVELOPMENT AND THE HEALTH SERVICES 21

Table 1 gives for a number of countries total national to the questionnaire used in preparing this Report budget (column 2) and government health budget (see Part II), as are the national budgets employed in (column 3) as estimated percentages of GNP. Column calculating columns2and 4, except where the figure 4 gives the government health budget as a percentage in column2is followed by an asterisk. Because of the of the total national budget. GNP has been extra- great diversity of the monetary flows making up the polated for1971/72from the years1968, 1969and1970 overall budget for health costs, the greatest care is except where otherwise indicated.The government called for when using the table, where the figures are health budgets employed in calculating the percentages orders of magnitude rather than precise values. in columns 3 and 4 are those appearing in the replies

TABLE 1.TOTAL NATIONAL BUDGET AND GOVERNMENT HEALTH BUDGET AS PERCENTAGES OF GROSS NATIONAL PRODUCT, AND HEALTH BUDGET AS A PERCENTAGE OF NATIONAL BUDGET (1972 or latest available data)

National budget Health budget Health budget Country as % of GNP as % of GNP as % of Comments national budget

(1) (2) (3) (4) (5)

Belgium 26.5 * 3.42 12.9 Bolivia 49.8 1.17 3.56 Canada' 19 * 6.8 35.9 Central African Republic ...... 8.44 Chile' ...... 15.3 Cyprus 22.2 1.12 5.03 Czechoslovakia 61.88 * 4.86 7.86 GNP is replaced by gross material product Denmark 1 19 * 4.16 21.9 Dominican Republic . . . 16 1.37 8.6 El Salvador 12.5 1.46 11.6 Finland 1 21 4.41 21.1 France 1 18.3 8.0 21.9 including 40 % for the public authorities and 60 for health insurance GermanDemocratic Republic ... 4.06 ... GNP is replaced by gross material product Guyana 18 * 8.83 29.1 Hungary 44.2 3.58 8.1 GNP is replaced by gross material product Iceland 1 9 * 5.26 58.4 Ireland 1 17 3.89 23.03 Israel 67 1.94 2.9 Jordan 30 ' 2.84 9.5 Khmer Republic ...... 10.15 Libyan Arab Republic ...... 2.42 ... Malaysia 1 37 * 2.5 6.72 GNP extrapolated from 1969 New Zealand' 24.6 4.82 19.6 Norway 1 21.2 5.77 27.12 Panama 13 * 2.17 16.7 Paraguay 9 * 2.37 26.4 Poland 49.7 3.85 7.76 GNP is replaced by gross material product Senegal 18.7 1.71 9.12 Singapore ... 1.3 ... Sri Lanka 14 * 3.68 26.3 Sudan 23 * 0.67 7.34 Sweden 31.5 7.00 22.3 Thailand 19.5 1.16 5.97 Tunisia 21.9 2.07 9.48 Turkey 1 12 * 2.56 21.37 United Kingdom 25.59 3.8 14.9 Upper Volta 16 * 0.77 4.81 GNP extrapolated from 1968 Venezuela 23 4.26 18.4

1 The health budget expressed as a percentage of national budget (column 4) includes the health insurance budget, as recommended in the questionnaire. Based on information published in Tables IA and 2A in the Yearbook of National Accounts Statistics, Vol. III (International Tables), United Nations, New York, 1973 (ST /STAT /SER.O /1 /Add.2). 22 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Because of the complexity of socioeconomic devel- This field is largely unexplored and warrants a thor- opment national authorities and international organi- ough study of the different systems governing the zations will be obliged to make a study of the formation formation of health budgets.Several countries are of health budgets, the first step towards optimization considering making such a study. of expenses and investments. At the international level cooperation between ILO Reports from many countries show the distribution and WHO has led to progress in the financing of per- of their global health budget among the main sectors sonal health care expenditure. In terms of recent ILO of the health system (Table 3 on page 27 has been norms, the expression "health care" includes pre- drawn up on the basis of this information). On the ventive and curative care and medical rehabilitation. other hand, there is little information for determining A Joint ILO /WHO Committee on Personal Health the origin of the monetary flows that feed the budgets Care and Social Security that met from 10 to 16 covering health expenditure. The sources of informa- November 1970 in Geneva studied this problem, which tion are only partial and incomplete. Of course, it is has been solved in various ways in different countries.' known that the countries of Western Europe meet However, in all cases, participation of health insurance their health expenses from the budgets of the central, in personal health care has made possible the quanti- intermediate, and local governments, the compulsory tative and qualitative development of such care, and health insurance funds, private mutual benefit societies, has therefore improved its effectiveness. and payments made by patients themselves. But little A study covering nine countries of Western Europe is known about the actual sums involved. Their relative was made in 1971 and 1972 by the WHO Regional magnitude varies according to whether current ex- Office for Europe, and a symposium on the role of penditure or capital investments are involved. In social insurance institutions in preventive medicine France, for example, government budgets only play was held there from 23 to 26 October 1973.2The a very small part -that corresponding to services to study itself and the conclusions of the symposium the indigent -in financing the current expenditure of showed that the participation of social insurance in public hospitals. On the other hand, state financing several preventive medicine programmes applying to of investments may amount to as much as 40 %. individuals was already very considerable and that the Health insurance covers some three -quarters of the health insurance institutions were ready to continue current expenditure of public hospitals and about 30 collaboration within the limits of budgetary possi- of capital expenditure.Patients themselves pay for bilities. part of the care, either in the form of cost -sharing or Cyprus, Ghana, the Philippines, and the Republic by direct payments, particularly in private hospitals. of Korea found it necessary to study the financing of The system is completely different in the United their health services in connexion with the organization Kingdom under the National Health Service, where of certain forms of social insurance during the period about 95 % of hospital expenses are covered by the 1969 -1972.In Latin America this problem has been central Government.Still other solutions exist in the of considerable importance for many years. It cannot Scandinavian countries, where the local authorities be denied that the taking over of a large part of per- manage and finance hospital expenses in large part. sonal care expenses by social insurance institutions The USSR and the United States of America have enables the budget of the health authorities to be financial mechanisms that are different again from the better balanced and sets free more resources for pri- examples given above. mary prevention and the raising of the level of health, ILO periodically publishes an exhaustive study of as regards both communities (general hygiene and social security costs, in particular the cost of medical environmental sanitation) and their individual mem- care for socially insured persons. The Eighth Inquiry, bers. covering the period 1967 -1971, which is not yet completed,willgive additional information on these ' See WHO Technical Report Series, No. 480, 1971. points. 2 See WHO document EURO /4305 of 7 January 1974. CHAPTER 4

FACTORS INFLUENCING THE DEVELOPMENT OF HEALTH PLANS

No country can claim to have a perfect health Studies on the utilization of inpatient and out- system.The developing countries are faced with patient care services are needed for guidance in immediate problems, such as communicable diseases planning. An international study of this kindon the and malnutrition, whose causes are bound up with utilization of hospitals by the public is in preparation the low level of education and standard of living of in WHO. Measurements of the demand forcare in their populations. These problems push into the back- relation to age and sex, and estimates of the severity ground other health hazards, which, in the developed of cases upon admission, show considerable differences countries, occupy the centre of the stage because of between populations with a high standard of living the progressive decline in the communicable diseases. and education and those living at a low socioeconomic From this standpoint it can be maintained without level.Such studies enable planning to be based on paradox that the complexity of health problems actual experience. becomes apparent only when the most obvious risks have been eliminated.This explains why ministries The findings show that where the level of education of health acquire their maximum importance only in is high, where the services are accessible, and where the developed countries, where organization, planning, the costs are borne by social insurance institutions, and coordination with other social ministries become these operate as factors favouring the acceptance of the major problems. In this striving for progress and preventive programmes and the demand for curative for improving the level of health and standard of care. living of the population, it is important to identify the factors that favour or impede such advances.It may Health personnel even happen that one and the same factor has positive All countries report that shortages of qualified and negative aspects. The most important of these personnel are a factor impeding the development of factors are summarized below. their health services.The shortages of physicians, nurses, pharmacists, dentists, and technicians have Acceptance of and demand for health services several causes. Some countries have not yet adequately There has been little research on the attitude of the developed their general education systems, and the public to health.Two aspects of health care con- number of students possessing the secondary school sumption should be distinguished: on the one hand, leaving certificate and desirous of embarking on the the receptivity of the public to services offered to it long and sometimes costly study of medicine is too or even imposed upon it, particularly services in the small. In other countries, doctors and nurses tend to preventive field; and, on the other hand, spontaneous emigrate to countries that can offer them more ad- demand for treatment, especially services of a curative vantageous conditions of work and remuneration. nature.In both these spheres, the observations that Doctors are often attracted to towns. Even when can be collected bring to light facts that are important for rational health planning. large, these contain in all only 20 -30 % of the popula- The attitude of the public to preventive services is tion in many developing countries, with the result that often passive or even guarded. Vaccinations, environ- medical saturation (one doctor for every 500 or 600 mental health measures, and systematic case -finding people on the average) is quickly attained, while the are sometimes thought of as authoritarian actions that rural areas remain medically understaffed. This phe- are best evaded.It is in overcoming this negative nomenon may prompt faculties of medicine to adopt attitude that health education is of major importance. a numerus clausus and block the training of additional But its chances of success are greater if account is staff. taken of sociological and anthropological surveys Lastly, financial stringencies may lead qualified revealing the psychological and cultural reasons that health personnel to give up the public sector for private may explain the public's reserve. practice. - 23 - 24 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Financing and administration alleviate cheaply many symptoms arising from benign for two conditions; and secondly, they can be trained to per- Financing may constitute an obstacle form vaccinations, apply dressings and give injections reasons. The first is the overall insufficiency of finan- correctly, and participate in health programmes.In cial resources, the second the inadequacy of budgetary the rural regions, particularly, they can make a sub- procedures and accounting methods. In those countries where the administration has not managed to put stantial contribution to the protection and promotion into operation a system to identify the real costs, of the health of the population. financial institutions such as social insurance and occupational accident insurance, or private individuals, Social and economic conflicts pay according to a scale of charges that are usually Social conflicts within a country hamper the develop- lower than the actual cost of the services; thus they ment of health campaigns by paralysing transport and do not contribute as much as they could and should provoking strikes.Wars between countries can have to meet medical expenditure. the same effect as regards civilian populations; on the other hand, the increased resources available to the Habits and customs military authorities sometimes make effective health In many countries, even among the developed surveillance possible.Nowadays we no longer see countries, quack treatment is still popular, by tradition epidemics deciding the outcome of a war, as was and also because it costs less.This has regrettable frequent in the past. consequences because it delays contact between the More insidious, perhaps, is the influence of economic patient and the official health service; patients suffering conflicts.Whatever discrepancies may be apparent from disorders that healers or traditional doctors between economic development and the improvement cannot cope with lose valuable time and may resort of social conditions, it is probable that if growth were to scientific medical care only at an advanced stage of halted, health programmes would be delayed and their illness, when it is too often incurable. sometimes even regress.The fear has been voiced But the existence of a large number of healers and that fuel restrictions may jeopardize the eradication traditional doctors can be an advantage if arrange- of smallpox, for example, which remains technically ments can be made to use them as medical auxiliaries attainable by 1975 provided that the surveillance after relatively short training.First, they are able to teams can continue their rounds without interruption. CHAPTER 5

HEALTH ESTABLISHMENTS

The main organizational problems erection of excessively large architectural units is to be avoided, and, on the other, the percentage of elderly All Member States possess buildings, equipment, patients suffering from long -term complaints is greatly and personnel for health establishments. These differ increasing in the general hospitals of certain countries. widely in nature, ranging from the village health post, In Sweden, for example, this latter development led installed in a traditional hut or a tent, to the giant thePermanent CommitteeforNationalHealth Except in the hospitals of the modern metropolis. Planning to introduce in 1972 a new planning method case of the most rudimentary health post these estab- that lays stress on caring for ambulatory patients and lishments contain beds for patients, technical equip- the chronic sick in special institutions rather than plac- ment for diagnosis and treatment, and general services ing them in the general hospitals. In the United King- to maintain the unit. dom, too, there is a tendency to transfer long -term The number of beds per thousand population is patients to special establishments so as to avoid increas- determined in Part II from the data communicated by ing the number of general hospital beds. Some special- governments to WHO; it is a global figure covering ists, including paediatricians and oncologists, argue for all categories of general and specialized hospitals. the maintenance of specialized establishments. Certain The distinction between public and private institutions sections of psychiatric hospitals for low -grade defec- is often not hard and fast, for there exist hospitals, tives or persons with senile dementia have to be main- health centres, and dispensaries of a voluntary nature tained. that play the role of public establishments.At the The problem of organization of health care in rural same time, many countries authorize public hospitals areas is discussed in the section on basic health serv- to accept paying patients in a so- called "private" ices (see page 29).Table 2 shows the percentage of sector. But the data at present available do not allow beds installed in small rural establishments, designated the analysis to be pursued so far. as rural hospitals or as medical centres, compared to The categories of establishment classified by spe- the number of beds in general hospitals, excluding cialty remain numerous. Many countries possess, in specialized establishments. addition to general hospitals, establishments for tuber- The percentages (column5) show considerable culosis,psychiatry,paediatrics,maternity,cancer, differences that may be due to several causes: first, ophthalmology, leprosy, convalescence, rehabilitation, the definition of "general hospital ", as opposed to traumatology, infectious diseases, etc. Two questions "rural hospital" and "medical centre ", is not always have been much discussed during the past decade. clear; secondly, the highest percentages are found First, should all the specialties and outpatient treat- mainly in the countries with scattered rural populations And ment be integrated into general hospitals ? and difficult communications, as is understandable secondly, should rural hospitals and health centres and justifiable; and lastly, it is probable that a good continue to provide beds ? many of the beds in the rural establishments are used In the developed countries there is a definite trend for maternity cases. towards integration: in view of the availability of rapid treatment for the mentally ill and for tuberculosis A trend is, however, developing in several countries towards removal of the beds in rural hospitals and patients, there is a strong move to integrate departments of psychiatry and phthisiology into general medical centres in districts easily catered for by the hospitals; and the outpatient departments of hospitals general hospitals in the cities. The average bed occu- can continue care after the patient's discharge.But pancy rates are generally below 50 % and may fall as it is probable that the integration of all the specialized low as 20 %. In the Netherlands an attempt is being services into general hospitals will never be complete. made to close the smallest hospitals, leaving estab- On the one hand, the number of hospital beds in the lishments with 400 -500 beds. This policy is also being large towns is such that the construction of separate followed by the USSR and the United Kingdom. buildings housing specialized services is essential if the In the United States of America it has been observed - 25 - 26 FIFTH REPORT ON THE WORLD HEALTH SITUATION

TABLE 2. NUMBER OF BEDS IN GENERAL HOSPITALS AND RURAL ESTABLISHMENTS (EXCLUDING SPECIALIZED HOSPITALS) (1972 or latest available data)

Rural establishments

Country or territory General Rural Medical Total Percentage hospitals hospitals centres (2) + (3) (4) : (1)

(1) (2) (3) (4) (5)

Argentina 91730 5178 5178 5.6 Bahrain 494 -- 34 34 6.9 Belize 310 68 72 140 45.2 Bolivia 3 327 1 114 - 1 114 33.5 British Solomon Islands Protectorate 258 529 626* 1155 448 Brunei 438 18 - 18 4.1 Canada 125 253 27 055 27 055 22 Chile 25 597 1 443 - 1 443 5.6 Congo 1 627 422 3 392 3 814 234 Cuba 17 382 1041 879 1920 11 Cyprus 1783 117 - 117 6.6 El Salvador 3 511 482 806 1288 36.7 Finland 22 732 12 715 - 12 715 55.9 French Territory of the Mars and Issas 820 78 45 123 15 Gilbert and Ellice Islands . 284 ** 324 200 524 184 Grenada 224 80 - 80 36 Guyana 1916 398 398 21 Iceland 1230 170 - 170 13.8 11977 2 210 763 2 973 25 Jordan 1 070 63 - 63 5.9 72 72 1.5 Libyan Arab Republic . . . 4 759 - Madagascar 4 670 7 215 4 735 11950 256 3 767 3 767 19.3 Malaysia, Peninsular . . . . 19 530 - Mali 2 046 679 - 679 33.2 Martinique 2 068 1 008 - 1 008 49 Mongolia 4 917 1618 - 1 618 33 New Caledonia 628 230 82 312 50 Niger 1311 573 415 988 75 Norway 19 688 1 363 - 1 363 6.9 Panama 2 913 428 143 571 19.6 Paraguay 2 365 85 178 263 11 Republic of Viet -Nam . . . . 20 882 363 14 886 15 249 73 Romania 111222 3 045 11234 14 279 12.8 Senegal 2 873 710 1 808 2 518 87.5 Thailand 30 510 - 2 700 2 700 7.4 Turkey 46 350 - 3 714 3 714 8.0 Venezuela 17 361 466 - 466 2.7 Upper Volta 1281 880 1 347 2 227 174 Western Samoa 294 336 - 336 114 Yugoslavia 77 513 - 7 253 7 253 9.4

Including rural maternity clinics. Twelve general hospitals and two district hospitals.

for the past decade that the inhabitants of rural areas Financing have a growing tendency to forsake the small local In general, governments are concerned at the sub- hospital in favour of the urban general hospital.In stantial- sometimes even major - percentage of the France it seems that only a few maternity and conva- resources allocated to health authorities that is spent lescent beds are still kept in the rural hospitals, and on hospitals.In the economically underdeveloped no surgery has been performed in them since 1958. countries, the costs of building and operating health HEALTH ESTABLISHMENTS 27

TABLE 3.OPERATING COSTS OF PUBLIC HOSPITALS IN RELATION TO CURRENT EXPENDITURE BUDGETS OF HEALTH AUTHORITIES, IN LOCAL CURRENCIES (MILLIONS), EXCLUDING CAPITAL EXPENDITURE (1972 or latest available data)

Current expenditure of health authorities

Operating Percentage Country or territory, and currency unit Ministry Other Intermediate - Local Total costs of public (7) : (6) of health ministries level authorities (2) + (3) + hospitals, authorities (4) +(5) all categories

(I) (2) (3) (4) (5) (6) (7) (8)

Antigua (EC $) 3.293 0.050 - - 3.343 1.506 45.0 Argentina (pesos) 1 097.9 371.1 1 401.8 908.0 3 778.9 2 696.3 71.0 Canada (Can $) 4 967.6 - 4 967.6 2 063.1 41.5 Central African Republic (CFA francs) 460 '')5 420 1 165 260 22.3 Cyprus (Cyprus £) 2.682 0.1 - -- 2.782 2.54 91.3 Denmark (kroner) 233.5 - -- 2110 1 800 4143.5 3455 83.4 El Salvador (colones) 37 - 37 20.7 65.9 French Territory of the Mars and Issas (Djibouti francs) 375.7 - - - - - 375.7 156.7 41.7 Grenada (EC $) 3.763 -- - 3.763 0.800 21.3 Guatemala (quetzales) 21.6 -- 21.6 15 69.4 India 1 (rupees) 3 416.8 -- 3 385.3 6 802.1 2 138.7 31.4 Israel (Israel £) 364.1 44.5 408.6 265 64.9 Laos3 (kips) 519 - -- - - 519 106 20.4 Liberia ($) 2.605 2.605 0.983 37.7 Madagascar3 (Malagasy francs) 3 233.5 -- 1 977.4 219.3 5 430.2 3 850.4 70.9 New Zealand (NZ $) 286 - 28 314 203.4 64.5 Norway (kroner) 5 073 - -- - 1 286 6 359 3 644 57.3 Panama (balboas) 5.753 9.742 1.991 7.950 25.436 9.826 38.6 Poland4 (zlotys) 2175 2 550 26 864 - 31 589 16 530 52.3 Singapore (Singapore $) 89 - - 89 48 53.9 Sri Lanka (rupees) 310 248 - 558 203 36.4 Thailand (baht) 1253 -- - - 1253 817.3 65.2 Tunisia (dinars) 14.6 - - - 14.6 12.6 86.3 Turkey (liras) 2119 1 695 - 438 4 252 3 315.8 78.0 United Kingdom: England and Wales (£) 2 081 - - 470 2 551 1292 50.6 Scotland (£) 252.2 2.6 - 56.8 311.6 163.7 52.5 Northern Ireland (£)5 64 - - 3 67 50.7 75.6 Western Samoa (talas) 1.171 - 1.171 0.719 61.4

1The intermediate -level authorities are the states. The central Government covers 17.17 % of he hospital expenses and the states 82.82%. Capital expenditure is included. 9 Cost of training of health personnel borne by Ministry of Health. 9 Including capital expenditure, which represents 8.6% of the total budget (column 6). 4 Including capital expenditure, which represents 4.1% of the total budget (column 6). 5 Estimate after deduction of 10 ° %, for capital expenditure. 28 FIFTH REPORT ON THE WORLD HEALTH SITUATION institutionsare almost entirely covered by state are being conducted on this subject, which is made still budgets.However, as soon as economic develop- more complex by the existence of private establishment allows, there appear mutual- benefit, or friendly - ments whose accounts are not readily available for society, and health- insurance systems that take charge inspection. The Centre for Income and Cost Studies of all or part of the hospital expenses incurred by their in France analyses, on the one hand, groups of hospital participants and, often, by the dependants. establishments defined by their average characteristics, It is therefore very difficult, without studies in con- and, on the other, the disparities that exist between siderable depth, to determine the percentage relation- those institutions, within the public and private sectors ship of the expenditure of medical care establishments respectively. to the budgets of the health authorities. An attempt So far we have considered only operating expenses. has nevertheless been made, using the replies to the But the capital investment costs may also be very questionnaire for this report, to show in Table 3 the heavy. On an average, the capital expenditure of the operating costs of the public hospitals (excluding health authorities amounts to between 8 % and 10 capital expenditure) as a percentage of the current of their overall budgets. It is known, too, that the cost expenditure budgets of the health authorities.Out of building a hospital is equal to approximately three of 26 countries and territories in the table, there are or four annual operating budgets. The sums devoted 16 where hospital expenses exceed 50 % of the govern- to investments usually come from the central government health budget. The percentages given in column ment in the developing countries.In the developed 8 only represent an order of magnitude, since the countries with market economies, the investments are overall budgets of the public hospitals may include usually shared between the government, the inter- expenses covered from sources other than govern- mediate -level and local authorities, and sometimes ment subsidies.For example, the hospitals may be social security.It is becoming common practice to authorized to accept paying patients.Depending on include in the operating budgets of health establish- the country, sums collected in this way are either kept ments the depreciation costs of the installations and by the establishment or repaid to the Treasury. Hos- buildings financed from the investment budget. pitals may be supplied in kind with drugs, X -ray films, cleaning materials, and nonperishable food from Administration and management central stores, and the value of these items is not shown in the accounts by the establishment.Finally, the The period 1969 -1972 witnessed major changes contribution of private insurance funds of every kind - in methods of administration and management of accident insurance, mutual benefit societies, health health establishments.In the developed countries insurance -is sometimes considerable.In the devel- such establishments are no longer planned as isolated oped countries, where social security systems cover elements, but considered as integral parts of systems. practically all the population, most of the hospital It is noteworthy that in the law to reform the hospital expenses are met by health insurance funds and the system promulgated in France on 31 December 1970 total amount of such expenditure may far exceed the the word "hospital" has disappeared and only the budget of the ministries of health.This does not term "public hospital service" is used in the text. The apply to the socialist countries, where by far the general tendency is to situate the administration of greater part of the expenditure of the establishments health establishments at the regional level. The United is borne by the State budget. Kingdom did so as early as 1948 and revised legislation A study dating from 10 years ago showed that the was due to come into force in 1974. France is trying cost of a hospital day was equal to approximately to induce public and private hospitals to form regional four times the daily per capita income. 1Since, on an groups that will have corporate status. Since 1971 Italy average, each individual "consumes" two hospital has established regional boards one of whose spheres days per year in the developed countries, every mem- of competence is public health. At this level, the oper- ber of the population therefore devotes one week's ation of regional systems and individual establish- worth of his annual income to expenditure on hos- ments must utilize modern management methods pital care; he covers those expenses either directly, or adapted from the theory of general administration. by paying his taxes, or by coati ibuting to health The technical discussions at the Twenty -sixth World insurance. It is therefore important for a government Health Assembly dealt with these subjects. 2Many to rationalize the management of hospitals and super- trial applications are in progress for the management vise their costs. In several countries, studies in depth of regional systems, using computers.

1 ABEL -SMITH, B.An international study of health expendi- 2 See Modern management methods and the organization of ture, Geneva, World Health Organization, 1967 (Public Health health services, Geneva, World Health Organization, 1974 Papers, No. 32). (Public Health Papers, No. 55). HEALTH ESTABLISHMENTS 29

Several countries are participating in research on received by hospital patients is grossly insufficient cost -effectiveness, systems analysis, communications their stay in hospital is longer, since convalescents between the local, regional, and national levels, defi- recover too slowly after initial treatment.With sup- nition of indicators, and measurement of the utilization plementary feeding such patients can be discharged of health institutions by the population.It has been more quickly and the efficiency of the hospitals is recognized that the preventive and curative health thus improved, as can be shown by World Food Pro- services must be considered as a single whole and that gramme statistics concerning patients' weights and the the way to the strengthening of health systems lies length of their stay in hospital. Of course, the figures through integration and planning.Research on the for these two parameters vary widely according to the cost -effectiveness relationship includes evaluation of category of patient. the quality of care. To take one example, a possible relation has been sought between the number of hospital beds per thousand population and the percentage Basic health services of deaths ascribed to "symptoms andill- defined For more than a thousand years -that is to say, conditions" in relation to overall mortality. Graph 7, since the creation of urban hospitals -town popu- established from the data supplied by the countries, lations have had easier access to health institutions shows that the diagnosis of cause of death is vaguer than have rural populations, especially when the latter in those with fewer beds per thousand population. are scattered over a large area with unreliable means A similar relation has been shown between precision of communication. This problem arose in an almost of diagnosis and number of physicians.Hence the identical form for preventive services when it became quality of the care a population receives depends on possible to organize them. The situation became still investments in health equipment and personnel. Up more complicated with the migration of peasants to a certain point, quantity of medical attention and towards the towns, which had the consequence of quality of care are linked. diminishing population density in the rural areas and Administration and management involve the estab- crowding together the migrants in the unorganized lishment of standards and agreed technical conditions. peripheries of large towns, where living conditions Health establishments have to comply with regulations developed that are sometimes worse than those pre- governing architecture, engineering, personnel, hygiene vailing in the most depressed rural areas. To give an of premises, fire safety, radiation, hospital infections, example from Part II of this Report, the Central and every other relevant subject.Many countries, African Republic mentions as its most important among them France, the Philippines, Sweden, the health problem the insufficient coverage of medical United Kingdom, the United States of America, and needs in the rural areas. all the socialist countries, have drawn up and applied Although this aspect of the organization of health such standards. services has engaged the attention of WHO since its The expansion of the World Food Programme has inception, the problem was scarcely touched on in had beneficial consequences for the equipment and the reports on the world health situation, except financing of hospitals in Burundi, Chile, Congo, in the first, which contains several passages concerned Guyana, Jamaica, Mali, Mexico, Pakistan, Peru, and with rural health and also an enumeration of the Somalia. The assistance has also benefited other in- functions of the simplest health unit (by whatever stitutions in many countries. The machinery and final name it is designated). This list is still valid, and some results of this Programme are complex. The case of 10 years ago UNICEF and WHO worked on a Chile is illustrative. For 730 days continuously from document that gave it formal recognition : August 1970, 13 500 inpatients in the hospitals of that country were each given daily a quantity of food 1. Protection of maternal and child health; equivalent to 750 calories.The budgets allocated to 2. Control of communicable diseases; the hospitals could therefore be reduced by the corre- 3. Environmental health; sponding amounts and the savings made were invested 4. Health education of the public; in the construction of 48 rural health centres each 5. Nursing with a public health orientation; and worth US$ 12 000 and providing coverage for 3000 per- 6. Medical care (the scope of which varies according sons.In all, 250 000 patients were given a balanced to needs and the accessibility of hospitals for diet with foodstuffs from developed countries through referral of patients). the World Food Programme, and it was thus possible to provide basic care for 138 000 rural inhabitants. A seventh function has been added: the recording Other countries are planning to request assistance of health statistics. under the Programme with a view to conducting com- The Twenty- fourth World Health Assembly ap- parable operations. In those countries where the food proved initsresolution WHA24.58 the General 30 FIFTH REPORT ON THE WORLD HEALTH SITUATION

GRAPH 7.HOSPITAL BED RATIOS IN RELATION TO SPECIFICITY OF REPORTED CAUSES OF DEATH (1972 or latest available data) 70

ÿ 60 o o THAILAND E ó 50

IRAQ O 40 o o BRUNEI DOMINICAN a> REPUBLIC BOLIVIA o

o CYPRUS VENEZUELA o PARAGUAYO PANAMA o GUATEMALA o

PHILIPPINES o SINGAPORE O

U PERU o UPPER VOLTA o

ARGENTINA o ' NORWAY MALAYSIA O 5 4 SURINAM o o NETHERLANDS ° 3 ISRAELo o GREECE GERMAN DEMOCRATIC

2 o REPUBLIC c DENMARK O o IRELAND SWITZERLAND CZECHOSLOVAKIA o 1 CUBA o UNITED KINGDOM o 0 C CANADA FINLAND 0.5 NEW ZEALAND o E 0.4 á0.3 E 0.2

01 1 2 3 4 5 6 7 8 9 10 15 Hospital beds per thousand population WHO 40202

1 Countries further from the oblique line show a lesser correlation; e.g., Cuba has a low percentage of deaths ascribed to symptoms and ill- defined conditions in spite of a rather low bed /population ratio.

Programme of Work for the period 1973 -1977.1 basic health services, reviewed at the fifty -first session With regard to rural communities, this programme of the Board (16 -25 January 1973). aIt is not proposed states: to summarize that document here, but some reflections derived from concrete experience may be added. It cannot be sufficiently stressed that particular In most countries, whether developed or developing, attention has to be paid to this problem, and if static health institutions have been established in the different solutions from those found useful for urban rural areas, and sometimes in the suburbs of the major areas might have to be applied, they must be no towns. These institutions (however they are designated) less adequate and appropriate.2 have been providing individual ambulatory medical This aspect of health organization became the care, at first mainly curative and later preventive, subject of an organizational study by the Executive integrating programmes of vaccination, maternal and Board on methods of promoting the development of child health, control of tuberculosis and other communicable diseases, and even dental hygiene. In many 1 WHO Official Records, No. 193, 1971, Annex 11. 2 WHO Official Records, No. 193, 1971, Annex 11, p. 74. 3 WHO Official Records, No. 206, 1973, Annex 11. HEALTH ESTABLISHMENTS 31 cases provision was further made for hospital beds the rural population is dense enough, where the rural for normal deliveries and medical care for patients establishments are between 15 and 25 km from the who could not be treated at home. The whole con- provincial hospital, and where the roads are prac- stituted a scaled -down hospital that was generally ticable. Such a decision does not in any case rule out designated by the name of rural hospital but was also the possibility of later promoting the largest rural given other names, such as medical centre, primary establishment in a province to the rank of secondary health centre, or local dispensary with beds. provincial hospital and staffing and equippingit This formula, however, met with growing difficulties, accordingly. As for the rural health services in regions which can be analysed as follows: that are sparsely populated and isolated geographically (1) Problems of power and supplies prevented these and by climate, the problem will persist as long as small hospitals with their limited numbers of beds the health authorities have insufficient funds to finance from acquiring the minimum equipment needed for economically unprofitable establishments. This type of organization, for which most countries the practice of scientific medicine (X -ray, laboratory, and surgical apparatus); opt when they see the problem clearly, provides an answer to the remark in the organizational study cited (2) This restriction on the technical possibilities of above: diagnosis and treatment, not to mention the frequently The use of scarce resources for doing "a bit of primitive living conditions in the villages, hampered everything" is also a waste of national treasure. The the recruitment of physicians trained in scientific cost of undertaking health actions is therefore a methods.These institutions therefore had perforce proper basis for self -examination. 1 to be entrusted to auxiliary health workers; Now it has to be recognized, when we analyse the (3) Economic development, even on a modest scale, replies reported in Part II, that many developing resulted in the improvement of roads, the creation countries have provided in the rural areas a substantial of private or public transport concerns, greater trade number, and sometimes the majority, of their hospital between town and country, and hence increased mobil- beds.This course of action seems to be justified by ity among the peasants, who were then able to go for the fact that in those countries 70 -80 % of the total treatment to urban centres. population lives in the country; but practical experience For these fundamental reasons, hospitalization in shows everywhere that the average bed occupancy rural health establishments has been a failure.In the rate in rural hospitals is abnormally low, while pro- developed countries, the rural hospitals have first had to vincial hospitals are overfull. restrict their functions (discontinuance of surgery and The organizational study referred to above com- obstetrical care of difficult cases), and then have been ments : converted into health centres for ambulatory preventive Both the operation of a health service and the and curative treatment, sometimes with an annex for statement of goals and priorities require consumer hospitalization of welfare cases and elderly invalids. approval.There is no single measure of such ap- In the developing countries it has usually been difficult proval, but underutilization, the development of to improve the technical standard of the care.The parallelhealthservicestructures(privatelyor rural population, having no confidence in such a withinspecial groups) and other measures do rudimentary institution, bypasses this level of health signify disapproval or criticism and should point service as soon as it needs qualified medical care and to a re- examination of existing solutions. 1 turns to the provincial hospital with its 200 or 300 beds, As with many social problems, the health authorities its team of five to 10 doctors, and its technical installa- will take account of the wishes of the population and tions; and the beds in the rural hospitals remain also of economic considerations.While the rural unoccupied most of the time. population tends to look, when it can, to the urban The health authorities are therefore faced with a establishments, the local authorities for their part dilemma; must they try to improve the rural hospital often insist for different reasons on keeping the estab- by staffing it at whatever cost with one or two doctors, lishments that are located at their level.Studies on or must they strengthen the provincial hospital, per- the economic profitableness of local establishments fecting its technical installations and increasing its may influence the final decision. Canada has conducted medical staff, which would enable mobile medical a large -scale survey on rural health centres in which teams to be seconded in rotation to visit the rural all the considerations concerning their utilization by establishments and supervise the quality of the work the population and the cost -effectiveness have been done by the auxiliaries ? brought out. During the period under review, a marked preference emerged for the latter formula in those cases where 1 WHO Official Records, No. 206, 1973, Annex 11, p. 105. CHAPTER 6

FAMILY HEALTH

The importance accorded to the health of the concerned, illustrates the situation in a number of family unit in each of the previous four reports bears European countries where the maternal and child witness to a major evolution that has taken place health (MCH) services were built up on solid found- over 15 years in people's minds and in the structure ations from 1945 to 1950.It shows that the majority of health establishments.The First Report gives of prenatal examinations are performed as curative considerable prominence to maternal and child health medicalinterventions. activities in the form they assumed after the Second A similar table could be drawn up for infants, and WorldWar- namely, a broadlyautonomous, the situation is still more unbalanced for children from purely preventive service, carrying out examinations 1 year old to school age. The report of the National of pregnant women and of children up to school Children's Organization in Belgium on its work in age.The relevant section no longer featured in the 1969 stated that expectant mothers were going less subsequent reports, for two essential reasons. and less to those prenatal clinics that were not directly In the first place it has become clear that in most attached to the maternity hospital chosen as the place countries except the socialist countries the traditional of delivery. Similar findings were made in many type of maternal and child health service has not countries and they pointed the way to the concept succeeded in meeting the needs of the majority of of integration. While this concept was being discussed pregnant women and healthy children.An irresist- at the national and international levels, it was being ible movement, starting from the local health establish- applied in practice in the rural health establishments ments with the support of the public, has brought and in the general hospitals possessing outpatient about a progressive integration of the premises and departments. staff of the maternal and child health service into the Secondly, in certain countries of Asia, the maternal general and maternity hospitals, even when their and child health services were given responsibility for financing has remained separate. The following table, birth control from the beginning of the last decade. established partly from data collected in the course At the same time, however, the principle of birth of a study by the WHO Regional Office for Europe, control was meeting with strong resistance on the the report of which was approved by the governments part of many governments.It became difficult, in a

Women registered at maternity clinics of Pregnant women hospitals or seen by Births registered at Percentage medical practitioners Country per year MCH clinics (2):(l) (estimate) (1) (2) (3) (4)

Austria (1970): City of Vienna 19 146 2 278 11.9 16 800

Belgium i (1969) 140 834 50 521 35.9 90 000 (1971) 140 664 48 329 34.4 92 000

France 1 (1967) 903 100 114 000 12.6 736 000 (1971) 878 647 172 000 19.6 708 000

United Kingdom: England and Wales (1972) 725 000 216 270 29.8 592 182 Scotland (1972) 78 550 31 544 40.2 46 000

1 Many MCH centres are integrated into hospitals. -32- FAMILY HEALTH 33 report on the world health situation, to reconcile such approach. The countries of Africa south of the conflicting tendencies. Sahara are interested, although most of them are Since 1968, however, the sphere of maternal and underpopulated; the countries of the Eastern Medi- child health has broadened considerably, and the terranean have adopted the policy; the countries of birth control issue lost much of its emotional content Latin America have been undertaking studiesin when it was demonstrated that the health of mothers depth since 1972; and the Maghreb countries are and children depends not only on individual measures reorganizing their administrations on the appropriate but far more on an approach that considers the family lines. as a whole. Independent of any doctrinal consideration Clearly, the success of suchalarge -scale and it is now recognized that too closely spaced births are complex programme will require the cooperation of a threat to the health of the woman and of her children, various institutions. Some countries, including Indo- and from this follows the concept of proper spacing nesia, are planning to merge the sections responsible of pregnancies and regulation of fertility.This new formaternal and childhealth,nutrition,health concept applies not only to the already overpopulated education, and birth control or family planning into countries with rapid demographic growth, but also a single department of family health. to the underpopulated countries and areas, where it Finally, emphasis must be laid on the influences is important to raise the level of family health in the exerted by the redistribution of national incomes, existing population. usually through the social security system. In countries This explains why many States have given a mandate where the birth rate is declining too rapidly, family to WHO and other intergovernmental organizations allowances, maternity benefits and paid maternity to consider as a whole the problems of maternal, leave can be used to encourage couples to have perinatal, and infant mortality and morbidity, nutrition children. These measures are reinforced by the of children and mothers, health education, and human effect of old age pensions, which ensure retired reproduction, all in relation to human rights.The persons some means of subsistence in those countries, 60 or so countries that request assistance from WHO whereas in poorer countries where there is no social belong to all the regions of the world.Those of security a large family represents an aging couple's South -East Asia have long since opted for the broader main guarantee of decent survival. CHAPTER 7

HEALTH PERSONNEL

Education doctor for every 500 -1000 inhabitants). This pessi- mistic forecast is based on the slowness of the devel- Important changes affecting the place of the edu- opment of primary education, the small proportion cation of health personnel in public health and the of children who embark on and complete secondary ways in which that education is given have occurred education, the long duration of medical studies, the in the last 10 years or so. Not until the Fourth Report high cost of establishing faculties of medicine, the on the World Situation was information given on the "brain drain" and the inadequacy of governments' interest shown by the authorities in the training of financialresources. In developing countries the their staff. This is because medical education in many concept of a team capable of resolving the medico - countries remained until about 15 years ago the social problems of the people is being elaborated. exclusive preserve of the universities, which in most It is therefore logical to train the members of the cases possessed teaching hospitals, both the former team to adopt a simultaneous and integrated approach and the latter coming under the supervision of the to the problems of public health and social welfare. ministries of education, which financed them more Experiments are in progress in Canada and Israel. or less completely.Responsibility for training nurses Man must be considered together with his environ- and other professional health workers was divided ment, and the training of public health personnel in various ways. must be planned on the basis of an integral approach The countries of Eastern Europe long ago placed to every aspect of individual and social life. This con- the training of all categories of health personnel cept of integrated training was launched at Cleveland, under the authority of their ministries of health. Ohio, in the United States of America as long ago as In 1958 France undertook a thorough reform that 1952 and has been adopted by several hundred medical unified university and hospital careers, thus initiating schools. a coordination of the activities of the ministries of These ideas have had numerous repercussions and health and of education. have already brought about profound changes in the Although the organization and structure of public structure and techniques of public health training. health teaching establishments still differ widely from The needs of the community, however, do not necess- country to country, completely new trends or gradual arily coincide with the demands of the community, changes in the curriculum and the timetable for and this means that initiative is required in evaluating courses of study are becoming apparent. those needs and satisfying them. Public health The fact that at intergovernmental level the training personnel must be trained to act to improve the level designed for doctors, nurses, technicians, and aux- of health and their education must therefore be iliaries of every kind has been made the responsibility directed towards acquiring skills rather than abstract of WHO as an agency specializing in public health knowledge.Their training must enable the public has certainly contributed to the acceptance by an health services to be strengthened.Consciousness increasing number of governments of the idea that of belonging to a team makes it possible for each the planning of the education of public health per- member to harmonize his work with that of his sonnel should be considered part of health planning colleagues.This concept is essential for organizing in general, which in its turn is part of socioeconomic the basic health services, which are run by resident planning. auxiliaries but rely on the doctors from the more The immediate consequence has been that education important centres. is being directed to the needs of the community. The very concept of training is being modified, the In the developing countries the number of doctors duty of teaching staff being not simply to impart who can be trained between now and the end of the learningex cathedra,but to help the student to learn; century will not make it possible to attain the ratios the student for his part is urged not to receive the normally observed in the developed countries (one instruction passively but to absorb it actively.The -34- HEALTH PERSONNEL 35

duration of studies is becoming more flexible and Many establishments for training public health permission to practise may be granted as soon as the personnel are changing their methods to differing student can demonstrate that he has acquired certain degrees and at different rates in accordance with the defined skills.Education is not given in a single trends mentioned above. Some faculties have already institution. Most countries recognize that neither set out along this new road.They are those of the teaching hospitals, which are well known for Yaoundé in theUnited Republic of Cameroon, selecting rare and difficult cases for research purposes Brasilia in Brazil, Hacettepe (Ankara) and Erzerum and with a view to training specialists, nor the class- in Turkey, Beersheba (University of the Negev) in rooms in the nursing school can ensure practical Israel, several medical schools in the United States of training.The students are therefore called upon to America and the USSR, and the Faculty of Medicine work in polyclinics, health centres, rural hospitals, or in Rabat (Morocco). even in patients' homes.Thus all public health establishments, and the community, are becoming training grounds for students.Consequently at least Distribution and migration some of the treating staff are called upon to play a part in teaching. A large majority of countries have instituted a It goes without saying that this method, while it system for registering the health professions, and the applies to the education of all personnel engaged in information available on the total number of doctors, the health professions, must be adapted when it is a nurses and qualified technicians is on the whole quite matter of trainingspecialists,teachingstaff and precise. In the case of unqualified auxiliary personnel research workers, whose numbers are determined on the statistics are less accurate, but some problems, the basis of the planned strength of various categories such as intercountry migration, scarcely apply to of staff for hospitals, university teaching centres, and this category of health worker. The following analysis researchinstitutes. will therefore be concerned mainly with doctors and Finally, continuing education has been consider- certificated nurses. ably developed over the last few years.'Countries The information available comes from two main of Eastern Europe have instituted a system under sources :the records of certificates and degrees and which members of the health professions are en- the listing of posts in public establishments and the couraged to attend theoretical and practical courses public health administration.However, while the periodically during their whole professional life: for total number of qualified health staff can be consid- example, in the institutes of advanced medical training ered to be known fairly accurately, information is in the USSR. This system has been improved and inadequate on two essential points: the distribution extended over the last few years to other countries. of doctors and nurses within each country, particu- In France, the United Kingdom, and the United States larly between towns and rural areas; and emigration of America various programmes have been launched and immigration. in which modern methods of information and teach- Itis known that the distribution within each ing are used. country is always uneven and that there is a con- Before such a pragmatic concept can be used centration of doctors in the large towns.This con- elsewhere it is necessary to evaluate what has been centration can be justified to a certain extent by the accomplished so that the methods of education can presence in the towns of specialists, the number of be adjusted and, where necessary, corrected.This whose potential clients is very much greater than that task is an extremely complex one.The methods of of the general practitioner. However, when there are work of health service staff continuously evolve as over 4000 -5000 persons per physician and 2000 per progress is made in medical science and changes nurse it is clear that some patients are not receiving occur in the morbidity pattern, without its being adequate medical attention. possible to speak of medical knowledge as universal Still less is known so far about migration, though except in the case of theoretical studies and some many countries are attempting to assess the extent of specialized disciplines.It goes without saying that the "brain drain ".The international migration of the studies of public health teams working in rural doctors and qualified nurses comprises, first, a flow areas where malaria and other parasitic diseases are from the developing countries towards countries that rife should have a different content from those of can offer more attractive working conditions; doctors teams in the large urban communities where cardio- and nurses trained in the universities and schools of vascular diseases and cancer are the main causes of the developing countries may emigrate to the developed death and invalidity. countries, while students who have carried out their 1 See WHO Technical Report Series, No. 534,1973 (Continuing studies in the latter may remain there instead of education of physicians). returning to the country of origin. Their professional 36 FIFTH REPORT ON THE WORLD HEALTH SITUATION activities in the receiving countries may be those of This has resulted in the very general trend towards general practitioner, but some may remain to qualify setting up a body of medical assistants who are as specialists with a view to returning home later, trained more rapidly and less expensively and are settling down and practising their (rarely required) capable of carrying out certain simple diagnostic, specialties in the large towns. curative, or preventive medical procedures. This There is also a flow in the opposite direction, from trend has a long history.Medical assistants have the developed towards the developing countries, within been trained in Fiji since 1878.The USSR has had the framework of bilateral assistance. Some countries feldshers for centuries and, since 1917, has organized thus have the assistance of an appreciable number of their training and defined their functions.France in young doctors from the developed countries who former times had its "public health officers ".In enlist in a civilian service that counts as military recent years numerous initiatives have been taken, and service and costs little either for the sending or the a world pattern has emerged.Despite the diversity receiving country.These young doctors, however, of the solutions adopted, two levels of training and are generally posted to the rural areas, and this tends skill can be distinguished among these assistants. to give impetus to the trend among the doctors of the The first level, the higher one, is that of assistants country concerned to concentrate in the towns, where with eight or nine years of basic studies and a three - economic development makes private practice fin- year or two -year course of special training. When ancially more rewarding than work in the public sector. they obtain their certificates they become full -time The increase in the number of schools and faculties employees of the central or regional government. of medicine in certain developing countries during the They are generally attached to the public health unit next 10 years is going to produce a number of doctors usually known as a health centre, which often has a and nurses whom the health authorities will not have few maternity beds and serves a district of 25 000- a large enough budget to pay.Some of those who 40 000 inhabitants.These medical assistants work graduate from these institutions will take up other under the supervision of doctors in the district hos- jobs, and some will try to emigrate. This phenomenon pital, who pay periodic visits to the two or three merits detailed study; the results could show the health centres in their district.Medical assistants of developing countries now best to cope with the this type ensure daily contact with the population situation. -mainly in the rural areas -in the Central African Theministriesmaybesharplydividedover Republic, Guatemala, Iran, Kenya, the Republic of this problem; some are aware of the dangers of Viet -Nam, the Sudan, and the United Republic of leavingruralareasdeprivedof qualifiedhealth Tanzania, where they play an important role.The personnel, but others do not seem to be envisaging Public Health School at Gondar (Ethiopia) and the any effective measures to restrict emigration. Finally, Royal School of Medicine at Vientiane (Laos) al- there may be both emigration and immigration in ready possess wide experience in training this category certain developed countries, whichresultsinan of staff.In the United States of America, despite the outflow of the most competent personnel in search of large number of doctors, the Medical School of Duke betterliving and working conditions, and their University in North Carolina has instituted a two -year replacement by immigrants from thedeveloping study programme.This initiative was followed by countries. several other medical schools, each course having its special features. Among these may be mentioned Auxiliary personnel the training designed for the "medex" at Stanford University,California,and HowardUniversity, There is a notorious shortage of doctors in almost all Washington, D.C.1 Certain universities in Indiana and countries.The shortage reaches catastrophic pro- New York State have similar aims.The University portions in the rural areas of the developing countries, of Colorado is training paediatric assistants. but has also been found in many developed countries, The second level is for young men and women with where governments are envisaging the extension of a primary education and some secondary schooling the preventive medicine programmes.The situation who, after a shorter training period, can carry out persists because the excess of doctors in the big cities simpler medical procedures. Rapid and intensive impels the medical schools, which are directed by the training enables them to acquire in a few months best qualified doctors in those cities,to apply a skillsmarkedly in advance of those of first -aid numerus claususor at least to impose stringent con- workers. These medical auxiliaries are generally ditions of admission.A large number of simple attached to village and hamlet health posts serving a medical procedures that do not require a very high degree of professional skill are often carried out by 1 The adaptation of suitable personnel, such as ex- service doctors -particularly when these outnumber nurses. medical corps personnel, for work as physicians' assistants. HEALTH PERSONNEL 37 few thousand inhabitants.They are often employed Finally, the obstacles,i.e.,objections from the part time and are administratively subject to the medical profession, the problem of the equivalence of local authorities of the community in which they live degrees and diplomas, and the real difficulty in defining and continue to work.The prototypes of these the procedures that medical assistants can perform on second -level auxiliaries are the "barefoot doctors" their own or under the supervision of physicians -or whom the People's Republic of China is training and are forbidden to perform -must not be passed over using throughout its territory. A precedent can be or their importance minimized. Whatever happens, the found in Venezuela in the auxiliaries who practise medical assistant remains an assistant, and this implies "medicina simplificada" (simplified medicine) and in careful supervision of his activities by the physician. Mexico in those known as "promodores de salud" The interest shown by numerous countriesin (health promoters).In China, the "barefoot doctor" first -level and second -level medical assistants should can be upgraded to the first level and even in some not cause us to forget the laboratory, radiology, cases become a fully fledged physician; similarly, the orsanitaryengineeringauxiliaries,theauxiliary system of continuing education and periodic refresher nurses and midwives, and others.Such categories training in operation in Bulgaria, Mongolia, and the have long existed and perform appreciable services USSR can open the doors of the medical schools to even if their training and functions do not present such the feldshers. original features as those of the assistant doctors. CHAPTER 8 PROTECTION AND IMPROVEMENT OF THE ENVIRONMENT

Industrial development, urbanization and the use The public health authorities and research bodies of new techniques have made people in the developed have intensified their efforts in four essential areas: countries and the inhabitants of large towns aware determination of the level of pollution in water, air, of the importance of the environment for health. food, work -places, and dwellings; establishment of This new awareness has occasionally led to excessive the tolerance level or acceptance threshold beyond anxiety, which some information media have ex- which pollution becomes harmful; elaboration of aggerated to the extent of portraying pollution as a a programme of action; estimation of the cost of new danger capable of causing worldwide catastrophes. investments in and operation of the services, and Thanks to the influence of the health services rural evaluation of the results. populations have acquired a better understanding of The policy followed by national administrations, the dangers involved in the water and soil pollution some of which have had serious and urgent problems that normally resultsfrom the concentration of to solve, generally covers, first, protective measures several hundred human beings in a village that only against pollutants affecting living conditions. Such has surface water available and neglects the proper measures require constant research on toxicity and on treatment of excreta. the diffusion and long -term effects of substances Some countries have set up ministries of the envi- deriving from industrial processes.It is a matter of ronment to evaluate the extent of the danger and interest above all for the developed countries, and determine the measures to be taken. Others, such as especially the populations of industrial cities (very Austria and the Netherlands, have amalgamated the roughly 20 % of the total world population), who departments of public health and the environment must be protected against the long -lasting, for the to form a single ministry.Yet others have set up most part degenerative, diseases caused by exposure bodies for coordination between the ministry of to pollutants.Secondly, the biological pollution of healthandtheotherministriesconcerned -for water and food in the less developed countries jeo- example, the ministry of public works and the local pardizes health, causing communicable and parasitic authoritiesresponsiblefordrinking -watersupply diseasesand inparticularacutegastrointestinal and sewage disposal systems; the ministry of agri- complaints. Governments areobliged to make culture,which regulatesthe useof insecticides, considerable investments to combat this hazard and fungicides,fertilizers,and vegetable and animal theassistanceof intergovernmental organizations hormones; the ministry of labour, which checks on and of the special funds for water supply and waste physicalconditionsinfactoriesand workshops; treatment is requested for the purpose. The measures the ministry of trade and industry, which supervises envisaged concern 80 % of the world population. the utilization of products employed in the home, In drawing up a programme of activities for such food additives, and substances used in production disparate objectivesitis important to distinguish processes and discharged by factories and workshops between the pollutants that have always troubled into the air, water or soil; and the ministry responsible human communities, and the new pollutants, which for atomic energy, one of whose major preoccupations are often more insidious and at the same time more is the storage of radioactive substances formed as dangerous.In the first group are smoke from fires, by- products of nuclear reactions. human and animal excreta, organic waste from the These new considerations have often made it slaughter of animals, and noise from handicraft necessary to promulgate or strengthen specific legis- workshops. These factors may create unhealthy, some- lation. For example, the Federal Constitution of times unbearable conditions, but they do not have Switzerland now includes an Article 24 septies "on perhaps such harmful long -term effects as the new the protection of man and his natural environment pollutantsarising from modern techniques, such against harmful or troublesome influences ".' as inorganic salts (lead, mercury, chromium, and cad- mium), radioactive isotopes, defoliants, insecticides, or 1 Federal Order of 24 June 1971 concerning the result of the referendum held on 6 June 1971(see International digest of hormone preparations.Priority activities should be health legislation, 23: 137 (1972)). determined on the basis of risk rather than discomfort. -- 38 - PROTECTION AND IMPROVEMENT OF THE ENVIRONMENT 39

The research and measures to be undertaken are water supply. 2In rural areas the situation is in concerned with the specific problems of power (the most cases very serious. burning of fossil fuels), transport, new products and In such a complex sector education of the public and materials, industrial wastes, domestic effluents (deter- the encouragement of a sense of civic duty should not gents), the increase in the temperature of water used be underestimated, since in the absence of other méans for the cooling of nuclear power stations and factories, they could appreciably improve the community's agriculturalchemicals,high- frequencyandlow - standard of living and level of health. Water supply frequency noise and vibrations, ionizing radiation, projects seem very expensive, but there are several food additives, food contamination, traffic accidents, ways of obtaining the financial resources and ensuring overcrowding due toincreased population, poor theparticipationof thepopulationsconcerned. housing, etc.It should also be noted that harmful Numerous examples of success can be quoted: substances such as lead or mercury salts may come the Dominican Republic, Egypt, Ethiopia, Ghana, Iraq, Kenya, Morocco, Nigeria, Sri Lanka, Surinam, and from several sources and may affect man in his place Turkey have been able to coordinate resources and of work, at home or elsewhere in his leisure time, obtain the participation of the community. A success- while bathing, for example, or during travel. ful programme isbased on technical competence Research institutes are trying to determine the ensured by the training of engineers and specialized long -term risks, such as carcinogenesis, gene mutations, workers, and the establishment of a revolving fund chronic degenerative diseases of the cardiovascular drawing an income from the government, the local and respiratory systems, mental illness and retarded authorities, intergovernmental organizations, and the growth. sale of the water at a fair price, thus enabling the WHO has undertaken a study of constraints found work to be extended gradually to other zones. by governments and local authorities in carrying out The Meeting of Ministers of Health of the Americas their programmes forthe construction of water held in Santiago, Chile, in 1972 laid down objectives for that continent for the next 10 years, and there are supply and sewage disposal systems. The publication hopes that in 1980 a larger proportion of the world summarizing the study also indicates research, surveys population as a whole will have a better environment. and other needs, which countries have classified by However, eradication of diseases transmitted through order of priority.'Most developing countries give polluted water does not automatically follow the first priority to the solution of concrete problems installation of a proper system of drinking -water connected with drinking -water (groundwater resources, supply and sewage disposal.It is true that cholera collection and utilization of rainwater, cheap means may disappear as soon as half the population is thus of filtration, and desalination). The topicality of these served, but dysentery and the typhoid group of problems is shown by the fact that in 75 developing diseases can only be eliminated by means of supple- countries over two -thirds of town -dwellerssuffer mentary measures such as chlorination, filtration, from a quantitatively and qualitatively inadequate pasteurization of milk, and general hygiene and cleanliness. ' World health statistics report, 26: 11 (1973), tables 11 and 18. 2 WHO Technical Report Series, No. 297,1965; No. 439,1970. CHAPTER 9

HEALTH PLANNING

The principle of planning in the health sector has study of the evolution of concepts up to 1990 with gained acceptance because the concepts of regional- five -year stages and annual instalments. The German ization,specialization, and integration have been Democratic Republic has studied a plan covering recognized as valid.Since primary and secondary 15 -20 years that can be broken down into five -year and preventive activities,curative medicine, and reha- one -year periods. In February 1973 Poland approved bilitation are carried out within the same system and a national plan for health and social welfare covering since that system is one of the sectors in a wider the period 1973 -1990. socioeconomic system, the need for rational planning In these countries the public health plan is drawn becomes evident.The planning process begins by up after study and discussion at every level.For defining the importance of the public health sector example, the Soviet plan is a synthesis of the results in relation to the socioeconomic system as a whole; of studies and opinions at three main levels: the the next step is to balance the subsystems of hygiene, central level, essentially political, where a choice is primary prevention, secondary prevention, curative made between the main alternatives; the level of medicine, and rehabilitation. The relative importance technical planning bodies at each stage in the admi- of the establishments called upon to put the pro- nistrative hierarchy (the USSR as a whole, the gramme into effect is then determined, and finally the constituent republics, the oblasts and krajs, and the size of the various elements making up those establish- urban and rural rayons); and the level of the local ments (staff, capital investment, and operating ex- health authorities.The plan is not final until expenses) is fixed.The purpose of the present chapter changes of opinion between various levels and the is to bring together the data supplied by the countries views of the staff of the establishments concerned themselves. have been taken into consideration. It has been seen that in applying the concept of (2) The developingcountrieshaveingeneral planning the public health sector meets with numerous adopted the concept of national health planning. obstacles, mainly due to the existence of established Possibly these countries for various reasons feel less political and legal structures that have failed to averse to the notion of planning than the developed evolve as quickly as technology.It must be added market economy countries.In the first place, many that the stumbling -block in every long -term plan of them have inheritedcentralized and authori- is the difficulty of reconciling the annual State budget tarian structures that the dominant powers established system with the forecastscovering several years during the first half of the twentieth century.Then proposed by the plan.It is for that reason that the again, the paucity of their technical and financial countries have given very diverse answers to the resources makes the local authorities accept without questions connected with the national health planning much discussion decisions taken at the centre. Finally, system in force and its modes of application.Three the priority aims are easy enough to define.It is groups of countries can be distinguished: scarcely possible to go wrong if it is decided to streng- (1) The socialist countries possess highly devel- then thestaffingof rural health establishments, oped planning mechanisms. Observance of the to provide more people with drinking -water or to principle that the public health sector forms a com- control Anopheles in malarious areas. However, ponent part of the socioeconomic system is ensured rational planning encounters some major obstacles by overall planning bodies, of which GOSPLAN in the in the lack or inadequacy of social legislation, shortage USSR and the National Planning Commission in of staff, budgetary restrictions, the sometimes un- Czechoslovakiaareexamples. Thesecountries coordinated development of private institutions of a prepare long -term plans and have acquired ex- commercial nature, and thedisparityinhealth perience over several decades. The ninth plan in the potential between the large towns and the rural areas. USSR extends from 1971 to 1975.Czechoslovakia These problems have been analysed in other chapters has made forecasts up to 1985 and has extended the of this report.

40 HEALTH PLANNING 41

TABLE 4. HEALTH PLANNING IN DEVELOPING COUNTRIES

Country Plans and the Main objectives Integration in the Planning bodies or territory periods covered socioeconomic plan

Central Plan 1971 -1975 Basic health services Integrated in the second - African development plan Republic Comoro Plan 1970 -1975 - - - Archipelago Cyprus Third plan 1972 -1976 Staff; technical equipment - Planning Board of the hospitals; district hospitals ; dental hygiene in schools; health education; control of medicaments Democratic First plan 1971 -1973 - Priority for economic - Yemen Health plan 1971 -1975 development India Fourth plan 1969/70- First and second plans - - States and Central 1974/75 primary prevention; third Government plan - public health services; fourth plan - integrated medical care; fifth plan - rural health Iraq Five- and 10 -year plans Rural health - - Laos Plan 1969 -1974 - Integration Supreme Commissariat for the Plan Liberia 10 -year plan 1969 -1976 Epidemiologicalservices - - (five-year plan 1972 -1976) Pakistan Seven -year plan an- Integrationof thepre- - - nounced in 1972 ventive, curative and emergency services Paraguay Socioeconomic plan - - Secretariat for Technical, Social and Economic Plan- ning established in 1962, Council for Social Prog- ress, established in 1967, and National Council for the Health Planestab- lished in 1968 Peru First plan 1966 -1970 Strengtheningofinfra- Integrated in the socio- - Second plan 1971 -1975 structureandestablish- economic plan 1967 -1970 Biennial operational plans mentstoensurebetter 1971 -1972 and 1973 -1974 coverageofthepopulation; water supply and waste disposal Republic of Plan 1972 -1975 Strengthening of services - The plan is prepared by Viet -Nam andinstitutions;health the provinces and munie - problems resulting from ipalities (55 in all)and the war harmonized at the centre Singapore 20 -year plan drawn up in Strengthening of the hos- - The first part, covering 10 1972 pitals years, has been adopted by the Government Sri Lanka Plan 1968 -1973 Integration of the special- - Parliament (plan for 1972 - ized services and decentral- 1976 submitted in 1971) ization 42 FIFTH REPORT ON THE WORLD HEALTH SITUATION

TABLE 4 (concluded)

Country Plans and the Main objective Integration in the Planning bodies or territory periods covered socioeconomic plan

Sudan Plan 1970 -1974 Preventive and social medi- - - cine; rural health services; mobileservicesforthe nomads; faculty of medicine; specialization of the regional hospitals Thailand Third plan 1972 -1976 Strengthening of establish- Integrated in the plan for - ments and staff socioeconomic development since 1972 Tunisia Plan 1969 -1970 - - Ministry of Health Turkey Second plan 1968 -1972 Control of the rise in popu-Coordinationwiththe Central Government, and lation; health personnel; socioeconomic plan health insurance societies balanced infrastructure that administer the health services Upper Volta Plan 1972 -1976 Basic health services - -

Table 4 has been drawn up on the basis of data commissions), Switzerland and Yugoslavia. However, supplied by certain developing countries.It will be a process of national planning has obviously been seen that the objectives of their plans are generally initiated in Switzerland by the establishment of a concrete and well defined, but that the integration of Swiss Hospital Institute and in Ireland by the 1972- the public health plan in socioeconomic development 1976 draft plan for specific programmes (medical and the nature of the general planning bodies are practitioners, hospitals for acute cases, mental health rarely made clear. services, community services for the aged, child health and health education) supported by the Medicosocial (3) The developed countries present a very different Research Board. picture.Some have no public health planning on a Finally, certain developed market economy countries national scale. Denmark, Norway, and the United have gradually established health programming and Kingdom are in this category; however, it is obvious planning mechanisms at the national level.Sweden that the health establishments and services follow possesses a National Institute for the Planning and precise directives and that coordination is strongly Rationalization of the Public Health and Social encouraged and often made obligatory by legislation. Welfare Services, its purpose being to restructure the The United Kingdom provided for the establishment of system of medical care by developing outpatient a planning body in 1973 in application of the National services and placing chronic patients in special insti- Health Service Reorganization Act of that year. tutions. The Social Service is also to be strengthened. Moreover, the social services of the local authorities Spain has carried out its second socioeconomic plan have studied and prepared 10 -year plans for the (1968 -1971) and has launched on the third plan period 1973 -1983.The Department of Health and (1972 - 1975), which, is concerned with the system of Social Security is being reorganized to coordinate the provision of medical care.Finland has drawn up an plans in the different sectors. In fact the three branches economic plan containing a health section. The law of the National Health Service to be integrated in of 1972 calls on the central Government to prepare 1974 will continue to develop along the main lines and publish a five -year plan for which the basic data established earlier. In particular, the 10 -year hospital are to be supplied by the local authorities. According plan is being put into practice in annual instalments. to the 1973 -1977 plan, investments in the primary In reality, therefore, a public health plan does exist. health services will be increased.France has long Other countries have no national health planning possessed a Commissariat général du Plan in which bodies proper, but have established planning mecha- special committees study projects prepared by the nisms at the provincial, state or regional level.This economic and social ministries, including the Ministry is the case in Canada (provinces of Manitoba, Nova of Health and Social Security. The complex mecha- Scotia, and Quebec), Ireland (eight regional health nism of coordination between the central authorities HEALTH PLANNING 43 and the local authorities through the intermediary of the number and distribution of the establishments, the regions has led to a division of decision -making their facilities for diagnosis and treatment and their powers between the health authorities, which, in bed capacity; budgetary allocations for capital in- principle, retain the initiative in making requests, vestment and operating expenses; and the education and the regional and national authorities, which lay and refresher training of the staff employed by public down directives and norms and control allocations health establishments. for equipment and operational budgets. The Hospitals An analysis of the structure of health planning Act of 31 December 1970 increased the responsibilities bodies in countries that have adopted this course of the health authorities in regard to planning. reveals very great diversity.The most important Thus there is evidence of a slow but certain evolution contraints are the power of local authorities, which towards the establishment of legislative, financial, hesitate to abandon their initiative to the regional and technical mechanisms for preparing and imple- authorities; the difficulty of foreseeing exactly when menting health plans integrated in plans for socio- payments will become due during a long -term plan; economic development. This process requires thorough and the lack of criteria for judging priorities in a study of the operation of the services and the way domain as diversified as that of public health. How- in which they are used by the people they serve. ever, there is a definite tendency to organize national Research must be carried out on optimizing the planning and programming of the health services, and effectiveness of the system and in this connexion probably the decades to come will see a harmonization modern analytical techniques are proving useful. of the methods used and an extension of their prac- Studies should concentrate on three main aspects : tical application. CHAPTER 10

PUBLIC HEALTH AND MEDICAL RESEARCH

The Second and Third Reports on the World Health increasingfinancialresourceshave enabledpro- Situation emphasize the importance of research, the grammes on a large number of research subjects to results of which play a decisive part in guiding the be carried out simultaneously. decisions that public health personnel are called upon to take either in the field or in the office.The This chapter will therefore deal rather with research scope of medical research covers not only the tradi- in public health than with clinical research, which tional sectors but also and above all domains as yet is concerned with individual cases and sometimes rare unexplored or inadequately known. diseases. However, since the distinction between To summarize in a few pages what has happened public health and clinical medicine is far from clearcut, throughout the world in the field of medical research itis impossible to confine comments exclusively to between 1969 and 1972 would be an impossible task, research on community health.Table 5 summarizes for in every country where the organization of medical the main subjects of research carried out by the various research has made it possible for the health author- research bodies in 23 countries or territories, with as ities to reply to the questionnaire for this Report, indication in most cases of the research budget.

TABLE 5.EXAMPLES OF THE ORGANIZATION OF HEALTH RESEARCH

Country or territory Research body Main subjects of research Research budget

Belgium Institute of Public Health and Financed by the National Epidemiology Scientific Research Fund and the Medical Research Fund

Canada Medical Research Council, pro-Pharmacology,nutrition,publicCan. $ 54.8 million in 1970/71 vincialgovernments,hospitals, health economics, utilization andCan. $ 63.1 million in 1971/72 universities and foundations L cost of the health services, public health problems

Cuba Ministry of Health, faculties of Sportsmedicine,epidemiology 1.5 % of the State budget medicine,NationalCentreforand microbiology, haematology, Scientific Research, specialistimmunology, nephrology, endo- institutes crinology, medical and surgical cardiology

Czechoslovakia The Czech and Slovak MinistriesMicrobiology,virology,neuro-181 100 000 korunas in 1966 of Health, the Czech and Slovakphysiology,oncology,genetics,260 700 000 korunas in 1971 Academies of Science, 29 institutes cardiovascular diseases, functioning of the public health system

Denmark Institutes,universities, StatensNumerous subjects Seruminstitut, hospitals

Finland Universities, State institutes, Blood circulation, rheumatic0.6 ° %, of gross national product, Academy of Sciences diseases, diseases of the locomotorof which 78 % goes to the uni- system versities, 9 % to the State institutes and9 % tothe Academy of Sciences

1 Research on chronic diseases is under the control of the Department of Veterans' Affairs. -44-- PUBLIC HEALTH AND MEDICAL RESEARCH 45

TABLE 5 (continued)

Country or territory Research body Main subjects of research Research budget

France National Institute for Health andMedical research, state of health156 737 000 francs paid by the Medical Research, university of the population, disease classi- Stateforthecurrentpriority hospitals, private foundations fication,utilizationofservices, programme,plussubsidiesto and institutes, 93 research groupsepidemiology foundations and institutes. and units Total: 211 387 000 francs

German Ministry of Health, Council forCardiovasculardiseases,gastro-FinancedbytheMinistryof Democratic Planning andCoordinationofenterology,diabetes, tumours,Health,industrial research pro- Republic Medical Scientific Work, 24 mental illness, chronic renal insuf-jects, public health establishments research commissions ficiency, infectious hepatitis, genetics, streptococcal and staphylococcal diseases, nutrition, environment

Hong Kong DepartmentofMedicineandViral hepatitis, tuberculosis, breast Health cancer, clinical research

Hungary Academy ofSciences,MinistryProgramme 1970 -1985includes: ofHealth,hospitals,nationallymph circulation, endocrinology, institutes disorders of the nervous system

Ireland MinistryofHealth, MedicalMorbidity, malformations,disa- Finaneed by the State in coordi- Research Council, Medico - bilities, mental health nation with the universities and social Research Board the main hospitals

Madagascar Government (through Intermin- Financed by Government foun- isterial Commission for Scientific dations and bilateral and inter- and Technical Research), hospi- national assistance tals,universityandinstitutes. Establishment of an Institute of Public Health Research is envisaged

Netherlands Universities, privateinstitutes, regionalhospitals,the pharmaceutical, electronics and medical equipment industries 1

New Zealand Medical Research Council,Cardiovasculardiseases,social private foundations and societiesandphysicalconsequencesof migrations

Norway Hospitals,universities, Research 10 % ofthetotalbudgetfor CouncilforScienceandthe general research Humanities, Royal Council for Scientific and Industrial Research

Poland Ministry of Health and SocialState of health of the population,Over95 % ofexpenditureis Welfare (14 institutes), Academyenvironmental and work hygiene,covered by the Government of Sciences, 10 medical academies,2 mental health, maternal and child Centre for Postgraduate Medicalhealth, rehabilitation, circulatory Training, MedicalTechnologysystem Centre

Romania Ministry of Health, Academy ofCommunicablediseasecontrol, 117millionlei,paidbythe Medical Sciences, Nationalcontrol of chronic degenerativeGovernment, in 1972 Council for Science and Techno-diseases, medical services logy, universities

1 Coordination by the Organization for the Advancement of Pure Research and the Central Organization for Applied Scientific Research. 2 Each medical academy is responsible for research in two or three voivodships (provinces). 46 FIFTH REPORT ON THE WORLD HEALTH SITUATION

TABLE 5 (concluded)

Country or territory Research body Main subjects of research Research budget

Singapore Medical Research Council Communicable diseases, child anthropometry, streptococcal diseases, rheumatoidarthritis, coronary heart disease

Spain Research Council, National School of Public Health, National School of Paediatrics, National Centre of Ecology and Virology, National Institute of Oncology, faculties and teaching establishments

Sweden Medical Research Council under Allbranchesof publichealth Government: 200 000 000 kronor the supervision of the Ministryand medicine Foundations: 20 000 000 kronor of Education, teaching hospitals Pharmaceutical industry: underthesupervisionofthe 30 000 000 kronor Ministry of Health and Social Total: about 250 000 000 kronor Welfare, laboratories and foundations

Switzerland Universities,hospitals,pharma-Alcoholism, drug addiction, healthContributions from the chemical ceutical industry, Public Healtheducation,environmentalpro-industry and private groupings. Commission of the Swiss Nationaltection,organization of nursing SwissNational Fund forthe Fund for the Encouragement ofcare, regional planning Encouragement of Scientific Scientific Research Research - 10.5 million francs in 1968 15.5 million francs in 1971

Thailand National Research Council, Bacterial diseases, viruses, myco- Department of Medical Sciences, logy, entomology, medicinal universities plants, drug control

United Kingdom Medical Research Council, All subjects,but with the£28 000 000plusvarioussub - of Great Britain universities, National Healthemphasis since 1972 on Govern- sidies.Total expenditure: and Service 1 ment requirements £55 986 000 in 1971/72 Northern Ireland

1 See the White Paper 'A Framework for Government Research and Development" for details of its organization and development and deliberations on the future of the Research Council system.

Public health research (1) In view of the constraints on the development of Public health research has three main aspects: the public health services and in conformity with the organization of the health services in the widest sense, rules of economics an effort must be made to obtain study of the diseases that those services are striving maximum efficiency in order to achieve the objective to control, and investigation of environmental factors. that the World Health Organization and all the governments havesetthemselves -namely,better Organization of the health services health for more people. The priority objectives listed in the Fifth General A growing number of research projects are con- Programme of Work covering aSpecific Period cerned with the possibility of applyingeffective (1973 -1977 inclusive)1 and in the Director -General's methods of organization and management. Itis report to the fifty -third session of the Executive essential first of all to define the problem by measuring Board on WHO's role in the development and co- it -hence the research on the utilization of health ordination of biomedical research 2 have been ac- centres providing outpatient care carried out in cepted as guidelines. Belgium, Canada, Iran, Israel, Tunisia, and Yugo- slavia.Utilization of hospitals by the various socio- 1 WHO Official Records, No. 193, 1971, Annex 11. economic groups has been studied in Belgium, Finland, a WHO document EB53/5 of 11 December 1973. France, the Federal Republic of Germany, India, PUBLIC HEALTH AND MEDICAL RESEARCH 47

Sweden, the United Kingdom and Yugoslavia. The creation of intercountry organizations such as the organization of the nursing services and planning European Economic Community (EEC), the Organi- problems connected with aging have been the subject zation of American States, and the Organization of of special study in Switzerland. African Unity is impelling the governments concerned Operational research and systems analysis are the to bring their social budgets into line and to improve means usually employed by the bodies that undertake their national accounting. The administration of this type of work.These methods require the col- the EEC has published documents on this subject. lection of reliable and comparable statistics and therefore contribute towards improvement of the (3) The development of manpower resources re- conventional services that provide information on quires research on the motivation of individuals in the operation of the health services (hospitals, health choosing the health professions, as well as on methods centres, preventive and curative services, etc.) and of teaching and their effectiveness, on the one hand on morbidity.Such research makes it possible in for courses of education leading to qualification and particular to optimize the distribution of the health on the other for continuing education and periodic services over a given area by taking into account the refresher training.The training and utilization of demographic composition of the population groups, medical auxiliaries also require numerous trials in the means of communication, available staff, financial various contexts in which they are to practise their professions. resourcesforcapital investment and operational expenditure, and the evolution of needs and demands for medical care.1 These methods have been adopted Diseases of public health importance as routine procedures in some of the countries mentioned above. To them must be added the procedures (1) Means are available for preventing a number of followed in France (hospital plan and map under the communicable diseases, particularly the use of vaccines provisions of the Hospitals Act of 31 December 1970), and sera, but research is essential in order to improve the USSR (particularly at the Semagko Institute), the the methods of administration (minimum doses, United Kingdom, and the United States of America. combinations of vaccines and immunization schedules), to increase the effectiveness and average duration of (2) The socioeconomic and financial problems are connected with those just mentioned but require activity, and to improve the storage and distribution of the vaccines, providing guarantees against possible econometric study.Studies on the cost of the health late sequelae and prolonging the duration of the services have become much more numerous, as is immunity acquired.To this must be added basic shown by the number of replies to the questionnaire dealing with financing and with the sums allocated research on the immunity mechanisms triggered off by some parasitic and viral diseases, with a view to by the central health authorities to the different sectors preparing new vaccines. as a proportion of the overall budget of the government and gross national product. Such studies have (2) An increasing number of research programmes been carried out in France by the Consumer Research are concerned with noncommunicable diseases, such and Documentation Centre (CREDOC) and the as cancer, metabolic disorders, and slowly developing Centre for Income and Cost Studies attached to the degenerative diseases. Commissariat général du Plan. This aspect of research Most of the developed countries place ischaemic reveals the involvement of the social security services heart disease first on the list of their main public in an increasing number of countries.Cooperation health problems. Identification of the causes of these between governments and the representatives of ILO complaints requires multidisciplinary research with and WHO at the national level, and between the the participation of numerous countries. headquarters of those two organizations at the inter- Cancer remains a challenge, but the extent of the national level, has proved effective in Cyprus, Ghana, progress made in diagnosis and therapy as a result the Libyan Arab Republic, Malta, and the Philippines, of research should not be underestimated. The part to name only a few. played by tobacco smoke absorbed in certain forms Not enough data are yet available to enable us to in the etiology of bronchopulmonary cancer has been determine with sufficient precision the way health demonstrated. budgets are formed - i.e., the nature and importance of the sources that provide the finance for public health and social security establishments. However, the Environmental health The environment in which the human individual 1 GRUNDY, F. & REINKE, W. A. Health practice research and formalized managerial methods, Geneva, World Health Organi- and human societies live and work is constantly being zation, 1973 (Public Health Papers No. 51). disturbed by new techniques of industrial and agri- 48 FIFTH REPORT ON THE WORLD HEALTH SITUATION cultural production and by the use of toxic products. in hospital -hence the importance of participation by Public opinion has been alerted to the pollution of the statistical departments of health establishments in the air, fresh water, the sea and the soil, and the an early warning system. impregnation of the plants and animals used for human The subjects that seem to have been most widely food with chemical products orphysicalagents studied are: organ grafts, tissue compatibility, re- (radioactive isotopes).Research is essential in order jection phenomena, genetic anomalies, viral hepatitis, to determine the extent of the hazard, and an almost cardiovasculardiseases,thepharmacotherapyof daily check must be kept on new products that might mental illness, kidney diseases, autoimmune diseases endanger the worker who makes them, the person and rheumatism, pharmacodynamics, toxicology, and who uses them, and the public in general. Countries resuscitation and monitoring techniques. are therefore interested in an exchange of views on WHO is continuing to play its coordinating and these products and also in an international early catalytic role in a number of fields of activity suggested warning system that should make it possible to avoid by the Advisory Committee on Medical Research. a certain number of individual and collective accidents. The Organization intendstoencourageregional offices to play a greater part in the general programme. Clinical research A large proportion of medical research in the world is carried out in WHO international and regional Some clinical research is being carried on in most reference centres and recognized collaborating insti- countries.It may even be said that the practice of tutions and laboratories.'Finally, the application of medicine involves a research aspect in the sense of science and technology to development has been the determining the effectiveness of, or contraindications subject of a world Plan of Action drawn up for the to, new medicaments marketed by the pharmaceutical Second United Nations Development Decade.2 industry.Here emphasis must be laid on the impor- The subjects at present considered to have priority tance of the continuing research carried out both by in public health and medical research are: public the pharmaceutical industry and by the drug control health problems connected with community drinking - services that most countries have established. water supply; communicable disease control; vector As already stated, it is difficult to draw a hard and control; nutrition; training of public health personnel; fast distinction between public health research and and human reproduction. Pathogenic complexes and clinical research.Some countries carry out clinical the conditions of human exposure and receptivity research on diseases that represent a threat to their are in constant evolution.Without research in the communities, but those same diseases are unknown new fields thus created, progress would be jeopardized. or uncommon elsewhere.Furthermore, it has been pointed out that the first sign of a new threat to public 1 See WHO Official Records, No. 213, 1974, Annex 5. health most often comes from clinical cases treated 2 United Nations document E/4962 Rev. 1. Part II

REVIEW BY COUNTRY AND TERRITORY Part II of this volume contains the reports submitted by governments in response to the request of the World Health Assembly in resolution WHA23.24.1 These reviews of the health situation in individual countries and territories have been grouped in alpha- betical order in the six regions of WHO. To facilitate reference an index to all the countries and territories is included at the end of the volume. All additional information and amendments received from governments in accordance with resolution WHA27.60 1 have been duly incorporated. As was the case in the earlier reports, the material contributed by governments was not always strictly confined to the period under review; it has again been considered undesirable to exclude valuable data solely on that account. In the sections on "Assistance from WHO" the starting date of each project is shown between brackets after its title; where the finishing date is not indicated the projects continued beyond the period under review. Names of cooperating agencies are abbreviated as follows: AID -United States Agency for International Development FAO -Food and Agricultural Organization of the United Nations ILO -International Labour Organisation PAHO -Pan American Health Organization UN- United Nations UNDP- United Nations Development Programme UNESCO- United Nations Educational, Scientific and Cultural Organization UNFPA- United Nations Fund for Population Activities UNICEF- United Nations Children's Fund

1 See note, p. II. AFRICAN RECTION

BURUNDI

Population and other statistics Medical assistants 120 Dentists 6 Dental assistants 6 According to the results of a sample survey carried Pharmacists 7 out in 1970 -1971, the population of Burundi was Veterinarians 12 Veterinary assistants 34 estimated to be 3 350 000. The annual natural popula- Midwives 29 tion increase is estimated to be 2 %. Assistant midwives 69 Nurses 235 The most frequently notified communicable diseases Assistant nurses 344 Sanitary engineer 1 in 1971 were: malaria, new cases (104 749), influenza Sanitarians 9 (50 254), measles (35 933), whooping -cough (18 080), Assistant sanitarians 49 Physiotherapist 1 dysentery, all forms (15 823), gonorrhoea (13 194), Laboratory technician 1 exanthematic typhus (6285), schistosomiasis (3717), Assistant laboratory technicians 21 X -ray technician 1 syphilis, new cases (3149), infectious hepatitis (2227), Health aides 126 tuberculosis, all forms, new cases (1833), leprosy (672), Other technical personnel 10 poliomyelitis (114), typhoid and paratyphoid fevers The medical school of the University of Bujumbura (113), trypanosomiasis (75). organizes a three -year course for medical students, who finish their medical training abroad.Training Organization of the public health services facilitiesfor health personnel available at Kitega The responsibility for all health services rests with include one school for medical technicians, one school for nurses and one for auxiliary nurses.Bujumbura the Minister of Public Health. The Ministry comprises the cabinet of the Minister and the Directorate - has one school for sanitary assistants. General.The following main technical units come under the authority of the Director -General: the Communicable disease control and immunization services department of hygiene and laboratories; the depart- Following the smallpox eradication programme ment of education of medical and health personnel; which started in 1967, no smallpox case has occurred and the department of medical care and pharmacies. since the end of 1970. Tuberculosis control measures The department of hygiene and laboratories comprises include BCG vaccination, case -finding and treatment, thesubdirectorateforsanitation,environmental and chemoprophylaxis. A trypanosomiasis control health, endemic diseases and laboratories, and the programme is being carried out in the north -east of the subdirectorate for health education, maternal and country. child health, and social medicine. Thefollowingimmunizationprocedureswere carried out in 1971: Hospital services Smallpox 770 153 At the end of 1970 Burundi had 146 hospitals and BCG 341 982 inpatientestablishments providing 4500 beds,of which 3164 were in government establishments. The Assistance from WHO bed /population ratio was 1.3 per 1000. The 4500 beds In 1972 WHO's assistance to Burundi included the were distributed as follows: following projects :

Category and number Number of beds Epidemiological services(1972- ) UNDP: to

General hospital 1 650 develop an epidemiological service; to strengthen the Rural hospitals 18 1 827 Medical centres 115 1 221 vital and health statistics service; and to train per- Maternity hospitals 10 504 sonnel. Tuberculosis hospital 1 240 Leprosarium 1 58 Smallpox eradication (1967- ):tocarry out maintenance and epidemiological surveillance work, Medical and allied personnel and training facilities and to evaluate the programme. In 1971 Burundi had 76 doctors, of whom 61 were Master plans for sanitation and drainage, Bujumbura in government service.The doctor /population ratio (1972- ) UNDP: to make engineering studies for was thus one to 47 600.Other health personnel the preparation of master plans and phased investment included : plans for sewerage, drainage and solid wastes disposal - 53 - 54 FIFTH REPORT ON THE WORLD HEALTH SITUATION systems for Bujumbura, and to formulate policy on of nurses and sanitation staff, and training of health related legal, managerial and financial matters. staff in health education techniques. Development of basic health services (1969- ) Health laboratory service (1971- ) to establish UNDP UNICEF :to plan the health services and and develop a blood bank in Bujumbura. improve basic health services,with emphasis on Medical school, Bujumbura (1972- ): to develop improvement of family health and nutrition, training the medical school of the University of Bujumbura.

CENTRAL AFRICAN REPUBLIC

Population and other statistics Outpatient facilities were available at the end of 1971 at 10 hospital outpatient departments, 31 medical At the last census, taken in 1970, the population of centres, which also have inpatient facilities, four health the Central African Republic was 2 255 536. centres providing altogether 492 beds, 82 dispensaries The birth rate is estimated at 46 per 1000 population, staffed by male nurses and auxiliary nurses, 204 the death rate at 25 per 1000, the infant mortality rate medical aid posts, and five mobile health units. These at 190 per 1000 live births, and the population increase latter are responsible for case -finding, vaccination at 2.1 % per annum. and endemic diseases control activities.Each unit The communicable diseases most frequently reported is generally staffed by a doctor, a medical assistant, in 1972 were : malaria (over 100 000), measles (2718), three"agents techniques" and approximately10 leprosy (1064), tuberculosis, all forms, new cases (431), assistant male nurses. meningococcal infections (231), trypanosomiasis (112). Medical and allied personnel and training facilities Organization of the public health services The responsibility for all health functions in the In 1972 the Central African Republic had 48 doctors, of whom only three were Central African.Other Central African Republic rests with the Minister of health personnel included : Public Health and Social Affairs. The Ministry comprises the cabinet of the Minister, who is assisted Medical assistants 13 Dentists 2 by a technical committee and a technical adviser, and Pharmacists 4 the Directorate -General. Among the services under Midwives 30 Midwifery aides 67 the Director -General are: the office of programming Nurses 581 Assistant nurses 68 and planning, the general administration, the pharma- Nursing aides 229 ceutical and supply service.The following technical Sanitary engineers 2 directorates also come under the authority of the Sanitarians 20 Director -General : urban health and hospitals, training, The arrangements for the training of health per- social affairs, and rural health and control of endemic sonnel at the National Institute of Public Health and diseases. For the control of endemic diseases the Medicosocial Training, Bangui, were as follows: country is divided into five sectors with administrative headquarters in Bangui, Berberati, Bossangoa, Bam- Category and admission Duration ofNumber ofNumber of requirements study students graduates bari and Bangassou.Each sector has mobile units (years) 1971/72 1972 for the campaigns against endemic diseases and for Nurses BEP 1 3 20 15 preventive activities. Assistant nurses BEP 1 40 35 Midwives Hospital services BEP 3 10 8 Sanitarians In 1970 the Central African Republic had 51 hospitals BEP 3 10 6 and other establishments for inpatient care, providing 1 Brevet d'éducation primaire (primary education). a total of 3468 beds, of which 3357 were in government - maintained establishments. The bed /population ratio Between 1969 and 1972 the National Institute of was thus 2.2 per 1000. The 3468 beds were distributed Public Health and Medicosocial Training trained as follows : altogether 32 male nurses, eight midwives, six sani-

Category and number Number of beds tarians and 67 assistant male nurses. The training of General hospitals 6 921 medical assistants will start at this institute in 1974. Rural hospitals 12 1 021 A university was established in the Central African Medical centres 31 1 476 Leprosaria 2 50 Republic in October 1970. Medical students, however, AFRICANREGION 55 continue to receive their training abroad, although the five -year period for establishing, extending and some return to their country for internship in the improving the social and health infrastructure. sixth year. The five -year national plan for 1971 -1975 which is integrated into the second development plan, has been Communicable disease control and immunization services prepared by the Ministry of Public Health and Social Malaria remains the most prevalent communicable Affairs, approved by the social commission, and disease in the Central African Republic, with more submitted to the national planning commission. The than 100 000 reported cases a year. At present chemo- main objectives of this health plan are: education and prophylaxis is the only control activity undertaken. training of health personnel; development of basic No smallpox case has been reported since1964. health services, particularly maternal and child health, Tuberculosisisconsidered a very serious health environmental sanitation, control of endemic diseases, problem. Trypanosomiasis is limited to a number of and health education; development of social services; residual foci.The incidence of intestinal parasitoses improvement of theurban healthinfrastructure, remains high; their control is mainly a problem of including improvement of the national hospital centre, health education and improved environmental health. and construction of urban maternity centres; and The number of leprosy cases continues to decline. establishment of a State pharmacy. The following immunization procedures were carried out in 1972: Assistance from WHO Smallpox 447656 In 1972 WHO's assistance to the Central African Yellow fever 239227 BCG 89873 Republic included the following projects: Measles 74661 Smallpox eradication (1969- ) Environmental sanitation Sanitation and drainage, Bangui (1969- ) UNDP: In 1971, of the 172 communities in the Central to plan and implement a sanitation and drainage programme for the residential districts of Bangui and African Republic only two had a piped water system serving 10 % of their inhabitants with piped water, to train sanitation workers. while 50% were supplied with water from public Development of basic health services (1969- ) fountains.Only Bangui had a sewerage system and UNDP UNICEF: to develop the basic health services, 10% of its inhabitants were living in houses connected train health staff, and plan and implement a long -term to sewers. sanitation programme. Nursing education (1966- ) UNDP: to upgrade Major public health problems and develop the basic nursing education programme The most important public health problems in the at the Bangui school of nursing. Central African Republic are the inadequate medical and health coverage, particularly in rural areas, and Government health expenditure the inadequacy of material and financial resources. In 1972 the total government expenditure amounted Efforts are being made to develop the basic health to 13 805.1 million CFA francs, of which 1165 million services, and a pilot area has been established at were spent on health services (1147 million on current Bimbo (12 km from Bangui).The services will be account and 18 million on capital account).The extended to the rest of the country.Malaria and its Ministry of Public Health and Social Affairs accounted control is also a very serious problem in the country. for 460 million CFA francs, the intermediate government level for 285 million and the local government National health planning level for 420 million.The expenditure on general The current five -year social and economic develop- public health services broken down by purpose or ment plan for 1971 -1975 followed the first, four -year programme included the following items: 32 million development plan for 1967 -1970.These two plans CFA francsforadministration and government place particular emphasis on economic development, personnel, 115 million for mass campaigns against whereas the social and health sectors are given only communicable diseases, immunization and vaccination, limited attention. Among the main priorities of the laboratory services and environmental health services, five -year development plan are: development of agri- and 18 million for education and training of health culture and livestock, commercialization of agricul- personnel. The government expenditure on hospitals tural products and improvement of transport facilities, amounted to 264 million CFA francs. The government professional education and training, and tourism. The contributions to health activities of social security plan allocations to the public health and social schemes and other nongovernmental social welfare affairs sectors amount to 2000 million CFA francs for systems amounted to 15 million CFA francs. 56 FIFTH REPORT ON THE WORLD HEALTH SITUATION

CONGO

Population and other statistics Sanitarians 6 Auxiliary sanitarians 31 Kinesitherapists 4 Population estimates and some other vital statistics Laboratory technicians 6 for the period under review are given below: Assistant laboratory technicians 44

1969 1970 1971 1972 The arrangements for the training of health per- Mean population 920 000940 000960 000980 000 sonnel were as follows: Number of live births 46 274 47 198 Birth rate (per 1000 population) . 42.0 42.0 Category and admission Duration Number ofNumber of Number of deaths 26 442 26 970 requirements of study schools students Death rate (per 1000 population) . 24.0 24.0 (years) 1971/72 Natural increase (%) 1.8 1.8 Nurses (State diploma) Number of infant deaths 8 329 8 496 BEPC or BEMG 1 3 1 117 Infant mortality rate (per 1000 live Nurses (certificate) births) 180.0 180.0 fourth grade 2 1 134 Midwives (State diploma)

BEPC or BEMG 4 1 90 The communicable diseases most frequently notified Senior State midwives in 1972 were: malaria, new cases (149 418), influenza State midwifery diploma . 2 1 4 Medical or health assistants

(15 514), measles (12 921), whooping -cough (7468), State nursing diploma . 2 1 10 amoebiasis (3424), tuberculosis of the respiratory Auxiliary laboratory technicians fourth grade 2 1 32 system, new cases (710), leprosy (504), poliomyelitis 1 Brevet d'études secondaires du premier cycle (secondary educa- (153), meningococcal infections (102), bacillary dysen- tion,first phase) or Brevet d'enseignement moyen général (below tery (89), typhoid fever (51), trypanosomiasis (49). fourth year).

Immunization services Hospital services The following immunization procedures were carried In 1971 the Congo had 107 inpatient establishments out in 1972: with 5541 beds, of which 5187 were in 97 government Yellow fever 191500 establishments.The bed /population ratio was thus Smallpox 117504

Cholera - 84357 5.8 per 1000. The 5541 beds, to which 150 461 patients BCG 52479 were admitted during the year, were distributed as Poliomyelitis 37500 Tetanus 31757 follows : Diphtheria 31135 Measles 27843 Category and number Number of beds Whooping -cough 726 General hospitals 2 1 627 Rural hospitals 4 422 Medical centres 100 3392 Specialized units Maternity hospital 1 100 In 1971 there were 14 maternal and child health in1971at Outpatientfacilities were available centres, 10 school health units, two dental clinics, two seven hospital outpatient departments, 18 medical hospital rehabilitation outpatient departments, one 80 infirmaries, 205 dispensaries and four centres, independentrehabilitationcentre,one psychiatric mobile health units of the major endemic diseases outpatient clinic and one public health laboratory. service.

Environmental sanitation Medical and allied personnel and training facilities In 1972, among the 292 main communities of the At the end of 1971, the Congo had 112 doctors, or country, 16 had a piped water system, which provided one doctor for 8570 inhabitants.Other health per- piped water to 47.9 % of the inhabitants of these sonnel included: 16 communities; 52.1 % of them had water from public fountains. In the same year, three communities Medical assistants 20 Dentists 3 had a sewerage system, which served 34.4 % of the Pharmacists 13 inhabitants of these communities. Pharmaceutical assistants 7 Veterinarians 4 Veterinary assistants 6 Midwives (State diploma) 59 Assistance from WHO Nurses (State diploma) 179 Certificated nurses and "agents techniques" . 558 In 1972 WHO's assistance to the Congo included the Assistant nurses 1 275 Sanitary engineer 1 following projects: AFRICAN REGION 57

Development of basic health services (1965- ) Government health expenditure UNICEF: to organize health services, and to train health staff. In 1971 total government expenditure amounted to 19 555.4 million CFA francs, of which 1185.0 million Nursingeducation(1967- )UNICEF:to were spent on health services. The per capita govern- strengthen programmes for the training of nurses, ment health expenditure amounted to1234 CFA midwives and medicosocial workers at Pointe -Noire. francs.

GUINEA -BISSAU

Population and other statistics Medical and allied personnel and training facilities At the last census, taken in December 1970, the In 1971 Guinea -Bissau had 55 doctors, or one population of Guinea -Bissau was 487 448. Population doctor for 10 240 inhabitants. Other health personnel estimates and some other vital statistics for the period included: under review are given in the following table: Pharmacist 1 Pharmaceutical assistants 9 1969 1970 1971 1972 Veterinarian 1 Midwife 1 Mean population 530 000 487 000 485 754 485 000 Auxiliary midwives 66 Number of live births 4415 2126 7906 8128 Nurses 34 Birth rate (per 1000 population) . 8.3 4.4 16.3 12.3 Auxiliary nurses 89 Number of deaths 1 018 1 605 1 044 1 355 Visiting nurse 1 Death rate (per 1000 population) 1.9 3.3 2.1 2.0 Assistant laboratory technician 3 Natural increase ( %) 0.64 0.11 1.42 1.03 X -ray technicians 2 Number of infant deaths . . . . 208 481 178 236 Social assistants 2 Infant mortality rate (per 1000 live Dental laboratory technician 1 births) 47.1 226.2 21.2 29.0 Number of deaths, 1 -4 years . . 178 192 192 In 1972 the arrangements for the training of nursing and midwifery personnel were as follows: The communicable diseases most frequently notified in 1971 were: dysentery, all forms (2539), gonorrhoea Category Duration Number ofNumber ofNumber of of study schools students graduates (2502), measles (1766), influenza (445), tuberculosis (years) (public) 1971/72 1972 of the respiratory system, new cases (437), infectious Nurses 1 1 42 - Auxiliary nurses . 1''% 1 28 23 hepatitis (187), whooping -cough (174), typhoid and Auxiliary midwives . 1 % 1 13 4 paratyphoid fevers (98), leprosy (90), trachoma (25), trypanosomiasis (25),poliomyelitis(12), meningo- Immunization services coccal infections (8). The following immunization procedures were carried out in 1969:

BCG 11127 Hospital services Smallpox 4939 Yellow fever 2073 In 1971 Guinea -Bissau had 34 hospitals, providing Diphtheria, whooping -cough and tetanus . . 260 Poliomyelitis 146 a total of 918 beds, equivalent to 1.9 beds per 1000 population.These beds were distributed as follows: Specialized units

Category and number Number of beds In 1972 Guinea -Bissau had three maternal and child

General hospital 1 407 health centres, which were attended by 3895 pregnant Rural hospitals 9 407 women and 7508 children up to 5 years of age.It is Maternity hospitals 24 104 estimated that 31 % of all deliveries in 1972 were attended by a doctor or qualified midwife.Other In 1972 outpatient medical care was available at specialized units included one school health service four hospital outpatient departments, at one polyclinic, unit, six dental health units, one hospital rehabilitation at 77 health centres, of which six had some inpatient department, one psychiatric outpatient clinic, one facilities, at 15 dispensaries, at 24 medical aid posts tuberculosis dispensary and one public health labo- and at three mobile health units. ratory. 58 FIFTH REPORT ON THE WORLD HEALTH SITUATION

LIBERIA

Population and other statistics Dentists 14 Pharmacists 3*

Veterinarian 1 At the last census, taken in April 1962, the popu- Midwives 104 lation of Liberia was 1 016 443. Population estimates Empirical midwives 126 Nurses 237 and some other vital statistics for the period under Practical nurses 41 review are given in the following table: Nursing auxiliaries 206 Sanitarians 73 Laboratory technicians 35 1969 1970 1971 1972 X -ray technicians 11 Health statisticians 3* Mean population 1149000* 1523 050 1571 477 1623547 Number of live births 77522 78 301 Health educators 3* Birth rate (per 1000 population) 50.9 49.8 Number of deaths 24 990 32 928 In government service. Death rate (per 1000 population) 16.4 21.0

Natural increase( %) . . . . 3.45 2.88 Number of infant deaths 10642 12 469 Infant mortality rate (per 1000 The arrangements for the trainingof medical and live births) 137.3 159.2 ... health personnel are as follows : Number of deaths, 1 -4 years 3 690 4 590 Death rate, 1 -4 years (per 1000 Category and admission Duration NumberNumber Number population at risk) . . . . . 18.2 21.4 requirements of study of of of (years) schoolsstudentsgraduates * Estimate (United Nations, 1972), not comparable with data for later (public) 1971/72 1972 years (see United Nations, Monthly Bulletin of Statistics, May 1974). Doctors college graduation . . . . 7 2 60 Medical assistants Organization of the public health services elementary (primary) education 2 1 19 9 The Director -General is the political and administra- Dental auxiliaries highschool(secondary tive head of the National Public Health Service. He education) 6 5 is assisted by deputy directors -general for medical months practical services, technical affairs and administration.There Laboratory assistants is,inaddition,anassistantdirector -generalfor elementary (primary) education 2 5 5 planning and a technical coordinator for technical Nurses assistance programmes. highschool(secondary education) 3 4* 37 14 Midwives elementary (primary) edu- Hospital services cation or second year high school 2 1 In 1969 Liberia had 33 hospitals providing a total Practical nurses of 2184 beds, of which 1121 were in 15 government elementary (primary) education or secondyear establishments. The bed /population ratio was 1.9 per high school 2 1 4 4 1000 population. The 2184 beds were distributed as Sanitarians elementary (primary) edu- follows : cation or second year Category and number Number of beds high school 2 1 4 4

General hospitals . . 28 1 701 Maternity hospital . . 1 143 * Including three private schools.

Paediatric hospital . . 1 67 Ophthalmology clinic 1 22 Tuberculosis hospital 1 191 Mental hospital 1 60 Communicable disease control Outpatient facilities were available in 1972 at 31 Malaria is the most prevalent communicable disease hospital outpatient departments,15 polyclinics of and constitutes a very serious health problem, as is which four provided hospitalization facilities, 32 health borne out by hospital and outpatient records and recent centres, 392 health clinics, 85 medical aid posts and limited malariometric surveys.Although the disease seven mobile health units operating under the smallpox is widespread, control activities including larviciding and measles control programme. and residual spraying are restricted to the Monrovia area.Tuberculosis is considered to be an important cause of morbidity.The leprosy prevalence rate is Medical and allied personnel and training facilities about 21.5 per 1000. The attack phase of the smallpox/ In 1969 Liberia had 110 doctors of whom 54 were measles control programme sponsored by the United in government service.The doctor /population ratio States Agency for International Development, which was one per 10 450. Other health personnel included: commenced in 1968, was completed in March 1972. AFRICAN REGION 59

The cholera epidemic which started in the second 1967 -1970.The 10 -year national health plan covers half of 1970 near Monrovia gradually extended to the period 1967 -1976.On the basis of this 10 -year other parts of the country.Priority was given to national health plan, an attempt was made to draw up nationwide cholera vaccination in addition to routine a more precise and compact plan -the five -year plan control measures. A total of 683 657 cholera vaccina- for epidemiological services (1972 -1976) for more tions were performed between August 1970 and effective and better prevention and control of com- August 1971, covering nearly half of the entire popula- municable diseases, as well as the related services, tion.The total numbers of cholera and noncholera under the National Public Health Service. This plan (diarrhoea)casesinLiberiafrom August1970 was approved during 1970. to February 1973 were 3629 cholera- positive with 213 deaths and 13 900 noncholera with 167 deaths. Other communicable diseases which account for a Assistance from WHO heavy morbidity and mortality includefilariasis, In 1972 WHO's assistance to Liberia included the onchocerciasis, schistosomiasis, helminthiasis, venereal following projects: diseases and the infectious diseases of childhood. Epidemiological service(1968- )UNDP: to develop an epidemiological service for the surveillance Specialized units and control of communicable diseases, and to establish a vital and health statistics unit in the National Public In 1972 maternal and child health care was based Health Service. on 18 prenatal centres and 43 child health centres. During the year 19 305 pregnant women, 9408 infants Smallpox eradication (1968- ) and 6671 children aged one to five years attended these centres.School health services were provided Nationalcommunitywatersupplyprogramme at 25 centres. (1972- ) UNDP :to develop an operational in- Dental treatment was given at seven dental health stitution capable of managing, administering and units, which were attended by nearly 3000 patients operating public water supply and sewerage facilities. in 1972. Other specialized outpatient establishments Development of basic health services (1968- ) in 1972 included one hospital rehabilitation outpatient UNICEF: to develop basic health services in accord- department, two psychiatric clinics, one tuberculosis ance with the national health plan; to train personnel, clinic, one leprosy clinic, two yaws surveillance units develop laboratory services and carry out antimalaria and one anticholera unit.Liberia had one public work. health laboratory which carried out about 10 000 examinations in 1972. Radiological services (1972- ): to strengthen the radiological services at the John F. Kennedy Memorial Medical Center and train the necessary staff. Environmental sanitation Medical School, Monrovia (1969- ) :to develop Monrovia, Greenville and Harper City are provided the medical school. with piped -water systems serving 80 % of their inhabitants.Monrovia area alone had public sewerage facilities which served 50% of its inhabitants. Government health expenditure For 1972 the Ministry of Health and Welfare Major public health problems reported expenditure by the National Public Health Service of US $2 658 715, of which $2 604 993 were The most important public health problems in spent on current account and $53 722 on capital Liberia are those related to the incidence of communi- account.Other ministries and departments reported cable diseases, particularly malaria, gastrointestinal expenditureof US $3 153 905 on health -related diseases, leprosy and tuberculosis. activities, of which $3 127 363 were spent on current account and $26 542 on capital account. The expen- National health planning diture on general public health services included $956 251foradministration, $983 426 for general An overall socioeconomic plan of the country, with hospitals and clinics and $521 830 for preventive a health component, was formulated for the period services. 60 FIFTH REPORT ON THE WORLD HEALTH SITUATION

MADAGASCAR

Population and other statistics Ministry of Labour.It is mainly concerned with At the last census, taken in January 1971, the pop- curative medicine, prevention of occupational accidents and control of working conditions. ulation of Madagascar was 7 655 134.Population The industrial estimates and some other vital statistics for the period health service operates in the major towns of the 1969 -1971 are given in the following table : country and in the main industrial centres.

1969 1970 1971 Hospital services Mean population 7311 252 7539 449 7655 134* Number of live births 254 452 263 217 274 028

Birth rate (per 1000 population) . . . . 34.8 34.9 35.8 In 1971 Madagascar had 841 hospitals and other Number of deaths 80 333 95 045 85 129 inpatient institutions, providing a total of 18 620 beds, Death rate (per 1000 population) . . . 11.0 12.6 11.1 Natural increase ( %) 2.38 2.23 2.47 of which 16 720 were in 662 government establishments. Number of infant deaths 14662 16468 15151 Infant mortality rate (per 1000 live births) 57.6 62.6 55.3 The bed /population ratio was 2.8 per 1000.The Number of deaths, 1 -4 years 16 395 19 953 17 024 18 620 beds were distributed as follows: Number of maternal deaths ... 178 200 Maternal mortality rate (per 1000 live Category and number Number of beds births) 0.7 0.7 General hospitals 9 4 670 Rural hospitals 169 7 215 "Census figure. Medical centres 638 4 735 Maternity clinics 7 39 Paediatric clinic 1 80 The communicable diseases most frequently notified Tuberculosis hospital 1 199 in 1971 were: malaria, new cases (177 847), influenza Psychiatric hospital 1 566 Leprosaria 14 996 (124 722), measles (64 567), whooping -cough (23 918), Rehabilitation centre 1 120 schistosomiasis (9858), respiratory tuberculosis, new cases (5978), bacillary dysentery (2519), leprosy (2484), In the public sector outpatient facilities were pro- meningococcal infections (1853), typhoid fever (1170), vided in 1972 at 75 hospital outpatient departments; diphtheria (841), rabies in man (389), paratyphoid four polyclinics, which two also had fever (268), amoebiasis (168), plague (93), scarlet fever accommodation; 99 health centres; 22 dispensaries; (48), poliomyelitis (15). 312 medical aid posts staffed by a male nurse and a midwife; 129 medical aid posts staffed by a male nurse; 55 midwifery posts staffed by a midwife; and 11 mobile Organization of the public health services health units. The overall responsibility for the health services in Madagascar rests with the Ministry of Social Affairs, Medical and allied personnel and training facilities which was established in May 1972.The Minister is assisted by the Secretary -General of Social Affairs, In 1971 Madagascar had 705 doctors (including who is in charge of the following services: finance, 20 State doctors qualified as dentists) of whom 534 were personnel, and studies and planning. The Directorate in government service.The doctor /population ratio of Health and Medical Services comprises the following was one per 10 830. Other health personnel included: services:curative medicine, border health protection Dentists (including doctors qualified as and communicable diseases. The Directorate of dentists) 75 Pharmacies and Laboratories isin charge of the Dental mechanics 6 Pharmacists 88 pharmacy inspection service and of the supply service. Assistant pharmacists 26* The Population Directorate comprises the following Midwives (State diploma) 244 ** Midwives (local diploma) 538 services :demography, health education and social Nurses (State diploma) 215 ** Nurses (local diploma) 1 887* medicine, and social assistance. Visiting nurses 53 Sanitarians 26 The country is divided into health provinces, health Auxiliary sanitarians 123 districts and municipal health bureaux. The provincial Kinesitherapists 2 Senior laboratory technician 1 health service is responsible for the health activities Laboratory technicians 2 in the six provinces.The health districts are under Assistant laboratory technicians 12 a district medical officer. "In government service. The occupational and industrial health services are "" Includingthosespecializedin, andpractising, kinesitherapy, closely linked with the health services.The occu- laboratory work or radiology but not mentioned under Kinesitherapists, pational health service has been established by the etc. AFRICAN REGION 61

The arrangements for the trainingof medical and medicaments. In an attempt to solve these problems, health personnel were as follows : the Ministry of Social Affairs has established the following priorities : to eliminate the imbalance between Category and admission DurationNumber NumberNumber urban and rural areas; to decentralize medicosocial requirements of of of of study schoolsstudents graduates education; and to integrate curative and preventive (years) (public) 1971/72 1972 Doctors health services. Sixth grade and competitive examination 5 1 211 32 Dentists National health planning diplomaoftheMedical School 1' /z 1 7 The second development plan (1972 -1974) indicates Nurses (State diploma) BEPC 1 and competitive that education and health will receive smaller capital examination 3 1 68 20 Midwives (State diploma) allocations but will have priority over the other sectors BEPC and competitive with regard to operating expenditure. A draft national examination 3 1 70 Midwives (local diploma) plan for public health establishments was prepared fourth grade and competi- with a view to obtaining a more balanced distribution tive examination . . . . 3 1 205 54 Sanitarians of health facilities between rural and urban areas and BEPC and competitive to achieving the integration of preventive, curative examination 3 1 26 8 Auxiliary sanitarians and health promotion activities. fifth grade and competitive examination 11/2 1 15 15

1 Brevet d'études secondaires du premier cycle (secondary education, Medical and public health research first phase). Scientific and technical research is the responsibility of the Government, which coordinates the research Immunization services activities. It is advised by an interministerial scientific and technical research committee which is subdivided The following immunization procedures were carried into specialized commissions. out in 1971: Medical and health research activities are carried BCG 703 297 out in hospitals, university laboratories and specialized Smallpox 431 272 Cholera 6 950 institutes.It is planned to establish a medical and Diphtheria, whooping- cough, tetanus, public health research institute whose function will typhoid and paratyphoid fevers 3250 Diphtheria,whooping- cough, typhoid be to coordinate all research activities.Medical and and paratyphoid fevers 2 190 public health research in Madagascar is financed by Yellow fever 1 052 Whooping -cough 32 the Government, by foundations and through bilateral and international aid. Specialized units Assistance from WHO In 1972 Madagascar had six specialized maternal and child health centres and two centres for paediatric In 1972 WHO's assistance to Madagascar included care.Between July 1971 and June 1972, visits were the following projects: paid to 246 440 pregnant women, 354 809 infants Water supply and sanitation, Tananarive (1971- ) and 425 809 children aged one to five years.Of all UNDP: to carry out a pre- investment study for deliveries in 1971, 71.1 % were attended by a doctor expansion and improvement of the water supply and or qualified midwife. In 1971, 483 285 schoolchildren for sewerage and solid wastes systems in Tananarive; were under the medical and health supervision of six and to make a national study of the water supply school health units.Dental care was provided at 67 dental dispensaries which recorded 108 737 patients sector. in 1971. Other specialized units included two hospital Development of health services (1968- ) : to organ- rehabilitation outpatient departments, two independent ize health services; to integrate specialized activities rehabilitation centres, seven psychiatric clinics, seven into the general health services; and to train health tuberculosis and nine leprosy outpatient departments. personnel. Madagascar also had one public health laboratory. Government health expenditure Major public health problems Total government health expenditurefor1971 The main health problem in Madagascar is the amounted to 5430.2 million Malagasy francs, of which insufficiency of financial resources to satisfy the most 4962 million were spent on current account and urgent needs for health manpower, equipment and 468 million on capital account.The expenditure at 62 FIFTH REPORT ON THE WORLD HEALTH SITUATION thecentral government level was 3233.5million environmental health services, 18.2 million on health Malagasy francs, at the intermediate level 1977.4 mil- education, 65.0 million on education and training, lion and at the local level 219.3 million. The per capita 8.6 million on nutrition, 58.0 million on maternal and expenditure on health services was 709 Malagasy child health and school health. The government francs. The breakdown of the expenditure on general expenditure on hospitals included1290.0 million public health servicesisgiven for 1094.2 million Malagasy francs on general and teaching hospitals, Malagasy francs as follows: 228.0 million on adminis- 246.0 million on specialized hospitals and 2314.4 mil- tration and government personnel, 483.0 million on lion on other health establishments. The government masscampaignsagainstcommunicablediseases, contributions to health activities of social security 10.3millionon vaccinationand immunization, schemes and other nongovernment social welfare 84.9 million on laboratory services, 138.1 million on systems amounted to 485.6 million Malagasy francs.

MALI

Population and other statistics own public health service under a regional director Population estimates and some other vital statistics of public health who is responsible to the Director - for the period under review are given below: General of Public Health.

1969 1970 1971 1972 Hospital services Mean population 4880600 5021 5005 142 9005 257 100 Number of live births 241 100 247 200 253 000 260 000 Birth rate (per 1000 population) 49.4 49.2 49.2 49.5 In 1972 Mali had 111 government hospitals and Number of deaths 145000 145200 145 400 146 000 establishments for inpatient care, providing 3803 beds Death rate (per 1000 population) 29.7 28.9 28.3 27.8 -equivalent to 0.7 beds per 1000 population. These Natural increase ( %) . . . . 1.97 2.03 2.09 2.17 beds, to which 95 517 patients were admitted during The communicable diseases most frequently notified the year, were distributed as follows: in 1972 were: malaria (475 991), measles (43 837), Category and number Number of beds syphilis, new cases(40 546),amoebiasis (36 241), General hospitals 10 2 046 influenza (32 941), gonorrhoea (23 972), whooping - Rural hospitals 35 679 Maternity centres 52 829 cough (11 165), trachoma (3662), tuberculosis of the Infectious diseases hospital 1 78 Ophthalmology institute 1 80 respiratory system, new cases (2117), meningococcal Other establishments for inpatient care 12 91 infections(631),poliomyelitis(497),typhoid and paratyphoidfevers(444),trypanosomiasis(165), Outpatientfacilitieswere availablein1972at diphtheria (24). hospital outpatient departments, 387 dispensaries, and 11 mobile health units (over 600 000 attendances). Organization of the public health services Medical and allied personnel and training facilities The overall responsibility for the health services in Mali rests with the Ministry of Public Health and In 1972 Mali had 135 doctors who were employed Social Affairs. The Director -General of Public Health by the government. The doctor /population ratio was is the executive authority. He is assisted by a technical one per 38 950 inhabitants.Other health personnel adviser and a deputy director -general. The Directorate - included :

General comprises technical divisions, central services, Medical assistants 4 and regionaldirectorates, the latter dealing with Dentists 7 Dental mechanics 4 regional hospitals, regional mobile health units, and Pharmacists 14 Midwives 168 health establishments of the administrative areas. Traditional birth attendants 167 The technical divisions are as follows: supplies; army Nurses 1 526 Auxiliary nurses 178 health services; medical care services; and preventive Sanitary engineers 2 and social medicine, divided into eight sections for Sanitarians 31 Laboratory technicians 36 maternal and child health, school health, tuberculosis X -ray technicians 17 control, communicable diseases, health education, public health and sanitation, mental health, and Mali has a national school of medicine, pharmacy nutrition. and dentistry, a secondary school for health personnel The country is divided into six regions which are which trains nurses, midwives, laboratory technicians, subdivided into 42 administrative areas (cercles) and sanitary technicians and medical secretaries, and a 286 districts (arrondissements).Each region has its school for the first -phase training of nurses. AFRICAN REGION 63

Immunization services Assistance from WHO The following immunization procedures were carried In 1972 WHO's assistance to Mali included the out in 1972: following projects:

Cholera 810247 Smallpox eradication (1965- ) BCG 448460 Measles 78634 Smallpox 76953 Drainage system for Bamako and water supply for Yellow fever 19384 selected provincial towns (1971- ) UNDP: to for- Smallpox and yellow fever 17343 Poliomyelitis 22726 mulate a staged programme for sewerage and storm Diphtheria, whooping -cough and tetanus 355 drainage for Bamako, carry out water supply studies Rabies 5727 Typhoid and paratyphoid fevers 4068 for selected provincial towns, and train personnel. Development of basic health services (1969- ): Specialized units to implement the national health plan; and to improve In 1972, 48 centres were engaged in maternal and methods for the diagnosis and treatment of malaria, child health.Dental treatment was provided at 13 establish a central environmental health unit, improve centres. There were two rehabilitation outpatient sanitation, and train health personnel. departments, one psychiatric outpatient clinic, one Nursing education (1964- ): to develop the pro- tuberculosis centre, and one public health laboratory. grammes for training nurses, midwives and medico - social workers at State -diploma and auxiliary levels, National health planning and to strengthen nursing and midwifery services. Mali has a 10 -year national plan for the development Schoolof Medicine,Pharmacy and Dentistry, of the health services covering the period 1966 -1976. Bamako (1969- ): to develop the school.

NIGER

Population and other statistics Hospital services Population estimates for the period under review In 1971 Niger had 57 inpatient establishments were as follows: providing 2299 beds (excluding the beds in the maternity clinics), or 0.6 beds per 1000 population. These 1969 3 909 373 beds were distributed as follows : 1970 4 016 032 4 130 000 1971 Category and number Number of beds 1972 4 210 000 General hospitals 3 1 311 Rural hospitals 7 573 The communicable diseases most frequently notified Medical centres 27 415 in 1972 were: measles (28 423), dysentery (14 388), Maternity clinics 20 influenza (5329), whooping -cough (3732), infectious Outpatient care was available in 1971 at 8 poly- hepatitis(2807),leprosy (2477), trachoma (2241), clinics, 34 health centres, 121 dispensaries, 34 medical meningococcal infections (2233), paratyphoid fevers aid posts and nine mobile health units. (165), poliomyelitis (129), diphtheria (47), cholera (43). Medical and allied personnel and training facilities Organization of the public health services In 1971 Niger had 69 doctors, equivalent to one doctor for 59 800 inhabitants. Other health personnel The Ministry of Health and Social Affairs includes included: a Directorate -General of Public Health and Social Dentists 5 Affairs, which is composed of the following directorates : Dental mechanics 3 Pharmacists 10 social affairs and maternal and child health, medical Veterinarians 21 establishments and medical education, mobile health Veterinary assistants 8 Midwives 34 services, pharmacy, health and nutrition education, Nurses 177 and general administration. Assistant nurses 569 Sanitary engineer 1 At the intermediate level there is a departmental Sanitarians 2 Auxiliary sanitarians 30 directorate of health and at the district level a district Physiotherapist 1 Laboratory technicians 11 medical and social service. X -ray technicians 6 64 FIFTH REPORT ON THE WORLD HEALTH SITUATION

The arrangements for the training of nurses and centres, one hospital rehabilitation outpatient depart- midwives were as follows: ment, and three tuberculosis centres.

Category and admission Duration Number of requirements of study students Assistance from WHO (years) 1971/72 State nurses BEPC 3 39 In 1972 WHO's assistance to Niger included the Certified nurses following projects: third grade 1 40 State midwives BEPC 3 5 Smallpox eradication (1967-

1 Brevet d'études secondaires du premier cycle (secondary education, Development of basic health services (1969- ) first phase). UNDP, Funds -in- trust, UNICEF: to expand basic health services in accordance with the national health Immunization services plan; to plan a long -term sanitation programme The following immunization procedures were carried including water supplies; and to train staff. out in 1971: Nursing education (1966- ) UNDP: to strengthen Cholera 2634495 the National School of Public Health, Niamey and Smallpox 1 051928 Measles 288542 train multipurpose health auxiliaries. BCG 189630 Yellow fever 147436 Typhoid and paratyphoid fevers 485 Government health expenditure Poliomyelitis 104 Diphtheria, whooping -cough and tetanus. . 63 In the financial year 1971/72 total government health expenditure amounted to 950.9 million CFA Specialized units francs. The per capita government health expenditure In 1972 Niger had 44 maternal and child health was 226 CFA francs.

NIGERIA

Population and other statistics hospitals. In addition there were 1221 beds in leprosaria and 531 beds in rural hospitals. The 35 716 beds, The following are population estimates for the period under review: 1 equivalent to 0.63 beds per 1000 population, were distributed as follows: 1969 53700000 1970 55070000 1971 56510000 Category and number Number of beds 1972 58020000 General hospitals 345 24991 Rural hospitals 531 The communicable diseases most frequently notified Medical centres 1289 4171 Maternity hospitals 20 996 in 1971 were: malaria, new cases (644 994), gonorrhoea Paediatric hospitals 2 386 (62 385), measles (88 722), bacillary dysentery (26 546), Infectious diseases hospitals 52 758 Tuberculosis hospitals 6 277 whooping -cough(21 447),tuberculosis,allforms, Psychiatric hospitals 6 1 542 Ophthalmology hospital 1 140 new cases (19 344), amoebiasis (17 769), dysentery, Orthopaedic hospitals 3 703 allforms(14 315),infectioushepatitis(14 206), Leprosaria ... 1221 cholera (11 439), leprosy (9421), meningococcal infections (7897), syphilis, new cases (7139), trachoma Outpatient facilities were available in 1972 at 569 (3079), influenza (2208), typhoid and paratyphoid hospital outpatient departments; at 78 polyclinics, fevers (757), trypanosomiasis (723), poliomyelitis (187), of which 38 provided hospitalization facilities;at diphtheria (64), rabies in man (27). 91 health centres, of which 49 provided hospitalization facilities;at 1459 dispensaries, of which 394 had Hospital services inpatient facilities; at 47 medical aid posts; and at 29 mobile health units. In1971Nigeria had 1724 hospitals providing 33 964 beds, of which 19 680 were in 887 government Medical and allied personnel 1 United Nations, Monthly Bulletin of Statistics, May 1974. These estimates are at variance with the 1963 census figure of In 1971 Nigeria had 1300 doctors, or one doctor 55 670 055, which it is thought may have greatly overstated the population (see also United Nations, Demographic Yearbook, per 43 500 inhabitants. Other health personnel 1971). included: AFRICAN REGION 65

Medical assistants 331 Wastes disposal and drainage, Ibadan, phase II Dentists 60 Dental assistants 122 (1971- ) UNDP: to carry out final design and Pharmacists 458 Pharmaceutical assistants 347 prepare tender documents for the construction of Veterinarians 257 sewerage and drainage facilities; to construct 25 com- Veterinary assistants 367 Midwives 3996 fort stations and two solid waste transfer stations; to Assistant midwives 259 organize a municipal waste disposal service; and to Nurses 6957 Assistant nurses 1 041 train staff. Sanitarians 905 Assistant sanitarians 1 105 Developmentof basichealthservices,Federal Physiotherapists 28 Laboratory technicians 346 (1968- ): to coordinate activities for the develop- Assistant laboratory technicians 172 ment of basic health services and training of personnel X-ray technicians 169 Health aides 1 481 and to organize antimalaria work as required. Other scientific or professional personnel 24 Other technical personnel 1 006 Development of basic health services, Western State (1968- ) UNDP, UNICEF: to develop the basic health services, placing emphasis on building up the Specialized units rural health infrastructure, carrying out environmental In 1972 Nigeria had 576 maternal and child health sanitation work and training the necessary personnel. centres, 99 prenatal clinics and 12 child health units. Development of basic health services, Kano State There were also 27 school health units, 22 dental (1969- ); Kwara State (1971- ); North-Western clinics, one hospital rehabilitation outpatient depart- State (1971- ); North -Eastern State (1971- ); ment, one independent medical rehabilitation centre, Benue Plateau State (1971- ); South -Eastern State eight psychiatric outpatient clinics, and 15 public (1971- ): to plan health services and develop basic health laboratories. health services, placing emphasis on the training of health personnel in both curative and preventive medicine. Assistance from WHO Development of basic health services, North - Central In 1972 WHO's assistance to Nigeria included the and Mid -West States (1968- ):to develop the following projects: basic health services, placing emphasis on building up the rural health infrastructure, carrying out envi- Epidemiological services, Federal (1968- ) UNDP: ronmental sanitation work and training the necessary to develop, at the federal level, an epidemiological personnel. service for planning, coordinating and evaluating programmes for the surveillance and control of com- Health education (1962- ) UNDP: to extend municable diseases; to develop a pattern for integrated health education and school health education services health laboratory services, and to train the necessary throughout the country and develop facilities for training personnel. personnel. School of radiography (1968- ): to train techni- Epidemiological services, Western State (1968- ); cians in radiography and in the maintenance and North - Western State (1971- ); North - Central, Kano repair of X -ray and electromedical equipment. and North -EasternStates(1968- );Mid -West State (1968- ) UNDP: to develop epidemiological Medical rehabilitation(1972- ) UNICEF: to services for planning, coordinating and evaluating strengthen the medical rehabilitation services. programmes for the surveillance and control of com- Vital and health statistics, Federal (1971- ): to municable diseases, and to train the necessary staff. develop vital and health statistics services for the whole country, plan and carry out epidemiological surveys, Smallpox eradication (1968- ) and train staff. Public health engineering education (1972- ): to Mental health, University of Ibadan (1968- ): to strengthen the teaching of public health engineering. develop postgraduate teaching in the Department of Health component in the Kainji Lake research project Psychiatry, Neurology and Neurosurgery of the Uni- (1968- ) UNDP /FAO: to provide for coordination versity of Ibadan Medical School. of the health components of the project. Medical college, Lagos (1968- ): to develop the Health component in South Chad irrigation project: teaching of anatomy at the medical school of the Feasibility study (1972- ) UNDP /FAO: to identify University of the Lagos. the health component and determine the preventive Medical school, Zaria (1967- ): to develop the measures needed in the project area. medical school. 66 FIFTH REPORT ON THE WORLD HEALTH SITUATION

SENEGAL

Population and other statistics Medical and allied personnel and training facilities Population estimates for the period under review In 1971 Senegal had 277 doctors, of whom 231 were are: in government service.The doctor /population ratio 1969 3755286 was one per 14 520. Other health personnel included: 1970 3930000 1971 4022000 Dentists 25 1972 4122000 Dental mechanics 4 Pharmacists 60 Pharmaceutical assistants 9 The communicable diseases most frequently recorded Midwives 275 in 1972 were: malaria (471 048), measles (31 185), Traditional birth attendants 52 Nurses 538 whooping -cough (26 319), influenza (24 173), schisto- Health assistants 1 447 somiasis (7237), trachoma (2275), tuberculosis of the Nursing aides 631 Ward attendants 689 respiratory system, new cases (2252), amoebiasis (1831), Sanitary engineers 2 leprosy(1802),meningococcalinfections(1131), Assistant sanitarians 179 Physiotherapists 2 diphtheria (377), cholera (320 suspected and 59 con- Laboratory technicians 12 Assistant laboratory technicians 58 firmed cases), poliomyelitis (145), typhoid fever (120), X -ray technicians 22 paratyphoid fever (11). The arrangements for the training of health person- Organization of the public health services nel were as follows : The Ministry of Public Health and Social Affairs Category and DurationNumber of Number of Number of admission of study schools students graduates is responsible for all public health and medical matters. requirements (years) 1971/72 1971 The organization of the public health services in Nurses BEPC 1 3 1 53 44 Senegal corresponds to the administrative division Auxiliary nurses into seven regions which are subdivided into 27 depart- CEPE 2 2 1 63 27 Midwives ments and 96 arrondissements.In each region there BEPC . . . 3 1 34 20 is a regional chief medical officer under whom are the Social workers and educators medical officers of the districts (circonscriptions). BEPC 3 1 36 5

1 Brevet d'études secondaires du premier cycle (secondary educa- Hospital services tion, first phase). 2 Certificatd'études primaires élémentaires(completedprimary In 1971 there were 41hospitals and inpatient education). establishments in Senegal providing altogether 5391 beds, equivalent to 1.3 beds per 1000 population. The Communicable disease control and immunization services 5391 beds, to which 129 234 patients were admitted during the year, were distributed as follows: The units of the endemic diseases control service, which comprises six sectors, are responsible for case - Category and number Number of beds finding activities for trypanosomiasis, leprosy and General hospitals 4 2873 schistosomiasis, treatment of trachoma patients, and Rural hospitals 4 710 Medical centres 33 1 808 tuberculosis control. They also carry out vaccination campaigns against smallpox, yellow fever and measles. In 1972, ambulatory medical care was available at Each unit covers about 200 000 inhabitants. Leprosy eight hospital outpatient departments.In each of treatment is carried out by mobile units. the 30 medical districts (circonscriptions) there were The following immunization procedures were carried one or two health centres and a certain number of out in 1972: health posts administratively dependent on the health centres. There were 33 health centres which provided Cholera 994079 BCG 677656 outpatient treatment and maternity care and which Yellow fever 292058 had a limited number of hospital beds.They were Smallpox 273264 Measles 176473 staffed by a doctor, a midwife, male nurses and Tetanus 35556 auxiliary personnel.There were 396 dispensaries in Diphtheria, whooping -cough and tetanus 26100 Smallpox and yellow fever 10643 the charge of a male nurse or a health assistant. The Typhoid and paratyphoid fevers 1 464 endemic diseases control service operated in 12 sectors. Diphtheria, whooping- cough, tetanus and poliomyelitis 1342 AFRICAN REGION 67

Specialized units a long -term plan for water supply, sewerage and storm In 1972 maternal and child health care was provided drainage for Dakar and surrounding areas. at 112 centres; 47 maternity centres and five paediatric Development of basic health services (1968- ) centres had some hospitalization facilities.Other UNICEF: to develop the basic health services to the outpatientestablishmentsforspecializedmedical level required to support mass campaigns against care included four school health units, eight dental communicable diseases. health units, three hospital rehabilitation outpatient Institute of Odontology and Stomatology, University departments, four psychiatric clinics, seven dispensaries of Dakar (1970- ) :to establish an institute of for leprosy patients and nine hospital laboratory tropical odontology and stomatology at the University services. of Dakar and to train personnel in dental health.

Assistance from WHO Government health expenditure In 1972 WHO's assistance to Senegal included the During the fiscal year 1971/72 total government following projects: consumption expenditure amounted to 41 440 million CFA francs, of which 3808.5 million were devoted Smallpox eradication (1970- ) to health services. The per capita government health Master Plan for Water Supply and Sewerage for expenditure was 936 CFA francs. Current expenditure Dakar and Surrounding Areas (1966- ) UNDP: for health services amounted to 3727 million CFA to develop a phased improvement programme within francs and capital expenditure was 81.5 million.

UPPER VOLTA

Population and other statistics Dioulasso.The directorate of Rural Health is responsible for the health services in the rural health The following are population estimates for the sectors and for the control programmes against the period under review : endemic diseases. 1969 5278000 1970 5383500 The country is divided into 11 rural health sectors 1971 5491000 each of which comprises about 500 000 inhabitants 1972 5610000 and is supervised by a medical officer. The rural health The birth rate is estimated at 50 per 1000 population, sector is subdivided into administrative areas (cercles) the death rate at 32 per 1000 population and the infant with about 80 000 inhabitants each. mortality rate at 180 per 1000 live births. The communicable diseases most frequently noti- Hospital services fied in1971 were: malaria, new cases (585 663), trachoma (56 747), measles (19 047), whooping -cough In 1971 Upper Volta had 28 hospitals and inpatient (11 282), syphilis, new cases (10 528), meningococcal establishments providing a total of 3508 beds, which infections (6054), leprosy (3074), influenza (2755), is equivalent to 0.6 beds per 1000 population.The cholera (1760, of which 69 were confirmed cases), 3507 beds were distributed as follows: tuberculosis, new cases (1287), infectious hepatitis (1071), gonorrhoea (918), typhoid fever (734), para- Category and number Number of beds General hospitals 2 1 281 typhoid fever (492), trypanosomiasis (114), polio- Rural hospitals 4 880 myelitis (104). Medical centres 22 1 347 Outpatient facilities were provided at 10 hospital Organization of the public health services outpatient departments,atnine medicalcentres, The public health services in Upper Volta are 45 health centres, 74 health subcentres, and by 170 administered by the Directorate -General of Health mobile case -finding and vaccination teams. in the Ministry of Public Health and Population. The Directorate -General of Health comprises four Medical and allied personnel and training facilities directorates: urban health, rural health, pharmaceutical services, and administrative services. The directorate In 1971 Upper Volta had 74 doctors, or one doctor of urban health is responsible for the health services for74 200 inhabitants. Other health personnel in the two main towns, Ouagadougou and Bobo- included : 68 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Medical assistants 43 Dental care was available at five dental units.Other Dentists 5 Pharmacists 12 specialized units included six rehabilitation outpatient Pharmaceutical assistant 1 Veterinarians 19 centres, two psychiatric clinics, and two ophthal- Assistant veterinarians 30 mological dispensaries. Veterinary nurses 167(1973) Midwives 55 Nurses 142 Environmental sanitation Assistant nurses 986 Sanitary engineer 1 Sanitary technicians 37 In 1972, of all communities in Upper Volta, seven Health assistants 9 comprising a total population of 305 402 had water Laboratory technician 1 Assistant laboratory technicians 20 supply systems. Health educators 8 Biochemist 1 Health statisticians 2 National health planning The arrangements for the training of health person- The second five -year development plan (1972 -1976) nel were as follows: includes the following health priorities: development of control programmes against communicable diseases; Category and admission DurationNumber Number Number of development of basic health services, particularly for requirements of studyof schoolsof students graduates (public) 1971/72 1972 mothers and children; training of health personnel; Nurses : and improvement of medical care services. BEPC 1 and entrance

examination . 3 years 1 97 32 Laboratory technicians Assistance from WHO AMA2and entrance examination . . . . 18 months 2 5 3 In 1972 WHO's assistance to Upper Volta included 1 Brevet d'études secondaires du premier cycle (secondary educa- the following projects: tion, first phase). 2 Assistance médicale autochtone (diploma of indigenous medical Tuberculosis control (1968- ) UNICEF: to carry assistant). out a countrywide BCG vaccination campaign; and to develop a comprehensive national tuberculosis Immunization services programme. The following immunization procedures were carried Smallpox eradication (1967- ) out in 1971: Development of basic health services (1968- ) UNDP, UNICEF: to plan, organize and develop the Smallpox 1521806 Cholera 1492293 health services, placing emphasis on maternal and Yellow fever 720506 BCG 611866 child health, environmental sanitation, and training Measles 255586 of staff. Diphtheria, whooping -cough and tetanus 3308 Poliomyelitis 179 Nursing education (1968- ) UNDP: to develop basic programmes for training nurses and midwives Specialized units to state registration level.

In 1972 maternal and child health services were Government health expenditure provided at three child health centres and 236 maternal and child health centres. During the year 37 085 preg- In 1972 the total health expenditure of the Ministry nant women, 173 930 infants and 1874 children aged of Public Health and Population amountedto one to five years attended these centres. School health 811 355 000 CFA francs. The per capita government services were provided at two school health units. health expenditure was thus 145 CFA francs.

ANGOLA

Population and other statistics 1969 1970 1971 1972 Birth rate (per 1000 population) 24.5 22.8 20.4 At the last census, taken in December 1970, the Number of deaths 12 879 13 530 15 136 Death rate (per 1000 popula- population of Angola was 5 673 046.Population tion) 2.4 2.4 2.6 estimates and some other vital statistics for the period Natural increase ( %) . . . . 2.21 2.04 1.78 Number of infant deaths. . 2 452 2 686 3 274 under review are given in the following table: Infant mortality rate (per 1000 live births) 18.5 20.8 28.1 1969 1970 1971 1972 Number of deaths,1 -4years . 2 637 2 382 2 940 Mean population 5 430 0005 673 0005 715 0005 810 000

Number of live births 1 . 132 840 129069 116 314 ... 1 Based on the baptisms recorded in Roman Catholic churches. AFRICAN REGION 69

The communicable diseases most frequently notified in 1971 were: malaria, new cases (154 170), influenza Duration Number Number of Number of Category of studyof schoolsstudentsgraduates (14 227), gonorrhoea (6587), measles (6236), (years) (public) 1971/72 1972 whooping -cough (2975), tuberculosis, all forms, new Doctors 6 1 549 14 cases (2802), dysentery, all forms (1584), infectious Veterinarians 5 1 122 15 Nurses 4 4 63 11 hepatitis (1081), syphilis, new cases (961), leprosy Assistant nurses 3 6" 518 53 (479), typhoid fever (305), meningococcal infections Assistant midwives 3 1 5 5 Laboratory technicians 3 2 74 21 (215), yellow fever (47), trypanosomiasis (22), polio- X -ray technicians 3 1 6 - Pharmaceutical assistants 3 2 48 13 myelitis (20), diphtheria (15). Rural health aides . . . . 1 2 383 226

* Two of these were private schools. Hospital services Immunization services In 1971 inpatient establishments in Angola included four central hospitals(in Luanda, Nova Lisboa, The following immunization procedures were carried Benguela and Sá da Bandeira), 12 regional hospitals out in 1970: at the district level, three subregional hospitals (in Smallpox 1986175 Lobito, Gabela and Cela) and 95 medical centres at BCG 423102 Yellow fever 71 198 the area level (delegaçáos de saude) In 1971 Angola Poliomyelitis 49 407 Tetanus 48 689 had 15 797 hospital beds, of which 6967 were in Whooping -cough 20 332 government- maintained establishments. The bed/ Diphtheria 18 879 population ratio was 2.7 per 1000. Typhoid and parathyphoid fevers . . . 15 394 Outpatient facilities were provided in 1971 at the hospital outpatient departments, at 253 medical centres, Specialized units of which 95 had hospitalization facilities, at 235 rural In 1971 Angola had 26 maternity clinics with in- dispensaries, at 340 health posts and 27 mobile health patient facilities, 11 prenatal centres and two child units. health units. During the year, 20 000 pregnant women and 39 327 infants under 1 year attended these services. Of all deliveries, 15 825 were attended by a doctor or Medical and allied personnel and training facilities qualified midwife.Three school health service units In 1970 Angola had 650 doctors, of whom 247 were supervised the health of over 91 000 schoolchildren. in government service.The doctor /population ratio The two psychiatric outpatient clinics were attended was one per 8630.Other health personnel included: by 4036 new outpatients. Angola also had 11 trypanosomiasis centres, 11 leprosy clinics, seven tuberculosis Dentists 23 Pharmacists 90 clinics and one public health laboratory. Pharmaceutical assistants 118 Veterinarians 3 Midwives 90 Government health expenditure Assistant midwives 121 Nurses 1882 In 1971 the total government health expenditure Assistant nurses 1 179 Sanitary engineer 1 amounted to 546 606 687 escudos, of which 486 353 735 Health aides 591 Laboratory technicians 9 were spent on current account and 60 252 952 on Assistant laboratory technicians 68 capital account. The per capita government expend- X -ray technicians 13 Assistant X -ray technicians 49 iture on health was thus 95.6 escudos. The government contributions to health activities of social security The arrangements for the training of medical and schemes and other nongovernmental social welfare health personnel were as follows: systems amounted to 116 257 771 escudos.

CAPE VERDE ISLANDS

Population and other statistics 1969 1970 1971 Mean population 261 734268 239271 864 At the last census, taken in December 1970, the Number of live births 9671 9379 9493 Birth rate (per 1000 population) 36.9 35.0 34.9 population of Cape Verde Islands was 272 071. Popu- Number of deaths 3452 2883 4147 Death rate (per 1000 population) 13.8 10.7 15.3 lation estimates and some other vital statistics for Natural increase (%) 2.31 2.43 1.96 Number of infant deaths 1 170 891 1 253 the years 1969 -1971 are given in the following table: Infant mortality rate (per 1000 live births) 121.0 95.0 132.0 70 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Of the 4147 deaths recorded in 1971, the main causes Dentist Pharmacists 8 were: 1 symptoms and ill- defined conditions (741), Pharmaceutical assistants 6 hypertensive disease, ischaemic heart disease, other Midwives 2 forms of heart disease (236), birth injury, difficult Assistant midwives 9 Nurses 3 labour and other anoxic and hypoxic conditions (213), Assistant nurses 37 pneumonia (162), malignant neoplasms (119), cerebro- Laboratory technician 1 vascular disease (114), accidents (91), bacillary dysen- X -ray technician 1 tery and amoebiasis, enteritis and other diarrhoeal Immunization services diseases (73), tuberculosis, all forms (51). The communicable diseases most frequently notified The following immunization procedures were carried in 1971 were: influenza (64), whooping -cough (58), out in 1969: tuberculosis, all forms, new cases (53), measles (42), dysentery, all forms (36). BCG 27645 Smallpox 13294 Yellow fever 2855 Hospital services Tetanus 413 (doses) Cholera 50 In 1969 Cape Verde had 15 hospitals providing a Diphtheria, whooping -cough and tetanus 50 total of 376 beds. The bed /population ratio was 1.5 per 1000. These beds were distributed as follows: Specialized units Category and number Number of beds In 1972 maternal and child health services were General hospitals 3 304 based on five centres. Other specialized units included Rural hospitals 8 32 Medical centres 4 40 two hospital outpatient rehabilitation departments, one psychiatric outpatient clinic, two mobile leprosy Outpatient facilities were provided at three hospital units and two public health laboratories. outpatient departments; five polyclinics, four health centres and five dispensaries, all of which had some inpatient facilities; and at 24 medical aid posts. Government health expenditure In1971 totalgovernmenthealthexpenditure Medical and allied personnel amounted to 19 995 760 escudos, of which 12 020 760 In 1969 Cape Verde had 22 doctors, or one doctor were spent at the central level and 200 000 at the local for11 360 inhabitants. Other health personnel level. The per capita government expenditure on health included: was 73 escudos.

COMORO ARCHIPELAGO

Population and other statistics responsible to the Government Council. The Direc- torate of Health comprises a central technical, admini- At the last census, taken between July and September strative and financial level, a pharmaceutical and sup- 1966, the population of the Comoro Archipelago ply service, and a training school for paramedical per- was 243 948. The population in 1969 was estimated at sonnel. The basic health and endemic disease control 262 613, in 1970 at 270 491 and in 1972 at 280 000. service which was established in 1970 has a central The communicable diseases most frequently notified unit, a laboratory, a statistical unit, and mobile health in in- and outpatient establishments in 1970 were: units.Its main functions are health education, epide- malaria, new cases (8166), whooping -cough (2492), miology,familyplanning,environmentalhealth, gonorrhoea (2093), measles (647), early syphilis (576), curative and preventive activities. infectioushepatitis(265),tuberculosis,allforms, new cases (234), bacillary dysentery (67), leprosy (57), Hospital services meningococcal infections (25), amoebiasis (5). In 1970 inpatient accommodation was provided at Organization of the public health services three general hospitals situated on Grande Comore, Anjouan and Mayotte; at five rural hospitals of which The health services of the Comoro Archipelago two were on Grande Comore, and the remaining three are administered by the Minister of Health, who is on Anjouan, Mayotte and Mohéli; and at two rural maternity centres situated on Grande Comore.At 'International Classification of Diseases, 1965 Revision. the end of 1972 the total bed capacity was 575. AFRICAN REGION 71

Ambulatory health services were available in 1971 is very common, 85% of the population being infested. at the hospital outpatient departments, at health Gonorrhoea ranks second among the communicable centres, two dispensaries or medicosocial centres and diseases with 9425 reported cases in 1972.Measles 50 rural medical aid posts.The basic health and is endemo- epidemic, with 7694 cases and 125 known endemic disease control service operates mobile health deaths in 1972. units. The following immunization procedures were carried out in 1971: Medical and allied personnel BCG 37661 Cholera 2201

In 1971 the Comoro Archipelago had 19 doctors, Smallpox 1 730 or one doctor for 14 210 inhabitants.Other health Diphtheria 52 Whooping -cough 48 personnel included: Tetanus 48

Dentists 2 Pharmacists 2 National health planning Veterinarian 1 Midwives 4 Assistant midwives 8 The main health objectives of the sixth five -year Nurses 70 Assistant nurses 57 development plan (1971 -1975) are the development Laboratory technicians 2 of basic health services and the control of the major X -ray technicians 2 Anaesthesia technicians 2 endemic diseases; the establishment at Moroni of a training school for health personnel (including nurses, Communicable disease control and immunization services auxiliary midwives, sanitarian, and laboratory technicians); and the improvement of the existing hospital Malaria is the most prevalent endemic disease and services. In realizing these objectives it is expected to represents nearly 50 % of all cases of communicable reduce the mortality and morbidity in the territory, diseases; nearly 69 000 malaria cases were reported to increase the availability and accessibility of the in 1972.It is estimated that 15.6 % of all patients health services and to educate the population to use the attending health establishments are suffering from available services. malaria. Control activities are directed towards standardization of treatment, chemoprophylaxis, and better knowledge of the infestation rate with a view to a Assistance from WHO global vector control operation. In 1972 WHO's assistance to the Comoro Archi- Tuberculosis is a public health problem mainly pelago included the following project: in Grande Comore, where 688 tuberculosis patients have been registered and where the morbidity rate Detielopment of basic health services (1970- ): is 0.57 % and the infection rate 0.10 %. In 1972, 126 to develop basic health services, carry out mass new tuberculosis cases were notified.Attendance of campaigns against yaws and syphilis, complete the patients for treatment is very irregular and the thera- study of malaria epidemiology and plan antimalaria peutic results are mediocre.A BCG vaccination measures suited to existing conditions. campaign for the age group 0 -15 years was carried out between 1970 and 1972, with 93 546 vaccinations Government health expenditure performed, representing an 85.04 % coverage. At the end of 1972 there were 481 leprosy cases in In 1971 total government expenditure amounted the whole territory, which represents a prevalence to 2008 million CFA francs, of which 1686.3 million rate of 0.17%. The control of the ambulatory patients were spent on current account and 321.7 million on constitutes one of the main concerns of the health capital account. The government health expenditure authorities. Filariasis is endemic in the whole territory, on current account amounted to 278.3 million CFA but more particularly in Mayotte where the micro - francs, and on capital account to 24.3 million.The filarial rate is 28.55 %.The disease appears to be budget of the basic health and endemic diseases control spreading to Grande Comore. Intestinal helminthiasis service was 40.4 million CFA francs.

SAO TOME AND PRINCIPE

Population and other statistics Population estimates and some other vital statistics At the last census, taken in November 1970, the for the period under review are given in the following population of Sao Tomé and Principe was 73 811. table: 72 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 Category and number Number of beds Mean population 66 300 73 631 74 445 77 048 General hospitals 19 1 896 Number of live births 3 258 3 274 3 275 3 892 Medical centres 31 54

Birth rate (per 1000 population) . . . 49.1 44.5 44.0 50.5 Number of deaths 947 921 859 840 Outpatient facilities were available in 1970 at the Death rate (per 1000 population) . . . . 14.3 12.5 11.5 10.9 Natural increase ( %) 3.48 3.20 3.25 3.96 hospitaloutpatientdepartments,onedispensary, Number of infant deaths 261 228 199 218 Infant mortality rate (per 1000 live births) 80.1 69.6 60.8 56.0 21 medical aid posts, and one mobile health unit. Number of deaths, 1 -4 years 217 250 188 172 Number of maternal deaths 6 2 2 6 Maternal mortality rate (per 1000 live births) 1.84 0.61 0.61 1.76 Medical and allied personnel and training facilities In 1971 São Tomé and Principe had 15 doctors, of Of the 840 deaths recorded in 1972, the main causes whom 10 were in government service.The doctor/ were: 1 senility without mention of psychosis, ill -de- population ratio was thus one to 4400. Other health fined and unknown causes (227), gastritis, duodenitis, personnel included: enteritis and colitis, except diarrhoea of the newborn (72), pneumonia (47), arteriosclerotic and degenerative Dentist 1 Pharmacists 6 heart disease, other diseases of the heart (44), birth Pharmaceutical assistants 8 injuries, post -natal asphyxia and atelectasis, infections Veterinarians 2 Assitant midwives 6 of the newborn, other diseases peculiar to early infancy Nurses 26 and immaturity (42), malaria (37),accidents (34, Assistant nurses 71 Health visitor 1 including 13 in motor -vehicle accidents), malignant Assistant laboratory technicians 5 X -ray technician 1 neoplasms (25). Other health auxiliaries 6 The communicable diseases most frequently notified in 1971 were: influenza (1646), bacillary dysentery The technical school of the health and welfare (586), infectious hepatitis (377), measles (203), gonor- services organizes an 18 -month course for assistant rhoea (169), tuberculosis, all forms, new cases (59), nurses.In the academic year 1969/70 there were 35 whooping -cough (56), typhoid and paratyphoid fevers students and 13 graduates. (14).

Hospital services Immnization services In 1969 there were 50 hospitals and inpatient estab- The following immunization procedures were carried lishments in Sao Tomé and Principe, providing a total out in 1969: of 1950 beds, of which 427 were in 14 government - Smallpox 42276 maintained establishments. The bed /population ratio BCG 5937 Tetanus 1 862 was 28.3 per 1000. The 1950 beds were distributed as Yellow fever 1 363 Poliomyelitis follows : 367 Diphtheria, whooping -cough and tetanus . . 29

SPANISH SAHARA

Population and other statistics tious hepatitis (174), whooping -cough (111), gonor- At the last census, taken in December 1970, the rhoea (98), pulmonary tuberculosis, new cases (73), population of the Spanish Sahara was 76 425. Popu- bacillary dysentery (22), trachoma (7), amoebiasis (7). lation estimates and some other vital statistics for the period under review are given in the following Hospital services table : 1969 1970 1971 1972 In 1971 the Spanish Sahara had six hospitals pro-

Mean population 6050076000 81000 91000 viding 258 beds, which represents 5.2 beds per 1000 Number of live births 1 1 155 1 195 3512 1896 population.These beds were distributed as follows: Number of deaths 1 354 363 340 404 Number of infant deaths 1 21 32 12 10 Category and number Number of beds

1 Excluding infants dying within 24 hours of birth. General hospitals 2 232

Rural hospital 1 12 The communicable diseases most frequently notified Medical centres 3 14 in 1971 were: influenza (3015), measles (1266), infec- Outpatient facilities were available in 1972 at the 1 International Classification of Diseases, 1955 Revision. general hospital outpatient departments, at four urban AFRICAN REGION 73 and 13 rural dispensaries, four rural medical aid posts and at the maternal and child health centre at El Aaiun. and eight mobile health units. During the year these centres recorded 6800 attendances by pregnant women.There were also four Medical and allied personnel and training facilities dental healthclinics,twohospitalrehabilitation outpatient departments, two psychiatric outpatient In 1971 the Spanish Sahara had 53 doctors, of whom departments, five tuberculosis dispensaries, five vene- 22 were in government service. The doctor /population real diseases dispensaries and two ophthalmological ratio was one per 940. Other health personnel included : and trachoma clinics. In 1972, 17 industrial establish- Medical assistants 44 ments offered medical and health services to their Dentists 3 workers. Pharmacists 4 Pharmaceutical assistant 1 Veterinarians 6 Midwives 3 Environmental sanitation Assistant midwives 5 Nurses 39 In 1972, of the 18 communities of the Spanish Health agents 77 Physiotherapist 1 Sahara 13 had piped water supplies serving 70 % of their inhabitants and sewerage systems serving 65 Training facilities for health personnel included two of their inhabitants. schools for health agents, one at the hospital of El Aaiun and the other at the hospital of Villa Cisneros. Major public health problems Tuberculosis constitutes the territory's most im- Communicable disease control and immunization services portant problem.Other matters for concern are the In 1972 a tuberculosis pre- eradication campaign disparity between the rapid population increase and was carried out in the whole territory, based on tuber- development, with a resulting increased demand for culin testing, BCG vaccination, and X -ray examination services, and the difficulty of recruiting medical and of the whole population above 30 years of age. Annual health personnel. vaccination campaigns are carried out against smallpox, tetanus, diphtheria, whooping -cough and poliomyeli- Medical and public health research tis. In 1970 a preventive cholera vaccination campaign was organized, together with a strict control of water Research activities are caried out by the health ser- supplies and health education. As a result of these vice of the territory in collaboration with the Medical measures no cholera case was reported in the territory. Faculty of Tenerife, the Ophthalmological Society of Cholera vaccination was made compulsory in 1971. the Canary Islands, and other national bodies. These A trachoma control programme is being carried out. activities are mainly concerned with the particular The following immunization procedures were car- medical and health problems in the Sahara region. ried out in 1971: Government health expenditure Cholera 70505 Poliomyelitis 10250 Diphtheria, whooping -cough and tetanus 10101 In 1972 total government expenditure amounted Smallpox 6905 to1209.7 million pesetas, of which 44.5 million BCG 3321 were spent by the health service. An additional sum of 87.4 million pesetas was spent on health services Specialized units by other government agencies. The government con- In 1972, prenatal and child health services were tribution to health activities of social security schemes available at the hospitals of El Aaiun and Villa Cisneros amounted to 14 million pesetas.

REGION OF THE AMERICAS

ARGENTINA

Population and other statistics Hospital services At the last census, taken in September 1970, the In 1971 Argentina had 2864 hospitals and other population of Argentina was 23 362 204.Population establishments for inpatient care, providing a total of estimates and some other vital statistics for the period 133 847 beds, which is equivalent to 5.7 beds per under review are given in the following table: 1000 population. These beds were distributed as follows: 1969 1970 1971 1972"

Mean population . . . . 22939 57223275 66223660 13924055 087 Category and number Number of beds Number of live births . 544 631 543 984 566 164 538 389 General hospitals 1 432 91 730 Birth rate (per 1000 Medical centres 1 054 5 178 population) 23.7 23.4 23.9 22.4 Maternity hospitals 216 3 300 Number of deaths . 223 430 222 062 229 621 229 062 Paediatric hospitals 31 2 947 Death rate (per 1000 Tuberculosis hospitals 31 5 434 population) 9.7 9.5 9.7 9.5 Psychiatric hospitals 57 20847 Natural increase (%) 1.40 1.39 1.42 1.29 Ophthalmology hospitals 10 225 Number of infant deaths 30536 31 902 30189 30599 Chronic diseases hospitals 5 1 594 Infant mortality rate (per Cancer hospitals 6 240 58.6 56.8 1000 live births) 56.1 53.3 Leprosaria 7 1 600 1 -4 Number of deaths, Gastroenterology clinics . . . 3 212 years 5 316 6 233 5 843 5 728 Rehabilitation centres . . . . 12 540 Death rate, 1 -4 years (per 1000 population at risk) 2.7 3.1 2.9 2.9 Number of maternal Outpatient facilities were available in 1971 at 812 deaths 733 758 726 711 Maternalmortalityrate hospital outpatient departments, 60 polyclinics, 223 (per 1000 live births) . 1.5 1.5 1.3 1.3 health centres, of which 12 also had some inpatient Provisional data. facilities,331dispensaries,of which 22 also had inpatient facilities, 2219 medical aid posts, 130 health Of the 222 062 deaths recorded in 1970, the main units and 117 other establishments. causes were: 1 chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease, other forms Medical and allied personnel and training facilities of heart disease (54 044), malignant neoplasms (35 994), In 1969 Argentina had 45 340 doctors, of whom cerebrovascular disease (20 011), symptoms and ill - approximately 30 000 were in government service. defined conditions (13 635), pneumonia (8607), birth The doctor /population ratio was one per 500.Other injury, difficult labour and other anoxic and hypoxic health personnel included: conditions, other causes of perinatal mortality (7687), accidents (5679, including 5616 in motor -vehicle acci- Dentists 12 948(1967) Pharmacists 2 625(1968) dents), bacillary dysentery and amoebiasis, enteritis Midwives 2 735 Nurses 13 737 and other diarrhoeal diseases (5544), diabetes mellitus Assistant nurses 8 564 (4515), cirrhosis of the liver (4363), tuberculosis, all Nursing auxiliaries 15 880 Laboratory technicians and auxiliaries 2 290(1968) forms (3135), suicide and self -inflicted injuries (2741), X -ray technicians and auxiliaries . . 2193(1968) congenital anomalies (2420), avitaminoses and other nutritional deficiency (2400), bronchitis, emphysema Argentina had nine medical faculties, six dental and asthma (2309). faculties, six faculties for pharmaceutical and bio- The communicable diseases most frequently notified chemical studies, one faculty for veterinary medicine in1971were:influenza (102 852),dysentery,all and one faculty for sanitary engineering. Nurses were forms (77 952), whooping -cough (23 511),measles trained in 95 schools (27 -month course) and auxiliary (22 832), tuberculosis, all forms, new cases (18 681), nurses in 70 schools (nine -month course).Other gonorrhoea (12 531), infectious hepatitis (8143), syph- training facilities included two schools for sanitation ilis, new cases (7298), trypanosomiasis (2404), typhoid assistants (nine -month course), eight schools for labo- and paratyphoid fevers (1369), scarlet fever (824), ratory assistants (nine -month course), seven schools leprosy (586), malaria, new cases (518), poliomyelitis for X -ray technicians (nine -month course) and three (467), diphtheria (414), trachoma (40), typhus, murine schools for health statisticians. (6). During the academic year 1970/71 total enrolment and graduation for certain categories of personnel 1 International Classification of Diseases, 1965 Revision. were as follows: -- 77 - 78 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category Number Number of studentsof graduates centres, 33 psychiatric clinics and 18 public health laboratories. Doctors 28 972 2 587 Dentists 5 211 732 Sanitary engineers 35 35 Medical and public health research Communicable disease control and immunization services During the period under review an investigation In spite of the preventive measures taken, the inci- into health behaviour and an analysis of the factors dence of paralytic poliomyelitis increased, with over that cause such behaviour were started, involving the 600 cases during 1971 and the last trimester of 1970. family, schools, work places and hospitals. The majority of cases (over 90 %) occurred among children aged 0 -6 years. A national vaccination Assistance from PAHO /WHO programme was launched in 1971 with the objective of vaccinating the total population at risk, i.e., the In 1972 PAHO /WHO's assistance to Argentina children aged between two months and 14 years and included the following projects: the women over five months pregnant.During the Communicable disease control (1972- ): to devel- first phase of this programme in 1971 about 20 million op the epidemiological surveillance systems, reduce doses of vaccine, and during the second phase, in the prevalence of a number of communicable diseases, 1972, 10 million doses, were distributed. This campaign conduct immunological studies for determining the achieved spectacular results, as only four confirmed level of protection against diseases for which there cases were recorded in 1972.An epidemiological are effective vaccines, and increase the vaccination surveillance system was established at the beginning coverage of the population. of the campaign. Malaria eradication programme (1951- There are on the average 400 000 cases of measles ). a year in Argentina, with an estimated mortality of Smallpoxeradication(1967- ):toeradicate 30 per 10 000, which can reach over 2000 deaths smallpox through vaccination of 90 % of the popu- during epidemic outbreaks; 90% of the deaths occur lation in 5 years, and to organize epidemiological among children under three years old.In 1972 a surveillance services. national measles vaccination programme was estab- Pan American Zoonoses Centre (1972- ) UNDP: lished with a view to covering the total population at to strengthen the programme of the Centre. risk, i.e., the children aged nine months to two years. The tuberculosis control programme continued to Bovine rabies control (1965- ) Grants to PAHO: progress. In order to achieve a coverage of over 75 Government of Argentina: to evaluate the vaccines in the age group 0 -15 years the following preventive used for the control of bovine rabies and conduct activities have been planned: vaccination of all new- studies on new vaccines. born children in public establishments, of all school- Engineering and environmental sciences (1967- ): children, and of special population groups, such as tostrengthen theorganizationof environmental conscripts. Case -findingiscarriedout through sanitation services and programmes and to train bacteriological examinations, and treatment is mainly professional and technical personnel. based on chemotherapy. During the period under review a venereal disease Water supplies (1960- ) : to construct and improve control campaign was started with a view to reducing the administration of water and sewerage services the increasing incidence of these diseases. The small- and to train personnel. pox eradication programme continued to progress Health services (1966 - ): to improve the health during the period under review. services. The following immunization procedures were car- Centre for utilization of computers in health pro- ried out in 1972: grammes (1968- ) UNDP: to develop the medical Poliomyelitis 9160000 computing centre at the Faculty of Medical Sciences, Smallpox 2142648 Diphtheria, whooping -cough and tetanus 800000 University of Buenos Aires. Diphtheria and tetanus 682316 BCG 488204 Applied nutrition (1972- ) UNDP: to determine Measles 457932 the nutritional status of the population and develop an applied nutrition programme in Salta Province. Specialized units Nutrition studies (1971- ) UNDP: to determine In 1971 maternal and child health care was based on the characteristics of malnutrition in the population 198 centres.There were also 29 school health units, of the north -east of Argentina and study the relation- 132 dental health units, 36 independent rehabilitation ship between malnutrition and malabsorption. REGION OF THE AMERICAS 79

Mental health (1966- ): to implement a national the teaching programme of the School of Public programme in social psychiatry, develop community Health of the University of Buenos Aires. mental health work, and train personnel. Medical education (1958- ):to improve the Dental health (1972- ): to install a deminerali- teaching at the schools of medicine. zation plant for testing and demonstrating to students Health manpower study (1968- ) : to make a study of the Institute of Sanitary Engineering the extraction of health manpower requirements and the means of of excess fluorine and arsenic from water. meeting them; and to collect data to enable the medical Radiation protection (1967- ):to develop a education and health personnel training programmes national radiation protection programme; and to to be reoriented. train personnel. Sanitaryengineeringeducation(1960- ):to Latin American Centre for Medical Administration improve the teaching at the Institute of Sanitary (1967- )Grantsto PAHO: Governmentof Engineering, University of Buenos Aires, and at Argentina;Kellogg Foundation:todevelopthe other schools of engineering. Centre. Training of statistical personnel (1965- ) :to School of Public Health (1958- ): to strengthen train statistical personnel.

BAHAMAS Category and number Number of beds Population and other statistics General hospitals 2 485 Medical centre 1 75 At the last census, taken in April 1970, the popu- Psychiatric hospital 1 200 lation of the Bahamas was 168 812. Population Lep rosari u m 1 20 estimates and some other vital statistics for the period Outpatient facilities were available in 1972 at one under review are given below: hospitaloutpatientdepartment,whichrecorded 47 120 attendances, and at13 dispensaries, which 1969 1970 1971 1972 recorded 42 392 attendances; three of the dispensaries Mean population 167 000 170 000 178 000 180 000 Number of live births 4995 4816 5132 4080 provided hospitalization facilities. Birth rate (per 1000 population) 29.9 28.3 28.8 22.7 Number of deaths 1 110 1 107 1 115 1 072 Death rate (per 1000 population) 6.6 6.5 6.3 6.0 Medical and allied personnel and training facilities Natural increase ( %) 2.33 2.18 2.25 1.67 Number of Infant deaths 146 152 192 116 In 1971 the Bahamas had 194 doctors, or one doctor Infant mortality rate (per 1000 live births) 29.2 31.6 37.4 28.4 for 950 inhabitants. Other health personnel included: Number of deaths, 1 -4 years . 33 44 39 Dentists 29 Death rate, 1 -4 years (per 1000 Dental technicians 2 population at risk) 2.0 1.8 Pharmacists 2 Veterinarians 4 The communicable diseases most frequently noti- Midwives 350 Assistant midwives 35 fied in the main hospital in 1972 were: syphilis, new Nurses 428 cases (541), measles (411), amoebic dysentery (271), Assistant nurses 172 Nursing auxiliaries 160 gonorrhoea (242), influenza (103), scarlet fever and Sanitary engineers 23 streptococcalsorethroat(100),tuberculosis,all Physiotherapists 12 Laboratory technicians 44 forms, new cases (82), infectious hepatitis (60), typhoid Occupational therapists 2 fever (3), leprosy (2). Health assistants 22 Health educator 1 Social workers 2 Organization of the public health services Nonmedical hospital administrators 3 The arrangements for the training of nursing and The Minister of Health has the responsibility for midwifery personnel were as follows in 1972: the provision of health services. He is assisted by the Category Duration Number ofNumber ofNumber of Permanent Secretary, who has the overall admini- and admission of study schools students graduates requirements (years) 1971/72 strativeresponsibility and by the Chief Medical Nurses : Officer, who is in charge of the technical departments GCE, "O" level 3 1 27 17 (1971) Assistant nurses: of the Ministry. BJC2 1'/, 1 29 Midwives: registered nurse's Hospital services certificate . . . 1 1 10 6 (1972) Auxiliary midwives : In 1972 the Bahamas had five hospitals and inpatient trained clinical establishments providing 780 beds, which is equivalent nurse's certificate 1 10 (1970) 9 (1970) to 4.3 beds per 1000 population.These beds were General Certificate of Education, ordinary level :secondary education, first phase. distributed as follows: 2Junior certificate. 80 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Communicable disease control and immunization services hospital rehabilitationoutpatient department, one Communicable diseases do not present significant psychiatric clinic and one public health laboratory. problems in the Bahamas.There was, however, a high incidence of measles. Following the poliomyelitis National health planning epidemic in Trinidad and Tobago, a territory -wide There is no national development plan, but the immunization campaign was initiated. Ministry of Health is studying a new approach to the The following immunization procedures were car- delivery of health care.It is proposed that the health ried out in 1968: services be operated from the two centres: the northern health complex based in Freeport and the central - Diphtheria, whooping -cough and tetanus 12515 south complex based in Nassau.This arrangement Poliomyelitis 7749 BCG 3388 should ensure a better coordination of the preventive Smallpox 2223 and curative health services.

Chronic and degenerative diseases Assistance from PAHO /WHO Hypertensive disease, diabetes and alcoholism are In 1972 PAHO /WHO's assistance to the Bahamas the most prevalent noncommunicable diseases in the included the following projects: Bahamas. Hypertension is widespread, with a signi- Health services (1972- ) Government of Bahamas : ficant percentage of the cases occurring among the to revise and update legislation relating to public younger age groups.Alcoholism accounted for over health and to food and drugs. 50 % of the male patients and for about 30 % of the female patients admitted to the psychiatric hospital. Medical laboratory technology (1972- ) UNDP: to provide training in medical laboratory technology.

Specialized units Government health expenditure In 1972 maternal and child health care was pro- In the fiscal year 1972 total government health videdatthreeprenatal and sevenchildhealth expenditure amounted to 12 770 000 Bahamas dollars, centres. School health services, including dental care, $12 070 000 on current account and $700 000 on were provided at one central unit and by medical capital account. The per capita expenditure on health visits to schools. Other specialized units included one amounted to $71.

BARBADOS

Population and other statistics hypertensive disease, ischaemic heart disease, other At the last census, taken in April 1970, the popu- forms of heart disease (476), cerebrovascular disease lation of Barbados was 238 141. Population estimates (292), malignant neoplasms (286), pneumonia (150), and some other vital statistics for the period under birth injury, difficult labour and other anoxic and review are given in the following table: hypoxic conditions, other causes of perinatal mortality (120), diabetes mellitus (93), accidents (68, including 1969 1970 1971 1972 36 in motor -vehicle accidents), congenital anomalies Mean population 235 947 237 500 236 400 236 000 Number of live births 5196 4 883 5 177 5 303 (28). Birth rate (per 1000 population) 20.9 20.6 21.9 22.5 Number of deaths 1 987 2 064 2 058 2 114 The communicable diseases most frequently notified Death rate (per 1000 population) 7.9 8.7 8.7 8.9 in 1972 were :diphtheria (24), tuberculosis, all forms Natural increase (%) 1.30 1.19 1.32 1.36 Number of infant deaths 217 224 151 180 (13), typhoid fever (7), infectious hepatitis (7). Infant mortality rate (per 1000 live births) 41.8 45.9 29.2 34.3 Number of deaths, 1 -4 years . 31 47 25 29 Death rate, 1 -4 years (per 1000 Organization of the public health services population at risk) 1.3 2.2 1.2 1.4 Number of maternal deaths 5 7 7 4 Maternal mortality rate (per 1000 The responsibilityfor the healthservicesrests live births) 0.9 1.4 1.4 0.8 with the Minister of Health, who is the political head Of the 2114 deaths recorded in 1972, the main of the Ministry and a member of the Cabinet. The causeswere :1chronicrheumaticheartdisease, administrative head of the Ministry is the Permanent Secretary, while the technical head is the Chief Medical 1 International Classification of Diseases, 1965 Revision. Officer. REGION OF THE AMERICAS 81

Hospital services Category Duration Number ofNumber ofNumber of and admission of study schools students graduates In 1972 Barbados had 13 hospitals providing a reguirements (Years) 1971/72 1972 Midwives : total of 2216 beds, of which 2104 were in 10 govern- nurse'scertificate 1 1 13 7 ment establishments.The bed /population ratio was 9 years general education . . . . 2 1 19 7 9.4 per 1000. The 2216 beds, to which 22 128 patients Psychiatric nurses: were admitted during the year, were distributed as 13 years general education . . . . 3 1 30 14 follows:

Category and number Number of beds Communicable disease control and immunization services General hospitals 4 657 Rural hospitals 5 826 Malaria, schistosomiasis, trypanosomiasis, oncho- Maternity hospitals 2 35 cerciasis, yaws, trachoma, smallpox and other tropical Psychiatric hospital 1 690 Leprosarium 1 8 and "quarantinable" diseases do not occur in Barbados. Leprosy is not a public health problem.Small num- Outpatient facilities were available in 1972 at one bers of typhoid fever, ankylostomiasis and ascariasis hospital outpatient department which had 10 573 new cases occur.Routine tuberculin testing was discon- outpatients during the year; three main health centres tinued from 1971, except for a tuberculin survey and six subcentres which together had 7123 new out- carried out in 1972, but BCG is administered to all patients; six dispensaries; and 11 medical aid posts children at school entry. Venereal diseases are treated which recorded 3418 new outpatients. free of charge at allhealth centres.Nonspecific Each health centre is staffed by a medical officer, urethritis accounted for a large number of attendances public health nurses and inspectors and provides (15 437) in 1972. mainly prophylactic services, laboratory and X -ray Routine immunization with trivalent oral polio- facilities. The dispensaries dispense drugs. The myelitis vaccine is administered to all children at- medical aid posts are staffed by district medical officers tending child health clinics.A mass vaccination and nurses provided by the central Government to campaign was carried out in 1971 for children under assist the indigent. the age of nine years. There were no poliomyelitis cases during the period under review.Since January Medical and allied personnel and training facilities 1971 immunization against diphtheria, poliomyelitis, smallpox and tetanus has been compulsory for all In 1971 Barbados had 130 doctors, of whom 89 children entering school.Routine immunization is were in government service.The doctor /population carried out at all child health clinics. ratio was one per 1840.Other health personnel The following immunization procedures were car- included: ried out in 1972:

Dentists 15 Poliomyelitis 31051 Registered pharmacists 64 Diphtheria, whooping -cough and tetanus 25446 Veterinarians 5 Smallpox 18197 Midwives 46* BCG 3925 Nurse /midwives 140* Tetanus 3028 Nurses 310* Typhoid and paratyphoid fevers 2329 Auxiliary nurses 172* Yellow fever 263 Sanitary engineer 1 Cholera 242 Sanitarians 84 Diphtheria 90 Physiotherapists 4 Occupational therapists 2

Nutritionist 1 Chronic and degenerative diseases Dietitians 2 Laboratory technicians 36 The cytology programme, which was provided X -ray technicians 11 Radiographers 14 with funds from the Population Council, was incor- Health educator 1 porated in the government health services in 1970. Pilot projects for the control of rheumatic heart In government service. disease and hypertension were started in 1970.

The arrangements for the training of nurses and Specialized units midwives were as follows: In 1972, 11 prenatal centres and 10 child health Category Duration Number ofNumber ofNumber of centres provided maternal and child health care. and admission of study schools students graduates requirements (years) 1971/72 1972 During the year they were attended by 4683 pregnant Nurses : women and 3669 children up to two years of age. Of 13 years general

education . . . . 3 1 167 37 all deliveries in 1972, 94.4 % were institutional, as Auxiliary nurses: 9 years general compared with 61.9 % in 1968. The four school health education . . . . 6 months 1 40 36 service units supervised the health of 76.3 % of the 82 FIFTH REPORT ON THE WORLD HEALTH SITUATION total school population.Dental treatment was pro- The objectives of the 1969 -1972 health plan were as vided at four dental clinics for schoolchildren and at follows: to increase the supply and improve the quality 16 dental clinics for adults, of which 12 were part - of health personnel; to integrate curative and preven- time mobile clinics.In 1972 there were altogether tive services and to improve inpatient and outpatient 20 753 attendances at dental clinics. The hospital care; to improve the collection and disposal of refuse; rehabiliation outpatient department recorded 1671 to reduce the incidence of those diseases for which new patients and the two psychiatric clinics were there are specific preventive techniques; to promote attended by 450 new outpatients.Tuberculosis and the participation of the community in the improvement venereal diseaseclinics were included among the of health standards; to improve standards of nutrition; services of the health centres. to develop and expand the mental health facilities; to reorganize and improve the school health services; to Environmental sanitation reduce infant and maternal mortality; to update and improve health legislation; and to improve medical There is a piped water system on the island.It is statistics. These objectives were not expressed in estimated that 65 % of the population were served quantitative terms. with piped water and 35 % obtained their water from The plan for the health sector is prepared by the public fountains.All water for domestic purposes is Ministry of Health and forwarded to the Economic chlorinated. There is no community sewerage system. Planning Unit, which is incorporated in the Ministry The collection and disposal of refuse, which had been of Finance and Planning. The integrated development theresponsibilityof thethreelocal government plan is then considered by the Cabinet.Individual councils, was transferred in 1969 to a statutory board, projects are approved by the Cabinet and by the central the sanitation and cemeteries board, which is ap- planning committee. pointed by the Minister of Health and which receives its funds by subvention through the Ministry.The board is advised by the Chief Medical Officer and the Assistance from PAHO /WHO senior public health engineer. In 1972 PAHO /WHO's assistance to Barbados included the following projects: Social and economic developments of significance for Veterinary public health (1972- ): to establish the health situation a national zoonoses control programme. With the abolition of the local government councils Engineering and environmental sciences (1970- ): in 1969, the Ministry of Health assumed responsibility to plan and implement environmental health pro- for the parochial infirmaries and medical services grammes. and for refuse collection. An attempt has been made Water supply and sewerage services administration to improve the quality of health care delivered by the (1971- ) : toimprove theadministration and former parochial services through a programme of management of water supply and sewerage services. administrative reform and upgrading.A national assistance board and a child care board were estab- Aedes aegypti eradication (1968- ) lished in 1969 to deal with the social and welfare Health services (1968- ) :to improve, expand problems of the indigent, the handicapped and those and integrate the curative and preventive health with other social disadvantages. The Health Services services and train personnel. Act, which was passed in 1969, conferred on the Minis- Hospital administration(1965- ) UNDP: to ter the power and responsibility to deal with a wide develop the Queen Elizabeth Hospital as the principal range of problems. It represented a significant step in medical centre of the country and coordinate its the reorganization of the health services. The Medical activities with those of other hospitals. Registration Act, which was passed in 1971, is the first of a series of acts to cover the registration of the Dental education (1972- ): to train staff for a health professions.Under the new Act, any person comprehensive programme of dental care for school- who holds a qualification to practise medicine in the children and pregnant women and for indigent persons. country in which the qualification was obtained is eligible, at the discretion of the medical council, for Government health expenditure registration. In the fiscal year 1972 /73 total government expenditure amounted to 128 million East Caribbean dollars, National health planning of which EC$19.95 million were spent on health The health plan forms part of the national develop- services.Of this sum, $18.8 million were spent on ment plan, which usually covers a four -year period. current account and $1.1 million on capital account. REGION OF THE AMERICAS 83

The per capita government expenditure on health was occupational health services; 53 924 for education $84.5.The government health expenditure included and training of health personnel.The government the following items: $1.7 million for administration expenditure on hospitals and clinics included EC$8.5 and government personnel; 44 066 for immunization million for general hospitals and clinics, 2.1 million and vaccination activity; 30 944 for laboratory services; for specialized hospitals and 2.4 million for other 188 368 for environmental health services; 12 952 for health establishments.

BOLIVIA

Population and other statistics social security and by other institutions which provide At the last census, taken in September 1950, the health services for their employees. The Ministry of population of Bolivia was 3 019 031.Population Social Welfare and Public Health is the supreme estimates and some other vital statistics for the period health authority in the country and coordinates all under review are given in the following table : health activities.It is organized on a decentralized basis with a wide delegation of functions to the 11 1969 1970 1971 1972 health regions. Mean population 4800 000 4930 000 5060 000 5190 000 Number of live births . 88951 87 887 85 270 ... Birth rate (per 1000 population 18.5 17.8 16.9 Hospital services Number of deaths 24491 29912 19264 Death rate (per 1000 popula- In 1970 Bolivia had 269 hospitals, providing 9674 tion) 5.1 6.1 3.8 beds, of which 6008 were in 145 government hospitals. Natural increase (%) . . . . 1.34 1.17 1.31 Number of infant deaths . 5 372 The bed /population ratio was thus 2.0 per 1000. The Infant mortality rate (per 1000 live births) 60.4 6008 beds in the 145 government hospitals were dis- Number of deaths, 1 -4 years 4496 tributed as follows: Death rate, 1 -4 years (per 1000 population at risk) 6.5 Category and number Number of beds Number of maternal deaths 1 091 rate General hospitals 26 3 327 1000 live births) 12.3 Rural hospitals 94 1 114 Maternity hospitals 6 242 Paediatric hospitals 5 219 Of the 19 264 deaths recorded in 1971, the main Tuberculosis hospitals 8 508 causes were :1 symptoms and ill- defined conditions Psychiatric hospitals 3 452 (5316), pneumonia (2290), whooping -cough (889), Ophthalmology hospital 1 33 Cancer hospital 1 28 tuberculosis, all forms (851), birth injury,difficult Leprosarium 1 85 labour and other anoxic and hypoxic conditions, other causes of perinatal mortality (662), streptococcal Outpatient facilities were available in 1972 at 87 sore throat and scarlet fever (448), influenza (446), hospital outpatient departments; at 45 polyclinics measles (324), malignant neoplasms (308), bronchitis, operated by the social security; 94 health centres, of emphysema and asthma (267), anaemias (248), bacil- which 83 had some inpatient facilities; 71 dispensaries; lary dysentery and amoebiasis, enteritis and other 61 medical aid posts in rural areas; three mobile diarrhoeal diseases (185). health units; and 369 health posts. The communicable diseases most frequently notified in 1972 were: influenza (16 507), tuberculosis,all Medical and allied personnel and training facilities forms, new cases (8739), measles (8334), malaria (8080 in 1971), whooping -cough (3294), gonorrhoea (1695), In 1970 Bolivia had 2143 doctors, or one doctor bacillary dysentery and amoebiasis (1538), syphilis, for 2300 inhabitants. Other health personnel included: new cases (1109), infectious hepatitis (702), typhoid Dentists 903 Pharmacists 1 600 fever (521), paratyphoid fevers (335), scarlet fever Veterinarians 250 and streptococcal sore throat (656), diphtheria (71), Midwives 45 Assistant midwives 40 typhus, louseborne (53), poliomyelitis (45). Nurses 542 Auxiliary nurses 1 264 Sanitary engineer 1 Organization of the public health services Sanitarlans 74 X -ray technicians 9 The health services in Bolivia are provided by the Health educators 12 Nutritionists 24 Ministry of Social Welfare and Public Health, by the The arrangements for the training of medical and 1 International Classification of Diseases, 1965 Revision. health personnel were as follows: 84 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category Duration Number ofNumber ofNumber of centres and one hospital rehabilitation outpatient and admission of study schools 1 students graduates requirements (years) 1971/72 1972 department.Other specialized outpatient establish- Doctors ments included four psychiatric outpatient clinics, two 2 bachillerato . 6 3 Dentists leprosyclinics,three tuberculosis clinics and one bachillerato . 5 4 ophthalmology clinic.Bolivia had 130 public health Pharmacists bachillerato . 4 3 laboratories. Veterinarians bachillerato . . . 6 1 Nurses (university Environmental sanitation level) bachillerato 4 2 120 17 Midwives It is estimated that 48 % of the urban population in bachillerato 4 2 75 9 Nurses Bolivia have piped drinking -water and 24 % are bachillerato . . . 4 1 (2) 50 40 served by sewage disposal systems. In the rural areas, Auxiliary nurses . . 9 months 1 (2) 105 Sanitary inspectors only 3 % of the population have piped water and bachillerato . . . 9 months 1 30 25 9 % suitable means of excreta disposal.Thirty -one per cent. of the population living in cities with over 1 Public (private) schools. 2 Certificate of six years of secondary education. 20 000 inhabitants are served by refuse collection systems. Communicable disease control and immunization services Major public health problems The malaria eradication programme was launched in 1957.In 1972 the transmission rate was 2.5 % in The most important public health problems in areas in the attack phase and 0.1 % in areas in the Bolivia are the incidence of communicable diseases consolidation phase.Tuberculosis is among the five (tuberculosis, measles, whooping- cough, malaria and principal causes of death. The tuberculosis mortality leprosy); maternal and infant mortality; malnutrition; rate was estimated to be 125 per 100 000 inhabitants inadequate environmental sanitation in rural areas; in 1971 for the whole country and 116.9 per 100 000 inadequateandinsufficienthealthinfrastructure, in Cochabamba.Control activities were intensified particularly with regard to administrative and planning in1971. Whooping -cough and measles remain systems, supervision, personnel, and health establish- important causes of infant mortality.Poliomyelitis ments. has ceased to represent a serious public health problem, following intensive vaccination of the age group up Social and economic developments of significance for to five years. Haemorrhagic fever presents an epidemic the health situation character among certain population groups of Bolivia. The disease is caused by the Machupo virus and is During the period under review, great efforts have transmitted by the rodent Callonys callosus. Leprosy been made to develop the agricultural sector in the is confined to the eastern and southern regions of the region of Santa Cruz, to develop the means of com- country.It is estimated that there are about 2000 munication and transport, to increase the infrastruc- leprosy cases, half of which are receiving treatment. ture in all sectors, and to establish and develop basic The following immunization procedures were carried industries. In 1970 the literacy rate in the age groups out in 1971: above 15 years was 36.6 %. The rural health services have been developed and extended. An Institute of Smallpox 412011 BCG 248202 Social Security has been established. Diphtheria, whooping -cough and tetanus 37461 Measles 31691 Yellow fever 26965 National health planning Poliomyelitis 4682 Typhoid and paratyphoid fevers 1278 The objectives of the health sector of the national development plan for the five -year period 1973 -1977 Specialized units follow the guiding principles of the 10 -year health In 1972 maternal and child health care was provided plan of the Americas.This plan determines the at 120 health centres.During 1971, 45 845 pregnant following priority areas for action: communicable women, 49 831 infants and 63 014 children aged one to diseases, nutrition, maternal and child health care, five years availed themselves of these services.In environmental sanitation, medical and hospital care 1971, of all deliveries, 12 090 were institutional and and dental health, and improvement of the health 28 211 were conducted at home by a doctor or qualified administration. The objectives of the health plan are midwife. The medical and health supervision of toincreaselife expectancy at birth through pro- schoolchildren was provided at 10 school health units. grammes for reducing maternal and infant mortality There were 14 independent medical rehabilitation and morbidity among children, to develop the health REGION OF THE AMERICAS 85 infrastructurethroughtheconstructionof new Bank) (Department Committee of Development and establishments in rural areas and the improvement of Public Works, Potosí) (Potosí Water Authority): to existing services in urban areas, and to increase the design new systems for and construct additions to the accessibility and availability of health services. Potosí water and sewerage services and to develop the administrative structure of the services. Medical and public health research Health services (1955- ) UNDP: to improve and Medical research is still at an early stage of develop- extend the health services in urban and rural areas ment in Bolivia. Research activities are carried out by and train health personnel. the Institute of Altitude Biology, by the Institute of Health services, Cochabamba and Tarifa (1966- ) Occupational Health,by theInstitutefor Chest UNDP: to develop the health services and improve Diseases, by the Sectoral Health Planning Office, and basic sanitation services in Cochabamba, Tarija and by the hospitals and laboratories. The main research some other departments. has been carried out on the biological and physio- Health educationin family planning (1972- ) pathological effects of high altitude on the human UNFPA: to plan the educational component in health body, on silicosis, and on health administration. aspects of family planning. Assistance from PAHO/WHO Health statistics (1968- ) UNDP: to develop a national statistics system to provide the data required In 1972 PAHO /WHO's assistance to Bolivia infor planning and programming in the health sector. cluded the following projects: Nutrition (1971- ):to develop nutrition pro- Epidemiology (1968- ) UNDP: to determine the grammes and programmes for controlling endemic prevalence and distribution of the main communicable goitre and cretinism in the population of isolated diseases and to study and apply measures for their areas. control. Occupational health (1971- ) UNDP: to expand Malaria eradication programme (1965- ) the industrial hygiene programme in order to reduce UNICEF mortality, morbidity and economic losses due to Smallpox eradication (1962- ): to carry out a occupational diseases and accidents in mining and programme of combined smallpox and BCG vac- other industries. cination. Medical care services (1972- ): to coordinate the Tuberculosis control (1963- ): to improve the work of the hospitals and other health facilities and efficiency of the tuberculosis control programme and train personnel in hospital administration. incorporate tuberculosis control work into the regular Medical education (1968- ): to revise the pro- work of the local health services. gramme of the three medical schools and incorporate Zoonoses control (1971- ): to implement demon- concepts of social and preventive medicine into the stration programmes for the control of rabies and curricula. other zoonoses of public health importance. Sanitaryengineeringeducation(1969- ):to Typhus (1968- ): to carry out a pilot control improve the university training of sanitary engineers programme. and train practising engineers and auxiliary staff in environmental sanitation subjects. Engineering and environmental sciences (1969- ): to improve the environmental health and sanitation Veterinary medical education (1967- ) : to improve levels of the urban and rural population. the teaching of veterinary medicine at the University of Santa Cruz de la Sierra. Watersupplies(1972- ):toprovidewater supplies and sewerage services to urban and rural Dental education (1968- ):tostrengthen the communities. teaching programmes of the faculties of dentistry of La Paz, Tarija and Sucre. Water supply and sewerage services administration 1971- ): to strengthen the administration of the national Water and Sewerage Corporation. Government health expenditure Water supply and sewerage service administration, In 1972 total government expenditure amounted Cochabamba (1971- ): to strengthen the Municipal to 6482.6 million pesos, of which 231.1 million were Water, Sewerage and Drainage Service and improve spent on health services. The per capita government its administration. expenditure on health was 44.5 pesos.The central Water supply and sewerage services administration, health authority accounted for 179 million pesos, the Potosi (1972- ) (Inter- American Development intermediate health level for 6.7 million and the local 86 FIFTH REPORT ON THE WORLD HEALTH SITUATION health level for 45.4 million.The expenditure on 10.1million were spent on general hospitals and general public health services included the following clinics, 11.4 million on teaching hospitals, 5.7 million items: 4.5 million pesos for campaigns against malaria on specialized hospitals and 6.6 million on other and haemorrhagic fever, 2.2 million for vaccination health establishments. The government contributions and immunization activities, 1.7 million for occupation- to health activities of social security schemes and al health services.The government expenditure on othernongovernmental socialwelfaresystems hospitals amounted to 33.8 million pesos, of which amounted to 3.1 million pesos.

CANADA

Population and other statistics Organization of the public health services At the last census, taken in June 1971, the population Responsibility for the administration of health of Canada was 21 568 315.Population estimates and services is the direct concern of provincial governments, some other vital statistics for the period under review with municipalities often exercising considerable in- are given in the following table : fluence over matters delegated to them by provincial legislatures. Although the patterns of health services 1969 1970 1971 1972 in different provinces are similar, their health organiza- Mean population . . . . 21 089 00021 377 00021 568 30021 820 500 Number of live births . . 369 647 371 988 362 187 347 319 tions, system of financing and administration vary from Birth rate (per 1000 popu- province to province. lation) 17.6 17.4 16.8 15.9 At the national level, the Department of National Number of deaths . . 154 477 155 961 157 272 162 413 Death rate (per 1000 Health and Welfare is the chief federal agency in population) 7.3 7.3 7.3 7.4 health matters.The health side of the Department, Natural increase ( %) 1.03 1.01 0.95 0.85 Number of Infant deaths 7 149 7 001 6 356 5 938 under the Deputy Minister of National Health, is Infant mortality rate (per organized in three branches: health protection, health 1000 live births) . . . 19.3 18.8 17.5 17.1 Number of deaths,1 -4 programmes and medical services.In addition, there years 1 411 1 263 1 230 1 259 is a long -range health planning group and a separate Death rate, 1 -4 years (per 1000 population at risk) 0.9 0.8 0.8 0.9 medical research council. Number of maternal The health protection branch is composed of seven deaths 77 75 66 54 Maternalmortalityrate organizationalunits:food,drugs,environmental (per 1000 live births) . . 0.2 0.2 0.2 0.2 health, nonmedical use of drugs, laboratory centre for disease control, field operations, and administrative Of the 162 413 deaths recorded in 1972, the main services.A central epidemiology service serves all causes were: 1 chronic rheumatic heart disease, hyper- directorates of the health protection branch. tensive disease, ischaemic heart disease, other forms of The health programmes branch administers federal heart disease (56 743), malignant neoplasms (32 265), aspects of Canada's two important health insurance accidents (23 810, including 16 649 in motor -vehicle programmes,i.e.,hospital and medical insurance. accidents),cerebrovascular disease (16 586),pneu- This branch is composed of the following organiza- monia (5154), congenital anomalies, birth injury, diffi- tional units: programme development and evaluation, cult labour and other anoxic and hypoxic conditions, hospital insurance and diagnostic services, medical other causes of perinatal mortality (4867), bronchitis, care, research programmes, health economics and sta- emphysema and asthma (3487),diabetesmellitus tistics, health manpower, health facilities design, health (3133), suicide and self -inflicted injury (2657), cirrhosis systems, health standards, task force on community of the liver (2236), symptoms and ill- defined conditions health, and programme finance and administration. (1252). The medical services branch has direct responsibility for the health care and public health services of Indians The communicable diseases most frequently notified in 1972 were: gonorrhoea (41 467), scarlet fever and and Eskimoes and of all residents of the Yukon and Northwest Territories, as well as quarantine and immi- streptococcal sore throat (12 224), infectious hepatitis gration medical services, occupational health services (7344), tuberculosis, all forms, active cases (3909), for federal employees, a national prosthetics service, measles (3136), syphilis, new cases (3064), who oping- and civil aviation medicine. cough (1297), bacillary dysentery (1290), meningococcal Other federal agencies carry out specialized health infections (361), typhoid fever (102), diphtheria (68), functions. The Federal Bureau of Statistics is respon- paratyphoid fevers (53). sible for gathering vital and other health statistics; the Department of Veterans Affairs administers hospitals 1 International Classification of Diseases, 1965 Revision. and health services for war veterans, and the Depart- REGION OF THE AMERICAS 87

ment of Agriculture has certain responsibilities con- Social workers 1 557* (1970) nected with health aspects of food production. Psychologists 733 * (1970) Provincial governments administer medical and hos- Employed by hospitals. pital insurance programmes, and are primarily responsible for health measures to prevent disease and The arrangements for the training of medical and improve the health standards of the community. The health personnel were as follows : basic range of public health services comprises pre- Category Duration Number ofNumber ofNumber of and admission of study schools students graduates ventive health services, hospital services, treatment requirements (years) (public) 1971/72 1972 services for tuberculosis, mental illness, and other Doctors : 2 -3 years university 4 -5 16 6 373 1 292 diseases, and rehabilitation and care of the chronically Dentists : ill and disabled. Most health functions are the respon- 1 -2 years university 4 10 2 086 396 Pharmacists : sibility of the provincial health departments, but in senior matricula- some provinces, certain programmes, such as hospital tion 4 8 2 323 461 Veterinarians: insurance, medical care insurance, tuberculosis control, 2 years university . 4 3 1292 225 Nurses (university cancer control, and alcoholism and drug addiction level): senior ma- programmes, are directed by separate public agencies triculation . . . 4 22 2 849 476 Nurses: directly accountable to the Minister of Health. Volun- junior matricula- tary organizations also provide specialized health tion2 2 -3 157 26 034 9 181 Auxiliary nurses: services. grade 10 to junior Local programmes to safeguard community health matriculation . . 1 110 4 766 4 395 Psychiatric nurses: are concerned with environmental sanitation, pre- junior to senior matriculation . 2 9 224 vention and control of infectious diseases, improvement Health service of maternal and child health, family planning and administrators : bachelor of arts 2 5 59 dental health, vital statistics, and health education and Optometrists : counselling. In addition, the larger city health depart- senior matriculation 5 2 353 48 ments and health units have developed specialized Audiologists, speech services in such areas as mental health, home care, and pathologists: senior matricula- rehabilitation of the chronically ill and the handi- tion,bachelorof arts 4 and 2 6 142 53 capped. A few health units and departments in most Occupational thera- provinces carry out health screening for chronic condi- pists : senior matricula- tions.The local health services also participate with tion 3-4 9 1 106 145 the provincial authorities in accident prevention pro- Dental assistants: junior matricula- grammes and in measures to control pollution of the tion 1 14 314 air, water and soil. Laboratory assistants : junior matriculation 1 1 11 Physical therapy Hospital services technicians : junior matriculation 3 4 31 Dietary technologists : In 1972 there were 1409 hospitals in Canada, pro- junior matriculation 2 -3 7 81 viding 210 461 beds, equivalent to 9.6 beds per 1000 Medical records technicians: junior population.These beds were distributed as follows: matriculation .. 1 -2 5 197 Laboratory technolo- Category and number Number of beds logists : General hospitals 913 125 253 junior to senior Psychiatric hospitals 123 54 277 matriculation . . . 2 -3 34 Tuberculosis hospitals 13 1 418 Physiotherapists : Other hospitals 360 29 513 senior matriculation 3 -4 11 521 290 Radiological technicians : Medical and allied personnel and training facilities junior matriculation 2 -3 about 32 785 (1971) Dental -hygienists: In 1971 Canada had 32 625 doctors, or one doctor for senior matriculation 2 -3 5 138 670 inhabitants. Other health personnel included: Dietitians : junior to senior Dentists 7664 (1972) matriculation . . . 3 -4 15 231 Dental hygienists 849 (1972) Medical records Pharmacists 11330 librarians: Veterinarians 2667 junior matriculation 3 -4 9 120 Nurses 104258 Respiratory techno- Practical nurses 36409 logists : Orderlies 10925 junior matriculation 2 -3 12 Dietitians 1 243" (1970) Physiotherapists 2007 * Laboratory technologists 9049 * (1970) 1 Completion of all grades offered in secondary education in the Occupational therapists 759 " (1970) province (usually grades 12 -13). Radiological technicians 4247" (1970) 2 One year of study less than senior matriculation (usually grades Medical records librarians 792 * 11 -12). 88 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Communicable disease control and immunization services Typhoid fever 101132 Cholera 67565 The most prevalent communicable diseases, such as Epidemic typhus 11634 measles, chickenpox and mumps, are controlled chiefly by immunization and preventive programmes. Every Chronic and degenerative diseases province has legislation covering the communicable Cancer, which is the second leading cause of death and venereal diseases. The role of the Federal Govern- in Canada, accounts for about one in five deaths; most ment includes information, consultation, research, and deaths from cancer occur in the middle and later years statistical and coordination activities; these are facili- of life.The standardized death rate has been rising tated by national advisory committees on immunizing steadily, from 136.2 per 100 000 population in 1971 to agents, venereal diseases and epidemiology. Smallpox, 138.7 in 1972.Special provincial agencies for cancer malaria, yaws, schistosomiasis, trypanosomiasis, tra- control, usually in the health department or a separate choma and onchocerciasis are all rare or nonexistent cancer institute, carry out cancer detection and treat- diseases in Canada.Poliomyelitis has also virtually ment, public education, professional training, and disappeared with the advent of routine immunization research in cooperation with local public health ser- procedures. vices, physicians, and the voluntary Canadian Cancer Venereal diseases are increasing at an alarming rate. Society branches.All cancer programmes provide a In 1972 more cases of gonorrhoea were reported than range of free diagnostic and treatment services to both in any year since 1945, and the number of reported outpatients and inpatients that is financed by the hos- cases of syphilis increased from 2489 in 1971 to 3054. pital insurance programmes or the federal -provincial In 1972 the incidence rate of gonorrhoea was 190.4 per cancer control grants (the federal cancer control grant 100 000 and of syphilis 14.5 per 100 000. About 57 expired in 1971/72). of venereal disease cases occurred in young people In all provinces health departments or other official between the ages of 15 and 24.More than 10 000 agencies administer programmes for the prevention Canadian teenagers were reported to have contracted and control of alcoholism, including public education either gonorrhoea or syphilis.As many cases of and related studies.According to conservative esti- venereal diseases, of gonorrhoea particularly, are not mates the number of persons currently requiring these reported, it is estimated that there are actually 200 000 services is 270 000, if a clinical definition of alcoholism cases of gonorrhoea and 7500 cases of syphillis occur- is used.Treatment services available are mainly for ring each year in Canada. Venereal diseases are one of outpatients but, with the increasing awareness of need, Canada's most serious communicable disease pro- most provinces have expanded facilities for inpatient blems.Control measures include routine premarital services. Other facilities for the treatment of alcohol- testing in four of Canada's 10 provinces, routine testing ism operated by official and voluntary agencies include of prenatal patients, widespread public education mea- hostels, special farms, and disintoxication units or sures, reporting of cases and contacts under provincial wards. Some provincial alcoholism agencies have legislation, vigorous follow -up of contacts, and obli- broadened their programmes to include other addic- gatory medical treatment provided under existing fed- tions. Because addictions are widely prevalent, street eral- provincial medical care plans.Innovative mea- clinics, hospitals, mental health services and other sures include mobile and street clinics, "hotline" tele- public and voluntary health and social agencies are phone and radio services, improved reporting pro- also involved in their diagnosis and treatment. cedures, and confidential treatment of teenagers. The majority of persons infected with active tuber- Specialized units culosis are now being treated on an outpatient basis. Free diagnostic services available through mobile and Public health nurses employed by the local health special clinics and routine hospital X -ray services services provide preventive health services to mothers, help to control the disease, as does the availability newborns, and children through clinics, home and of effective treatment methods. BCG vaccine is used hospital visits, and school health services.All pro- on a limited scale. vincial health departments have established maternal The following immunization procedures were carried and child health consultant services that cooperate out in 1971: with the public health nursing services. In 1972 there were (excluding the Province of Quebec) 451 prenatal Tetanus 1 486158 service units, 911 child health units, and 154 school Diphtheria 1225699 Whooping -cough 892168 health units. Preventive and emergency dental health Smallpox 883214 care was available at 318 dental clinics for school- Rubella 713784 children and 20 dental clinics for adults. In 1971 there Measles 321890 BCG 253307 were 40 independent medical rehabilitation centres and REGION OF THE AMERICAS 89

36 hospital rehabilitation departments, 230 psychiatric the family planning grants programmes), the Medical outpatient clinics, about 28 venereal disease clinics, Research Council, the Canada Council, the Inter- 65 tuberculosis clinics, including part -time clinics, and national Development Research Center of Canada, 62 family planning clinics, including part -time clinics. and the Canadian International Development Agency. Canada also had 45 public health laboratories. During the period under review the Committee on the community health centre project presented its Major public health problems recommendations for action to make community With the successful control of the major communi- health care a priority, to slow down the increase in the costs of health services, and to make services reflect cable diseases, including tuberculosis, this group has more fully the objectives, priorities and relationships lost much of its former significance. However, venereal which society wishes to establish for health care in the diseases and infectious hepatitis remain unsolved and future. are even growing problems, together with the still not Canada has made its most significant progress in fully understood complex of the virus diseases.The evolving comprehensivesocialpolicies long -term and degenerative diseases have come increas- and programmes since 1950. As the result of both federal and ingly to the foreground. Cardiovascular diseases and provincial initiatives, important health, social welfare cancer continue to show high morbidity and mortality rates, although improved diagnostic and treatment and income security programmes have been instituted or developed on a nationwide basis. procedures are having some effect.Allergies and dia- The range of social security and income support measures has also betes also remain unsolved problems, although morta- been expanded to protect Canadians against income lity from diabetes is reduced by drug treatment. Mental loss and to alleviate poverty, exacerbated by high illness and emotional behavioural disorders continue unemployment and inflation in recent years. All levels to be major health problems. of government recognize that comprehensive strategies To a considerable and increasing degree, ill health is are needed to improve the delivery of services and to a consequence of inappropriate habits, such as alcohol eliminate disparities among provinces and communities addiction, improper diet, lack of exercise, smoking, with regard to the range and standards of service. In and drug abuse and addiction. 1969 the report of the Task Force on Costs of Health Services in Canada widely published the fact that Progress in the health services health costs were rising at a rate in excess of the growth Significant developments have taken place in the of Gross National Product.The recommendations areas of population growth and health delivery systems. contained in the report have formed the bases for a The current rate of population growth in Canada is the large number of measures taken by the federal and lowest since the Second World War. This reduction in provincial governments to curb health care costs. New population growth stems particularly from the drama- arrangements for financing health care are being con- tic decline in fertility, but the decrease in the volume of sidered with the objective of reducing the rate of cost net migration has also significantly contributed to the escalation and of enabling the provinces to achieve reduction in the rate of growth. Although Canada has flexibility to determine priorities and pursue the most not developed any specific measures designed to in- efficient and effective approaches to health care.In- fluence population changes, the 1969 amendment to the creasing emphasis is being given to the concept of Criminal Code permitted the legal dissemination of health promotion. birth control information and the sale of contracep- tives, and cleared the way for federal activity in the National health planning family planning field.In 1972 the family planning division, which is responsible for the federal pro- The Province of Quebec has enacted legislation gramme, was created within the Department of Na- aimed at reorganizing both health and social services. tional Health and Welfare. The objective of the pro- The legislation specifically establishes regional health gramme is, in cooperation with provincial and muni- and social service councils, with four levels of health cipal governments and voluntary agencies, to ensure care establishments being designated to provide health the accessibility and availability of family planning and social services.Each establishment is supported services to all Canadians who want them. Provincial by an appropriate professional advisory council or departments are encouraged to make maximum use of council of physicians and dentists. Community repre- the provisions of the federal -provincial shared -cost sentation is ensured on the governing boards of each health and welfare programmes for the development health care establishment. of family planning services.Sources of government In the Province of Manitoba, policies and objectives funds for research in family planning include the have been defined in order to rationalize health care Department of National Health and Welfare (through delivery through the establishment of district health 90 FIFTH REPORT ON THE WORLD HEALTH SITUATION councils with basic services centred on community Can $12.3 million, or about 33 % of the Health Re- health centres.An integrated single unit delivery sources Fund expenditure in 1971/72, was used to system has been established with the reorganization build research facilities. of the Provincial Department of Health and Social The major subjects of the research activities sup- Development. Health care delivery in the Province is ported by the Department of National Health and changing towards a comprehensive and integrated Welfare were pharmacology, pharmaceutical chemis- service. try, nutrition, microbiology, pesticides, food additives, In the Province of Nova Scotia the establishment of clinical laboratory procedures, health services, prosthe- a regional management system to integrate and coor- tics, epidemiology, physical fitness, and environmental dinate all health services has been recommended. health including radiation protection, human ecology Legislation exists permitting the establishment of re- and health effects of air and water pollution.The gional councils of health. The provincial government Department of Veterans Affairs supports a variety of has accepted the concept of the coordinated regional clinical studies in chronic disease problems including health system which entails a complete reorganization psychiatric research.Studies in radiation biology and of the Provincial Department of Public Health, consoli- other life sciences important to health are conducted dating hospital and medical insurance commissions by the National Research Council.A number of in a unified health commission with subordinate re- voluntary agencies also support medical research in gional and community health boards.Five regions Canada. Research isalso financed by provincial have been designated for the organization of health governments through various councils and foundations services. as well as direct research grants. Plans in other provinces are being developed on a The Health Economics and Statistics Directorate in continuous basis, but no comprehensive new plans the Health Programmes Branch provides socioeco- have been put forward recently. nomic research and advisory services on a wide range of subjects which include medical care, hospital care, community health services, health expenditure, man- Medical and public health research power resources, and other matters related to health Federal government expenditure for health science costs and utilization. research is estimated at 63.1 million Canadian dollars for 1971/72, as compared to Can $54.8 million for Government health expenditure 1970/71. The Medical Research Council accounted for $35.6 million, the Department of National Health and During the fiscal year 1971/72 total government Welfare for $27.2 million, and the Department of health expenditure amounted to 4854.8 million Cana- Veterans Affairs for $300 000. The majority of federal dian dollars. Altogether Can $224 were provided per grants supporting health science research in universities capita for the health of the population. Of the central and hospitals have been channelled through the Medi- government health expenditure, Can $133.6 million cal Research Council, which reports to Parliament were spent by the Department of National Health and through the Minister of National Health and Welfare. Welfare, $1469.8 million by other departments and Of the Council's total expenditure in 1971/72 for dental, as federal contributions to provincial, local and terri- pharmaceutical and medical research Can $23.5 million torial governments, $3118.6 million by provincial were allocated for grants -in -aid, $8.6 million for re- health authorities (excluding federal contributions), search scholarships and fellowships, and $3.3 million $132.8 million by local health authorities. The govern- for other research support and promotion. ment expenditure on general public health services Under the Public Health Research Grant and the included the following items : Can $160.6 million for National Health Grant the Department of National administration and government personnel; $22.6 mil- Health and Welfare distributed in 1971/72 Can $7.7 lion for laboratory services, $5.3 million for environ- million for applied and developmental research projects mental health services, and 14.7 million for training of and related scientific activities conducted by univer- personnel. The government expenditure on hospitals sities, hospitals, health departments, and other non- was Can $2953.0 million, and $143.0 million were spent profit health organizations. The expansion of research on other health establishments. The government con- facilities continues to be one of the key objectives of tributions to health activities of social security schemes the Health Resources Programme of the Department and other nongovernmental social welfare systems of National Health and Welfare; it is estimated that amounted to Can $11.9 million. REGION OF THE AMERICAS 91

CHILE

Population and other statistics health services are provided by the national medical At the last census, taken in April 1970, the popu- service for civil servants, the army, the police, the lation of Chile was 8 834 820.Population estimates State railways, the universities, and the prison autho- and some other vital statistics for the period under rities. The health activities of these bodies are coordi- review are given below: nated by the National Advisory Health Council. The National Health Service, which is under the control of 1969 1970 1971 1972 the Ministry of Public Health, is centralized at the Mean population . . . 9566 000 9726 000 9922 000 10123 000 policy- making level and decentralized at the executive Number of live births . . 286 807 261 609 273 518 277 891 Birth rate (per 1000 popu- level.Its main components are the National Council lation) 28.1 26.9 27.6 27.5 Number of deaths 84680 83166 83240 88658 and the Directorate -General. The Minister of Public Death rate (per 1000 Health is Chairman of the National Council, which population) 8.9 8.6 8.4 8.8 Natural increase ( %) . 1.92 1.83 1.92 1.87 includes representatives of public and private organiza- Number of infant deaths 21 156 20 750 19 271 19 752 tions. The Directorate -General, which has the overall Infant mortality rate (per 1000 live births) . . 78.7 79.3 70.5 71.1 responsibility for the National Health Service,is Number of deaths, 1 -4 organized in two departments -the administrative and years 3 466 3 684 3 075 2 885 Death rate, 1 -4 years (per the technical. The functions of the latter department 1000 population at risk) 3.3 3.5 2.9 2.6 Number of maternal consist in the establishment of standards, assessment, deaths 488 439 389 452 technical supervision and control, planning and eva- Maternalmortalityrate (per 1000 live births) . . 1.8 1.7 1.4 1.6 luation. Its subdepartments are concerned with health protection, promotion and rehabilitation,statistics, Of the 83 240 deaths recorded in 1971, the main architecture and planning. A subunit of the technical causes were: 1 pneumonia (11 180), chronic rheumatic department deals with rural health.The technical heart disease, hypertensive disease, ischaemic heart department is also in charge of the zonal directorates, disease, other forms of heart disease (10 322), malignant which represent the second health administrative level. neoplasms (10 000), cerebrovascular diseases (5934), The country is divided into 13 health zones and one birth injury, difficult labour and other anoxic and subzone (Arica). Each health zone is subdivided into hypoxic conditions, other causes of perinatal mortality health areas, of which there are at present 55. At all (4534), symptoms and ill- defined conditions (4453), levels there are technical and administrative advisory accidents (3983, including 1810 in motor -vehicle acci- councils which are responsible for maintaining effective dents), bacillary dysentery and amoebiasis, enteritis coordination and of which the members are hospital and other diarrhoeal diseases (3934), cirrhosis of the directors.The hospitals represent the executive and liver (3495), tuberculosis, all forms (2275), diabetes operational units of the health service, which is based mellitus (1212), bronchitis, emphysema and asthma on the concept of integral medical assistance. (1202), congenital anomalies (1076), influenza (1061), avitaminoses and other nutritional deficiency (1048). Hospital services The communicable diseases most frequently notified in1972 were: influenza (14 609), measles (6299), In 1970 Chile had 281 hospitals and inpatient estab- typhoid and paratyphoid fevers (4527), scarlet fever lishments, providing a total of 35 861 beds, of which (3481), whooping -cough (3380), syphilis, new cases 35 105 were in 260 government establishments. The (2982), infectious hepatitis (2458), diphtheria (662), bed /population ratio was 3.7 per 1000.The 35 681 amoebiasis (144), meningococcal infections (80), polio- beds were distributed as follows: myelitis (11), typhus (4), rabies in man (1). Category and number Number of beds General hospitals 180 25 597 Rural hospitals 64 1 443 Organization of the public health services Maternity hospitals 5 97 Paediatric hospitals 6 1441 Infectious diseases hospital 1 154 The National Health Service is responsible for the Tuberculosis hospitals 5 1 140 public health activities in the country and for medical Psychiatric hospitals 5 4 631 Cancer hospital 1 106 care servicesfor beneficiariesof social insurance Hospital for chronic diseases 1 205 schemes. The Ministry of Public Health provides 95 Hospitals for traumatology 8 490 Hospital for physiotherapy 1 88 of all health services in Chile. Additional medical and Other establishments 4 469 Outpatient facilities were available in 1972 at 174 1 International Classification of Diseases, 1965 Revision. hospital outpatient departments, which recorded 5.5 92 FIFTH REPORT ON THE WORLD HEALTH SITUATION million attendances; at 131 polyclinics, which recorded The incidence rate of syphilis in Santiago dropped 2.6 million attendances; at two mobile health units, from 36.6 per 100 000 in 1969 to 20 per 100 000 in 1972, and 912 other outpatient establishments. which is a 46 % decrease. The incidence rate of gonorrhoea in Santiago dropped from 104 to 61.6 per 100 000 Medical and health personnel and training facilities between 1969 and 1972, which is a 31.2 % decrease. The following immunization procedures were carried In 1970, 4401 doctors were working in government out in 1971: service in Chile. The doctor /population ratio was thus Poliomyelitis 948873 one to 2220. Other health personnel employed by the Smallpox 941529 Government included: Diphtheria and whooping -cough 912925 BCG 583168 Measles 402539 Dentists 1 140 Diphtheria 392759 Pharmacists 321 Typhoid and paratyphoid fevers 232372 Midwives 1 101 Nurses 1 666 Assistant and auxiliary nurses 16 597 Specialized units Laboratory technicians 352 Nutritionists 397 Other health workers 607 In 1972 there were seven maternal and child health Social workers 651 centres, 352 dental health units for adults and eight for schoolchildren, 24 medical rehabilitation centres and The arrangements for the trainingof medical and two psychiatric clinics. health personnel were as follows:

Category DurationNumber of Number of Number of Environmental sanitation and admission study schools 1studentsgraduates requirements (years) 1971/72 1972 In 1970, of Chile's total population 21.6 % had water Doctors 12 years from a piped water system and 43.7 % were living in general education 7 3 (3) 2 983 265 dwellings connected to sewers. Dentists 12 years general education 5 2 (1) 1 103 96 Pharmacists Social and economic developments of significance for 12 years the health situation general education 5 1(1) 621 46 Veterinarians 12 years Industrial production increased in 1970 and 1971 by general education . . 5 1 (1) 447 about 8 % annually, as compared to 3.8 % during the Nurses (university level) 12 years period 1965 -1969. Agricultural and livestock produc- general education . . 4 9 (3) 2 531 335 tion increased by 5.1 % in 1971. The national unem- Sanitary technicians 12 years ployment rate decreased to 4.6 % in 1971 and to 4 general education . . 3 1(1) 22 in 1972. During the years 1970 -1972, 65 000 housing Occupational therapists 12 years units were constructed. Basic education increased by general education . . 3 1 62 15 over 6 % to cover 99 % of all children aged between Sanitary inspectors . . . 3 months ... 30 6 and 14 years.The increase in the Gross National Auxiliary nurses . . . . 1 25 (6)" 2 000 1 800 Product was 8.3 % in 1971. The period 1971 -1972 was 1 Public (private) schools. marked by the maintenance of the infant mortality " Public (private) courses. rate at 70 per 1000. There was also a 15 % increase in the number of deaths due to accidents and violence Communicable disease control and immunization services between 1970 and 1972.

During the period 1969 -1972 mortality rates for the National health planning following diseases declined: measles, poliomyelitis, whooping -cough and typhoid fever. The mortality rate The health policy of the six -year health plan for for measles dropped from 3.5 per 100 000 in 1969 to 1971 -1976 is directed towards the extension of the 1.6 per 100 000 in 1972, that for poliomyelitis from coverage provided by the health services and improve- 0.2 to 0 and that of typhoid fever from 0.9 to 0.6. Tu- ment of their administration. The following areas in berculosis is still one of the main causes of death and public health are considered to have priority: maternal was responsible for 2.7 % of all deaths in 1972 as com- and child health, dental health, care for old people, pared to 3.4 % in 1969, which represents a 20.2 % reduc- environmental health, occupational health and pre- tion.The tuberculosis mortality rate was 29.6 per vention of occupational accidents, zoonoses control, 100 000 inhabitants in 1969 and 23.6 per 100 000 in food hygiene and nutrition, mental health, and the 1972. establishment of a single health service. REGION OF THE AMERICAS 93

Assistance from PAHO /WHO Institute of Occupational Health and Air Pollution Research (1961- ): to contribute to the solution of In 1972 PAHO /WHO's assistance to Chile included problems of industrial hygiene and occupational health. the following projects: Hospital maintenance (1966- ): to carry out a Tuberculosis control (1964- ):to extend the study of maintenance of hospital buildings, installa- national tuberculosis control programme as part of tions and equipment. the general health services. Teaching and research in demography (1972- ) : Veterinary public health (1971- ):to eradicate to carry out research on fertility patterns and popula- canine rabies, implement a programme for anthrax tion changes, and on demography and its relationship control in Ñuble Province, and control other zoonoses. to health; and to improve statistical information and Engineering and environmental sciences (1968- ): teaching in these fields. to plan and implement environmental sanitation pro- Rehabilitation (1960- ) UNDP: to implement a grammes, and train personnel. rehabilitation programme. Water supplies (1970- ): to plan and implement Cancer (1965- ): to extend a programme, begun water supply and sewerage programmes for urban and in Santiago, for detection of cancer of the cervix uteri, rural areas. and to train staff. Health services(1961- ) UNDP Grants to PAHO: School of Public Health (1958- ): to strengthen Organization of American States: to strengthen the the teaching at the Department of Public Health and administration of the national health services. Social Medicine of the University of Chile and expand Health manpower studies (1968- ) :to carry out its facilities. studies on health manpower requirements and utiliza- Medical education (1962- ) : to expand and streng- tion. then medical education, and to develop a programme Bacteriological Institute (1972- )UNDP: to re- of medical internships in rural hospitals for students organize the Institute. of the medical profession. Maternal and child care (1967- ): to develop a Training in the medical use of radioisotopes (1962- programme of training and research on biological and ): to provide training in the medical use of radio- social aspects of human reproduction and child growth isotopes and in radiation protection. and development; and to improve maternal and child Nursing education (1971- ): to organize program- health care. mes of specialization in nursing. Maternal and child health and family welfare service Sanitary engineering education (1965- ) : to streng- (1972- ): to carry out an expanded programme of then and extend teaching and research in sanitary maternal and child health care and family planning. engineering. Clinical and social paediatrics courses (1967- ) : to Veterinary medical education (1966- ):to im- provide intensive training in clinical paediatrics and in prove the teaching programme at the School of Live- the administration of health services for infants and stock Sciences and Veterinary Medicine of the Uni- children. versity of Chile. Nutrition (1971- ): to develop and implement Dental education (1965- ): to implement a pro- plans for initiating or strengthening nutrition programme for the teaching of preventive and social grammes and to incorporate nutrition work into local dentistry at the school of dentistry of the University health services. of Concepción. Training in nutrition and human growth and development (1971- ) (Cornell University, United States of America): to train Latin American research workers Government health expenditure in nutrition and human growth and development. In 1972 total government expenditure amounted to Mental health (1965- ) UNDP: to develop com- 36 600 million escudos, of which 2900 million were munity mental health techniques in a health district spent on health services by the Ministry of Public of Santiago, and to conduct epidemiological studies Health and 2700 million by the National Health on mental disorders. Service. 94 FIFTH REPORT ON THE WORLD HEALTH SITUATION

COLOMBIA

Population and other statistics Hospital services At the last census, taken in July 1964, the population In 1971 Colombia had 773 hospitals and other of Colombia was 17 484 508.Population estimates inpatient establishments providing 46 179 beds, or 2.1 and some other vital statistics for the period under beds per 1000 population. These beds were distributed review are given in the following table: as follows: Category and number Number of beds 1969 1970 1971 1972 General hospitals 658 31582

. . . 20 463 07821 117 109 21 22488 Mean population 791 818 285 Maternity hospitals 30 723 Number of live births. 671 843 676 887 683192 684568 Paediatric hospitals 25 3394 Birth rate Tuberculosis hospitals 16 1984 (per 1000 population) 32.8 32.1 31.4 30.4 Psychiatric hospitals 27 6800

Number of deaths . . 179 581 180 017 181 645 Ophthalmology hospitals 4 149 Death rate Cancer hospital 1 140 5 (per 1000 population) . 8.8 8.5 8.3 Orthopaedic hospitals 379 Leprosaria 2 840 Natural increase (%) . . 2.40 2.36 2.31 Hospital for toxicology 1 13 Number of Infant deaths 49361 47627 46363 Hospitals for cardiology 2 135 Infant mortality rate Other hospitals 2 40 (per 1000 live births) . 73.5 70.4 67.9 Number of deaths, 1 -4 years 24 256 Outpatient facilities were available in 1972 at 482 Death rate, 1 -4 years (per hospital outpatient departments; at 303 polyclinics, 1000 population at risk) 8.4 Number of maternal of which 129 had some inpatient facilities; at 450 health deaths 1 487 1 556 1 498 centres, of which 17 had inpatient facilities; and at Maternal mortality rate 27 dispensaries, 877 medical aid posts and 253 con- (per 1000 live births) 2.2 2.3 2.2 sultation services. The communicables diseases most frequently notified in 1971 were: influenza (111 666), gonorrhoea Medical and allied personnel and training facilities (36 005), measles (29 866), tuberculosis of the respiratory system, new cases (19 620), malaria, new cases In 1969 Colombia had 9468 doctors, or one doctor (17 585), whooping -cough (15 786), scarlet fever and for 2160 inhabitants. Other health personel included: streptococcal sore throat (9669), typhoid and para- Dentists 2 743 typhoid fevers (7383), diphtheria (619), poliomyelitis Pharmacists 1 200 Veterinarians 1 350 (465), meningococcal infections (323), leprosy (321), Nurses 2115 typhus, murine (69), rabies in man (54), yaws, new Assistant nurses 8970 Nursing auxiliaries 8663 cases (18), relapsing fever, tickborne (1l). Sanitary engineers 40 Sanitarians 1 446

Organization of the public health services The country has nine faculties of medicine, four of dentistry, four of pharmacy and five of veterinary The health services in Colombia are organized at medicine. three levels: central, regional and local. At the central level, the Ministry of Public Health is responsible for Communicable disease control and immunization services the general policy and planning of public health; the supervision, assessment, coordination, and technical Morbidity and mortality from communicable dis- and administrative evaluation of health programmes; eases are still high, although in many cases ways of the coordination of health plans and programmes with controlling them are available. Priority is given to the the national economic and social development plan; following activities: antimalaria campaign, campaign and the planning, carrying -out and supervision of against yaws, campaign against Aedes aegypti, main- training of personnel for the public health service. tenance of a level of immunity against diseases control- The regional administrations are in charge of the lable by vaccination (diphtheria, whooping- cough, supervision, assessment, coordination and evaluation tetanus,tuberculosis,smallpox), mass vaccination of health programmes within their areas. At the local (poliomyelitis and measles), and the control of vene- level, there are hospitals, health centres, health posts real diseases. Intestinal infections are still widespread. and other health institutions. A high percentage of children under 5 years of age Additional medical and health services are provided are suffering from malnutrition, which is one of the by the social security institute, the social welfare estab- reasons for the high rate of deaths from communi- lishments and the armed forces. cable diseases in this age group. REGION OF THE AMERICAS 95

The following immunization procedures were car- Assistance from PAHO /WHO ried out in 1972: In 1972 PAHO /WHO's assistance to Colombia Smallpbx 1825307 included the following projects: Poliomyelitis 994129 BCG 830918 Diphtheria, whooping -cough and tetanus 736198 Malaria eradication programme (1958 - Tetanus 189979 UNICEF Typhoid and paratyphoid fevers 86798 Yellow fever 48653 Smallpox eradication (1967- ): to carry out a campaign aimed at vaccinating at least 80 % of the Specialized units population against smallpox and to organize epidemiological surveillance. In 1972 there were 19 prenatal and child health service units.They were attended by 137 081 pregnant Veterinary public health (1971- ): to implement women, 158 732 infants and 15 450 children aged programmes for the control of the main zoonoses, 1 -4 years. Domiciliary care was given to 15 539 preg- and train the necessary staff. nant women and to 16 039 infants.Psychiatric con- Rabies controif (1971- ): to implement a pilot sultations were given at 28 psychiatric clinics. project for the control of rabies in the Cauca River Valley, in preparation of a national control programme. Environmental sanitation Engineering and environmental sciences (1970- ): It is estimated that 84 % of the urban population to improve the national, regional and local environ- and 28 % of the rural population have access to mental sanitation programmes. drinking -water supply systems. Excreta disposal Water resources studies (1969- ) : to conserve and systems, including individual disposal systems, serve make best possible use of the water resources of the 59 % of the urban population and 32 % of the rural Bogotá savannah and the Ubaté and Chiquinquirá population. valleys. Water supply and sewerage services administration, Major public health problems Palmira (1971- ): to improve the administration and management of the city's water and sewerage The main public health problems in Colombia are: authority. rising demands on health services as a result of the rapid population increase, low levels of nutrition and Water supply and sewerage services administration inadequate environmental health conditions that are (1971- ): to strengthen and improve the organiza- reflected in the high morbidity and mortality rates tion and administration of the National Institute of among the young age groups; inadequacy of health Municipal Development. resources to meet present and future health needs; Aedes aegypti eradication (1951- ) shortage of health manpower and uneven distribution Investigation and control of dengue fever (1972- ) of medical and auxiliary personnel; low levels of Grants to PAHO: US Army Medical Research and staff remuneration and lack of incentives for retaining Development Command: to intensify field and labo- medical personnel, particularly in rural areas; absence ratory studies on dengue fever and similar virus of mechanisms for carrying out a well- defined hos- diseases; to increase the services for surveillance of pital policy; inadequate and insufficient equipment in yellow fever; and to strengthen and modernize the medical care establishments; deficient statistical ser- national virus laboratory. vices. Air pollution (1971- ):to determine the air pollution problem in the main cities, initiate pro- National health planning grammes of prevention and control and establish the The plan for the health sector gives priority to the services required for their development. development of its structures and administrative pro- Health services (1951- ) UNDP UNICEF: to cesses with a view to improving the efficiency and extend the coverage of the health services and improve effectiveness of the services given to the population, their structure and operation. including an improvement in coverage of certain rural areas and a better utilization of available re- NationalInstituteofHealth(CarlosFinlay) sources.The final aim isthe development of a (1950- ):to strengthen the work of the public national health system through which the efforts of health laboratory and the production of biologicals the institutions forming part of it will be integrated at the National Institute of Health. and coordinated.Priority is also being given to im- Social services (1970- ) UNICEF (United Na- provements in environmental sanitation and nutrition. tionsSocial Development Programme) (FAO): to 96 FIFTH REPORT ON THE WORLD HEALTH SITUATION carry out intersectoral programmes aimed at providing Nursing education (1968- ): to establish a centre comprehensive care to children and young adults for education and research in maternal and child within the context of protection of the family. health nursing to serve Colombia and other countries in Latin America. Clinical and social paediatrics (1964- ) UNICEF: to improve the preparation of paediatricians. Sanitary engineering education (1964- ): to improve the teaching of sanitary engineering inthe Nutrition (1964- ):to train teachers for the universities and provide short intensive courses in schools of nutrition and dietetics. sanitary engineering subjects. Radiation protection (1972- ):to establish a Veterinary medical education (1969- ) : to improve national radiation protection programme. the teaching of veterinary public health and related subjects. Health and population dynamics (1968- ):to extend maternal and child health care and family wel- Dental education (1961- ): to develop the dental fare services to the rural areas, improve their admin- education programmes at the National University, istration and the reporting system; and train rural Bogotá, and the universities of Valle, Antioquia and health personnel. Javeriana.

School of Public Health (1959- ): to strengthen Government health expenditure the School of Public Health of the University of Antioquia. In 1971 total government expenditure was 22 291.3 million pesos, of which 1630.2 million were spent by Medical education (1965- ) : to strengthen medical the Ministry of Public Health. The current expendi- education. ture on public health services amounted to 692.3 mil- Centre for the teaching of pathology (1967- ): to lion pesos. The government expenditure on hospitals strengthen the centre for the teaching of pathology. was 376.2 million pesos.

CUBA

Population and other statistics cerebrovascular diseases (4694), birth injury, difficult At the last census, taken in September 1970, the labour and other anoxic and hypoxic conditions, other population of Cuba was 8 553 395.Population esti- causesof perinatalmortality(3270),pneumonia mates and other vital statistics for the period under (3018),accidents(2822,including861in motor - review are given in the following table: vehicle accidents), suicide and self -inflicted injuries (1265), congenital anomalies (1263), bronchitis, emphy- 1969 1970 1971 1972 sema and asthma (1024), diabetesmellitus (890),

Mean population . . 8336 953 8472 131 8602 987 8749 171 bacillary dysentery and amoebiasis, enteritis and other Number of live births . . 238 095 241 919 256 014 247 997 Birth rate diarrhoeal diseases (848), cirrhosis of the liver (580), (per 1000 population) . 28.6 28.6 29.8 28.3 nephritis and nephrosis (469), tuberculosis, all forms Number of deaths 1. . . 55 677 53 385 52 231 49 447 Death rate (407), symptoms and ill- defined conditions (106).

(per 1000 population) . 6.7 6.3 6.1 5.6 Natural increase ( %) 2.19 2.23 2.37 2.27 The communicable diseases most frequently notified Number of infant deaths 1 11 366 9 073 9 201 6 961 Infant mortality rate in 1972 were: infectious hepatitis (10 021), measles (per 1000 live births) . 47.7 37.5 35.8 28.7 (5313), syphilis, new cases (2151), whooping -cough Number of deaths, (1268),tuberculosis, 1 -4 years 1 1 671 1163 1 048 969 all forms, new cases (1272), Death rate, 1-4 years (per gonorrhoea (703), typhoid fever (449), leprosy (319), 1000 population at risk) 1.8 1.2 1.1 1.0 Number of maternal tetanus (151), malaria, imported cases (34). deaths 1 205 173 164 141 Maternal mortality rate

(per 1000 live births) 0.9 0.7 0.6 0.6 Organization of the public health services 1 Provisional figures. Of the 49 447 deaths recorded in 1972, the main The health services of Cuba are organized according causes were:' chronic rheumatic heart disease, hyper- to the following principles and concepts : tensive disease, ischaemic heart disease, other forms - concentration of all health components, including of heart disease (12 003), malignant neoplasms (8929), the pharmaceutical industry, in the Ministry of Public Health, which has legal, administrative and 1 International Classification of Diseases, 1965 Revision. financial powers; REGION OF THE AMERICAS 97

- accessibility of the health services to the whole hospitalization facilities, which recorded 1.6 million population, which is made possible through an attendances; 280 polyclinics with outpatient facilities extensive health service network providing total only, which recorded nearly 15 million attendances; coverage.Health services are free of charge in and 110 rural medical aid posts, which recorded over respect of hospital care, including medicaments, 800 000 attendances. medical consultations, laboratory tests and X -ray examinations; Medical and allied personnel and training facilities - popular participation in the implementation of the In 1968 Cuba had 7000 doctors, or one doctor for health programmes through various organizations, 1150 inhabitants.Other health personnel included such as the Women's Federation of Cuba, the 4373 nurses and 7650 auxiliary nurses. National Association of Small Farmers, and the Red Cross; The arrangements for the training of medical and health personnel are as follows: integration of preventive, curative and restorative health services. Category Duration Number of Number of Number of and admission of study schools studentsgraduates requirements 1 The health services are organized in an articulated (years) 1971/722 1972 Doctors system of a progressive series of preventive and cura- 13 6 4 1 171 853 Dentists tive health service units, according to the concept of 13 4 2 242 333 regionalization. This system provides for the delivery Pharmacists 13 5 1 220 52 of services at various levels and for distinct categories, Veterinarians suited to geographic and demographic conditions, the 13 5 3 466 110 Nurses health problems of the population and the develop- 10 2 and 3 28 4 112 471 ment of the communities.It also promotes technical Auxiliary nurses 6 1 28 6 110 1 355 and administrative coordination and communication Midwives 10 2 ... 280 51 between all levels. Paediatric nurses Theorganizationalstructurecomprisesthree 10 3 480 161 Auxiliary paediatric hierarchical levels: central, for policy- making, plan- nurses ning, guidance and supervision of health activities; 6 1 3 282 643 Laboratory technicians provincial and regional, for control and coordination; 10 2 7 1 545 584 and local, for execution. The rural medical aid posts, Pharmacy technicians 10 2 7 1 317 368 the polyclinics and the rural hospitals are basic ele- X -ray technicians 10 2 7 682 217 ments of this health service network. The administra- Sanitary workers tive structure includes the Ministry of Public Health 10 3 7 609 74 Physiotherapists at the central level and the health directorates at the 10 7 43 13 provincial and regional levels. Dental auxiliaries 6 6 months 19 1 286 400 Laboratory auxiliaries Hospital services 6 1 11 41 41 Public health statisticians 9 3 7 608 In 1972 Cuba had 321 hospitals and other in- Social workers patient establishments providing altogether 38155 beds, 6 2 2 29 Psychologists to which 1 159 538 patients were admitted during the 13 5 2 97 53 year.The bed /population ratio was 4.4 per 1000. The 38 155 beds were distributed as follows: 1 In years of general education. 2Numbers admitted. Category and number Number of beds General hospitals 91 17 382 Communicable disease control and immunization services Rural hospitals 52 1 041 Medical centres 79 879 Maternity homes 50 4 852 No cases of "quarantinable" diseases were recorded Paediatric hospitals 20 4 772 during the period under review.As a result of the Tuberculosis hospitals 6 1 529 Psychiatric hospitals 12 5 687 malaria eradication programme, which was launched Ophthalmology hospital 1 154 in 1959 and integrated into the general health services Cancer hospitals 3 640 Orthopaedic hospitals 2 322 in 1967, no indigenous malaria case was recorded Leprosaria 2 581 after 1967. The incidence of diarrhoeal diseases con- Clinic for cardiovascular surgery 1 60 Clinic for neurology and neurosurgery . 1 81 tinued to decline. Whereas the mortality due to these Rehabilitation clinic 1 175 diseases dropped from 22.9 per 100 000 inhabitants Outpatient services were available in 1972 at 114 in 1969 to 9.6 per 100 000 in 1972, the morbidity hospitaloutpatientdepartments,whichrecorded remained stationary because of inadequate hygienic nearly 3 million attendances; 40 polyclinics providing and sanitary conditions. The decline in mortality was 98 FIFTH REPORT ON THE WORLD HEALTH SITUATION mainly due to the fact that the patients resorted to Malignant neoplasms represent the second most medical attention at an early stage. important cause of death, with approximately 15 In view of the results achieved through the tubercu- of all deaths. The cancer mortality rate was 98.1 per losis control programme that started in 1963, a new 100 000 inhabitants in 1969 and 100.7 per 100 000 in control programme was initiated in May 1970 which 1972. A large -scale control programme against cancer is based on bacteriological examination, ambulatory of the uterus was initiated in 1967, with approximately treatment at the polyclinics for all bacteriologically 300 000 women being screened annually. A lung can- confirmed cases, BCG vaccination of the newborn and cer detection programme has been initiated as a pilot revaccination of the schoolchildren, with systematic project. examination of all contacts.The tuberculosis inci- The diabetes mortality rate was 9.7 per 100 000 in dence rate fell from 43.9 per 100 000 inhabitants in 1972. A national register for diabetes patients has 1969 to 14.5 per 100 000 in 1972 and the mortality rate been established, day centres have been opened for declined from 10.7 per 100 000 to 4.3 per 100 000 dur- these patients and health education activities have ing the same period. The prevalence of leprosy re- been undertaken. mained at 0.5 per 1000 inhabitants.It is estimated that over 96 % of the leprosy cases are under treatment and that about 80 % of the contacts are followed up. Specialized units The annual poliomyelitis vaccination campaign was continued during the period under review. In 1972 maternal and child health care was based on The number of tetanus cases decreased from 291 49 maternity hospitals and hospitals for mothers and in 1969 to 151 in 1972 as a result of intensive vaccina- children, and on 20 paediatric hospitals. In the same tion programmes and of a growing number of institu- year, 242 078 confinements took place in hospitals tional deliveries.In recent years, about 70 % of all and health centres.Altogether 97 % of all deliveries tetanus cases occurred among persons over 45 years, were attended by a doctor or qualified midwife. Den- particularly among retired workers and among house- tal care was provided at 74 stomatological clinics. wives who were not covered by the vaccination pro- Psychiatric consultations were given at 12 centres in grammes directed more particularly at the working mental hospitals.Rehabilitation outpatient services population and the schoolchildren. The present vac- were available at one specialized hospital outpatient cination campaign is directed towards this group at clinic and at 16 general hospital rehabilitation depart- risk. ments. Health care for industrial workers is provided During the period 1969 -1972, the incidence of syphi- at 24 units in polyclinics located in the big industrial lis, particularly early syphilis, increased from 7.8 to centres.Other outpatient facilities in specialized cli- 24.4 per 100 000. A new venereal diseases control nical fields were provided at 23 tuberculosis clinics, programme was started towards the end of 1971. one physiotherapy clinic and one clinic for sports The following immunization procedures were car- medicine. There were also 31 public health laborato- ried out in 1971: ries.

Tetanus 2058471

Poliomyelitis 1119930 Diphtheria 754644 Major public health problems Typhoid and paratyphoid fevers 649525 Whooping -cough 437939 BCG 356279 The major public health problems of Cuba are as Smallpox 101302 follows : (1)problems related to the deficiencies in sanitary Chronic and degenerative diseases conditions, particularly in environmental sanitation; The cardiovascular diseases represent the most (2)insufficient development of the domestic phar- important cause of mortality, with about 20 % of all maceutical industry, as a result of which Cuba has to deaths.The mortality rate from these diseases was import finished products or raw materials at a high 152.7 per 100 000 inhabitants in 1969 and 129.4 per cost; 100 000 in 1972.Cardiovascular patients represent 14.8 % of all discharged patients in the hospitals of the (3)the persistence of a number of infectious dis- capital city.Intensive care units have been created eases not yet under control such as diarrhoeal diseases, for the treatment of these diseases and a domiciliary intestinal parasitoses, typhoid fever and leprosy; care service for persons above 65 years of age has (4)the increasing prevalence of certain chronic been established. Health education activities are diseases such as asthma, diabetes and cardiovascular directed against smoking habits. diseases, and of accidents; REGION OF THE AMERICAS 99

(5)the need to adapt the structure of the health reference centre for provincial, regional and hospital services to the prevalence and incidence of commu- laboratories. nicable and chronic diseases; (6)the relative shortage of certain qualified health Medical and public health research personnel such as nurses and medical specialists. Medical and public health research activities are carried out by the Ministry of Public Health, the Social and economic developments of significance for faculties of medicine, the National Scientific Research the health situation Institute and the various institutes under the Ministry During the period under review a system of com- of Public Health dealing with sports medicine, public bined education and employment was introduced health, epidemiology and microbiology, haematology through which students participate in the social pro- and immunology, endocrinology and metabolic dis- duction process. The free services for health and edu- eases, gastroenterology, cardiology and cardiovascular cation were maintained.The female working popu- surgery. lation continued to increase.Legislation on occupa- During the period under review a Vice- Ministry for tional health and safety was extended. Education and Research was established in the Min- The agricultural and livestock production continued istryof Public Health, together with a national to be developed and modern agricultural techniques research directorate and an advisory and assessory introduced. There was extensive building of houses in commission. rural and urban areas. The medical and public health activities are financed from the state budget, which allocates 1.5 % of its National health planning resources. The main trends and activities of the basic health planning process are defined through the following Assistance from PAHO /WHO programmes: vaccination, control of acute diarrhoeal In 1972 PAHO /WHO's assistance to Cuba included diseases, tuberculosis control, venereal disease control, the following projects: Aedes aegypti eradication, early detection of cancer of the uterus, malaria eradication.These programmes Communicable disease control (1967- ) UNICEF: are implemented through the existing health service to carry out programmes of vaccination against cer- network and within the organizational health struc- tain communicable diseases and integrate them into the work of the general health services. ture. Evaluation and assessment of these programmes are carried out at each administrative and functional Tuberculosis control (1969- ) :to extend the level. tuberculosis control programme to the whole country A five -year national health plan for the period 1976- and integrate it into the general health services; and to 1980 is being prepared as an integral part of the overall train personnel. economic development plan. This health plan defines Venereal diseases (1969- ): to improve the epi- priorities based on morbidity trends and on the nutri- demiological and laboratory aspects of the venereal tional status of the population, and it proposes a more disease control programme. adequate utilization of available resources and opti- Zoonoses control (1969- ): to plan and imple- mum productivity. In the plan period it is intended ment programmes for the control of zoonoses. to add 24 000 hospital beds, giving 6.2 beds per 1000 Engineering and environmental sciences (1969- ): inhabitants in 1980; 100 polyclinics, 129 dental service to strengthen environmental sanitation programmes. units, 1900 dental teams, and 36 dental laboratories; Aedes aegypti eradication (1953- ) 7500 doctors, giving one doctor for 750 inhabitants; and 1500 dentists.It is expected that the increased Health services (1959- ) UNDP: to improve the availability of health facilities will result in a higher organization and operation of the general health ser- utilization rate of the services: 6 to 7 medical consulta- vices and the administration of government medical tions per year and per person in 1980 as against 4.2 in care institutions and to develop special services at the 1972; 0.9 dental consultations per year and per person national level. in 1980 as against 0.4 in 1972; 16 hospital admissions Laboratory services (1968- ): to strengthen the per 100 inhabitants in 1980 as against 13 in 1972. National Instituteof Hygiene, Epidemiology and Epidemiological surveillance activities are to be Microbiology. intensified in order to achieve a reduction in the inci- Modernization of laboratory services(1971- ) dence and mortality of the major communicable dis- UNDP: to expand the facilities of the new Finlay eases.The National Institute of Hygiene, Epidemio- Institute for the production of biologicals for the pre- logy and Microbiology sets standards and acts as a vention, diagnosis and treatment of communicable 100 FIFTH REPORT ON THE WORLD HEALTH SITUATION diseases, improve the quality of such products, and Occupational health (1969- ) :to strengthen the train personnel. national programmes of industrial hygiene and safety and of air pollution control. Maternal and child care (1972- ): to develop a maternal and child care programme, with special Medical education (1965- ): to strengthen and emphasis on the control of communicable diseases, develop medical education. prenatal and postnatal care, and family planning. Sanitaryengineeringeducation(1966- ):to Nutrition(1965- )UNDP: toimplement a strengthen the teaching of sanitary engineering at the training programme for nutrition personnel and a University of Havana and improve the preparation of programme of nutrition education, and to study nutri- personnel engagedinthenational environmental tion problems. sanitation programmes.

DOMINICAN REPUBLIC

Population and other statistics The communicable diseases most frequently notified in 1972 were: influenza (83 630), amoebic and bacillary At the last census, taken in January 1970, the dysentery (7619), measles (5202), scarlet fever and population of the Dominican Republic was 4 006 405. streptococcalsorethroat(3660), whooping -cough Population estimates and some other vital statistics (3132),tuberculosis,allforms, new cases (1559), for the period under review are given in the following infectious hepatitis (1451), typhoid and paratyphoid table: fevers (1198), diphtheria (397), malaria, new cases 1969 1970 1971 1972 (261), schistosomiasis (207), leprosy (60), poliomye-

Mean population . . . 3 950 000 4 060 000 4190 000 4300 000 litis (5), yaws, new case (1). Number of live births . 155 057 163 045 161 803 Birth rate

(per 1000 population) . 39.3 40.2 38.6

Number of deaths . . . 27 065 24 925 25 245 Hospital services Death rate (per 1000 population) . 6.9 6.1 6.0 In 1972 the Dominican Republic had 306 hospitals

Natural increase ( %) . . 3.24 3.41 3.26 Number of infant deaths 9 594 8 171 7 912 providing a total of 11 975 beds, of which 9063 were in Infant mortality rate 108 government hospitals. The bed /population ratio (per 1000 live births) 61.9 50.1 48.9 was 2.8 per 1000. The 11 975 beds, to which 371 788 Number of deaths, 1 -4 years 4 611 3 262 3 518 patients were admitted during the year, were distrib- Death rate, 1 -4 years (per uted as follows: 1000 population at risk) 8.5 5.9 6.2 Number of maternal Category and number Number of beds deaths 176 167 168 Maternal mortality rate General hospitals 286 9117 (per 1000 live births) 1.1 1.0 1.0 Maternity hospitals 5 378 Paediatric hospitals 7 648 Tuberculosis hospitals 2 480

Of the 25 245 deaths recorded in 1971, the main Psychiatric hospital 1 700 causes were:symptoms and ill- defined conditions Ophthalmological clinics 2 20 (9455), congenital anomalies, birth injury, difficult Cancer hospital 1 150 Leprosarium 1 132 labour and other anoxic and hypoxic conditions, Geriatric hospital 1 350 other causes of perinatal mortality (2792), bacillary dysentery and amoebiasis, enteritis and other diarrhoeal Outpatient facilities were available in 1971 at 77 diseases(2130),chronic rheumatic heartdisease, hospitaloutpatientdepartments,whichrecorded hypertensive disease, ischaemic heart disease and other 798 657 attendances;at13health centres, which forms of heart disease (1416), malignant neoplasms recorded 132 605 attendances; at 100 dispensaries, (902), pneumonia (771), accidents (768, including 369 which recorded 58 092 attendances; and at 35 rural in motor -vehicle accidents), cerebrovascular disease clinics, which recorded 11 021 attendances. (633), avitaminoses and other nutritional deficiency (539),bronchitis,emphysema and asthma(486), Medical and allied personnel and training facilities tetanus (444), cirrhosis of the liver (373), tuberculosis, all forms (238), meningitis (227), anaemias (217). In 1971 the Dominican Republic had 2050 doctors, of whom 831 were in part -time government service. The doctor /population ratio was one per 2040. Other 1 International Classification of Diseases, 1965 Revision. health personnel included: REGION OF THE AMERICAS 101

Dentists 570 Environmental sanitation Pharmacists 208 Veterinarians 57 Nurses 188* In 1972, of the 8744 communities in the Dominican Assistant nurses 792* Republic, 120 urban and 472 rural communities had a Nursing auxiliaries 068* piped water system serving 56.0 % of the urban Sanitary engineers 5* Sanitary inspectors 272* population and 7.2 % of the rural population. Of the Laboratory technicians 277* 150 urban communities, 29 communities (with 4.2 X -ray technicians 46* of the total urban population), and 7904 out of Health educators 27* Nutritionist 1* 8594 rural communities (83.8 % of the total rural Nutrition assistants 14* population) had no water supply facilities.In 1971, 16.9 % of the urban population was living in houses "In part -time government service. connected to sewers. The Dominican Republic has one private and one public medical school.In addition,the medical school of the Universidad Central del Este started Assistance from PAHO /WHO teaching activities in 1971. There are also two dental In 1972 PAHO /WHO's assistance to the Dominican schools, two pharmacy schools and two veterinary Republic included the following projects: schools. Other arrangements for the training of health personnel in 1972 were as follows: Malaria eradication programme (1952- ) UNICEF. Category DurationNumber of Number of Number of of study schools studentsgraduates Tuberculosis control (1963- ) UNPD: to extend 1971/72 1972 the national tuberculosis control programme and Nurses 3 years 1 47 18 integrate it into the general health services; and to Auxiliary nurses . . . . 9 months 2 89 78

Laboratory technicians . 6 weeks 1 46 46 train personnel.

Sanitary inspectors . . 6 weeks 1 50 50 Engineering and environmental sciences (1971- ) Dental auxiliaries. . . 4 weeks 1 20 18 Organization of American States: to implement a programme for the installation of latrines. Immunization services Watersupplies(1962- ):toprovidewater supply facilities to 62 % of the urban and 25 % of the The following immunization procedures were carried rural population and sewerage facilities to 17 % of the out in 1972: urban population; to integrate into the National Tetanus 229262 Institute of Water Supply and Sewage Disposal 45 BCG 193294 of the systems operated by the municipalities. Poliomyelitis 169481 Diphtheria 118372 Healthservices(1953- ) UNDP Grantsto Whooping -cough 102440 PAHO: Organization of American States UNICEF: Smallpox 1214 to develop the health services and improve their organization and functioning. Specialized units Laboratory services (1968- 1971): to organize public health and clinical diagnostic laboratory services in In 1972 maternal and child health care was based hospitals and regional laboratories, to establish and on 84 prenatal and child health centres which were standardize procedures, and to train personnel. attended by 77 327 pregnant women, 90 803 infants Nutrition (1965- ): to implement a national food and 195 352 children aged 1 -5 years. Domiciliary care and nutrition policy, train health service and hospital was given to 4150 pregnant women and to 25 870 personnel in nutrition, and develop nutrition education infants.In all, 78 830 deliveries were conducted in and food supplement programmes hospital in 1972. School health services were provided in 14 school health units which were attended by Health and population dynamics: meeting,Santo 95 271 schoolchildren, or 35 % of the total school Domingo (1972). The services of a medical officer and population.Dental care was provided at 29 school financial support were provided for a meeting to dentalclinics,where83 190schoolchildren were discuss sources of support for the strengthening and treated, and at 32 dental clinics for adults, where expansion of the national maternal and child health 13 115 patients were treated.There were also five and family planning programme. psychiatric outpatient clinics. The public health Medical education (1968- ) : to strengthen medical laboratory carried out over 811 800 examinations in education, with emphasis on the teaching of preventive 1972. medicine. 102 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Nursing education (1958 -1972): Grants to PAHO: subjects in the regular civil engineering courses and Organization of American States: to strengthen the organize courses for the continuing education of National School of Nursing. sanitary engineering personnel. Sanitary engineering education (1969- ): to revise Dental education (1965- ): to develop, in the and improve the teaching of sanitary engineering country's two dental schools, new plans of study.

EL SALVADOR

Population and other statistics Organization of the public health services At the last census, taken in June 1971, the population The Ministry of Public Health and Social Welfare of El Salvador was 3 549 260.Population estimates is responsible for the organization, administration, and some other vital statistics for the period under planning and evaluation of all health services in the review are given below: country. The Directorate -General of Health is in charge of the organization and execution of the whole 1969 1970 1971 1972 programme of disease prevention and health promo- . . . 3549 260 3760 437 Mean population . 3390 171 3533 628 tion. The Directorate -General of Social Welfare is in Number of live births . . 142 699 141 471 154 309 153 006 Birth rate charge of the programme for crèches, orphanages and 43.5 40.7 (per 1000 population) . 42.1 40.0 old people's homes. Number of deaths . . . 33 655 35 094 28 752 32 202 Death rate Other government bodies providing curative health (per 1000 population). 9.9 9.9 8.1 8.6 services include the Institute for Social Security, the Natural increase (%) . . 3.22 3.01 3.54 3.21 Number of infant deaths . 9 039 9 429 8 093 8 908 National Telecommunications Administration,the Infant mortality rate Institute for Rural Colonization, the prison medical (per 1000 live births) . 63.3 66.6 52.4 58.2 service, the Institute for the Rehabilitation of the Dis- Number of deaths, 1 -4 years 6131 5 921 4 082 abled and the El Salvador Red Cross. Death rate, 1 -4 years (per For health administration purposes the country is 1000 population at risk) 13.1 12.1 8.7 Number of maternal divided into five health regions, each of which is deaths 128 143 162 181 administered by a regional director of health. Maternal mortality rate (per 1000 live births) . 0.9 1.0 1.0 1.1 Hospital services Of the 28 752 deaths recorded in 1971, the main In 1971 El Salvador had 86 hospitals with 7183 causes were :1 symptoms and ill- defined conditions beds, of which 6573 were in 85 government establish- (10 063), bacillary dysentery and amoebiasis, enteritis ments.The bed /population ratio was 2.0 per 1000. and other diarrhoeal diseases (4349), accidents (1228, The 7183 beds, to which 220 490 patients were admitted including 443 in motor -vehicle accidents), bronchitis, during the year, were distributed as follows : emphysema and asthma (1191), birth injury, difficult labour and other anoxic and hypoxic conditions, Category and number Number of beds General hospitals 10 3 511 other causes of perinatal mortality (969), pneumonia Rural hospitals 28 482 (838), chronic rheumatic heart disease, hypertensive Medical centres 36 806 Maternity hospitals 3 307 disease, ischaemic heart disease, other forms of heart Paediatric hospital 1 337 disease (720), malignant neoplasms (692), cerebro- Tuberculosis hospitals 4 905 Psychiatric hospitals 2 728 vasculardiseases(565),avitaminosesandother Cancer hospitals 2 107 nutritional deficiency (495), anaemias (477), influenza Outpatient facilities were provided in 1972 by the (384), measles (350), tetanus (302). Ministry of Health at 19 hospital outpatient depart- The communicable diseases most frequently notified ments, which recorded nearly 700 000 attendances; in 1972 were: influenza (82 104), malaria, new cases nine health centres, which recorded 138 173 atten- (38 335), measles (9917), syphilis, new cases (9729), dances; 65 health unitsand dispensaries, which gonorrhoea (8174), amoebiasis (4422), infectious hepa- corded 686 124 attendances; 95 medical aid posts and titis (3990), tuberculosis of the respiratory system, new vaccination centres; and one mobile health unit. cases (3889), whooping -cough (2996), scarlet fever Additional outpatient services are provided by the and streptococcal sore throat (1584), typhoid fever Social Security Institute. (804), trypanosomiasis (180), diphtheria (176), poliomyelitis (71), paratyphoid fever (35), rabies in man Medical and allied personnel and training facilities (11), leprosy (3). In 1972 El Salvador had 952 doctors, or one doctor 1 International Classification of Diseases, 1965 Revision. for 3950 inhabitants. Other health personnel included: REGION OF THE AMERICAS 103

Dentists 372 government bodies concerned with the preparation Pharmacists 578 Veterinarians 30 and execution of the health plan are :the National Traditional midwives about 900 Nurses 974 Economic and Social Planning and Coordinating Assistant nurses 2 379 Council,theNationalHealthCommission,the Nursing auxiliaries 285 Sanitary engineers 11 Ministry of Public Health and Social Welfare and the Sanitarians 163 Social Security Institute. Laboratory technicians 179 X -ray technicians 64 The health sector of the national development plan Nutritionists, dietitians 12 includes (a) a health policy statement which emphasizes Health educators 13 Hospital administrators 22 the position of health within the overall development, The arrangements for the training of medical and the integration and coordination of all health compo- allied personnel were as follows: nents, the priority to be given to the rural areas, the extension of health services to cover 70 % of the total Category DurationNumber of Number of Number of and admission of study schools studentsgraduates population, and the participation of the population; requirements (years) (public) 1971/72 1972 (b) an investment programme which defines priority Doctors projects of the Ministry of Public Health and Social secondary education 1 Dentists Welfare (the construction of 55 health posts, 37 health secondary education 1 Pharmacists units, 11 health centres and one regional hospital) secondary education 1 and of the Social Security Institute (the construction Nurses secondary education 3 2 262 120 of five peripheral outpatient clinics in San Salvador, Assistant nurses four departmental outpatient clinics and 13 outpatient 3 years secondary education 1 2 221 221 clinics in various towns of the country); (c) the national Health inspectors . . . 9% months 1 57 57 health plan for the period 1973 -1977.This plan envisages the following priority programmes : Immunization services The following immunization procedures were car- - environmental sanitation programme, particularly ried out in 1972: for the building of latrines and the provision of water supply in rural areas, and refuse collection Diphtheria, whooping -cough and tetanus 471614 BCG 325523 in urban areas. It is proposed to increase the pro- Smallpox 291886 portion of the population with latrines from 16 Poliomyelitis 105861 Measles 10728 in 1972 to 81 % in 1977; to increase the 23 Typhoid and paratyphoid fevers 7317 coverage by rural water supply systems in 1972 to Specialized units 49 % in 1977; and to achieve a 90 % coverage of refuse collection systems in urban areas of more In 1972 medical and health care services were than 20 000 inhabitants. provided to 43 811 pregnant women, 100 833 infants and 210 227 children aged 1 -4 years.Domiciliary - nutrition programme inordertoreduce the visits were paid to 550 pregnant women, 11 908 infants prevalence of malnutrition in the age group under and 15 700 children aged 1 -4 years. Of all deliveries five years from 25 % to 15 %, thus achieving a 40 in 1972, 42 713, or 26 %, were conducted in hospital. reduction.This programme will be part of the Dental treatment was given to 144 782 adults and to maternal and child health care programme. The 52 471 schoolchildren.El Salvador had two hospital programme also proposes the iodization of all rehabilitation outpatient departments and six inde- salt supplies. pendent rehabilitation centres.The psychiatric out- - health protection in order to reduce morbidity patient clinic recorded 21 201 new outpatients in 1972. and mortality among the population through a In 1971 the tuberculosis centre had 29 343 outpatients. vaccination programme which will cover 80 % of The 44 public health laboratories carried out nearly the population at risk. Special emphasis is given to 2 million examinations in 1972. the control of tuberculosis through immunization activities, health education and specific treatment Environmental sanitation of cases and contacts; and to malaria control In 1972, of El Salvador's 261 communities, 124 had activities in order to reduce the incidence of the piped water systems, which served 87 % of their disease to a level where it does not present a serious inhabitants.Sixty -two communities had a sewerage public health problem and to create the necessary system, which served 78.1 % of their inhabitants. conditions for an eradication programme. - a comprehensive medical care programme (pre- National health planning ventive, curative, rehabilitative and social) for the The national health plan is part of the 1973 -1977 population of urban and rural areas, concentrating plan for economic and social development. The on mothers and children.It is hoped to increase 104 FIFTH REPORT ON THE WORLD HEALTH SITUATION

during the five -year period the coverage from the the identification of nursing needs and for improving present 24 % to 50 % of the population concerned, the distribution and utilization of nursing personnel. particularly of infants and of children inthe Laboratory services (1970- ):to develop and age -group 1 -5 years; to increase the percentage of strengthen the national health laboratory services and institutional deliveries to 45 % of all deliveries; to train personnel. increase the percentage of pregnant women recei- Medical care services (1970- ): to improve the ving prenatal care from 28 % to 50 %. The pro- organization and administration of the medical care gramme proposes to increase medical attention services with a view to extending coverage by 10 %, through outpatientactivities, which are given integrate curative and preventive medical care services priority over the hospital services.It is hoped to into a regional system, and train staff. increase the consultations per inhabitant from Medical education (1965- ): to strengthen under- 0.38 in 1972 to 1.2 in 1977, to increase the coverage provided from 30 % to 70 % and to expand the graduate, postgraduate and continuing medical educ- fluoridation of water for the prevention of dental ation. caries. Hospital admission rateswill increase Sanitaryengineeringeducation(1965- ):to from 5.8 to 7.5 per 100 inhabitants, representing a strengthen the teaching of sanitary engineering at the 30 % increase. The hospital bed utilization will be University of El Salvador and improve the preparation increased by 17 %. of professionnal and auxiliary personnel engaged in environmental sanitation programmes. Assistance from PAHO /WHO Government health expenditure In 1972 PAHO /WHO's assistance to El Salvador included the following projects: In 1971 total government expenditure amounted to Malaria eradication programme (1955- ) 336.3 million colones, of which 39.2 million were UNICEF spent on health services.Current health expenditure Engineering and environmental sciences (1971- ) amounted to 37 million colones and capital health UNDP: to plan and develop national environmental expenditure to 2.2 million colones.The per capita sanitation programmes. government healthexpenditure was 11colones. Current Water supplies (1961- ): to plan and develop included the following items: 9.1 million colones for national programmes of water supply and sewerage administrative and government personnel; 214 591 systems for urban and rural areas. for immunization and vaccination activity; 230 000 Air pollution (1970- ): to determine the extent for laboratory services; 827 500 for environmental of air pollution in San Salvador through the establish- health services; 436 258 for education and training of ment of a sampling station as part of the Pan American health personnel.The government expenditure on Air Pollution Sampling Network. hospitals amounted to20.7million colones and Health services (1963- ): to carry out integrated included 12.8 million for general hospitals and clinics, health programmes as part of a national health plan. and 7.9 million for teaching hospitals.The govern- Nursing services (1972- ) UNDP: to improve ment contributionstohealthactivitiesofsocial the training of nurses and nursing auxiliaries and security schemes and other nongovernmental social increase training facilities, to carry out studies for welfare systems amounted to 214 591 colones.

GRENADA Population and other statistics 1969 1970 1971 1972 Natural increase ( %) . 1.91 2.12 2.15 2.19 At the last census, taken in April 1970, the popula- Number of infant deaths 110 90 75 47 Infant mortality rate tion of Grenada was 95136. Population estimates (per 1000 live births) . 39.90 32.83 26.05 15.99 and some other vital statistics for the period under Number of deaths, 1 -4 years 36 58 37 19 review are given in the following table:

1969 1970 1971 1972 Among the main causes of death recorded in 1971 were: 1 chronic rheumatic heart disease, hypertensive Mean population . . 104 376* 94 401 98 743 103 991 2 879 2 939 Number of live births . . 2 757 2 741 disease, ischaemic heart disease, other forms of heart Birth rate (per 1000 population) . 26.41 29.04 28.94 28.26 disease (111), cerebrovascular disease (102), malignant

. 743 739 660 Number of deaths . . 768 neoplasms (82), pneumonia (45), bacillary dysentery Death rate (per 1000 population) . 7.36 7.87 7.43 6.35

* United Nations estimate before the 1970 census. 1International Classification of Diseases, 1965 Revision. REGION OFTHE AMERICAS 105 and amoebiasis, enteritis and other diarrhoeal diseases Dentists 5 Pharmacists 29

(37),congenitalanomalies,birthinjury,difficult Veterinarian 1 Midwives 121 labour and other anoxic and hypoxic conditions, Nurses 130 other causes of perinatal mortality (31),diabetes Assistant nurses 22 Nursing attendants 96 mellitus (27), symptoms and ill- defined conditions (23), Sanitary engineers 2 accidents (21), bronchitis, emphysema and asthma (18), Sanitary inspectors 13 Physiotherapist 1 cirrhosis of the liver (10). Laboratory technicians 8 The communicable diseases most frequently notified X -ray technicians 2 Health educator 1 in 1971 were: influenza (1893), gonorrhoea (1569), Nutritionist 1 measles (469), syphilis, new cases (205), whooping - cough (174), bacillary dysentery (169), typhoid and The nursing school organizes a three -year nursing course and a one -year auxiliary nursing course. The paratyphoid fevers(82),infectioushepatitis(42), amoebic dysentery (30), leprosy (30), tuberculosis, all midwifery school provides a one -year course. During forms, new cases (11). the 1971 /72 school year, 150 nurses, 25 auxiliary nurses and 17 midwives were enrolled at these schools and 12 nurses and 14 auxiliary nurses graduated. Organization of the public health services The medical and public health services of Grenada Specialized units are under the supervision of the Minister for Health, In 1972 maternal and child health care was based on Housing and Labour, who is a member of the Cabinet, 36 centres, which were attended by 839 pregnant to which he is responsible for all health activities. women and 1734 infants and children up to 5 years Within the Ministry a policy advisory committee has of age.All deliveries were attended by a qualified been established, of which the Minister is chairman. midwife or a doctor. Dental treatment was provided The Parliamentary Secretary is politically responsible at seven dental clinics. There were also six psychiatric for the health section of the Ministry, the Permanent outpatient clinics and six clinics for the treatment of Secretary is the chief executive officer of the Ministry, venereal diseases, yaws and leprosy, which recorded and the Chief Medical Officer is the senior professional 9760 new patients in 1972. officer, is responsible for all technical services and advises theMinister. Under the Chief Medical Environmental sanitation Officer are the following: the chief technical officer (public health), the medical officer of health, the The Government is engaged in an extensive pro- health education officer and the chief nursing officer. gramme for the improvement of water supplies.

Hospital services National health planning In 1971 Grenada had seven establishments for Grenada does not have a formal development plan inpatient care, providing a total of 650 beds, which is in operation.Planning is carried out at the sectoral equivalent to 6.6 beds per 1000 population.These level on a short -term basis and mainly geared to 650 beds were distributed as follows: deriving the optimum benefits within the limits of the scant resources available. A draft national health plan Category and number Number of beds has been prepared which proposes implementation General hospital 1 224 over a 10 -year period commencing in 1973. Among District hospitals 2 80 Tuberculosis sanatorium 1 40 the objectives of this health plan are the improvement Mental hospital 1 180 of hospital services, strengthening of hospital adminis- Chronic diseases hospital 1 124 Clinic 1 2 tration, maintenance of health care facilities and developmentof peripheralhealthcarefacilities, Outpatient care was given in 1972 at the hospital standardization of immunization programmes, and outpatient departments; at five health centres of which development of a health education programme. one also had a maternity delivery unit; at 23 medical stations; and at 28 dispensaries located in health Assistance from PAHO /WHO centres and medical stations. In1972 PAHO /WHO's assistanceto Grenada Medical and allied personnel and training facilities included the following projects: In 1971 Grenada had 21 doctors, of whom 14 were Aedes aegypti eradication (1969- ) in government service.The doctor /population ratio Health services (1969- ): to strengthen the health was one to 4760.Other health personnel included: services and train staff. 106 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Government health expenditure about $800 000 on hospitals and approximately Total government health expenditure for1972 $150 000 on contributions to health activities of social amounted to 4 235 673 East Caribbean dollars, of security schemes and other nongovernmental social which EC $473 000 werespentoncapitaland welfare systems. Almost EC $1 million were allocated $3 762 673 on current account.More than EC $2 to environmental health -half of it to investments. million were spent on general public health services; The per capita expenditure on health was EC $42.

GUATEMALA

Population and other statistics Organization of the public health services At the last census, taken in April 1964, the popu- The Ministry of Public Health and Social Welfare lationof Guatemala was 4 287 997. Population is responsible for all public health and social assistance estimates and some other vital statistics for the period services in the country.The Minister is advised by under review are given in the following table: the National Health Council and the epidemiology, planning andstatisticsoffice. The Directorate - 1969 1970 1971* 1972

Mean population . . . 5 010 000 5280000 5 440 000 5 600 000 General of Public Health is organized in the following Number of live births . . 215 397 212 151 222 848 ... divisions: education and training, communicable and Birth rate (per 1000 population) . 43.0 40.2 41.0 noncommunicable diseases and accidents, maternal Number of deaths . . . 85174 77 333 75 583 and child health and family health, environmental Death rate (per 1000 population) . 17.0 14.6 13.9 health, tuberculosis, medical care and nursing, labo- Natural increase ( %) . 2.60 2.56 2.71 Number of infant deaths 19 659 18 483 18 510 ratories.The division of malaria comes under the Infant mortality rate direct responsibility of the Minister of Public Health (per 1000livebirths) 91.3 87.1 83.1 Number of deaths, and Social Welfare. 1 -4 years 21238 17116 The country is divided into eight health regions Death rate, 1 -4 years (per 1000 population at risk) 30.3 22.0 which are headed by a regional chief responsible for Number of maternal the direction and implementation of regional health deaths 441 329 Maternal mortality rate programmes. Each health region comprises three or (per 1000 live births) . . 2.0 1.6 more departments.In each department thei e are a " Provisional data. varying number of health centres, which are in charge Of the 77 333 deaths recorded in 1970, the main of the health posts located in their area. causes were : 1bacillary dysentery and amoebiasis, In addition to the health services provided by the enteritisandotherdiarrhoealdiseases(18 392), Ministry of Public Health and Social Welfare, the symptoms and ill- defined conditions (12 908), influenza Guatemala Institute of Social Security operates its (7065), pneumonia (5609), malaria (3209), congenital own medical care services which cover the whole anomalies, birth injury,difficult labour and other country with regard to accident and maternity cases, anoxic and hypoxic conditions, other causes of peri- whereas services for the treatment of common diseases natal mortality (2723), measles (2350), meningitis only operate in the capital city.It is estimated that (2160), whooping -cough(2126),anaemias (1965), 10 % of the country's population attend the health bronchitis, emphysema and asthma (1957), accidents establishments of the Institute of Social Security. (1793,including 433 in motor -vehicleaccidents), Hospital services chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease, other forms of heart disease In 1970 Guatemala had altogether 12 304 hospital (1623),tuberculosis,allforms(1297),malignant beds, to which 229 942 inpatients were admitted during neoplasms (1247). the year. The bed /population ratio was 2.4 per 1000. The communicable diseases most frequently notified Ambulatory care was available in 1972 at two in 1972 were: influenza (17 995), malaria, new cases hospitaloutpatientdepartmentswhichrecorded (9307), tuberculosis, all forms, new cases (5085), amoe- 168 333 patients, 78 health centres, of which six pro- bic dysentery (4563), gonorrhoea (3820), whooping - vided hospitalization facilities for maternity cases, cough (2210), syphilis, new cases (1494), measles (1474), three dispensaries, 325 medical posts and 19 mobile typhoid fever (794), bacillary dysentery (496), infec- health units. tious hepatitis (471), poliomyelitis (135), scarlet fever Medical and health personnel and training facilities andstreptococcalsorethroat(41),paratyphoid In 1970 Guatemala had 1435 doctors, or one fevers (22). doctor per 3620 inhabitants.Other health personnel 1 International Classification of Diseases, 1965 Revision. included: REGION OF THE AMERICAS 107

Dentists 292 Pharmacists 195 two psychiatric outpatient clinics, which recorded Veterinarians 126 1926 new patients.In 1972, 42 public health labo- Nurses 749 Auxiliary nurses 3 497 ratories carried out nearly 200 000 examinations. Sanitary engineers 43 Sanitarians 152 Laboratory technicians 142 Environmental sanitation X -ray technicians 43 Nutritionists 41 In 1972, of the total population of Guatemala, Health educators 9 833 800 (14.8 %) had a piped water supply in their Doctors, dentists, pharmacists and veterinarians dwellings and1 315 100 (23.4 %) had water from are trained at the San Carlos University of Guatemala, public fountains; 773 600 (13.8 %) were living in which is an autonomous institution, although it is houses connected to sewers. owned by the State and receives 90 % of its finances from government sources. Major public health problems The arrangements for the training of medical and The most important public health problems in health personnel in Guatemala are as follows: Guatemala are those caused by the incidence of com- Category DurationNumber of Number of Number of municable diseases and by malnutrition, particularly and admission of study schools studentsgraduates requirements (years) (public) 1971/72 1972 among the child population. A joint action has been Doctors undertaken by the Ministries of Public Health and bachillerato 1 6 1 1 216 77 Dentists Social Welfare, Education, Economy and Agriculture, bachillerato 6 1 464 35 with a view to improving educational and nutritional Pharmacists bachillerato 6 1 303 17 conditions. A programme has been initiated to fortify Veterinarians sugar with vitamins. bachillerato 6 1 282 13 Sanitary engineers bachillerato 2 1 7 7 Nurses Assistance from PAHO /WHO bachillerato 3 2 189 47 Medical assistants In 1972 PAHO /WHO's assistance to Guatemala bachillerato 3 1 73 - included the following projects: Laboratory technicians bachillerato 1 1 14 12 Physiotherapists Malaria eradication programme (1955- ) bachillerato 3 1 78 5 UNICEF Sanitary inspectors bachillerato 1 17 12 Measles control (1972- ) : to carry out a campaign Social workers bachillerato 3 2* 227 16 for vaccinating children against measles. 1 Certificate of six years of secondary education. Engineering and environmental sciences (1969- ): * One of these schools was private. to develop water supply and environmental sanitation programmes in urban and rural areas and to train Immunization services personnel. The following immunization procedures were carried Air pollution (1971- ): to install two air -sampling out in 1972: stations in Guatemala City to provide the information

Typhoid and paratyphoid fevers 259504 necessary for planning air pollution control measures. Measles 255441 Health services (1954- ) UNICEF: to improve Diphtheria, whooping -cough and tetanus . 189412 Smallpox 134416 the organization of the health services and develop Poliomyelitis 54324 them in accordance with the national health plan. Specialized units Nursing services (1968- ) Pan American Health and Education Foundation (Kellogg Foundation): to In 1972 maternal and child health care was provided improve nursing services and administration. at 78 prenatal centres and 393 child health centres. During the year, 45 639 pregnant women and 52 279 Laboratory services (1964- ) UNDP: to reor- children up to 5 years of age attended these centres. ganize the health laboratories, train staff, and improve Domiciliary care was given to 59 931 infants. In 1970, facilities for the production of biologicals. 53 018 deliveries were attended by a doctor or qualified Health statistics (1972- ):to reorganize and midwife. In 1971, 7463 schoolchildren had access to develop the health statistics unit in the Ministry of the school health service. Dental treatment was given Public Health and Social Welfare; to revise statistical at 20 dental health units to 23 361 schoolchildren and procedures; and to train statistical personnel. 30 908 adults.In 1971 the two independent medical Health and population dynamics (1972- ):to rehabilitation centres recorded 714 new patients and extend health care to 40 % of pregnant women and the two hospital rehabilitation departments 3283 new of children under 5 years of age and family guidance patients.Psychiatric treatment was given in 1972 at services to 20 °% of women of childbearing age. 108 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Cancer control (1972- ): to train personnel in Dental education (1969- ):to improve dental cytotechnology and to provide, in maternity clinics, education. diagnostic and follow -up services for uterine cancer. Government health expenditure Medical education (1966- ): to reorganize undergraduate and postgraduate medical education, and In 1972 total government budget expenditure on the education of allied health personnel; and to health amounted to 21.6 million quetzales or 8.6 % of improve the training of teaching staff. the total government expenditure.The per capita expenditure on health was thus 3.8 quetzales.The Sanitaryengineeringeducation(1967- ):to allocation of government health expenditure on current improve teaching and research, and organize a pro- account was as follows : 15 million quetzales on hospi- gramme of continuing education, at the Regional tals and 2 million on general public health services. School of Sanitary Engineering for Central America The government contributions to health activities of and Panama, University of San Carlos. social security schemes and other nongovernment Veterinary medical education (1962- ) : to improve socialwelfaresystems amounted to3.2million the teaching at the school of veterinary medicine of quetzales on current account and 1.3 million on capital the University of San Carlos. account.

GUYANA

Population and other statistics control of three medical officers of health, who are in At the last census, taken in April 1970, the popula- charge of all preventive health programmes.Each tion of Guyana was 714 000.Population estimates region is further divided into medical districts, with a and some other vital statistics for the period under district medical officer responsible for both curative review are given below: and preventive services in the district.In each town, the local government authority also provides preven- 1969 1970 1971 1972 tive health services through maternal and child health Mean population . . 693 000 714 000 735 000 757 000

Number of live births . . 23167 25497 18242 centres and health stations. Birth rate (per 1000 population) . 33.4 35.7 24.8 Number of deaths . . . 5073 4600 3820 Hospital services Death rate (per 1000 population) . 7.3 6.4 5.2 In 1971 Guyana had 43 hospitals and inpatient Natural increase (%) . . 2.61 2.93 1.96 Number of infant deaths . 933 establishments, providing altogether 3450 beds, of Infant mortality rate which 2830 were in 31 government institutions. The (per 1000 live births) . 40.3 bed /population ratio was 4.7 per 1000. The 3450 beds, Provisional data. to which 69 548 inpatients were admitted during the year, were distributed as follows : The communicable diseases most frequently notified in 1972 were: influenza (2119), typhoid fever (361), Category and number Number of beds General hospitals 14 1 916 malaria, new cases (266), tuberculosis, all forms, new Rural hospitals and aid posts 24 398 cases (97), measles (65), diphtheria (11). Tuberculosis hospital 1 246 Psychiatric hospital 1 450 Leprosarium 1 354 Organization of the public health services Convalescent home 1 46 Rehabilitation centre 1 40 The Ministry of Health is entrusted with the res- Outpatient facilities were provided in 1972 at two ponsibility for the health services of the whole country. hospital outpatient departments, 22 polyclinics provi- The Minister of Health is advised by the Central ding hospitalization facilities, 41 health centres, 21 Board of Health and other advisory bodies, such as dispensaries, and 10 medical aid posts which have the Pharmacy and Poisons Board, the General Nursing less than 10 beds and are visited periodically by a Council and the Medical Board. The Permanent Secre- doctor. tary has the overall administrative responsibility for the Ministry. The central administrative services are organized under the Principal Assistant Secretary. Medical and allied personnel and training facilities The technical departments are under the Chief Medical In 1971 Guyana had 171 doctors, of whom 101 Officer. were in government service.The doctor /population For purposes of health administration, the country ratio was thus one per 4300.Other health personnel isdivided into five regions, which are under the included: REGION OF THE AMERICAS 109

Dentists 20 Environmental sanitation Pharmacists 4 Veterinarians 10 Midwives 1 591 In 1972, 93 % of the urban population and 82 % of Nurse /midwives 81 the rural population were served with piped water Nurses 100 Assistant nurses 591 and 30 % of the urban population were living in houses Nursing auxiliaries 390 connected to sewers. Sanitary engineers 4 Sanitary inspectors 100 Physiotherapists 3 Laboratory technicians 50 Health educators 2 Assistance from PAHO/WHO Nutritionist 1 Nonmedical hospital administrators 13 In1972 PAHO /WHO's assistanceto Guyana The arrangements for the training of health person- included the following projects: nel in 1972 were as follows: Malaria eradication programme (1961- ). Category Duration Number of Number of and admission of study schools students Veterinary public health (1972- ): to develop a requirements (years) (public) 1971/72 Nurses coordinated zoonoses control programme, improve GCE, "O" level, 1 reporting and surveillance systems, and train personnel. 4 subjects 3 4* 240 Assistant nurses Engineering and environmental sciences (1969- ) : certificate of proficiency, or GCE, "O" level, to plan and implement programmes for improving 2 subjects 2 1 120 Midwives environmentalconditions,andto train personnel. certificate of proficiency, or GCE, "O" level, Development of potablewatersupply,sanitary 2 subjects 2 2 90 sewerage and storm drainage (1972- ) UNDP (UN) : Laboratory technicians GCE, "O" level, 5 to carry out a sector study on water supply and sewer- subjects 2 1 age; to improve the management and administration Physiotherapists GCE, "O" level, 5 of the Guyana water authority; and to train personnel. subjects 1 Radiographers Aedes aegypti eradication (1969- ) GCE, "O" level, 5

subjects 2 1 Public health inspectors Health services (1963- ) UNICEF: to formulate GCE, "O" level, 5 and implement a national health plan, improve the subjects 2 1 27 Medical assistants administrative structure of the Ministry of Health and GCE, "O" level, 5 train personnel. subjects 3 1 ... 1 General Certificate of Education, ordinary level : completion of first Nursing services (1965- ) UNDP: to develop the phase of secondary education. nursing services and improve nursing education and "Including two private schools. administration. Immunization services Dental health (1972- ):to establish a dental health unit, expand dental services, train auxiliary The following immunization procedures were car- dental staff and promote dental health by means of ried out in 1972: educational and preventive measures. Poliomyelitis 49168 Diphtheria, whooping -cough and tetanus . 42444 (doses) Health and population dynamics (1971- ):to Typhoid and paratyphoid fevers 31683 Tetanus 15864 develop a comprehensive maternal and child health BCG 7241 and family health programme. Smallpox 5763 Yellow fever 2337

Specialized units Government health expenditure In 1972 prenatal and child health services were In 1972 the central government health expenditure provided at 103 maternal and child health centres. amounted to 13 261 329 Guyana dollars, of which There were also 42 school health units. Dental $ 12 484 329 were spent on current account and treatment was given at seven dental health units to $ 777 000 on capital account. The government health 12 308 schoolchildren and 16 156adults. Other expenditure included the following items: Guyana specialized medical and health care establishments $ 221 644 for laboratory services, $ 50 000 for environ- includedoneindependentmedicalrehabilitation mental health services, $ 66 500 for education and centre, one hospital rehabilitation outpatient depart- training of health personnel, and $ 427 000 for general ment, two psychiatric clinics, one tuberculosis clinic, hospitals and clinics.The government contributions one venereal diseases clinic and one leprosy clinic. to the national insurance scheme amounted to Guyana There were also seven public health laboratories. $ 90 886. 110 FIFTH REPORT ON THE WORLD HEALTH SITUATION

HAITI

Population and other statistics Medical and allied personnel and training facilities At the last census, taken in September- October 1971, In 1972 Haiti had 412 doctors, or one doctor for the population of Haiti was 4 243 926.Population 12 310 inhabitants. Other health personnel included: estimates and some other vital statistics for the period Dentists 85 under review are given in the following table: Midwives 34 Nurses 407 1969 1970 1971 1972 Assistant nurses 126

Mean population . . . . 4768101 4867 000 4969113 5073 000 Nursing auxiliaries 960

Number of live births. . 177755 176192 137 621 Sanitary engineers 3 Birth rate Sanitary officers 41 (per 1000 population) 37.3 36.2 27.1 Sanitary inspectors 147

Number of deaths . . 80 772 74 955 69 109 Physiotherapists 3 Death rate Laboratory technicians 83 (per 1000 population) . 16.9 15.4 13.6 Assistant laboratory technicians 83 Natural increase ( %) . . 2.04 2.08 1.35 X -ray technicians 20 The communicable diseases most frequently noti- The arrangements for the training of medical and fied in 1972 were: influenza (24 993), malaria, new allied personnel were as follows : cases (4000), pulmonary tuberculosis, new cases (3038), Category DurationNumber of Number of Number of amoebiasis (2140), whooping -cough (1963), syphilis, and admission of study schools studentsgraduates new cases (1650), gonorrhoea (1595), measles (1046), requirements (years) (public) 1972 1972 typhoid and paratyphoid fevers (899), infectious hepa- Doctors Philosophy 1 6 1 540 77 titis (279), bacillary dysentery (155), trachoma (155), Dentists meningococcal infections (26), diphtheria (17), yaws, Philosophy 5 1 40 10 Pharmacists new cases (14), scarlet fever (9), poliomyelitis (5). Philosophy 3 1 37 9 Nurses Rhetoric2 3 3 137 60 Organization of the public health services Nursing auxiliaries fourth grade 8 months 1 ... 48 The organization of the public health services is governed by the new organic law of the Department 1 Completed secondary education at a level equivalent to the French baccalauréat. of Public Health and Population. The new adminis- 2Secondary education, preflnal level. trative and technical structures which have been established include the following divisions and services: Communicable disease control and immunization services general administration; family health; public welfare; public health, preventive and community medicine; Tuberculosis is highly prevalent in the country, medical research; special national programmes; con- with an estimated morbidity rate of 1.2 %, and a posi- trol of external assistance; central nursing bureau; tivity rate of about 34 % among children under 15 statisticalsection; planning and evaluation. The years of age.Preventive measures against this dis- domiciliary rural health service was integrated into ease include vaccination, case -finding and treatment the national malaria eradication service. on an ambulatory and inpatient basis. However, not The district health services are also being reorga- enough resources are available to give the programme a nized. Each district will be administered by a medical strong impact. Tetanus neonatorum is also highly pre- administrator who is directly responsible to the Direc- valent, particularly in rural areas. Control activities tor- General, and divided into subdistricts each com- are still very limited.Communicable parasitic dis- prising a health centre with inpatient facilities, a health eases are also highly prevalent in the whole country centre for ambulatory care, and satellite dispensaries. and are connected with poor sanitation and environmental, nutritional and educational conditions. Mala- ria remains an important health problem throughout Hospital services the country although following the malaria cam- In 1972 Haiti had 38 hospitals and inpatient estab- paign the incidence of the disease has been consi- lishments, providing a total of 3494 beds. The bed/ derably reduced.Smallpox has been absent from population ratio was 0.7 per 1000. Haiti for many years but vaccination is continued. A Outpatient medical care was provided in 1972 at poliomyelitis mass vaccination campaign was carried 11 hospital outpatient departments, 12 health centres, out in 1972, following a recrudescence of the disease and 142 dispensaries of which eight had some inpatient in the Caribbean area.The incidence of venereal facilities. diseases is estimated to be high. REGION OF THE AMERICAS 111

The following immunization procedures were car- Malaria eradication programme (1961- ) ried out in 1972: UNICEF

Poliomyelitis 308900 Yaws control (1950- ): to implement a yaws con- Smallpox 274608 trol campaign, combined with a smallpox vaccination BCG 75555 Tetanus 14148 campaign. Typhoid and paratyphoid fevers 3971 Measles 261 Engineering and environmental sciences (1971- ): to carry out a programme of latrine construction in Environmental sanitation Mirebalais and neighbouring localities. At the end of 1972, 16 % of the urban population of Water supplies (1960- ) :to extend the water Haiti had an adequate water supply. In the rural areas supply system of Port -au- Prince and of 12 towns in the provision of water is very precarious. the interior and construct small water supply systems in other areas. Major public health problems Health services (1957- ) Organization of Ameri- can States UNICEF :to develop integrated public The most important public health problems are the health services at the national and local levels, estab- heavy incidence of communicable diseases, particu- lish a demonstration area in Les Cayes, and train larly of parasitic diseases, and the prevalence of mal- personnel. nutrition. Publichealthservices(1972- )UNDP:to develop a system of public health services suitable for National health planning the whole country. A five -year development plan was prepared for the Laboratory services (1953- ) : to strengthen and years 1972 -1976 by the National Planning Commis- improve the national public health laboratory and the sion. The global and rectoral priorities of this plan hospital and field laboratories. include: road networks, agriculture, power, tourism, Nutrition (1961- ) Research Corporation, USA, education, with emphasis on professional and voca- UNICEF (FAO) (UNESCO): to improve the nutritional education, human and social development, tional status of the population through nutrition edu- including family planning, and industry. In the public cation, supplementary feeding programmes for vul- health area, the Government proposed a programme nerable groups, and other measures. based on preventive health measures, improved sani- tationfacilities,nutrition, and community health Healthandpopulation dynamics (1970- ) centres. UNFPA: to develop an integrated maternal and The Department of Public Health and Population child health and family planning programme. is collaborating with the National Planning Commis- Medical education (1968- ): to improve the phy- sion in the formulation of a national health plan which sical facilities, the educational programme, and the places emphasis on the regionalization of the health system of examinations, of the faculty of medicine. service structure and on the reduction of mortality and Nursing education (1968- ) : to improve the teach- morbidity through programmes in the field of nutrition ing given to the nursing schools and the training of and communicable disease control. nursing auxiliaries. Sanitaryengineeringeducation(1971- ):to Assistance from PAHO /WHO improve the teaching of sanitary engineering and the In 1972 PAHO /WHO's assistance to Haiti included laboratory and library facilities at the School of Science the following projects: of the University of Haiti.

MEXICO

Population and other statistics 1969 1970 1971 1972 Mean population . . . 47 273 81348925 898 50645 860 52436 995

Number of live births . . 2 037 561 2132630 2231 399 2346 002 At the last census, taken in January 1970, the popu- Birth rate lation of Mexico was 48 225 238. Population estimates (per 1000 population) . 43.1 43.6 44.1 44.7 Number of deaths . . . 458 886 485 656 458 323 476 206 and some other vital statistics for the period under Death rate (per 1000 population) . 9.7 9.9 9.0 9.1

review are given in the following table : Natural increase ( %) . . 3.34 3.37 3.51 3.56 112 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 had some hospitalizationfacilities;at 591 health Number of infant deaths . 139 366 146 008 141 261 142 964 Infant mortality rate centres, of which 416 had some inpatient accommoda- (per 1000 live births) . 68.4 68.5 63.3 60.9 tion; at six dispensaries; and at 299 medical aid posts. Number of deaths, 1 -4 years 63 394 70 563 59 047 Death rate, 1 -4 years (per Medical and allied personnel and training facilities 1000 population at risk) 9.8 10.6 8.6 Number of maternal deaths 3 204 3 050 3 266 In 1970 Mexico had 33 981 doctors, or one doctor Maternal mortality rate for 1440 inhabitants. Other health personnel included: (per 1000 live births) . 1.5 1.4 1.5 Dentists 5101 Of the 458 323 deaths recorded in 1971, the main Nurses 8 997 Assistant nurses 22211 causes were:1 bacillary dysentery and amoebiasis, enteritis and other diarrhoeal diseases (67 500), pneu- The arrangements for the training of medical and monia (63 104), symptoms and ill- defined conditions health personnel were as follows: (62 659), chronic rheumatic heart disease, hypertensive Category DurationNumber of Number of disease, ischaemic heart disease and other forms of of study schools 1graduates (years) 1971 heart disease (31 542), birth injury, difficult labour and Doctors 6 22(3) 2131 other anoxic and hypoxic conditions, other causes of Dentists 5 12 430 Pharmacists 6 128 perinatalmortality(25 429), malignant neoplasms Veterinarians 5 8 312

(18 389), cerebrovascular diseases (12 621), cirrhosis Dental hygienists . 1 month 1 18

Laboratory assistants 1 12 of the liver (10 764), accidents (10 619, including 4115 Nurses 3 65(26) 989 in motor -vehicle accidents), tuberculosis, all forms Assistant nurses . . 3 -12 months 51(1) Midwives 2 (9076), diabetes mellitus (7994), bronchitis, emphysema Sanitarians 1 1 26 and asthma (7334), measles (7107), influenza (7096). The communicable diseases most frequently notified 1 Public (private) schools. in 1972 were: influenza (65 429), measles (59 164), amoebiasis (47 791),malaria, new cases(28 384), Immunization services whooping -cough (21 902),tuberculosis,allforms, The following immunization procedures were car- new cases (18 135), gonorrhoea (14 323),syphilis, ried out in 1972: new cases (11 210), typhoid fever (7645), bacillary Poliomyelitis 7763349 dysentery (5781), infectious hepatitis (4401), scarlet Smallpox 3934918 fever and streptococcal sore throat (2690), paraty- Diphtheria, whooping -cough and tetanus . 1398566 Measles 1062169 phoid fevers (1354), leprosy (731), poliomyelitis (309), BCG 648560 diphtheria (127), rabies in man (66), murine typhus (27), trachoma (6), meningococcal infections (6). Specialized units In 1971 Mexico had 102 prenatal centres and 28 Hospital services child health units. Other specialized units included 89 In 1971 Mexico had 1521 hospitals and inpatient school health services, five independent medical reha- establishments, providing 62 566 beds, of which 53 654 bilitation centres, 19 hospital rehabilitation outpatient beds were in 1062 government establishments.The departments, 20 psychiatric outpatient clinics, one bed/ population ratio was thus 1.2 per 1000.The venereal diseases clinic, one leprosy clinic, and 115 62 566 beds were distributed as follows: public health laboratories. Category and number Number of beds Assistance from PAHO/WHO General hospitals 373 31 242 Rural hospitals 975 16 408 Maternity hospitals 102 2 794 In1972 PAHO /WHO's assistancetoMexico Paediatric hospitals 28 2 746 included the following projects : Tuberculosis hospitals 10 1 311 Chest diseases hospital 1 304 Psychiatric hospitals 20 5 507 Malaria eradication programme (1956- ) UNDP. Cancer hospital 1 186 Tuberculosis control (1960- Hospital for cardiology 1 148 ): to improve and Hospital for gastroenterology 1 178 extend the national tuberculosis control programme. Orthopaedic hospitals 3 560 Traumatology hospitals 4 732 Zoonosescontrol (1970- ) : to plan and imple- Chronic diseases hospital 1 410 Leprosy hospital 1 40 ment programmes for the control of zoonoses. Outpatient facilities were available in 1971 at 672 Environmental pollution control (1972-): to iden- hospital departments; at 673 polyclinics, of which 305 tify environmental pollution problems, organize control measures, and plan the development of the federal, 1 International Classification of Diseases, 1965 Revision. state and local agencies concerned. REGION OF THE AMERICAS 113

Water supplies (1960- ):to develop national Medical education (1958- ): to improve medical programmes for water supply and sewerage systems. education. Health services (1966- ): to improve the health Nursing education (1958- ):to improve basic services, especially in the rural areas; and to train the nursing education and provide advanced training in necessary health personnel. nursing education and administration and various nursing specialities. Immunology research and training centre (1968- ): Sanitaryengineeringeducation(1961- ):to to provide postgraduate training in immunology and develop sanitary engineering education and research carry out research on immunological problems of local at various universities. public health importance, particularly as they relate to infectious diseases. Veterinary medical education (1969- ): to develop the teaching of preventive medicine and public health Poliomyelitisvaccine production(1968- ):to in the schools of veterinary medicine. increase the production of live poliomyelitis vaccine at the National Institute of Virology to meet the needs Government health expenditure of the Latin American countries. In 1972 government health expenditure amounted Modernizationofnationalhealthlaboratories to 2 714 436 000 pesos, of which 1 996 723 000 were (1970- ) UNDP: to modernize the national health spent on current account and 717 713 000 on capital laboratories responsible for the production of vaccines account.The government health expenditure at the and sera, control of food and drugs, diagnosis of intermediate level amounted to 434238000 pesos and at infectious diseases, training of personnel and research the local level to 2 280 198 000 pesos. The per capita into public health problems. government health expenditure was 51.7 pesos.The Health and population dynamics (1972- ):to government expenditure on general public health ser- obtain, over an extended period, sociodemographic vices, which amounted to 580 747 000 pesos, included : data for determining patterns of population change, 51 484 000 for mass campaigns against communicable including information on mortality, morbidity, ferti- diseases; 158 138 000 for immunization and vaccina- lity, and migration. tionactivities;30 806 000 for laboratory services; 56 134 000 for environmentalhealth services; Seminarsonmaternity- centred familyplanning 70 686 000 for occupational health services; 1 471 000 (1972- ): to plan and carry out a national maternal foreducation and trainingof health personnel. and child health and family planning programme, The government expenditure on hospitals includ- using seminars to further its implementation. ed 613 015 000 pesos for general hospitals and clinics Rehabilitation (1972- ): to plan and implement a and 38 702 000 for other health establishments. The programme for training medical and allied personnel government contribution to health activities of social to staff physical, vocational and social rehabilitation security schemes and other nongovernment social services. welfare systems amounted to 205 198 000 pesos.

PANAMA

Population and other statistics 1969 1970 1971 1972 Death rate, 1 -4 years (per At the last census, taken in May 1970, the population 1000 population at risk) 9.0 7.6 7.2 Number of maternal of Panama was 1 428 082.Population estimates and deaths 72 72 63 56 some other vital statistics for the period under review Maternal mortality rate (per 1000 live births) . 1.4 1.4 1.1 1.1 are given in the following table:

1969 1970 1971 1972 Of the 9857 deaths recorded in 1971, the main causes

Mean population . . . 1391 840 1434 400 1478 300 1523 500 were :1 symptoms and ill- defined conditions (1777), Number of live births. . 52 799 53 287 54 948 54 179 chronic rheumatic heart disease, hypertensive disease, Birth rate

(per 1000 population) . 37.9 37.1 37.2 35.6 ischaemic heart disease, other forms of heart disease Number of deaths . . . 9 791 10 225 9 857 9 112 (1131), malignant neoplasms (672), pneumonia (610), Death rate (per 1000 population) . 7.0 7.1 6.7 6.0 congenital anomalies, birth injury, difficult labour and Natural increase (%) . . 3.09 3.00 3.05 2.96 Number of infant deaths . 2 109 2156 2 064 1 772 other anoxic and hypoxic conditions, other causes of Infant mortality rate perinatal mortality (598), bacillary dysentery and amoe- (per 1000 live births) 39.9 40.5 37.6 33.7 Number of deaths, biasis, enteritis and other diarrhoeal diseases (559), 1 -4 years 1 579 1 400 1 337

Provisional data. 1International Classification of Diseases, 1965 Revision. 114 FIFTH REPORT ON THE WORLD HEALTH SITUATION cerebrovascular diseases (556), accidents (538, includ- Category DurationNumber of Number of Number of and admission of study schools studentsgraduates ing 209 in motor -vehicle accidents), measles (294), requirements (years) (public) 1971/72 1972 bronchitis, emphysema and asthma (232), tuberculosis, Doctors all forms (231), anaemias (161), tetanus (150), diabetes bachillerato (premedical studies) . 5 1 44 mellitus (143), whooping -cough (132), avitaminoses Dentists and other nutritional deficiency (117). bachillerato (premedical sciences) 5 1 181 - The communicable diseases most frequently notified Pharmacists bachillerato (sciences) 5 1 in 1972 were: influenza (20 978), tuberculosis,all Nurses (university level) bachillerato (sciences) 4 1 39 forms, new cases (1834), whooping -cough (1597), Auxiliary nurses gonorrhoea (1558),measles(1319),malaria, new secondary education, first phase 6 months 3 243 156 cases (913), infectious hepatitis (764), scarlet fever and Laboratory technicians streptococcal sore throat (712), syphilis, new cases bachillerato (sciences) 1 1 8 8 Sanitary inspectors (696), amoebic dysentery (575), bacillary dysentery (65), bachillerato (sciences)5 months 1 25 17 paratyphoid fevers (31), typhoid fever (15), trypanosomiasis (13), diphtheria (10), poliomyelitis (2). 1 Certificate of six years of secondary education. Immunization services Hospital services The following immunization procedures were car- In 1971 Panama had 52 hospitals, providing a ried out in 1972: total of 4735 beds, of which 4300 were in 40 govern- Poliomyelitis 135907 ment- maintained establishments. The bed /population Diphtheria, whooping -cough and tetanus . 86370 Measles 61110 ratio was 3.2 per 1000.The 4735 beds, to which Smallpox 56995 123 261 patients were admitted during the year, were BCG 48527 Diphtheria and tetanus 29463 distributed as follows: Tetanus 28654 Yellow fever 7285 Category and number Number of beds General hospitals 22 2913 Specialized units Rural hospitals 12 428 Medical centres 16 143 In 1972, 15 prenatal and child health centres were Paediatric hospital 1 315 Psychiatric hospital 1 936 engaged in maternal and child health care. They were attended by 28 496 pregnant women, 8183 infants Outpatient services were available in 1972 at 22 and 5048 children aged 1 -5 years.In the same year, hospitaloutpatientdepartments,which recorded domiciliary care was given to 4143 pregnant women, 246 203 new patients; at 23 polyclinics of the Social and to 18 672 infants up to 4 years of age.In 1972, Security Fund; at 15 health centres providing hospi- 36 371 deliveries (69.2 % of all births) were attended talization facilities, which recorded 40 708 new out- by a doctor or qualified midwife.Dental care was patients; and at 48 other health centres, which had available at 76 dental health units, at which 41 765 306 505 new outpatients. adults and 51 596 schoolchildren were treated.Psy- chiatric consultations were given at five centres which Medical and allied personnel and training facilities recorded 2491 new patients in 1972. The tuberculosis outpatient clinic was attended by 1139 new patients. In 1971 Panama had 1006 doctors, of whom 924 The public health laboratory carried out 710 341 were in government service.The doctor /population examinations in 1972. ratio was thus one per 1470. Other health personnel included : Environmental sanitation Dentists 156 Pharmacists 269 In 1972, of Panama's total population, 1 052 216 Veterinarians 16 Nurse /midwives 172 inhabitants were living in communities with a piped Nurses 948 water system, 62.7 % of them having piped water to Assistant and auxiliary nurses 1 895 Sanitary engineers 24 their dwellings and 6.4 % having water from public Sanitary Inspectors 130 fountains.In the same year, 1 230 151 inhabitants Physiotherapists 3 Laboratory technicians 289 (80.7 % of the total population) were living in houses X -ray technicians 93 connected to sewers. Health educators 14 Nutritionists 16 Nonmedical hospital administrators 4 Assistance from PAHO /WHO The arrangements for the training of medical and In1972 PAHO /WHO's assistanceto Panama allied personnel in Panama in 1972 were as follows: included the following projects: REGION OF THE AMERICAS 115

Malaria eradication programme (1956 - Nursing education (1966- ):to improve basic UNDP /UNICEF. nursingeducation,establishpostbasic and post- Engineering and environmental sciences (1970- ): graduate courses and prepare nurses for teaching to strengthen the structure of the Department of posts. Sanitary Engineering of the Ministry of Public Health, Sanitaryengineeringeducation(1965- ):to to plan and develop environmental sanitation pro- improve the teaching of sanitary engineering at the grammes, and to train sanitation personnel. University of Panama and organize short intensive Water supplies(1960- )(USAID) (National courses. Institute of Aqueducts and Sewerage, Panama): to Dentaleducation (1966- ) (Universityof improve the operating capacity of the water supply Panama) :to improve the teaching at the school of agency and implement national programmes for the dentisty of the University of Panama, and to train construction of water supply and sewerage systems. auxiliary dental personnel. Aedes aegypti eradication (1969- ). Health services (1952- ): to improve and extend Government health expenditure the health services, train health personnel, and promote community participation. The general government health expenditure on current account during the fiscal year 1972 amounted Maternal and child health (1971- ): to extend the The Ministry of Health ac- medical care provided during pregnancy and child- to 25 436 951 balboas. counted for 5 753 025 balboas, other ministries for birth, encourage family planning, improve the health 9 742 254, the regional authorities for 1 991 520, and careof children, and expand the immunization the health area authorities for 7 950 152.Of the programme. 20 351 874 balboas devoted to general public health Medical care services (1968- ) : to expand medical services, 9 029 832 were spent on administration and care services, and to integrate health activities so as government personnel, 1 453 361 on malaria eradic- to achieve a better utilization of the physical resources ation, and 2 202 996 on environmental health services. available. Government expenditure on general hospitals and Medical education(1967- ):to improve the clinics was 7 950 152 balboas and that on psychiatric administration and technical level of the school of hospitals 1 875 366. Per capita expenditure on health of medicine of the University of Panama. services was 16.7 balboas.

PARAGUAY

Population and other statistics Among the main causes of death in 1971 were :2 symptoms and ill- defined conditions (2553), bacillary At the last census, taken in July 1972, the population of Paraguay was 2 328 790. 1 Population estimates dysentery and amoebiasis, enteritis and other diarrhoeal and other vital statistics for the period under review diseases(1471),chronic rheumatic heartdisease, are given in the following table: hypertensive disease, ischaemic heart disease, other forms of heart disease(1095), pneumonia (915), 1969 1970 1971 1972 malignant neoplasms (767),congenital anomalies, Mean population . . 2306 300 2386 000 2470 0002580000 Number of live births. . 83954 87952 79620 birth injury, difficult labour and other anoxic and Birth rate hypoxic conditions, other causes of perinatal mortal- (per 1000 population) . 36.4 36.8 32.2 Number of deaths . . . 12540 13327 14226 11'876 ity (534), cerebrovascular disease (471), avitaminoses Death rate (per 1000 population). 5.4 5.0 5.8 5.1 and other nutritional deficiency (340), measles (339), Natural increase (%) . 3.10 3.18 2.64 tuberculosis, all forms (312), bronchitis, emphysema Number of infant deaths 2760 2927 3072 2590 Infant mortality rate and asthma (271), tetanus(236), anaemias (189), (per 1000 live births) . 32.9 33.3 38.6 accidents (172, including 153 in motor -vehicle acci- Number of deaths, 1 -4 years 1 063 1 296 1 913 1 010 dents). Death rate, 1 -4 years (per 1000 population at risk) 3.0 3.6 5.0 3.2 The communicable diseases most frequently notified Number of maternal in1971were: influenza (18 289), measles (4230), deaths 137 175 127 133 Maternal mortality rate tuberculosis, all forms, new cases (2001), syphilis, new (per 1000 live births) 1.6 2.0 1.6 cases (1986), whooping -cough (1243), bacillary dysen- * United Nations estimate, including 35000 jungle Indians. tery (883), gonorrhoea (772), malaria, new cases (423), 1 Not including an estimated jungle Indian population of 35 000. 2 International Classification of Diseases, 1965 Revision. 116 FIFTH REPORT ON THE WORLD HEALTH SITUATION scarlet fever and streptococcal sore throat (342), Category and admission requirements Duration of study infectious hepatitis (297), leprosy (288), poliomyelitis Laboratory technicians (141), diphtheria (74), typhoid and paratyphoid fevers bachillerato 6 months Laboratory auxiliaries (58), meningococcal infections (52), trypanosomiasis secondary education 3 months (18). Auxiliary nurses primary education 9 months Hospital services Immunization services In 1971 Paraguay had 133 government hospitals providing a total of 3865 beds -equivalent to 1.6 beds The following immunization procedures were car- per 1000 population.These beds were distributed ried out in 1971: as follows: Smallpox 328761 BCG 125398 Category and number Number of beds Poliomyelitis 76743 General hospitals 98 2365 Tetanus 23800 Rural hospitals 4 85 Diphtheria 13774 Medical centres 21 178 Whooping -cough 13774 Maternity hospital 1 116 Typhoid and paratyphoid fevers 4964 Infectious diseases hospital 1 30 Tuberculosis hospitals 2 375 Psychiatric hospital 1 504 Cancer hospital 1 26 Specialized units Leprosaria 2 124 Traumatology hospital 1 46 During the period under review, maternal and child Convalescent home 1 16 health care and school health services were provided Outpatient facilities were available in 1972 at 30 at all government health centres and health posts. hospitaloutpatientdepartments,whichrecorded During 1972, 56 397 pregnant women, 42 724 infants 125 421 new patients; at 85 health centres which and 58 938 children aged 1 -5 years availed themselves provided inpatient care; and at 162 health posts, of these services. Domiciliary care was given to 1936 which recorded 69 674 new outpatients. infants. Of all deliveries in 1972, 55.4 % were attended by a doctor or qualified midwife. School health Medical and allied personnel and training facilities services were provided to59 031schoolchildren. Dental care was given to 24 295 adults and 17 197 In 1970 Paraguay had 1023 doctors, or one doctor schoolchildren at 15 health centres and four health for 2340 inhabitants. Other health personnel included: posts in the capital city, and at 52 health centres and four health posts in the interior of the country. Medical Dentists 186 Pharmacists 31 rehabilitation facilities were available in one hospital Veterinarian 1 rehabilitationoutpatientdepartment. Psychiatric Midwives 239 Nurses 260 consultations were given at four centres.Other out- Assistant nurses 776 patient facilities in specialized clinical fields included Auxiliary nurses 240

Sanitary engineer 1 two tuberculosis clinics and three leprosy clinics. The Sanitary inspectors 77 Laboratory technicians 68 public health laboratory carried out 145 000 exami- X -ray technicians 38 nations in 1972. Blood transfusion technicians 3 Anaesthesia technicians 3 Biochemists 4 Health educators 8 Environmental sanitation Nutritionists 14 Statisticians 10 In 1972, of the 167 communities in Paraguay, nine, In 1971/72 the arrangements for the trainingof with a population of 413 940, had a piped water supply medical and health personnel were as follows : system. This served 43.04 % of the inhabitants of these nine communities, of which a further 2.59 % had Category and admission requirements Duration of study access to water from public fountains.The capital (years) city has a sewerage system and in 1972, 31.69 % of its Doctors bachillerato 1 6 inhabitants were living in houses connected to sewers. Dentists bachillerato 5 Pharmacists bachillerato 4 National health planning Veterinarians bachillerato 5 The technical, economic and social planning secre- Sanitary inspectors

bachillerato 1 tariat of the Presidency of the Republic was established in 1962.It has overall responsibility for all planning 1 Certificate of six years of secondary education. activities in the country and collaborates with the REGION OF THE AMERICAS 117 planning units of the various ministries. A planning Nutrition (1960 -1966;1971- ):to implement unit was also set up in 1962 in the Ministry of Public programmes for improving the nutritional status of Health and Social Welfare.Other high -level bodies the population; and to train the necessary personnel. involved in the planning process are the Council for Mental health (1972- ): to determine the pre- Social Progress, established in 1967, and the National valence and incidence of mental illness, formulate a Council for Health Coordination, established in 1968. mental health policy, and set up the organization for Two five -year plans for the periods 1958 -1962 and its implementation. 1969 -1973 and two two -year plans for the period 1965- 1966 and 1967 -1968 have been formulated. Medical care services (1970- ): to develop the medical care services and improve their administration; and to train staff. Assistance from PAHO /WHO Health and population dynamics (1971- ):to 1972 PAHO /WHO's assistanceto Paraguay improve maternal and child care in rural clinics and In in the Clinical Hospital, Asunción; and to organize a included the following projects: residency programme in obstetrics, gynaecology and Communicable diseases (1965- ) UNICEF: to paediatrics in the faculty of medicine of the National implement a communicable disease control programme University. integrated into the general health services. Medical education (1964- ) : to strengthen medical Malaria eradication programme (1957 - education by promoting teaching programmes in UNICEF preventive and social medicine at the undergraduate and postgraduatelevelsand improving teaching Studyof thesocioeconomic impact of malaria methods. (1968- ): to show quantitatively the effect of malaria in reducing economic productivity in a predominantly Sanitaryengineeringeducation(1967- ):to agricultural area in process of development, and the strengthen the teaching of sanitary engineering at the economicbenefitstemming fromeradicationof faculty of engineering of the National University and malaria. organize courses in environmental sanitation subjects for professional, technical and auxiliary personnel. Smallpox eradication (1967- ):to carry out maintenance and surveillance operations in order to Veterinarymedicaleducation (1971- ): to keep the country free from smallpox. strengthen veterinary medical education. Veterinary public health (1971- ) : to carry out a Dental education (1966- ):to strengthen the coordinated programme of epidemiological investiga- teaching at the dental school of the National Univer- tions, pilot projects and control measures for reducing sity, Asunción and to develop field training pro- morbidity and mortality from the zoonoses. grammes for dental students.

Engineering and environmental sciences (1969 - ): to develop environmental sanitation programmes. Government health expenditure

Water supplies (1961- ): to plan and implement In1972totalgovernmenthealthexpenditure a national water supply and sewerage programme. amounted to1987.8million guaraníes,of which Health services (1955- ) UNDP UNICEF (ILO) 1697.9 million were charged to current account and (FAO) (UNESCO): to plan health services at the 289.9 million to capital account.The Ministry of national level and develop the health service infra- Public Health and Social Welfare accounted for 601.17 structure to permit coverage of 70 % of the population million guaraníes, health -related activities of other by 1974. ministries for 1336.7 million and the local health Health services in developing areas (1972- ): to authorities for 49.9 million.The per capita ratio of improve the health services, and particularly those for current health expenditure was 729 guaraníes and the mothers and children, in the rural areas. per capita ratio of capital health expenditure was 124 guaraníes.The breakdown of the government Health statistics (1971- ): to improve the cover- expenditure on general public health services was as age and quality of vital and health statistics and train follows: 51.59 million on administration and govern- statistical personnel. ment personnel, 148.36 million on campaigns against Administrative methods and practices in public health communicable diseases, 41.84 million on maternal (1971- ): to improve the structure, organization and child health and vaccination, and 19 million on and operation of the administrative services of the laboratory services.The breakdown of the govern- Ministry of Public Health and Social Welfare. ment expenditure on hospitals, which amounted to 118 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1680.8 million guaraníes, was as follows: 568.3 million government contributionstohealthactivitiesof on general hospitals and clinics,83.5 million on social security schemes and other nongovernment teaching hospitals, 27 million on specialized hospitals, social welfare systems amounted to 46.2 million and 1001.8 million on other health establishments. The guaraníes.

PERU

Population and other statistics Organization of the public health services At the last census, taken in June 1972, the population The health sector in Peru comprises two levels: the of Peru was 13 570 000.Population estimates and central policy- making organization and the peripheral some other vital statistics for the period under review executive organization. At the central level the are given below. Ministry of Health comprises the National Health

1969 1970 1971 1972 and Social Welfare Council, the General Inspectorate

Mean population . . . 13177 959 13586 30014015 00014456 000 and theHigher Directoratewith thefollowing Number of live births . . 471 878 479 518 493 590 directorates -general:administration,socialwelfare Birth rate (per 1000 population) . 35.8 35.3 35.2 programmes, health programmes, and special health Number of deaths . . . 103922 112042 87 335* 89 367 Death rate programmes. The public health school and the offices (per 1000 population). 7.9 8.2 6.2 6.3 of sectoralplanning,technicalhealthstandards, Natural increase (%) . . 2.79 2.72 2.90 Number of infant deaths . 31 590 31 212 26 469 organization and methods also come under the Infant mortality rate higher directorate.The intermediate and peripheral (per 1000 live births) . 66.9 65.1 53.6 Number of deaths, levels comprise the health regions and health zones 1 -4 years 16 245 22 781 11 736 and the hospital areas. Death rate, 1 -4 years (per 1000 population at risk) 9.2 12.5 6.3 An important role in the health field is also played Number of maternal by various public, semi -public and private organiza- deaths 1 075 1 030 964 Maternal mortality rate tions, such as the national institutes of health, the (per 1000 live births) . 2.28 2.15 1.95 institute for maternal and child care, the public welfare societies, the national health and social welfare fund, Provisional data. the Social Security, the health services of the armed forces and of the police, and the medical services of Of the 112 042 deaths recorded in 1970, the main other ministries. pneumonia (17 524), bacillary dysentery causes were: Programme coordination between the central author- and amoebiasis, enteritis and other diarrhoeal diseases ity and the peripheral establishments, and inter- (10 227), symptoms and ill- defined conditions (9665), departmental coordination in the field of health, are measles (8337), bronchitis, emphysema and asthma carried out by the sectoral health planning office and (5495 in 1972), influenza (5228), malignant neoplasms by a number of interministerial commissions. (5077), chronic rheumatic heart disease, hypertensive disease, ischaemic heartdisease,other forms of heart disease (4920), tuberculosis, all forms (4271), Hospital services birth injury, difficult labour and other anoxic and hypoxic conditions, other causes of perinatal mortality In 1970 Peru had 282 hospitals with a total of 34 491 (3271), avitaminoses and other nutritional deficiency beds, of which 18 560 were in 85 government hospitals, (2058), whooping -cough (2057). 11 150 in 67 hospitals run by various other organizations such as the Social Security and the armed forces The communicable diseases most frequently notified (the latter provided about 5500), and 4137 in 130 in 1972 were: influenza (36 471), tuberculosis, all forms, hospitals of the private sector. An additional 644 beds new cases (21 324), whooping -cough (10 210), malaria, were provided in 346 health centres, of which 277 were new cases (10 036), measles (8407), typhoid and para- operated by the Ministry of Health in rural areas. typhoid fevers (6524), gonorrhoea (5123), infectious Ambulatory health care was also available at 917 hepatitis (4592), bacillary dysentery (3883), syphilis, health posts. new cases (3329), amoebiasis (909), scarlet fever and streptococcal sore throat (488), poliomyelitis (144), plague (118), diphtheria (99), meningococcal infections Medical and allied personnel and training facilities (60), leprosy (48). In 1972 Peru had 8023 doctors, of whom 5300 were in government service.The doctor/population ratio 1 International Classification of Diseases, 1965 Revision. was thus one to 1800. Other health personnel included : REGION OF THE AMERICAS 119

Dentists 2 542 of Health. They were attended by 123 452 pregnant Pharmacists 2 422 Veterinarians 900 women, 243 119 infants and 269 686 children aged Midwives 1 050 Nurses 5 040 1 -5 years. Domiciliary care was given to11 924 Auxiliary nurses 11 357 pregnant women, 23 360 infants and to 31 899 children Sanitary engineers 220 Sanitarians 210 aged 1 -5 years. In 1971, 87 481 deliveries were conduc- Assistant sanitarians 60 ted in hospitals. The 128 school health service units Physiotherapists 55 Laboratory technicians 985 provided medical and health supervision to 315 558 X -ray technicians 401 schoolchildren. The 267 dental health units provided Health educators 40 treatment to 434 001schoolchildren and 594 719 The arrangements for the training of medical and adults. There were 16 hospital rehabilitation outpatient health personnel were as follows: departments, one independent rehabilitation centre, and eight psychiatric outpatient clinics. Category Duration Number of Number of and admission of study schools 1graduates requirements (years) 1972 Environmental sanitation Doctors secondary education, In 1971, of Peru's total population, 51.3 % were and entrance examina- served with piped water and 35 % had water from tion 7 4 (1) 265 Dentists public fountains; 39 % of the population were living secondary education, in houses connected to sewers. and entrance examination 5 3 88 Pharmacists Major public health problems secondary education, and entrance examina- The main health problems in Peru are, in order of tion 5 3 131(1969) Veterinarians priority, the diseases which can be brought under secondary education, and entrance examina- control by vaccination; the diseases which are mainly tion 5 3 57 caused by deficient environmental conditions; tuber- Sanitary engineers secondary education, culosis; the diseases which can be eradicated or reduced and entrance examina- through general health measures. tion 5 1 34 Nurses (university degree) secondary education, and entrance examina- Social and economic developments of significance for tion 4 5 43 the health situation Nurses secondary education, The period under review has been characterized by and entrance examination 3 8 (2) 232 the development of the agricultural, industrial and

Auxiliary nurses 6 months 240 commercial sectors and the expansion of communica- Laboratory technicians secondary education, tions and transport. and entrance examina- The results of the last census indicate that the tion 3 2 8 Sanitarians 1 12 population living in the metropolitan area of Lima X -ray technicians . . . 3 6 increased from 8.0 % of the total population in 1940 Physiotherapists . . . 3 5 to 25.9 % in 1972. The economically active population 1 Public (private)schools. in the age group 15 -64 years decreased from 53.6 % in Training in hospitals. 1940 to 45.7 % in 1970/71, whereas the economically dependent population under 15 and above 65 years increased from 46.4 % in 1940 to 50.3 % in 1970/71. Immunization services The percentage of women in the reproductive age The following immunization procedures were carried was 46.8 in 1940 and 42.6 in 1970/71. The Govern- out in 1972: ment has launched a programme for the development of preventive, curative and promotive health services Smallpox 2 419 276 in small rural communities and in remote population BCG 1 972 456 Poliomyelitis 1 844 791 centres as well as for their economic and social devel- Diphtheria, whooping -cough and tetanus . 1 414 717 opment. Special programmes have been prepared for Typhoid and paratyphoid fevers 775 169 Measles 365 229 the promotion of health, education and agricultural Yellow fever 166 519 services in the communities of the Amazon River and Lake Titicaca basin. Specialized units The Government has started a repertory of basic medicaments and has launched programmes for In 1971 maternal and child health care was provided nutrition, in particular of mothers and children and at 391 general outpatient care centres of the Ministry of hospital patients. 120 FIFTH REPORT ON THE WORLD HEALTH SITUATION

National health planning Assistance from PAHO /WHO The sectoral health plan for 1966 -1970, which was In 1972 PAHO /WHO's assistance to Peru included integrated into the social and economic development the following projects: plan for 1967 -1970, was followed by the sectoral Malaria ) : health plan for 1971 -1975, which is part of the social eradicationprogramme (1957- UNICEF and economic development plan for the same period. This latter sectoral plan was prepared by the sectoral Smallpox eradication (1967- ):to protect the planning office and submitted for approval to the country against smallpox by means of systematic National Planning Institute.The sectoral plans are vaccination of 90 % of the population and. epidemio- converted into plans of operation through biennial logical surveillance. plans. There are at present biennial plans for 1971 -1972 Veterinary public health (1966- ):to control and for 1973 -1974. brucellosis in goats and to reduce the incidence of Peru has a national planning system within which the disease in man. the various sectoral plans are coordinated and inte- Rabies control (1970- ) :to control human and grated into the national economic and social develop- canine rabies in Lima and Callao. ment plan. This system includes at the national level the National Council for Economic and Social Devel- Plague control (1963- ) :to carry out epidemio- opment, the National Planning Institute, the Advisory logical studies of plague and implement a control Planning Council and Economic Planning Committee, programme. and at the regional or sectoral level the sectoral offices Chagas' disease (1970- ) : to carry out surveys to of the various ministries and the regional planning determine the extent of infection with Chagas' disease, offices. clinical and epidemiological studies, and vector control The sectoral health plan for 1971 -1975 sets out a measures. number of priorities for the construction and equip- Engineering and environmental sciences (1968- ): ment of health establishments, such as hospitals, to plan and carry out environmental sanitation work. health centres and health posts, with a view to devel- Water supplies (1972- ): to extend water supply oping the health infrastructure and to achieving a and sewerage facilities. better health coverage of the population and a better utilization of available resources. Water supply and sewerage services administration, The objectives of the plan for the provision of rural Lima (1970- ): to improve the administration of water supply, which was initiated in 1964 and which the Lima Sanitation Corporation. will be completed in 1975, is to provide services to Water supply and sewerage services administration 930 rural communities with populations varying be- (1972- )(Inter- AmericanDevelopmentBank) tween 400 and 2000 inhabitants, thus covering alto- (Directorate -General of Sanitary Works): to constitute gether 108 000 inhabitants or 14 % of the total rural a team of national consultants in order to reorganize population and over 30 % of the population specifi- the administrativestructure of the water supply cally served by this programme. systems in several major cities. The aim of the rural sewerage programme is to Air pollution (1967- ): to determine air pollution provide services, by 1975, to 65 rural centres, each levels, plan control measures, and train staff for their of which has a population of between 1000 and 2000, implementation. forming a total rural population of 97 000. It is Health services (1956- ) UNDP: to strengthen planned to achieve coverage of the whole rural popu- and extend the health services in accordance with the lation. national health plan. Medical and public health research Healthservices,Piura and Tumbes (1970- ) UNICEF: to develop and extend integrated health The medical and public health research activities services in the two Departments. carried out in Peru are mainly directed towards the Maternal and child health (1972- ): to improve study of the etiology, clinical pathology, diagnosis and and extend activities for the health care of mothers treatment of diseases; the epidemiology of various and children. communicable and chronic and degenerative diseases; a number of viruses; the human environment; human Nutrition (1965- ) UNICEF (FAO): to imple- health behaviour; influence of cultural and personal ment an applied nutrition programme. factors on the incidence of diseases; nutrition; dental Nutritionrehabilitationcentresinthehighlands health; health manpower; cost /benefit analysis; and (1967- ) Grants to PAHO: Research Corporation, health needs of the population. United States of America: to continue the work of REGION OF THE AMERICAS 121 the nutrition rehabilitation centres that have been for the training of teachers of biochemistry and phys- established in the central highlands. iology at the University of San Marcos. Mental health (1972- ): to establish a mental Nursing education (1959- ):to strengthen the health policy, improve the administration and orga- teaching of nursing in the five universities. nization of the mental health institutions, develop Sanitaryengineeringeducation(1964- ):to rehabilitation services in hospitals, organize a system strengthen the teaching of sanitary engineering at the of mental health services oriented towards the com- National University of Engineering, improve labo- munity, and train specialized personnel. ratory and libraryfacilities and develop applied Medical care services (1970- ): to strengthen the research projects. administrative and technical systems of the central Veterinary medical education (1965- ): to revise Air Force hospital, and improve the organization of the plans of study in the schools of veterinary medicine. the country's hospital system. Dental education (1969- )Grants to PAHO: Cancer control (1971- ): to establish a compre- Overseas Development Administration, United King- hensive programme for the detection and control of dom: to review the curricula of the schools of dentistry cancer of the uterine cervix. and strengthen the teaching programmes. School of Public Health (1963- ): to strengthen the School of Public Health. Government health expenditure Interdisciplinary action in health (1972- ):to carry out a multidisciplinary teaching programme During the years 1971 and 1972 total government for specialists in the health sciences. expenditure amounted to 115 605 million soles, of which 71 523 million were spent on current account Medical education (1964- ): to strengthen the and 44 082 million on capital account. The Ministry training of physicians at the undergraduate and post- of Health accounted for 6423 million soles. including graduate levels, improve the training of teachers, and 5912 million for current expenditure and 471 million introduce curriculum changes to place more emphasis for capital expenditure. In addition 519 million soles on the preventive and socialaspects of medical were spent on health activities by other ministries, practice. excluding however the expenditure of theSocial Training programme for instructors in biochemistry Security. The per capita government expenditure on and physiology (1971- ) : to implement a programme health was 451 soles.

URUGUAY

Population and other statistics hypertensive disease, ischaemic heart disease, other Population estimates and some other vital statistics forms of heart disease (6994), malignant neoplasms for the period under review are given in the following (5601), cerebrovascular disease (3542), symptoms and table: ill- defined conditions (1749), accidents (1319, including 1969 1970 1971 1972 203 in motor -vehicle accidents), birth injury, difficult

Mean population . . . 2 851 600 2 866 100 2921 000 2 956 300 labour and other anoxic and hypoxic conditions, Number of live births . . 61 100 64671 65 953 Birth rate other causes of perinatal mortality (986), diabetes

(per 1000 population) , 21.4 22.4 22.6 mellitus (695), pneumonia (680), bronchitis, emphys-

Number of deaths. . . , 27544 26441 28527 Death rate ema and asthma (549), avitaminoses and other nutri- (per 1000 population) , 9.7 9.2 9.8 tional deficiency (379), bacillary dysentery and amoe- Natural increase ( %) . . 1.17 1.32 1.28 Number of Infant deaths . 2 958 2 757 2 663 biasis, enteritis and other diarrhoeal diseases (312), Infant mortality rate congenital anomalies (310), suicide and self -inflicted (per 1000 live births) . 48.4 42.6 40.4 Number of deaths, injuries (304), cirrhosis of liver (302). 1 -4 years 369 287 255 Death rate, 1 -4 years (per The communicable diseases most frequently notified 1000 population at risk) 1.7 1.3 1.1 Number of maternal in1972 were: influenza (10 439), measles (7926), deaths 47 50 46 infectious hepatitis (2322), tuberculosis, all forms, new Maternal mortality rate (per 1000 live births) . 7.7 7.7 7.0 cases (1550), gonorrhoea (594), meningococcal infec- Of the 28 527 deaths recorded in1971, the main tions (492), syphilis, new cases (434), scarlet fever and streptococcal sore throat (392), typhoid fever (104), causeswere: 1chronicrheumaticheartdisease, whooping -cough (90), leprosy (13), diphtheria (4), 1 International Classification of Diseases, 1965 Revision. trypanosomiasis (4), poliomyelitis (2). 122 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Hospital services Assistance from PARO /WHO In 1971 Uruguay had 149 hospitals and other In1972 PAHO /WHO's assistanceto Uruguay inpatient establishments, providing 16 603 beds. The included the following projects : bed /population ratio was thus 5.6 per 1000. Am- Epidemiology bulatory care was provided at the hospital outpatient (1972- ):toorganize,atthe departments, at 127 polyclinics and at one mobile central level, a team for coordination of epidemiological surveillance; to carry out surveys and prepare health unit. programmes for communicable disease control; to train personnel; and to improve data collection and Medical and allied personnel and training facilities analysis. In 1971 Uruguay had 3170 doctors, or one doctor Smallpox eradication (1967- ): to keep the coun- for 920 inhabitants. Other health personnel included: try free from smallpox by a programme of vaccination and epidemiological surveillance measures. Dentists 1 331 Veterinarians 600 Hydatidosis control (1971- ):to expand and Nurses 988 intensify the hydatidosis control programme. The arrangements for the training of medical and Chagas' disease (1968- ): to carry out a pro- health personnel were as follows in the academic year gramme based on the systematic spraying of houses 1971/72: with insecticides, for the control of Chagas' disease. Category and admission requirements DurationNumber of of study schools Engineering and environmental sciences (1968- ): (years) (public) toplan and implement environmental sanitation Doctors bachillerato 1 6 1 programmes and train personnel. Dentists bachillerato 5 1 Water supplies (1960- ): to plan and implement Pharmacists bachillerato 4 1 national water supply and sewerage programmes. Veterinarians . bachillerato 5 1 Health services (1955- ): to develop the health Nurses (university training) services in accordance with a national health plan, bachillerato 4 1 Nurses (basic training) reorganize their technical and administrative structure bachillerato 4 1 Midwives at the national, regional and local levels, and train bachillerato 4 1 the necessary health personnel. Auxiliary nurses secondary education 1 1 Laboratory technicians Laboratory services(1971- ):toorganizea bachillerato 2 1 national system of health laboratory services. Laboratory assistants bachillerato 2 1 Health statistics (1965- ) : to establish a national Physiotherapists bachillerato 2 1 health statistical system.

1 Certificate of six years of secondary education. Mental health (1965- ) :to improve the statistical information on mental health problems, draw up a mental health programme and train personnel. Immunization services Occupational health (1967- ): to control occu- The following immunization procedureswere car- pational diseases in industry. ried out in 1972: Medical care services and hospital administration Poliomyelitis 596016 (1966- ) UNDP: to reorganize and improve the BCG 383600 Tetanus (simple and combined) 332065 medical care and hospital services and train personnel. Whooping -cough 180953 Smallpox 173554 Health and population dynamics (1971- ):to Diphtheria (simple and combined) 141547 Measles 99930 improve maternal and child health and family planning Cholera 717 activities in semirural areas and train the necessary Yellow fever 550 personnel. Chronic diseases (1971- ): to establish a national Specialized units rheumatology service, develop a national programme In 1972 maternal and child health services were for the control of rheumatic diseases, carry out based on 26 centres. There were also 74 dental units, epidemiological research on these diseases, and estab- 12 psychiatric outpatient units and 78 public health lish a centre for specialized training of physicians from laboratories. the western hemisphere. REGION OF THE AMERICAS 123

Training of health personnel (1971- ): to provide University of the Republic (1971- ): to strengthen training for staff with technical and administrative the programme of the various schools of the University responsibilities in the health service. of the Republic.

VENEZUELA

Population and other statistics (5395), infectious hepatitis (1853), bacillary dysentery (515), trypanosomiasis (470), leprosy (343), typhoid At the last census, taken in February 1961, the pop- and paratyphoid fevers (119), diphtheria (144), polio- ulationof Venezuela was7 523 999.Population myelitis (80), schistosomiasis (51). estimates and some other vital statistics for the period under review are given in the following table: 1 Hospital services 1969 1970 1971 1972

Mean population 1 . . 9943 665 10275 143 10616 907 10919163 In 1971 Venezuela had 341 hospitals and other

Number of live births . . 397 003 392 583 405 964 412 435 Bird rate establishments for inpatient care, providing a total (per 1000 population) . 39.9 38.2 38.2 37.8 of 32 632 beds, or 3.1 beds per 1000 inhabitants. These Number of deaths . . . 67784 68493 70478 73548 Death rate beds were distributed as follows: (per 1000 population). 6.8 6.7 6.6 6.7 Natural increase (%) 3.31 3.14 3.16 3.11 Category and number Number of beds Number of infant deaths 16953 19356 20320 21335 General hospitals Infant mortality rate 101 17 361 Rural hospitals 26 466 (per 1000 live births) . 42.7 41.7 50.2 51.7 Maternity hospitals Number of deaths, 15 1 134 Paediatric hospitals 8 868 1 -4 years 7 269 7 515 7114 8 318 Tuberculosis hospitals 14 Death rate, 1 -4 years (per 2 808 Psychiatric hospitals 23 4 995 1000 population at risk) 5.4 5.4 5.3 6.0 Hospitals for surgery Number of maternal 5 293 Ophthalmology hospitals 2 49 deaths 332 362 374 391 Chronic diseases hospital 1 Maternal mortality rate 60 Cancer hospitals 3 268 (per 1000 live births) . 0.8 0.9 0.9 0.9 Orthopaedic hospitals 2 314 Leprosaria 2 600 figures. Hospitals for general medicine 2 175 1 Mid -year estimates. Hospital for urology 1 28 Hospital for ear, nose and throat condi-

tions 1 24 Convalescent homes 135 3 171 Of the 73 548 deaths recorded in 1972, the main Other establishments causes were 2 symptoms and ill- defined conditions 18 (15 073), chronic rheumatic heart disease, hypertensive Ambulatory medical care was provided in 1972 at disease, ischaemic heartdisease,other forms of 31 hospital outpatient departments, which recorded heart disease (8678), malignant neoplasms (5809), 2.1 million attendances; at 37 health centres, which bacillary dysentery and amoebiasis,enteritisand recorded 4 million attendances; at 1930 dispensaries, other diarrhoeal diseases (5640), birth injury, difficult which recorded1.5millionattendances;at501 labour and other anoxic and hypoxic conditions, medicaturas (outpatient treatment centres); and at 46 other causes of perinatal mortality (5409), accidents health units, which provided only preventive health (5276, including 2816 in motor- vehicle accidents), care. pneumonia (4843), cerebrovascular disease(3140), delivery without mention of complication (1305), measles (1222), diabetes mellitus (1001), tuberculosis, Medical and allied personnel and training facilities all forms (947), avitaminoses and other nutritional deficiency (932), bronchitis, emphysema and asthma In 1972 Venezuela had 11 222 doctors, or one (905). doctor for 980 inhabitants.Other health personnel The communicable diseases most frequently noti- included: fied in 1972 in the reporting area were: measles Dentists 2 686 (43 782),influenza(36 218), gonorrhoea(36 038), Pharmacists 2 749 Veterinarians 888 scarlet fever and streptococcal sore throat (19 869), Empirical midwives 600 Nurses 5535(1971) malaria, new cases for the whole country (18 062), Auxiliary nurses 17 752(1971) syphilis, new cases (14 184), whooping -cough (13 319), Sanitary engineers 308 Sanitarians 137 amoebiasis (12 609), tuberculosis, all forms, new cases Physiotherapists 36 Laboratory technicians 716 X -ray technicians 153 1 United Nations data. Dietitians 374 Auxiliary dietitians 550 2 International Classification of Diseases,1965 Revision. Medical librarians 343 124 FIFTH REPORT ON THE WORLD HEALTH SITUATION

The arrangements for the trainingof medical and employment and 356 986 routine periodic examina- health personnel were as follows : tions were carried out. In 1972 there were 130 public Category DurationNumber ofNumber of Number of health laboratories in Venezuela, which carried out and admission of study schools students graduates over 5.6 million examinations. requirements (years) (public) 1971/72 1972 Doctors bachillerato i 6 7 6 395 827 Assistance from PAHO /WHO Dentists bachillerato 5 3 1 744 315 Pharmacists In 1972 PAHO /WHO's assistance to Venezuela bachillerato 4 2 1 672 120 included the following projects: Veterinarians bachillerato 5 3 2 257 173 Nurses (university level) Veterinary public health(1972- )Grants to bachillerato 4 2 126 38 Dietitians -nutritionists PAHO :Government of Venezuela :to plan and bachillerato 4 2 239 40 implement national programmes for the prevention Nurses secondary education, and control of zoonoses and train professional veter- first phase 3 13* 1 840 665 inary workers. Auxiliary nurses 1 year of secondary Venezuelan equine encephalitis (1971- ): to carry education 1 11 430 390 primary education . . 4 months ** 132 132 outepidemiologicalinvestigationsof Venezuelan Midwives encephalitis and develop a stable and effective vaccine. certificate of nursing . 1 1 16 16 Dental auxiliaries Chemical and industrial contamination (1971- 1972): 6 years primary education 9 months 1 32 31 a consultant studied the effects of chemical and industrial contaminants from the Tablazo Petrochemical Certificate of six years of secondary education. Complex. * Including four private schools. ** 11 courses In seven health service units. Water supplies (1960 -1973) (National Institute of SanitaryWorks,Venezuela):toreorganizethe Immunization services National Institute of Sanitary Works. The following immunization procedures were carried Air pollution (1971- ): to carry out investigations out in 1972: for the determination of air pollution levels. Health services (1964- ) : to improve the admin- Poliomyelitis 3 342 915 Tetanus 1 486 476 istration and organization of the health services and BCG 963 045 Yellow fever 936 185 extend their coverage; to train health personnel. Diphtheria and whooping -cough 924 197 Typhoid and paratyphoid fevers 846 389 Nursing services (1972- ) : to prepare and imple- Smallpox 786 023 ment a long -term plan for the delivery of nursing care. Measles 139 805 Laboratory services (1966- ): to organize labo- Specialized units ratory services at the national, regional and local levels and train personnel. In 1972, 644 centres were engaged in maternal and ) UNDP: child health care.They were attended by 69 629 National Institute of Hygiene (1964- pregnant women and 88 103 children aged 2 -6 years. to improve the organization and programmes of the Institute. Domiciliary care was given to 37 440 pregnant women, to 115 780 children under 2 years and to 59 879 Administrativemethods and practicesinpublic children aged 2 -6 years.In 1972, of all deliveries, health (1972- ): to improve the administration of 253 461 were institutional and 141 were conducted the health services and prepare relevant legislation. at home by a doctor or qualified midwife.School Nutrition (1965- ):to formulate a nutrition health services were provided at 175 centres, which policy and develop a programme for improving the were attended by 148 378 schoolchildren, representing nutritional status of the population. 34.2 % of the total school population.Dental care Mental health (1964- ): to extend and improve was provided at 48 dental units for schoolchildren the mental health services. and at 34 dental units for adults.During the year 27 337 schoolchildren received dental treatment. The Dental materials centre (1969- ) :to develop 12hospitalrehabilitationoutpatient departments training and research, and the quality control and recorded 6421 new patients during the year.Psychi- standardization of dental materials, at the Centre for atric outpatient consultations were given at 150 psy- Dental Materials established in the School of Dentistry chiatric clinics, which were attended by 21 763 new of the Central University, Caracas, in 1969. outpatients.In 1972, 93 industrial establishments Radiation protection (1970- ): to plan and imple- offered medical and healthservices;16 415 pre- ment a national radiation protection programme. REGION OF THE AMERICAS 125

Medical care services (1966- ):to coordinate Veterinary medical education (1966- ): to improve the medical care services provided by the hospitals the teaching of veterinary medicine. and health centres, extend medical care facilities, and Dental education (1966- ):to train auxiliary train the necessary personnel. personnel and strengthen the programme for the National system of maintenance and engineering of teaching of dentistry. health care facilities (1972- ) UNDP: to develop a national system of engineering and maintenance of Government health expenditure hospitals and other health care facilities. Of the total government expenditure, 10 988 million Rehabilitation(1967- ):tostrengthenand bolívares in 1971, 2024.86 million were spent on health develop rehabilitation services and train personnel. services, including 1996.5 million on current account School of Public Health (1961- ): to develop and 28.3 million on capital account. The per capita the school and improve its programmes of study. government expenditure on health was 190 bolívares. The central government health expenditure, which Medical education (1958- ): to improve medical was 1070.8 million bolívares, included 949.8 million education. spent by the Ministry of Health and Social Welfare Sanitary Engineering Research Centre (1971- ) and 120.9 million spent by other ministries.The UNDP Funds -in- trust: to establish a sanitary engi- expenditure atthe intermediate government level neering research centre for quality control of air, amounted to 624.6 million bolívares, and that at the water and soil. local government level to 329.5 million.

ANTIGUA

Population and other statistics The communicable diseases most frequently notified in1972 were: influenza (1368), gonorrhoea (603), At the last census, taken in April 1970, the popu- whooping -cough (135), early syphilis, new cases (47), lation of Antigua was 70 000. Population estimates 1 measles (10), yaws, new cases (9), pulmonary tuber- and some other vital statistics for the period under culosis, new cases (8), bacillary dysentery (6), leprosy review are given in the following table: (3).

1969 1970 1971 1972 Organization of the public health services Mean population . . 60 000 70 000 70 000 70 000

Number of live births . . 1 527 1 540 1 700 1 573 Birth rate The medical and public health services of Antigua (per 1000 population) . 25.8 22.0 24.3 22.5 are under the supervision of the Minister of Education, Number of deaths . . . 410 411 414 455 Death rate Health and Culture. The Parliamentary Secretary is (per 1000 population) . 6.8 5.9 5.9 6.5 Natural increase ( %) . . 1.90 1.61 1.84 1.60 responsible for the health section of the Ministry. Number of infant deaths . 51 42 38 32 The Permanent Secretary is in charge of the admini- Infant mortality rate (per 1000 live births) . 33.4 27.3 22.4 20.3 stration, whereas the Chief Medical Officer is respon- Number of deaths, sibleforallprofessional andtechnicalservices 1 -4 years 10 13 6 4 Death rate, 1 -4 years (per related to health, namely the preventive, curative and 1000 population at risk) 1.4 1.8 0.8 0.5 Number of maternal environmental health services. deaths 1 1 1 1 Maternal mortality rate (per 1000 live births) 0.65 0.65 0.59 0.62 Hospital services In 1970 Antigua had three hospitals with altogether Of the 455 deaths recorded in 1972, the main causes 430 beds, equivalent to 7.2 beds per 1000 population. were: 2 chronic rheumatic heart disease, hypertensive These 430 beds, to which 4719 inpatients were admit- disease, ischaemic heart disease, other forms of heart ted during the year, were distributed as follows: one disease (93), cerebrovascular disease (78), malignant government general hospital with 220 beds, one gov- neoplasms (60), accidents (44, including 37 in motor - ernment psychiatric hospital with 160 beds, and one vehicle accidents), bacillary dysentery and amoebiasis, government leprosy hospital with 50 beds. enteritis and other diarrhoeal diseases (21), pneumonia Outpatient facilities were provided in 1972 at one (17), anaemias (15). hospital outpatient department which recorded 12 000 new outpatients during the year, at three health 1 United Nations estimated data. centres and 14 dispensaries. Three of these establish- 2 International Classification of Diseases, 1965 Revision. ments provided home visiting facilities. 126 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Medical and allied personnel and training facilities were attended by 3810 schoolchildren and 1197 In 1970 Antigua had 23 doctors, or one doctor per adults.Psychiatric consultations were provided at 2600 inhabitants. There were also three dentists and one outpatient clinic which recorded 42 new patients in 1972. 144 nurses. Antigua has a nursing school which organizes a three -year course, and a midwifery school which has a Environmental sanitation one -year course.During the 1971/72 school year, In 1971, of the total population of Antigua 30.8 72 nurses and 13 midwives were enrolled at these were served with piped water, 69.2 % had water from schools, and eight nurses and seven midwives grad- public fountains and 12.1 % were living in houses uated. connected to sewers.

Immunization services Assistance from PAHO /WHO The following immunization procedures were car- In1972 PAHO /WHO's assistancetoAntigua ried out in 1972: included the following projects:

Poliomyelitis 34215 Aedes aegypti eradication (1969- ) Typhoid and paratyphoid fevers 6246 Diphtheria, whooping -cough and tetanus . . 3921 Hospital administration, Antigua (1972- ) UNDP: Smallpox 1073 to reorganize the administrative structure and man- Specialized units agement of the Holberton Hospital and train personnel in hospital administration. In 1972 Antigua had 10 prenatal centres and 17 child health centres. They were attended by 511 preg- Government health expenditure nant women, 1330 infants and 258 children aged 1 -5 years. Prenatal care is also provided by private doctors In 1972 the total central government health ex- and at the general hospital.Domiciliary visits were penditure amounted to3 343 365 East Caribbean paid to 98 pregnant women, 201 infants and 214 dollars, of which EC $3.293 365 were spent on current children up to 5 years of age. In 1972, of all deliveries account by the Ministry of Health and $50 000 by about 20.4 % were attended by a doctor or qualified other ministries.The government expenditure on midwife, either in hospital or at home. School health generalpublichealthservices amounted to EC services were provided at three school health services $1 135 000 and the government expenditure on hos- units. Dental care was available at three units which pitals to $1 506 350.

BELIZE

Population and other statistics cough (23), meningococcal infections (7), typhoid and At the last census, taken in April 1970, the popu- paratyphoid fevers (3), poliomyelitis (2), lation of Belize was 119 934.Population estimates and some other vital statistics for the period under Organization of the public health services review are given in the following table: The integrated health services in Belize come under

1969 1970 1971 1972 the Minister of Health, who is responsible to the

Mean population . . . 120 000 120 000 124 000 130 000 National Assembly for all health activities. The Chief

Number of live births . . 4 652 4 455 Birth rate Medical Officer, who is also the senior health officer,

(per 1000 population) 38.8 37.1 advises the Government on all health matters. He is Number of deaths . . 754 797 Death rate assisted by a medical officer of health, a principal

(per 1000 population) 6.3 6.6 nursing officer and a pathologist. The curative service

Natural increase ( %) . 3.25 3.05 Number of infant deaths 226 provides for hospitalization and outpatient care, and Infant mortality rate the preventive service provides maternal and child (per 1000 live births) 50.7 health services, domiciliary midwifery and environ- The communicable diseases most frequently notified mental control services. in 1972 were: measles (501), gonorrhoea (349), syphilis, The countryisdivided intosixadministrative new cases (331), influenza (176), bacillary dysentery districts, each of which has a hospital staffed by a (96), malaria, new cases (86), infectious hepatitis (50), medical officer and nursing personnel.The main tuberculosis,all forms, new cases (27), whooping- district towns have a public health nurse who is in REGION OF THE AMERICAS 127 charge of maternal and child health services and a Communicable disease control and immunization services public health inspector who is responsible for environ- The malaria eradication programme continued to mental control services in the district. progress. The tuberculosis control service continued Health services in rural areas are provided through withitspreventive,case -finding and supervisory health centres which are staffed by rural health nurses. programme. The outbreak of rabies which started in Villages in the more remote areas are served by the Cayo district in 1970 and claimed three lives monthly visits of mobile clinics. continued in 1971 in the Stann Creek district and in the Belize district. In 1970 there was also an outbreak Hospital services of bacillary dysentery with 2764 cases.In 1969 a venereal disease clinic was opened in Belize City. In 1972 Belize had 13 hospitals with 641 beds, of During 1971 mass typhoid fever vaccinations were which 606 were in 11 government- maintained estab- carried out in the areas bordering Guatemala, following lishments. The bed /population ratio was 4.9 per 1000. an outbreak in that country. The 641 beds were distributed as follows: The following immunization procedures were carried out in 1972: Category and number Number of beds General hospitals 5 310 Poliomyelitis 108 969 Rural hospitals 3 68 Diphtheria, whooping -cough and tetanus . 14 234 Medical centres 3 72 Smallpox 6 667 Tuberculosis hospital 1 52 Tetanus 4 626 Psychiatric hospital 1 139 Typhoid and paratyphoid fevers 3 201 BCG 2 724 Outpatient facilities were available in 1972 at seven hospital outpatient departments, and at 22 health Specialized units centres, which are staffed by a nurse /midwife and are visited periodically by the district medical officer. In 1972 maternal and child health services were The health centres provide first -aid treatment for based on 29 centres which recorded 16 733 attendances by pregnant women, 14 505 by infants and 26 322 by minor ailments, and maternal and child health care. children aged 1 -5 years.Domiciliary care was given to 945 pregnant women, 673 infants under one year Medical and allied personnel and training facilities and 818 children aged 1 -5 years. Of all deliveries in 1972,54.6 % were conducted under professional In 1970 Belize had 41 doctors, of whom 26 were in medical supervision (2628 in hospital and 77 at home). government service. The doctor /population ratio was Specialized outpatient facilities included also a dental one per 2930 inhabitants.Other health personnel clinic, a psychiatric clinic, a tuberculosis clinic and included: a venereal disease clinic. Belize had three public health

Dentists 3 laboratories.

Pharmacist 1 Dispensers 29 Veterinarians 2 Midwives 18 Environmental sanitation Assistant midwives 112 Nurses and nurse /midwives 75 A national water and sewage authority was estab- Assistant practical nurses 51 lished and provided with statutory powers to provide Nursing auxiliaries 17 Sanitary engineer 1 and administer water and sewerage systems. A public Sanitarians 17 Laboratory technicians 7 water supply system and a sewage treatment plant X -ray technicians 4 were completed in Belmopan, the new capital city, during the period under review. Five urban areas are The arrangements for the training of health person- at present provided with a piped water supply. With nel were as follows in 1972: the completion of three rudimentary water systems in Category DurationNumber of Total Number of rural areas during the reporting period, the number of and admission of study schools enrolment graduates rural communities served with piped water supplies requirements (years) (public) 1971/72 1972 increased to 15.During the same period some 2000 Nurses 9 years general educa- latrines were built in rural areas; 73 % of the rural tion 3 1 19 6 Assistant (practical) population were provided with sanitary waste dispo- nurses sal systems. 9 years general education 1 1 45 33 Midwives 9 years general educa- Major public health problems tion 1 1 13 7 Dispensers Diseases of the gastrointestinal tract continue to be 12 years general education 3 1 2 2 the major health hazard in the country. These condi- 128 FIFTH REPORT ON THE WORLD HEALTH SITUATION tions are aggravated by the unsatisfactory environmen- Malaria eradication programme (1956 - tal health situation. Work in this field is now in pro- UNICEF gress in all six districts of the country. Gastroenteritis Engineering and environmental sciences (1971- ): is still the most important cause of mortality among to develop a national programme of environmental infants and preschool children (1 -5 years) and is sanitation. responsible for some 20 % of the deaths occurring at this time of life. Dysenteries, helminthiasis, diarrhoea Aedes aegypti eradication (1972- ) and enteritis account for the majority of cases seen at Health services (1962- ) UNICEF: to improve hospital outpatient departments and requiring hos- and extend the health and sanitation services, and to pitalization. train personnel. Pneumonia and bronchial diseases come next as Sanitaryengineeringeducation(1966- ):to major causes of morbidity. In most cases, the under- develop short courses in sanitary engineering and lying cause of these conditions is malnutrition, such environmental sanitation subjects. as avitaminosis, anaemias and other deficiency states. The environmental health problem is complicated by the lack of well -planned and well- executed programmes Government health expenditure for refuse collection and disposal and by poor housing In 1972 total government expenditure was 25 287 817 conditions. British Honduras dollars, of which BH $1 946 917 were spent on health services. Current health expen- Assistance from PAHO /WHO diture was BH $1 789 400 and capital health expen- In 1972 PAHO /WHO's assistance to Belize included diture $157 517. The per capita expenditure on health the following projects: was BH $15.

BRITISH VIRGIN ISLANDS

Population and other statistics Organization of the public health services At the last census, taken in April 1970, the popula- The territory's health services are under the admin- tion of the British Virgin Islands was 9672. Population istration of the Ministry of Natural Resources and estimates and some other vital statistics for the period Public Health. The Chief Medical Officer is in charge under review are given in the following table: of the Health Department, which also includes a chief nursing officer and a chief public health inspec- 1969 1970 1971 1972 tor. Mean population . 9000 10 400 10 200 10 020

Number of live births . . 238 313 301 304 Birth rate Hospital and specialized services (per 1000 population). 26.4 30.1 29.5 30.4 Number of deaths . . . 74 58 59 63 Death rate In 1972 the British Virgin Islands had one hospital (per 1000 population) . 8.2 5.6 5.8 6.3 Natural increase ( %) . . 1.82 2.45 2.37 2.41 with 34 beds in Road Town.In the government Number of infant deaths . 11 8 7 16 capital expenditure for 1973/74 provision was made Infant mortality rate (per 1000 live births) . 46.2 25.6 23.3 52.6 for the construction in Road Town of a new and Number of deaths, modern hospital with 45 to 50 beds. 1 -4 years 2 1 3 Outpatient facilities were provided in 1972 at the Of the 63 deaths recorded in 1972, the main causes hospital outpatient department, at the Central Public were: 1 hypertensive disease, ischaemic heart disease, Health Clinic in Road Town and at eight health and other forms of heart disease (12),congenital centres, of which four were opened during the period anomalies, birth injury, difficult labour and other under review.These health centres are located at anoxic and hypoxic conditions,other causesof Tortola, at Virgin Gorda and Anegada.They are perinatal mortality(12), pneumonia (8),cerebro- staffed by nurses and assistant nurses and are regularly vascular disease (7), symptoms and ill- defined condi- visited by a doctor.They provide general medical tions (6), malignant neoplasms (3). and child health care. At the Central Public Health The communicable diseases most frequently notified Clinic special consultations were instituted in 1971 and in 1971 were: gonorrhoea (86), measles (44), whooping - 1972 for diabetics, food handlers and immigrants. cough (24), bacillary dysentery and amoebiasis (22), Advice on family planning and cervical cancer detec- meningococcal infections (22), infectious hepatitis (4). tion were added to the established antenatal and postnatal consultations. Once a month four child welfare 1 International Classification of Diseases, 1965 Revision. consultations are held by a doctor and nurse in school REGIONOF THE AMERICAS 129

rooms and private houses for the population in hill Chronic and degenerative diseases areas and remote villages. Hypertensive heartdiseaseis common inthe In 1972, 89 % of all deliveries were attended by a British Virgin Islands.Mental disorders present a doctor or qualified midwife in hospital or at home. particular problem, with a high incidence of mild All government schools are periodically visited by a psychoneurotic symptoms. A local mental health doctor and a nurse.Dental care was provided for programme was initiated in 1972. Diabetes mellitus is schoolchildren in one dental clinic, which gave treat- common in the territory, mainly in the age group 50 ment to 1891 schoolchildren in 1972. A mental health years and above. service, which started operating in 1972, is steadily extending its range of activities. Thus mental patients, who previously had to be transferred to the mental Environmental sanitation hospital in Antigua, can be treated on the island.In At present the public water supplies distribution 1972 a small school was opened for mentally and system serves only a limited number of the islands' physically handicapped children. The laboratory inhabitants. In Tortola, where most of the population services are run by a trained laboratory technician. is concentrated, the water supply comes largely from rain water catchment in individual domestic cisterns, Medical and allied personnel and training facilities serving 71 % of all houses, but there is a piped water supply to part of Road Town. This is tested daily for In 1970 the British Virgin Islands had seven doctors, chlorine dosage and bacteriologically examined once of whom five were in government service. The doctor/ weekly. Cistern water is also examined bacteriologi- population ratio was thus one per 1430 inhabitants. cally when it appears necessary. Other health personnel included: Major public health problems Dentists 2 Pharmacist 1 Midwives 5 Abatement of litter and solid waste disposal are Traditional birth attendants 2 among the main health concerns in the territory. The Nurses 14 Assistant nurses 3 House Refuse Regulations were passed in 1971 and Nursing auxiliaries 17 The Sanitary inspectors 2 the Abatement of Litter Regulations in 1970. Laboratory technicians 2 garbage disposal system isgradually gaining the X -ray technician 1 support and cooperation of the population. There are no proper training facilities for health personnel in the British Virgin Islands. Health Social and economic developments of significance for personnel are trained at the University of the West the health situation Indies, Jamaica and at the nursing schools in Jamaica, The importance of the agricultural sector continues Trinidad and Tobago, and Barbados. to decline. The major industry in the territory is tourism, with arrivals increasing from 29 500 to 44 800 Communicable disease control and immunization services between 1969 and 1972. The tourist facilities are well spread throughout the islands and provide employment The territory is free from schistosomiasis, malaria, opportunities in a number of localities.There is no smallpox, trachoma and yellow fever.Tuberculosis family planning campaign or stated aims concerning does not represent a public health problem. Primary population growth.In the late 1960s there was a active syphilis is uncommon, but gonorrhoea and non- large net immigration, mostly from the Caribbean specific urethritis present a problem because of the area.With the recession of the early 1970s this difficulty in following up cases. Planned immunization immigration stopped. During the period under review of infants and schoolchildren has increased in efficiency there has been an extensive building programme for and parents are accepting it more readily.There is primary schools, and nearly all of these are now now a regular vaccination programme for infants completed. against diphtheria, whooping -cough and tetanus, poliomyelitis and smallpox and for children aged 2 years against measles, yellow fever and typhoid fever. Assistance from PAHO /WHO The following immunization procedures were car- In 1972 PAHO /WHO's assistance to the British ried out in 1970: Virgin Islands included the following project:

Poliomyelitis 3 028 Aedes aegypti eradication (1969- ): to eradicate Diphtheria, whooping -cough and tetanus . . 433 Aedes aegypti from the West Indies, including the Smallpox 338 Yellow fever 8 British Virgin Islands. 130 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Government health expenditure were spent on health services, representing a per capita outlay of $50.Of the total government health In 1972 total government expenditure amounted expenditure, US $462 000 were spent on current to US $6 005 000; 8.3 % of this total, or $501 000, account and $39 000 on capital account.

FALKLAND ISLANDS ( MALVINAS)

Population and other statistics Immunization services The last census was taken in December 1972. Pop- The following immunization procedures were car- ulation estimates and some other vital statistics for ried out in 1968: the period under review are given in the following Smallpox 155 table: Diphtheria, whooping -cough and tetanus . . . 44 1969 1970 1971 1972 BCG 34

Mean population . . . 2 082 2 045 2 000 1 957

Number of live births . . 58 34 39 Birth rate Specialized units (per 1000 population) . 27.9 16.6 19.9 Number of deaths . . . 24 15 .. 12 In 1972 maternal and child health care was based on Death rate (per 1000 population) 11.5 7.3 .. 6.1 one centre, which was attended by 39 pregnant women Natural increase ( %) . . 1.64 0.93 .. 1.38 and 39 infants.All deliveries took place in hospital. Number of infant deaths . 2 ... 1 Infant mortality rate The total school population was under the medical (per 1000 live births) . 58.8 25.6 and health supervision of the school health service unit. Dental treatment was given at one dental Hospital services clinic to 1047 patients.The Falkland Islands (Mal- In 1970 the Falkland Islands (Malvinas) had one vinas) had one public health laboratory. general government hospital, which provided 27 beds; 176 inpatients were admitted to this hospital.The Environmental sanitation bed /population ratio was 13.2 per 1000. Outpatient facilities were provided at the hospital's Port Stanley has a water supply system providing outpatient department, which recorded 914 new all inhabitants with piped water.All houses in this patients in 1972. city are connected to sewers.

Medical and allied personnel Government health expenditure In 1970 there were four doctors in the Falkland The general government expenditure on current Islands (Malvinas), working in government service. account during the fiscal year 1971/72 amounted to The doctor /population ratio was one to 500. Other £521 851 and the general government health expen- health personnel included: diture on current account to £57 702, of which 30 519 Dentists 2 were spent on general public health services. The per Nurse /midwives 3 Assistant nurses 5 capita expenditure on health services was thus £29.

FRENCH GUIANA Population and other statistics Organization of the public health services At the last census, taken in October 1967, the popu- French Guiana constitutes an administrative unit lation of French Guiana was 44 392. Population and headed by a Prefect designated by the central adminis- other vital statistics for the period 1969 -1972 are given tration in Paris.The responsibility for the health in the following table: sector in the department rests with the Departmental 1969 1970 1971 1972 Medical Inspector of Health and the Director of Mean population . . . 48 200 48 800 51 216 52 472 Health and Social Affairs, who answer to the Prefect. Number of live births . . 1 433 1 601 1 606 1 647 Birth rate (per 1000 population). 29.7 32.8 31.4 31.4 Number of deaths . . . 431 402 367 391 Hospital services Death rate (per 1000 population) . 8.9 8.2 7.2 7.5 Natural increase ( %) 2.08 2.46 2.42 2.39 In 1971 French Guiana had one general hospital Number of infant deaths 72 86 69 79 with 680 beds and one psychiatric hospital with 110 Infant mortality rate (per

1000 live births) . . . . 50.2 53.7 43.0 48.0 beds. The bed /population ratio was thus 15.4 per 1000. REGION OF THE AMERICAS 131

Outpatient care was provided at the general hospital BCG 1 102 Cholera 314 outpatient department. Diphtheria, tetanus, typhoid and paratyphoid fevers 80 Medical and allied personnel and training facilities Specialized units In 1971 French Guiana had 27 doctors, or one doctor for 1850 inhabitants.Other health personnel Maternal and child health care was provided at included eight dentists and 13 midwives. The training the hospital outpatient department, which in 1972 school for nurses organized a 28- months course which recorded 2852 attendances by pregnant women, 3828 was attended by 19 students, of whom nine graduated for infants and 251 for children aged1 -5 years. in 1972. French Guiana also had one tuberculosis and one venereal diseases outpatient clinic. Communicable disease control and immunization services There is malaria transmission in the rural areas of Environmentál sanitation French Guiana. Aedes aegypti is still present in the The urban areas in French Guiana were provided department in spite of great efforts ro eradicate this with piped water systems which served all of their vector.Tuberculosis is also present, with 51 cases in inhabitants.Sewerage systems existed in two com- 1971 and 41 in 1972. The incidence of syphilis doubled between 1971 and 1972, whereas the number of munities. gonorrhoea casesslightly decreased.There were altogether 311 venereal disease cases in 1972. Assistance from PAHO /WHO The following immunization procedures were car- In 1972 PAHO /WHO's assistance to French Guiana ried out in 1971: included the following projects :

Yellow fever 14 349 Malaria eradication programme (1963- ) Smallpox 5 201 Diphtheria, tetanus and poliomyelitis 2 731 Laboratory services (1967- ):todevelop the Diphtheria,whooping- cough,tetanusand virus research laboratory of the Pasteur Institute in poliomyelitis 1 516 Poliomyelitis 1 149 Cayenne.

MARTINIQUE Population and other statistics malignant neoplasms(269),hypertensivedisease, At the last census, taken in October 1967, the popu- ischaemic heart disease and other forms of heart disease (238), cerebrovascular disease (167), congenital lation of Martinique was 320 030.Population estimates and some other vital statistics for the period anomalies, birth injury, difficult labour and other under review are given in the following table: anoxic and hypoxic conditions, other causes of perinatal mortality (117), cirrhosis of the liver (79), diabetes 1969 1970 1971 1972 mellitus (33), tuberculosis, all forms (32), bronchitis, Mean population . 332 300 338 200 340 000 340 000 emphysema and asthma (30), accidents (27, including Number of live births' . 8893 9275 9214 8657 Birth rate 26 in motor -vehicle accidents), pneumonia (26). (per 1000 population) 26.8 27.4 27.1 25.5 The communicable diseases most frequently notified Number of deaths 1. . 2 493 2 559 2 230 2 280 Death rate in 1971 were: tuberculosis, all forms, new cases (97), (per 1000 population) . 7.5 7.6 6.6 6.6 Natural increase ( %) . 1.93 1.98 2.05 1.89 gonorrhoea (66), syphilis, new cases (29), typhoid and Number of infant deaths 344 316 258 243 paratyphoid fevers (14), meningococcal infections (7). Infant mortality rate

(per 1000 live births) . 38.7 34.1 28.0 28.1 Number of deaths, Hospital services 1 -4 years 113 65 Death rate, 1 -4 years (per In 1968 Martinique had 15 hospitals, providing a 1000 population at risk) 2.8 1.7 Number of maternal total of 3741 beds, to which 42 698 patients were deaths 11 4 Maternal mortality rate admitted during the year.The bed /population ratio (per 1000 live births) . 0.03 0.01 was 11.5 per 1000.The 3741 beds were distributed 1 Data exclude the number of infants dying before registration of birth. as follows: Category and number Number of beds Of the 2230 deaths recorded in 1971, the main causes General hospitals 2 2 068 were: symptoms and ill- defined conditions (409), Rural hospitals 7 1 008 Tuberculosis hospital 1 196 Maternity hospitals 4 109

1 International Classification of Diseases, 1965 Revision. Psychiatric hospital 1 360 132 FIFTH REPORTON THEWORLD HEALTH SITUATION

Outpatient facilities were available in 1972 at eight Immunization services hospital outpatient departments and at three poly- The following immunization procedures ware car- clinics which provided hospitalization facilities. ried out in 1971: Diphtheria, tetanus and typhoid and paratyphoid fevers 19085 Medical and allied personnel and training facilities Smallpox 18668 Poliomyelitis 12052 Diphtheria,whooping- cough,tetanus,and In 1971 Martinique had 214 doctors, equivalent to poliomyelitis 7140 one doctor per 1590 inhabitants.Other health per- Diphtheria, tetanus and poliomyelitis 5644 Typhoid and paratyphoid fevers 1994 sonnel included: Yellow fever 1148 Diphtheria, whooping -cough and tetanus . . . 541

Dentists 75 Pharmacists 83 Specialized units Midwives 89 In 1972 maternal and child health care was based on The arrangements for the training of nurses and 47 prenatal centres and three child health centres. midwives in Martinique were as follows: During the same year 8580 deliveries were conducted in hospital under professional supervision.Of the Category Duration Number of Number of Number of total school population, 87 % had access to health and of study schools studentsgraduates medical services provided by the school health unit. (public) 1971/72 1972 Martinique hadalsoonepsychiatricoutpatient Nurses 28 months 1 87 53

Midwives 3 years 1 29 5 clinic and one public health laboratory.

MONTSERRAT

Population and other statistics MedicalOfficerisresponsibleforthetechnical services, namely the hospital services, the district At the last census, taken in April 1970, the popula- services and sanitation. There are two district medical tion of Montserrat was 11 458. Population estimates officers, one in charge of the central district and the and some other vital statistics are given in the fol- other in charge of the two rural districts. The hospital lowing table: matron is responsible for all nursing services and the 1969 1970 1971 1972

Mean population . . 14 608 12 300 11 837 12 444 chief health inspector for the sanitation services.

Number of live births . . 264 302 269 318 Birth rate

(per 1000 population) . 18.1 24.6 22.7 25.6 Hospital services Number of deaths . . . 138 121 123 144 Death rate In1970 Montserrat had one generalhospital (per 1000 population) . 9.4 9.8 10.4 11.6

Natural increase (%) . . 0.87 1.48 1.23 1.40 providing 58 beds and one maternity centre with Number of infant deaths . 10 13 11 10 28 beds.The total bed capacity of 86 beds was Infant mortality rate

(per 1000 live births) 37.9 43.0 40.9 31.5 equivalent to 7.0 beds per 1000 population. Ambula- tory medical care was available in 1972 at the hospital Of the 144 deaths recorded in 1972, the main causes outpatient department and at 12 health centres. were: 1 hypertensive disease, ischaemic heart disease, other forms of heart disease (35), cerebrovascular Medical and allied personnel and training facilities disease (17), malignant neoplasms (17), symptoms and ill- defined conditions (10), pneumonia (9), diabetes In 1969 Montserrat had eight doctors of whom four mellitus (6). were in government service.The doctor /population The communicable diseases most frequently notified ratio was one to 1880. Other health personnel included : in 1972 were: influenza (33), gonorrhoea (19), tuber- Dentists 2 culosis, all forms, new cases (2), measles (21. Dispensers 5 Veterinarian 1(1968) Midwives 9 Organization of the public health services Nurses 19 Student nurses 16 The medical and public health services of Montserrat Nursing auxiliaries 18 Sanitary inspector 1 are under the supervision of the Minister of Health, Assistant sanitarians 3 Education and Welfare. The Permanent Secretary is Laboratory technician 1 X -ray technician 1 in charge of the administration, whereas the Chief Nursing and midwifery training is carried out at 1 International Classification of Diseases, 1965 Revision. one school, which offers a three -year course for nurses REGIONOF THE AMERICAS 133 and a one -year course for midwives.In 1971/72 development finance and marketing corporation was there were 13 student nurses and four student mid- established, providing various types of credit urgently wives. needed by farmers. An agricultural laboratory started functioning.Plans for low- income housing schemes Specialized units were developed. A provident fund was established In 1972 prenatal care was given to 308 pregnant which eventually will reduce the dependence of the women and domiciliary care to 450 children aged 0 -5 aged on public assistance.A water authority was years.All deliveries were attended by a doctor or also established. qualified midwife, either in hospital (257 deliveries) or at home (61deliveries). One dental health unit Assistance from PAHO/WHO provided services to 4124 adults and schoolchildren. In 1972 PAHO /WHO's assistance to Montserrat There was also one psychiatric outpatient clinic. included the following projects: Environmental sanitation Engineering and environmental sciences (1972 - UNDP: to train environmental health personnel. In 1972, of Montserrat's total population, 60 had piped water and 40 % had water from public Aedes aegypti eradication (1969- ) fountains. Laboratory services (1968- ):to develop the laboratory services in Dominica to enable them to Major public health problems provide specialized pathology services for the island and for Montserrat. Protein malnutrition, especially in the pre -school age group, is one of the main health problems in Montserrat. Other health problems concern the Government health expenditure incidence of gastroenteritis, gonorrhoea, diabetes and In 1972 total government expenditure amounted to hypertension. EC $5 701 414, of which $544 401 represented the centralgovernment'scurrenthealthexpenditure, Social and economic developments of significance for giving a per capita expenditure of $43.7. The govern- the health situation ment contributionsto healthactivitiesof social During the period under review emphasis was given security schemes and other nongovernmental social to the development of the agricultural sector. A welfare systems amounted to EC $1200.

ST KITTS, NEVIS AND ANGUILLA

Population and other statistics disease, ischaemic heart disease and other forms of heartdisease(77),cerebrovasculardisease(77), At the last census, taken in April 1970, the popula- symptoms and ill- defined conditions (64), congenital tion of St Kitts, Nevis and Anguilla was 64 000. anomalies, birth injury,difficult labour and other Population estimates and some other vital statistics for St Kitts -Nevis for 1969 -1971 are given in the anoxic and hypoxic conditions, other causes of perinatalmortality(58),pneumonia (47),malignant following table: 1969 1970 1971 neoplasms (40), bacillary dysentery and amoebiasis, Mean population 51 047 50 378 50 804 enteritis and other diarrhoeal diseases (27), diabetes Number of live births 1 226 1 156 1 107 mellitus(25),avitaminoses and othernutritional Birth rate (per 1000 population) . . 24.0 22.9 21.8 Number of deaths 414 633 439 deficiency (19). Death rate (per 1000 population) . 8.1 12.6 8.6 The communicable diseases most frequently notified Natural increase ( %) 1.59 1.03 1.32 Number of infant deaths 56 56 72 in 1972 were: gonorrhoea (81), whooping -cough (67), Infant mortality rate (per 1000 live births) 45.7 48.4 65.0 syphilis, new cases (51), influenza (16), tuberculosis, Number of deaths, 1 -4 years . 20 23 11 all forms, new cases (15), infectious hepatitis (6), Death rate, 1 -4 years (per 1000 popu- tion at risk) 3.4 4.0 1.9 measles(4),scarletfever and streptococcalsore Number of maternal deaths . . . . 5 2 throat (4). Maternal mortality rate (per 1000 live births) 4.1 1.7 0.9 Hospital services Of the 541 deaths recorded in 1972, the main causes were: 1 chronic rheumatic heart disease, hypertensive In 1971St Kitts, Nevis and Anguilla had five hospitals with 257 beds, equivalent to 5.0 beds per 1 International Classification of Diseases, 1965 Revision. 1000 inhabitants. The 257 beds, to which 4147 patients 134 FIFTH REPORT ON THE WORLD HEALTH SITUATION were admitted during the year, were distributed as 2077 domiciliary visits were paid toinfants and follows : 3507 to children aged 1 -5 years.All deliveries were Category and number Number of beds attended by qualified health personnel.The health General hospitals 2 218 of the total school population was supervised by the Rural hospital 1 20 Psychiatric hospital 1 6 district public health nurse.Dental treatment was Leprosarium 1 13 given at five dental health clinics.Other specialized Outpatient facilities were available at four hospital units included three psychiatric outpatient clinics outpatient departments, one polyclinic,16 health which recorded 26 new patients in 1972, one leprosy centres and four dispensaries. outpatient clinic and one public health laboratory which carried out over 26 000 examinations during 1972. Medical and allied personnel and training facilities Environmental sanitation In 1971 St Kitts, Nevis and Anguilla had 16 doctors, of whom 14 were in government service. The doctor/ The total population of St Kitts has access to piped population ratio was thus one to 4180. Other health water; however 19 487 inhabitants including 86 % of personnel included: the urban population and 35 % of the rural population have piped water house connexions. Dentists 3 Chemists and druggists (with certificate to practise) 13 Veterinarian 1 Local midwives 7 Assistance from PAHO /WHO Nurse /midwives 15 Nurses 43 Student nurses 65 In 1972 PAHO /WHO's assistance toSt Kitts, Auxiliary nurses 2 Nevis and Anguilla included the following projects: Sanitarians 14 Laboratory technicians 4 X -ray technicians 2 Aedes aegypti eradication (1969- ): to eradicate Nonmedical hospital administrator 1 Aedes aegypti from the West Indies including St Kitts. Aedes aegyptiinspector 1 Laboratory services (1968- ): to develop the The training of nurses is carried out in a three -year laboratory services in Dominica to enable them to course available at two hospitals -the J. N. France provide specialized pathology services for the island General Hospital in Basseterre and the Alexandra and for St Kitts. Hospital in Nevis.The midwifery training course Familyplanningprogramme, StKitts -Nevis In lasts one additional year for graduate nurses. (1971- )UNFPA: todevelopanintegrated 1971/72, there were 26 nursing students, of whom maternal and child health and family planning pro- eight graduated, and seven midwifery students and gramme. graduates.

Government health expenditure Immunization services In 1972 total government expenditure amounted to The following immunization procedures were car- 14 266 161East Caribbean dollars.of which EC ried out in 1971: $14 078 944 were spent on current account and $187 217 on capital account. The Ministry of Educ- Typhoid and paratyphoid fevers 15153 Smallpox 3323 ation, Health and Welfare accounted for EC $1 635 795 Diphtheria, whooping -cough and tetanus 2444 on current account and other ministries for $199 622. Poliomyelitis 1510 BCG 767 The current expenditure on general public health servicesincluded EC$1 015 290 for administration and government personnel, $20 422 for immunization Specialized units and vaccination activity, $4000 for laboratory services, $145 183 for environmental health services and $2000 In 1972 maternal and child health care was based for veterinary services.The current expenditure on on 19 prenatal centres and 22 child health centres, hospitals included EC $278 515 for general hospitals which were attended by 1038 pregnant women and and clinics,$58 099 for specialized hospitals and 3141 children aged 1 -5 years. During the same year, $93 786 for other health establishments. REGION OF THE AMERICAS 135

ST LUCIA

Population and other statistics Outpatient facilities were available at four hospital outpatient departments, 24 health centres and two At the last census, taken in April 1970, the popula- dispensaries. tion of St Lucia was 101 100. Population estimates and some other vital statistics for the period under review are given in the following table: Medical and allied personnel

1969 1970 1971 1972

Mean population . . 99 802 101 500 103 200 104 500 In 1972 St Lucia had 28 doctors, or one doctor for Number of live births. . 4209 4936 4 208 4 300 Birth rate 3730 inhabitants. Other health personnel included: (per 1000 population) . 42.1 48.6 40.6 41.1 Dentists 2 Number of deaths . . . 810 852 804 971 Death rate Pharmacists 11 Veterinarian 1 (per 1000 population) . 8.1 8.4 7.8 9.3 Nurse /midwives Natural increase (%) . . 3.40 4.02 3.28 3.18 62 Number of infant deaths . 197 296 148 225 Sanitary engineer 1 Infant mortality rate Sanitarians 18 Physiotherapists (per 1000 live births) . 46.8 60.0 35.2 52.3 2 Number of deaths, Laboratory technicians 11 X -ray technicians 1 -4 years 61 61 41 64 2 Death rate, 1 -4 years (per 1000 population at risk) 4.3 4.2 3.0 4.3 Number of maternal deaths 3 1 Immunization services Maternal mortality rate (per 1000 live births) . 0.7 0.2 The following immunization procedures were car- Of the 971 deaths recorded in 1972, the main causes ried out in 1972: were:chronic rheumatic heart disease, hypertensive Poliomyelitis 92415

disease, ischaemic heart disease, other forms of heart Diphtheria, whooping -cough and tetanus . . 5635 disease (127), cerebrovascular disease (86), pneumonia BCG 552 Smallpox (79), birth injury, difficult labour and other anoxic 462 and hypoxic conditions, other causes of perinatal mortality (78),bacillary dysentery and amoebiasis, Specialized units enteritis and other diarrhoeal diseases (74), symptoms and ill- defined conditions (57), influenza (42), accidents In 1972 St Lucia had 26 maternal and child health (29, including 8 in motor -vehicle accidents). centres, which were attended by 3697 pregnant women The communicable diseases most frequently notified and 3336 infants.Dental treatment was given to in 1972 were: influenza (2629), gonorrhoea (628), 4869 schoolchildren at two dental health units, and to syphilis,new cases(495),schistosomiasis(432), 5486 adults at three dental health units. measles (343), whooping -cough (172), tuberculosis, all forms, new cases (74), typhoid fever (38), bacillary dysentery (17), yaws, new cases (10). Assistance from PAHO f WHO

In 1972 PAHO /WHO's assistance toSt Lucia Hospital services included the following project: In 1972 St Lucia had six hospitals and other inpatient Aedes aegypti eradication (1969- establishments, providing 512 beds, of which 400 beds were in four government establishments.The bed/ population ratio was 4.9 per 1000. The 512 beds were Government health expenditure distributed as follows:

Category and number Number of beds In 1972 total government expenditure was EC

General hospitals 2 333 $32 476 312.The central government health expen- Rural hospitals 2 57 diture amounted to EC $2 854 595, of which $2 512 017 Mental hospital 1 110 Other establishment 1 12 were spent on current account and $342 578 on capital account. The per capita government expenditure on 1 International Classification of Diseases, 1965 Revision. health was EC $27. 136 FIFTH REPORT ON THE WORLD HEALTH SITUATION

SURINAM

Population and other statistics to indigents. A social security scheme is being developed which comprises a general health insurance plan At the last census, taken in January 1972, the popu- for the whole territory. The Ministry of Public lation of Surinam was 384 900. Population estimates Works is responsible for the disposal of solid wastes and some other vital statistics for the period under and for sewerage. review are given in the following table:

1969 1970 1971 1972 " Hospital services

Mean population . 380 000 390 000 410 000 420 000 Number of live births . 13114 12 710 13 754 14 603 In 1971 Surinam had 17 hospitals and inpatient Birth rate

(per 1000 population) 36.05 34.15 36.13 37.51 establishments providing altogether 2112 beds, of

2 640 2 396 Number of deaths . . 2 465 2 584 which 1605 were in seven government hospitals. The Death rate

(per 1000 population) 6.78 6.94 6.93 6.15 bed /population ratio was 5.2 per 1000 population. Natural increase ( %) . 2.93 2.72 2.92 3.14 Number of infant deaths 387 469 538 310 Ambulatory health care was available in 1972 at Infant mortality rate the hospital outpatient departments; at 20 health (per 1000 live births) 29.51 36.90 39.12 21.20 Number of deaths, centres, which are staffed by a doctor, one or more 1 -4 years 142 206 148 132 nurses, a midwife, a pharmaceutical assistant and Number of maternal deaths 6 9 12 4 auxiliary workers, and of which 13 provided hospi- Maternal mortality rate talization facilities; at 21 dispensaries; at 38 medical 0.46 0.71 0.87 0.27 (per 1000 live births) aid posts staffed by a male auxiliary nurse; and at " Provisional figures. two mobile health units. Of the 2396 deaths recorded in 1972, the main causes were: 1 chronic rheumatic heart disease, hypertensive Medical and allied personnel and training facilities disease, ischaemic heart disease, other forms of heart In 1971 Surinam had 173 doctors, of whom 63 disease(171),congenital anomalies,birthinjury, labour and other anoxic and hypoxic condi- were in government service.The doctor /population Other health personnel tions,other causes of perinatalmortality(147), ratio was thus one to 2370. malignant neoplasms (123), cerebrovascular disease included:

(112),symptoms andill- definedconditions(65), Dentists 23 accidents (56, including 33 in motor -vehicle accidents), Pharmacists 13 Pharmaceutical assistants 23 pneumonia (47), diabetes mellitus (46), bronchitis, Midwives 42 Assistant midwives 10 emphysema and asthma (32), nephritis and nephrosis Nurses 395 (23). District nurses 17 Assistant nurses 118 The communicable diseases most frequently notified Nursing auxiliarles 378 in 1971 were: malaria, new cases (1547), leprosy (194), Sanitary engineer 1 Sanitarians 56 tuberculosis,allforms, new cases(100), typhoid Laboratory technicians 39 fever (20), amoebic dysentery (13), paratyphoid fevers Auxiliary laboratory personnel 16 X -ray technicians 24 (9), diphtheria (4). Health educator 1 Nutritionist 1

Organization of the public health services In 1969 a faculty of medical sciences with a seven - Surinam's public health administration is highly year curriculum was started by the University of centralized. The responsibility for the health services Surinam under the Ministry of Education.Between 1966 and 1972 some 30 medical students were each rests with the Ministry of Health, which coordinates the health services provided by the Government, year sent to the University of Leyden in the Netherlands for the three -year preclinical training period.Since privatereligiousorganizationssubsidized bythe Government, and private industrial enterprises. The 1972, with the opening of the institute for basic Ministry of Education is responsible for the training medical sciences, the whole medical training programme is provided in Surinam. By the end of 1972, of doctors and the Ministry of Social Affairs provides 160 medical students were enrolled in the medical custodial care for the elderly, a feeding programme for selected groups of schoolchildren and a medical faculty. Nurses are trained in one public and two private care payment scheme as part of the socialassistance nursing schools, which offer a three -and -a- half -year 1 International Classification of Diseases, 1965 Revision. course.Preliminary steps were taken to reorganize REGION OF THE AMERICAS 137

the basic training programme for nurses.In 1972 a of the population were reasonably well supplied with survey of nursing needs and resources was carried out. drinking- water. Postbasic courses were started and nursing tutors are being trained.One public and two private schools for midwifery training organize a three -year course. Major public health problems Since the end of 1968 three centralized officially recognized two -year training courses for nursing aux- The main public health problems in Surinam are iliaries have started each year. During the school year the need for an evaluation and reorganization of the 1971/72, 196 nurses, 188 nursing auxiliaries and 49 administrativeinfrastructureand foranational midwives were enrolled at these schools and 30 nurses, health plan, and the lack of a sufficient number of 54 nursing auxiliaries and 22 midwives graduated. adequately trained personnel.Programmes for inte- Other training facilities in Surinam included one grated and regionalized rural health services, including school for medical laboratory assistants (two -year environmental health, maternal and child health, course) with 18 students and two graduates in 1971/72; dental health, mental health, control of vectors and one school for pharmaceutical assistants (three -year parasites and leprosy control are also needed.The course) with 48 students and four graduates; one increased number and improved distribution and school for laboratory technicians (four -year course) utilization of health facilities and health manpower, with 63 students and nine graduates. the improvement of hospital facilities and a general health insurance plan should contribute to the extension of health coverage. Communicable disease control and immunization services Programmes exist for malaria eradication, Aedes Social and economic developments of significance for aegypti eradication, and for the control of tuberculosis, the health situation leprosy, filariasis, and intestinal parasites.A pilot project is being prepared to try out new methods for During the period under review, in the absence of the control of schistosomiasis. Immunization against stated policies and long -term planning, the general smallpox, poliomyelitis, diphtheria, whooping -cough trend of development in Surinam was short -range and tetanus is statutory, but is not regularly enforced programming accordingtoavailablefunds with in all localities. emphasis on social security and improved living and The following immunization procedures were car- working conditions, consolidation of existing facilities ried out in 1971: and gradual replacement of dilapidated structures. Initiatives of private enterprise, selectively endorsed Smallpox 12676 by the Dutch Development Aid, covered a great part Poliomyelitis 12000 Yellow fever 1146 of the capital investment, while the local government Cholera 226 resources were used for current expenditure.Rural development was encouraged through the promotion Specialized units of small -scale farming, education of women in home economics, provisionof electricity and drinking - In1972 maternal and child health services were water and improved road and telephone communi- available in two centres.School health services were cations.Development activities in the interior of provided at one centre, which was attended in 1971 by Surinam are relatively simple and comprehensive. On 19 440 schoolchildren. Dental care was given in 1972 a modest scale regional systems are being developed to 18 090 schoolchildren at one dental health clinic. in which preventive and curative medicine as well as In 1972 the independent medical rehabilitation centre general education are integrated.Locally trained recorded 233 new outpatients.Psychiatric treatment auxiliaries who work under the supervision of trained was provided at three outpatient clinics to 12 731 nurses are extensively used.Radiotelephone com- patients. There were also clinics for the treatment of munications and air connexions have been established. schistosomiasis,filariasis, tuberculosis and leprosy. General education at the primary level is compulsory Surinam also has one public health laboratory. and free of charge, but is still seriously limited by the shortage of classrooms and teachers.Activities in Environmental sanitation this sector mainly consisted in building schools. The literacy rate was estimated at 70 to 80 % of the popula- At the end of 1971 it was estimated that 153 000 tion aged 15 years and over. The unemployment rate of Surinam's total population were living in houses was estimated at 18 to 20 % of the economically connected to a piped water system and a further active population, excluding the tribes in the interior 124 000 had easy access to piped water. Thus 72.5 of the territory. 138 FIFTH REPORT ON THE WORLD HEALTH SITUATION

National health planning sanitation programme and a rural water supply programme. National health planning is still at a preliminary stage. There is, however, a growing awareness of the Water supplies (1964- ) UNDP: to plan and necessity for a systematic approach to the establishment design piped water supply and sewerage systems for of an infrastructure and administrative framework. communities in the Lower Surinam River basin No new health programmes have been initiated but (excluding Paramaribo) and the heavily populated existing programmes have been reinforced and great coastal area, and for selected inland communities. emphasis has been placed on better availability and Aedes aegypti eradication (1969- ) UNDP accessibility of health services.The needs for the Health services (1965- ): to improve and extend extension of the health coverage are being assessed the health services in accordance with the national but this is hampered by insufficient data. health plan, improve their administration, and train health personnel. Assistance from PAHO /WHO Medical education (1968- ): to strengthen and improve medical educationat theUniversity of In1972 PAHO /WHO's assistancetoSurinam Surinam, Paramaribo. included the following projects:

Malaria eradication programme (1957- ) Government health expenditure Veterinary public health (1971- ):to develop measures for the control of zoonoses and set up a In 1971 total government current health expenditure amounted to 176 977 580 Surinam guilders, of which veterinary laboratory. 13 289 020 were spent by the Ministry of Health. The Engineering and environmental sciences (1971- ): per capita expenditure on health services was 431 to plan and implement a general environmental guilders.

TURKS AND CAICOS ISLANDS

Population and other statistics dispensaries in the rest of the Islands and some of them have bed accommodation. At the last census, taken in October 1970, the popu- Outpatient facilities were available in 1972 at the lation of the Turks and Caicos Islands was 5500. hospital outpatient department, and at six health Population estimates and some other vital statistics centres and six medical aid posts. Maternal and child for 1970 and 1971 are given in the following table: health care was available at four centres. About 90 of all deliveries were attended by a doctor or qualified 1970 1971 midwife.Dental care services were provided at one Mean population . . . 6000 6000 dental unit. Number of live births . . 176 190 Birth rate (per 1000 population). 29.3 31.7 Medical and allied personnel Number of deaths . . . 47 59 Death rate (per 1000 population) . 7.8 9.8 In 1970 there were two doctors in the Islands. Natural increase ( %) . . 2.15 2.19 There were also a public health inspector and two Number of infant deaths . 8 9 Infant mortality rate (per sanitarians. 1000 live births) . . . 45.5 47.4 Government health expenditure Hospital services In 1972 the total government health expenditure In 1970 hospital accommodation was provided at one on current account amounted to 160 000 Jamaican general hospital with 18 beds and at an infirmary in dollars. The per capita expenditure for health purposes Grand Turk which had 10 beds. In addition, there are therefore amounted to approximately $26.7. SOUTH -EAST ASIA REGION

INDIA

Population and other statistics hospitals, 1270 beds in 20 paediatric hospitals, 17 916 At the last census, taken in April 1971, the popula- beds in 38 psychiatric hospitals, and 35 177 beds in 521 tuberculosis clinics. tion of India was 547 367 926. The following are popu- The bed /population ratio lation estimates for the period under review: was 0.6 per 1000. The primary health centres and subcentres form the 1969 527950000 nucleus of all health services in the rural areas. 1970 539860000 1971 551827000 Inadequate financial resources and the shortage of 1972 563490000 medical and paramedical personnel have seriously The birth rate was 37 per 1000 in 1970, the death handicapped the provision of services by these prima- rate 15.9 per 1000, and the infant mortality rate 139 ry health centres to the growing population. The per 1000 live births. The estimated rate of population fifth plan envisages an increase in the number of growth was thus 2.11 %. primary health centres and subcentres to one sub - centre for 5000 inhabitants, converting about 200 Organization of the public health services primary health centres to make 30 referral hospitals, and upgrading taluka and district level hospitals.In Health is primarily a subject for state adminis- 1972 there were 5192 primary health centres, in the trations under the Constitution. The Central Govern- country, of which 2101 have been functioning with ment determines the broad health policy and planning one doctor, 2951 with two doctors and 140 without through the Central Health Council.It also arranges doctors.The staffing pattern of the primary health for the collection and exchange of information and centres is being expanded to provide the basic health renders financial and technical assistance to the state infrastructure for the communicable diseases eradi- and Union territory governments and other bodies cation programmes, particularly the malaria eradi- for the implementation of important health pro- cation programme.In 1971 there were also 10 272 grammes, including the control of communicable dispensaries. and other major diseases throughout the country. The Ministry of Health and Family Planning Medical and allied personnel and training facilities comprisestheDepartmentofHealthandthe Directorate -General of Health Services. In 1970 India had 112 000 doctors, or one doctor The central directorate -general of health services for 4820 inhabitants. Other health personnel included: is administered by the Director -General of Health Dentists 9000 Services who is assisted by the Additional Director - Pharmacists 51000(1967) Auxiliary nurse /midwives 39000 General, the Deputy Director -General (Medical), the Nurses 66000 Director of Civil Defence, the Drugs Controller Health visitors 7800 (India), the Senior Architect, the Additional Senior The arrangements for the education and training Architect, the Director of the Central Government of medical and health personnel were as follows : Health Scheme and the Director of Administration. Category DurationNumber of Number of Number of UndertheAdditionalDirector -Generalarethe and admission of study schools 1studentsgraduates following:theDirectorof thenational malaria requirements (years) 1971/72 1972 programme, Director - Doctors eradication theAssistant premedical education 4'/, 83 (16) 12 673 9 587 General (BCG), the Deputy Director -General (Health Dentists 4 15* 586 ** ... Pharmacists 2 34 1 749 ** Administration), the Director of the Central Health Nurses (university level) 21/2 14 (4) 739 194 Education Bureau, the Tuberculosis Adviser,the Nurses matriculation 3 % 248* 19 099 5 779 Director of the National Institute of Communicable Midwives Diseases, and the Deputy Director -General (Small- 2 or 3 years of secondary education 2 312* 11 002 5 036 pox). Laboratory technicians 1 25* 600 ** Radiographers 2 20* 250 ** Sanitation assistants 1 35* 2 000 ** Hospital services Dental auxiliaries (operating) 4 15* 586 ** In 1969 India had 14 286 hospitals and establishments for inpatient care providing a total of 331 633 1 Public (private) schools. * Public and private schools combined. beds. This figure includes 8331 beds in 166 maternity ** Annual admission capacity. - 141 - 142 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Communicable disease control and immunization services The production of freeze -driedvaccineisbeing increased. The national malaria eradication programme was The national leprosy control programme became a launched in India in 1958 /59.The total number of centrally sponsored programme in 1969/70.Itis malaria cases reported at the end of 1972 was 0.74 now operating in 23 states and Union territories, million, compared with 75 million cases in 1952. The covering 25 % of the high and moderate endemicity entire country is covered by 39 325 malaria unit areas. areas; 234 control units and 1443 survey, education Technical guidance and assessment of the programme and treatment centres attached to the primary health and training of personnel are carried out by the centres are functioning under the programme in Central Government. In 1969/70, 26 % of the popu- whichvoluntaryorganizationsandinternational lation was living in areas in the attack phase, 18 % in agencies are also participating.The incidence of the consolidation phase and 56 % in the maintenance venereal disease is high in large cities, industrial and phase. There has been a sharp increase in the incidence pilgrimagecentres,seaportsandinsome sub - of malaria in urban areas due to certain operational Himalayan tracts.The venereal disease control pro- and administrative deficiencies. gramme is a centrally sponsored scheme with 172 There has been an increase in the number of cases clinics.Training and research are carried out at two of smallpox in 1972 over 1971. This increase can be centres, at Madras and Delhi. The national trachoma attributed to the improved reporting and surveillance control programme which was launched in1963 activities. The cases recorded during 1972 are mostly continued to operate in the various states of the concentrated in three states -Bihar, Uttar Pradesh country. At the end of 1972, 63.9 million inhabitants and West Bengal.In other states, the situation has were covered by the programme. No case of plague has improved considerably. Top priority is given to pri- been reported since 1967.The national filariasis mary vaccination, timely detection and reporting of control programme which was started in 1955 operates cases, epidemiological investigations todetect the 119 control units. source of infection and effective containment measures. The following immunization procedures were car- Freeze -dried vaccine is produced in four centres in ried out in 1968 and 1971: the country. The national cholera control programme, Smallpox 82980000(1968) which started during the fourth five -year plan, has Cholera 15200000(1968) been made a centrally sponsored scheme, which BCG 10423000(1971) initially covered the seven states having large endemic Chronic and degenerative diseases areas, namely Andhra Pradesh, Bihar, Maharashtra, Mysore, Orissa, Tamil Nadu and West Bengal.It Cancer is not notifiable and there are no accurate has been recently extended to the remaining states. statistics available on the extent of the problem.It Thanks to the ready availability of modern therapy, is estimated that about 200 000 persons die of cancer the cholera mortality rate has dropped considerably. annually and that the morbidity rate is 85 per 100 000. Adequate quantities of cholera vaccine are available The Indian Council of Medical Research has been in the country. supporting fundamental, experimental, and clinical Under the national tuberculosis programme 547 research and epidemiological studies in cancer.In tuberculosis clinics are functioning in the country, of addition Tata Memorial Hospital, Bombay and the which 264 are district tuberculosis centres.Nearly ChittaranjanNationalCancerResearchCentre, Calcutta were also engaged in the study of cancer in 37 000 tuberculosis beds are available in the country the country. and17tuberculosisdemonstration and training Although it is difficult to assess the exact magnitude centres are functioning.It is proposed to establish of the mental health problem, it has been estimated one such centre in each state to provide basic training that between 1 % and 3 % of the population is mentally to different categories of personnel.Research acti- retarded. Major socioeconomic and cultural changes vities related to the epidemiology and surveillance followed by rapid growth of population and fast programmes are being conducted at the National urbanization have aggravated the problem.There Tuberculosis Institute, Bangalore. BCG vaccination are 38 mental hospitals with 17 916 beds in the is continued as an integral part of the national tuber- country. Among the inpatients admitted to these culosis control programme. A total of 282 vaccination hospitals during 1969, psychosis accounted for 91 %. teams have been functioning, 251 million persons The organization of mental health services, it is being have been tuberculin- tested and nearly 170 million realized, has to be effected through community based have been vaccinated with BCG. It is planned to pro- services.Mobile mental health teams are at present vide one BCG team for each district by the end of the operating in some rural areas of the country where no fourth plan to give BCG vaccination to all newborns. mental health services are available. SOUTH -EAST ASIA REGION 143

Specialized units has been gradually deteriorating. The availability of In 1972 maternal and child health care was provided health manpower in the country isstill below the at 48 482 service units: maternal and child health recommended norms.In order to bridge this gap a centres, primary health centres and subcentres in national strategy for health has been formulated rural areas; and maternal and child health centres, particularly with reference to the goals to be pursued maternity homes, maternity wards in general hospitals, during the fifth five -year plan (April 1974 -March maternity hospitals, and children's wards in general 1979). The most important component of the strategy hospitals, in urban areas. As dental diseases among for health concerns the rural areas. children and adults are increasing at an alarming rate, efforts have been made to provide dental care facilities Medical and public health research and dental education. There are at present 248 dental Research activities are coordinated by the Indian clinics at the district level, 130 at taluka and 85 at Council of Medical Research. They are wholly primary health centres, and 55 at various hospitals. financed by the Government of India.The Council In addition, five mobile units have been established gives financial support to a large number of research to serve the rural areas. Psychiatric consultations were projects.The scientific work of the Council is con- given in 1969 at 29 outpatient departments of 38 ducted inthe followinginstitutes:the National psychiatric hospitals; there were 59 984 new outpa- Institute of Nutrition, Hyderabad, the Virus Research tients.Other specialized outpatient facilities in 1972 Centre, Poona, the Tuberculosis Chemotherapy Centre, included 547 tuberculosis clinics, 189 venereal disease Madras, the Cholera Research Centre, Calcutta, the clinics, 234 leprosy control units, and 1448 leprosy Indian Registry of Pathology, New Delhi, the National survey, education and treatment centres.India had Institute of Occupational Health, Ahmedabad, the 216 public health laboratories. Institute for Research in Reproduction, Bombay. The National Institute of Communicable Diseases, Delhi, National health planning was established in 1963 as the national centre for research and training in communicable diseases and The first and the second five -year plans incorporated the general policy for development of health with their control in India. emphasis on control of communicable diseases, improvement of environmental sanitation, provision of Assistance from WHO maternal and child health services, training program- In 1972 WHO's assistance to India included the mes, health education and nutrition.The broad following projects: objectives of the third plan were to expand the health services, and increased emphasis was laid on preven- Tuberculosis Chemotherapy Centre, Madras tive and public health services. The fourth plan stressed (1955- ) UNDP: to undertake controlled clinical the expansion of medical and public health facilities, trials to find simple, effective and inexpensive methods and efforts were made to provide an effective base of tuberculosis control through domiciliary chemo- for health services in rural areas. The main emphasis therapy of ambulant patients, and to carry out related of the fifth five -year plan has been given to the devel- research. opment of rural health services.During the first Leprosy control (national programme) (1961- ) plan period the outlay for health was about 5.93 % of UNICEF: to develop a leprosy control programme and the total investment.Similarly during the second, train the necessary staff. third and fourth plans the health outlay was 4.9 %, National tuberculosis programme (1956- ) 4.2 % and 7.27 % respectively of the total outlay. UNDP UNICEF: to develop a national tuberculosis In the fourth five -year plan (1969/70 -1974/75) out programme; train health workers. of the total allocation for health of 115 553 million Health education; assistance to states (1971- ) rupees, 12 701 million were earmarked for the con- UNDP: to set up and develop state health education trolof communicable diseases, 9822 million for bureaux, and to coordinate the health education education, training and research, 16 478 million for activities of the general health services with those of primary health centres, hospitals, dispensaries etc., the family planning programme or integrate them into 40 700 million for water supply and sanitation, and the programme. 31 500 million for family planning. Although the achievements of planned de\ elop- Medical education (1965- ): to improve teaching ment are by no means insignificant, disparity still and research in medical colleges. exists in the distribution of health services between Paediatric education (1958- ) UNICEF: to ex- the rural and urban areas.The primary health pand and improve teaching of paediatrics in medical centres have too large a coverage and their effectiveness colleges and develop courses in paediatric departments. 144 FIFTH REPORT ON THE WORLD HEALTH SITUATION

IndianCouncil of Medical Research(statistics) Publichealthengineeringeducation(1972- ) (1962- ): to strengthen the Council's statistical UNPD: to train sanitary engineers. unit and train staff for medical research. Nursing administration,Chandigarh and Gujarat Postbasic nursing education (1962- ): to expand (1968- ):to develop nursing administration in postbasic nursing education. teaching hospitals and promote in- service training and coordination of nursing services and nursing Malaria eradication programme (1958- ) education. (U SAID) Virological techniques (1971- ): to develop labo- Productionoffreeze -driedsmallpox vaccine ratory capacity for the diagnosis and surveillance of (1964- ) UNICEF: to increase the production of virus diseases and establish competence in the pro- freeze -dried smallpox vaccine. duction and testing of live poliomyelitis vaccine. Central Public Health Engineering Research Institute, National Instituteof Health Administration and Nagpur (1961- ):to develop the Institute as a Education (1965- ) UNICEF: to conduct studies major research centre for environmental sanitation in district health administration at Rohtak (Haryana) problems, coordinate research programmes and train as a prelude to the promotion and planning of com- research workers. prehensive health care services at the district level; to Applied nutrition programme (1964- ) UNICEF formulate research and teaching programmes per- (FAO): to expand and improve the health component taining to health administration. of the applied nutrition programme assisted by FAO, Seminars and workshopsonmedical education UNICEF and WHO. (1965- ) : to strengthen medical teaching. Strengtheningof healthservices(epidemiology) Drug laboratory techniques and biological standard- (1963- ) UNDP: to establish or improve health ization (1967- ): to develop the services for the intelligence units in state health directorates; to train quality controlof pharmaceutical and biological staff; and to develop the National Institute of Com- preparations and train staff. municable Diseases, Delhi. Water pollution (1971- ): to provide technical Strengthening of health services, Punjab and Haryana advice. (1967- )UNICEF: tostrengthenthehealth Smallpox eradication (1967- ): to develop the services at state, district and local levels. eradication programme, carry out periodic assess- Training of radiological technicians (1967- ): to ments, and train staff. raise the standard of training of radiological technicians Training of medical teachers (1971- ) UNDP: at the Postgraduate Institute of Medical Education to provide further training to medical teachers. and Research, Chandigarh. Cancer control pilot project, Tamil Nadu (1968- ) : Strengthening of laboratory services (1965- ) : to to develop a pilot project for the early diagnosis and strengthen health laboratory services and improve control of oropharyngeal and cervical cancer and set training. up a training centre at Kancheepuram. Training in health education (1968- ): to estab- Training in veterinary public health (1967- ): to lish and develop three postgraduate health education initiate and support studies of zoonoses at the National training centres with rural and urban field practice Instituteof CommunicableDiseases,Delhi,the areas. Haffkine Institute, Bombay, the Indian Veterinary Radiation Medicine Centre, Bombay (1967- ): Research Institute, Mukteswar -Kumaon, and other to strengthen the Centre. institutions, public health laboratories and medical colleges. Medical rehabilitation(1969- )UNICEF: to expand medical rehabilitation services and establish Integration of maternal and child health services into the general health services (1970- ):to integrate training schools in the various disciplines. maternal and child health services, including family Occupational health (1970- ): to conduct courses planning, into the general health services in certain in occupational health and to initiate research projects states. in specific industries. Groundwater training course (1970- ): to train School fortrainingof technicians(1967- ) staff in groundwater development and utilization for UNDP: totraintechniciansintheinstallation, community water supplies. maintenance and repair of electrical and mechanical Strengthening of health statistical services (1972- ) : equipment used in health institutions. to strengthen health intelligence units in state health Improvement of dental education (1966- ) UNDP departments and train staff. SOUTH -EAST ASIA REGION 145

Physical therapy school, Baroda (1968- ): to Strenthening of the teaching of human reproduction, train physical therapists. family planning and population dynamics in nursing and National Institute of Communicable Diseases, Delhi midwifery education (1972- ) UNFPA: to improve (1971- ): to strengthen the faculty of the Institute. the maternal and child health and family planning Nutritiontraining(1970- ):tosupportthe componentsof thetrainingof auxiliarynurse/ National Institute of Nutrition, Hyderabad. midwives; to improve the teaching of human repro- Village water supply (1971- ) UNICEF: to plan duction, family planning and population dynamics in and coordinate the development of community water teaching institutions for nursing personnel. supplies in rural areas, and to train staff. Medical toxicology unit (1972- ): to undertake Nursinginclinicalspecialties,New Delhiand studies of the effect of air pollutants and organochlorine Rajasthan (1972- ):to improve clinical practice pesticides in man. in certain nursing specialties. Control of air pollution (1971- ): to study the Government health expenditure airpollution problems connected with industrial development and promote a control programme. During the fiscal year 1971/72 the government Strengthening of the teaching of human reproduction, expenditure of 6802.1millionrupees on general family planning and population dynamics in medical public health services included the following items : colleges (1971- ) UNFPA: to strengthen teaching 2254.4 million rupees for the control of communicable and research in the relevant departments of medical diseases,1620.2millionformedicaleducation, colleges. training and research, 2138.7 million for hospitals, Strengthening of family planning aspects of nursing dispensaries, primary health centres and other medical administration (1972- ) UNFPA: to strengthen care programmes, 277.1million for Indian social the nursing and midwifery components of health care medicine, including homeopathy, and 411.8 million during the maternity cycle. for other public health programmes.

MONGOLIA

Population and other statistics charge of the Central Institute of Hygiene, Epidemio- logy and Microbiology, the Institute of Quarantinable At the last census, taken in January 1969, the popu- Diseases, the medical Press, and Health Education lationof Mongolia was1 197 600. Population House. The three departments under the Deputy estimates and some other vital statistics for the period Minister for Planning and Finance are: planning and under review are given in the following table: statistics,finance,administrationand economics. 1969 1970 1971 1972 The Medical Institute comes under the authority of the Mean population . . 1210 000 1250 000 1280 000 1320 000 Minister of Public Health. The Ministry also has a Number of live births . . 46 800 50100 Birth rate scientific council. (per 1000 population) . 38.6 40.2 Number of deaths . . . 13900 15 300 The country is divided into 18 aimaks (adminis- Death rate trative regions), each of which has about 20 somons (per 1000 population) . 11.5 12.3 Natural Increase (%) . . 2.71 2.79 (districts). The somons are further divided into brigades. An integrated hospital and a sanitary - Organization of the public health services epidemiological station has been established in each aimak. The aimak hospital serves on average a radius The responsibility for the organization and adminis- of 350 to 400 km and more.Somons have smaller tration of the health services rests with the Ministry hospitals, feldsher and midwife stations. A feldsher of Public Health.The Minister of Public Health is station serves a radius of 15 to 100 km with a popu- assisted by the first Deputy Minister, the Deputy lation of 1000 to 2000.Sometimes, several somons Minister for Hygiene and Preventive Services, the share one hospital.The town and aimak sanitary - Deputy Minister for Planning and Finance, and the epidemiological stations, which are staffed by an advisory board. The first Deputy Minister is in charge epidemiologist,amicrobiologist andahygienist of the three directorates dealing respectively with together with auxiliary personnel, are directed and curative and preventive services, maternal and child guided by the Central Institute of Hygiene, Epidemio- health, and medical supply and industry. The Deputy logy and Microbiology, and are responsible for plan- Minister for Hygiene and Preventive Services is in ning, organizing and performing the public health 146 FIFTH REPORT ON THE WORLD HEALTH SITUATION

activities in their areas.The doctor working at the Communicable disease control somon level is responsible for both medical care and The public health problems in Mongolia appear to public health activities in his district. be mainly the infectious diseases.Viral hepatitis and measles are widespread over theentire country. Hospital services Gastrointestinal infections, associated with the lower In 1970 Mongolia had 351 government hospitals standards of personal and public hygiene in some providing 11 926 beds, or 9.2 beds per 1000 inhabitants. areas, are important public health problems during the These beds were distributed as follows: summer months. Brucellosis and echinococcosis have been recognized as the zoonoses of major public Category and number Number of beds health importance. Streptococcal infections and their General hospitals 76 4917 Rural hospitals 176 1 618 sequelae also seem to be increasingly serious problems. Maternity hospitals 3 506 Outbreaks of diphtheria and whooping -cough were Paediatric hospitals 22 1 500 Infectious diseases hospitals 3 660 a major health and economic problem before the mass Tuberculosis hospitals 46 1 485 immunization campaigns.The incidence of tuber- Psychiatric hospital 1 450 Cancer hospital 1 110 culosis is declining thanks to vaccination programmes. Hospitals for dermatology and venereology 23 680 Specialized units Outpatient facilities were provided in 1972 at 300 hospitaloutpatientdepartmentswhichrecorded In 1972 maternal and child health care was provided 632 600 new outpatients; at 49 polyclinics located in at 61 prenatal service units and 133 child health towns and aimak centres, of which 43 provided hospi- centres; 76 309 pregnant women and 54 379 infants talization facilities and which, altogether, recorded received these services.Domiciliary care was given 2 447 100 attendances; at 1176 health centres which to 38 100 pregnant women and 30 700 infants.All recorded nearly 4 4 million attendances and of which deliveries in 1972 were conducted under professional 327 had inpatient facilities; at 47 dispensaries, of medical supervision.Dental treatment was given at which 44 had altogether 860 beds and which recorded 35 dental health units to over one million patients. 1 327 200 attendances; at 26 medical aid posts, which Otherspecializedhealthestablishmentsincluded recorded nearly 600 000 attendances; at 12 mobile 95 hospital rehabilitation departments, one psychia- health units with 89 000 attendances; at 746 primary tric outpatient clinic, and 32 public health laboratories feldsher health units; and at 23 emergency cafe which carried out over a million examinations in 1972. stations. Each aimak has a tuberculosis dispensary and a dispensary for dermatology and venereal diseases. Medical and allied personnel and training facilities In Ulan Bator there is also an oncological dispensary. At the end of 1972 Mongolia had 2578 doctors, Environmental sanitation includingstomatologists,or one doctor for 512 inhabitants. Other health personnel included: Of Mongolia's 224 communities 19, with a total of inhabitants, piped -watersystem; Feldshers 2107 636 000 had a Pharmacists 172 50 % of the population were thus served; 18.5 % had Assistant pharmacists 800 Nurses 4 628 water from public fountains. Only two communities, Midwives 421 with a population of 33 000, had a sewerage system; Nurse /midwives 95 X -ray technicians 206 only 2.6 % of the population were thus served. Laboratory technicians 596 Dental technicians 48 Major public health problems The arrangements for the training of medical and health personnel were as follows: The control of brucellosis is still regarded as a top priority. Infectious hepatitis, meningitis, influenza and Category DurationNumber of Number of Number of of study schools students graduates enteric infections are still major causes of morbidity. (years) (public) 1971/72 1972 Chronic and degenerative diseases such as cancer and Doctors 6 1 1 020 166 cardiovascular diseases are emerging as important Dentists (stomatologists) 5 1 88 20 Pharmacists 5 1 24 health problems.Much attention is being paid to Hygienists 5 1 51 24 modernization of laboratory services in support of Medical assistants . . 4 3 830 280 Assistant pharmacists 2 1 117 31 various disease control programmes and of environ- Sanitation assistants . 3 1 75 24 mental protection. Other main public health concerns Dental auxiliaries . . . 2 1 24 Laboratory assistants . 2 1 145 26 are those related to environmental health, particu- Radiographers 2 1 30 19 Nurses 2 4 755 434 larly air pollution, radiation hazards, and occupational SOUTH -EAST ASIA REGION 147

health. Much emphasis is placed by the health autho- Environmental health (community water supply) rities on health planning, modern management of (1966- ) UNDP: to develop water supplies and healthservices,healthinformationsystems and sanitation, particularly in the rural areas. health economics. Medical education (1970- ):to develop and improve medical education. National health planning Health statistics(1967- ):todel, elop health The health objectives of the fifth five -year national statistics services and train personnel. development plan (1971 -1975) are: to improve the Nursingsertiic:sand education(1968- ):to quality of medical care; to strengthen the emergency developschoolsofnursing,strengthentraining healthservices;to update hospitalsupplies and programmes and improve nursing services. equipment; to further develop maternal and child Cardiovascular diseases (1969- ):to study the health services and to reduce infant mortality; to epidemiology of certain cardiovascular conditions, in develop medical educational research;to expand order to determine further action. facilities;to sanatoria and medical rehabilitation Cancer (1968- ): to study the epidemiology of improve environmental sanitation, particularly supply cancer, improve radiotherapy, and train personnel. of community water and sewage disposal.During the fifth plan period, the number of hospital beds Strengthening of radiological services (1971- ): will increase to 12 985, the number of doctors to to train engineering technicians, and to promote 2950, the number of nurses to 5012 and the number of radiation protection practices in health institutions. feldshers to 2826.In 1975 there will be 257 medical Brucella vaccine production (1972- ) UNDP: to health centres and 952 rural feldsher health units. produce freeze -dried Brucella vaccine and establish laboratory facilities for its testing. Assistance from WHO Health education (1970- ): to plan and implement a health education programme. In 1972 WHO's assistance to Mongolia included Dental health services (1972- ):to strengthen the following projects: dental health services, train dental health personnel, Strengtheningof healthservices(epidemiology) and study the feasibility of a fluoridation programme. (1963 -1972): to carry out epidemiological surveys of Epidemiological services and surveillance (1972- ) : the prevailing communicable diseases; to advise on the to develop the epidemiological surveillance of diseases use of epidemiological methods, and to train personnel. of public health importance. Public health laboratory services (1964- ) UNDP, UNICEF: to develop the health laboratory services Government health expenditure and train personnel. In1972totalgovernmenthealthexpenditure Tuberculosis control (1963 -1972) UNDP: to orga- amounted to 218.9 million tughriks, of which 199.9 nize a comprehensive tuberculosis control programme million were spent on current account and 19.0 throughout the country. million on capital account; the total includes 15.8 Maternal and childhealthservices(1965- ) million tughriks spent on education and training of UNDP: to develop maternal and child health services health personnel. The per capita health expenditure and establish referral facilities. was 165.8 tughriks.

SRI LANKA

Population and other statistics 1969 1970 1971 1972

Number of deaths 1 . . 102 356 94 129 96 328 Death rate At the last census, taken in October 1971, the pop- (per 1000 population) . 8.3 7.5 7.5 ulation of Sri Lanka was 12 747 755.Population Natural Increase ( %) . . 2.21 2.19 2.24 Number of Infant deaths . 18 902 18 506 .. . estimates and some other vital statistics for the period Infant mortality rate under review are given in the following table: (per 1000 live births) . 50.7 50.3 1 Provisional data. 1969 1970 1971 1972 The communicable diseases most frequently notified Mean population . . . 12 252 00012 514 000 12 762 00013 030 000 Number of live births . . 372 774 367 201 381 780 ... in 1972 were: malaria, new cases (125142), tuberculosis, Birth rate (per 1000 population) . 30.4 29.4 29.9 all forms, new cases (6441), infectious hepatitis (4168), 148 FIFTH REPORT ON THE WORLD HEALTH SITUATION gonorrhoea (4012), typhoid and paratyphoid fevers Rural hospitals 72 Maternity homes 34 (1748), leprosy (880), syphilis, new cases (683), polio- Chest hospitals 4 myelitis (301), whooping -cough (282), diphtheria (206), Peripheral health units 94 bacillary dysentery (181), amoebiasis (37). Facilities for ambulatory treatment were available in 1972 at 334 hospital outpatient departments, 322 Organization of the public health services central dispensaries, and 224 branch dispensaries.

The responsibility for the health services in Sri Medical and allied personnel and training facilities Lanka rests with the Ministry of Health. The Minister of Health is assisted by a Parliamentary Secretary, a In 1971, 2120 doctors, 1205 medical assistants and Permanent Secretary and an Assistant Secretary. The 5003 nurses were working in government service. Ministryisorganized into two departments, the Sri Lanka has two medical faculties, eight basic Department of Health Services and the Department schools of nursing, a psychiatric affiliation school at of Ayurveda.The Department of Health Services Mulleriyawa, and apostbasic nursing school in is headed by a Director, under whom are the deputy Colombo. directors of medical services, public health services, laboratories, and administration and finance.The Communicable disease control Deputy Director of Public Health Services has three assistant directors dealing respectively with sanitation, The Government has given tuberculosis control epidemiology, communicable diseases and statistics; high priority for over two decades and the services maternity and child welfare; quarantine matters and of a number of chest clinics and chest hospitals are liaison with agencies such as WHO and UNICEF. now available to the public. Furthermore, the tuber- There is also a Chief Public Health Nursing Officer culosis service now has a large number of well- trained who supervises the work of midwives. medical personnel.In 1970 Sri Lanka had 2277 Sri Lanka is divided into nine provinces, each of tuberculosis beds.The number of registered tuberculosis patients declined from 10 519 in 1960 to 5762 which comprises two or three health districts.These health districts are divided into health areas each with in 1970.In 1969 the tuberculosis morbidity rate was about 100 000 inhabitants.The health districts are 5.1per 100 000 inhabitants and thetuberculosis in the charge of superintendants of health who are mortality rate was 9.2 per 100 000. BCG vaccination directly responsible to the Ministry of Health.The was given 533 851 persons in 1970. During the period integratedcommunity- oriented health areas have medical officers of health. underreview,the Each health area has a peripheral health unit and tuberculosis control project, which was established in each health district has a base hospital with 200 to 1968 in the North -Western Province, was extended to 250 beds, or a district hospital with 50 to 150 beds, or a further three provinces.The concept of this pro- both. There are larger general hospitals in the major gramme is that both curative and preventive tuber- towns. culosis control work is carried out by the health There are two types of peripheral health units in servicesavailablein the province, with technical Sri Lanka. The complete peripheral unit comprises a supervisionand coordinationbytheprovincial central dispensary, a maternity ward with about 20 tuberculosis control officer. beds, and a general ward with about 25 beds, usually Malaria continued to be the main health problem The population in 1969 of the non - in the charge of a qualified doctor.The incomplete in the island. peripheral unit may be a dispensary only, or a dis- malarious areas was about 3 081 000. The recrudes- pensary with either a maternity unit or a general ward. cence of malaria started in 1964/65 and assumed Most of them are staffed by assistant medical practi- epidemic proportions in 1967/68 with an estimated island -wide total of over two million cases. Although tioners. Some of the dispensaries have visiting stations staffed by assistant medical practitioners. theincidence of the disease declined throughout 1971, transmission continues on a significant scale. The emergency programme which was started at the Hospital services end of 1968 involved the gradual reintroduction of In 1970 Sri Lanka had 335 inpatient health establish- regular DDT spraying operations in all health areas ments providing altogether 37 753 beds, to which affected by the epidemic and in some health areas in over 2 million patients were admitted during the year. the meso- endemic zones. The bed /population ratio was thus 3.0 per 1000. Progress has been made during the last years in the These health establishments were as follows: control of filariasis.Infection due to Wuchereria

General hospitals 11 bancrofti is restricted to a narrow belt extending along Base hospitals 12 the south -west coast of the island. The coverage of the District hospitals 95 Cottage hospitals 13 population at risk is almost total, and because of the SOUTH-EAST ASIA REGION 149 improvement and extension of routine control mea- national health planning and to monitoring the per- sures the infection rates have decreased significantly. formance of the health services, improve the processing Filariasis and thegastrointestinaldiseases which of data on health manpower, and train staff. cause some 40 % of all morbidity in the country are Medical education (1963- ): to develop under- primarily a problem of environmental sanitation. graduate and postgraduate teaching programmes and provide training for teachers. Specialized units Nursing advisory services (1969- ) :to develop In 1972, 1327 centres were engaged in maternal and nursing and midwifery education and services. child health care. During the year, 154 528 pregnant Filariasis control (1965- ) UNDP women, 328 322 infants and 463 823 children aged 1 -5 Malaria eradication programme (1960- ) Domiciliary care was years attended these centres. Medical rehabilitation (1972- ): to improve the given to 228 211 pregnant women, 140 036 infants rehabilitation services and train staff. and 111 415 children up to 5 years. About 75 % of all deliveries occur ininstitutions, another 20 % are Community water supply and sanitation (1963- ) attended at home by qualified midwives and only UNICEF: to develop programmes of water supply, 5 % are unattended by professional personnel.In sewage disposal, storm -water drainage and general 1971 there were 126 independent medical rehabili- sanitation, and to train personnel. tation centres and 101 hospital rehabilitation out- Strengthening of laboratory services (1966- ): to patient departments. In 1970 there were also 13 tuber- develop specialized diagnostic and reference services, culosis clinics and 26 tuberculosis branch clinics. and to train staff. Development of health education (1969- ):to National health planning strengthenhealtheducationservicesandhealth education teaching. A five -year plan for the development of health services was formulated in 1959. This was followed in Tuberculosis control (1966- ) UNICEF: to carry 1967 by the development of a further five -year plan. out a community- oriented tuberculosis control pro- In 1968 a plan for the strengthening of the national gramme in all provinces. health services over the period 1968 -1973 was prepared. Quality control of biological and pharmaceutical Its fundamental objective was the progressive inte- products (1971- ) gration of the curative and preventive aspects of the Strengthening of epidemiological services (1970- Government's health services, the gradual merging Occupational health and industrial hygiene of thespecialized communicable diseasecontrol (1968- ): to control health hazards in industry. programmes into the framework of an integrated community health service, and the progressive dele- Port health services (1972- ): to strengthen port gation of authority to divisional, district and peripheral health services. levels.A national medium -term five -year plan for Maternal and child health services (1968- ): to the period 1972 -1976, within which there are inter - improve maternal and child health and family health sectoralplans, was developed and presentedto services, and to provide courses for nursing and Parliament at the end of 1971. The health sector of medical personnel. this national plan included a framework within which Public health nutrition (1969- ): to carry out a annual implementation programmes can be related to pilot project for the control of nutritional anaemia. budgetary provision.The Health Planning Unit has Public water supply, drainage and sewerage for the been placed within the Department of Health Servi- south -west coastal area (1967 -1972) UNDP: the master ces, with the Director of Health Services as chiefof plan was finalized, and personnel were trained. planning. Dental health (1970- ): to develop training programmes and expand dental health services as part Assistance from WHO of the general health services. In 1972 WHO's assistance to Sri Lanka included the National health planning (1970- ): to establish following projects: and strengthen a national health planning unit in the Ministry of Health and train personnel. Leprosy control (1967- ): to assess the leprosy problem, develop an integrated control programme Veterinary public health services (zoonoses control) and train personnel. (1972- ): to develop zoonoses control services. Health statistics (1964- ) UNDP: to establish Strengthening of electromedical division (1972 - ): an information system geared to the requirementsof to train technicians and improve workshops. 150 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Health manpower study (1971- ) UNFPA: to Government health expenditure make a study of the work of Ministry of Health staff providing health care to rural communities as part In the period 1 October 1971 to 31 December 1972, of family health services; and to carry out a national the total government health expenditure amounted to study of health manpower. 558 028 538 rupees, of which 552 748 524 were charged to current account and 5 280 014 to capital account. Training of anaesthesiologists (1972- ): to establish a national training centre. Accordingly, the per capita expenditure on health for that period was 45.1 rupees.Of the total health Vector control (1972- ): to carry out studies of expenditure, the current expenditure of the Ministry arthropod vectors of diseases, and control measures; of Health accounted for 309 957 225 rupees.The and to control insect nuisances in areas important for government expenditure on general public health tourism. services included the following: 6 584 800 rupees for Healtheducationin familyhealth(1972- ) administration and government personnel, 13 531 906 UNFPA: to strengthen health education in the family forimmunization,vaccinations,mass campaigns health programme. against communicable diseases and environmental Family health (1971- ) UNFPA: to promote healthservices, 4 419 192 for laboratoryservices, family health as an integral part of the general health 6 918 617 for education and training of health per- services. sonnel,12 382 634forspecialized hospitals, and Strenghtening of nursing and midwifery education 202 527 037 for general hospitals, teaching hospitals (1972- ) UNFPA: to strengthen the education and other health establishments.The government provided in the eight basic schools of nursing, the contributions to health activities of social security Mulleriyawa affiliationschool, and the postbasic schemes and other nongovernmental social welfare school of nursing in Colombo. systems amounted to 1 146 771 rupees.

THAILAND

Population and other statistics (8289),tuberculosis,all forms (7715), pneumonia (6737), congenital anomalies, birth injury,difficult At the last census, taken in April 1970, the popula- labour and other anoxic and hypoxic conditions, tion of Thailand was 34 152 000. Population estimates other causes of perinatal mortality (5310), malignant and some other vital statistics for the period under neoplasms (5127), malaria (4168), avitaminosis and review are given in the following table: other nutritional deficiency (4003), cerebrovascular 1969 1970 1971 1972 disease (2736), complications of pregnancy, child- Mean population . . 33539 51834438 377 35361 32536573 576 birth and the puerperium, delivery without mention Number of live births . . 1133 526 1145 293 1221 228 1189 950 Birth rate of complication (2677), cirrhosis of the liver (1692), (per 1000 population) . 33.8 33.3 34.5 32.5 suicide and self -inflicted injuries (1661), bronchitis, Number of deaths .. . 243 444 223 899 227 990 248 676 Death rate emphysema and asthma (1205), tetanus (1099). (per 1000 population) . 7.3 6.5 6.4 6.8

Natural increase ( %) . . 2.65 2.68 2.81 2.57 In 1972 the provincial health offices reported 30 186 Number of Infant deaths . 29 705 29 252 27 495 28 999 cases of gonorrhoea, 15 587 new cases of tuberculosis Infant mortality rate (per 1000 live births) . 26.2 25.5 22.5 24.4 of the respiratory system, and 5833 cases of syphilis. Number of deaths, 1 -4 years 29 490 23 648 23 901 24 868 Number of maternal Organization of the public health services deaths 2 927 2 589 2 559 2 677 Maternal mortality rate (per 1000 live births) 2.6 2.3 2.1 2.2 The responsibility for the organization and administration of the public health services rests with the Of the 248 676 deaths recorded in 1972, the main Ministry of Public Health, which has the following causes were: 1 symptoms and ill- defined conditions main departments: (41 697), accidents (11 230, including 3971 in motor - vehicle accidents), chronic rheumatic heart disease, (1) The Office of the Under - Secretary of State is in hypertensive disease, ischaemic heart disease and other charge of international health, health planning and forms of heart disease (8823), bacillary dysentery and epidemiology. amoebiasis,enteritis and other diarrhoealdiseases (2) The Department of Medical and Health Services deals with health personnel training, family health, 1 International Classification of Diseases, 1965 Revision. dental health, rural health, the control of malaria, SOUTH -EAST ASIA REGION 151

filariasis, leprosy, venereal diseases and tuberculosis Category and number Number of beds the provincial hospitals, the mental health institute Psychiatric hospitals 14 7 471 Hospital for the mentally deficient 1 350 the dermatology institute and the national institute Establishment for drug addicts . 1 500 of cancer; Leprosaria 2 2 400 Hospital for tropical diseases 1 112 (3) The Department of Medical Sciences comprises Outpatient medical and health care was available the divisions of medical entomology medical analy- in 1971 at 130 hospital outpatient departments, which sis, public health laboratory, radiation protection, had 6.5 million new outpatients during the year; at toxicology, medical research, drug analysis, institute 3808 health centres which recorded 526 053 new out- of virus research, food and beverage analysis. patients; at 250 health centres providing also hospi- (4) The Department of Health Promotion isin talization facilities, which had over 3 million new charge of the following divisions: nursing, nutrition, patients; at 5884 medical aid posts at the tambon and food and drug control,vitalstatistics,health village levels; at 92 mobile health units; at 75 private education,environmentalhealth,occupational clinics providing hospitalization facilities and at 2872 health, medical registration. private clinics with outpatient facilities only.

Coordination between the departments is established Medical and allied personnel and training facilities through ad hoc meetings of the directors -general of these departments under the chairmanship of the In 1971 Thailand had 4048 doctors, or one doctor Under - Secretary of State. Whereas training of health per 8735 inhabitants. Other health personnel included: personnel with qualifications under the level of a Dentists 532 bachelor degree is the responsibility of the Ministry of Dental hygienists 222 Pharmacists 1 579 Public Health, training of health personnel with Nurses 9 760 qualifications equivalent to the bachelor degree or to Practical nurses 5 803 Midwives 4 989 a postgraduate degree comes under the Ministry of Sanitary engineers 81 State University. Sanitarians and health workers 5 615 At the provincial and district levels, the provincial chief medical office and the district health office are The arrangements for the trainingof medical and responsible for all health and medical services. These health workers were as follows: offices are administratively responsible both to the Category DurationNumber of Total Number of and admission of studyschools 1 enrolment graduates Department of Medical and Health Services and to requirements (years) 1971/72 1972 the provincial government.Several divisions in the Doctors Department of Medical and Health Services operate completed secondary education 7 4 1 508 373 mobile teams in the provinces to carry out certain Dentists completed secondary specializedhealth programmes,suchasmalaria education, and 2 years eradication,venerealdiseasecontrol,tuberculosis predental course . . 4 3 476 73 Pharmacists control, leprosy control, maternal and child health completed secondary and school health. education 5 3 1100 150 Veterinarians The last administrative level includes municipalities, completed secondary education 6 2 390 26 sanitary districts, and the newly established greater Sanitary engineers Bangkok administration.This level represents the completed secondary education 4 1 38 4 most decentralized typeof administration which Dental auxiliaries allows a high degree of autonomy and participation completed secondary education 2 1 36 7 from the public. Nurse /midwives (certificate) 10 years general edu- Hospital services cation 4 3 642 628 Nurses (diploma) 12 years general edu- In 1972 there were 491 hospitals and establishments cation ...... 3 14 (2) 4 630 415 Nurses (bachelor's for inpatient care, providing altogether 45 393 beds. degree) The bed /population ratio was 1.3 per 1000 inhabitants. 12 years general education 4 4 410 58 These beds were distributed as follows : Practical nurses 10 years general Category and number Number of beds education 1 10 621 625 Practical nurses General hospitals 170 30 510 10 years general 292 2 700 Medical centres education 18 months 6 694 334 Maternity hospitals and maternity homes 8 750 Infectious diseases hospital 1 150 Tuberculosis hospital 1 450 1 Public (private) schools. 152 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category DurationNumber of Total Number of of the programme in the consolidation phase. A target and admission of study schools 1enrolment graduates requirements (years) 1971/72 1972 of 27.39 million persons in this category by 1976 has Midwives been set; 7.86 million persons living in consolidation 10 years general areas will education 18 months 5 690 581 still come under the national malaria 2 (1) 135 33 eradication programme. A concentrated effort will Sister tutors diploma or certificate in be made to complete the attack phase forall but general nursing and 2 6.8 million people. years experience . . . 1 1 40 40 Public health nurses The magnitude of the venereal disease problems diploma or certificate in general nursing and 2 necessitated the implementation of a five -year pro- years experience . . 1 1 133 130 gramme for the strengthening of venereal disease control measures, the establishment of more effective Public (private) schools. coordination and cooperation from all medical and health agencies and for greater emphasis on personnel Communicable disease control and immunization services training. Control measures include case -finding, The expansion of the national tuberculosis program- health education and contact -tracing. In 1972, 184 222 me continued with the gradual integration of control venereal disease cases were detected and treated. measures into the general health services.It is esti- Treatment and control measures were administered mated that there are 600 000 tuberculosis patients, in 1972 through 98 venereal disease control units. 85 % of whom live in rural areas. In 1972 over 21 000 Endemic filariasisisrestrictedto the southern patients were under active treatment.Tuberculosis provinces of the country, particularly to the provinces control is based on BCG vaccination without prior along the eastern coast.It is estimated that about tuberculin testing, symptomatic case -finding through 2 million persons are at risk of filarial infection. The microscopic examination of sputum, and ambulatory filariasis control programme was organized in 1961 treatment. These control measures have been extended and three filariasis control units were established in to all provinces outside Bangkok and Thonburi that three provinces in the southern part of the country. have no tuberculosis units. The number of such units Mass drug treatment and DDT residual house spraying which operate at first class health centres has reached have contributed to lower the transmission rate. There are four tuberculosis headquarters situated Leprosy is hyperendemic in Thailand. The leprosy in Bangkok, Chiengmai, Khon Kaen and Yala. and control programme now covers 45 provinces and is five zonal tuberculosis centres which function as based on case -finding activities, surveillance of house- diagnostic, curative and preventive centres. Additional hold contacts and schoolchildren and rehabilitation zonal chest clinics are planned in the northern and activities. Each year a large number of nurses, medical central regions. students and junior health workers attend training Epidemiological andstatisticaldata show that courses in leprosy control. malaria control measures have been effective and A cholera outbreak occurred at the end of 1967 and economically rewarding.The malaria mortality rate throughout 1968. An epidemic of haemorrhagic fever has been reduced to a very low level. The morbidity was reported in 1969/70 in 60 provinces; 3575 cases is also decreasing. Malaria cases still occur, however, and 62 deaths occurred.Malathion fogging was among the population poorly protected because of carried out in the infected areas.A poliomyelitis operationaldifficulties. Malaria transmissionis vaccination programme was started in the Bangkok relatively low in a large part of the country, but still municipal area and extended in 1970 to Thonburi exists in some areas owing to imported cases from the municipal area and to a northern province. hill and forest areas where transmission has been The following immunization procedures were car- reduced but not completely interrupted. Spraying ried out in 1972: and surveillance operations are the main control Cholera 7 854362 activities. Spraying, which is carried out in all endemic Smallpox 5318179 BCG 1 108437 areas in one or two annual cycles, covered over 7 Typhoid and paratyphoid fevers 242849 million inhabitants in 1972.Surveillance operations Poliomyelitis 169666 are carried out in areas where spraying has been Yellow fever 244 withdrawn and in areas in the attack phase where Specialized units malaria surveys indicate low endemicity.In 1972 these operations covered 26.4 million inhabitants in Maternal and child health care was provided in 1971 areas in the consolidation phase and 2.8 million in in all hospitals and health centres as well as at six areas in the attack phase. A revised eradication plan maternal and child health centres which also had was established for the period 1971 -1976, and aims at hospitalizationfacilities,at 11 municipal maternal the gradual integration into the general health services and child health centres and at1537 midwifery SOUTH -EAST ASIA REGION 153 centres.During the year, 364 951 pregnant women, doctors, 79 % of all dentists and 67 % of all nurses are 211 428 infants and 325 770 children aged 1 -5 years practising in Bangkok, whose population represents availed themselves of these services. Domiciliary only 8 % of the country's total population. In addition, care was given to 462 308 pregnant women and to the utilization of doctors and nurses in many instances 644 117 infants under 1 year. Of all deliveries in 1971, does not correspond to their training. A study on the nearly 300 000 were conducted in hospital.School number of doctors and nurses who went abroad for health services were given in all health centres and at training during the years 1965 -1969 showed that 16 provincial school health units.Dental treatment 54.4 % of the 2165 doctors, or 12 % of the total was provided at dental clinics in general hospitals number of Thai doctors, and 75.5 % of the 1806 and in some health centres, and at 30 school dental nurses remained abroad.Although the budget of clinics.In 1971 the 13 hospital rehabilitation out- theMinistryof PublicHealth has considerably patient departments recorded 70 314 new outpatients increased in the last years, the financial problem in and the 62 psychiatric outpatient clinics 235 238 new the public health field continued to be severe. outpatients.Other specialized outpatient establishments included 11 tuberculosis clinics, 327 malaria National health planning units, 82 venereal disease units and 51 leprosy units. The first national economic and social development Environmental sanitation plan was formulated in 1961 and the second in 1967. But only the third plan, covering the period 1972 -1976, Of Thailand's 41 506 communities 820, with a pop- included health programmes as an integral part of ulation of 4 million, had piped water systems serving social and economic development. The major objec- 11 % of the population.Most inhabitants of small tives of the third development plan related to health villages have water from ponds, protected shallow are: to improve social conditions of the rural popu- wells, cisterns or deep wells equipped with hand lation through better education, health services and pumps. public utilities; to accept family planning as a government policy and to reduce the population growth Major public health problems rate through family planning services, especially in the rural areas, from approximately 3 % to 2.5 % in Thailand is facing the serious implications of rapid 1976; to expand training of health personnel categories population growth, with a natural increase rate of where there is a shortage, as in the case of doctors and nearly 3 %.If the birth rate does not decline, it is nurses; to provide potable water supplies in rural areas estimated that the population will reach close to for about 20 000 villages, and 100 provincial water- 100 million by the year 2000.Infectious diseases works for 30 provinces. affecting the digestive and respiratory systems have Previously, health service programmes were initiated become the main public health problem in Thailand, by operational divisions and departments and sub- taking the place of malaria.Efforts to improve mitted to the National Economic Development Board environmental sanitation have therefore been inten- for budget allocation. At the time of the formulation sified.The relatively slow decrease of the death rate of the third development plan, a joint health planning for children aged 1-4 years and the high incidence of committee was established, whose members belong complications of pregnancy, childbirth and puerperium to the Ministry of Public Health, to the National call for greater emphasis on maternal and child health Economic Development Board and to other govern- care.The existing government health services are ment agencies concerned.The Ministry of Public inadequateincoverage and arenotsufficiently Health thus participatesdirectlyin the planning utilized by the population. In 1968 the Department of process. The National Economic Development Board Health reported that its services covered not more is responsible for the intregation of the health plan than 25 % of the rural population and that only into the overall socioeconomic development plan. An about 15 % of the deliveries in these areas were attempt has been made to specify health development conducted by government midwives. goals in terms of health impact objectives, such as The lack of proper coordination between preventive reducing the mortality and morbidity due to certain and curative health services is an important adminis- communicable diseases, expanding the provision of trative problem. Unnecessary overlapping and dupli- safe water supply, improving sanitary conditions, cation in many health activities make investments increasing awareness among the population, especially costly but less productive.The shortage of doctors in the field of nutrition, mental health and personal and nurses is another serious public health problem, hygiene.One of the main objectives of the health which is aggravated by the maldistribution between plan is to increase and expand health facilities and urban and rural areas.It is estimated that 60 % of all manpower resources in order to cope with the rapidly 154 FIFTH REPORT ON THE WORLD HEALTH SITUATION

rising demands and to improve the availability of Strengthening of laboratory services (1968- ): to medical care services. organize nationalhealth laboratoryservices and strengthen the teaching of laboratory sciences and Medical and public health research training in medical laboratory technology. Quality control of drugs (1970- ): to strengthen The institutions in Thailand concerned with medical legislation and laboratory competence in the quality and public health research are the universities, various control of pharmaceutical preparations and train departments and divisions in the Ministry of Public drug analysts and drug inspectors. Health,particularlythe Department of Medical Sciences, the division of nutrition, the division of Venereal disease control (1967- ): to train staff malaria eradication, the national cancer institute, and strengthen the control programme. and the National Research Council, which was set Dental health (1967- ): to improve the education up in 1959 and whose main function is to make of dental staff, and to strengthen dental services. recommendations concerning research activities to the Nursing education and services (1968- ): to study Council of Ministers, and to allocate research grants. nursing needs and resources,strengthen nursing The main subjects of research carried out by the services and education, and develop university -level Department of Medical Sciences included: bacterial courses for nurses. diseases, virus diseases, fungi, medical entomology, Aedes aegypti, medicinal plants, drug analysis and National community water supply, drainage, sewerage toxicology, food analysis, and radiation protection and pollution control (1969- ) UNDP UNICEF: to and hazards. plan, organize and administer a national environmental health programme, and to train personnel. Assistance from WHO Medicalrehabilitation(1968- ):todevelop rehabilitationservicesincertainhospitals inthe In 1972 WHO's assistance to Thailand included provinces and in Bangkok and to train the necessary the following projects: staff. Strengthening of healthservices(integrationof Education in public health (1968- ): to develop specialized programmes) (1964- ) UNDP UNICEF: the teaching programme of the Faculty of Public to promote the integration of specialized communi- Health, Mahidol University, Bangkok. cable disease programmes into the general health Medical education and training(1971- ):to services and develop the rural health services. develop the teaching and training programmes of the Vital health and health statistics (1971- ):to four medical faculties at Chiengmai, Chulalongkorn, develop a coordinated health statistics system and to Mahidol and Thonburi Universities, and of the train staff. Faculty of Postgraduate Studies, Mahidol University, Facultyof TropicalMedicine(1967- ):to and the Faculty of Dentistry, Chiengmai University. strengthen the Faculty of Tropical Medicine, Mahidol Health planning and administration (1970- ) :to University, Bangkok. strengthen and improve national health planning and Epidemiology (1966- ) UNDP: to organize and health administration. strengthen a national epidemiological service, under- Production of biologicals (1971- ): to develop the take studies of specific health problems and train production of vaccines and sera and their testing in personnel. accordance with WHO minimum requirements, and Malaria eradication programme (1962- ) to prepare national standards and reference' reagents for vaccines and sera. Food control administration (1971- ): to establish a national food control administration in the Improvement of anaesthesiology(1971- ):to Department of Medical Sciences, Ministry of Public develop training programmes in anaesthesiology at Health; and to train staff. Mahidol University, Bangkok. Vectorborne disease control (1970- ):to train National Institute of Dermatology (1972- ): to staff in medical entomology and vectorborne disease establish a national institute of dermatology that will control; and to continue the work of the Aedes provide facilities for diagnosis, treatment, training Research Unit, Bangkok. and research. School for medical radiography, Bangkok (1965- ) School for medical physicists (1971- ) UNDP: UNDP: to train radiological technicians in X -ray to train medical physicists. diagnosis,radiotherapy and nuclear medicineat Teaching of human reproduction, family planning and Ramathibodi Hospital, Bangkok. population dynamics in medical schools (1970- ) SOUTH -EAST ASIA REGION 155

UNFPA: to strengthen teaching and research in the million represented the government health expenditure. medical school department involved in the teaching Of this sum, 1253 million baht were spent on current of human reproduction. account and 502 million on capital account. The per capita expenditure on health was thus 48 baht. The Faculty of VeterinarySciences(1972- ):to strengthen the Faculty of Veterinary Sciences, Chula - breakdown of the expenditure on general public longkorn University. health services, which amounted to 937 million baht, was as follows: 68 million for the expenditure on Bioenvironmental engineering (1971 -1972) UNDP: a administration and government personnel; 165 million consultant reviewed the curriculum of the Sanitary for the control of communicable diseases; 11 million Engineering Department, Facultyof Engineering, for laboratory services; 317 million for environmental Chulalongkorn University and the teaching and labo- healthservices;661 800foroccupational health ratoryfacilitiesand made recommendationsfor services; 40 million for veterinary services; and 335 improvements. million for education and training of health personnel. The identifiable government expenditure on hospitals amounted to 817 million baht, of which 394 million Government health expenditure were spent on general hospitals and clinics, 85 million In the fiscal year 1971/72, total government expen- on teaching hospitals,132 million on specialized diture,excludinglocalgovernmentexpenditure, hospitals and 206 million on other health establish- amounted to 29 000 million baht, of which 1755 ments.

EUROPEAN REGION

AUSTRIA

Population and other statistics tection.Within this Ministry are four Divisions, dealing respectively with personnel; public health; At the last census, takenin May 1971, the population food, veterinary administration and environmental of Austria was 7 456 403.Population estimates and protection; and legal affairs.In addition to the some other vital statisticsfor the period under review Supreme Health Council, there are a number of are given in the followingtable: advisory bodies such as the commission for the publication of the Austrian Pharmacopoeia, the commission 1969 1970 1971 1972 for fixing the prices of drugs, the commission for nurs- Mean population . 7 372 858 7390930 7456403 7 472 844 Number of live births . 121 377 112 301 108 510 104 033 ing problems, the commission against alcoholism, the Birth rate (per 1000 population) 16.5 15.2 14.6 13.9 commission for drugs on prescription, the control Number of deaths . . 98 715 98 819 97 334 95 323 commission on registry of pharmaceutical prepara- Death rate

(per 1000 population) . 13.4 13.4 13.1 12.8 tions, the commission for environmental health, the Natural increase ( %) 0.31 0.18 0.15 0.11 Austrian Codex Alimentarius commission, and the Number of Infant deaths 3 089 2 908 2 832 2 622 Infant mortality rate commission for radiation protection.The bacterio- (per 1000 live births) . . 25.4 25.9 26.1 25.2 Number of deaths, logical and serological institutes, the pharmaceutical 1-4 years 519 500 426 422 control institute, the vaccine institutes, the serum Death rate, 1 -4 years (per 1000 population at risk) 1.0 1.0 0.9 0.9 control institutes, the institute for experimental phar- Number of maternal macology and balneology, and the federal food control deaths 39 27 33 25 Maternal mortality rate institute also come under the Federal Ministry of (per 1000 live births) . 0.3 0.2 0.3 0.2 Health and Environmental Protection. The Federal Ministry is not responsible for the sanit- Of the 95 323 deaths recorded in 1972, the main ary services of communities, first -aid ambulances, causes were: 1 chronic rheumatic heart disease, hyper- hospitals, spas or health resorts. In these matters the tensive disease, ischaemic heart disease, other forms of federated provinces (Bundeslcinder) are competent. heart disease (27 566), malignant neoplasms (19 133), The highest executive authority in the nine federated cerebrovasculardisease(14 742),accidents(6136, provinces is the state government (Landesregierung). including 2892 in motor -vehicle accidents), cirrhosis of Each chief of province (Landeshauptmann) is bound by the liver (2267), pneumonia (2029), bronchitis, emphy- the regulations of the Federal Ministry.Each pro- sema and asthma (1934), suicide and self -inflicted vincial government has a health department under the injuries (1745), symptoms and ill- defined conditions direction of a supervisory health officer (Landes - (1622), birth injury, difficult labour and other anoxic sanitdtsdirektor) who isassisted by the necessary and hypoxic conditions, other causes of perinatal specialists. In each province there is a health council mortality (1548), diabetes mellitus (1305), tuberculosis, which acts in an advisory capacity. all forms (859). The district authorities, which represent the next The communicable diseases most frequently notified administrative level, are subordinated to the chief of in1972 were: gonorrhoea (11 136),scarlet fever the Bundesland. At every district level there is a health (10 066), infectious hepatitis (3917), tuberculosis, all officer and, in many district offices, also auxiliary forms, new cases (2676), syphilis, new cases (997), health officers. The district authorities have establish- whooping -cough(547),typhoid and paratyphoid ed school dental clinics and centres for maternal and fevers (238), meningococcal infections (95), dysentery, child health, tuberculosis control, early detection of all forms (29), diphtheria (18), malaria, new cases (13). cancer, control of venereal diseases, crippling diseases, mental health, alcoholism, and geriatrics. Organization of the public health services At the lowest administrative level are the communities. They are obliged by law to engage a community The supreme health authority in Austria is the physician.Several small communities may have one Federal Ministry of Health and Environmental Pro- community physician between them.He assists the mayor in an advisory capacity in health activities of a 1 International Classification of Diseases, 1965 Revision. local character. - 159 - 160 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Hospital services Category Duration Number of Number of Number of and admission of study schools students graduates In 1972 Austria had 81 390 beds in hospitals and requirements 1 1971/72 1972 Doctors : other inpatient establishments, to which1 211 872 12 10 terms and patients were admitted during the year.The bed/ 3 years population ratio was 10.9 per 1000.The beds were internship 3* 5966 526 Dentists : distributed among the various services as follows: 12 14 terms 3* 124 67 Dentists(not medically Category Number of beds qualified) : General medicine 14633 9 about 7 General surgery 12104 years 1* 25 24 Obstetrics and gynaecology 5001 Pharmacists : Paediatrics 3823 12 9 terms 3* 1 060 133 Wards for infants 514 Veterinarians : Infectious diseases 1510 12 9 terms 1* 446 21 Intensive care 110 Dermatology and venereology 1352 Nurses : Radiology and radiotherapy 272 9 3 years 54* 4968 1 287 3 ** Ophthalmology 1 183 Ear, nose and throat diseases 1312 Auxiliary nurses: Orthopaedics 994 9 135 -210 Neurosurgery 232 hours 60 courses 607 633 Stomatology 203 Midwives : 9 Urology 1129 2 years 6* 115 50 Accidents 3120 Medical Laboratory Tuberculosis and other chest diseases 4361 technicians : Neuropsychiatry 14094 Maturity2 27 months 4 (9 351 125 Chronic diseases 2976 courses) Convalescence 944 Physiotherapists : Geriatrics 5128 Maturity 27 months 3 (4 131 68 General 6317 courses) Others 78 Occupational therapists : Maturity 3 years 1 (2 33 courses) Outpatient facilities were available in 1971 at 616 Orthoptists : Maturity 2% years 2 (2 6 hospital departments or ambulatoria (Ambulanzen); courses) at 257 independent ambulatoria, of which 155 are Logopaedists : Maturity 2 years 3 (4 63 21 operated by health insurance institutions;at 306 courses) medical aid posts, which include first -aid units of the Radiographers: Maturity 21 months 7 (10 143 63 Austrian Red Cross Society and ambulatoria of the courses) municipality of Vienna; and at 2363 accident first -aid Dietitians : Maturity 2 years 3 (6 50 9 units. courses) In years of general education, unless otherwise stated. 3 Certificate of completion of secondary education. * Public. Medical and allied personnel and training facilities ** Private. In 1971 Austria had 13 946 doctors, including 1426 physicians specialized in odontology and practising Communicable disease control and dentistry. The doctor /population ratio was one to 530. immunization services Other health personnel included: There have been no cases of any disease subject to theInternationalHealth Regulationsduring the Dentists without medical qualifications 1744 period under review.The number of hepatitis cases Pharmacists 2672 Pharmaceutical assistants 274* slightly decreased, passing from 5135 cases in 1969 to Veterinarians 1 093 3917 cases in 1972. There were a number of limited Midwives 1 274 Nurses 15350* epidemics of typhoid and paratyphoid fevers which Assistant nurses 5632* were rapidly brought under control.The malaria Physiotherapists 515* Occupational therapists 69* cases notified during the period were all imported cases. Technical logopaedic and phoniatric personnel 12* The incidence of venereal diseases considerably increas- Orthoptists 13* ed, from 3744 cases of gonorrhoea in 1969 to 11 136 Dieticians 90* Laboratory technicians 1109* cases in 1972 and from 629 cases of syphilis in 1969 to Assistant laboratory technicians 377* 997 cases in 1972. This increase is, however, partly due X -ray technicians 758* Health aides 3000* to more complete notification of cases. The number of tuberculosis cases decreased during the period under * In hospital establishments. review, although the disease remains an important health problem. The arrangements for the training of medical and The following immunization procedures were carried health personnel were as follows: out in 1971: EUROPEAN REGION 161

Poliomyelitis 770732 (Oct. 1971 -Aug. 1972) ment has reached its lowest level since the Second Diphtheria and tetanus 185513 Smallpox 183781 World War. In 1972 the average rate of growth of the BCG 114936 Tetanus 98647 gross national product was 6.5 %. Diphtheria, whooping -cough A number of changes and improvements have been and tetanus 94653 adopted in the field of social insurance. The agricultural accident insurance and the sickness insurance for Specialized units retired persons have been improved. A separate law In 1969 maternal and child health care was provided on pension funds for farmers has been created and a at 116 prenatal centres and 3006 child health service new law on sickness insurance of independent workers units to 37 729 pregnant women and 514 654 children was set up. Much attention was given to environmental of 0 -5 years of age.Other specialized units included protection, particularly to the problems of water and 59 public and private independent medical rehabilita- air pollution, noise control and waste disposal.The tion centres, and 30 medical rehabilitation departments Dangerous Drugs (Narcotics) Act was amended in attached to hospitals, 32 psychiatric outpatient clinics, 1971. The penal provisions of this act have been 120 tuberculosis clinics, and 67 medical diagnostic amended to provide for suspension of criminal pro- laboratories. ceedings against persons found to possess only such quantity of a dangerous drug (narcotic) as does not Environmental sanitation exceed the person's own weekly need, provided that this person agrees to undergo the necessary medical Of Austria's population (excluding Vorarlberg, with treatment and control. 4 % of the total population), 5 216 095 inhabitants or 73 % were served with piped water systems, and 3 668 483 inhabitants, or 52 %, were living in houses Medical and public health research connected to sewers. Medical research has been carried out at the uni- Major public health problems versity hospitals in Vienna, Graz and Innsbruck, and in a great number of other institutes. Research is also Among the most important health tasks are those of carried out at the Austrian Institute for Cancer reducing the infant mortality. Great efforts are being Research and at the research institutes for rheumatic made to improve the technical equipment in obstetric diseases. and paediatric units and to establish centres at easily and rapidly accessible places in the whole country for neonatal care of newborn babies at risk.Preventive Government health expenditure medical examination of pregnant women will be enforced through a system linking the payment of the ln 1971 total government expenditure amounted to national allowance for childbirth to the evidence that 101 701.3 million Austrian schillings.Total govern- such examinations have been carried out.Another ment health expenditure at the federal and provincial urgent health problem is the improvement of early levels, excluding the expenditure of the communities detection of cancer.The development of preventive and of the social insurance institutes amounted to medical examinations is also an important health task. 8505.6 million schillings, of which 7513.3 million were spent on current account and 992.3 million on capital account; 988.2 million were spent on public health Social and economic developments of significance for services, 7506.4 million on hospital services and 11.0 the health situation million in government contributions to health activ- During the period under review the country's ities of social security schemes and other nongovern- economic capacity has been fully utilized. Unemploy- ment social welfare systems.

BELGIUM

Population and other statistics 1969 1970 1971 1972

Mean population . . 9 612 660 9637 729 9673162 9711 115 At the last census, taken in October 1970, the popu- Number of live births . . 141 799 142168 141 527 135456* lation of Belgium was 9 650 944. Population estimates Birth -rate (per 1000 population) . 14.7 14.8 14.6 13.8 and some other vital statistics for the period under Number of deaths . . . 120471 118660 119471 119429* Death rate review are given below : (per 1000 population) . 12.5 12.3 12.4 12.0 162 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 cil, the Higher Nursing Council, the Higher Family Natural increase ( %) . . 0.22 0.25 0.23 Number of Infant deaths . 3013 2999 2882 2á5s Council, the Study Commission for Health Policy, and Infant mortality rate the provincial medical commissions. (per 1000 live births) . 21.2 21.1 20.4 18.1 Number of deaths, 1 -4 years 574 505 511 Death rate, 1 -4 years (per Hospital services 1000 population at risk) 0.9 0.9 0.9 Number of maternal In 1971 Belgium had 474 hospitals providing 80 392 deaths 29 29 29 Maternal mortality rate beds, of which 27 817 were in 146 government hos- (per 1000 live births) . 0.2 0.2 0.2 pitals.The bed /population ratio was 8.3 per 1000. * Provisional data. The 80 392 beds, to which 1 037 401 patients were admitted during the year, were distributed as follows: Of the 119 471 deaths recorded in 1971, the main Category and number Number of beds causes were :1 diseasesof the circulatory system General hospitals 337 45 828 (52 188), neoplasms (24 434), symptoms and ill- defined Tuberculosis hospitals 18 2390 conditions (9939), diseases of the respiratory system Psychiatric hospitals. 64 26553 Geriatric hospitals 11 1 320 (8251), accidents, poisonings, and violence (8123), Hospitals for chronic diseases . . 44 4301 diseases of the digestive system (3968), diabetes mellitus (3411), senility without mention of psychosis (2461), Medical and allied personnel and training facilities cirrhosis of the liver (1219), influenza (343). The communicable diseases most frequently notified In August 1972 Belgium had 15 500 doctors, equiv- in 1972 were: tuberculosis, all forms, new cases (2716), alent to one doctor per 630 inhabitants. Other health infectious hepatitis (1139), gonorrhoea (884), menin- personnel included, in 1971: gococcal infections (519), scarlet fever (506), syphilis, Dentists 1 640 new cases (298), bacillary dysentery (67), typhoid and Dental science graduates 1 285 Pharmacists 6 856 paratyphoid fever (42), diphtheria (17), malaria, new Veterinarians 1 364 Midwives 3 333 cases (2), poliomyelitis (1), typhus (1). Physiotherapists 5 617

1 "Dentistes capacitaires ". Organization of the public health services The Ministry of Public Health and Family Welfare is The arrangements for the training of medical and composed of the general secretariat and the following health personnel were as follows: administrativedivisions :generalservices,public Category DurationNumber of Number of Number of health, social medicine, medical care establishments, and admission of study schools studentsgraduates welfare, family and housing, compensation for war requirements (years) 1970/71 1971 injuries. Certain public health matters are also includ- Doctors : secondary education 17 470 1412 ed in the functions of other ministries. The Ministry Dentists : secondary education 3 (6) 449 147 of Employment and Labour deals with occupational Pharmacists : health and hygiene, occupational diseases and social secondary education 55/ 3 808 431 Veterinarians : reintegration of handicapped persons. Veterinary secondary education 6 2 1 826 82 medicine is the responsibility of the Ministry of Agri- Laboratory assistants: baccalauréat 3 7 (9) 1 104 298 culture. The Ministry of Social Security is in charge of Dietitians : baccalauréat 3 3 (3) 416 73 sickness and invalidity insurance. Demographic and Logopedists : mortality statistics are dealt with by the Ministry of baccalauréat 3 6 (5) 888 125 Midwives : Economic Affairs. The Ministry of National Educa- baccalauréat 3 5 (12) 105 tion and Culture is responsible for the medical faculties Nurses : 5 781 ( baccalauréat 3 20 (29) 1 1418 and for training of paramedical personnel.Health Auxiliary nurses: services of the army, navy and air force are administer- secondary professional education 2 20 (49) 3 596 1587 ed by the Ministry of National Defence. The Ministry Physiotherapists : of Justice is in charge of the prison medical service. baccalauréat 3 11 (10) 3 621 851 The Ministry of Public Health and Family Welfare 1 Public (private) schools. is assisted by a number of advisory and consultative bodies, such as the Higher Public Health Council, the Communicable disease control and Pharmacopoeia Commission, the Medicaments Com- immunization services mission, the Higher Pharmacy Council, the Consult- ative College for Social Medicine, the Hospital Coun- There is an extensive legislation dealing with the prevention and control of communicable and quarant- 1 International Classification of Diseases, 1965 Revision. inable diseases and their notification. EUROPEAN REGION 163

The royal decree of 1 March 1971 which ensures the on the dangers of alcoholic toxicomania. In addition uniformity of the various preventive measures against to the curative activities of the psychiatric establish- communicable diseases and adapts them to recent ments, the National League for Mental Hygiene, which international conventions and to modern epidemio- is similarly subsidized, plays a very active part in the logical concepts, makes compulsory the declaration of campaign for mental health.It is engaged in a very all suspected and confirmed cases of quarantinable efficient education activity, and it provides psychiatric diseases, nonquarantinable diseases subject to the inter- dispensaries which are both for prevention and treat- national health regulations, communicable diseases ment. These dispensaries also organize consultations subject to the national health regulations such as for alcohol addicts.The demand for psychiatric bacterial diseases, viral diseases, parasitic diseases, hospital beds tends to increase, mainly because of the rickettsial and pararickettsial diseases.The royal growing number of senile mental cases occuring with decree of 17 March 1971 relates to the preparation of the extension of the average life span, and also because foodstuffs and prohibits handling of foodstuffs by of the increasing number of oligophrenic patients who persons who are a source of contamination.If the are kept alive by modern medical treatment. persons concerned are suffering from an infectious In 1969 the number of deaths from cancer was disease they are obliged to submit to medical examin- 23 564, representing 24.4 per 10 000 inhabitants. The ation and treatment.Since 1971 notification of all National Society for the Control of Cancer, which is forms of tuberculosis is compulsory. According to the also subsidized by the Ministry of Public Health and royal decree of 17 March 1971 which governs the hand- Family Welfare, is in charge of the medicosocial and ling of foodstuffs, persons suffering from infectious educational activities of cancer control.It works in tuberculosis aie prohibited to be employed in the close collaboration with the associations of mutual aid commercial preparation and sale of foodstuffs. Follow- societies, and collects and analyses an important ing the royal decree of 20 November 1972 the control amount of cancer morbidity and mortality data. The of tuberculosis is organized, coordinated and carried cancer centres organize the detection and treatment of out by the Ministry of Public Health and Family malignant tumours.Hospital and university centres Welfare. The National Tuberculosis League acts as an and a number of private foundations are engaged in the advisory and consultative body to the Ministry of control of cardiovascular diseases. Public Health and Family Welfare and to other Particular attention is also given to the control of ministries concerned with tuberculosis control.The rheumatic diseases.The activities for the control of regional tuberculosis coordination commissions also chronic and degenerative diseases also include the pre- play an active role in the control of disease. Since 1945 vention of congenital malformations and degenerative each case of venereal disease must be the subject of diseases of childhood.Particular attention has been an anonymous declaration made by the consulting given in recent years to the prevention of phenylketo- physician to the health inspector.The patient is nuria. obliged to submit to medical treatment. If he fails to do so, the consulting physician addresses a formal Specialized units declaration to the health inspector who can make inpatient treatment compulsory. In 1971 there were 343 prenatal centres; 229 790 The following immunization procedures were carried gynaecologicalexaminationswereperformedfor out in 1971: 48 329 pregnant women registered there. There were 1167 centres for infants and children up to 5 years of Poliomyelitis 486 453 Diphtheria, whooping -cough and tetanus 389 505 age,at which 223 351children,including 71 658 Diphtheria and tetanus 140 472 Smallpox about 120000 infants, were registered. Domiciliary care was provided Typhoid and paratyphoid fevers for 141 044 infants and children up to 5 years of age, and tetanus about 112 000 Tetanus 95 135 and 5126 infants living in sparsely populated areas Cholera 35 528 were visited by mobile services.Of all deliveries in Yellow fever 7 231 Typhoid and paratyphoid fevers 214 1969, 97.3 % were conducted in maternity clinics. Dental examinations of schoolchildren are carried out Chronic and degenerative diseases in health centres. In 1972, 60 473 psychiatric consultations were given in 49 dispensaries. There were 107 The National Committee against Alcoholism, which tuberculosis dispensaries which provided services to is subsidized by the Ministry of Public Health and Fam- 12 590 active cases and 20 820 contacts. The 16 ily Welfare is in charge of the campaign against alco- mobile tuberculosis teams carried out nearly 2 million holism, in which the main emphasis is placed on health radiological examinations and over 1.3 million tuber- education in primary and secondary schools, on mea- culin tests. In 1972, 213 331 radiological examinations sures for traffic security and information of the public were carried out in the dispensaries. A total of 928 483 164 FIFTH REPORT ON THE WORLD HEALTH SITUATION radiological case -finding tests were made.The 10 This plan, however, only indicates trends, as the cancer centres carried out 109 913 screening examin- private sector and the communities play a very im- ations. In 1971 there were 24 venereal disease dispen- portant part in the provision of health services. The aries which recorded 1815 syphilis and 952 gonorrhoea Ministry of Public Health and Family Welfare also patients.School health services were provided to the collaborates with the Planning Office in the Ministry total school population at 183 health centres, 58 of Economic Affairs. The introduction of the planning, medical school health centres, and by 2169 school programming, budgeting systems is expected to facil- health teams.In 1971, 550 industrial establishments itate the preparation of a national health plan. offered medical services to their workers, 64 establishments offered first -aid services and 21 561 establishments relied on outside first -aid services.Over 2.8 Medical and public health research million workers were covered by medical and health services in industry.In 1972, Belgium had 15 public Research activities are carried out by the Ministry health laboratories which carried out over 600 000 of Public Health and Family Welfare, and more partic- examinations. ularly by the Institute of Public Health and Epidemio- logy, by research workers supported by the National Major public health problems Scientific Research Fund and by the Medical Research Fund. The major public health problems in Belgium are those of a highly industrialized country which has a high economic and social standing. Among the public health problems causing particular concern to the Government health expenditure health authorities are the following: air pollution, ionizing radiation, and noise; the appearance of ani- In 1971 total government expenditure amounted to mal rabies in the eastern regions of Belgium, the need 371 251 million Belgian francs, of which 47 921 million for total immunization of the population against the were spent on public health services. The public health expenditure on current account was 41 648 million communicable diseases, the introduction of communi- In cable and even quarantinable diseases into the country francs and that on capital account 6272 million. as a result of increased and more rapid international 1971 the expenditure by the provinces on public health and hygiene amounted to 747 million francs. In 1968 air traffic; overcrowding in psychiatric establishments and the problems associated with the treatment of the communes spent 1796 million francs on public health and hygiene. The hospital boards spent 2907 mental disorders; the shortage of hospitals and more In 1972, the expenditure on particularly of university hospitals; and the increas- million francs in 1969. ing incidence of cardiovascular diseases, malignant public health services included the following items: 658 million francs for general administration and per- neoplasms and accidents. sonnel; 312 million for mass campaigns against communicable diseases, immunization and vaccination National health planning activities; 111 million for laboratory services; 2969 million for environmental health; 43 million for occup- In 1960 a health investment plan for the period 1961- ational health;107 million for veterinary public 1975 has been prepared, including the following pro- health; 1119 million for education and training of grammes : health personnel at the university level. The govern- (1)social housing, homes for the elderly and for ment expenditure on hospitals included 3204 million orphans; francs for general hospitals and clinics, 1631 million for teaching hospitals, 775 million for specialized (2)hospitals for acute and chronic disease patients hospitals, and 927 million for other health establish- and for the mentally sick; ments. (3)preventive medicine and health promotion; In 1971 government contributions to health activi- (4)environmental hygiene,includingdrinking - ties of social security schemes and other nongovern- water distribution, sewage and refuse disposal, and mental social welfare systems amounted to 25 520 abattoirs. million francs. EUROPEAN REGION 165

BULGARIA

curative health services, public health and epidemio- Population and other statistics logy, pharmacy, health development and economics, medical education and research. At the last census, taken in December 1965, the At the regional level the health services are directed population of Bulgaria was 8 227 866.Population by the public health department of the regional estimates and some other vital statistics for the period people's council. The public health department is in under review are given below: the charge of a medical officer.The chief medical officers of the regional hospitals are also responsible 1969 1970 1971 1972 for the rural health services. The public health depart- Mean population . 8434 200 8489 600 8536 400 8576 200

Number of live births . 143060 138745 135422 131 316 ments of the regional people's councils also administer Birth rate (per 1000 population) 17.0 16.3 15.9 15.3 the sanitary and epidemiology inspectorates.

Number of deaths . . 80183 77 095 82 805 84174 Death rate (per 1000 population) . 9.5 9.1 9.7 9.8 Hospital services Natural increase ( %) . . 0.75 0.72 0.62 0.55 Number of infant deaths . 4363 3788 3375 3435 Infant mortality rate In 1971 Bulgaria had altogether 67 583 hospital (per 1000 live births) . 30.5 27.3 24.9 26.2 Number of deaths, beds -equivalent to 7.9 beds per 1000 population. 1 -4 years 619 620 632 600 These beds were distributed as follows: Death rate, 1 -4 years (per 1000 population at risk) 1.2 1.2 1.2 1.1 Number of maternal Category Number of beds deaths 49 62 46 General medicine 12783 Maternal mortality rate General surgery 7703 . 0.34 0.45 (per 1000 live births) 0.34 Obstetrics 6509 Paediatrics 7217 Infectious diseases 3442 Of the 82 805 deaths recorded in 1971, the main Tuberculosis and other chest diseases 9023" causes were: 1 chronic rheumatic heart disease, hyper- Ophthalmology 1354 Otorhinolaryngology 1422 tensive disease, ischaemic heart disease and other Traumatology 1413 forms of heart disease (20 624), cerebrovascular disease Urology 726 Oncology 1586 (16 590), malignant neoplasms (11 651), pneumonia Gynaecology 3415 Dermatology and venereology 1377 (5970), symptoms and ill- defined conditions (4495), Neurology 2452 bronchitis, emphysema and asthma (4183), accidents Psychiatry 5104 (3657, including 1148in motor -vehicle accidents), Other specialities 2057 influenza (1877),suicide and self -inflictedinjuries Including sanatoria. (1053), birth injury, difficult labour and other anoxic and hypoxic conditions, other causes of perinatal Outpatient medical care was provided in 1971 at mortality (958), tuberculosis, all forms (840), diabetes 132 hospital outpatient departments; 49 polyclinics; mellitus (642), congenital anomalies (551), cirrhosis of 1890 rural health posts and health districts and 37 the liver (535), nephritis and nephrosis (518). rural feldsher health posts. The communicable diseases most frequently notified in 1971 were: influenza (481 022), dysentery, all forms Medical and allied personnel and training facilities (19 971), infectious hepatitis (14 895), measles (12 505), gonorrhoea (7443), tuberculosis, all forms, new cases In 1971 Bulgaria had 16 183 doctors -or one doctor (6202), scarlet fever (2919), whooping -cough (1836), for 530 inhabitants. Other health personnel included: syphilis, new cases (878), meningococcal infections Feldshers 5012 (114), typhus (40), typhoid and paratyphoid fevers (22), Dentists 3131 leprosy (1). Dental assistants 1 305 Pharmacists 2464 Pharmaceutical assistants 3475 Midwives 6016 Organization of the public health services Nurses 26381 Sanitary inspectors 495 Sanitarians 202 The responsibility for the overall organization and Physiotherapists 807 administration of the health services rests with the Laboratory technicians 3847 X -ray technicians 886 Ministry of Public Health. The main departments of Health statisticians 202 the Ministry of Public Health are: preventive and The arrangements for the training of medical and 1 International Classification of Diseases, 1965 Revision. health personnel were as follows : 166 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category t Duration Number of Number of Number of of study schools studentsgraduates follow -up centres not attached to hospitals will be (years) 1971 /72 1972 extended. Early and systematic treatment in and out- Doctors 6 5 817 738 side hospitals will be improved and there will be better Dentists 5 1 440 162 Pharmacists 5 6" 1 236 163 coverage of patients suffering from mental and nervous Veterinarians 5 756 140 diseases by various forms of rehabilitation and social Feldshers 3 854 218 Dental auxiliaries . . . 2 196 89 readaptation.Psychiatric and neurological care for Laboratory assistants . 2 526 252 children and adolescentsisalso being improved. Nurses 2 17 4108 1 543 Midwives 2'/, 1 255 259 Particular attention is also being paid to geriatric care. Radiographers 2 180 108 Cardiovascular diseases in Bulgaria are an important Pharmacy assistants . 2 426 178 cause of morbidity and are responsible for over 50 Yo 1 The admission requirement for all these categories was the com- of deaths and invalidity. Control and preventive mea- pletion of secondary education (XI class). Three faculties of medicine, one of stomatology, one of pharmacy, sures include the provision of specialized care, training one of veterinary medicine. of specialized personnel, the introduction of "dispensarization" as a basic method for case detection, system- Communicable disease control and atic treatment and follow -up, and expansion of rehabi- immunization services litation establishments. No quarantinable diseases occurred in Bulgaria in 1973. Measles, mumps and scarlet fever are still wide- Specialized units spread. Measles immunization of children aged 1 -10 years has been included in the nationwide immuniza- In 1971 maternal and child health care was based on tion schedule. Immunization against mumps is also 2581 combined clinics for mothers and children. There carried out for the same age group. Dysentery and were 593 medical units in schools, 1786 stomatological viral hepatitis are the most serious problems among care units, 208 medical rehabilitation units and 33 the infections of the gastro -intestinal system. Tuber- psychiatric clinics. Health care to workers was provid- culosis is still a widespread disease. Control measures ed in 504 workers' hospitals, workers' polyclinics, are based on BCG vaccination, chemoprophylaxis, health posts in factories and offices. In addition, there and preventive mass radiography examinations of the were 321 feldsher health posts which provided medical population, particularly of the persons aged 45 -50 and health services in industry. Other specialized out- years. Treatment of tuberculosis patients in hospitals patient clinics included 292 clinics for tuberculosis or at home isfree of charge.Rehabilitation of patients, oncological dispensaries, skin and venereal tuberculosis patients is widely practised. disease dispensaries and sports medical dispensaries. The following immunization procedures were carried out in 1972: Social and economic developments of significance for the health situation Tetanus 1 280789 BCG 791704 Measles 601579(1971) The period under review has been marked by an Diphtheria 576615 Poliomyelitis 530427 accelerated industrialization of the country, accom- Smallpox 442728 Whooping -cough 348729 panied by rapid urbanization.The integration and Typhoid and paratyphoid fevers 22192 specialization of agricultural cooperatives and the organization of agrarian and industrial units have Chronic and degenerative diseases also been accelerated. The incidence of cancer is increasing. The registered cancer morbidity has increased from 53.3 per 100 000 National health planning in 1952 to 214.8 per 100 000 in 1972.This increase shows partly improved registration and treatment at The public health development plans are prepared oncological dispensaries. The morbidity due to simultaneously with the economic development plans malignant neoplasms has remained fairly stable. The which are prepared jointly by the ministries of finance, incidence of mental diseases recorded in 1971 was trade,labour and social maintenance, education, 14 per 1000. Schizophrenia, epilepsy, mental retarda- architecture and welfare and coordinated by the State tion and neuroses are among the most frequently Planning Committee. Public health plans are worked recorded mental conditions. The control programme out for the whole country and separately for each provides for a considerable increase in the provision region. There are prospective health plans which cover of beds and personnel. It is planned that the number of 5 years and 20 years and annual plans. They are based psychiatric beds will reach 1.0 per 1000 inhabitants in on the following indicators: hospital beds, personnel, 1980. The network of diagnostic, treatment and and health establishments. EUROPEAN REGION 167

Medical and public health research Assistance from WHO In 1972 WHO's assistance to Bulgaria included the Medical and public health research activities are following projects : carried out by the establishments for higher medical education and by specialist research institutes and Scientificcentre forhygieneand epidemiology centres. During the period under review research (1968- ) UNDP: to establish a central technical activities were carried out in the field of communicable and scientific body grouping a number of formerly and noncommunicable diseases, on the relation bet- independent specialized institutions. ween man and his environment, and on the organiza- Training of medical teachers (1972- ): to provide tion of health services. Research activities are financed additional training in the educational sciences to entirely from the State budget. teachers in medical teaching institutions.

CZECHOSLOVAKIA

Population and other statistics gonorrhoea (14 302), tuberculosis, all forms, new and relapsed cases (11 885),syphilis, new cases (688), At the last census, taken in December 1970, the typhoid and paratyphoid fevers(248), whooping - population of Czechoslovakia was 14 361 557. Popu- cough (118), trachoma (102), meningococcal infections lation estimates and some other vital statistics for the (46). period under review are given in the following table:

1969 1970 1971 1972* Organization of the public health services Mean population . . 14415 468 14333 616 14406 772` 14481 304 The organization of the health services in Czechoslo- Number of live births. . 222 934 228 531 237 242 251 238 Birth rate vakia follows the federative system of government (per 1000 population) . 15.5 15.9 16.5 17.3 Number of deaths . . . 161 276 165567 165 231 160 335 introduced in 1969. Health and medical care are with- Death rate in the exclusive competence of the national republics, (per 1000 population) . 11.2 11.6 11.5' 11.1 0.62 the Czech and the Slovak Socialist Republics. Each Natural increase ( %) . . 0.43 0.43 0.50* Number of infant deaths . 5 147 5 059 5 142 5 383 republic has a ministry of health. There is no central Infant mortality rate (per 1000 live births) . 23.1 22.1 21.7 21.4 health authority at the federal level.Matters of Number of deaths 1 -4 years 891 813 821 - nationwide concern are dealt with by the Council for Death rate, 1 -4 years (per Health Services, which also establishes the necessary 1000 population at risk) 1.02 0.96 0.96 Number of maternal coordination of activities.The ministers of health deaths 46 50 42 43 of both republics are represented in this council. Each Maternal mortality rate (per 1000 live births) . 0.21 0.22 0.18 0.17 ministry of health is the supreme authority in health matters throughout the republic. The following Provisional data. institutes come directly under the Ministry of Health: the research institutes, the Central Library and Infor- Of the 165 231 deaths recorded in 1971, the main mation Centre, the Institute of Health Statistics, the causes were 1: chronic rheumatic heart disease, hyper- State Institute for Drug Control, the Postgraduate tensive disease, ischaemic heart disease, other forms of Medical and Pharmaceutical Institute and the Institute heart disease (47 353), malignant neoplasms (32 403), for Further Training of Auxiliary Medical Personnel, cerebrovascular disease (24 572), bronchitis, emphy- the State spas, and the firms for the production of sema and asthma (8736), accidents (8463, including drugs, sera, vaccines and certain sanitary goods. 3178 in motor -vehicle accidents), pneumonia (4037), Over 95 % of the preventive and curative health suicide and self -inflicted injuries (3486), birth injury, facilities are administered by regional and district difficult labour and other anoxic and hypoxic condi- national committees. Technical guidance and control tions,other causes of perinatal mortality (2710), is provided by the ministries through the health depart- diabetes mellitus (2601), cirrhosis of the liver (2205), ments of the regional and district national committees. symptoms and ill- defined conditions (2069), influenza Only a small number of health facilities are under the (1374), congenital anomalies (1253), tuberculosis, all control of other ministries. The Ministry of Transport forms (1241), nephritis and nephrosis (1104). deals with railway health services, the Ministry of The communicable diseases most frequently notified National Defence and the Ministry of the Interior with in 1972 were: scarlet fever (22 713), bacillary dysentery the armed forces' health services, and the Ministry of (19 576), infectious hepatitis (17 480), measles (16 072), Labour and Social Affairs with the establishments for 1 International Classification of Diseases, 1965 Revision. old people and for the chronically ill and handicapped. 168 FIFTH REPORT ON THE WORLD HEALTH SITUATION

The Ministry of Health has its advisory bodies, i.e. the national health, to organize postgraduate education of Minister's Board and the Scientific Council of the doctors and other health personnel.The Regional Ministry of Health. It is responsible to the government Institute which is headed by a physician is a methodo- concerned for the organization and administration of logical centre for professional guidance of health the health services. centres in the region. The regional institutes comprise The administration of the health services is widely regional hospitals with polyclinics, most of them decentralized to the regions and districts.Health belonging to the medical faculty, regional hygiene services in the region are administered by the Regional stations, regional schools for the training of para- National Committee.The most important health medical personnel, and possibly other, very specialized matters are dealt with by the plenary session of the facilities. Regional National Committee and by the Regional The public health service, which is in charge of National Committee Council which is an executive environmental and occupational health, is empowered body of the Regional National Committee plenum. by law to take action in any sphere in the interest of In addition to these elected bodies, there is a health health protection and development. At the ministries' commission composed of Regional National Com- level, this service is headed by the chief public health mittee deputies and representatives of trade unions, officers and at the regional and district level by the of the Red Cross and other agencies which is an advi- regional and district public health officers of the sory and supervisory body of the Regional National regional and district national committees. Committee.The Health Department, headed by a medical officer,is the administrative body of the Hospital services Regional National Committee. In the district the health services are administered by In 1972 Czechoslovakia had 505 hospitals and in- the District National Committee.The organization patient establishments providing 175 021 beds, or 12.0 and administration of the district governing bodies is beds per 1000 population.These beds, to which similar to that in the region.Technical management 2 787 902 inpatients were admitted during the year, and professional guidance of health services is provided were distributed as follows : by regional authorities assisted by the Regional Ins- titute of National Health. Category and number Number of beds General hospitals 243 113 364 The local national committees do not administer any Maternity centres 11 188 Paediatric hospitals 16 2 854 health establishments, they are in charge of general Tuberculosis hospitals 35 8 293 questions pertaining to health. Psychiatric hospitals 32 16 409 Institute for the care of mother and child 1 146 Most of the health facilities are administered by Institute for clinical and experimental district national committees.They form one single medicine 1 281 Rheumatological research institutes . 2 126 functional and economic unit, the District Institute of Research institute for blood transfusion 1 42 National Health, which provides the necessary health Traumatological research institute . 1 55 Institute for nutrition 1 30 services to the population, supplies drugs, secures Balneological institute 1 103 Institute for endocrinology 1 160 education of paramedical and auxiliary health per- Cancer hospitals 3 469 sonnel, and organizes postgraduate training of health Functional rehabilitation institutes. 2 342 Convalescent homes 37 3 470 personnel. The District Institute, which is headed by a Balneological institutions 117 28 689 physician, comprises one or several hospitals with polyclinics, other polyclinics which are outside the In 1972 outpatient facilities were available at 401 hospital complex, community health centres, health polyclinics which provide curative and preventive care centres at places of work, medical posts, maternity and in several specialities; at 2411 health centres; at 2139 child welfare clinics, district hygiene stations and phar- medical posts which are under the control of the health macies. Depending on the size of the district, the fol- centres and which provide general health or dental lowing facilities may also form part of the District services; at 75 mobile units including 18 dental units, Institute:tuberculosissanatoria, mental hospitals, 26 X -ray units, 11 resuscitation units, 16 blood trans- industrial institutes of national health,specialized fusion units and four laboratories.The outpatient children's sanatoria, children's homes, convalescent establishments recorded altogether over 183.5 million homes, and schools for the training of auxiliary attendances in 1972. medical personnel. Health facilities serving a wider population than that Medical and allied personnel and training facilities of a district are administered by the Regional National Committee and form the Regional Institute of National In 1972 Czechoslovakia had 31 521 doctors, equiv- Health. Its task is to provide highly specialized services alent to one doctor per 461 inhabitants. Other health that cannot be offered by itsdistrict institutes of personnel included : EUROPEAN REGION 169

Dentists (university degree) 4311 Dental practitioners 1 533 of poliomyelitis or smallpox during the period under Other higher -level personnel 3175 review. In 1972 there were five imported malaria cases. Dental laboratory technicians 5177 Pharmacists 5674 The following immunization procedures were car- Pharmaceutical assistants 3044 ried out in 1971/72: Midwives 6024 Qualified nurses 70459 Tetanus 2 167 093 Sanitary assistants 1938 Poliomyelitis Physiotherapists 3355 903 626 Smallpox Laboratory technicians 8429 803 525 X -ray technicians 3523 Diphtheria, whooping -cough and tetanus 599 071 BCG Other health auxiliaries 22763 389 348 Measles 276 914 The arrangements for the training of medical and Diphtheria and whooping -cough 215 617 Cholera 37 993 health personnel were as follows: Typhoid and paratyphoid fevers and tetanus 7 995 Typhoid and paratyphoid fevers 2134 Category Duration Number of Number of Number of Yellow fever and admission of study schools studentsgraduates 1 238 Plague 47 requirements (years) 1971/72 1972 Doctors : secondary education 6 11 9 663 1 336 Chronic and degenerative diseases Dentists : secondary education 5 7 2 633 299 Hygienists and Cardiovascular diseases are at present among the epidemiologists: main health problems in the country.Effective pre- secondary education 6 1 790 96 Pharmacists: vention of these diseases, particularly of complication secondary education 5 2 1 357 219 Veterinarians : of atherosclerosis, is limited by the knowledge of their secondary education 6 2 1 088 pathogenesis. A special working group was set up in Nurses: primary education . 4 18 497 3 884 the Ministry of Health of the Czech Socialist Republic secondary education 2 131 77 Auxiliary nurses: with a view to introducing and promoting new pre-

primary education 2 I 2418 1073 ventive and curative methods. The final objective is to Midwives : reduce the present high mortality from cardiovascular primary education . . 4 646 141 secondary education . 2 516 260 diseases, particularly among middle -aged men, and to Laboratory technicians: primary education . . 4 1 882 457 influence favourably the morbidity. In order to have secondary education . 2 218 144 accurate information on the prevalence and incidence Physiotherapists : primary education . 4 153 95 of cardiovascular diseases, and on the use of health secondary education 2 76* 588 372 Radiographers and services, investigations were carried out in selected X -ray technicians : polyclinics in Prague and in the Central Bohemia secondary education 2 471 264 Sanitarians Region. Six district institutes of national health were primary education . 4 215 123 selected for the implementation of a comprehensive secondary education 2 134 81 Dental technicians: care programme for persons suffering from acute primary education . 4 1 290 336 myocardial infarction. A new methodological pro- Pharmaceutical laboratory technicians : cedureforearlyrehabilitationof cardiovascular primary education . . 4 937 213 patients,particularly of patientsafter myocardial secondary education . 2 235 184 infarction, is being introduced.This procedure has "Schools for secondary education in health subjects; they are subdivided into several branches, each branch being represented In one resulted in a shorter hospitalization period for the or several schools. patients and in a decline in thromboembolic complications. The programme has first been applied in research Communicable disease control and institutes in Prague and then in other institutes in the immunization services Czech Socialist Republic. Trachoma occurs mainly in the western regions of Cancer screening programmes have been organized Slovakia.The incidence of venereal diseases, which for all women over 30 years of age. Radiophotography increased between 1962 and 1969, started to decline in for population groups at high risk is used for lung 1970, with 15 583 cases in 1972 as against 18 953 in cancer detection. In the prevention and treatment of 1969. The decline was particularly marked for gonor- mental disorders, including alcoholism, drug addiction rhoea, with 14 302 cases in 1972, whereas the incidence and gerontopsychiatric problems, emphasis is laid on of syphilis increased.The morbidity and mortality outpatient care, particularly in polyclinics. Therapeu- from tuberculosis continued to decline in 1972, with tic rehabilitation plays an important role in the treat- 9862 newly diagnosed cases, of which 1259 were non - ment of rheumatic diseases. pulmonary. The declining mortality trend was particularly marked in the Slovak Republic where the mortal- Specialized units ity rate in 1972 was 6.9 per 100 000 population, whereas in the Czech Republic it was 7.5 per 100 000 (7.3 per Prenatal and child health services are available at the 100 000 for the whole country). There were no cases specialized departments of the polyclinics and health 170 FIFTH REPORT ON THE WORLD HEALTH SITUATION centres providing general outpatient care. In addition The objective of the population policy in Czechoslo- there were 115 prenatal units and 2531 child health vakia is to increase the birth rate.To this end the units.These services were attended by 292 448 preg- Government has adopted the following measures: nant women, 250 989 infants and by 1 143 736 children maternity benefits, paid maternity leave, allowances aged 1 -5 years in 1972. Domiciliary care was given in paid to working mothers for two years after the ter- the same year to 292 448 pregnant women and 250 989 mination of the paid maternityleave,children's infants. Of all deliveries in 1972, 247 869 were institu- allowances, improved prenatal and postnatal and tional.School health services are provided by the child care, health education, and family planning paediatric departments of polyclinics. The total school services.The number of inhabitants of productive population had access to these services. Dental health age (15 -59 years for men and 15 -55 years for women) services are available at the dental departments of poly- increased by 0.8 % between 1968 and 1971, and the clinics and dental medical posts of health centres; they total manpower by 0.9 %. The participation of women recorded in 1972 over 6.5 million attendances by in employment rose by 2.4 % during this period. The children and about 21.3 million attendances by adults. number of secondary and vocational schools rose by The 253 medical rehabilitation departments of hos- 4.1 %. There are a growing number of specialists at pitals with polyclinics recorded 971 812 patients during alllevels. The overall developments are directed 1972. Psychiatric consultations were given at 303 out- towards more intensive regional planning. patient clinics to 298 623 new patients. Occupational health care was available at 38 polyclinics, and at 536 National health planning health centres and 1313 medical posts which also provide general outpatient care. All industrial workers The health plans in Czechoslovakia form part of are covered by these services.There were also 134 the overall economic development plans. Planning in public health laboratories of regional and district the health field is based on instructions issued by the hygiene stations which carried out 24.8 million exami- State Planning Commission for the whole national nations in 1972. sector, which are incorporated into the instructions issued by the Czech and the Slovak planning commis- Major public health problems sions. A prognosis of health service development until 1985 was elaborated for the whole country and for The most important public health problems in both republics. Based on this prognosis a concept of Czechoslovakia are mainly related to the delivery of health service development until 1990 was drawn up. health care, to more intensive environmental health Five -year plans and annual plans are prepared for the protection and to the improvement of prevention and whole country, for the republics, the regions, the dis- treatment of the prevailing diseases, mainly chronic and trics and the various health establishments.They degenerative diseases. Efforts are focused on a planned determine the targets and resources to meet the over- and balanced development of the health care services, all health objectives within the plan period. Coordina- on their improved quality and better accessibility, on tion of health plans with other plans for the national modernization of the health facilities, better technical development is already estabished during the planning equipment and increased health manpower. process which is controlled by the Federal Govern- ment, the governments of the two republics and by the Social and economic developments of significance for State Planning Commission and the central planning the health situation authorities of both republics. The ministries of health of the two republics coordinate the health plans within The national economy of Czechoslovakia developed their competence. The implementation and evaluation very favourably during the period under review. The of the health plans are subject to a similar hierarchical living conditions of the population were improved. control. The gross agricultural production increased by 5.6 The concept of health planning is geared towards the between 1968 and 1971, and the gross industrial transition from individual, mainly curative, care, to production by 22.3 %. The national per capita income the care of whole population groups with emphasis at constant 1967 prices increased by 18.7 % between on the preventive aspects.Because of the rising 1968 and 1971, and the per capita consumption by demands on health services, the emphasis will be shift- 12.6 %. Science and research developed in keeping ed from the extension of these services to a more with the needs and possibilities of the national eco- efficient utilization of the health facilities network and nomy. Although investments in this field decreased by of health manpower. The care formerly provided in 2.8 % between 1968 and 1971, the total volume of individual specialities will be provided by teams of basic resources and equipment increased during that specialists.Spa treatment will be an integral part of period. comprehensive health services. EUROPEAN REGION 171

The 20 -year development plan for the main health logy, genetics, human reproduction, cardiovascular facilities network has fixed the following objectives: diseases, operation of the health care system. Health - The hygiene stations will concentrate on problems research is at present directed and coordinated through related to, and measures conducive to, optimum living three plans.The branch plan provides for develop- and working conditions.The number of doctors in ment of research in all health sectors and is coordinated these stations will increase in the Czech Socialist by the Scientific Council of the ministries of health Republic from 5.7 per 100 000 population in 1970 through 51 main branch commissions. The State plan to 10.3 per 100 000 in 1990, and in the Slovak Socialist for basic research provides for research into a number Republic from 4.4 per 100 000 to 10.3 per 100 000. of problem groups. Basic research is coordinated by the Czechoslovak Academy of Sciences.The State - The existing uneven hospital distribution will give plan for scientific and technological research deals way to a network of larger hospitals with polyclinics with the most important health problems of signific- having a wider regional coverage and which will ance for the development of the country. The expen- become the centres of a satellite system of additional diture from the State budget on health and medical inpatient and outpatient facilities.It is planned to research carried out in research institutes of the increase the hospital bed capacity between 1970 and ministries of health amounted to 181.1 million korunas 1990 by 0.55 per 1000 population in the Czech Socialist in 1966 and to 260.7 million in 1971. Republic and by 3.5 per 1000 population in the Slovak Socialist Republic.The number of doctors in outpatient services will increase between 1970 and 1990 by Assistance from WHO 5.02 per 10 000 population in the Czech Socialist Republic and by 5.74 per 10 000 in the Slovak Socialist In1972, WHO's assistanceto Czechoslovakia Republic. ,included the following project: - It is planned to transform some of the smaller Federal Research and DevelopmentCentre for hospitals into specialized establishments for patients Environmental Pollution Control (1969- ) UNDP: suffering from degenerative and chronic diseases. to establish in Bratislava a federal research and Some of the existing tuberculosis sanatoria will be development centre, with subcentres in Prague and changed into such establishments. In some regions the Bratislava. mental hospitals will be extended and modernized. The rehabilitation facilities will be improved. Government health expenditure

Medical and public health research In 1972 total government expenditure was 216 568.7 million korunas, of which 17 021.8 million were spent Medical and public health research activities are on health services, 2023.7 million on capital account carried out in research institutes of the ministries of and 14 998.1 million on current account.The per health, in some institutes and laboratories of the Czech capita health expenditure was 1985 korunas. The total Academy of Sciences and of the Slovak Academy of central government health expenditure amounted to Sciences; in the medical and pharmaceutical faculties 3947.3 million korunas, including total expenditure by and their institutes and clinics. In 1970 there were 29 the ministries of health of 889.9 million and expen- research institutes in the country employing 4584 diture by other ministries of 3057.4 million. The inter- research workers. In 1971, six clinical and paraclinical mediate government expenditure was 12 876.8 million research institutes under the Czech Ministry of Health and the local government expenditure 197.7 million. merged to become the Institute of Clinical and Experi- The expenditure on general public health services mental Medicine, and four hygiene and epidemiology included the following items: 93.5 million korunas for institutes were integrated to become the Institute of administrationand government personnel;542.7 Hygiene and Epidemiology. The Scientific Council of million for mass campaigns against communicable the ministries of health plan and organize basic and diseases,immunization andvaccinationactivity, applied research activities, and the two academies of laboratory services, environmental health services and sciences plan and organize research investigations. occupational health services; 603.8 million for veterin- During 1971 and 1972 it was decided to give the scien- ary services; and 914.2 million for education and tific councils of the ministries of health the planned training of health personnel. The government expen- management of medical and public health research. diture on hospitals included the following: 4461.4 A national coordinating body was also set up. million korunas for general hospitals; 1609.4 million Research activities have been carried out in the fol- for teaching hospitals; 884.8 million for specialized lowing main fields: microbiology, virology and immu- hospitals; and 5859.7 million for other health establish- nology, neurophysiology and neuropathology, onco- ments. 172 FIFTH REPORT ON THEWORLD HEALTH SITUATION

DENMARK

Population and other statistics directly in charge of the operation and management of mental hospitals. The Statens Seruminstitut and At the last census, taken in September 1970, the variousotherlaboratoriesalso come under the population of Denmark was 4 950 598.Population Ministry of the Interior.The Ministry of Social estimates and some other vital statistics for the period Affairs is responsible for the health insurance scheme, under review are given in the following table : occupational health, care of the old, the mentally 1969 1970 1971 1972 deficient and the physically disabled, and vocational

Mean population . . . . 4891 000 4928 757 4963 000 4995 000 rehabilitation.Other ministries dealing with health Number of live births . . 71 298 70 802 75 359 75 505 Birth rate questions in their respective fields are the Ministry of (per 1000 population) . 14.6 14.4 15.2 15.1 Education, the Ministry of Agriculture, the Ministry Number of deaths . . . 47 943 48 233 48 865 50 445 Death rate of Housing and the Ministry of Justice. (per 1000 population) . 9.8 9.8 9.9 10.1 At the local level, the elected bodies, primarily the Napural Increase ( %) . . 0.48 0.46 0.53 0.50 Number of Infant deaths . 1058 1005 1019 921 local governments, have a general responsibility to Infant mortality rate (per 1000 live births). . 14.8 14.2 13.5 12.2 provide and operate sufficient facilities for inpatient Number of deaths, care. They are also in charge of a number of other 1-4 years 232 221 202 187 Death rate, 1-4 years (per services such as school health and tuberculosis control 1000 population at risk) 0.7 0.7 0.6 0.6 Number of maternal services. Other local bodies such as the Health Com- deaths 12 6 4 3 mittee and the Building Council are responsible for Maternal mortality rate 0.1 0.1 0.1 (per 1000 live births) 0.2 environmental sanitation, food hygiene and housing. The national government, however, exerts a strong Of the 50 445 deaths recorded in 1972, the main influence even on those matters which are formally left causes were:chronic rheumatic heart disease, hyper- to be dealt with by local bodies. In addition, a con- tensive disease, ischaemic heart disease, other forms of siderable portion of the local governments' expenses heart disease (16 503), malignant neoplasms (11 815), for health and medical care are defrayed by the national cerebrovascular disease (5099), accidents (2266, includ- government. ing1196inmotor -vehicleaccidents),bronchitis, emphysema and asthma (1388),suicide and self - With a view to coordinating the activities of the inflicted injuries (1189), congenital anomalies, birth various agencies concerned with health matters, the injury, difficult labour and other anoxic and hypoxic national government has a central agency, the National conditions, other causes of perinatal mortality (918), HealthService,which -besidescertainexecutive symptoms and ill- defined conditions (954), diabetes functions in the administration of health services -has mellitus (717), cirrhosis of the liver (496), peptic ulcer an advisory and supervisory role with respect to the (373), hyperplasia of the prostate (235). various health functions of government departments as The communicable diseases most frequently notified well as those of the local authorities.Its executive in 1972 were: influenza (217 682), measles (56 909), functions include the licensing of medical personnel, gonorrhoea (17 102), scarlet fever (8756), infectious the control of the production, import and sale of drugs hepatitis (1189), whooping -cough (422), syphilis, new and the regulation of the sale of narcotics.It is also cases (331), malaria, new cases (30), typhoid and para- in charge of the collection and publication of all medi- typhoid fevers (27). cal statistics. The staff of the National Health Service consists mainly of members of the medical, pharma- Organization of the public health services ceutical and nursing professions.

At the national level, almost all the major ministries Changes in the provision of health services are concerned with some aspects of the publichealth services, so that none can be regarded as having general Up to April 1973 the primary health care services responsibility in matters of health, though the Ministry were mainly organized and financed through compul- of the Interior is generally considered as the supreme sory membership of the local health insurance, sub- health authority, as it administers medical and non- sidized and controlled by the State. The Public Health medical personnel, hospitals, drugs, food hygiene, Security Act of June 1971 which came into force in maternal and child health, environmental sanitation April1973assignstheadministration of health and certain other domains; a special department is security to the country boroughs and to the local 1 International Classification of Diseases, 1965 Revision. municipalitiesof Copenhagen and Frederiksberg. EUROPEAN REGION 173

Expenditure on health security is paid by the county ments proper, nor are there health centres or public boroughs and 35 % of the amount is refunded by the dispensaries of a general nature.Outpatient care is State. The contributions of the citizens are paid primarily in the hands of private general practitioners through income tax. All Danish citizens and foreigners and specialists. with residence in Denmark are automatically entitled to the benefits of the Public Health Security Act. Medical and allied personnel and training facilities There are two sections of the service, one for the lower At the end of 1972 Denmark had about 8000 income group, which comprises 82 % of the population, practising doctors, equivalent to one doctor for 600 and another for the higher income group, which inhabitants. Otherpractisinghealthpersonnel comprises 18 %. The first of these groups is entitled to included :

free medical treatment of any kind, whereas the second Dentists 3800 Pharmacists 2000 group enjoys less extensive benefits.Hospital treat- Pharmaceutical assistants 400 ment is free for both groups. Fully -qualified midwives 550 Fully- qualified nurses 40000" Until1970 more than 100 municipalities were Trained nursing aides 15000 immediately responsible for the hospital services for Veterinarians 1600 somatic conditions. The Hospitals Act of April 1970 Physical therapists 2800 has increasedStatesupervision,particularly with * About 13 800 were not working as nurses. regard to planning of hospitals. The management of The arrangements for the training of medical and the daily hospital administrationis,however, the health personnel in 1972 were as follows: responsibility of 14 county boroughs and of the two Category DurationNumber of Number of Number of local municipalities of Copenhagen and Frederiksberg. and admission of study schools 1students graduates Mental hospitals are mostly State hospitals. requirements (years) 1971/1972 1972 Doctors : The Daily Cash Benefit (sickness or maternity) Act 12 years general came into force in April 1973. The daily cash benefit is education 6 V -7 3 7 170 601 Dentists : payable to a person who, on medical grounds, is 12 years general unable to carry out his usual or similar work.In education 5 2 1200 200 Pharmacists : some cases, however, the benefit is payable also in the 12 years general education 5 1 500 90 event of partial incapacity for work. The Daily Cash Veterinarians : Benefit Act provides for a compulsory as well as a 12 years general education 5% 1 460 54 voluntary insurance scheme. Persons working as Nurses, with postbasic employees are ensured daily cash benefits on a com- university education : 12 years general pulsory basis from the first day of absence.Other education and basic persons qualifying for daily cash benefit are eligible nursing education . 10 months 2 261 226 General nurses: for the benefit after five weeks' illness as from the age 18 years and first day of absence, but may join a voluntary scheme 10 years general education 334 33 5 334 1 381 covering the first five weeks' illness. Persons carrying Practical nurses: age 18 years and out domestic work may be ensured the benefit on the 9 years general voluntary basis only. The benefit for a week cannot education 8 months 72 2 400 2 300 Nursing home assistant exceed 90 % of the average weekly earnings of the nurses : beneficiary. age 19 years and 9 years general The health insurance services also pay part of the education 2 2 (1) 300 100 Practical mental nurses: costs of medicaments if they are included in a list age 18 years and issued by the Minister of Social Affairs. 7 years general education 1 11 495 280 Midwives : Hospital services 9 years general education and 1 year In 1973, the number of hospitals and other inpatient practical 3 1 110 33 Laboratory assistants: establishments was 138, with 45 109 beds (equivalent 10 years general to 9.0 beds per 1000 population), which were distribut- education 3 (2) 950 300 Dental hygienists . 2 1 25 0 ed as follows : Physiotherapists : age 19 years and Category and number Number of beds 10 years general General hospitals for somatic conditions 94 28 656 education 3 (4) 440 140 Specialized hospitals for somatic Radiographers :

conditions 22 3390 nursing certificate . . 10 weeks 48 48 Psychiatric hospitals 15 10553 X -ray technicians : Municipal hospitals for chronic diseases 7 2 510 age 18 years and 10 years general Apart from emergency departments, Danish general education 3 2 90 30 hospitals do not usually operate outpatient depart- i Public (private) schools. 174 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category Duration Number of Number of Number of Specialized units and admission of study schools 1students graduates requirements (years) 1971/1972 1972 Occupational therapists : Regular prenatal service units and well baby clinics age 19 years and 10 years general have been established, women being entitled to free education 3 (3) 300 100 prenatal case and free obstetrical aid in a hospital or Auxiliary occupational therapists : similar public institution, or in the home. Midwifery age 18 years 10 months (4) 140 140 centres are organized as part of the hospital system. Chiropodists : age 18 years 1'A (1) 60 40 Other services for pregnant women and for children 1 Public (private) schools. are generally provided by the general practitioners and visiting public health nurses. All pregnant women are The postgraduate training programme in public legally entitled to five medical examinations by a doc- health, including administration, is being revised. As tor, three during pregnancy and two after, and the from September 1973 the training of dental assistants, required number of examinations by a midwife during which previously had been organized by dentists, is pregnancy, the expenses being borne by the county available at a government -controlled school. boroughs, which also reimburse the cost of three examinations by a physician of infants during their first year and of one examination per year of children Communicable disease control and aged 1 -7 years. Local government authorities employ immunization services visiting public health nurses, 50 % of the costs being reimbursed by the Government. Almost all deliveries The fight against tuberculosis has resulted in the are attended by a midwife and usually by a doctor also. lowest morbidity ever known in Denmark. Since 1959 Every school must employ a school doctor, who is there have been only two deaths from this disease in responsible for supervising the health of the children. persons under 30 years of age. The incidence of serum Most schools also employ a school nurse. Local hepatitis due to use of narcotics in some population government authorities are obliged to provide free groups and the incidence of venereal diseases have dental care for all children of compulsory school age. remained unchanged. Preventive measures against the The education, rehabilitation and care of several Salmonella type of infections include strictly enforced categories of handicapped persons are wholly or in part control of production and marketing of eggs and food- the responsibility of special services in particular for stuffs containing raw eggs. Between early spring 1964 the mentally ill and the mentally defective, epileptics, and 1970 a number of rabies cases have been diagnosed among wild animals, especially foxes, north of the the crippled, persons with speech defects, the blind and the deaf. Under the National Assistance Act it is the German border in the southern part of Jutland. Steps duty of the State to take care of a person suffering from have been taken to reduce the number of foxes in these any such disability and being in need of residential care areas. Since 1970 there have been no cases of rabies in southern Jutland. or foster -family care under supervision. The Rehabilit- ation Act develops and supplements the services for The following immunization procedures were carried disabled persons. out in 1972/73: It applies to persons with other handicaps than those covered by the legislation referred

Poliomyelitis (Sabin) 250000 to above, as well as to persons suffering from such Diphtheria, tetanus and poliomyelitis (Salk) . 225000 handicaps but who do not require help from the special Whooping -cough 200000 Smallpox 70000 care services. In addition to persons suffering from any BCG 64500(1970/71) physical or mental disability the Rehabilitation Act applies to persons whose disability has chiefly social causes. Chronic and degenerative diseases There are 12 independent rehabilitation centres, 12 nursing institutions for treatment of rheumatic diseases The main problemsasregardscardiovascular and for rehabilitation of orthopaedic patients or other diseases are associated with the degenerative and surgical patients. There are also 35 certified convales- arteriosclerotic types.The incidence of rheumatic cent homes. Among the general hospitals eight have heart disease has been declining. There is an increasing psychical medicine departments and two are operating interest in preventive measures, and public information rehabilitation departments.In 1971 there were 36 through various agencies is intensified. Registration of curative and preventive tuberculosis hospital depart- all cases of acute myocardial infarction and of stroke ments and chest clinics in Denmark.In 1973 there within a well- defined area has been established. The were 54 clinics where treatment is given for venereal Ministry of the Interior, the National Health Service, diseases. No industrial, commercial or other establish- various hospital departments and the Danish Heart ment is under legal obligation to provide medical and Foundation participate in these efforts. health services to its workers. EUROPEAN REGION 175

Besides the various centralized laboratories operated services.The central government health expenditure by the national government, such as the Statens amounted to 233.5 million kroner; the intermediate Seruminstitut, the National Food Institute -a govern- government level accounted for 2210 million and the ment- operated food toxicology laboratory and control local government authorities for 2800 million.The institute -the State Pesticide Laboratory and the breakdown of the expenditure on general public health State Laboratory for Radiation Hygiene, a large services included 6.5 million for immunization and number of laboratories for the control of meat and vaccination activity, 90 million for environmental dairy products are operated by local governments. health services, 105.5 million for occupational health services and 17 million for education and training of health personnel.The government expenditure on Government health expenditure hospitals which amounted to 4555 million kroner included the following items: 3600 million for general In the fiscal year 1971/72, total general government hospitals and clinics, 325 million for teaching hospitals health expenditure amounted to 5243.5 million kroner, and 630 million for specialized hospitals. The govern- of which 4143.5 million were spent on current account ment contributions to health activities of social security and 1100 million on capital account. This is equivalent schemes and other nongovernment social welfare to an expenditure of 1053 kroner per head on these systems amounted to 455 million kroner.

FINLAND

Population and other statistics hernia (170), symptoms and ill- defined conditions At the last census, taken in December 1970, the (160). population of Finland was 4 622 299. Population The communicable diseases most frequently notified estimates and some other vital statistics for the period in 1972 were: influenza (20 277), measles (14 159), under review are given in the following table: gonorrhoea (13 850), scarlet fever and streptococcal sore throat (6263), respiratory tuberculosis, new cases 1969 1970 1971 1972* (3664), infectious hepatitis (236), early syphilis, new Mean population . . 4623785 4606307 4 612 142 4 636 000

Number of live births . . 67 450 64 559 61 067 59 070 cases (149), meningococcal infections (111), typhoid Birth rate and paratyphoid fevers (62), whooping -cough (40), (per 1000 population) . 14.58 14.01 13.24 12.74 Number of deaths . . . 45966 44119 45876 44426 dysentery (11), malaria, new imported cases (4). Death rate

(per 1000 population) . 9.94 9.57 9.95 9.58 Natural increase ( %) 0.46 0.44 0.33 0.32 Organization of the public health services Number of Infant deaths 962 854 727 666 Infant mortality rate (per 1000 live births) . 14.26 13.22 11.82 11.27 The responsibility for the provision of health services Number of deaths, 1 -4 years 243 211 180 to the population lies primarily with the local author- Death rate, 1 -4 years (per ities, i.e., with the commune or the municipality, while population at risk) . . 0.80 0.74 0.63 Number of maternal the role of the central government is limited mainly to deaths 10 8 5 legislative and other coordination, control and financial Maternal mortality rate (per 1000 live births) . 0.15 0.12 0.08 support.At the local level the elected communal * Provisional data. council nominates a health board which is divided into two sections: a supervisory section which is in charge Of the 45 918 deaths recorded in 1971, the main of environmental sanitation and a general section which causes were: 1 chronic rheumatic heart disease, hyper- is responsible for other matters related to health. For tensive disease, ischaemic heart disease, other forms of the realization of certain plans and the provision of heart disease (16 481), malignant neoplasms (8042), services the communes are free to form federations. cerebrovascular disease (6020), accidents (2983, includ- In some fields, such as hospital care, mental health and ing1191in motor -vehicleaccidents), pneumonia tuberculosis services, such collaboration has long been (1975), bronchitis, emphysema and asthma (1076), established.In 1972 and 1973 the primary health suicide and self -inflicted injuries (1002), birth injury, services were organized in the same way and the 483 difficult labour and other anoxic and hypoxic condi- communes of the country were grouped into 224 health tions, other causes of perinatal mortality (753), diabetes centre districts. mellitus (648), influenza (645), tuberculosis, all forms In 1968 the health administration at the ministerial (377), nephritis and nephrosis (269), cirrhosis of the level was reorganized and the Ministry of Social Affairs liver (195), peptic ulcer (180), intestinal obstruction and and Health was established. The National Board of International Classification of Diseases, 1965 Revision. Health, which comes under this Ministry, is responsible 176 FIFTH REPORTON THE WORLD HEALTH SITUATION

for the administrative and technical aspects of the Category and number Number of beds health services, for central planning and for health Rheumatic diseases hospital . . 1 317 Establishment for occupational health. 1 9 manpower. Establishment for alcohol addicts .. . 1 125 The central administration functions through the Hospitals for the mentally deficient . . . 14 4 587 administrations of the provinces, but the National Ambulatory care was provided in1971at 463 Board of Health also has direct contact with the hospital outpatient departments, which recorded over communes and communal federations.In 1971 the 2 700 000 attendances, and at 323 establishments for provincial health offices, which were previously direct- examination and treatment which have a doctor in ed by a medical officer of health, were transferred to the charge. newly established Department of Social Affairs and Health within the Provincial Board. This Department deals with matters related to health and social welfare Medical and allied personnel and training facilities and to environmental and veterinary health. In 1972 Finland had 5475 doctors, or one doctor for Although the community is considered as primarily 849 inhabitants. Other health personnel included: responsible for the health services, there are important private group practices, especially in the larger cities, Dentists 2 916 Dental technicians 526 and a few private hospitals. Dental nonoperating assistants 934 A compulsory sickness insurance scheme covers the Pharmacists 4 762 Technical pharmaceutical assistants . . 393 whole population. It is limited to extramural services Veterinarians 586 Midwives 1 280 and covers private doctors' fees, the costs of prescribed Nurses 20 590 drugs (partly or completely), travel expenses, and daily Practical nurses 9576 Health inspectors 491 allowances, including a 174 -day maternity allowance. Physiotherapists 899 Laboratory technicians 1 624 Radiographers 879 Changes in the provision of health services Opticians 536 The new legislation concerning primary health The arrangements for the training of professional services, which was adopted in January 1972, is a very and auxiliary healthpersonnel in Finlandare as important step towards strengthening the health follows : services.The country is divided into health centre Category DurationNumber of Number of Number of districts formed by one or several communes and in and admission of studyschools2 studentsgraduates requirements 1 (years) 1971/72 1972 which a health centre organizes all health services. Doctors : Each health centre district comprises approximately 12 6 -7 3 2 482 348 Dentists 15 000 inhabitants, or even less in sparsely populated 12 5 -6 2 733 140 areas.The centre provides such preventive health Pharmacists (lower degree) : services as vaccination and maternity services, and 12 2-2% 1 (1) 182 124 Pharmacists (higher basic diagnostic, curative and rehabilitation services. degree) : Dental services are included in the activities of the 12 5 -7 1 226 52 centres, which also have beds for acute and chronic Veterinarians : 12 6 -7 1 168 26 patients.Most services are given free of charge; for Nurses (basic training) : 9 21/2 21 (5) 3 266 1 533 some a minimal charge is required. Nurses (with specialization) : graduation as Hospital services nurses 1 1 51 51 Practical nurses: 9 1 16(1) 618 618 At the end of 1972 there were altogether 69 653 Children's nurses: hospital beds in 749 inpatient establishments.The 9 1 3 (2) 287 341 Laboratory technicians : bed /population ratio was 15.0 per 1000.The total bed 9 2' /z 2 246 80 capacity was distributed as follows: Physiotherapists : 9 21A 6 410 156 Radiographers : Category and number Number of beds 9 2% 3 103 106 General hospitals 77 22 782 Occupational Rural hospitals 432 12 715 therapists : Tuberculosis hospitals 17 3 332 9 1 12 12 Health centres 125 4 695 Dental assistants : Maternity hospital 1 284 9 1 3 154 168 Paediatric hospital 1 200 Psychiatric attendants: Psychiatric hospitals 73 19 928 9 11A 9 300 191 Hospital for orthopaedic surgery 1 260 Chiropodists : 1 1 16 Hospital for plastic surgery 1 30 9 16 Neurological hospitals 2 329 Gynaecology clinic 1 29 1 In years of general education. Hospital for general medicine 1 31 2Public (private) schools. EUROPEAN REGION 177

Two new medical schools were opened in the autumn Specialized units of 1972. Their curriculum differs from that of the other medical schools. Medical students will get training at In 1971 maternal and child health was based on 1329 health centres after five years of study. prenatal units and 2091 child health units.During 1971, 60 847 pregnant women were registered at the maternal health centres and 59 924 infants and 421 218 Communicable disease control and children aged 1 -6 years attended the child health units. immunization services In the same year 99.9 % of all deliveries were attended by a doctor or qualified midwife in hospital or at home. Communicable diseases represent at present only a In the 1969/70 school year 97.5 % of all municipalities minor public health problem in Finland, mainly be- provided school healthservices,including school cause of extensive routine vaccination campaigns. dental services for primary schoolchildren; 214 237 Poliomyelitis has not occurred since 1964 and the last primary schoolchildren and 109 610 secondary school- case of diphtheria was reported in 1965.Preventive children were examined by school doctors, and 491 544 measures against typhoid have also been successful and schoolchildren were examined by the school dentists. no case was reported in 1972. Although the incidence In 1971 other specialized medical treatment centres of venereal diseases is still increasing, the most recent included180independentmedicalrehabilitation figures are no longer alarming and the situation centres, 92 hospital rehabilitation outpatient depart- appears to be under control. ments, 76 psychiatric clinics, 45 tuberculosis outpatient Tuberculosis, which has always represented a very clinics, 33 venereal diseases clinics and 21 outpatient serious health problem in Finland, now shows a clinics for rheumatic diseases.The central public tendency to decline. All forms of tuberculosis of childhealth laboratory and the seven regional public health ren have nearly disappeared and pulmonary tuber- laboratories carried out nearly 1.5 million examinations culosis of young adults has become rare.There are, in 1971. however, still numerous cases of pulmonary tuberculosis among persons over 35 years of age.The achievements which have been recorded in the control Environmental sanitation of tuberculosis are mainly due to the nearly 100 % BCG In 1971 Finland had 483 communities, of which 393, vaccination of all children born since the second world war, systematic and continuous mass screening and with a population of 2 715 000, had piped water sys- follow -up with mass X -ray, completely free and easily tems. Thus 59 % of the country's total population were accessible diagnostic services, and a sufficient number served with piped water. Of the total number of communities 373, with a population of 2 492 000, had a of availabletuberculosis hospitalbeds. Special attention has been given to the chemotherapy for the sewerage system. Thus 54 % of the total population treatment of chronic cases.Extramural treatment is were living in houses connected to sewers. increasingly used instead of inpatient treatment. In 1972 the following immunization procedures were Major public health problems carried out: With the relatively high standard of living, the aging Smallpox 117401 of the population, the continuously growing indus- Tetanus 115450 trialization, and increased traffic and urbanization, the Poliomyelitis 104006 health problems of the developed countries have also Diphtheria (simple and combined) 74414 become typical for Finland. The relatively low Whooping -cough (simple and combined) . 62891 BCG 60750 population density has, to some extent, limited the Typhoid and paratyphoid fevers 3280 effects of environmental pollution, except in some big cities.The mortality and morbidity rates in Finland Chronic and degenerative diseases are relatively high, especially if compared with those in the other northern countries, but the reasons are not The frequency of cardiovascular diseases is a very clearly understood. There are very marked differences serious health problem in Finland, particularly in the within the country and less favourable rates are found rural areas of eastern Finland. An extensive study has in the less developed areas. The health attitudes and been started in North Karelia with the objective of health behaviour of the population are another con- influencing the living habits that are considered relevant cern of the health authorities.Health insurance and risk factors in coronary heart disease, such as smoking, cheap or free services are intended to induce people to food and working habits. This study is associated with consult the health personnel at an early stage in their an effective and systematic health education pro- illness. The new legislation concerning primary health gramme. services should provide a solution to this problem. 178 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Social and economic developments of significance for same period and it has to ensure the coordination bet- the health situation ween the local plans and the overall national plan. The plans concentrate on major indicative aspects suchas There was rapid economic growth in 1969 and 1970 manpower, overall costs and main lines of pro- which slackened in 1971 but regained momentum in grammes; the local authorities are relatively free to 1972. The growth of the gross national product was solve the technical details.This indicative type of approximately 8.5 % in 1969 and 7 % in 1970. Unem- planning is suited to the markedly decentralized deci- ployment was reduced from 4 % in 1968 to 2.8 % in sion process in Finland. 1969 and to 1.9 % in 1970. In 1971 the cost of living The plan for the years 1973 -1977 greatly increases the index rose by 6.5 %. In 1972 the unemployment situa- investments in primary services. The number of doc- tion deteriorated somewhat, and prices rose even more tors in these services will increase by about 90 %, which than in 1971. represents about one -third of all new doctors.The During the period under review, the whole educa- corresponding figure for dentists will be 150 each year, tional system was reorganized. New legislation has which represents nearly 100 % of the estimated num- been introduced which provides for a uniform and ber of new dentists graduating. The same type of plan- continuous school system. The divisions between ning was to be introduced in 1973 in the hospital elementary, secondary and higher education will be services. abolished, which will result in a higher level of education for the whole population. With rapid industrial growth the problems of Medical and public health research environmental pollution have increased. Measures to reduce the effects of pollution are being taken at several The universities traditionally play a central role in levels; they include technical improvements in industry research activities.Several foundations also support and its production processes, building of chemical and research activities in the field of medicine and public biological purification plants, and biological treatment health, most of which is applied research. Basic of sewage in the larger cities. research is supported by the Finnish Academy of Finland has a relatively low and stable natural pop- Sciences, which has attracted growing interest and ulation increase.Family planning programmes have increasing funds. An overall research plan including been carried out for several years and were intensified medical research was adopted for the 1970s.The during the years 1971 and 1972. During 1969 and 1970 diseases of the heart and blood circulation and rheu- emigration from Finland reached such proportions matic diseases are among the main goals of research that the population decreased and special measures had in the health field. to be taken to reverse the migration flow. New legis- In Finland about 0.06 % of the gross national in- lation on induced abortion, sterilization and castration come is used for medical research.In 1968, 78 % of came into force in 1970. the total research allocation was used in universities, about 9 % in State -owned research institutes, and about 9 % was administered by the Finnish Academy National health planning of Sciences. There exists a system of medium -range economic planning for the central government. The economic Government health expenditure plan is a relatively loose framework which enables the decision -makers to adopt correct policies when decid- In1971totalgovernment current and capital ing annual budgets. A section of the economic plan is expenditure amounted to 10 043.1 million markkas, devoted to health, and the separate health plans are of which 2114 million were devoted to health services, coordinated with it. including 1822.7 million on current account and 291.3 Under the new legislation which was passed in 1972 million on capital account. The central government the central government has to prepare and publish an health expenditure amounted to 908.0 million markkas official national health plan for the next five years. The and the local authorities health expenditure to 1206.0 National Board of Health has the right to request from million. The per capita central and local government each local authority a plan for its own activities for the health expenditure was 458 markkas. EUROPEAN REGION 179

FRANCE

Population and other statistics shares with the Ministry of Labour, Employment and Population the following services: the division of At the last census, taken in March 1968, the popu- international relations, the general inspectorate for lation of France was 49 778 540. Population estimates social affairs, the office of public relations, the service and some other vital statistics for the period under for studies and provisions, the directorate for general review are given below : administration of personnel and budget. 1969 1970 1971* 1972* A state secretariat is attached to the Ministry and is Mean population . . 50314 88250768 389 51248 508 51701 000 in charge of social development and rehabilitation. Number of live births 842 245 850 376 878 647 ** 872 082 ** Birth rate (per The Ministry of Public Health and Social Security 1000 population) 16.7 16.7 17.1 16.9 Number of deaths 573 335 542 272 551 514" 545 075 ** comprises the following directorates and services: the Death rate (per Directorate -General of Health, the Directorate of 1000 population) 11.4 10.7 10.8 10.6 Natural Increase ( %) 0.53 0.60 0.63 0.63 SocialSecurity, the Directorate of Hospitals, the Number of infant Directorate of Social Development and the Central deaths 16 515 15 432 12 490 11 568 Infant mortality rate Pharmacy and Drugs Service. (per 1000 live The Directorate -General of Health is in charge of the births) 19.6 18.1 14.2 13.2 Number of deaths, formulation, application and control of public health 1 -4 years 2 864 2 662 2 642 Death rate, 1 -4 years activities.It includes a division for hospital develop- (per 1000 population ment and four subdirectorates dealing with health at risk) 0.8 0.8 0.8 Number of maternal professions,public health,health protection, and deaths 210 239 151 230 maternal and child health and health education. The Maternal mortality rate (per 1000 Directorate of Hospitals is in charge of all matters live births) . . . . 0.3 0.3 0.2 0.3 concerning hospitals and inpatient establishments.It * Provisional figures. comprises the following services and subdirectorates: ** Excluding Infants dying before registration of birth. building and equipment, personnel, hospital control, and provisions and coordination. Of the 545 075 deaths recorded in 1972, excluding Since the reorganization of the health administra- the deaths of infants dying before registration of birth, tion at the level of the departments and regions in 1964 the main causes were: 1 malignant neoplasms (110 550), each department has a director of health and welfare, hypertensive disease, ischaemic heart disease, other who, under the authority of the prefect, is responsible forms of heart disease (108 220), cerebrovascular for environmental protection, prevention of diseases, disease (74 870), accidents (39 655), cirrhosis of the Each depart- liver (17 626), pneumonia (9119), suicide and self - maternal and child health protection. ment also has a public health doctor who is responsible inflictedinjuries(8267),diabetesmellitus(8142), for inspection and technical supervision of the health bronchitis, emphysema and asthma (6512), influenza services and facilities of the department and who comes (4764), benign neoplasms (4098),tuberculosis,all under the authority of the prefect, serving as his forms (3512), birth injury, difficult labour and other medical technical adviser.At the regional level, the anoxic and hypoxic conditions (3390),congenital regional director of health and welfare is responsible anomalies (3215), acute rheumatic fever and chronic for coordinating the administrative and financial rheumatic heart disease (2423), nephritis and nephrosis control of hospital establishments and for preparing (1813). regional health and social equipment plans.He is The communicable diseases most frequently notified assisted by a regional public health doctor.At the in1972 were:tuberculosis,all forms, new cases communal level the mayor is responsible for the health (30 455), measles (4923), scarlet fever (2302):, meningococcal infections (1440), typhoid and paratyphoid protection of the commune. fevers (1040), whooping -cough (614), infectious hepatitis (78), amoebiasis (59), diphtheria (43), poliomyelitis Hospital services (41), typhus (26). In 1971 France had altogether 539 700 hospital beds, or 10.5 beds per 1000 population.These beds were Organization of the public health services distributed as follows : Category Number The Ministry of Public Health and Social Security Hospitals for general medicine 316100 is the supreme authority in health matters, family wel- Hospitals for tuberculosis and chest diseases 47000 Hospitals for mental diseases 119400 fare, old age, social services and social security.It Cancer centres 3800 Medical rehabilitation centres 12100 1 International Classification of Diseases, 1965 Revision. Rest and convalescent homes 41300 180 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Outpatient health care was provided in 1971 at 470 between 6.6 per 100 000 population in 1969 and 4.4 public hospital outpatient departments, which recorded per 100 000 in 1972.Morbidity and mortality from 9.8 million patients; at 720 medical care dispensaries whooping -cough have continued to decline, with 126 attached to private or public hospitals or independent deaths during the period under review as against 283 of hospitals which recorded approximately 7 million deaths during 1965 -1968.The diphtheria morbidity outpatients in 1972; in the consulting rooms of 51 500 rate, which was 0.1 per 100 000 in 1969, reached 0.08 doctors, where an estimated 180 million visits and in 1972. The tetanus mortality remained constant. A consultations were recorded in 1972. vaccination programme for adults and old people at risk was started in 1972. The number of notified cases Medical and allied personnel and training facilities of poliomyelitis continued to decline, going from 68 in 1969 to 37 in 1972. A recrudescence of the disease, In 1971 France had 71 780 doctors, or one doctor for with 82 cases, occurred in 1970 among immigrants. 730 inhabitants. Other health personnel included: Polio vaccination is given to children before they Dentists 20 740 reach the age of 18 months. An average of one million Pharmacists 26 500 Pharmaceutical assistants 15 000 persons are vaccinated annually against poliomyelitis. Veterinarians 5 850 (1972) Typhoid and paratyphoid fevers continued to decline. Midwives 9 032 Nurses (state diploma) 95 151 Between 1969 and 1972 the number of declared cases Nurses (authorized) 21 983 fell from 1374 to 1040 and the morbidity rates from Children's nurses 3000 Psychiatric nurses 33 462 2.7 to 2.09 per 100 000 population.Vaccination is Assistant nurses 51 000* Kinesitherapists 20 841 compulsory only for certain professional categories at Orthophonists 2 013 risk, such as nurses and doctors. Cerebrospinal Assistant orthoptists 373 Dietitians 600 meningitis has shown a constant increase since 1968, Laboratory technicians 3 000* with 1440 cases in 1972 as against 910 in 1969. During X -ray technicians 2 000* the same period the morbidity rate increased from 1.8 * In government service. to 2.7 per 100 000. There was also an increase in the The arrangements for the training of medical and number of deaths. The incidence of viral hepatitis is health personnel were as follows: increasing and the number of deaths reached 439 in 1972 as against 297 in 1965. Category DurationNumber of Number ofNumber of and admission of study schools students graduates Tuberculosis remains an important public health requirements (years) 1971/72 1972 problem. The mortality rate for tuberculosis (all Doctors : forms) declined from 10.7 per 100 000 inhabitants in baccalauréat . 7 36* 87 688 6 800 (1969) Dentists : 1968 to 7.3 per 100 000 in 1971.According to data baccalauréat . 5 16* 8 758 1 095 (1969) provided by tuberculosis dispensaries, the incidence Pharmacists : baccalauréat . 5 30* 2 400 (1970) was 57.6 per 100 000 in 1971, whereas the prevalence Veterinarians : baccalauréat or 4+1 was 240.3 per 100 000 inhabitants in 1969. The tuber- diploma in agro- prepa- culosis risk is much higher in adults than in children. nomic engineering ratory 3* 1 389 548 ** Nurses (university The disease mainly affects the male population in the level) : age group above 50. The tuberculosis incidence baccalauréat plus 3 years preparatory . . 2 1* 24 12 appears to be higher among male adults living in rural Nurses : areas than in those living in urban areas. The morbidity baccalauréat . . . . 28 months 255 25 618 10 002 Midwives: is clearly higher among foreign workers, among whom baccalauréat. . 3 31 1 637 430 Laboratory technicians the incidence was 245 per 100 000 in 1970, than among and assistants : the French population.There were 925 tuberculosis baccalauréat . . . . 2 16 992 398 Kinesitherapists dispensariesin1971responsibleforcase -finding baccalauréat . . . . 3 35 6 616 1 461 activities,clinicalbacteriological and radiological X -ray technicians :

baccalauréat . . . 2 17 1 004 284 diagnosis, BCG vaccination and individual and collec- Ergotherapists : tive prophylaxis. The current policy is to close certain baccalauréat . . . . 3 6 205 nonactive dispensaries and to regroup the dispensaries Public institutions. ** 240 degrees and 308 certificates of completion of studies. in bigger and better -equipped establishments. The incidence of venereal diseases is known mainly Communicable disease control and through medical reports,asnotification of these immunization services diseases by the treating doctor is compulsory.The number of gonorrhoea cases was relatively stable There was one, so far unexplained, indigenous case during the period 1960 -1969, but increased in 1970 by of cholera in 1970, and there were three imported 20 %. The morbidity rate in 1970 was 31 per 100 000 cases in 1971. The scarlet fever morbidity rate varied inhabitants. In 1970, for the first time, the Paris area EUROPEAN REGION 181 accounted for less than 50 % of all notified cases, do not exist but certain epidemiological surveys carried whereas the morbidity increased in the departments out by the National Institute for Health and Medical with large urban populations, and also in certain rural Research indicate the increasing prevalence of these areas. The proportion of cases in women remained at diseases in the age -group of 40 years and above. These about 25 %. The annual syphilis morbidity rate surveys show that 57.7 % of persons between 60 and remained unchanged and was 8.1 per 100 000 inhabi- 64 years in a given population group are suffering from tants in 1970. Whereas in 1967 the Paris area account- cardiovascular diseases.The incidence of ischaemic ed for 50 % of all cases, it accounted for 34 % in 1970. heart disease is also considerable.Control and pre- The proportion of cases in women was about 30 %. vention of these diseases is based on early detection and An influenza epidemic occurred in 1969 with 23 600 treatment of atherosclerosis and hypertension.Since deaths. 1967 five clinics for the prevention of cardiovascular The following immunization procedures were carried diseases have been established and receive financial out in 1971: support from the Government.

Smallpox 1 277 853 Poliomyelitis 989 024 Specialized units Diphtheria, tetanus and poliomyelitis . . 987346 BCG 841 980 Diphtheria, whooping- cough, tetanus and In 1971 there were 530 prenatal, 7520 infant care and poliomyelitis 400 197 1700 child health centres.They were attended by Diphtheria, whooping -cough and tetanus 136 132 Diphtheria and tetanus 122 684 172 000 pregnant women and one million children aged Diphtheria, tetanus, typhoid and paratyphoid Domiciliary care was given to 228 000 fevers 67 042 0 -5 years. Tetanus and poliomyelitis 36 778 pregnant women, to 750 000 infants and to 840 000 children aged 1 -5 years. Of all deliveries in 1971, 97 Chronic and degenerative diseases were institutional and 3 % were conducted at home under professional care.In the same year, 1695 The diabetes mortality rate is 16 to 17 per 100 000 school health centres looked after 6 million school - inhabitants and 1.5 % of the total mortality. The dia- children-96 % of the total school population. Dental betes morbidity estimates vary between 1.5 % and 3 care was given at 460 dental health units which of the population. Specialized diabetes detection and recorded 4 million consultations in 1972.This figure prevention centres were opened in hospitals of the main represents only about 10 % of the dental consultations French towns. given by private dentists. In 1972 France had 110 inde- There are at present no reliable morbidity statistics pendent medical rehabilitation centres and 33 hospital and epidemiological data with which to estimate the and health centre rehabilitation outpatient depart- prevalence of rheumatic diseases in France.From ments. Together they recorded 57 000 patients in 1972. surveys carried out by the Social Security on the Psychiatric consultations were available in 1971 at 1000 incidence and the cost of rheumatic diseases, it would clinics, which were attended in 1971 by 124 000 new appear that the number of new patients suffering from patients.In 1969 medical and health services were rheumatic diseases increased in the last seven years provided by 3400 industrial establishments.Health from 4.8 to 6.2 % of all patients examined for the care services in industry covered 90 % of the total purpose of social security benefits.The number of number of industrial workers. Other outpatient benefits paid to patients suffering from rheumatic facilities in certain specialized clinical fields included diseases has increased from 2722 in 1960 to 4000 in 410 venereal disease dispensaries, which recorded 1970. Among the rheumatic diseases, chronic inflam- 360 000 new outpatients in 1971, and 940 tuberculosis matory rheumatism is the most common form (35 % of dispensaries, which recorded 305 000 new patients in all cases) followed by neuritis and various forms of 1971.There were 111 public health laboratories in neuralgia (30 %), coxarthritis (10 %), tumours and 1972. metastases (10 %), bone diseases and osteo -articular infections and gout (5 %).There are 635 specialized Environmental sanitation doctors for the treatment of rheumatic diseases, or one rheumatologist for 100 000 inhabitants, and 1860 beds In 1970, 90.9 % of France's total population were in specialized hospitals or hospital services. served with piped water and 74.5 % of the population Cardiovascular diseases are a very serious health were living in houses connected to sewers. problem in France. In 1971, 204 000 deaths were due to these diseases representing 37 % of the general Major public health problems mortality, and 400 deaths per 100 000 inhabitants. The mortality due to ischaemic cardiopathy is increasing. The perinatal mortality rate was about 26 per 1000 General morbidity statistics for cardiovascular diseases in 1968, which corresponds to 22 000 deaths, and 22.8 182 FIFTH REPORT ON THE WORLD HEALTH SITUATION per 1000 in 1971. In 1970 a programme was launched This law stipulates the establishment in each region of a to reduce the perinatal mortality rate to 18 per 1000 in map of health needs and of the requirements for equip- 1980. The measures envisaged in this programme ment to meet these needs, on the basis of criteria set up include training of medical personnel, collection of by the Ministry of Public Health and Social Security. statisticaldata and research,vaccinationagainst The map provides programme guidelines for the rubella, prenatal surveillance, medical supervision of extension of hospital establishments and hospital deliveries, and establishment of intensive neonatal equipment. New provisions will define the relations reanimation centres. Special attention is also given to between the public and private hospital establishments. early detection of the risks of perinatal accidents. The law also provides for a regular flow of information between the treating physician and thehospital establishment. Social and economic developments of significance for the health situation National health planning The period under review has been marked by a The health sector of the sixth general plan (1971- rising birth rate which, after having dropped from 18.1 1975) includes priority programmes for the coordina- to 16.7 per 1000 between 1964 and 1970, again reached tion of control measures against those diseases which 17.1 per 1000 in 1971.The falling birth rate was a cause a high mortality or invalidity, namely perinatal major preoccupation of the Government, as France accidents, alcoholism and drug addiction, mental has the lowest population density and the highest diseases, occupational accidents and traffic accidents, percentage of aged persons in Western Europe.In diseases of old age, cardiovascular diseases and cancer. economic terms this means a large number of pen- The measures envisaged in the plan for achieving these sioners and a heavy social burden for the smaller objectives include an improved information system, proportion of active persons. Simultaneously with the increased health manpower resources and improved rising birth rate there was in 1971 a reduction in hospital facilities. mortality, particularly infant mortality, which had With regard to health manpower it is proposed to dropped by 40 % in 10 years. Immigration of foreign develop the training facilities and to take the necessary labourers and their families remained high during the steps for preventing the emigration of trained person- four year period and reached 330 000 in 1971 and 1972. nel.It is hoped to double the present number of doc- In 1972 the growth rate of the gross national pro- tors by 1985 and to reach a doctor /population ratio of duct in France was 5.6 %, compared to 7.7 % in 1969. 200 per 100 000. In order to ensure a high standard of Exports increased by 70 % between 1969 and 1972. medical education a law was passed in 1971 which The gross fixed capital formation represented 20 % of limits the number of medical students to the openings the gross national product in 1960 and 25 % in 1972. for training in hospital establishments.The sixth The living conditions of the population have been general plan also envisages group practice. The num- improved and the income of households has grown by ber of hospital administrators will be increased and 60 %, which resulted in a 26 % increase in the pur- their training improved. Measures are being taken to chasing power.Social benefit allowances have pro- improve nursing and to develop the training facilities gressed; they represent at present one -quarter of the for this category of personnel. There is a great demand revenue of the inhabitants. Progress has been achieved for technical personnel, and it is proposed to establish in improving the compulsory pension scheme, in posts for engineers and technicians in hospitals. extending the protection of independent workers with With regard to the improvement of hospital facilities regard to disease and old age, in establishing a scheme special attention is given to the university hospital for special allowances for handicapped persons, in centres, the hospitals for mental diseases and the developing the family allowance, the housing allow- establishments for the care of old people.Efforts are ance, in improving the compensations paid to the being directed towards better use of the technical elderly unemployed, and in increasing the minimum hospital equipment through a pooling system linking old -age benefits. several establishments and through the development In 1971, 500 000 housing units were built. Important of outpatient consultations.It is planned to create investments have been made in the educational and 25 000 new hospital beds, building several 300 -bed cultural, research, transport and health fields.The hospitals and one 500 -bed hospital during the sixth expenditures of the national social budget increased by plan period. 58 % during 1969 -1972. During this period, the sixth general plan for the period 1971 -1975 was formulated. Medical and public health research Following a law issued in 1970, the hospital care system was reorganized with a view to ensuring a The main functions of the National Institute for greater cohesion within the medical services structure. Health and Medical Research are toadvise the EUROPEAN REGION 183

Government on the health situation of the country, Social Security accounted for 4494 million francs, to carry out studies on health problems, to collect other ministries for 1254 million and the intermediate information on medical research activitiesin the and local health levels for approximately 600 million. country and abroad, and to promote and encourage The expenditure on public health services at all govern- medical research activities in France. A priority pro- ment levels, which amounted to 6351 million francs, gramme for medical and public health research has included the following items: 525 million for adminis- been adopted with the following four main research tration and government personnel, 495 million for topics :diseases and problems of sociopathologic immunization and vaccination activities, 212 million character, neurological and neuropsychological dis- for laboratory services (research), 155 million for occu- eases,diseasesrelated tocellulardisorders, and pational health services, and 917 million for education problems of human therapy.The cost of this pro- and training of health personnel. The expenditure for gramme is estimated at 115 million francs. occupational health services is charged to the indus- trialestablishments and representsapproximately Government health expenditure 600 million francs.The government capital expenditure on hospitals amounted to 747 million francs and In 1972 total government expenditure amounted to included 501 million for general hospitals and clinics 183 000 million francs.The national social budget and teaching hospitals, 173 million for specialized amounted to 197 000 million francs, of which 48 000 hospitals and 73 million for other establishments. The million were spent by the social insurance scheme for government contributions to health activities of social health purposes. The total government health expen- security schemes and other nongovernment social diture was 32 000 million francs, of which 23 000 welfare systems amounted to 1800 million francs, and million were spent on current account and 9000 million 1500 million were contributed for medical aid to on capital account. The Ministry of Public Health and indigents.

GERMAN DEMOCRATIC REPUBLIC

Population and other statistics (3410), congenital anomalies, birth injury,difficult labour and other anoxic and hypoxic conditions, other Population estimates and some other vital statistics causes of perinatal mortality (2987), cirrhosis of the for the period under review are given in the following liver (2035), hyperplasia of the prostate (1887), peptic table : 1969 1970 1971 1972 ulcer (1737), tuberculosis, all forms (1467), intestinal

Mean population . . 17076 48817058 229 17049 644 17042 988 obstruction and hernia (1130). Number of live births. . 238 910 236 929 234 870 200 443 The communicable diseases most frequently notified Birth rate (per 1000 population) . 14.0 13.9 13.8 11.7 in1971were:scarlet fever (43 133), gonorrhoea Number of deaths . . . 243 732 240 821 234 953 234 425 (27 717), infectious hepatitis (19 935), tuberculosis, all Death rate (per 1000 population) . 14.3 14.1 13.8 13.7 forms, new cases (9704), dysentery, all forms (8957), Natural increase ( %) . . -0.03 -0.02 0 -0.2 Number of infant deaths . 4 849 4 382 4 230 3 537 measles (5542), whooping -cough (3777),influenza Infant mortality rate (1154), early syphilis (381), typhoid and paratyphoid (per 1000 live births) . 20.3 18.5 18.0 17.6 Number of deaths, fevers (350), meningococcal infections (66). 1 -4 years 946 861 773 705 Death rate, 1-4 years (per 1000 population at risk) 0.91 0.86 0.80 0.60 Organization of the public health services Number of maternal deaths 100 102 96 60 Maternal mortality rate The Ministry of Health is responsible for the admi- (per 1000 live births) . 0.41 0.42 0.41 0.26 nistration of the health services.It issues laws and decrees defining the health policy of the country, if Of the 234 425 deaths recorded in 1972, the main they are not promulgated by the People's Chamber or causes were: 1 chronic rheumatic heart disease, hyper- the Council of Ministers. For administrative purposes tensive disease, ischaemic heart disease and other forms the country is divided into areas (Bezirke) districts of heartdisease(63 611),malignantneoplasms (Kreise) and municipalities, each of which has a (37 809), cerebrovascular disease (15 387), bronchitis, council with a health and social welfare department emphysema and asthma (11 015), accidents (9423, headed by the area or district health officer, who is including 2530 in motor -vehicle accidents), suicide and elected deputy to the people's representation at the self- inflicted injuries (5452), symptoms and ill- defined respective level, and who is advised by specialists. conditions (4635), pneumonia (3998), diabetes mellitus The health and social welfare departments of the area 1 International Classification of Diseases, 1965 Revision. and district councils are under the technical control 184 FIFTH REPORT ON THE WORLD HEALTH SITUATION and supervision of the higher level (the Ministry Category DurationNumber of Number of Number of and admission of study schools studentsgraduates of Health, the area and district authorities) and requirements (years) (public) 1971/1972 1972 under the political and administrative control of the Doctors and dentists: High school graduation 5 9 9 223 1 487 people's representation (the Parliament) and of the Pharmacists: area or district council. High school graduation 4 3 569 209 Veterinarians: At the central, area and district level there are High school graduation 5 2 Nurses: governmental sanitary inspection units which are Completion of tenth responsible for environmental health protection and grade 2%z 13 000* 4 600* Auxiliary nurses: control, including air and water pollution, waste Completion of eighth water control,protection against and control of grade 1 -2 Midwives: epidemics(includingimmunization),community Completion of health, food hygiene, and industrial hygiene. tenth grade 2 Nurses for outpatient Medical and social services are free of charge. They care: are financed by the social insurance and government completion of tenth grade 2 1200 450 funds. Laboratory technicians completion of tenth grade 2 1 450 850 Dental laboratory 59 Hospital services technicians : completion of In 1972 the German Democratic Republic had 608 tenth grade 2A 1 400 280 Physiotherapists : hospitals with 186 075 beds, equivalent to 10.9 beds per completion of 1000 population. tenth grade 2% 1 430 300 Sanitarlans: General inpatient care is provided at local and completion of tenth grade 2 300 150 district hospitals, whereas specialized inpatient services X -ray technicians : are available at larger district and area hospitals, as completion of tenth grade 2 700 350 well as at the university hospitals.Some highly spe- Medical social workers : cialized inpatient establishments are under the direct completion of control of the Ministry of Health. tenth grade 2 700 350 Outpatient medical and health care was provided in * Including midwives and auxiliary 1972 at 100 teaching hospital outpatient departments, which recorded 5.4 million attendances; at 385 poly- Communicable disease control and clinics, including 99 polyclinics at places of work, which immunization services altogether recorded over 62.7 million attendances; at 860 "ambulatoria ", including 163 urban and 389 The communicable diseases have lost their previous rural "ambulatoria" (medium -sized outpatient units) significance as a result of comprehensive preventive and 252 "ambulatoria" at places of work, which measures and of the general improvement in living together recorded 27 million attendances; at 576 urban conditions.Excluding tuberculosis, their share in all and 366 rural Ambulanzen, which are small outpatient causes of death has fallen to 0.44 %, or to one death per units served by a hospital or larger outpatient establish- 16 000 population. ment and where specialists work on a part -time basis; The last cases of poliomyelitis occurred in 1962, and at 1480 consulting rooms of government -employed only three cases of diphtheria were notified in 1972. doctors, which recorded 21.7 million attendances; and Vaccination against measles has been compulsory at 2040 consulting rooms at places of work, which since 1970 and has dramatically reduced the incidence recorded 5.9 million attendances. of the disease from 14.8 new cases per 10 000 in- Preventive health services are provided at outpatient habitants in 1969 to 0.3 per 10 000 in 1972.The establishments.There is an increasing tendency to incidence rate of mumps was 48.8 per 10 000 popula- integrate preventive, diagnostic, curative and rehabilit- tion in 1971 and is expected to be reduced sharply ation services and to create a functional unity of in- following the introduction of vaccination with a live- patient and outpatient care. virus vaccine. There are no longer any tetanus cases among children.The control of scarlet fever still Medical and allied personnel and training facilities presents a serious health concern. The incidence rate has risen considerably during the past years and In 1972 the German Democratic Republic had reached 47.3 per 10 000 population in 1973. Infectious 28 590 doctors, or one doctor for 600 inhabitants. hepatitis is at present a relatively common infectious There were also 7447 dentists and 2935 pharmacists. disease, with an incidence rate of 11.7 per 10 000 popu- The arrangements for the training of medical and lation.Progress has been made in early detection, health personnel were as follows: particularly in schools, day- nurseries, crèches, etc. as a EUROPEAN REGION 185

result of improved screening techniques. In addition, kidney diseases were recorded.The dialysis centres, gammaglobulin is widely used as a preventive measure which increased in number from 13 to 27 between to interrupt the chains of infection. With improved 1967 and 1972, recorded 7764 patients. According to a general sanitary conditions, the incidence of intestinal rough estimate, there are one million patients suffering infections has been reduced considerably since 1966. from rheumatic diseases in the German Democratic The incidence rates for typhoid and paratyphoid fevers Republic. Rheumatoid arthritis is the form most in 1972 were respectively 0.1 and 0.4 per 10 000 popu- frequently found among patients attending the 205 lation and 5.6 for Salmonella infections.Viral infec- district centres for arthritis "dispensarization ".In tions, particularly those of the respiratory system, show 1971, 9 % of all new cases showed permanent disable- the highest incidence rate.Since 1968 the incidence ment. The diabetes prevalence rate was 213 per 10 000 rate of gonorrhoea has increased again, reaching 12.8 population at the end of 1972. new cases per 10 000 population in 1969 and 20.6 in 1972. The incidence rate of syphilis has shown only Specialized units minor fluctuations over the past four years. The tuberculosis incidence has steadily fallen by In 1972 the 980 prenatal units and 10 203 child about 10 % annually and was 5.01 per 10 000 popu- health centres were attended by 207 001 pregnant lation in 1972.There are practically no cases of the women, 200 337 children under 1 year, and 1 399 054 disease among children and very few among adoles- children aged 1 -6 years. Domiciliary visits were paid cents and young adults. This reduction of the disease to 39 714 pregnant women, to 178 323 children under is mainly due to a well- organized "dispensarization" 1 year and 526 879 children aged 1 -3 years.In 1972, system, (early detection and follow -up), annual mass 30 % of all children up to 3 years of age were in crèches. X -ray examinations of the whole population, a very Of all deliveries in 1972, 196 181 were institutional. high BCG vaccination coverage of newborn children School health services were provided at 314 units, (99.6 %), repeated tuberculin tests and, if necessary, which served 704 561 schoolchildren between the first revaccinations of children and young persons. and tenth grade. Dental care was provided at 508 units for schoolchildren and 2129 units for adults. During 1972, 5 638 750 dental treatments were given to school- Chronic and degenerative diseases children and 14 886 924 to adults.In the same year 3689 outpatient units, 1298 of which were staffed by Chronic and degenerative diseases which are more nurses, provided health and medical care to industrial frequent in the older age groups are important health workers, serving 59 % of all industrial workers. The problems in the German Democratic Republic, where occupational health services are financed by the indus- the life expectancy for women is 74.2 years and for trial establishments.The 296 venereal diseases out- men 68.9 years.The programmes for the treatment patient clinics were attended in 1972 by 35 442 patients and control of several chronic diseases are based on and the 306 tuberculosis clinics by 8541 patients. general care units at district level and in some instances at communal level, and specialized care, guidance and supervision at area level. Environmental sanitation In 1971 cardiovascular diseases caused 54 % of all In 1972, 81.6 % of the country's total population deaths, or 74 deaths per 10 000 inhabitants, 13.2 % of were served with piped water and 61.9 % were living in all hospital patient -days and about 7 % of all cases of houses connected to sewers. absenteeism due to health reasons.In 1971 about 137 500 patientsattended the 264 cardiovascular Major public health problems outpatient units.It is expected that the number of patients suffering from cardiovascular diseases will The main health problems in the German Demo- continue to grow, because of intensified diagnostic cratic Republic are, in general, related to the organiza- activities, early detection, improved therapy, as well as tion and administration of health services, to the increasing life expectancy and a growing proportion of effective delivery of these services and to their exten- old people. Cancer is notifiable in the German Demo- sion.The health authorities also have to meet the cratic Republic.There are annually about 340 new challenge of the problem of health and social care for cases of cancer per 10 000 population.Medical care the increasing number of elderly persons. and social assistance is provided at 204 specialized local units. Each year about 60 cancer cases per 10 000 Social and economic developments of significance for population are discharged from hospitals. This the health situation figure corresponds to about 4 % of all hospital dis- charges. Cancer is responsible for 15 % of all new cases Industry is the leading economic sector in the Ger- of permanent disablement. In 1971, 2912 deaths from man Democratic Republic. The industrial gross 186 FIFTH REPORT ON THE WORLD HEALTH SITUATION product amounted to 154 600 million marks in 1971 health objectives and numerical indices of targets to be and to 167 900 million in 1972. Of the net economic attained,thus giving the generalorientationfor product, 95 % are provided by the public industrial balanced development of health and social care. The sector, 1 % by the semipublic sector and 4 % by the plans of the health establishments are prepared on the private sector. The agricultural sector, which consists basis of guidelines issued by the Ministry of Health for mainly of cooperative farms and a small number of the different categories of health and social facilities. government- operated farms, has since 1966 been able The administrator in charge of the health establish- to meet almost entirely the country's essential food ment has to report on the implementation of the plan requirements. Because of industrialization of agricul- to his own staff and to the department of health and tural production, the number of agricultural workers social welfare of the local and county councils, to the has decreased from 915 030 in 1969 to 839 704 in 1972. deputies at the same level and to the health department The consequences of the two world wars have resulted at the higher level. The plans are given statutory power in an unfavourable age and sex structure of the popula- by the assemblies of deputies at the county, district, tion which is characterized by a large proportion of municipal and village level. At the national level, the old people (16 % of the population are 65 years and Parliament enacts planning legislation. above). The measures adopted in 1972 to increase the The five year plan for 1971 -1975 includes plans for birth rate include: payment of an allowance (1000 the expansion of health establishments and the setting marks) per child; paid 18 -weeks maternity leave; up of new hospitals and health centres. The polyclinics reduction of working hours (40 hours a week) and will become increasingly the centres of outpatient prolonged leave without wage loss for working mothers medical care.The provisions for the promotion of with three and more children under the age of 16 years. health deal with the care of the aged, nutrition, dental In 1972, 6800 million marks were spent on education, care, extension of drinking -water fluoridation, medical vocationaltraining,university and medium -grade treatment in spas and health resorts, and factory health education, and adult education and training.This services. represents a 128 % increase over the 1969 expenditure. During the period under review, the expenditure for education amounted to an average 8.1 % of the total Medical and public health research government expenditure (excluding capital expen- The Minister of Health is responsible for the coor- diture). In 1972 the cultural and social sectors (educa- dination of medical research.He is advised by the services, with the tion, culture, health and social Medical Science Department of his own Ministry and exception of science and research) accounted for 4.5 the Council for Planning and Coordination of Medical of the total investment sum. In 1972 the labour force Scientific Work, which makes recommendations on numbered about 8.3 million persons, of which about the main medical research trends. The medical research half were women. The employment rate of women of activities undertakeninthe German Democratic working age amounts to 84 %. Republic include central research programmes and projects organized under the auspices of 24 research National health planning commissions which have their own advisory boards and central institutions, and other research projects The plans for health and social services are part of including projects carried out by the industries for the the overall national economic plans.Planning is development of medical equipment and pharmaceutical carried out at national and territorial levels, i.e. at the preparations.Research activities are mainly directed county, district, municipal and community level, and towards the following fields: cardiovascular diseases, by the health establishments.The long -term plans gastroenterology, diabetes, tumours, mental diseases, which cover a period of 15 to 20 years identify demands chronic renal insufficiency, human genetics, infectious in the health and social care fields and establish hepatitis, staphylococcal and streptococcal diseases, priorities to meet these demands. Long -term planning and problems of nutrition and of the environment. ismainly carried out by the central government The central research projects are financed by the Minis- authorities.Medium -term plans cover a five year try of Health, industrial research projects by the univer- period and short -term plans cover one year.These sities or industries concerned. Other research activities plans propose practical measures to be adopted for are financed by local health institutions. achieving the established priorities and lay down budgetary provisions.They are prepared by both national and local authorities and by the health Government health expenditure establishments. The Ministry of Health transmits to the local and In the fiscal year 1972 the total government health intermediate health authorities statements on the expenditure amounted to 4013 million marks, includ- EUROPEAN REGION 187 ing 3836 million on current account and 177 million on immunization and vaccination and control of infec- capital account. The per capita government expendi- tious diseases; 84 million for environmental health ture on health was thus 235 marks. The central govern- services; 162 million for ambulatory medical care at ment health expenditure was 759 million marks and places of work; 123 million for veterinary services. The included 227 million for establishments under the government expenditure on hospitals included 1432 direct authority of the Ministry of Health, and 532 million marks for general hospitals under the control million under other ministries.The expenditure on of county and district authorities; 434 million for health and medical establishments under the control of teaching hospitals; 280 million for tuberculosis, psy- counties, districts, municipalities and villages amount- chiatric and neurological hospitals; 839 million for ed to 3254 million marks.The health expenditure outpatient establishments.The government contri- broken down by programmes or purposes of expendi- butions to health activities of the social security scheme ture included the following items: 37 million marks for amounted to 7232 million marks.

HUNGARY

Population and other statistics infections (73), whooping -cough (63), diphtheria (9), malaria, new cases (4), poliomyelitis (2). At the last census, taken in January 1970, the population of Hungary was 10 315 000.Population estimates and some other vital statistics for the period Organization of the public health services under review are given in the following table: The health services in Hungary are controlled and 1969 1970 1971 1972 financed by the State, and it is the responsibility of the

Mean population . . 10303 000 10338 000 10368 000 10399 000 Government to provide health care to all citizens. All Number of live births . . 154318 151 819 150 640 153 265 Birth rate major branches of the medical profession have a (per 1000 population) . 15.0 14.7 14.5 14.7 national institute which is responsible for the pro- Number of deaths . . . 116 659 120197 123 009 118 991 Death rate fessional control and supervision of the medical care (per 1000 population) . 11.3 11.6 11.9 11.4 Natural increase ( %) 0.37 0.37 0.26 0.33 for the whole population of the country. There are at Number of infant deaths 5 511 5 449 5 294 5 092 present 37 national institutes which act as consultants Infant mortality rate (per 1000 live births) . 35.7 35.9 35.1 33.2 to the Ministry of Health. They are in direct contact Number of deaths, with the Ministry of Health and with the institutes at 1 -4 years 515 592 514 Death rate, 1 -4 years (per the regional and county levels. 1000 population at risk) 1.0 1.1 0.9 The Ministry of Health is the central executive health Number of maternal deaths 83 64 53 organ. At the local level there are the county and the Maternal mortality rate municipal health departments. (per 1000 live births) . . 0.5 0.4 0.4

Of the 123 009 deaths recorded in 1971, the main Hospital services causes were: 1 chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease, other forms of In 1971 there were altogether 84 064 hospital beds, heart disease (38 575), malignant neoplasms (23 231), to which 1 744 473 patients were admitted during the cerebrovasculardisease(17 622),accidents(5935, year. The bed /population ratio was 8.1 per 1000. The including 1954 in motor -vehicle accidents), suicide and beds were distributed as follows: self -inflictedinjuries(3737),birthinjury,difficult labour and other anoxic and hypoxic conditions Category Number of beds General medicine, surgery and obstetrics 33200 (3400), bronchitis, emphysema and asthma (2588), Paediatrics 8 349 tuberculosis, all forms (1850), influenza (1555), cirrho- Infectious diseases 4057 Tuberculosis and chest diseases 12935 sis of the liver (1428), pneumonia (1330), congenital Psychiatry 8373 anomalies (1044), peptic ulcer (946), diabetes mellitus Ophthalmology 1931 Otorhinolaryngology 2276

(932). Dermatology 1516 The communicable diseases most frequently notified Neurology 2853 Orthopaedics 1620 in 1972 were: scarlet fever (9965), infectious hepatitis Urology 1314 Radiotherapy 693 (9473), dysentery, all forms (9208), measles (6825), Stomatology 186 typhoid and paratyphoid fevers (151), meningococcal Rheumatology 715 Sanatoria 2390 Chronic diseases 1485 1 International Classification of Diseases, 1965 Revision. Intensive therapy 171 188 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Outpatient facilitieswere provided in1972 at Category Duration Number of Number of and admission of study studentsgraduates 184 polyclinics, which recorded nearly 56 million requirements 1 (years) 1971/72 1972 attendances; at 3898 health centres, which recorded Auxiliary nurses: 52.2 million attendances; at 682 medical aid posts, a 6 months 10 169 which recorded 15.1 million attendances; and at 130 Midwives 12 2 yearsday -school, 271 132 mobile health units, which recorded over 188 000 10 months special high school attendances. Children's nurses: 12 2 yearsday -school, 523 506 3 years on- the -job Medical and allied personnel and training facilities training Dietitians : In 1971 Hungary had 21 017 doctors, or one doctor 12 2 yearsday -school, 99 55 10 months special for 490 inhabitants. Of these physicians, 19 274 were high school in government service.Other health personnel in X -ray technicians : 12 2 years on- the -job 302 196 government service included : training, 10 months special Medical assistants 87 high school Dentists 2176 Dental assistants 313 1 In years of general education, the first eight in comprehensive Dental aides 1500 schools, the remaining four in high schools. Pharmacists 4199 Pharmaceutical assistants 6234 2 Excluding 27 who, having completed special high school courses, M d iwives 1900 were required to have five months' further training. Nurses 30259 Assistant nurses 14760 Other nursing personnel 3491 There were in all11 991 graduates from special Sanitary inspectors 1154 health high schools in 1971/72. Sanitarians 551 Physiotherapists 589 Assistant laboratory technicians 4160 X -ray technicians 2092 Communicable disease control and The arrangements for the training of medical and immunization services health personnel were as follows:

Category DurationNumber of Number ofNumber of The control of infectious diseases has been success- and admission of study schools students graduates fully conducted through extensive vaccination pro- requirements 1 (years) 1971/72 1972 grammes. Malaria and schistosomiasis occur only as Doctors : 12 6 4 1072 913 imported cases. Since the introduction of compulsory Dentists : poliomyelitis vaccination in 1959, no epidemic out- 12 5 2 141 156 Pharmacists: break of the disease has occurred in the country. The 12 4% 2 234 208 incidence of typhoid fever decreased from 215 cases Veterinarians: 12 5 1 107 92 in 1969 to 100 in 1972. There has also been a slight Dental assistants (operating) : decline in the incidences of dysentery and infectious 12 2 1 131 153 hepatitis. Notifications of salmonellosis increased Dental aides: 8 18 months on- the -job 120 152 from 2869 in 1970 to 4975 in 1972. As a result of sys- training, tematically conducted vaccinations, diphtheria has 5 months special high school been eradicated almost completely. Measles vaccina- Laboratory assistants: tion was made compulsory in 1969, and the incidence 12 2 years day -school, 486 336 3 years on- the -job of the disease fell from 53 254 notified cases in 1969 training, 10 months special to 3359 in 1971. The control of tuberculosis continued high school successfully, with a morbidity decrease of 17.2 Sanitary assistants: 8 6 -12 months 220 333 between 1968 and 1969, and of 12.5 % between 1971 Public health and 1972.Photofluoroscopic screening carried out epidemiological inspectors : regularly every year proved to be effective.It is esti- 12 2 years 113 86 Pharmacy assistants : mated that with this method 63 -64 % of the new tuber- 12 2 years on- the -job 741 638 culosis cases could be detected, as well as 45 -50 % of training, 15 months special the newly recorded cases of cancer of the lung. Tuber- high school culosis mortality decreased by 26 % during the period Physiotherapists2: 12 2 yearsday -school, 34 under review. The number of syphilis cases dropped 1 yearspecialhigh from 490 to 276 between 1969 and 1970, but increased school Nurses : again by 72.2 % from 331 in 1971 to 570 in 1972. In 8 2 yearsday -school, 2594 2000 3 years on- the -job 1972, 86.5 % of all syphilis cases occurred in Budapest. training, The incidence of gonorrhoea dropped by 17 % between 10 months special high school 1970 and 1972. EUROPEAN REGION 189

The following procedures were carried out in 1972: Major public health problems Poliomyelitis 1 301 269 Among the most important health problems which Diphtheria, whooping -cough and tetanus 692226 Smallpox 276 077 require study and action are: environmental health BCG 262 589 protection, control of air, water and soil pollution; the Diphtheria and tetanus 125 709 Tetanus, typhoid and paratyphoid fevers 41 096 provision of an increased number of hospital beds; Typhoid and paratyphoid fevers 1 747 Yellow fever 500 and a greatly increased supply of diagnostic and Epidemic typhus 385 therapeutic equipment. The number of hospital beds will be increased in the first place in the major county Chronic and degenerative diseases and regional establishments.It is planned to develop three main categories of hospital facilities: the inten- Data on mortality and causes of death indicate that sive care departments or wards; the active care depart- the chronic diseases play a major role in the total ments, which are primarily concerned with the diag- mortality figures. The incidence of heart and vascular nosis and treatment of patients whose recovery or diseases and of tumours is particularly high.These discharge from hospital may be expected within one or diseases are also major causes of chronic morbidity. two weeks following admission; and the chronic care Efforts are therefore being made to develop progres- units, which it is planned to set up in sanatoria func- sively the active continuous care of patients suffering tioning separately from the general hospitals, and as from these diseases.According to this concept the departments in a hospital. Particular attention will be chronic diseases are divided into two groups: those for devoted to a substantial increase in the number of beds which, at almost all phases of diagnosis and treatment, in psychiatric inpatient establishments.Other major only specialist doctors and health workers can provide concerns of the health administration are the reduction adequate care; and those for which regular care can be of premature births, the development of family plan- providedbynonspecialists,althoughspecialized ning and guidance, the prevention of unwanted preg- expertise may be needed for diagnosis. nancies, the improvement of health care for expectant mothers and infants, the improvement of large -scale Specialized units epidemiological studies and the development of a complex screening system. In 1972 there were 910 centres engaged in maternal and child health care. They were attended by 156 987 Social and economic developments of significance for pregnant women, 149 158 infants and 662 380 children the health situation aged 1 -5 years. All deliveries were attended by a doctor or a qualified midwife.School health services were In 1972, 48 % of the country's inhabitants were provided at 203 school health units to1 119 261 active wage- earners, as compared with 46.6 % in 1968; schoolchildren, representing 87.2 % of the total school 48 % of the population lived in towns and urban population. Dental care was available at 1681 dental centres as compared with 41.7 % in 1968. Moderniza- health units, which provied treatment to 0.7 million tion of industry and the building of electric power schoolchildren and to 9.6 million adults. There were plants have continued. The share of industry in the 11 hospital rehabilitation outpatient departments and overall national product increased to over 80 %, six independent medical rehabilitation clinics.Psy- whereas that of agriculture fell below 20 %. chiatric consultations were given in 1972 at 135 spe- The Public Health Act which came into force in cialized outpatient clinics to 31 661 new patients.In 1972 provides comprehensive free medical care for the 1972, 1312 industrial establishments provided health population. Since 1972 the whole population is and medical services to their workers. Thus 80 % of the covered by health insurance, for which 2 % of the total industrial workers were covered by health care in population (private artisans, private shop- owners, etc.) industry.Other specialized outpatient clinics in 1972 have to pay fees proportionate to their income. included 186 tuberculosis dispensaries, 124 skin and Despite the very high demand on outpatient services, venereal diseases dispensaries,67 ontological dis- part of the population does not turn to the doctor even pensaries and 170 sport dispensaries.Hungary also when in need of medical care. In 1969 the Ministry of had 24 public health laboratories. Health issued a departmental order regulating the work of the general practitioners and defining their tasks. Environmental sanitation Guiding principles were issued for the general practitioners with regard to the continuous medical care of In 1971, 35 % of Hungary's total population were patientssufferingfromnoncontagiousdiseases. served with piped water and 25 % were living in houses According to the concept of continuous care it is the connected to sewers. physician, or the health service, who summons the 190 FIFTH REPORT ON THE WORLD HEALTH SITUATION patient for examination or treatment as often as the 7000 to 7500 beds to reach 90 000 beds in 1975, or 8.8 patient's condition requiresit. In 1969, guiding beds per 1000 inhabitants; an increase in the specialist principles were also issued on the establishment of consultation hours by 7000 to over 47 000 hours in "leading area hospitals ", which generally cover the 1975; an increase of medical districts for adults and territory of a county. In 1970 a departmental order of children to 5000 in 1975; the provision of 8000 to 9000 the Minister of Health regulated the establishment of new places in nurseries for infants up to two years of intensive care units, as part of the efforts to develop the age; an increase of beds in social welfare establish- integrated, progressive care of patients.These units ments to 30 000 in 1975. are to be established first within the large national institutes, teaching hospitals and county area leading Medical and public health research hospitals, and later in the smaller town hospitals and the local hospitals of larger towns. The departmental Medical research, particularly basic research, is the order aims at ensuring the nationally uniform provision joint responsibility of the Hungarian Academy of of intensive care and the development of a network Sciences and of the Ministry of Health, which have set which covers the whole country in a planned and terri- up a joint coordinating committee. Research activities torially uniform distribution. are carried out at the universities, the institutes of the There has been a significant drop in the morbidity Academy of Sciences, the national institutes, and in among infants up to the age of 11 months, partly as a hospitals and outpatient clinics.A national long - result of the regulation which frees young mothers range plan for scientific research covering the period from work for 36 months after the delivery.Family 1970 -1985 has been worked out. Important contribu- planning and the prevention of unwanted pregnancies tions have been made to research in such fields as is increasingly part of the work of physicians.The lymphatic circulation, endocrinology, neurology, ma- number of induced abortions decreased by 45 ternal and child health, immunology and allergology, between 1971 and 1972. dermatology, ophthalmology, radiation biology, microbiology, pharmacology, morphology and environ- National health planning mental sanitation The national economic development plans, which cover a five -year period, provide for the balanced de- Assistance from WHO velopment of the national economy, the continuous In 1972 WHO's assistance to Hungary included the increase of productivity and efficiency and a steady following projects : increase in living standards, including the expansion of the health services. There are three kinds of national Training of sanitary engineers (1971 -1972) UNDP: to economic development plans: the long -range plan for organize the training of sanitary engineers and to train the period 1971 -1985; the medium -range plan (at teachers of sanitary engineering. present the fourth five -year plan, for the period 1971- 1975); and the annual or operative plan. These plans Pilot zones for water quality management (1969- ) form an interdependent system, the basic method of UNDP: to establish pilot zones for water quality planning being the medium -range plan. management. The national health and welfare plan is part of the Public health laboratories (1971- ) :to improve overall national economic development plan. Based on health laboratory facilities. the most important trends for the development of health and welfare outlined in the national economic Medical training institutes (1966- 1972): the objective plan, the Ministry of Health issued guiding principles of this project was to investigate new trends in medical for the organization and administration of the health schools. Fellowships were provided to enable medical services to be considered for the fourth five -year plan. teachers to observe developments in medical education The national health plan is prepared in close collabora- in other European countries. tion between the Ministry of Health, the National Economic Planning Authority, the county councils and Government health expenditure the Council of Budapest. The broad health objectives of the fourth five -year In 1972 the total government expenditure amounted plan include reduction of the mortality and morbidity to 132 725 million forints, of which 10 752 million rates and of the incapacity to work, as well as improve- were spent on health services -8842 million on current ment of the accessibility of health establishments. account and 1910 million on capital account.The Specific targets set out in the health plan for 1971- expenditure of the Ministry of Health amounted to 1975 are : an increase in hospital accommodation by 2687 million forints, including 2116 million for current EUROPEAN REGION 191 expenditure and 571 million for capital expenditure. administrative and government personnel; 305 million The expenditure at the local government level was for mass campaigns against communicable diseases, 8065 million forints, including 6726 million for current immunization activities, laboratory services, environ- expenditure and 1339 million for capital expenditure. mental health services, occupational health services The per capita government health expenditure amount- and veterinary services; 489 million for education and ed to 1034 forints. The government health expenditure training of health personnel. The government expen- included the following items: 2091 million forints for diture on hospitals amounted to 8661 million forints.

ICELAND

Population and other statistics The bed /population ratio was 14.3 per 1000.The 2923 beds were distributed as follows: At the last census, taken in December 1970, the population of Iceland was 204 930. Population Category and number Number of beds estimates and some other vital statistics for the period General hospitals 14 1230 Rural hospitals 11 170 under review are given in the following table: Maternity hospitals 4 39 Tuberculosis hospitals 2 24 1969 1970 1971 1972 Psychiatric hospital 1 220 Leprosarium 1 4 Mean population . . . 202 920 204 104 206 092 209 275 Hospitals for chronic diseases 6 628 . . 4218 4023 4277 4584 Number of live births Rehabilitation centres 2 260 Birth rate Establishments for alcohol addicts . . 2 68 (per 1000 population) . 20.8 19.7 20.7 21.9" Establishments for mentally deficient . 5 280 Number of deaths .. . 1 451 1 457 1 501 1 447 Death rate Outpatient facilities were available in 1972 at two (per 1000 population) . 7.2 7.1 7.3 6.9 Natural increase (%) . . 1.36 1.26 1.34 1.50 hospital outpatient departments, two health centres, Number of Infant deaths 49 53 55 53 Infant mortality rate and two dispensaries.

(per 1000 live births) . . 11.6 13.2 12.9 11.6 Number of deaths 1 -4 years 13 11 15 8 Death rate, 1 -4 years (per Medical and allied personnel and training facilities 1000 population at risk) 0.7 0.6 0.9 0.5 Number of maternal In 1971 Iceland had 305 doctors, or one doctor for deaths 1 - 2 - Maternal mortality rate 700 inhabitants.Other health personnel included : (per 1000 live births) . . 0.24 - 0.47 - Dentists 106 " Provisional data. Pharmacists 96 Veterinarians 25 Midwives 141 Of the 1501 deaths recorded in 1971, the main Nurses 591 Assistant nurses 256 causes were: 1 chronic rheumatic heart disease, hyper- Sanitarians 7 tensive disease, ischaemic heart disease, other forms Assistant sanitarians 11 Physiotherapists 31 of heart disease (439), malignant neoplasms (290), Laboratory technicians 79 cerebrovascular disease (202), accidents (139, including 27 in motor -vehicle accidents), pneumonia (113), birth The arrangements for the trainingof medical and injury, difficult labour and other anoxic and hypoxic health personnel were as follows: conditions, other causes of perinatal mortality (35), Category DurationNumber of Number of Number of bronchitis, emphysema and asthma (18), symptoms and admission of study schools studentsgraduates and ill- defined conditions (16), influenza (12). requirements (years) 1971/72 1972 Doctors : The communicable diseases most frequently notified completed grammar in 1972 were: influenza (6851), whooping -cough (142), school 7 1 300 20 Dentists : scarletfever(112),measles(77),meningococcal completed grammar infections (9), infectious hepatitis (1), typhoid fever (1). school 6 1 49 9 Pharmacists : completed grammar school 3 1 31 4 Hospital services Nurses : completed high school 3 1 211 72 In 1970 Iceland had 48 hospitals with 2923 beds, to Midwives : completed high school 2 1 23 12 which 33 783 inpatients were admitted during the year. Laboratory technicians: completed grammar 1 International Classification of Diseases, 1965 Revision. school 2 1 39 11 192 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Immunization services alcoholism, venereal disease control and occupational health. This centre recorded 24 289 outpatients during The following immunization procedures were carried 1970. out in 1971:

Poliomyelitis 18 575 Diphtheria, whooping -cough and tetanus 16825 Government health expenditure Smallpox 7309 Diphtheria and tetanus 1002 Cholera 610 In 1971totalgovernmenthealthexpenditure Typhoid and paratyphoid fevers 360 BCG 193 amounted to 2630 million krónur, of which 2445 mil- Yellow fever 61 lion were spent on current account and 185 million on capital account. The per capita government expendi- Specialized units ture on health services was 12 760 krónur. The Minis- try of Health accounted for 1600 million krónur and In 1970 seven health centres, which provided tuber- other ministries for 65 million. The direct expenditure culosis control services and maternal and child health of municipalities and the expenditure of local medical care, were attended by 718 pregnant women and 1985 care funds, less grants from central and local govern- children. The health centre of Reykjavik also provides ments, amounted to 965 million krónur. The govern- services in the fields of mental health, prevention of ment expenditure on hospitals was 1805 million krónur.

IRELAND

Population and other statistics conditions (583), diabetes mellitus (419), peptic ulcer (250), influenza (243), nephritis and nephrosis (218). At the last census, taken in April 1971, the popula- The communicable diseases most frequently notified tion of Ireland was 2 978 000 (provisional data). in 1972 were: measles (2796), infectious hepatitis (593), Population estimates and some other vital statistics for whooping -cough (231), scarlet fever (178), dysentery, the period under review are given in the following all forms (156), meningococcal infections (29), typhoid table: and paratyphoid fevers (12). 1969 1970 1971 1972

Mean population . . 2921 000 2944 000 2971 230 3014 000 Number of live births. . 62 912 64 382 67 551 67 643 Birth rate Organization of the Public Health Services

(per 1000 population) . 21.54 21.87 22.74 22.4

Number of deaths . . . 33 734 33 686 31 890 33 848 Death rate The Minister for Health, who is the head of the (per 1000 population). 11.55 11.44 10.73 11.2 Natural increase ( %) 1.00 1.04 1.20 1.12 Department of Health, is responsible for the health Number of infant deaths 1 293 1 255 1 214 1 200 services. All statutory powers are vested in the Infant mortality rate

(per 1000 live births) . 20.55 19.49 17.97 17.74 Minister, who issues regulations and orders and super- Number of deaths, vises the activities of the health boards and other exe- 1-4 years 214 210 202 204 Death rate, 1-4 years (per cutive agencies in the provision of health services. 1000 population at risk) 0.86 0.83 0.80 0.81 Number of maternal The functions of the Department of Health include: deaths 20 20 17 23 preventive and curative health care; treatment and Maternal mortality rate care of the physically and mentally ill; regulation and (per 1000 live births) . 0.32 0.31 0.25 0.34 control of training and registration of health personnel; Of the 33 848 deaths recorded in 1972, the main control of appointments and conditions of service of causes were: 1 chronic rheumatic heart disease, hyper- health officers; research; food safety; pharmaceutical tensive disease, ischaemic heart disease, other forms quality control; registration of births, deaths and of heart disease (10 944), malignant neoplasms (5703), marriages; collection and publication of health infor- cerebrovascular disease(4672), pneumonia (1988), mation and statistics. The Minister for Health and his bronchitis, emphysema and asthma (1886), accidents Department are advised by a number of bodies: the (1448,including 600 in motor -vehicleaccidents), National Health Council, the Food Advisory Com- congenital anomalies, birth injury, difficult labour and mittee, the Therapeutic Substances Advisory Com- other anoxic and hypoxic conditions, other causes of mittee, the National Drugs Advisory Board. To perinatal mortality (934), symptoms and ill- defined maintain contact with the health services, local health committees, whose function is mainly advisory, have 1 International Classification of Diseases, 1965 Revision. been established in each county. A number of other EUROPEAN REGION 193

special advisory bodies are constituted from time to provided free of charge to children suffering from such time to advise on specific problems. conditions as mental handicap, mental illness or cere- In accordance with the provisions of the Health Act, bral palsy.Drugs and medicines are given free of 1970, eight health boards were established in April charge to adult persons suffering from mental handi- 1971 to take over the administration of the health cap, cerebral palsy, epilepsy, diabetes, etc. The Volun- services from the 26 county councils.The health tary Health Insurance Board meets the needs of the boards comprise larger and more effective units, a upper income group. The number of persons covered number of counties in each region being grouped for by the Board's scheme increased from 78 000 in 1960 to this purpose.The members of the health boards 450 000 in 1972. Under the Health Act, 1970 the sys- comprise elected members of the city and county tem of general medical services provided to those councils and persons elected by medical practitioners entitled to free health services by local district medical and members of ancillary professions.Each health officers based on over 600 dispensary districts was board comprises a chief executive officer, who is replaced in 1972 by a service with the greatest practic- responsible for community care, special hospital care able choice of doctors and the least practicable distinc- and general hospital care, programme managers and tion between private patients and those availing them- functional officers, such as finance officer, personnel selves of the public health services. This new scheme is officer and planning and evaluation officer. based in nearly all areas on agreements with partici- The Hospitals Council and the Regional Hospital pating doctors. Boards at Dublin, Cork and Galway, which were Welfare services associated with the health services established under the Health Act, 1970 share with the comprise payment of maintenance allowances to Minister, the Department of Health and the health physically and mentally disabled persons, rehabilita- boards the function of controlling and coordinating tion programmes, financial assistance and domestic the hospital services.In addition to being a general help for the aged, maintenance and care of orphans advisory body on hospital services, the Hospitals Coun- and children deserted by their parents, contributions cil is also concerned with regulating the numbers and to voluntary bodies providing similar services. Increas- types of consultant appointments in hospitals and ing attention is being given to the social services aspects with specifying the qualifications for these appoint- of community health care and to the need for organized ments. The Council has 23 members, and half of them voluntary service. A national social service council has must be registered medical practitioners engaged in a been set up for this purpose. consultant capacity in the provision of hospital services. Half of the members of a Regional Hospital Board are Hospital services appointed by the health boards and the other half by The Irish general hospital system is organized in two the Minister. ways. Some of the hospitals are owned and operated The Minister for Health also exercises some measure by health boards and the others - generally referred of supervisory control over certain professional coun- to as voluntary hospitals - by lay boards or by reli- cils (such as the Medical Registration Council, the gious orders.The voluntary hospitals are almost Dental Board, the Nursing Board, the Pharmaceutical always located in the city areas and particularly in Society, and the Opticians Board) and executive bodies Dublin.The development of the general hospital (such as the Voluntary Health Insurance Board, the services has proceeded over the years on the pattern Mass Radiography Board, the Medical Research of regional, county and district hospitals.With the Council, the National Rehabilitation Board, the Blood exception of a small number of private hospitals, the TransfusionAssociation,andtheMedico - Social voluntary hospitals participate in the provision of Research Board). services for those entitled to them under the Health Acts.The majority of these voluntary hospitals are Changes in the provision of health services teaching hospitals associated with at least one of the Under the Health Act, 1970, steps have been taken to medical schools. improve and extend the health services.Each health The main feature of the health board hospital system board has the responsibility to make health services is the county hospital, of which there is one in most available to the population.Full eligibility for free of the 26 counties, providing general medical, surgical general medical services is confined to adult persons and maternity care for the areas. The county hospital and their dependants who are not in a position to pay generally has between 100 and 150 beds. The regional without undue hardship for medical services. About hospitals, which are located in the main centres of the 30 % of the population are considered to fall into this country, provide a complete range of specialized category.Limited eligibility for free selected medical services.Each county has one or more district hos- services is extended to about another 60 % of the popu- pitals, the services of which are limited to medical and lation.Hospital inpatient and outpatient services are maternity cases requiring nonspecialized care. Where- 194 FIFTH REPORTON THE WORLD HEALTH SITUATION

as the health boards provide inpatient and outpatient dentistry 50 each year. A pharmacy course is organized services for the mentally ill, they do not operate special at the University College, Dublin, in association with institutions for the care and treatment of mentally the College of Pharmacy, and is conducted by the handicapped persons, but make arrangements for the Pharmaceutical Society of Ireland.Nursing courses admission of such persons to residential centres (hos- are conducted under the supervision of the Nursing pitals, homes and schools) conducted by voluntary Board in approved training hospitals. Courses leading bodies, mainly religious orders.The health boards to additional nursing qualifications are conducted by have taken over the operation of the ambulance ser- University College, Dublin, and in certain hospitals. vices formerly provided by the local health authorities. The arrangements for the training of nurses are as With the changes in the administrative structures follows : of the health services under the Health Act, 1970, and Category DurationNumber of Number of Hospitals Council and and admission of study schools graduates theestablishment of the requirements (years) 1971 Regional Hospital Boards, steps have been taken General nurses : towards the integration and reorganization of the school -leaving certificate 3 26 914 hospital services based on the development of regional Psychiatric nurses: and larger hospitals. Intermediate certificate 3 24 336 In 1971 Ireland had 260 hospitals providing al- Sick children's nurses: school -leaving together 35 490 beds, of which 25 058 were in 136 certificate 3 3 108 government establishments. The bed /population ratio Nurses for mentally handicapped: was 11.9 per 1000. The 35 490 beds were distributed as school -leaving follows: certificate 3 5 33 Basic Midwives: Category and number Number of beds certificate of general General hospitals 66 11 977 nursing or sick Rural hospitals 59 2 210 children's nursing . 10 420 Medical centres 61 763 Postregistration Maternity hospitals 7 993 tuberculosis nurses: Paediatric hospitals 4 754 certificate of general 4 501 Tuberculosis hospitals nursing 1 1 2 Infectious diseases hospitals 7 567 Postregistration Psychiatric hospitals 37 16 000 orthopaedic nurses : Orthopaedic hospitals 10 1 192 certificate of general Ear, nose and throat hospitals 2 227 nursing 1 1 4 Cancer hospitals 3 306 Public health nurses : certificate of general Medical and allied personnel and training facilities nursing and midwifery 9 months 2 68 Nurse tutors: general registration In 1971 Ireland had 3565 doctors, or one doctor for and 4years nursing 830 inhabitants. Other health personnel included: experience 2 Dentists 659 Courses of the National University of Ireland. Pharmacists 1652 (1966) Veterinarians 957 Nurses and midwives 19284 Training facilities are also provided for physio- Health Inspectors 164(1966) therapists, radiographers, health inspectors, dietitians, Physiotherapists 215(1966) medical laboratory technicians, pharmaceutical assis- In government service. tants, speech therapists, occupational therapists, psy- There are five medical schools in Ireland, three of chiatric social workers and dental ancillaries. them at the National University of Ireland's constituent colleges in Dublin, Cork and Galway, one at Communicable disease control and immunization services Trinity College, Dublin and one attached to the Royal College of Surgeons in Ireland.Courses in dentistry The incidence of tuberculosis has shown a marked are conducted at the University College, Dublin, decline and the number of notified new tuberculosis Trinity College, Dublin, and the Royal College of cases dropped from 3166 in 1961 to 1236 in 1971. The Surgeons in Ireland in association with the Dublin tuberculosis mortality rate is 0.09 per 1000 cases. The Dental Hospital; at the University College, Cork in arrangements within the health boards for the notifica- association with the Cork Dental Hospital; and at the tion and diagnosis of this disease are supplemented by University College, Galway which offers the predental the activities of the Mass Radiography Board which and first dental courses. Each of the medical and dental operates mobile X -ray units throughout the country. schools limits the number admitted to the first medical Hospital treatment for tuberculosis and other com- year, but not necessarily those admitted to the pre- municable diseases patients is free to all.Measures medical and predental year. The numbers of graduates forpreventivehealth and community protection in medicine are approximately 350 each year and in include the payment of maintenance allowances to EUROPEAN REGION 195

persons undergoing treatment for infectious diseases; policy objectives mentioned under "National health allowances may also be paid to carriers for treatment. planning" below. The scheme is primarily applicable to tuberculosis patients, but it covers also persons suffering from poliomyelitis, diphtheria, typhoid and paratyphoid Social and economic developments of significance for the health situation fevers, typhus, dysentery, Salmonella infections, scarlet fever and streptococcal sore throat. In order to control the spread of infectious diseases, the health boards also The Government's third programme for economic supervise the hygiene of food supplies and the quality and social development covered the years 1969 -1972. and safety of food and drugs. It outlined the objectives of the national development Vaccination and immunization schemes are operated policy in the main sectors of activity. The introduction by the health boards.Prophylactic campaigns have of a social development programme into this third concentrated on smallpox, diphtheria, BCG, polio- programme has helped to shape the social aspects in myelitis vaccination, and in 1971 on vaccination against accordance with national aspirations. Emigration has rubella for girls aged 12 and 13 years. Routine small- been reduced and for the first time in this century the pox vaccination of children has been discontinued. population has, according to the 1971 census figure, The following immunization procedures were carried shown an increase. The three economic programmes out in 1971: (1958 -1963, 1964 -1970, 1969 -1972) have resulted in the transformationof thecountry from abasically Diphtheria 87798 agricultural economy into a modern industrial society. BCG 66297 Poliomyelitis 66228 Smallpox 6889 National health planning Chronic and degenerative diseases Work on the development of planned programme The mortality from diseases of the heart and cancer budgeting for the health services is in progress.It is continued to be a significant public health problem. associated with the establishment of the eight Regional While the death rate from heart diseases declined Health Boards and will supersede the traditional sys- slightly in 1971/72, with 364 deaths per 100 000 popu- tem. The main features of this scheme are to relate lation, the death rate from cancer continued to rise, objectives to the national health policy; to link object- particularly in respect of cancer of the lung, for which ives and activities in the form of programmes; to the rate is 33 per 100 000 population. establishmulti- annualprogrammebudgetswith cost and output estimates; to undertake in -depth Specialized units analytical studies of various government programmes, schemes and expenditure; to set up procedures for In 1971 there were approximately 100 child health systematic review and analysis of programmes; and service clinics. During the same year, the school health to institute management information systems.The service provided medical and health supervision to health boards will also operate on a programme bud- 532 843 schoolchildren, representing 70 % of the total geting basis in accordance with that of the Department school population. There were also 241 dental health of Health. units, including seven mobile dental units, which The Department of Health and the health boards provided treatment to 37 956 adults and 204 974 will be involved in the planning process.The three schoolchildren.Psychiatric outpatient consultations overall programmes adopted by the health boards are: were available at 182 psychiatric clinics, which recorded community care, general hospital care and special 6590 new outpatients in 1971. hospital care. They aim at defining desirable standards across the whole spectrum of health services and draw- Environmental sanitation ing up plans to bring existing services to these levels, taking into account the resources available and conse- In 1971, 78.7 % of Ireland's total population were quently establishing an order of priorities. The served with piped water and 1.79 % had water from management structure of the health boards is adapted public fountains; 68 % were living in houses connected to the three programmes, with a programme manager to sewers. for community care, separate programme managers for general hospital care and for special hospital care Major public health problems in the larger areas, and only one programme manager for both hospital care systems in smaller areas.It is The main public health problem areas in Ireland are proposed to establish programme review committees those included in the priority areas for development of at senior manager level to monitor programme per- 196 FIFTH REPORT ON THE WORLD HEALTH SITUATION formance and review and evaluate the effectiveness of include a general and psychiatric hospital inpatient the various services in achieving policy objectives. The survey, the establishment of an ischaemic heart disease following are regarded as priority areas for the develop- and stroke register, and a study of the incidence of ment of policy objectives during the period 1972 -1976: alcoholism and drug abuse. The Medico -Social (a) general practitioner services; (b) reorganization Research Board is fully financed from government and coordination of hospital services for acute diseases, sources. Research facilities and laboratory services are takingintoaccountthegrowingspecialization; provided by the Research Board in its own laboratories (c) improvement of psychiatric services in specialized and in the laboratories of the universities and larger and general hospitals; (d) care for mentally handicap- hospitals.Increased efforts and resources are being ped adults; (e) community services, particularly for devoted to health information and health education of old people; (f) child h ealth services; and (g) health the public. education. Government health expenditure Medical and public health research In the fiscal year 1970/71 the total general govern- Medical research is carried out by the Medical ment expenditure was £300 million, of which £69 mil- Research Council, mainly with funds made available by lion was government health expenditure, excluding the Minister for Health. A Medico - Social Research health expenditure for the armed forces, health- related Board, which has 12 members appointed by the expenditure for nurseries, school meals, refuse disposal, Minister for Health, was established in 1965 with a view etc., and payments to thesocial insurance fund to organizing and administering surveys and statistical (amounting to somewhat less than £1 million). Of the research on the incidence of human diseases, injuries, £69 million, £66 million were spent on current account deformities and defects and on the operation of the and £3 million on capital account.The per capita health services.Projects undertaken by the Board government expenditure for health was £23.

ITALY

Population and other statistics Of the 522 654 deaths recorded in 1971, the main causes were: 1 chronic rheumatic heart disease, hyper- At the last census, taken in October 1971, the popu- tensive disease, ischaemic heart disease, other forms lation of Italy was 54 025 211.Population estimates of heartdisease(151 009),malignant neoplasms and some other vital statistics for the period under (99 362), cerebrovascular disease (72 406), accidents review are given in the following table: (25 557, including 13 067 in motor -vehicle accidents), bronchitis, emphysema and asthma (18 205), symptoms 1969 1970 1971 1972* and ill- defined conditions (17 511), pneumonia (16 836),

Mean population . . . . 53316 98853661 140 54004 60254409 807 cirrhosis of the liver (16 247), birth injury, difficult

Number of live births . . 932 466 901 472 906 182 886 431 labour and other anoxic and hypoxic conditions, other Birth rate causes of perinatal mortality (14 511), diabetes mellitus (per 1000 population) . 17.5 16.8 16.8 16.3 (12 314), peptic ulcer (3985), tuberculosis, all forms Number of deaths . . . 539 129 521 096 522 654 519 382 Death rate (3682), benign neoplasms (3486), intestinal obstruction (per 1000 population) . 10.1 9.7 9.7 9.5 and hernia (3517), suicide and self -inflicted injuries

Natural increase ( %) . . 0.74 0.71 0.71 0.68 (3220), nephritis and nephrosis (3068). Number of infant deaths 28759 26639 25 830 23906 The communicable diseases most frequently notified Infant mortality rate in 1971 were: measles (63 490), infectious hepatitis (per 1000 live births). . 30.8 29.6 28.5 27.0 Number of deaths, (42 546), scarlet fever (12 689), typhoid andpara- 1 -4 years 4 025 3 646 3 250 typhoid fevers (11 569), influenza (9318), whooping - Death rate, 1 -4 years (per cough (9256), gonorrhoea (8293), tuberculosis,all 1000 population at risk) 1.1 1.0 0.9 Number of maternal forms, new cases (6793), syphilis, new cases (3884), deaths 565 491 457 376 meningococcal infections(2510),diphtheria(610), Maternal mortality rate bacillary dysentery (94), typhus (31), malaria, new (per 1000 live births) 0.6 0.5 0.5 0.4

* Provisional data. 1 InternationalClassification of Diseases, 1965 Revision. EUROPEAN REGION 197

cases (27), poliomyelitis (20), trachoma (15), leprosy Poliomyelitis 4227974(1970) Diphtheria and tetanus 1 719659

(15). Smallpox 1565402

Typhoid and paratyphoid fevers 1 141718 Tetanus 881433 Organization of the public health services The period under review has been marked by the Specialized units transfer of competence in the health field to the regions. The law of 16 May 1970 provides for this regionaliza- In 1972 maternal and child health care was based on tion.In addition to their traditional functions in the 1960 prenatal centres and 6280 child health centres. field of hospital care, pharmaceuticals, and medical During the year, 260 270 pregnant women, 580 210 care to nonhospitalized patients, the regions are now infants and 100 200 children aged 1 -5 years attended responsible for services for maternal and child health, these services. Domiciliary visits were paid to 370 410 occupationalhealth,sportsmedicine, and social pregnant women, 410 200 infants and 78 000 children diseases. The various plans for reorganization of the aged 1 -5 years.Of all deliveries in 1972, 84% were healthservicesincludethefollowingprovisions: attended by a doctor or qualified midwife.School establishment of a national health service; establish- health services were available in 48 % of all munici- ment of a network of local health units in charge of all palities and served 42 % of the country's total popula- health activities in a given territory; and financing of tion.Dental treatment for schoolchildren was given the national health service through taxes. in approximately 200 dental health units. There were also 870 dental clinics for adults, which are part of the municipal polyclinics.Other specialized units Hospital services included 337 independent rehabilitation centres and In 1971 Italy had 2253 hospitals and inpatient 92 public health laboratories. establishments, providing altogether 572 304 beds, of which 478 688 were in 1342 government establishments. The bed /population ratio was 10.6 per 1000.The Assistance from WHO 572 304 beds, to which 8 392 343 patients were admitted during the year, were distributed as follows: In 1972 WHO's assistance to Italy included the fol- Category and number Number of beds lowing projects: General hospitals 983 260 851 Rural hospitals 525 103 520 Reorganization of regional public health services, Medical centres 234 14 869 Fruili- Venezia -Giulia (1972) Funds -in- trust: two con- Tuberculosis hospitals 167 43 716 Psychiatric hospitals 199 113 164 sultants assisted in making a review of existing re- Other hospitals 145 36184 sources and pending health legislation, and in defining areas requiring further study; and submitted sug- Medical and allied personnel gestions concerning the organization of the health and medical services in the Fruili- Venezia -Giulia region. In 1971 Italy had 99 341 doctors, including physicians practising dentistry, or one doctor for 540 Nursing education and administration (1969- ): inhabitants. Other health personnel included: to prepare nurses for teaching and administrative posts and develop basic and post basic nursing education Pharmacists 37200 Veterinarians 7732 programmes. Midwives 18828 Nurses 39308* Assistant nurses 88091* X -ray technicians 4485 Government health expenditure *Working in hospitals. In 1972 the health expenditure by the Ministry of Immunization services Health amounted to 202 300 million lire. The government health expenditure at the intermediate and local The following immunization procedures were carried levels amounted to 590 000 million lire.The govern- out in 1969: ment expenditure on hospitals was 2588 million. 198 FIFTH REPORT ON THE WORLD HEALTH SITUATION

MONACO

Population and other statistics Dentists 29 Pharmacists 50 At the last census, taken in March 1968, the popula- Pharmaceutical assistants 20 Veterinarians 2 tion of Monaco was 23 035. Population estimates for Midwives 5 the years 1969 and 1970 are given below: Nurses 101 Assistant nurses 115

1969 1970 Sanitary engineer 1

Mean population . . . . 23000 23000 Assistant sanitarians 7

Number of live births . . 213 522 Physiotherapists 14 Birth rate Assistant laboratory technicians 12 (per 1000 population) . 9.3 22.7 X -ray technicians 7 Number of deaths . . . . 279 452 Death rate (per 1000 population) . 12.1 19.6 Natural increase (%) . -0.28 1.31 Monaco has no medical faculty. Medical students Number of Infant deaths . 2 2 Infant mortality rate (per are trained abroad, mainly at French medical schools. 1000 live births) . . . . 9.4 3.8 There is a nursing school.

Organization of the public health services The Directorate for Health and Social Action was Specialized units established by sovereign decree in 1966. It is under the authority of the Government Councillor forthe Maternal and child welfare services are based on the Interior who is responsible for all health and social Children's Aid Centre called the Foyer Sainte Dévote. activities in Monaco. The Director is assisted by a In general, however, prenatal and infant care is provid- medical inspector and a pharmaceutical inspector. ed in the consulting rooms of private practitioners. All schoolchildren are examined annually. The office Hospital services of occupational health supervises the health whole working population of about 18 000, including Hospital facilities are provided at the Princess Grace nonresidents. Hospital, which comprises 206 beds and to which a clinic with 76 beds, a maternity home and an old people's home are attached. Government health expenditure Medical and allied personnel and training facilities In 1969 government health expenditure amounted In 1970 Monaco had 47 doctors, of whom 29 were in to 3.6 million francs on current account and 1.9 mil- government service. The doctor /population ratio was lion francs on capital account. Per capita expenditure one to 510. Other health personnel included: for health purposes was therefore 236 francs.

NETHERLANDS

Population and other statistics 1969 1970 1971 1972 Infant mortality rate (per 1000 live births) . 13.2 12.7 12.1 11.7 At the last census, taken in December 1970, the Number of deaths, population of the Netherlands was 13 119 430. Popu- 1 -4 years 863 776 792 751 Death rate, 1 -4 years (per lation estimates and some other vital statistics for the 1000 population at risk) 0.9 0.8 0.8 0.8 period under review are given in the following table: Number of maternal deaths 48 32 30 23 Maternal mortality rate 1969 1970 1971 1972 (per 1000 live births) . 0.2 0.1 0.1 0.1

Mean population . . . 12877 98413038 52613194 497 13328 593 Number of live births . . 247 588 238 912 227 180 214 133 Birth rate Of the 110 243 deaths recorded in 1971, the main (per 1000 population) . 19.2 18.3 17.2 16.1 causes were: 1 chronic rheumatic heart disease, hyper- Number of deaths . . . 107 615 109 619 110 243 113 576 Death rate tensive disease, ischaemic heart disease, other forms of (per 1000 population) . 8.4 8.4 8.4 8.5 Natural increase (%) 1.08 0.99 0.88 0.76 Number of infant deaths 3276 3045 2757 2505 'International Classification of Diseases, 1965 Revision. EUROPEAN REGION 199 heart disease (33 413), malignant neoplasms (25 707), and partly by private organizations for social health cerebrovasculardisease(12 136),accidents(6235, care, which are heavily subsidized by the central including 3171 in motor -vehicle accidents), symptoms government and which play an important role in and ill- defined conditions (3914), bronchitis, emphy- providing health facilities.Financial accessibility is sema and asthma (3272), pneumonia (2654), congenital guaranteed by a system of health insurance which is anomalies, birth injury,difficult labour and other compulsory for approximately 70 % of the population, anoxic and hypoxic conditions,other causesof namely those with an income below the equivalent of perinatal mortality (2606), diabetes mellitus (2413), about $8000. suicide and self -inflicted injuries (1090), hyperplasia of the prostate (625), intestinal obstruction and hernia Medical and allied personnel (583), peptic ulcer (562), cirrhosis of the liver (558). The communicable diseases most frequently notified At the end of 1971 the Netherlands had 17 381 in 1972 were: scarlet fever (1977), infectious hepatitis doctors, or one doctor for 760 inhabitants.Other (1205), meningococcal infections (248), bacillary dysen- health personnel included: tery (171), leprosy (56), typhoid and paratyphoid fevers Dentists 3 648(1972) (42), malaria, new cases (17), amoebiasis (2). Dental hygienists 48 Pharmacists 1114(1972) Midwives 829(1972) Auxiliary midwives 3 850 Organization of the public health services Nurses 25 500 Assistant nurses 7800 The public health services in the Netherlands are the Veterinarians 1 630 Physiotherapists 5 300 responsibility of the Ministry of Public Health and Laboratory assistants 7 500 X -ray technicians 5 400 Environmental Hygiene. A number of national Meat and cattle Inspectors 975 institutes and of advisory bodies in the field of public health act in an advisory capacity to the Ministry. Coordination with other ministries whose activities Immunization services are related to public health is generally ensured by The following immunization procedures were carried interministerial consultative agencies.The Ministry out in 1971: of Education and Sciences is responsible for the train- Diphtheria, whooping -cough, tetanus and ing of health personnel, and, generally speaking, the poliomyelitis 1 711 177 Ministry of Social Affairs for insurance matters. Smallpox 403 065 However, the Ministry of Public Health and Environ- mental Hygiene has recently become the responsible Chronic and degenerative diseases government agency for health insurance (sick fund insurance and long -termhealthcareinsurance). The diseases of a highly industrialized and urbanized Supervision of health care delivery is entrusted to the society, such as cardiovascular diseases and mental State Supervisory Public Health Service, which has disorders, are increasing in importance. The principal central and provincial offices. causes of death are malignant neoplasms, cardiovascular diseases, cerebral haemorrhages and traffic Hospital services accidents.It is estimated that the number of persons with coronary heart disease is about 25 000 a year and At the end of 1972 there were 250 hospitals in the that at least 50 000 persons are injured each year in Netherlands, with a total of 70 000 beds in general road accidents, very many of whom require long -term hospitals and 40 000 beds in psychiatric hospitals. rehabilitationcare. Programmes forprevention, Some are public hospitals, usually operated by local treatment and rehabilitation include screening for authorities, but most are run by private nonprofit cardiovascular diseases in industrial medical services, organizations.Endeavours are being made to close improvement of ambulance transport and of traumato- smaller hospitals, so that the optimum bed capacity of logical centres in hospitals, and expansion of clinical 400 to 500 will be attained in all cases. and ambulatory rehabilitation facilities. The Netherlands has a dense network of preventive medical facilities such as clinics and advisory bureaux Environmental sanitation distributed throughout the country.They provide health care for youth, industrial workers and mental In 1971, 865 communities had piped water systems cases, and are also active in the prevention of certain and 99 % of their dwellings were served with piped diseases, such as tuberculosis. These services employ water.All communities had a sewerage system and over 1000 health officers and some 3500 district nurses. approximately 75 % of the total number of dwellings They are operated partly by local authorities and firms, were connected to sewers. 200 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Major public health problems of the hospital system. The extension of this planning system to all health facilities through the enactment of The main public health problems in the Netherlands a further act is under discussion. are cardiovascular diseases and traffic accidents. The State Supervisory Public Health Service has engaged specialists for cardiovascular diseases and for the Medical and public health research medical aspects of traffic accidents.Another serious Medical and public health research activities are problem, related to the aging of the population, is carried out in universities and associated institutes, the health care of old people, for whom a number of independent institutes, and in university and large inpatient and outpatient facilities are already available regional hospitals.Research work is not confined to and additional facilities are to be established. clinical medicine, but also includes epidemiological and organizational research in the field of social health National health planning care. Important research work is also carried out by industry, particularly the pharmaceutical industry, the The enactment of the Hospital Facilities Act has electronicsindustryand themedicalequipment stimulated the preparation of provincial hospital plans manufacturers.The Organization for the Advance- which will be combined into a national plan. Planning ment of Pure Research and the Central Organization takes place at various regional and national levels, for Applied Scientific Research are coordinating the involving both private and government organizations research activities. They also give research subsidies.

NORWAY

Population and other statistics other anoxic and hypoxic conditions, other causes of perinatal mortality (773), bronchitis, emphysema and At the last census, taken in November 1970, the asthma (526), suicide and self -inflicted injuries (317), population of Norway was 3 888 305. Population diabetes mellitus (298), benign neoplasms (228). estimates and some other vital statistics for the period The communicable diseases most frequently notified under review are given in the following table : in 1972 were: measles (9951), gonorrhoea (9598),

1969 1970 1971 1972" scarlet fever (2981), whooping -cough (1634), tuber-

Mean population . . 3850 977 3877 386 3903 039 3932 800 culosis, all forms, new cases (444), infectious hepatitis Number of live births . . 67 746 64 551 65 550 64 260 (253), early syphilis, new cases (184), meningococcal Birth rate (per 1000 population) . 17.6 16.6 16.8 16.3 infections (82), typhoid and paratyphoid fevers (16). Number of deaths . . . 38 994 38 723 38 981 39 198 Death rate (per 1000 population) . 10.1 10.0 10.0 10.0 Organization of the public health services Natural increase ( %) . . 0.75 0.66 0.68 0.63 Number of infant deaths . 933 823 836 725 Infant mortality rate The Ministry of Social Affairs has overall respon- (per 1000 live births) . 13.8 12.7 12.8 11.3 Number of deaths, sibility for both health and social services.In the 1 -4 years 237 226 213 193 Death rate, 1 -4 years (per health sector, executive action is taken by the National 1000 population at risk) 0.9 0.9 0.8 0.7 Directorate of Health Services with a medical adminis- Number of maternal deaths 10 7 13 trator -the Director -General -asitshead. The Maternal mortality rate Directorate is divided into a number of divisions . 0.1 0.1 0.2 ... (per 1000 live births) dealing respectively with local health services, finance Provisional figures. and employment, social medicine, psychiatry, hygiene, Of the 38 981 deaths recorded in 1971, the main nursing services, pharmacy, dentistry, and hospitals. Norway is divided into 19 provinces, one of which causes were: 1 chronic rheumatic heart disease, hyper- is the capital city, Oslo. The Provincial Public Health tensive disease, ischaemic heart disease, other forms of Officer represents the National Directorate of Health heart disease (13 056), malignant neoplasms (7322), Services at the provincial level.His main duty is to cerebrovascular disease(5951), pneumonia (2417), superintend health services within the province and to symptoms and ill- defined conditions (2063), accidents supervise the carrying out of the laws and regulations (2012,including 537in motor -vehicleaccidents), on medicine and sanitation.He also supervises the congenital anomalies, birth injury, difficult labour and activities of all local public health officers and oversees 1 International Classification of Diseases, 1965 Revision. all health personnel working within his area. As the EUROPEAN REGION 201

provincial committees, headed by the Provincial Public Category and number Number of beds Health Officer, assess the benefits from the rehabilita- General and local hospitals 96 19 688 Cottage hospitals 68 1 363 tion and disability insurance scheme, the Provincial Maternity hospitals 22 243 Public Health Officer is in a key position with regard Tuberculosis hospitals 6 355 Mental hospitals 21 8352 to the medicosocial work carried out in the province. Orthopaedic hospitals 5 523 According to the Norwegian Health Law of 1860 Hospitals for rheumatic diseases . 6 541 Cancer hospital 1 336 every commune has a board of health with the local Hospital for epileptics 1 180 Rehabilitation hospitals 3 325 Public Health Officer as the chairman of the board. Other specialized hospitals 32 893 Whereas in rural districts he continues the duties of health administrator and general practitioner, in urban All hospital care is free of charge for the patient. areas he is a full -time public health officer. The main According to the Hospital Act, ambulatory care is duties of the local health board are: environmental regarded as part of the hospital activities. Ambulatory health, communicable diseases control, family health, specialist care is offered partly by specialists outside school health, mental health, health education. the medical establishments, partly by hospital doctors Changes in the provision of health services.Since and in inpatient establishments as an integrated part January 1971 the country has an integrated coordinated of their services. The volume of this integrated ambu- social insurance system covering the whole population. latory care is expected to grow rapidly with the reor- The most important conditions covered according to ganization and expansion of the hospital services the national insurance scheme are: medical care, initiated by the Hospital Act.In 1973, 20 health including hospital care, physiotherapy, certain dental centres were established. services, family planning, sickness benefit limited to 90 % of the income, rehabilitation benefit, permanent Medical and allied personnel and training facilities disability benefit for a 50 % reduced working capacity, occupational accidents and diseases, unemployment At the end of 1971 Norway had 5681 doctors, or one benefit, old age or retirement pensions, benefits in case doctor to 690 inhabitants.Other health personnel of death and loss of bread -winner awarded to widows included:

and children under 18years,maternitybenefits, Dentists 3495 benefits to unmarried mothers, child allowances, war Pharmacists 1311 Pharmaceutical assistants 494 injuries. The scheme is financed by a special premium Veterinarians 765 paid in addition to the ordinary taxes, and by contri- Midwives 719 Nurses 14453(1970) butions from employers, municipalities and the State. Assistant nurses 5000 In May 1973 a parliamentary bill was passed stress- Physiotherapists 2300(1970) ing the importance of primary health care and preventive health measures.According to this bill the In 1972 the arrangements for the training of profes- provinces will have the responsibility for planning and sional and auxiliary health personnel were as follows: running the primary health services in close coopera- Category DurationNumber of Total Number of and admission of study schoolsenrolment graduates tion with the municipalities.Health centres will requirements (years) 1971/72 1972 assume considerable importance in the future organiza- Doctors : tional pattern.Close collaboration with the social artium 6 -6% 2 1200 200 Dentists : services is also stressed. artium 5 2 625 120 Primary medical care is given either by the local Pharmacists : artium 5 1 200 40 public health officer (the district doctor) or by private Veterinarians : practitioners. An increasing part of the specialist care artlum 5 % -6 1 210 35 Dental auxiliaries: is given in hospital outpatient departments. artium 2 1 32 16 Laboratory assistants : artium 2 9 320 160 Hospital services Physiotherapists : artium 2 1 200 100 In 1971 Norway had 261 hospitals and inpatient Radiographers : secondary education 2% 1 40 20 establishmentsprovidingaltogether32 799beds, Medical secretaries: equivalent to 8.4 beds per 1000 population. In addi- artium 1 1 22 22 Nurses : tion there were 444 somatic nursing homes and somatic secondary education 3 29 4 900 1 400 nursing departments in combined old -age and nursing Auxiliary nurses: secondary education 1 42 2 000 1 900 homes with 14 525 beds, and 110 psychiatric nursing Midwives : homes with 3739 beds.The 32 799 beds, to which State registed nurse's 526 942 patients were admitted during the year, were certificate 1 2 90 90 distributed as follows: 1 Degree conferred on students passing university entrance. 202 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Communicable disease control and chiatric outpatient consultations were given in 1972 immunization services at three polyclinics for adults, at 21 polyclinics for children and adolescents, and at 43 polyclinics in Since the introduction of oral poliomyelitis vac- mental hospitals and clinics.Medical and health cination the incidence of this disease has been rapidly services were provided in 1972 in 2100 industrial decreasing, from an annual average of 728 cases in establishments,coveringabout335 000workers. 1951 -1955 to only one case annually during the period Other specialized units included one tuberculosis under review. The majority of the population and more hospital, three venereal diseases polyclinics and four than 90 % of all children have been immunized. The public health laboratories,including the national tuberculosis morbidity and mortality continue to public health institute. decrease steadily. The incidence rate shows a particularly marked downward trend among the young adult group on which the mass BCG vaccination programme Environmental sanitation has been concentrated. A central case register was established in 1962, and since 1969 the case -finding In 1972 Norway had a total of 1 075 145 dwelling programme carried out by the national mass radio- units, of which 997 594, or approximately 93 %, were graphy service has concentrated on high -risk groups provided with piped water.The urban population selected according to an analysis made by this register living in houses connected to public sewerage systems and the national mass radiography service. Particular totalled 1.5 million, while 2 230 000 inhabitants living attention is given to the care of tuberculosis patients in rural areas had adequate sewerage disposal systems, having additional problems, such as mental illness, such as pit privies or septic tanks. mental subnormality or alcoholism. The incidence of gonorrhoea has increased from 1866 cases in 1955 to Major public health problems 6107 in 1969 and 9598 cases in 1972.Although the number of syphilis cases has decreased, the annual The most important public health problems in rate of decrease is now slowing down. Norway are ischaemic heart disease, cancer, cerebro- The immunization scheme for children includes vascular diseases, traffic accidents and environmental vaccination against smallpox, diphtheria, whooping - pollution. cough, tetanus,poliomyelitis, measles and tuberculosis. The following immunization procedures were Social and economic developments of significance for carried out in 1971: the health situation

Poliomyelitis 164500 Smallpox 107190 A law on hospital planning, coordination and Diphtheria, whooping -cough and tetanus . 98500 Diphtheria and tetanus 89500 financing came into force in 1970, giving the provinces BCG 60000 full responsibility for the planning, construction and Typhoid and paratyphoid fevers 53500 Measles 40000 running of hospitals and most other somatic health Diphtheria 33000 establishments. The plans are approved by the Govern- Cholera 17800 Tetanus 8200 ment, which may modify them. Planning and extension Yellow fever 6800 of health establishments and of their medical activities Whooping -cough 1200 are subject to the supervision of the Director -General of Health Services in accordance with detailed direc- Specialized units tives of the Government. The expenses in connexion In 1972 there were approximately 1400 centres with running these establishments are covered by the engaged in maternal and child health care. As a rule national insurance scheme and by the owner, mainly prenatal care is provided by the general practitioner. the province. In 1972, 98 -99 % of all deliveries were conducted in medical establishments.It is estimated that at least Medical and public health research 90 % of all children under one year of age receive medical care services.According to law the public Medical and public health research is carried out in health officer in each municipality is responsible for the research institutions,in hospitals and universities. school health services which cover the total school Norway has no coordinated research programme. The population. In 1972 dental care was given to 626 000 threeresearchcouncils,namely,the Norwegian schoolchildren in 1200 dental clinics and to 1 600 000 Research Council for Science and the Humanities, the adults in approximately 2000 dental clinics. Norway Agricultural Research Council of Norway and the has four independent medical rehabilitation centres Royal Council for Scientific and Industrial Research, and four hospital rehabilitation departments.Psy- spend about 15 % of the total research expenditure. EUROPEAN REGION 203

Medical research accounts for approximately 10 % of which amounted to 1429 million kroner, included: this share. 23 million for administration and government personnel, 9 million for campaigns against communicable diseases, 33 million for laboratory services, 60 million Government health expenditure for environmental health services, 28 million for veterinary services, and 259 million for education and In1971totalgeneral government expenditure training of health personnel. The government expen- amounted to 18 663 million kroner. The total central diture on hospitals was 3644 million kroner and includ- government health expenditure amounted VW- ed: 1946 million for general hospitals and clinics, 663 millionon kroner and the health expenditure at the local million for teaching hospitals, 858 million for specializ- government level to 1286 million.The government ed hospitals and 177 million for other health establish- health expenditure on general public health services, ments.

POLAND

Population and other statistics dysentery, all forms (10 505), whooping -cough (3414), typhoid and paratyphoid fevers (365), meningococcal At the last census, taken in December 1970, the infections(228),poliomyelitis(43),typhus(23), population of Poland was 32 642 270.Population diphtheria (5). estimates and some other vital statistics for the period under review are given in the following table: Organization of the public health services 1969 1970 1971 1972

Mean population . . 32555 000 3252600032805 00033068 000 The Minister of Health and Social Welfare is the Number of live births . . 531 135 545 973 562 341 575 725 Birth rate highest authority in matters of health service adminis- (per 1000 population) . 16.3 16.6 17.2 17.4 tration, responsible for the medical and health care Number of deaths . . . 262 823 266 799 283 702 265 250 Death rate and social welfare of the population and for organizing (per 1000 population) . 8.1 8.1 8.7 8.0 Natural increase ( %) . 0.82 0.85 0.85 0.94 disease prevention and for supervising health activities Number of infant deaths 18 209 18112 16 564 16 377 generally.The territorial instruments of health ser- Infant mortality rate (per 1000 live births) . 34.3 33.1 29.5 28.5 vice administration are the health and social welfare Number of deaths, departments of the presidiums of voivod people's 1 -4 years 2197 2136 2171 1986 Death rate, 1 -4 years (per councils in voivodships or in towns with the status of 1000 population at risk) 1.1 1.1 1.1 1.0 Number of maternal voivodships, and the corresponding departments of deaths 174 161 126 103 people's councils in the districts and municipal divi- Maternal mortality rate sions of towns of voivodship status. The Minister lays (per 1000 live births) . 0.33 0.29 0.22 0.18 down the functions of these various departments; he Of the 265 250 deaths recorded in 1972, the main issues directives and promulgates legislation for the causes were: 1 chronic rheumatic heart disease, hyper- organization and planning of health service establish- tensive disease, ischaemic heart disease, other forms of ments and their staff and to define their tasks.The heart disease (60 337), malignant neoplasms (47 640), instructions from the Ministry of Health and Social symptoms and ill- defined conditions (23 004), accidents Welfare govern in particular: (16 253, including 4446 in motor -vehicle accidents), cerebrovascular diseases (14 361), pneumonia (8768), - the work of agencies and institutions dispensing bronchitis, emphysema and asthma (8080),birth medical and health care and social welfare services; injury, difficult labour and other anoxic and hypoxic - the development of health services, whatever conditions, other causes of perinatal mortality (6565), authorities are directly competent, and the establish- tuberculosis, all forms (6068), suicide and self -inflicted ment of principles regulating their position and injuries (3960), congenital anomalies (3471), cirrhosis cooperative role; of the liver (3102), diabetes mellitus (2808), nephritis - general requirements for pharmaceutical pro- and nephrosis (2617). ducts and health and medical equipment; The communicable diseases most frequently notified in 1972 were: influenza (182 119), measles (109 102), - the planning of the training of health and medical infectious hepatitis (84 705), scarlet fever (42 249), personnel (including postgraduate studies),their employment and distribution, and of the formation 1 International Classification of Diseases, 1965 Revision. of senior scientific medical staff; and 204 FIFTH REPORT ON THE WORLD HEALTH SITUATION

- the assessment of health conditions and the Category and number Number of beds Paediatric hospitals 28 6 546 setting of environmental health standards. Infectious diseases hospitals 21 5 057 Besides the means that the Minister thus has of super- Tuberculosis hospitals and sanatoria 91 25 439 Psychiatric hospitals and sanatoria . 42 39 909 vising the departments of health and social welfare he Hospitals for general surgery 7 1 775 Ontological hospitals 7 1 073 advises on the use of credit from investments for the Hospitals for dermatology and health services. The academies of medicine and venereology 6 723 Hospitals for rheumatology 5 1 222 medical research institutes also come directly under Rehabilitation hospitals 4 1 026 Ophthalmology hospital 1 320 his responsibility. Hospitals and homes for chronic disease patients 147 18 796 Slight changes were made in the organization of the Other hospitals 3 399 health services in 1972 that do not affect local (district), Outpatient facilities were available in 1972 at 174 regional (voivodship) or interregional (intervoivod- hospital outpatient departments organized in general ship) institutions. hospitals, clinical hospitals and in research institutes; The district health services include: the district or at 26 polyclinics with inpatient facilities comprising zone (rayon) hospital, the peripheral district poly- voivodship tuberculosis and dermatology and venereal clinic which serves the outer area of the entire district, diseasesdispensaries,and voivodshippsychiatric the zone (rayon) polyclinics which are brances of the clinics; at 2039 rayon, peripheral, voivodship poly- peripheral polyclinic, the district emergency centre clinics, voivodship maternal and child care centres posts, the district health or epidemiological station, the and 2338 clinics in industrial establishments; at 2775 rural health centres, crèches and pharmacies. In the rural health centres, eight dispensaries, 708 rural voivodships there are general and specialized hospitals, medical aid posts, 122 rural stomatological mobile autonomous specialized polyclinics and polyclinics units, 695 feldsher units, 25 nursing stations, 76 student attached to the hospitals, health and epidemiological clinics, 375 emergency stations and 419 municipal and emergency centres, as well as tuberculosis sana- and dental clinics organized in towns by physicians toria, centres for rehabilitation, child neuropsychiatry who provide medical care on a paying basis. and neurotic diseases, psychiatric hospitals, establishments for alcohol addicts, tuberculosis preventoria and "half -way" sanatoria.At the intervoivodship Medical and allied personnel and training facilities level there are the clinical hospitals of the medical In 1971 Poland had 51 186 doctors, of whom 48 207 academies, the research institutes and certain psychia- were in government service.The doctor /population tric hospitals and groups of sanatoria. ratio was one per 640.Other health personnel in- Special health services have been established for cluded: certain population groups, such as workers in industry, schoolchildren and students. Feldshers 4650 Dentists (stomatologists) 14132 In order to improve the activities of the health care Dental technicians 3604 system and to coordinate the health services, a new Pharmacists 12851 Pharmaceutical technicians 5684 organization has been created integrating the func- Veterinarians 6109 tions and structures of the health services at the district Veterinary assistants 2719 Midwives 12488 level to form the integrated medico -sanitary care Qualified nurses 87128 service. This scheme was applied in 1972 in 11 districts Assistant nurses 20436 Sanitary Instructors 3199 and extended to all districts in 1973. Sanitary inspectors 255 Physiotherapists and masseurs 2418 Laboratory technicians 18966 Laboratory technician aides 803 Hospital services X -ray technicians 124 Dieticians 1509 Disinfectors 485 In 1971 Poland had 1467 hospital establishments School hygienists 1237 with 251 593 beds, of which 247 925 beds were in 1427 government- maintained establishments. The bed/ The arrangements for the training of medical and population ratio was 7.7 per 1000. The 251 593 beds, health personnel were as follows : to which 3 695 600 inpatients were admitted during the Category DurationNumber of Number of Number of year, were distributed as follows: and admission of study schools studentsgraduates requirements (years) 1971/72 1972 Doctors 6 10 14 460 2 290 Category and number Number of beds Dentists (stomatologists) 5 9 3 564 618 General hospitals 499 139 594 Pharmacists 5 8 4 217 718 Other establishments for general care Veterinarians 5 4 2 699 272 (rural maternity centres, infirmaries Sanitary engineers . . . 4, 6 3 654 471 etc.) 590 6 506 Hospitals for gynaecology and 1 Baccalaureate, unlessotherwise indicated (completed secondary obstetrics 16 3 208 education). EUROPEAN REGION 205

Category Duration Number ofNumber of Number of Chronic and degenerative diseases and admission of study schools studentsgraduates requirements 1 (years) 1971/72 1972 Nurses (university level) : The diseases of the circulatory system have become a baccalaureate, plus nursing diploma and social problem; they occupy the first place among the 2 years' experience . 4 1 178 causes of morbidity and mortality. Intensive care units Qualified nurses: are being developed in the hospitals and in cardiology baccalaureate . . . 2 or 2'/, 72 37 489 1 060 primary school . . 5 101 1 1 4 566 clinics, and emphasis is placed on early detection Nursing aides:

primary school. . . 3 3 151 37 through mass examinations. The increase in the num- Midwives 2'A 20 2 287 651 ber of cancer cases is continuing. Special attention is Laboratory technicians 2 18 2 036 670

Physiotherapists . . 2 9 679 183 given to early detection and to the provision of ade- Ergotherapists 2 2 147 57 X -ray and electrical quate treatment. The network of oncological services technicians 2 11 952 314 and of specialized laboratories is being extended. The Sanitary instructors 2 8 760 244 growing incidence of mental disorders also requires Dental technicians . 2 10 965 171 Pharmaceutical special efforts in extending the network of specialized technicians 2 11 1 238 398 Social workers 2 6 538 156 inpatient and outpatient establishments, including Biologists, those for children aged 0 -3 years. The prevention of microbiologists, biochemists 5 10 932 680 alcoholism and the prophylaxis and treatment of traumas are a growing preoccupation of the health 1 Baccalaureate, unless otherwise indicated (completed secondary education). authorities.

Communicable disease control and Specialized units immunization services Consultations for women and children are organized only in urban polyclinics.Medical care for women Significant achievements have been recorded in the and children in rural areas is provided by doctors control and eradication of communicable diseases, working in general health centres and medical aid mainly thanks to compulsory preventive vaccination posts. In 1972 there were 1888 clinics for prenatal care activities and to early hospitalization of patients. and 2511 urban paediatric rayons, each of them having Typhoid fever, trachoma, diphtheria, and whooping - a child population of 1500 to 2500.In 1972 urban cough are being eradicated. The incidence of polio- health establishments were attended by 697 200 preg- myelitis and malaria is rare. Most of the malaria cases nant women, 379 600 infants and 74 000 children aged are imported. The incidence of measles is decreasing 1 -2 years. Of all deliveries in 1972, 99.9 % were following the introduction of preventive vaccination attended by a doctor or qualified midwife.There among certain groups of children.The incidence of were 7442 doctors' consulting rooms in schools, which scarlet fever remains high, and infectious hepatitis provided medical and health supervision to 6.9 million continues to be an important health problem.The schoolchildren.Dental treatment was given at 4389 generaltuberculosisincidenceisdecreasing,the dental health units for schoolchildren and 6390 dental number of recorded tuberculosis cases having dropped health units for adults, which recorded altogether 44.1 by half during the period 1960 -1971.This result is million consultations.There were 35 rehabilitation mainly due to BCG vaccination, early treatment in hospitals, sanatoria and dispensaries and to early sanatoria and 2045 beds in rehabilitation services in general hospitals. Psychiatric consultations were detection through mass examinations.The venereal given in 466 dispensaries in peripheral and voivodship disease control programme includes the development polyclinics, municipal hospitals and research institutes, of treatment and laboratory facilities at the hospitals which in 1972 were attended by 170 217 new out- and dispensaries, and of health education. There has patients. There were also 2338 dispensaries in indus- been an important decrease in the number of syphilis trial establishments which carried out 2.4 million pre- cases and a somewhat lesser decrease in the number of employment medical examinations of workers and gonorrhoea cases. 3.4 million routine periodic examinations. Other The following immunization procedures were carried specialized units included 502 tuberculosis dispensaries, out in 1972: 574 dermatological and venereal diseases dispensaries,

Tetanus 3988395 393 rheumatological dispensaries, 643 ophthalmolo- Poliomyelitis 3214224 gical dispensaries and 411 sanitary and epidemiological Diphtheria 2895049 Typhoid and paratyphoid fevers 2735171 stations. These specialized outpatient services are Smallpox 2068425 attached to the peripheral and voivodship polyclinics, BCG 1604857 Whooping -cough 1037071 the municipal hospitals and the research institutes. Yellow fever 4219 Epidemic typhus 287 The 243 public health laboratories of the sanitary and 206 FIFTH REPORT ON THE WORLD HEALTH SITUATION epidemiological stations carried out over 9.4 million medical personnel working in these areas. Important examinations. developments related to maternal and child health care included the decrees of 1972 extending paid Environmental sanitation maternity leave to 16 weeks for the first child and to 18 weeks for each subsequent child, and regulating In 1971, of the 889 urban agglomerations in Poland, leave without pay for working mothers. which had a total population of 17.3 million, 726, with 16.7 million inhabitants, had piped water systems, National health planning serving 74.3 % of the urban population. Of the 889 urban communities, 694, with 16.5 million inhabitants, The national health and social welfare plan for the had sewerage systems; 62.6 % of the urban population period 1973 -1990 was approved by the Government lived in houses connected to sewers.Of the 45 246 presidium in February 1973.This plan defines the rural communities, with a total population of 15.5 following general areas of activity: the provision of million, 4683 communities had piped water systems, comprehensive and easily accessible preventive, cura- 1674 had water from public fountains, 7926 had water tive and restorative services to the whole population; from public wells and 950 had sewerage systems. theestablishment of adequate healthconditions, particularly in respect of community hygiene, nutrition, Major public health problems occupation and education; the improvement of the health status of workers; the improvement of the The main public health problems in Poland are: health consciousness of the population; and the improvement of health services and extension of the protection of the human environment, particularly network in order to increase their accessibility to the against the pollution of air, water and soil. population with increased health manpower and im- It is hoped that through the implementation of this proved quality of care; improvement of the health plan the following overall objectives will be achieved : status of the population and life expectancy through complete accessibilityof the health services and intensified control activities against communicable elimination of the existing imbalance between rural diseases and diseases due to urbanization and indus- and urban areas; improved health and sanitary status; trialization, and through reduction of infant mortality; reduction of infant mortality; improvement of the health protectionof the workers; environmental prevention and treatment of the most important protection; an increase in the efficiency of the health diseases. The plan also proposes to increase the medi- and social services activities through functional and cal and health manpower resources so as to reach the organizational integration of the health facilities and following ratios in 1990: 20 doctors, 5.6 dentists, 5.6 improvement of the administrative system; growing pharmacists and 59 nurses and midwives per 10 000 participation of the academies of medicine in the health inhabitants.It is planned to increase the number of service, closer coordination with the departments of admissions to the10 medical academies and to health and social welfare, and full utilization of the establish 60 new schools for the training of health per- results of medical science; and an increase in social sonnel of intermediate levels.Postgraduate medical welfare benefits, particularly with regard to integrated education will be intensified. The targets for the health care for old people. care network include the following ratios for 1990: 71 beds per 10 000 inhabitants in general and teaching hospitals, excluding psychiatric establishments; 20 beds Social and economic developments of significance for per 10 000 inhabitants in psychiatric establishments the health situation and in psychiatric hospital services; 25 beds per 10 000 The period under review has been marked by an inhabitants in special social welfare homes for patients increased development of industry, improved living suffering from chronic diseases; 40 beds per 10 000 conditions, better occupational health and security inhabitants in crèches. conditions,extendedpublicservicesand higher salaries.Particular attention has been given to the Medical and public health research development of primary, secondary and vocational schools.Efforts have been made to develop rural Research activities in medicine and public health areas and to improve living conditions in these areas. care are carried out in 14 research institutes which come Since 1972 free medical care is provided to the rural under the authority of the Ministry of Health and population (over 6 million inhabitants) who previously Social Welfare, in 10 medical academies, in the post- were not covered by health insurance. In order to graduate medical education centre and in the general provide better health and medical services in rural centre for medical technology. Over 40 000 research areas, special incentives are given to medical and para- workers are employed in these research establishments, EUROPEAN REGION 207 each of which has its scientific council which prepares and field investigations for the development of a long- guiding principles, acts in an advisory capacity, super- term programme for the protection of waters against vises the training of scientific staff and evaluates the pollution. research activities which have been carried out. The Environmental Pollution Abatement Centre, Katowice various research activities are coordinated by the (1971- ) UNDP: to promote the control of air and Scientific Council in the Office of the Minister of water pollution, liquid and solid wastes treatment and Health and Social Welfare.The long -term medical disposal, and water and air quality management. research questions are included as key issues in the prospective plan of the Polish Academy of Sciences, Mental health(1967- ) UNDP: toprovide whereas the research activities related to the actual training in child mental health and the rehabilitation of psychiatric patients in order to strengthen the mental needs of the health and medical services are defined by the Minister of Health and Social Welfare. For the health services. period 1971 -1975 priority has been given to the follow- Training in social medicine (1971- ): to develop ing fields: evaluation of the health status of the popu- curricula in social medicine and public health in lation,environmental health,occupational health, medical faculties and to train teachers. mental disorders and mental health protection, maternal and child health, rehabilitation, diseases of the Government health expenditure circulatory system. Research activities in medical and public health fields are mainly financed by the State In 1972 total government expenditure amounted to (over 95 % of the expenditure). The activities of the 407 130 million zlotys, of which 31 589 million were medical academies are integrated into the activities of spent on health services, including 30 296 million on the public health services.Each medical academy current account and 1293 million on capital account. covers two or three voivodships.Their cooperation The per capita government health expenditure was 955 comprises the following main areas: scientific research zlotys. The expenditure by the Ministry of Health and to meet the needs of the territory, medical education, Social Welfare was 2175 million zlotys, the expenditure postgraduate training, specialized surveillance, and by other ministries on health -related activities 2549.8 highly specialized medical services. million and by the intermediate health authorities 26 864 millionThe expenditure on general public Assistance from WHO health services included the following items: 106.8 In 1972 WHO's assistanceto Poland included the million zlotys for administration and government following projects: personnel, 12.7 million for mass campaigns against communicable diseases, 33.0 million for vaccination Tuberculosis control (1960- ) UNDP UNICEF: activities, 779.5 million for occupational health services to carry out tuberculosis control work and to follow and 1614.9 million for education and training of up the results of the studies carried out since 1964 on health personnel.The government expenditure on the detection and treatment of new cases in pilot hospitals included 9266.7 million zlotys for general tuberculosis control areas. hospitals,1320.6millionforteachinghospitals, Protection of river waters against pollution (1965- 2236.2 million for specialized hospitals and 5942.6 1972) UNDP: toundertake laboratoryresearch million for other health establishments.

PORTUGAL

Population and other statistics 1969 1970 1971 1972 Number of infant deaths 10 580 10 027 9 408 7 234 At the last census, taken in December 1970, the Infant mortality rate (per 1000 live births) 55.8 58.0 49.8 41.4 population of Portugal was 8 668 252.Population Number of deaths, 1 -4 years 2 293 2 330 2 003 1 623 estimates and some other vital statistics for the period Death rate, 1 -4 years (per under review are given in the following table: 1000 population at risk) 3.1 3.2 3.0 2.7 Number of maternal 1969 1970 1971 1972 deaths 150 127 103 96 Maternal mortality rate Mean population . . . 8 996 900 8611 100 8 600 900 8 578 200 (per 1000 live births) . 0.79 0.73 0.54 0.55 Number of live births . . 189 739 172 891 189 042 174 685 Birth rate (per 1000 population) . 21.1 20.1 22.0 20.4 Of the 98 688 deaths recorded in 1971, the main Number of deaths . . . 101 088 93093 98688 90315 Death rate causes were:1 cerebrovascular diseases (19 423), symp- (per 1000 population) . 11.2 10.8 11.5 10.5 Natural increase (%) . . 0.99 0.93 1.05 0.99 1 International Classification of Diseases, 1965 Revision. 208 FIFTH REPORT ON THE WORLD HEALTH SITUATION

toms andill- definedconditions(14 651),chronic Category DurationNumber of Number of Number of and admission of studyschools2 students graduates rheumatic heart disease, hypertensive disease, ischae- requirements 1 (years) 1971/72 1972 mic heart disease, other forms of heart disease (13 143), Doctors : 11 6 3 7131 368 malignant neoplasms (11 400), pneumonia (4516), Pharmacists : accidents(4280,including 2164 in motor -vehicle 11 4 3 1 673 281 accidents), bronchitis, emphysema and asthma (2745), Veterinarians : 11 5 1 233 21 cirrhosis of the liver (2621), birth injury, difficult labour Nurses (university level) : 11 4 1 90 24 and other anoxic and hypoxic conditions, other causes Nurses (basic training): 9 3 11 (12) 310 of perinatal mortality (1851), tuberculosis, all forms Auxiliary nurses: (1245), bacillary dysentery and amoebiasis, enteritis 6 1 % 11 (12) 780 and other diarrhoeal diseases (1244), nephritis and Midwives: Nursing training . 1 4 25 nephrosis (1144), diabetes mellitus (868), influenza Auxiliary midwives: (804). Auxiliary nursing training 1 36 The communicable diseases most frequently notified Laboratory technicians : 9 1 2 109 in 1972 were: tuberculosis, all forms, new cases (8603), Physiotherapists

11 2 1 82 18 gonorrhoea (1463), typhoid and paratyphoid fevers Sanitarians : (1158),meningococcalinfections(701),infectious 4 2 41 X -ray technicians hepatitis (679), malaria, new cases (590), syphilis, 9 45 new cases(435),diphtheria(214),typhus(185), 1 Years of general education, unless otherwise stated. schistosomiasis (145), whooping -cough (133), scarlet 2Public (private) schools. fever (128), poliomyelitis (75), trachoma (29), leprosy (10). Immunization services The following immunization procedures were carried Hospital services out in 1972:

Poliomyelitis 999 191 In 1971 Portugal had 619 hospitals and inpatient Smallpox 738 559 establishments,providing Diphtheria, whooping- cough, and tetanus. 651 142 54 477beds,of which Tetanus 606 737 25 624 were in 177 government establishments.The Diphtheria and tetanus 233 449 BCG 215 136 bed /population ratio was 6.3 per 1000.The 54 477 Cholera 111 679 beds, to which 692 177 patients were admitted during Yellow fever 40 529 the year, were distributed as follows: Typhoid and paratyphoid fever 7 202

Category and number Number of beds Specialized units General hospitals 477 32 719 In 1972 maternal and child health care was based on Maternity hospitals 29 1 413 Tuberculosis hospitals 54 6 686 333 centres where 100 298 consultations for pregnant Psychiatric hospitals 31 10 149 Other establishments 28 3510 women and 406 576 consultations for infants were given. During the same year, 24 199 visits were paid Outpatientfacilitieswere provided in1972at to pregnant women and 89 884 to infants.Of all hospital departments, at 66 health centres and 2028 deliveries in 1972, 84 260 were institutional and 50 879 medical aid posts. were attended at home by a doctor or qualified midwife. Medical and allied personnel and training facilities Portugal also had two independent medical rehabilitation centres and 35 psychiatric clinics. Specialized In1972 Portugal had 8972 doctors,including services in tuberculosis, venereal diseases, malaria and doctors practising dentistry.The doctor /population oncology were provided at 144 centres. ratio was one to 970. Other health personnel included: Government health expenditure

Dentists without medical qualifications . . . . 63 Non -operating dental assistants and In1971the total government expenditure was technicians 606 Pharmacists 2 787 32 722 million escudos, of which 4729 million were Pharmaceutical assistants 4 235 devoted to health services, including 4531 million on Veterinarians 407 Nurses 4 149 current account and 198 million on capital account. Midwives and nurse /midwives 1 259 The per capita government health expenditure amount- Auxiliary nurses and nurse /midwives 5 349 Social workers 715 ed to 549 escudos. The central health administration accounted for 1478 million escudos, and the local The arrangements for the training of medical and administrations for 64 million.In addition, 3187 health personnel were as follows: million were spent for social welfare purposes. EUROPEAN REGION 209

ROMANIA

Population and other statistics Category and number Number of beds Maternity hospitals 13 4 800 At the last census, taken in March 1966, the popu- Paediatric hospitals 28 5 657 Infectious diseases hospitals . 12 3011 lationof Romania was19 103 163. Population Tuberculosis hospitals 71 19 874 Psychiatric hospitals 36 10 262 estimates and some other vital statistics for the period Hospitals for dermatology and under review are given in the following table: venereal diseases 5 922 Hospital for accidents and traumatology 1 120 1969 1970 1971 1972 Ophthalmology hospital 1 165 Mean population. . . . 20010 00020252 541 20470 00020663 000 Cancer hospitals 2 560

Number of live births . . 465 764 427 034 400 146 389 153 Centre for rheumatic diseases 1 168

Birth rate Geriatric clinic 1 360

(per 1000 population) . 23.3 21.1 19.5 18.8 Endocrinology institute 1 250 Number of deaths . . . 201 225 193 225 194 306 189 793 Institute for internal medicine . 1 231 Death rate Gastroenterology centre 1 150 (per 1000 population) . 10.1 9.5 9.5 9.2 Cardiology centre 1 143 Natural increase ( %) . 1.32 1.16 1.00 0.96 Stomatology clinic 1 76

Number of infant deaths 25 584 21 110 16 964 15 566 Hospital for Infectious chest diseases 1 90 Infant mortality rate (per 1000 live births) . . 54.9 49.4 42.4 40.0 Number of deaths, Outpatient generalmedicalcare was provided 1 -4 years 3 847 3 858 3 691 3 507 through 3826 healthcircumscriptiondispensaries, Death rate, 1 -4 years (per 1000 population at risk) 2.72 2.40 2.09 1.89 which recorded altogether 55 million attendances and Number of maternal treatments in 1972.Specialized ambulatory care was deaths 491 497 522 506 Maternal mortality rate available at 397 polyclinics, which recorded approx- 1.05 1.16 1.30 (per 1000 live births) 1.30 imately 62 million attendances and treatments in 1971. The communicable diseases most frequently notified in 1971 were: influenza (501 039), measles (97 084), Medical and allied personnel and training facilities infectioushepatitis(58 429),gonorrhoea (29 700), tuberculosis, all forms, new cases (27 419), bacillary In 1971 Romania had 31 246 doctors and stomato- dysentery (21 828), whooping -cough (17 628), scarlet logists, or one doctor for 655 inhabitants. Other health fever (13 548), syphilis, new cases (7866), meningo- personnel included: infections(396), coccal typhoid and paratyphoid Medical assistants 22921 fevers (315), poliomyelitis (21), diphtheria (9), rabies Dental assistants 829 Pharmacists 4 837 in man (3). Pharmaceutical assistants 266 Midwives and obstetrical feldshers 3911 Assistant midwives 8016 Organization of the public health services Nurses 32 432 Sanitary engineers 26 Sanitarians 2 697 The Ministry of Health is in charge of the health Assistant sanitarians 3 146 services of the country.Its main functions are plan- Physiotherapists 631 Laboratory technicians 3 236 ning, establishing standards, education and training Assistant laboratory technicians 908 of medical and health personnel, and distribution of X -ray technicians 1 232 Health statisticians 610 medical equipment and supplies. Other technical health personnel 3341 The departmental health directorates are responsible for the provision of health services in the departments. The 16 medical, dental and pharmaceutical faculties These directorates are under the technical control of in Romania had altogether 10 863 students in 1971/72. the Ministry of Health and under the administrative Training of health personnel is provided in specialized control of the people's councils of each department. schools which had approximately 14 000 students in 1971/72. Hospital services Communicable disease control and immunization sery ices In 1971 Romania had 2719 hospitals and health centres, providing 173 296 beds, equivalent to 8.5 beds The tuberculosis incidence continues to decline.It per 1000 population.The beds were distributed as was 126.3 per 100 000 inhabitants in 1972. The follows : syphilis morbidity is increasing;it reached 35 per Category and number Number of beds 100 000 in 1972.There is a general increase in the General hospitals 378 111 222 number of viral infections of the respiratory and Rural hospitals 76 3 045 Health centres 2 088 11 234 digestive system and of infectious hepatitis.Control 210 FIFTH REPORT ON THE WORLD HEALTH SITUATION activities mainly comprise epidemiological surveillance, culture, education and health reached 3272 million lei. immunization campaigns, and mass preventive treat- Legislation concerning the family and population ment. growth has been enacted during the period under The following immunization procedures were carried review.Special importance has been attached to the out in 1972: development of the rural areas and of the medical care network in these areas.During the school year Cholera 6 819982 Smallpox 3360114 1972/73, 2.7 million schoolchildren attended primary Typhoid and paratyphoid fevers 3205687 schools, 300 000 attended professional schools and Tetanus 2448410 Poliomyelitis 1 508767 144 000 higher educational establishments. BCG 1454803 Diphtheria, whooping- cough, and tetanus 1103851 Diphtheria 784703 Diphtheria and tetanus 581009 National health planning Measles 10000 Yellow fever 1 551 The public health plan is an integral part of the overall national economic development plan.There Chronic and degenerative diseases are annual and prospective plans. The preparation of the health plan is based on national indicators sub- Cardiovasculardiseases,cancer and rheumatic mitted by the Ministry of Health, the departmental diseases are very common in Romania. The health people's councils, and some government agencies which authorities have embarked on priority programmes operate their own health care system, such as the Minis- for their prevention and for the provision of medical try of Transport and Telecommunications; on general assistance, including large -scale detection activities, guidelines included in the national plan in relation to prophylactic measures and health education. health; and on territorial indicators submitted by the departments. The plan indicators cover medical care Specialized units establishments, health manpower resources and preventive activities. In 1972 there were 305 obstetrical and gynaecological outpatient services, 251 paediatric services in poly- Medical and public health research clinics and 860 school health and paediatric dispensaries.Medical care for workers was available through The Ministry of Health, through the Academy for 1369 medical dispensaries in industrial establishments, Medical Sciences, coordinates the medical research 85 industrial polyclinics, 63 industrial hospitals and activities carried out in the various research institutes, 1064 health care and first -aid posts in industrial according to plans prepared by the National Council establishments. for Science and Technology. The Ministry of Health also plans and coordinates the research work under- Major public health problems taken by the university clinics and the medical care units.These research activities are financed by the The health problems which are still the main preoc- State. The amount spent in 1972 for medical research cupations of the Ministry of Health are related to the purposes was 117 million lei.The main medical and incidence of chronic and degenerative diseases, espe- public health research activities undertaken during ciallycancer,cardiovasculardiseases,rheumatic the period under review relate to the control and diseases and neuropsychiatrie diseases; general and treatment of communicable diseases, to epidemio- maternal and infant mortality; tuberculosis, and the logical, clinical and therapeutic studies of a number of virus diseases. chronic and degenerative diseases, to environmental health, and to the provision of medical and health services. Social and economic developments of significance for the health situation Assistance from WHO The development of agriculture and industry was accelerated during the period under review.Global In 1972 WHO's assistance to Romania included the industrial production increased by 11.7 % between following projects. 1971 and 1972.Efforts continued to achieve a better Water and air pollution control, phase I (1969 -72) distribution of industrial establishments throughout UNDP :assistance was provided to strengthen the the country with a view to improving the economic Institute of Hydrotechnical Research, to enable it to potentialities of the less developed regions.In 1972 investigate and to develop methods leading to control the investments inscience (excluding technology), of severe and urgent wateripollution problems. EUROPEAN REGION 211

Water and air pollution control, phase II (1971- ) Emergency assistance (1971 -1972) UNDP: Equip- UNDP: to establish a programme for air and water ment was provided for the production of vaccines. pollution control, carry out studies on various aspects Training of health personnel (1970- ): to develop of pollution, methods of treatment and control, and postbasic teaching institutions and prepare teachers for train personnel. various groups of health personnel.

SPAIN

Population and other statistics which comes under the Ministry of the Interior.It comprises six subdirectorates -general, for preventive At the last census, taken in December 1970, the medicine and welfare, for general services, for veterin- Population population of Spain was 33 823 918. ary health services, for pharmacy, as well as a general estimates and some other vital statistics for the period health inspectorate and a technical secretariat.The under review are given in the following table: subdirectorate -general for preventive medicine and 1969 1970 1971 1972 welfare is in charge of epidemiological services, sanitary 34 364 553 Mean population . . 33291 78733 645 60234 003 178 control and campaigns, and medical care services. The Number of live births . . 658 931 656 102 664 770 665 569 Birth rate general health inspectorate is responsible for the super- 19.4 (per 1000 population) . 19.8 19.5 19.6 vision of the health establishments, health services and Number of deaths . . . 297 169 280170 301 670 280 335 Death rate personnel. 8.1 (per 1000 population) . 8.9 8.3 8.9 The institutions dependent on theDirectorate - Natural Increase (%) . . 1.09 1.12 1.07 1.13 Number of infant General of Health include a number of technical, deaths I 14 899 13 632 12 552 10 905 Infant mortality rate educational and welfare centres: the national schools (per 1000 live births) . 22.6 20.8 18.9 16.4 of health and of puericulture with their regional Number of deaths, 1 -4 years 2 492 2 408 2 560 2 348 departments, the school for health instructors, the Death rate, 1 -4 years (per national institutes of ophthalmology, leprosy, onco- 1000 population at risk) 1.06 0.87 0.85 Number of maternal logy, haematology and haemotherapy, rheumatology deaths 221 217 Maternalmortalityrate and rehabilitation, the national centre of virology and 0.33 (per 1000 live births) 0.34 ecology,the nationalhospitalfor communicable 1 Excluding stillbirths and infants dying within 24 hours of birth. diseases, the main children's hospital. The Central Commission for Hospital Coordination Of the 301 670 deaths recorded in 1971, the main has been established to organize and group the various causeswere :1chronicrheumaticheartdisease, medical care establishments.The National Health hypertensive disease, ischaemic heart disease and other Council acts as a consultative body to the Directorate - forms of heart disease (67 274), malignant neoplasms General of Health. (47 575), cerebrovascular disease (42 805), symptoms The administration and organization of the health and ill- defined conditions (24 446), pneumonia (13 220), services in the 52 provinces of the country are the bronchitis, emphysema and asthma (12 982), accidents responsibility of the provincial health offices, which (12 338, including 4672 in motor -vehicle accidents), are under the authority of the Directorate -General of cirrhosis of the liver (7747), influenza (4594), diabetes Health. mellitus (5675), nephritis and nephrosis (4186), tuberculosis, all forms (3594), birth injury, difficult labour Hospital services and other anoxic and hypoxic conditions, other causes of perinatal mortality (2281). In 1971 Spain had 1406 hospitals and establishments The communicable diseases most frequently notified for inpatient care, providing 175 541 beds. The bed/ in 1972 were: influenza (520 520), measles (181 625), population ratio was 5.2 per 1000. The 175 541 beds scarlet fever (3845), meningococcal infections (2653), were distributed as follows: typhoid and paratyphoid fevers (2235), dysentery, all Category and number Number of beds forms (1656),poliomyelitis(158),trachoma(66), General hospitals 982 106 851 diphtheria (33), leprosy (24). Maternity hospitals 195 4 591 Paediatric hospitals 23 2 059 Psychiatric hospitals 121 43 909 Tuberculosis hospitals 46 13 935 Organization of the public health services Other hospitals 39 4 196 The organization of the public health services is the Outpatient medical facilities were provided in 1971 responsibility of the Directorate -General of Health, at 336 hospital outpatient departments, at 1310 polyclinics, of which 607 provided hospitalization facilities, 1 International Classification of Diseases, 1965 Revision. 212 FIFTH REPORT ON THE WORLD HEALTH SITUATION and at 114 health centres, 310 dispensaries and 53 also a considerable reduction in whooping -cough and mobile health units. tetanus cases.Control activities against trachoma, leprosy, venereal diseases and malaria were continued Medical and allied personnel and training facilities during the period under review. An extensive tuberculosis control campaign among the school population, In 1971 Spain had 47 419 doctors, or one doctor for with tuberculin testing, BCG vaccination, and photo- 720 inhabitants.Other health personnel included : scopy, has been launched in recent years.

Dentists 3 534 The following immunization procedures were carried Pharmacists 16 550 out in 1972: Veterinarians 7 523 Midwives 4 116 Poliomyelitis 2416318 Nurses 27 822 Whooping -cough 1328639 Assistant nurses 8000 Diphtheria 1327272

Tetanus 1324368 The arrangements for the training of medical and Cholera 919478 BCG 680777 health personnel were as follows: Smallpox 402678 Typhoid and paratyphoid fevers 159208 Category Duration Number of Number of Number of and admission of study schools 1students graduates requirements (years) 1971/72 1972 Specialized units Doctors : bachillarato 8 Cou8 6 18 (1) 38108 2 444 In 1971, there were 399 prenatal centres and 383 Dentists: child health centres; 680 946 pregnant women attended degree of Licentiate in Medicine and Surgery 2 1 these centres.Other specialized units included 145 Pharmacists : dental health units, 115 hospital rehabilitation out- bachillerato COU 5 5 (1) 8 353 629 patient departments, 85 independent rehabilitation Veterinarians : bachillerato clinics, 193 psychiatric outpatient clinics, 93 dermato- COU 5 4 2166 86 logical dispensaries, three leprosy clinics, 93 trachoma Medical auxiliaries (ATS) 4 including clinics and 114 tuberculosis dispensaries. nursing skills : bachillerato elemental 5 3 139 (10) 12 225 2 536 Midwives: Environmental sanitation ATS 1 3 (2) 58 52 Auxiliary midwives: ATS 1 16 In 1971 all communities with over 10 000 inhabitants Laboratory technicians: were provided with piped water and sewerage systems. ATS 2 1 6 6 Physiotherapists : It is estimated that 64 % of the total population were ATS 2 20 (2) 407 176 Podiatrists : served with piped water, and 7.5 % had water from ATS 2 1 120 40 public fountains; 61 % were living in houses connected Paediatric auxiliaries: ATS 2 1 19 13 to sewers. Psychiatric auxiliaries : ATS 2 1 52 20 Food inspectors: Major public health problems degree of licentiate . . 1 1 Sanitarians degree of licentiate . . 1 1 The main public health concerns in Spain are the 1 Public (private) schools. following:eradicationofcertaincommunicable 9 Certificate of seven years of secondary education preceded by five diseases such as brucellosis and tuberculosis; decen- years of primary education. 3 Certificado oficial universitario (official university entrance certifi- tralization and regionalization of healthservices; cate). extension of hospital facilities; development of out- 4 Ayudante técnico sanitario (certificated medical auxiliary). 5 Certificate of secondary education, first phase. patientmedicalcare;controlof environmental pollution, particularly water pollution; rural environ- Communicable disease control and immunization services mental health; accident prevention; social and health assistance to the subnormal; social and medical reha- An intensivesurveillance and health education bilitation. campaign was undertaken in 1972 for the prevention of a cholera outbreak. The water supply of all communi- Social and economic del elopments of significance for ties with over 300 inhabitants was chlorinated. Cholera the health situation vaccine was produced by the National Health School and by the National Centre for Virology and Ecology. The economic and social changes during the period Following the vaccination campaigns against polio- under review greatly influenced the evolution of the myelitis, diphtheria and tetanus, the poliomyelitis social security, health and social welfare sector. Efforts morbidity dropped by 88.3 % and the diphtheria have been made to revalue social benefits. The social morbidity by 98 % between 1962 and 1972. There was services of the social security were developed and a EUROPEAN REGION 213 better coordination between the social and health Medical and public health research services at all levels has been established. The rising Medical and public health research is carried out in cost of social development and the need to provide training and research centres among which the most more and better services are causing concern to the important are: the National School of Public Health authorities.In 1972 over 28 million persons received and its departments, the National School of Paediatrics assistance,benefitsand services from thesocial and the National School for Health Instructors, the security. The benefits paid increased from 196.2 mil- National Centre of Ecology and Virology, the National lion pesetas in 1971 to 242.3 million in 1972, the health Institute of Oncology and the Spanish Institute of benefits accounting for 31 % of the total expenditure Haematology and Haemotherapy. All these establish- and pensions for 30 %.Special attention has been ments work closely with the medical faculties and with given to the provision of social and health services for the Research Council. the old people and for the physically and mentally handicapped, and to the improvement of environ- Assistance from WHO mental working conditions. In 1972 WHO's assistance to Spain included the following projects : National health planning Epidemiological studies of virus diseases of public The second economic and social development plan, healthimportance(1971 -1972) UNDP: tostudy which covered the period 1968 -1971, comprised a methods for the prevention and control of enteric, number of health objectives for the improvement of respiratory and other virus diseases of public health hospital care services, the coordination of the health importance and to provide training facilities. delivery system at the central, provincial and local Pollution of the Bilbao District (1971 -1972) UNDP: level, and the formulation of the financial requirements to investigate the problem of air pollution. of the health infrastructure. The establishment of 400 Nursing education and nursing service administration health centres at the district and subdistrict level is one (1971- ): to develop and strengthen postbasic and of the health targets in the third economic and social basic nursing programmes. development plan, which covers the period 1972 -1975. Mental healthservices(1971 -1972) UNDP: to Provision is also made in this plan for the moderniza- develop the mental health services, especially those tion and the conversion of existing equipment of the for the rehabilitation of psychiatric patients. government hospital network with a view to supple- Training of health personnel (1971- ): to prepare menting the hospital network of the local corporations. teachers and develop teaching institutions for various Subsidies will also be provided for private establish- categories of health workers. ments.One of the major objectives of the national Medical education (1971- ): to improve medical health plans is the education and training of all education by developing curricula and methods of categories of health personnel. Health education of the teaching and evaluation. public is also given special attention, and health education programmes are being developed in primary Government health expenditure and secondary schools and in industrial centres. The In 1971 the total health expenditure of the Direc- health plans aim at reducing the mortality and mor- torate- General of Health amounted to 8807 million bidity due to communicable diseases such as typhoid pesetas, of which 7703 million were spent on current fever, brucellosis and tuberculosis, and to noncom - account and 1104 million on capital account.In municable diseases such as cancer, mental disorders addition, 12 342 million pesetas were spent by the and rheumatism; at reducing the disabilities due to Social Security, including 9301 million for general traffic and occupational accidents; at increasing the hospitals and clinics and 2804 million for outpatient availability of health services for the population; at services. The government expenditure on mass increasing the number of hospital beds to 10 per 1000 . campaigns against communicable diseases amounted inhabitants. t to 187.5 million pesetas.

SWEDEN

Population and other statistics 1969 1970 1971 1972

Mean population . . 7968 018 8042 818 8098 328 8122 293 At the last census, taken in November 1970, the Number of live births . . 107 622 110 150 114 484 112 273 Population Birth rate population of Sweden was 8 076 903. (per 1000 population) . 13.51 13.70 14.14 13.82 estimates and some other vital statistics for the period Number of deaths . . . 83 352 80 026 82 717 84 056 Death rate under review are given in the following table: (per 1000population) . 10.46 9.95 10.21 10.35 214 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 Ministry.Besides the professional staff required for Natural increase ( %) . 0.31 0.38 0.39 0.35 administrativepurposes,theNational Board of Number of infant deaths 1 264 1 212 1 270 1 215 Infant mortality rate Health and Welfare has a scientific advisory panel (per 1000 live births) . 11.7 11.0 11.1 10.8 Number of deaths, which assists in development and research. Only 1 -4 years 269 251 193 214 particularly important matters are decided by the Death rate, 1 -4 years (per 1000 population at risk) 0.56 0.54 0.42 0.48 Ministry; others are decided by the Board. However, Number of maternal the Board's decision can always be brought to the deaths 11 11 11 10 Maternal mortality rate Government's consideration by an appeal. The Board (per 1000 live births) . 0.10 0.10 0.10 0.10 is a considerably larger organization than that section of the Ministry which deals with public health and Of the 82 717 deaths recorded in 1971, the main medical care. causes were: 1 chronic rheumatic heart disease, hyper- Sweden has a special system whereby the Minister tensive disease, ischaemic heart disease, other forms of and the Ministry of Health and Social Affairs do not heart disease (32 993), malignant neoplasms (17 458), possess any independent right of decision but prepare cerebrovascular disease (9035), accidents (3436, includ- questions for decision by the Government ( "the King ing1314 in motor -vehicleaccidents), pneumonia in Council "). (2011), suicide and self -inflicted injuries (1648), bron- The sickness insurance is supervised by the National chitis, emphysema and asthma (1093), diabetes mellitus Social Insurance Board which is also under the Minis- (963), peptic ulcer (890), cirrhosis of the liver (751), try of Health and Social Affairs.Insurance is com- birth injury, difficult labour and other anoxic and pulsory.Benefits include free care for hospitalized hypoxic conditions, other causes of perinatal mortality patients, doctors' services and pharmaceutical pres- (737), congenital anomalies (558). criptions at reduced cost for outpatients. A national The communicable diseases most frequently notified dental insurance scheme was established in January in 1972 were: gonorrhoea (31 498), influenza (25 855), 1974, covering all citizens from the age of 17 for 50 measles (18 490), scarlet fever (5147), tuberculosis, all of the dental care fees. Dental care is totally free for forms, new cases (1792), infectious hepatitis (958), children, whereas pregnant women can receive reim- whooping -cough (758),syphilis, new cases(371), bursement of 75 % of the fees for ordinary dental care. bacillary dysentery (206), meningococcal infections The county councils and county boroughs cooperate (92), amoebiasis (65), typhoid and paratyphoid fevers in the seven regions into which Sweden is divided for (56), malaria (27). health care purposes.Each region has a regional hospital with at least 30 specialties.In each county Organization of the public health services there is at least one central general hospital with 15 to 20 specialties, and also several general hospitals. The Ministry of Health and Social Affairs is res- The number of specialized general hospitals is being ponsible for the national health services, which are reduced. operated or controlled by public authorities within the In January 1972 the departments of food and nutri- limits drawn by the Medical Care Act, 1963, and other tion were transferred from the former National Board legislation in this field.The administration of the of Public Health to the National Food Administration, medical services and the prophylactic health care at the those concerned with environmental hygiene to the local level is principally the duty of the county councils, National Environmental Protection Board, and those each of which is governed by a properly elected body concerned with occupational medicine to the National and each of which elects a medical services board as the Board of Occupational Safety and Health. executive body for medical care work.The county In January 1968 the Institute for the Planning and councils receive state subsidies to cover certain special Rationalization of Health and Social Welfare Services aspects of medical care, such as mental nursing and the was founded as the result of an agreement between the work of district medical officers, and are empowered Government, the Federation of the Swedish County to impose taxes to cover other health service expen- Councils and the three county boroughs, and took over diture. all the work and staff from three earlier institutions The central administration of public health and -among them the important Central Board of medical care in Sweden isdivided between two Hospital Planning -which have now ceased to exist. authorities: the Ministry of Health and Social Affairs and the National Board of Health and Welfare. The latter was established in 1968 following the amalgama- Hospital services tion of two separate boards concerned with health and In 1971 Sweden had 715 hospitals and inpatient social welfare. Only administration staff serve in the establishments providing altogether 121 050 beds, of 1 International Classification of Diseases, 1965 Revision. which 114 218 were in 508 government establishments. EUROPEAN REGION 215

The bed /population ratio was 14.9 per 1000.The Diphtheria, whooping -cough and tetanus 124900 121 050 beds, to which 1 390 838 patients were ad- Diphtheria and tetanus 35900 mitted during the year, were distributed as follows. Cholera 28000 Yellow fever 7500 Epidemic typhus 5700

Category and number Number of beds Whooping -cough 1 200 General hospitals 92 56 236 Diphtheria 800 Rural hospitals 52 3 479 Plague 650 Infectious diseases hospitals 2 489 Tuberculosis hospitals 13 2131 Psychiatric hospitals 31 25 458 Chronic and degenerative diseases Chronic diseases hospital 1 777 Hospitals for rheumatic diseases 3 337 Coast sanatorium 1 250 Cardiovascular diseases are among the main causes Hospital for epileptics 1 153 Nursing homes for the chronically sick259 21 183 of death, accounting for more than 50 % of all deaths. Geriatric hospitals 32 1 377 The National Board of Health and Welfare has Private nursing homes 6 442 Mental nursing homes 222 8 738 therefore initiated a 10 -year programme on nutrition and physical activity with the aim of preventing the Outpatient medical and health care was available in development of cardiovascular diseases and of rehabil- 1971 at about 200 hospital outpatient departments, itating disabled persons.Deaths due to malignant which recorded 3.8 million new patients; and at about neoplasms represent roughly 20 % ofalldeaths. 850 urban and rural district medical officers' stations, Screening procedures are being implemented increas- which recorded 5.8 million attendances. ingly and have to be evaluated before a decision on their further development can be taken. Medical and allied personnel and training facilities Specialized units In 1971 Sweden had 11 250 doctors, or one doctor for 720 inhabitants. Other health personnel included : In 1971 Sweden had 667 maternal welfare centres and 1273 child welfare centres.All pregnant women Dentists 6660 Dental chairside assistants 7500 and all children aged 0 -5 years were under medical and Pharmacists 3220 health supervision.Domiciliary care was given to Pharmaceutical technicians 6500 Veterinarians 900 116 800 pregnant women, to 99 % of all infants and Midwives 590 to 73 % of all children aged 1 -7 years. Of all deliveries Nurses /midwives 1600 Nurses 35000 in 1971, about 114 200 were attended by a doctor or Assistant nurses 8500 Nursing auxiliaries 60000 qualified midwife. The whole school population Sanitary engineers 700 had access to the 1900 school health service units which Sanitarians 600 Assistant sanitarians 60 existed in 1972.Public dental care was provided Physiotherapists 2890 Occupational therapists 660* in 1971 at 999 dental clinics to 884 500 schoolchildren Laboratory technicians 2000* between 7 and 16 years of age and to 662 700 adults. Laboratory aides 1300* X -ray technicians 530* Specialized medical rehabilitation clinics were available Social workers 790* at 14 general hospitals.In 1971 other specialized * Working in hospitals. unitscomprised29independentchildguidance clinics, 25 child guidance clinics at hospitals,six The arrangements for the training of medical and independent clinics for drug addicts, 25 tuberculosis health personnel were as follows: dispensaries, and 11 public health laboratories.

DurationNumber of Number of Number of At the end of 1972 there were approximately 400 Category of study schools studentsgraduates doctors employed in medical and health services of (years) (public) 1971/72 1972 industry, trade, communications and official adminis- Doctors 5% 6 7072 740 Dentists 5 4 1 866 343 tration. It is roughly estimated that about 50 % of the Pharmacists 1 729 382 persons employed in industry are covered by specific Veterinarians 1 326 46 Nurses (university level) 1 -1% 4 504 243 medical and health services provided by the industry. Logopedists ... 2 16 - But the general medical services provided by health authorities are available to industrial workers as to the Immunization services general population.

The following immunization procedures were carried Environmental sanitation out in 1969:

Smallpox 810 000 In 1972, 96 % of Sweden's total population had Tetanus 380 000 piped water supplies and 95 % were living in houses Poliomyelitis 228000 (1970 -1971) Typhoid and paratyphoid fevers 134 500 connected to sewers. 216 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Major public health problems task of shaping instruments for the evaluation of health policies and of suggesting any suitable reor- Among the communicable diseases, gonorrhoea, which reached its highest incidence in 1972, is the main ganization of the health delivery system to make it more economical.In view of the increasing costs of public health problem.Cardiovascular diseases and medical care, there is a strong tendency to rationalize cancer are also causing serious concern.Another problem of great importanceis smoking and its procedures by all possible means and to save resources Increased information activities are and expenditure. consequences. There is an increasing awareness of the need for undertaken as preventive measures. The alcohol integration of medical care and public health, as well problem is of considerable magnitude, and studies on as of social work in general. The importance of this new approaches to prevention and treatment are well under way. The drug problem is of great concern to policy is increasingly shown in the planning of future the authorities -both the abuse which is especially developments. Another important trend in the Swedish medical care delivery system is the concentration of noted among young people, and the overconsumption intensive medical care in the most appropriate hos- of psychotropic drugs at allages. Government - pitals,closing small nonspecialized hospitals and supported information activitiesare being under- small hospitals with few specialized departments. taken continually. The rapid development of hospital services over the Social and economic developments of significance for past decade, which was mainly determined by the the health situation paucity of doctors and by the promotion of efficiency, and the concentration of ambulatory care in outpatient During the period under review the percentage of the hospital departments, resulted in an imbalance in the population employed in agriculture and related fields health care system, with a preponderance of hospitals. continued to decrease. The number of working hours The present policy is to rectify this situation, advocat- in these sectors decreased by 1 -2 %. A slight decrease ing the development of health centres linked to hos- due to automation and structural rationalization also pitals or independent of and outside the hospital took place in the industrial and productive sectors, hierarchy.In health centres linked with general hos- whereas the public services, trade and communications pitals it is planned to use the hospital specialists for showed a slight increase.The population increase ambulatory care given by the centre. In the same way remained very low.The immigration excess was X -ray and laboratory equipment will be used both by important during the first part of the period under the hospitals and the health centres as common review. However, the situation changed in 1972. The resources.The independent health centres will vary immigration is now controlled by a special immigra- according to the different needs of the geographical tion board. The age structure is changing in Sweden areas. The minimum medical staff will include three to with the continuous decrease in the economically five doctors, mainly general practitioners. In the larger active population and as a consequence of the extended health centres there will be up to 15 doctors, of whom duration of education and the increased percentage of perhaps two -thirds will be specialists and the remaining old people. third generalists. Itis expected that these large To reduce the concentration in metropolitan areas, organizations will function like group practices, except the authorities are providing financial support for the that they will be owned and run by the county settlement of industries in problem areas and for councils, which will provide the facilities.The devel- decentralization of a number of government agencies. opment of health centres will relieve the already Unemployment increased from 2.1 % in 1967 to 2.7 overburdened hospitals.These centres, which will in 1972. A new element is the unemployment among cover a population varying between 10 000 and 15 000, young people with university education; it is to some will also include social workers. extent the consequence of the expansion of higher Among the functions of the health centres, pre- education in the 1960s. ventive medicine and health education are expected to receive special attention. Health education, which was National health planning started at the national level 10 years ago, has become In 1972 the Permanent Committee for National an important sector. It is supervised by a steering com- Health Planning introduceda new system with mittee under the chairmanshipof theDirector - emphasis on ambulatory care and on care for the General of the National Board of Health and Welfare, chronically ill in nursing homes instead of general with representatives of the county councils, the muni- hospitals. cipalities, the educational authorities, and professional The National Board of Health and Welfare, together and voluntary associations. The national committee with the Institute for Planning and Rationalization collaborates closely with local committees at county of Health Welfare Services, has been entrusted with the level.In 1972 the national budget contributed 3.8 EUROPEAN REGION 217

million kronor to the expenditure for health education activities of the Swedish Medical Research Council and the local authorities contributed an estimated sum cover the entire field of medical, dental, veterinary - of 1 to 2 million kronor. medical and pharmaceutical sciences. The total annual government allocations to medical Medical and public health research and public health research amount to approximately 200 million kronor. Private foundations provide Medical and public health research activities are about 20 million honor. The amount spent by the carried out by the universities and the Swedish Medical pharmaceutical industry for research has been estimat- Research Council, which come under the Ministry of ed at about 30 million kronor. Education, and by the university hospitals which are financed by the Ministry of Health and Social Affairs Government health expenditure and by the county councils. Medical and public health research is also performed in various laboratories of In 1971 total government expenditure amounted to the public sector, such as the National Bacteriological 57 871 million kronor, of which 14 890 million were Laboratory, the National Defense Research Institute, spent on capital account and 42 981 million on current the National Food Administration, and the Institute account. Of this latter amount 15 887 million kronor for Occupational Medicine. were spent at the central government level and 27 094 In addition totheSwedish Medical Research million at the local government level.The total Council, the following bodies supporting medical and government health expenditure amounted to 12 630 public health research can be classified as research million kronor, of which 11 040 million were current councils: the Swedish Work Environment Fund, the expenditure and 1590 million capital expenditure. The Cancer Society, the National Board for Technical per capita government expenditure on health was 1519 Development, The Bank of Sweden Tercentenary kronor. The central health administration accounted Fund, etc.These research councils award grants to for 2230 million kronor, the compulsory social insur- individual research workers, groups or institutions, ance funds for 1600 million and the county councils for and initiate and support new research activities. The 8800 million.

SWITZERLAND

Population and other statistics ing 1811 in motor -vehicle accidents), diabetes mellitus (1597), pneumonia (1412), bronchitis, emphysema and At the last census, taken in December 1970, the asthma (1291), congenital anomalies, birth injury, population of Switzerland was 6 269 783. Population difficult labour and other anoxic and hypoxic condi- estimates and some other vital statistics for the period tions,other causes of perinatal mortality (1198), under review are given in the following table: suicide and self -inflicted injuries (1160), cirrhosis of the 1969 1970 1971 1972 liver (960), influenza (739), symptoms and ill- defined

Mean population . . . 6212 000 6267 000 6324 000 6385 000 conditions (717), tuberculosis, all forms (380). Number of live births . . 102 520 99 216 96 261 91 342 Birth rate The communicable diseases most frequently notified (per 1000 population) . 16.5 15.8 15.2 14.3 in 1972 were: influenza (12 348), measles (3375), scarlet Number of deaths . . . 58 002 57 091 57 856 56 489 Death rate fever (2035), tuberculosis, all forms, new cases (1603), (per 1000 population) . 9.3 9.1 9.1 8.8 whooping -cough(832),infectioushepatitis(768), Natural increase (%) 0.72 0.67 0.61 0.55 Number of infant deaths 1 574 1 495 1 383 1 216 meningococcal infections (142), typhoid and para- Infant mortality rate typhoid fevers (75), bacillary dysentery (65), Q -fever (per 1000 live births) . 15.4 15.1 14.4 13.3 Number of deaths, (3), diphtheria (3), poliomyelitis (2). 1 -4 years 377 318 356 327 Death rate, 1 -4 years (per 1000 population at risk) 0.9 0.8 0.9 0.8 Number of maternal Organization of the public health services deaths 30 24 26 20 Maternal mortality rate (per 1000 live births) . . 0.3 0.2 0.3 0.2 Switzerland is a Confederation in which the cantons Of the 57 856 deaths recorded in 1971, the main have a large degree of autonomy. The responsibilities causes were: 1 chronic rheumatic heart disease, hyper- in the field of public health are divided between the tensive disease, ischaemic heart disease, other forms of cantons and the Confederation.Regular contacts heart disease (16 316), malignant neoplasms (12 046), have been established between the responsible cantonal and federal public health authorities. cerebrovascular disease (6641), accidents (3926, includ- The Federal Government has legislative competence 1 International Classification of Diseases, 1965 Revision. in the following fields :control of communicable 218 FIFTH REPORT ON THE WORLD HEALTH SITUATION

diseases, tuberculosis and rheumatic diseases, and Category DurationNumber of Number of Number of and admission of study schools studentsgraduates measures against alcoholism; training of doctors, requirements (years) 1971/72 1972 dentists, pharmacists and veterinarians; sickness and Pharmacists: maturité2 5 % 5 485 70 accident insurance, disablement, life and endowment Veterinarians : 2 insurance; occupational health and security, food maturité 5 2 447 51 Nurses (general hygiene, control of narcotics trade, protection against nursing) : ionizing radiation, water pollution, environmental 18 years of age and 9 years general protection and control of public nuisances.The education 3 17 (21) 3289 1 057 Psychiatric nurses: federal offices which play the main role in the field of 18 years of age and public health and which are attached to the federal 9 years general education 3 19 (1) 874 252 department of the interior are: the Federal Public Maternal and child health Health Service, the federal offices for social insurances nurses : 18 years of age and andenvironmentalprotection,andtheFederal 9 years Statistical Bureau. In many of the above -mentioned education 3 5 (6) 1 013 280 Assistant nurses: fields where the legislative competence belongs to 18 years of age and the Confederation, the execution of federal laws is 8-9 years general education 1'/, -2 17 (6) 910 436 entrusted to the cantons. Laboratory technicians: 17 years of age and Intercantonal agreements, for instance in matters of 10 years general public welfare and control of pharmaceutical prepara- education 3 5 (6) 461 168 Laboratory assistants: tions, define the relations between the cantons and 16 years, and 8 -9 years establish a coordination system.The cantons are general education . . 1'A 1 14 19 directly responsible for hospitals, medical practice, 1 Public (private) schools. 2School- leavingcertificateof 12 -13years of general education medical care, housing hygiene, school health services, awarded at age 18. etc.The cantons can delegate these responsibilities to the communes. Immunization services

Hospital services In 1972 the following number of vaccination doses were checked for sale in Switzerland: In 1971 Switzerland had 440 hospitals and inpatient Poliomyelitis 1127000 (1971) establishments providing altogether 72 268 beds. The Smallpox 700000 bed /population ratio was 11.4 per 1000.The 72 268 Tetanus 600000 Diphtheria 370000 beds were distributed as follows: BCG 220000* Whooping -cough 160000 Category and number Number of beds Cholera 150000 General hospitals 233 37 564 Measles 17000 Maternity hospitals 8 739 Yellow fever 15000* Paediatric hospitals 9 1 181 Typhoid and paratyphoid fevers 12000 Tuberculosis hospitals 14 1 353 Epidemic typhus 450 Psychiatric hospitals 50 18 363 Establishments for the aged, chronically * Approximate number of reported vaccinations. Ill and infirm 60 6 560 Other specialized hospitals 66 6 508 Chronic and degenerative diseases Medical and allied personnel and training facilities With the control of the communicable diseases and In 1971 Switzerland had 10 452 doctors, including with the growing prosperity of the population, the those no longer active and those abroad. The doctor/ chronic and degenerative diseases have gained in population ratio was one per 610. Other health per - importance. Rheumatic and cardiovascular diseases, sonnel included: cancer, alcoholism, and diabetes are causing increasing Dentists 2 440 concern to public health authorities and private Veterinarians 858 Nurses 14160 organizations, as are accidents.Public information Assistant nurses 7225 and health education campaigns are carried out in Physiotherapists 850 X -ray technicians 638 schools.

In 1972 the arrangements for the training of medical Environmental sanitation and health personnel were as follows: Category DurationNumber of Number of Number of In 1972 the whole population of Switzerland had and admission of study schools 1studentsgraduates piped water supplies, and 80 -85 % of the inhabitants requirements (years) 1971/72 1972 Doctors : were living in houses connected to sewers; about 15 maturité2 6 5 6 337 656 had septic tanks or pit latrines.About half of the Dentists : maturité2 5 4 937 171 country's inhabitants live in houses which can be EUROPEAN REGION 219 connected to water treatment plants in service.It is National health planning estimated that at present the waste -water of 40 -45 Some larger cantons have prepared hospital net- of the population is treated in treatment plants. The work plans which take into account the situation number of inhabitants served by these installations has existing in neighbouring cantons.Within this inter - doubled during the last six years, which means that the cantonal cooperation, it has been decided to establish number of connexions to a central plant has increased the Swiss Institute for Hospitals, whose function will annually by an average 3.5 % since 1966. be to prepare the scientific basis for hospital planning, management and construction, and to study other Major public health problems problems related to the hospital system in general. The main public health problems in Switzerland are those common to all industrialized countries, particu- Medical and public health research larlythe problems resulting from pollution and environmental deterioration as well as the chronic and Almost all medical research is carried out in univer- degenerative diseases. sities, university institutes and hospitals, and by the pharmaceutical and chemical industry.In addition Social and economic developments of significance for to its own research activities, the chemical industry the health situation contributes important funds to clinical research and to basic research which is carried out in its own laborato- The great economic prosperity, with the resulting ries or, more often, is undertaken by hospitals and uni- inflationary tendencies and the general shortage of versity institutes. Research in fields such as alcoholism, personnel in all economic sectors, continued.The toxicomania, health education, environmental protec- foreign labour force in Switzerland remained consider- tion, organization of nursing services, regional health able, with 660 000 foreign workers in 1970 for a total planning is carried out by private organizations with population of 6 267 000, as compared to 435 000 the assistance of the public authorities. The attribu- foreign workers in 1960 for a total population of tions of the Swiss National Fund for the Encourage- 5 429 000.The population increase, which reached ment of Scientific Research, which was established in its maximum in 1964 with a birth rate of 19.2 per 1000 1952 and which is financed by the public authorities, population, continued to decline. A number of were extended in 1970 by the creation of the health measures were taken during the period under review to research commission, which finances a number of protect the environment. A new constitutional article applied research activities in the field of medicine and enabling the Confederation to legislate in the field of public health. The financial contribution of the environmental protection was adopted. A federal law national fund towards medical research was 10.5 mil- on trade in toxic substances and its ordinance of lion francs in 1968 and 15.5 million in 1971; the enactment entered into force in 1970.The law on contributiontowardsclinicaland publichealth control of epidemic diseases was revised and was to enter research was 1.2 million francs in 1970 and 2.3 million into force in 1974. The health and sickness insurance in 1971. The 1973 budget of the Swiss Institute for system is also being revised. Hospitals is 0.5 million francs.

TURKEY

Population and other statistics Precise data on infant mortality are not available, but it is estimated to be of the order of 153 per 1000 live At the last census, taken in October 1970, the births.Turkey has a young population, with about population of Turkey was 35 665 549. Mid -year 41.1 % in the age group 0 -14 and about 54.5 % in the population estimates for the period under review age group 15 -64 years. were as follows : The main causes of death reported in 1971 were:

1969 34380000 chronic rheumatic heart disease, arteriosclerotic and 1970 35230000 degenerative heart disease, other diseases of the heart 1971 36110000 1972 37010000 (29 684), pneumonia (13 426), birth injuries, postnatal asphyxia and atelectasis, infections of the newborn, The birth rate is estimated to be 40.8 per 1000 and other diseases peculiar to early infancy and immaturity the death rate 13.5 per 1000, giving an annual rate of increase of the population of the order of 2.73 %. 1 International Classification of Diseases, 1955 Revision. 220 FIFTH REPORT ON THE WORLD HEALTH SITUATION

(12 329), malignant neoplasms (7533), senility with- bed /population ratio was 2.1 per 1000.The 75 410 out mention of psychosis, ill- defined and unknown beds, to which 1 523 317 patients were admitted during causes(7511),gastritis,duodenitis,enteritisand the year, were distributed as follows: colitis,except diarrhoea of the newborn (6960), Category and number Number of beds vascular lesions affecting the central nervous system General hospitals 343 46 350 (6549), accidents (4713, including 1559 in motor - Medical centres 294 3 714 Maternity hospitals 30 4 759 vehicleaccidents),tuberculosis,allforms (2621), Paediatric hospitals 4 1 570

Infectious diseases hospital 1 100 cirrhosis of the liver (839), diabetes mellitus (714), Tuberculosis hospitals 72 13 047 nephritis and nephrosis (712). Psychiatric hospitals 4 5000 The communicable diseases most frequently record- Cancer hospital 1 175 Ophthalmology hospital 1 150 ed in 1972 were : measles (23 601), infectious hepatitis Venereal diseases hospitals 2 140 Rabies hospital 1 50 (7711),whooping -cough(6105),malaria(2892), Leprosarium 1 265 typhoid and paratyphoid fevers (2164), scarlet fever Rehabilitation centre 1 90 (1723),diphtheria(792),meningococcal infections Ambulatory care was provided in 1972 at 371 (716), dysentery, all forms (715), poliomyelitis (424), hospital outpatient departments; at 437 polyclinics leprosy (110), rabies in man (49). belonging to the private health sector; at 292 medical Organization of the public health services centres with between 10 and 25 beds; at 872 health centres (ocaks), which are located in the areas where The administration of the health services is the res- health servicesare nationalized and which serve ponsibility of the Ministry of Health and Social approximately 10 000 inhabitants each; at 442 exami- Welfare. The Minister of Health and Social Welfare is nation and treatment establishments located in dis- assisted by an under -secretary of state and his assistant, trict centres where health services are not nationalized; and by three deputy under -secretaries of state.The and at 2382 health stations, which are part of the various directorates -general of the Ministry deal with nationalized health services and which serve approxi- public health, medical care establishments,social mately 3000 inhabitants each. services,tuberculosis control, malaria eradication, professional education, pharmacy and pharmaceuti- Medical and allied personnel and training facilities cals, nationalized health services, family planning, maternal and child health, mental health, trachoma In 1971 Turkey had 16 514 doctors, of whom 8755 control, cancer control, personnel, health education were in government service.The doctor /population and medical statistics,supplies, external relations. ratio was one per 2190 inhabitants.Other health The Minister of Health and Social Welfare is advised personnel included: by a number of consultative bodies, such as the direc- Dentists 3517 torate- general of planning and coordination,the Pharmacists 3477 Midwives 12176 consultative council, and the legal council. Nurses 15454* At the provincial level, the health directorate, which Assistant nurses 4267 Malaria and sanitation aides 4132 advises the governor of the province, is responsible to the Ministry of Health and Social Welfare for all Including 10285 male nurses or "health officers ". health and social welfare activities in the province. The arrangements for the training of medicaland The medical officers are in charge of the health health personnel were as follows: activities in the districts of the provinces where health Category DurationNumber of Number of Number of services are not yet nationalized. and admission of study schools studentsgraduates The nationalized health services include the follow- requirements (years) (public) 1971/72 1972 Doctors : ing components: health centres (ocaks), which serve a lycée 6-7 10 8 749 765 population of approximately 10 000 inhabitants and Dentists : lycée 4 3 2 168 158 which provide domiciliary, ambulatory and preventive Pharmacists: care; environmental health services; basic laboratory lycée 4 4 7 528 522 Veterinarians : services; vaccinations; health and nutrition education; lycée 5 2 658 62 Nurses (university level): and health stations, which serve a population of about lycée, plus nursing 3000 inhabitants in rural areas and provide maternal school 3 -4 5 648 104 Health administrators : and child health services. lycée 4 1 139 31 Nurses: Intermediate education Hospital services (8 years) 4 28 3 747 598 Auxiliary nurses: In 1971 Turkey had 755 hospitals and inpatient primary education . . 3 29 1 869 573 establishments providing altogether 75 410 beds, of 1 Higher secondary school education(four years), preceded by which 49 400 were in 578 government hospitals. The three years intermediate and five primary. EUROPEAN REGION 221

Category DurationNumber of Number of Number of schizophrenia.Research is being undertaken in the and admission of study schools studentsgraduates requirements (years) (public) 1971/72 1972 field of rheumatic diseases, diabetes and goitre. Midwives : intermediate education 4 5 837 174 Rural midwives : Specialized units primary education . . 3 29 3 369 1 046 Laboratory technicians : intermediate education 4 1 276 32 In 1972 there were 63 maternal and child health X -ray technicians: centres, 70 district service units and 759 rural maternal intermediate education 4 1 210 41 Sanitarians : and child health service posts.There were also 20 intermediate education 4 1 141 29 hospital rehabilitation units, one independent medical rehabilitation centre, 12 psychiatric outpatient clinics, Communicable disease control and and 230 tuberculosis, 41 trachoma, 28 leprosy and 19 immunization services venereal disease dispensaries.Industrial establishments which employ more than 50 workers provide No major epidemics have occurred or been intro- medical services and preventive medical care. Turkey duced into Turkey for many years. With the excep- had 42 public health laboratories in 1972. tion of the cholera outbreak in 1970, there has been a downward trend in most diseases. The tuberculosis control campaign has shown very Environmental sanitation good results.Over 90 % of the population were vac- In 1971, out of 36 636 communities, 628 had piped cinated during the period under review. However, the water systems serving 36 % of the total population and number of tuberculosis cases isstill high (200 000 577 communities had sewerage systems serving 26 cases). The tuberculosis mortality rate has dropped to of the population. 20 per 100 000, and the infection rate dropped by 2 %. The malaria eradication campaign has achieved great success and the number of malaria cases has Major public health problems decreased except in the area of Çukurova, where an epidemic occurred in 1972.Leprosy continues to be The main preoccupations of the health authorities endemic in some of the eastern and western provinces are, in order of priority: extension of the Çukurova of Turkey, and itis estimated that the number of malaria epidemic; poor environmental health condi- registered cases under control is only one -quarter of tions, particularly in rural areas; deficient nutritional the total number of cases. Trachoma still shows a high status, particularly in the large towns; lack of health prevalence in the east and south -east of Turkey. awareness of the population; increase of intestinal The following immunization procedures were carried parasitoses,particularlyinlarge towns;lackof out in 1971: efficient food control; unbalanced distributionof medical personnel and hospital beds throughout the Cholera 10526475 country; limited financial resources; insufficient health Smallpox 2959376 Poliomyelitis 2876139 establishments and professional and auxiliary health Typhoid and paratyphoid fevers 2462493 manpower. Diphtheria, whooping -cough and tetanus 2257103

BCG 1 160433 Measles 360398 National health planning

Chronic and degenerative diseases The second five -year development plan was completed at the end of 1972. The third five -year plan covers Because of the demographic evolution, chronic and the period 1973 -1977. The health targets of the third degenerative diseases occupy an increasingly important five -year plan are :family planning, reduction of place among the causes of death.Epidemiological mortality rates, development of rehabilitation centres surveys in the field of cardiovascular diseases were and facilities, improved utilization and distribution of initiated in 1970, and the results so far obtained medical care facilities and health manpower, improved indicate an incidence of 2 %, with a predominance of health education of the public, and the establishment rheumatic heart diseases, followed by arteriosclerotic of new medical faculties.The health sector of the heart diseases. It is estimated that cancer is the fourth development plan is coordinated with the overall cause of death. Mental diseases represent 18 % of all economic and social strategy and planning targets. hospital outpatient consultations. Epidemiological Sectoral plans are established with a view to relating surveys which have been undertaken since1965 investment allocation to the social targets defined in indicate that the most prevalent mental disorders are the overall plan. The health sector of the plan covers psychoneurosis,mentalretardation,epilepsyand such fields as population growth, health manpower, 222 FIFTH REPORT ON THE WORLD HEALTH SITUATION

regional balance of the health infrastructure, greater Training of public health laboratorytechnicians uniformity of health services, equitable distribution of (1969- ): to train laboratory technicians required services and better coverage. for the development of countrywide public health Health services will be administered by a single laboratory services and prepare an expanded teaching organization, a health insurance scheme will gradually programme. be implemented, health manpower recruitment and Training in preventive and social medicine (1969- ) : salaries will be reorganized and a system of compulsory to develop undergraduate and postgraduate medical service will be introduced. education.

Assistance from WHO Government health expenditure In 1972 WHO's assistance to Turkey included the During the fiscal year 1 March 1972 -28 February following projects: 1973, total government health expenditure amounted to 4252 million Turkish liras, of which 3760 million Malaria eradication programme (1957- ) were spent on current account and 492 million on Environmental sanitation (1964- ): to develop the capital account. The per capita government expen- environmental sanitation services and train sanitation diture on health was 115 Turkish liras.Expendi- personnel. ture by the Ministry of Health and Social Welfare accounted for 2119 million liras, other ministries 1695 Promotion of training and programmes in sanitary million, and local authorities 438 million. The govern- engineering,Middle East and IstanbulTechnical ment expenditure on general public health services Universities (1970- ) UNDP: to train environmental health personnel, and to promote specific included the following items: 223.7 million liras for expenditure on administration and government per- environmental health programmes in various govern- sonnel, 397.5 million for mass campaigns against ment agencies. communicable diseases, 157 million on immunization Master Plan for Water Supply and Sewerage for the and vaccination activities, 35.8 million on laboratory Istanbul Region (1965 -1972) UNDP: to prepare a services, 102 million on environmental health services, master plan, and feasibility and preliminary engineer- 163.7 million on veterinary health services, and 575.1 ing, and other organizational studies, for the extension million on education and training of health personnel. and improvement of the water, sewerage and storm The government expenditureonhealthservices drainage systems of Greater Istanbul and the develop- included the following: 2143.1 million liras on general ing industrial areas in the vicinity. hospitals and clinics, 637 million on teaching hospi- Development of public health services and training of tals, and 535.7 million on specialized hospitals. The personnel (1970- 1 UNICEF: to strengthen national government contributions to health activities of social health services at the central, regional and peripheral security schemes and other nongovernmental social levels. welfare systems amounted to 117.5 million liras.

UNION OF SOVIET SOCIALIST REPUBLICS

Population and other statistics fever (319 500), measles (291 400), whooping -cough At the last census, taken in January 1970, the popu- (34 500), typhoid and paratyphoid fevers (19 600), lation of the USSR was 241 720 134.Population diphtheria (500), poliomyelitis (180). estimates and some other vital statistics for the years 1969 -1971 are given below: Organization of the public health services 1969 1970 1971 1972 The public health services in the USSR are a part Mean population . . . 239500000241720 000243 900 000247 480 000 Number of live births . . 4087000 4226 000 4 372 000 ... of the State system, coming under the Executive Birth rate Committees of the Soviets of Workers' Deputies, which (per 1000 population) 17.0 17.4 17.8 Death rate act as the main organizers of health care. (per 1000 population) 8.1 8.2 8.2 The central health authority is the Ministry of Health Natural Increase ( %) . 0.89 0.92 0.96 Infant mortality rate of the USSR, whose responsibilities are laid down by (per 1000 live births) 25.8 24.7 23.0 the Council of Ministers. The Minister of Health of The communicable diseases most frequently notified the USSR is a member of the Government, and is in 1972 were: infectious hepatitis (480 400), scarlet appointed by the Supreme Soviet. EUROPEAN REGION 223

In the Union and Autonomous Republics, minis- rural district hospital.These feldsher /midwife posts terial councils direct the work of the ministries of are under the medical supervision of the district out- health.The republics are divided into kraj, oblasts patient clinic or hospital, as well as of the central (regions), municipalities and districts.The oblast is rayon hospital. The functions of the feldsher /midwife divided for administrative purposes into rural and posts include preventive medical care, first aid, referral urban rayons. All these levels have soviets of workers' of patients and home care. The rural district hospitals deputies and their executive committees, which are or outpatient clinics provide curative and preventive political authorities and which are ultimately respon- services to the whole district and carry out sanitary sible for the provision of health services to the popu- measures. These hospitals have a bed complement of lation. The departments of health under the executive between 30 and 200 beds. The policy adopted in recent committees of the soviets of workers' deputies at the years is to enlarge rural district hospitals and to various levels receive directives in purely medical develop rural outpatient units and polyclinics.The matters from the health authority of the higher level. central rayon hospitals, which are the main health The work of the health department of the rayon (dis- establishments of the rural health care system, are set trict) is carried out by the central rayon hospital under up in all rural administrative centres.The central its medical director. Health departments in the rural rayon hospitals provide general and specialized inpa- rayons have been abolished and their functions taken tient care, polyclinic and emergency care services and over by the medical directors of the central rayon are responsible for the administration and technical hospital, called the chief physicians of the rayon. management of all medical services in the rayon. The The health services in the USSR are divided into two central rayon hospital has 200 to 400 beds. The oblast, groups: (a) the curative and preventive services, and kraj and Republic hospitals have a bed complement of (b) sanitation and epidemiological services. 600 to 1000 beds and provide highly qualified specializ- The main type of curative and preventive services ed medical care. establishment is the combined hospital and poly- The health care of workers and employees in clinic.In addition, there are specialized hospitals, industrial undertakings constitutes an important sec- treatment and follow -up centres ( "dispansers "), indus- tor of the health services.Industrial health care has trial health units, and emergency medical care stations. developed from medical first aid posts to combined Alongside the polyclinical departments which form an curative and preventive services, medico -sanitary units, integral part of the hospital complex there are also based on the workshop district which covers 1500 to polyclinics outside this hospital complex. The poly- 2000 employees.The medico- sanitary units have a clinics play a major role in the public health system for polyclinic and inpatient facilities with a full range of the provision of health services. The activities of both specialized services, health posts, sanatoria and pre- types of polyclinics are organized on the basis of ventoria.At the beginning of 1972 there were 1440 territories and districts. The area served by the poly- medico- sanitary units, 32 620 health posts,13 069 clinic is divided into ucastok (medical districts) each workshop districts and 1820 sanatoria and preventoria containing an adult population of 3000 and a child under the Ministry of Health. Medical care for workers population (up to 14 years of age) of 1000. The poly- is also provided by the municipal health services (polyclinic provides all the basic forms of specialized out- clinics, hospitals and "dispansers ").The number of patient care, emergency care and domiciliary care. workshop districts under the municipalities increased Specialistunitsforcardiorheumatology,gastro- from 4136 in 1965 to 6335 in 1971. The establishment enterology, pulmonology and other specialized fields of large medico -sanitary units in industrial under- have been set up within the polyclinic. A considerable takings and their interaction with the territorially based amount of outpatient care is also given by "dispan- health services has had a beneficial effect on the health sers" dealing with tuberculosis, cancer, psychoneuro- of the workers, resulting in a declining incidence of logical disorders, venereal and skin diseases, endo- sickness during the last 10 years. crinous disorders, and medical rehabilitation.Each Institutions belonging to the Ministry of Social "dispanser" has an outpatient department and spe- Security work in close contact with the health authori- cialized inpatient facilities.The work of these "dis- ties. pansers" is organized on a territorial basis. The medical care delivery system in the USSR is organized in a hierarchic network ranging from the Hospital services feldsher /midwife posts through the rural district and central rayon hospitals to the oblast, kraj and Republic In 1972 there were 25 800 hospital establishments in "dispansers ". The feldsher /midwife posts are set up in the USSR with a total bed complement of 2 727 300 each locality with a population of some 700 to 3000 beds (equivalent to 11.1 beds per 1000 population), inhabitants and within a distance of 7 km from the which were distributed as follows : 224 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category Number of beds Communicable disease control and General medicine 562900 immunization services General surgery 362600 Oncology 47700 During the period under review the decline in the Gynaecology 157500 Tuberculosis 265500 morbidity of certain communicable diseases continued. Infectious diseases 205300 A number of these diseases, including smallpox, Infectious diseases of childhood 335200 Ophthalmology 39400 cholera and plague, were successfullyeradicated. Ear, nose and throat diseases 41000 Following the mass vaccination of children at school Venereal and skin diseases 55300 and in other establishments the annual incidence of Mental diseases 274500 Neurology 76300 whooping -cough has declined to 17 per 10 000. Only Obstetrics 200100 sporadic cases of diphtheria have been recorded. The Others 104000 incidence of typhoid and paratyphoid fevers has been reduced to 8 per 10 000.The problems of the pre- During the five -year plan period, the network of vention of influenza and infectious hepatitis are still to medical establishments was considerably extended. be solved. In 1971 there were 34 328 outpatient units and polyclinics and 38 000 emergency medical care stations. The annual number of visits to doctors was 10.8 in Chronic and degenerative diseases 1971 per urban inhabitant and 3.5 per rural inhabitant. Chronic diseases, particularly cardiovascular dis- A considerable amount of domiciliary care was provid- eases and cancer, occupy an important place among ed by outpatient units and polyclinics with nearly 108 causes of death. Special attention is given not only to million home visits to urban inhabitants and over 101 the treatment of cardiovascular diseases, but also to million to rural inhabitants.The development of the prevention of coronary insufficiency, hypertension inpatient and outpatient care shows the steady exten- and atherosclerosis.Purely medical measures such sion of specialized medical care.In 1971 there were as case -finding and follow -up, timely admission to the followingspecialistoutpatientservices:6496 hospital, accessibility to sanatorium and spa treatment neurological units in urban polyclinics, 2726 cancer play an important part. In large cities, specialist teams units, 7327 ear, nose and throat units, 7052 ophthal- have been set up within the emergency medical care mological units, 3254 cardiorheumatological units, system to deal with infarctions, thromboembolism 2741 endocrinological units.In 1972 there were and shock conditions and to provide the most urgently 18 618 X -ray units, 3550 functional diagnosis units and needed first -aid. In the large hospitals, cardiological 8052 electrocardiography units.In order to render departments, special wards for infarction and inten- qualified outpatient care more accessible to the popu- sivecareunitshave been organized.The net- lation in remote rural areas, mobile outpatient units work of cardiorheumatological unitsisstill being and polyclinics, attached to the central rayon hospitals, developed in the USSR, their number having increased have been organized.Specialized medical buses are from 2770 in urban and 29 in rural areas in 1968 to operating to provide X -ray, dental, diagnostic and 3254 and 38 respectively at the end of 1971. Problems clinical services, as well as maternal and child health of cardiology are studied, in particular at the Mjasni- care and laboratory services. kov All -Union Institute of Cardiology and at similar institutes in the Union Republics. Medical and allied personnel and training facilities Special attention is also being given to the campaign against cancer and to the improvement of detection, In 1972 there were 731 800 doctors, stomatologists recording, diagnosis and treatment. The network of and dental practitioners in the USSR.This gives a cancer institutes,units and departments has been doctor /population ratio of one to 340Other health considerably extended, from 2498 in municipal and personnel included: 210 in rural areas in 1968 to 2726 and 261 respectively in 1971. A new cancer research centre is being built Feldshers 501000 Dental technicians 27600 in Moscow. Feldshers /midwives 79800 Midwives 231700 Social and economic developments of significance for Nurses 1 106500 Laboratory technicians 94600 the health situation X -ray technicians 27100 Other auxiliary personnel 120000 The eighth five -year national economic development plan was completed in 1970.During the plan During the five -year plan period 1966 -1970, 151 000 period the level of social production rose altogether by doctors were trained, which represents an increase of 150 %. The national income increased by 41 %, and 22 000 over the preceding plan period. social labour productivity rose by 37 % as against 29 EUROPEAN REGION 225 during the preceding five -year period. A number of form by the Supreme Soviet of the USSR, after which social problems were solved during the plan period it has the force of law. 1966 -1970:the minimum wages of workers and em- The health sector of the ninth five -year economic ployees rose to 60 roubles a month, the average wages plan for 1971 -1975 provides for the expansion of of workers and employees for the whole country rose hospital and medical services, increased production by 26 % and the income of collective farmers from of drugs, medicaments and medical equipment, an social work increased by 42 %. Guaranteed payment increase in the number of doctors and auxiliary medical for work was introduced for collective farmers, the personnel, the extension of the network of sanatoria, pensionable age was reduced, and sickness and preventoria, rest homes and other establishments for invalidity benefits established. During the plan period, the promotion of health. The objective is to increase 199 000 million roubles were allocated for education, the number of hospital beds during the five -year period health services and other cultural and social services of by 336 700 to reach a total bed complement of 3 mil- the population.Some 80 000 million roubles were lion, mainly through the construction of new hospitals. spent on those unfit for work (war veterans, disabled The bed /population ratio will be 11.7 per 1000 in 1975 ex- servicemen, injured industrial workers and workers as against 10.9 per 1000 in 1970. The number of phar- suffering from a temporary loss of working capacity) macies will be increased by more than 2000. Particular and on grants for students. The allocation for research attention is given to the improvement and expansion amounted to 41 000 million roubles. Social consump- of medical care services in rural areas with the planning tion funds rose by 150 % during the five -year period, of 530 new rayon hospitals and outpatient polyclinics, reaching 64 000 million roubles in 1970. providing altogether 60 000 beds, and of 119 new Basic health care legislation for the whole country sanitation and epidemiology stations. The number of and the Union Republics was adopted, and was places in the homes for the disabled and old people brought into force in July 1970.This code clearly will be increased by 74 700 to a total of 360 800. defines the rights and duties of all State authorities and Capital investment inthe construction of health citizens in the field of health protection. It formulates establishments under the plan amounts to 6371 mil- general principles for the organization and adminis- lion roubles. Between 1971 and 1975 it is planned to tration of health services and the establishment and build 200 general and specialized hospitals, including operation of medical care institutions. This code also 31 hospitals with 1000 and more beds each, 16 emer- sets forth the rights of medical workers. Special atten- gency care hospitals with 800 -900 beds each, 24 reha- tion is devoted to maternal and child health. bilitation hospitals for adults and children with 420- 520 beds each, 19 cancer hospitals with 450 beds each, National health planning and a "half -way house" with 120 beds attached to each hospital.An additional 199.5 million roubles The long -term plan for the development of the health from funds provided by voluntary communist working services is an integral part of the overall five -year parties are allocated for the construction of children's national economic plan.Health planning, like plan- hospitals with polyclinics, cardiological and therapeutic ning in all other branches of the national economy, wards, providing altogether 16 700 beds. is based on a combination of central planning and The five -year plan also provides for the construction local initiative. of large research centres in cancerology and cardiology, Three groups of bodies are involved in health plan- research institutes in rheumatology, psychiatry, gynae- ning at all levels of the health planning process: the cology and obstetrics, and parasitology, and a branch central authorities (Soviets of Ministers, the Executive of the Academy of Medical Sciences in Siberia. Some Committees of the Soviets of Workers' Deputies), the of these centres will be financed from funds derived planning authorities (the State Planning Commission from voluntary communist working parties. (GOSPLAN) of Union and Autonomous Republics, oblast, urban and rayon planning commissions) and Medical and public health research the Republic and local health authorities. Draft health plans are prepared at the rayon level, then submitted to The state budget allocates funds for medical and the rayon planning commission, and, after examination public health research in accordance with the long -term and approval by the rayon executive committee, to the plan for the development of research in 1971 -1975. oblast Executive Committee and Planning Commission This plan was endorsed in 1970 by the Academy of or direct to the Soviet of Ministers and to the GOS- Medical Sciences of the USSR and by the Ministry PLAN of the Union Republic. The GOSPLAN, after of Health of the USSR. The research projects carried careful examination of the plans, submits its conclu- out during the period under review covered, among sions together with a combined draft plan to the Soviet other subjects, the organization of rural and urban of Ministers of the USSR. The plan is given its final medical care; the health status of the population in 226 FIFTH REPORT ON THE WORLD HEALTH SITUATION different rayons; consumption norms for hospital, Research activities are being expanded in the field of outpatient, polyclinic, hygiene and preventive care, prevention of cardiovascular and virus diseases, cancer, and medical and auxiliary staff up to 1990; establish- accidents, and treatment and rehabilitation of patients ment of an automated system of health planning and suffering from these conditions. In 1972, 74 institutes, administration; economic aspects of health care and including 52 medical and advanced medical training rational organization of the work of medical personnel; institutes and 22 research institutes, participated in a further rational specialization of medical care and study on "social hygiene and the organization and development of the network of medicalservices. administration of the health services ".

UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND

Each of the three component parts of the United (3772),influenza(3006),nephritis andnephrosis Kingdom- England and Wales, Scotland, and North- (2663), intestinal obstruction and hernia (2473). ern Ireland -has its own ministry or department of The communicable diseases most frequently notified health and publishes its own statistics. in 1972 were: measles (143 720), infectious hepatitis (12 023), scarlet fever (11 068), tuberculosis, all forms, new cases (11 013), dysentery,all forms (10 028), ENGLAND AND WALES' whooping -cough(2087),acutemeningitis(1494), typhoid and paratyphoid fevers (205), poliomyelitis Population and other statistics (6). At the last census, taken in April 1971, the population of England and Wales was 48 603 945. Population Hospital services estimates and some other vital statistics for the period In 1971 England and Wales had 2452 hospitals with under review are given below: a total of 445 387 beds -equivalent to 9.1 beds per 1969 1970 1971 1972 1000 population. These beds, to which 5 494 040 in- Home population . . . . 4855000048 873 00048 815 00049029000 patients were admitted during the year, were distributed Number of live births . . 797 538 784 486 783 155 725 000 Birth rate as follows : (per 1000 population) . 16.4 16.1 16.0 14.8 Category and number Number of beds Number of deaths . . . 579 378 575 194 567 262 591 907 Death rate General hospitals 1 086 198603

(per 1000 population) . 11.9 11.8 11.6 12.1 Maternity hospitals 222 8 625 Paediatric hospitals 36 4188 0.45 Natural increase ( %) 0.43 0.44 0.27 Number of infant deaths . 14 391 14 267 13 720 12 454 Infectious diseases hospitals . 18 234 Infant mortality rate Tuberculosis hospitals 62 6 546

(per 1000 live births) . 18.0 18.2 17.5 17.2 Psychiatric hospitals 158 116 149 Number of deaths, Other specialized hospitals 870 111 042 1 -4 years 2 559 2 326 2 204 2 307 Death rate, 1-4 years (per Ambulatory medical care was provided in 1972 at 1000 population at risk) 0.77 0.72 0.70 0.74 Number of maternal 2420 hospital outpatient departments, which recorded deaths 155 146 133 111 over 15.78 million new outpatients during the year. Maternal mortality rate

(per 1000 live births) . 0.19 0.19 0.17 0.15 Provisional figures. Medical and allied personnel and training facilities Of the 591 907 deaths recorded in 1972, the main In 1971 there were 62 000 doctors in England and causes were: z chronic rheumatic heart disease, hyper- Wales, of whom 55 000 were in government service. tensive disease, ischaemic heart disease, other forms of The doctor /population ratio was one to 790.Other heart disease (197 251), malignant neoplasms (118 950), health personnel in government service included: cerebrovascular disease (81 961), pneumonia (45 426), Dentists 13400 Dental technicians 305 bronchitis, emphysema and asthma (29 898), accidents Dental surgery assistants 606 (16 488, including 6928 in motor -vehicle accidents), Dental hygienists 66 Pharmacists 13900 birth injury, difficult labour and other anoxic and Pharmaceutical technicians 1300 hypoxic conditions, other causes of perinatal mortality Veterinarians 772 Veterinary assistants 356 (5637), diabetes mellitus (5312), congenital anomalies Midwives 18500 (4413), peptic ulcer (4034), symptoms and ill- defined Pupil midwives 5600 Nurses 118200 conditions (3815), suicide and self -inflicted injuries State -enrolled nurses 47200 Nursing auxiliaries 80400 ' See also under United Kingdom (p. 231). Student and pupil nurses 67400 2 International Classification of Diseases, 1965 Revision. There were in all 6377 veterinarians. EUROPEAN REGION 227

Sanitary inspectors 5500 Specialized units Physiotherapists 4700 Chiropodists 1 307 Occupational therapists 1 801 In 1972 maternal and child health care in England Remedial gymnasts 235 and Wales was based on 6722 centres. These centres Speech therapists 199 Laboratory technicians 5400 are provided as part of the local health authority's Student and junior laboratory technicians 5800 Radiographers 4900 duties. The domiciliary and health visitors work from Electro- encephalography technicians . . . 207 them. During the year, 216 270 pregnant women Cardiology technicians 693 Audiology technicians 257 attended the local authority clinics and 592 182 the Medical physics technicians 687 hospital antenatal clinics; 585 320 infants and 1 197 997 Dietitians 357 Biochemists 627 children aged1 -5 years received services at these Opticians 7094 Psychologists 468 centres. Domiciliary visits were made to 776 326 Social workers 14608 infants and to 2 287 337 children aged1 -5 years. About 80 % of all expectant mothers are confined in The arrangements for the trainingof medical and National Health Service hospitals and approximately health personnel were as follows: 16 % are confined in their own homes under the care of the family doctor and the domiciliary midwife. In Category Duration Number of Number of and admission of study schools students 1971, 2906 school clinics were provided by 163 local requirements (years) (public) 1971/72 authorities, where over 8.5 million schoolchildren, or Doctors : 94.3 % of the total school population, received some (decidedby individual universities) 5 -6 32 3 150 form of health care during the year. Dentists : During the same year 1620 fixed and 272 mobile GCE "A" level 1 . . . . 4 -5 17 896 Veterinarians : dental clinics were provided by 163 local authorities.

GCE, "A" level . . . . 4 Dental technicians: They were attended by 23.4 million patients. Industrial apprenticeship training 16 1 120 rehabilitation facilities are provided at 25 units run by Dental nursing assistants : the Department of Employment, seven centres run GCE, "O" level 2 . . . . 1 -2 11 321 Dental surgery assistants : by voluntary organizations and two run by local 2 GCE, "O" level . . . 1 -2 29 757 Dispensing opticians: authorities. In 1972, 161 800 new patients attended the GCE, "O" and "A" levels 2 -4 4 235 hospital rehabilitation outpatient departments, and Occupational therapists: GCE, "O" level . . . . 3 1 21 225 704 new patients attended the 1021 psychiatric Speech therapists : outpatient clinics. There were also 483 child guidance GCE, "O" and "A" levels 3 3 147 Dietitians : clinics, of which 264 were in part -time use only, and GCE, "O" and "A" levels 1'A-3 4 154 Chiropodists : which are provided by local education authorities, or GCE, "O" level . 3 4 346 other bodies, for the treatment of schoolchildren with Sanitarians:

GCE, "O" level . . . . 3 (or 4 22 692 emotional or behavioural difficulties. part-time) All premises subject to the Factories Act, of which Radiographers :

GCE, "O" level . . . 2 12 361 there were 206 500 in February 1971, are required to Medical laboratory technicians : have first -aid facilities. If a factory employs more than ONC, "O" and "A" levels3 2 -5 58 3 985 50 persons these facilities must be in the charge of a Nurses : responsible person trained in first -aid treatment.In GCE, "O" level . . . . 1 -2 2 81 'Cadet' nurses: 1971 approximately 33.5 % of all industrial workers Up to GCE, "O" level standard 1 -2 76 2 799 were covered by medical and health services in indus- Midwife teachers : try; 191 552 pre -employment examinations were given GCE, "O" level 1 2 13 to young people leaving school and entering factory 1 General Certificate of Education, advanced level (completed secondary education). employment. 3 General Certificate of Education, ordinary level (secondary education, In 1972, 225 hospital groups had at least one chest first phase). 3 Ordinary National Certificate, ordinary and advanced levels. clinic each; together these recorded 346 408 new outpatients.The 198 venereal disease clinics recorded Immunization services 308 009 new outpatients. England and Wales had 62 public health laboratories, which in 1971 performed The following immunization procedures were carried nearly 4 million examinations. out in England and Wales in 1972:

Tetanus 1539941 Government health expenditure

Diphtheria 1361303 Whooping -cough 739471 Poliomyelitis 697438 Total government expenditure for the fiscal year BCG 552395 1971 amounted to £12 727 million, of which £2551 Measles 513210 Rubella 292419 million were spent on health services. Current govern- 228 FIFTH REPORTON THE WORLD HEALTH SITUATION ment health expenditure amounted to £2333 million self -inflicted injuries (417), nephritis and nephrosis and capital expenditure to £218 million. The per capita (330). government expenditure on health was £52. The total The communicable diseases most frequently notified government health expenditure includes school health in 1972 were: measles (5524), dysentery, all forms and personal social services (child care and other local (3472), infectious hepatitis (1750), tuberculosis,all authority welfare services) but excludes school meals, forms, new cases (1687), scarlet fever (570), whooping- refuse disposal, etc. The central government account- cough (220), meningococcal infections (116), typhoid ed for £2081 million and the local health authorities and paratyphoid fevers (29), malaria, new cases (27), for £470 million.The government expenditure on poliomyelitis (4). general public health services included £5.097 million for immunization and vaccination activity and £3.023 million for education and training of health personnel. Hospital services The government expenditure on hospitals included the following outlays: £587 million for general hospitals In 1971 Scotland had 365 hospitals and inpatient and clinics, £249 million for teaching hospitals, £448 establishments providing 62 926 beds, to which 704 992 million for specialized hospitals and £8 million for inpatients were admitted during the year.The bed/ other health establishments. population ratio was 12.1 per 1000The 62 926 beds were distributed as follows :

Category and number Number of beds SCOTLAND General and local hospitals 168 24 567 Maternity hospitals 45 2 589 Paediatric hospitals 5 652 Infectious diseases hospitals 8 2420 Population and other statistics Tuberculosis hospitals 5 316 Psychiatric hospitals 36 19354 Hospitals for mental deficiency 18 6 940 At the last census, taken in April 1971, the popu- Orthopaedic hospitals 3 573 lation of Scotland was 5 227 706. Population estimates Geriatric hospitals 57 4 461 Convalescent homes 13 717 and some other vital statistics for the period under Other hospitals . . 7 337 review are given below:

1969 1970 1971 1972 pital outpatient departments, which recorded nearly Home population . . . . 5208 500 5213 700 5217 400 5210 400 2.9 million new outpatients during the year, and at 39 Number of live births . . 90 290 87335 86 728 78550 Birth rate health centres, which provide general medical services, (per 1000 population) . 17.3 16.8 16.6 15.1 dental services and health education. Number of deaths . . . 63 821 63 640 61 614 65 017 Death rate (per 1000 population) . 12.3 12.2 11.8 12.5

Natural increase (%) . . 0.50 0.46 0.48 0.26 Number of infant deaths . 1 902 1 714 1 722 1 477 Medical and allied personnel and training facilities Infant mortality rate (per 1000 live births) 21.1 19.6 19.9 18.8 Number of deaths, In 1971Scotland had 8122 doctors working in 1 -4 years 330 315 262 279 government service. The doctor /population ratio was Death rate, 1 -4 years (per 1000 population at risk) 0.9 0.9 0.7 0.8 thus one per 640.Other health personnel in govern- Number of maternal ment service included: deaths 13 17 14 13 Maternal mortality rate (per 1000 live births) 0.14 0.19 0.16 0.17 Dentists 1562 Dental hygienists 15 Pharmacists 2832 Of the 65 017 deaths recorded in 1972, the main Pharmacy technicians 264" Midwives 2164 causes were: 2 chronic rheumatic heart disease, hyper- Assistant midwives 2530 tensive disease, ischaemic heart disease, other forms of Registered general nurses and State -enrolled nurses 22203 heart disease (22 412), malignant neoplasms (12 913), Nursing auxiliaries 27262 cerebrovascular disease (10 385), pneumonia (3039), Laboratory technicians 1518* Radiographers 675* bronchitis, emphysema and asthma (2854), accidents Physiotherapists and remedial gymnasts 826 Chiropodists, dietitians, occupational (2319,including 867in motor -vehicleaccidents), therapists, speech therapists, industrial diabetes mellitus (708), birth injury, difficult labour therapy managers 578* Opticians, dispensing opticians, orthoptists, and other anoxic and hypoxic conditions, other causes social workers 1237 of perinatal mortality (674), congenital anomalies Other technical staff 213" (466), peptic ulcer (433), influenza (422), suicide and In hospital service.

' See also under United Kingdom (p. 231). The arrangements for the training of health and 2 International Classification of Diseases, 1965 Revision. nursing personnel were as follows: EUROPEAN REGION 229

Category DurationNumber of Number of Number of and admission of study schools studentsgraduates Environmental sanitation requirements (years) 1971/72 1972 In 1972, 98.2 % of the population of Scotland were Registered nurses: GCE, "O" level 1, living in houses connected to piped public water 3 subjects 3 41 2851 1 449 Enrolled nurses: supplies and 98 % to public sewers. Of the remainder lower general many live in isolated houses or clusters of houses education 2 54 2290 1 125 Midwives : connected to private water and sewerage systems.

qualified nurses only 1 or1 %* 28 1 126 1 054 Laboratory technicians : Government health expenditure GCE, "O" level, 4 subjects 3 4 Total government health expenditure for the fiscal Physiotherapists : GCE, "O" level, year 1971/72 amounted to £311.6 million, of which 5 subjects 3 3 351 62 Radiographers: £285.3 million were spent on current account and GCE, "O" level, £26.3 million on capital account. These figures 4 subjects 2 4 202 66 Occupational therapists: include health expenditure by the Scottish Office, the GCE, "O" level, ScottishDevelopmentDepartment,theScottish 5 subjects 3 2 211 43 Education Department and the Department of the 1 General Certificate of Education, ordinary level (secondary education, first phase). Environment, as well as expenditure by the Scottish * Depending on nursing qualifications. Home and Health Department. The per capita government expenditure was thus £59. The central govern- Immunization services ment level accounted for £252.2 million, other depart- The following immunization procedures were carried ments for £2.6 million and local health authorities for out in 1972: £56.8 million. The government expenditure on general Tetanus 204774 public health services included the following items: Poliomyelitis 172804 £17.9millionfor Diphtheria 167337 administration and government Whooping -cough 79281 personnel, £500 000 for immunization and vaccination Measles 69450 BCG 62688 activities, £5 4 million for laboratory services, £11.2 Smallpox 31686 million for environmental health services, and £1.6 Specialized units million for education and training of health personnel (excluding the costs of producing graduate doctors). In 1972, health services for mothers and children The government expenditure on hospitals included the were provided in 684 centres, which were attended by following outlays: £62.1 million for general hospitals 31 544 pregnant women, 56 993 infants and 96 856 and clinics, £46.4 million for teaching hospitals, £51.8 children aged 1 -5 years. Domiciliary visits were paid to million for specialized hospitals and £3.4 million for 26 142 pregnant women, to 82 505 infants and to other health establishments. 303 261 children aged 1 -5 years. Of all deliveries, 77 315 were conducted in hospital and 1579 at home. School NORTHERN IRELAND health services were available to the total school population at 2833 school health units. Under the Hospital Population and other statistics and Specialist Services of the National Health Services At the last census, taken in April 1971, the popula- in Scotland medical rehabilitation is provided to a tion of Northern Ireland was 1 527 593.Population varying extent through the general hospitals, some of estimates and some other vital statistics for the period which have grouped the various technical medical under review are given in the following table: services into a special department or centre. There are in addition four special rehabilitation units or hospitals 1969 1970 1971 1972 Home population . . . . 1512 500 1524 000 1536 257 1549 400 in Scotland.A committee was set up in 1968 to Number of live births . . 32 428 32 086 31 765 29 994 consider ways and means of achieving an active reha- Birth rate (per 1000 population) . 21.4 21.1 20.7 19.4 bilitation approach which will permeate the medical Number of deaths . . . 16 338 16 551 16 202 17 032 Death rate care system, and in the light of this to make recommen- (per 1000 population). 10.8 10.9 10.6 11.0 dations on the future organization and development of Natural Increase ( %) . . 1.06 1.02 1.01 0.74 Number of infant deaths . 790 734 722 616 rehabilitation services in Scotland, including the num- Infant mortality rate (per 1000 live births) . 24.0 23.0 23.0 21,0 bers of trained personnel required to provide these Number of deaths, services. In 1972, 19 600 new outpatients attended the 1 -4 years 104 96 102 111 Death rate, 1 -4 years (per 140 hospital rehabilitation departments.Psychiatric 1000 population at risk) 0.80 0.75 0.81 0.88 consultations were given at 103 psychiatric clinics, Number of maternal deaths 5 6 3 which recorded 26 200 new outpatients in 1972. In the Maternal mortality rate same year, 634 industrial establishments had first -aid (per 1000 live births) . 0.15 0.19 0.10 posts.Scotland had eight public health laboratories. 1 See also under United Kingdom (p. 231). 230 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Of the 17 032 deaths recorded in 1972, the main The arrangements for the training of medical and causes were: 1 chronic rheumatic heart disease, hyper- health personnel were as follows: tensive disease, ischaemic heart disease, other forms of Category DurationNumber of Number of Number of heart disease (6237), malignant neoplasms (2715), and admission of study schools studentsgraduates cerebrovascular disease (2528), bronchitis, emphysema requirements (years) (public) 1971/72 1972 Doctors : and asthma (890), pneumonia (820), accidents (696, 13 years general including344inmotor -vehicleaccidents),birth education 6 1 677 115 Dentists : injury, difficult labour and other anoxic and hypoxic 13 years general education 5 1 87 16 conditions, other causes of perinatal mortality (288), Pharmacists : congenital anomalies (205), diabetes mellitus (183), 13 years general education 4 1 65 13 influenza (107). Public health inspectors : The communicable diseases most frequently notified GCE, 1 "O" level, 3 subjects ; "A" level, in1972 were: measles (5842),infectious hepatitis 2 subjects 3 1 29 9 (1105), scarlet fever (410), dysentery, all forms (336), Physiotherapists (university diploma) : meningococcal infections (155), whooping -cough (106), GCE, "O" level, 5 typhoid and paratyphoid fevers (2). subjects ; "A" level, 1 subject 3 years 1 40 23 2 months Physiotherapists : Hospital services GCE, "O" level, 4 subjects; "A" level, At the end of 1971 Northern Ireland had altogether 1 subject 3 1 97 13 Dental auxiliaries 17 721 hospital beds giving a bed /population ratio of (operating) : 11.5 per 1000. These beds, to which 219 428 patients GCE, "O" level, 4 were admitted during the year, were distributed as subjects, and age 17 years 2 1 8 4 follows: State registered nurses : Category Number of beds GCE, "O" level, 5 subjects 3 21 2 391 656 General medicine 1 370 State enrolled nurses: General surgery 1 595 No particular Obstetrics and gynaecology 1 567 requirement 2 19 764 298 Paediatrics 436 Midwives: Infectious diseases 265 State nurse Tuberculosis and other chest diseases 526 registration, or Mental diseases 7106 enrolment 1 3 282 199 Ophthalmology 52 Laboratory technicians : Otorhinolaryngology 431 GCE, "O" level, 2 201 Geriatrics and chronic diseases 4 subjects 2 1 100 30 Orthopaedic surgery 508 Radiographers: Other medical and surgical specialities 1 664 GCE, "O" level (English, maths.) 2 3 80 38 Ambulatory medical care was provided in 1971 at Dental technicians: 49 hospital outpatient departments, which recorded No particular requirement 4 -5 1 30 4 nearly1.5million attendances, and at 29 health Dental surgery assistants: centres. RSA2stage I or equivalent 1 1 5 4 Medical and allied personnel and training facilities 1 General Certificate of Education, advanced level (completion of secondary education), and ordinary level (secondary education, first In 1971 Northern Ireland had 1901 doctors or one phase). doctor for 800 inhabitants.Other health personnel 2Royal Society of Arts. included: Immunization services Dentists 483 Dental technicians 17 The following immunization procedures were car- Pharmacists 659 Pharmacy technicians 13 ried out in 1972: Dispensing assistants 3 Veterinarians about 250 Poliomyelitis 38946 Midwives 1 028 Measles 20065 Assistant midwives 85 Diphtheria, whooping -cough and tetanus . 18377 Nurses 4 720 BCG 17159 Assistant nurses 3672 Diphtheria and tetanus 16387 Health inspectors 178 Tetanus 9832 Physiotherapists 230 Poliomyelitis, diphtheria, whooping -cough and Speech therapists 29 tetanus 8194 Orthoptists 14 Diphtheria, tetanus and poliomyelitis . . . 6546 Occupational therapists 49 Smallpox 1804 Chiropodists 42 Dietitians 29 Laboratory technicians 348 Specialized units X -ray technicians 238 Social workers 133 In 1971 Northern Ireland had 26 prenatal units and 1 International Classification of Diseases, 1965 Revision. 211 child health centres.Pregnant women made a EUROPEAN REGION 231 total of 28 654 attendances, and 28 772 children under lies with the Secretary of State for Wales. The Secre- 2 years of age and 5850 children aged 2 -5 years attend- tary of State for Social Services is responsible to ed these centres. During the same year 28 654 domici- Parliament and isadvised by the Central Health liary visits were paid to expectant mothers, 250 270 to Services Council and certain standing advisory com- infants and 289 993 to children aged 1 -5 years. Of all mittees dealing with special subjects. deliveries, 31 145 were conducted in hospitals and 247 The National HealthService,which covers a at home. All schoolchildren had access to the school comprehensive range of hospital, specialist, medical, health services. Examinations and inspections are dental, ophthalmic, pharmaceutical, medical appliance carried out on the school premises. Dental treatment and local authority services, is available to all residents was given in 94 dental clinics for schoolchildren and in the United Kingdom.It is administered in three 94 dental service units for expectant and nursing parts: the hospital and specialist services, the general mothers. Psychiatric consultations were given at practitioner services and the local health authority 63outpatientclinics,which recorded 6017 new services. These three parts are to be unified under the patients in 1971.The 16 public health laboratories National Health Service Reorganization Act, and the carried out 2.3 million examinations in 1971. new National Health Service was expected to start in April 1974.In 1971 responsibility for the personal social services passed to the new social services depart- Environmental sanitation ments of local authorities. The local authority health In 1971, 85 -90 % of the population of Northern services are as follows: care of mothers and young Ireland had piped water and were living in houses children, family planning, domiciliary midwifery ser- connected to sewers. vices, health visiting, home nursing, vaccination and immunization, prevention of illness, care and after- care, ambulance services and health centres. Government health expenditure There will be three levels of planning: central strategic planning and monitoring by the Department of Total general government expenditure for the fiscal year 1971/72 amounted to £559.1 million, of which Health and Social Security; regional planning and general supervision of operations by regional authori- £74.1 million were for health services. Current government health expenditure amounted to £67.6 million ties; and area planning and operational control by area and capital expenditure to £6.5 million.The per authorities. The boundaries of the area health autho- capita government expenditure on health was £48. rities will match those of the new local government areas. The health services for which the area health The central government accounted for £70.7 million authority is responsible will be based on communities and the local authorities for £3.4 million. The government expenditure on general public health services (districts), each with a district general hospital and included the following items: £600 000 for adminis- a population of between 200 000 and 500 000. Under tration and government personnel,£400 000 for the new National Health Service the status of general and dental practitioners, ophthalmic medical practi- environmental health services, and £22.6 million for tioners, opticians and pharmacists will remain unchan- occupational health services. The government expenditure on hospitals amounted to £50.5 million, of ged. There will be 14 regional health authorities based on which general hospitals and clinics, teaching hospitals the present hospital regions but, as each new region will and specialized hospitals accounted for £49.7 million. consist of a number of complete health areas, some adjustments to the present hospital regional boundaries will be necessary. UNITED KINGDOM Each regional health authority will have a medical school. As with the present Natio- nal Health Service, the Secretary of State will continue Organization of the public health services to have responsibility to Parliament for the reorganized Service as a whole and will determine national policy. England and Wales The new community health councils will represent the Under the National Health Service Act, 1946 it is the views of the consumer. There will be one for each of responsibility of the Secretary of State for Social the area health districts. The cost of the new National Services to promote the establishment of a compre- Health Service will continue to be financed mainly hensive health service.There is a separate Act for from taxation and met from monies voted by Parlia- Scotland and also one for Northern Ireland.The ment. health services in these countries are run on very England and Wales are divided into 14 large hospital similar lines to the one in England and 'Wales.Since regions, each of which is linked to a university with 1969 the responsibility for the health service in Wales one or more medical schools and is, as far as possible, 232 FIFTH REPORT ON THE WORLD HEALTH SITUATION a natural "catchment area" within which patients tually eliminated, while the incidence of tuberculosis needing . special treatment are usually referred from in all its forms has dropped steeply.Mortality rates small local hospitals to larger centres. Except for the from the acute specific infections of childhood, in teaching hospitals of their area, the regional hospital particular measles and whooping -cough, have also boards are responsible, under the general guidance of fallen greatly.The fall in deaths from tuberculosis the Department, for planning and coordinating the does not accurately demonstrate the fall in incidence development of the hospital and specialist services of of the disease, since many of those dying today are their regions and for the general supervision of their elderly people originally infected many years ago. administration. Under the general guidance and super- Although tuberculosis is still a substantial cause of vision of the regional boards, the day -to -day running absence from work, the number of work days lost from of the hospitals is entrusted to hospital management this cause in Great Britain between 1951 and 1969/70 committees appointed by and responsible to the boards. dropped from 27 million to 3.6 million.Influenza At present there are about 290 management com- remained potentially the greatest killer among the mittees. acute infections; 4000 to 5000 deaths are attributable One of the major changes in the organization of to this cause in every two or three years, while another general practice is the continuing trend away from 10 000 to 20 000 deaths are attributed to an associated single- handed practices and towards practices in part- rise in incidence of pneumonia or bronchitis.Bron- nerships or groups. The percentage of doctors prac- chitis (excluding acute bronchitis) is the leading cause tising single- handed in England and Wales was 22.7 of absence from work, particularly among men, and in 1968 and 20.1 % in 1971; that of group practices of was responsible for the loss of over 33 million work four was 14.4 % in 1968 and 17.0 % in 1971. days among men in 1969/70 in Great Britain.In 1954 the fall in the incidence of gonorrhoea and Scotland syphilis had levelled off; since then there has been an The Scottish National Health Service is provided increase in the incidence of gonorrhoea but not of under separate legislation which, however, is broadly syphilis. Gonorrhoea is still less prevalent in Scotland similar to that for England and Wales, subject to than in England and Wales. certain differences of administration. The Secretary of State for Scotland is responsible to Parliament for the Chronic and degenerative diseases Service and is advised by the Scottish Health Services Council and other advisory bodies.There are five Accompanying the steady decline in mortality from regional hospital boards which cover all hospitals, and communicable diseases there has been an increase in there are similar institutions for the general medical reported sickness and death from degenerative diseases. and local authority services. A large part of this increase can be attributed to aging of the population. The effects of degenerative condi- Northern Ireland tions on morbidity as opposed to mortality are shown by the marked increase in hospital admissions for The health services delivery system in Northern arteriosclerotic heart disease.Some forms of cancer Ireland is similar to that in the remainder of the and cardiovascular disease show an incidence which United Kingdom. In 1972 new legislation was passed is higher in Scotland than in most other countries. for the provision of integrated services, thus abolishing This applies particularly to cancer of the lung and the distinction between services provided and admi- atherosclerosis. The increase in deaths from cancer in nistered by the hospital authority, the general health England and Wales from 15 % of all deaths in 1947 services board and local authorities. Under the new act to over 20 % in 1971 is mainly due to lung cancer. health and social services boards will be established. Acute coronary care units are being encouraged, and Each of the four boards will provide comprehensive in the near future every district general hospital will health services on behalf of the Ministry of Health and have such a unit.Investigations and trials are also Social Services. In contrast to the rest of the United being conducted at six centres throughout the United Kingdom a broad range of personal social services is Kingdom to study the mode of early conveyance of the being brought under the same administrative frame- affected patients to the nearest unit. The incidence of work as the health services. rheumatic diseases in the United Kingdom is known to be high. More prominence will be given to the service Communicable disease control needs of patients suffering from these conditions and to rehabilitation in general. Both incidence and mortality from a number of In England and Wales 40 % of all deaths of men infectious conditions have fallen over the last 20 -30 between the ages of 15 and 24 are due to road accidents. years.Diphtheria and poliomyelitis have been vir- Injury from this cause is also a common cause of EUROPEAN REGION 233

absence from work among men and of admission to keeps the whole field of medical research under review hospital. Deaths from accidental poisoning have and gives priority in its programme of work to special greatly increased in the last 10 years. needs in the research field which cannot be met by other organizations and to new and promising lines National health planning of investigation, irrespective of the sponsor.Under the new arrangements introduced in 1972, with the The National Health Service Reorganization Act, publication of the Government White Paper "A 1973 provides for collaboration between the new area Framework for Government Research and Develop- health authorities and the personal social services ment" there will be an increased emphasis on work on departments of their matching local authorities to commission from government departments to meet secure that the needs of each area for health and social governmental research needs. care should be assessed and met through the coordinat- The Council's arrangements for providing support ed planning of services; it also provides for the establish- for research fall under four main headings: ment of a statutory joint consultative committee. A (1)the work undertaken by its own scientific staff planning system for the reorganized National Health in the National Institute for Medical Research, the Service is being developed by the Department of Clinical Research Centre and inthe Council's Health and Social Security and is expected to come research units, which are generally located within into operation in 1975. universities; The personal social services departments of local authorities have prepared development plans for the (2)long -term grants in support of specific research period 1973 -1983. The collective local authority view programmes in university departments; provided by the plans will be used to formulate (3)short -termgrantstoresearchworkersin national strategies and to determine an appropriate universities and elsewhere; rate of development. The planning effort in the reor- (4)fellowships and scholarships. ganized National Health Service and in local authority personal social services will be backed by a greatly During the years 1969 -1973, 10 new units were set strengthenedadministrativeorganizationinthe up. They cover research into different aspects of phar- Department of Health and Social Security. A plan- macology, epidemiology, cell biology, disablement, ning system is being developed for the Department to leukaemia and the behavioural sciences.During the coordinate the planning activities of divisions and to same period approximately 110 long -term grants were ensure the compatibility of plans with resources. awarded covering many of the main fields of bio- Much of the planning undertaken within the frame- medical research, about 40 fellowships, more than work of the three planning systems is based on previous 800 scholarships and approximately 2500 project planning.The 10 -year capital programme for hos- grants. pital building will continue to be carried forward The Council receives its funds primarily by way of annually.Increasing attention will be given to man- an annual parliamentary grant -in -aid, which in 1972/ power planning.Initial efforts have concentrated on 73 amounted to about £28 million. A substantial pro- medical manpower, and a central manpower committee portion of its income in the future will come from was established in 1972 to advise on the planning and commissions from government departments. The monitoring of hospital medical and dental staffing. Council also receives grants from other public and Targets have been set for the number of new posts to be semipublic bodies for the promotion of research on established annually in each region up to 1975/76, particular subjects and is able to administer private with the most rapid growth in the regions which at funds or properties entrusted to it by grant, gift or present have the lowest rates of staffing. bequest. The healthdepartmentsinitiateandsupport Medical and public health research research in aid of their departmental policies and administrative responsibilities.As part of the new Medical research in the United Kingdom is carried arrangements arising from the publication of the out through the agency of the Medical Research Coun- above -mentioned White Paper, a Chief Scientist has cil, the universities and the National Health Service, been appointed with a small team of advisers, whose all of which are supported from government funds, main task is to strengthen the collaboration between and through a number of voluntary organizations. The all concerned in the formulation, management and main function of the Medical Research Council is to implementation of the Department's research and assistthe balanced development of medical and development programme. relevant biological research in the country in partner- The types of investigation which the departments ship with other agencies concerned.To this end it promote cover a wide spectrum and can be grouped in 234 FIFTH REPORT ON THE WORLD HEALTH SITUATION

sixbroad areas:clinicalresearch,publichealth ters funds of the former voluntary hospitals. In 1970 a research, the national health and welfare services Scottish advisory committee on computers in the health research, equipment research and development, build- service was set up to advise the Secretary of State. ing research and development, and special develop- The bulk of the medical and operational research is ments. carried out in university departments attached to In Scotland the Home and Health Department is teaching hospitals or the National Health Service. concerned with the promotion and stimulation of Governmental expenditure on medical research in medical, operational and equipment research by indi- the United Kingdom greatly increased during the viduals,healthserviceauthorities and university period under review, from an estimated total of departments. The Department is also concerned with £43 176 000 in 1969/70 to £55 986000 in 1971/72. These the administrative arrangements for the support of figures include the expenditure of the Medical Research computer projects and computer development in the Council, the Ministry of Overseas Development, the national health service in Scotland. During the period Health Departments, and the estimated expenditure of under review, the Secretary of State for Scotland was the Ministry of Defence and the Office of Population advised on medical research by an advisory committee Censuses and Surveys, together with the approximate whose membership represented the main medical amount devoted to medical research out of the general specialties.This committee also advised the Scottish grants made to the universities on the advice of the Hospital Endowment Research Trust which adminis- University Grants Commission.

YUGOSLAVIA

Population and other statistics inpatients were admitted during the year, were distributed as follows : At the last census, taken in March 1971, the population of Yugoslavia was 20 504 516. Population Category and number Number of beds General hospitals 140 77 513 estimates and some other vital statistics for the period Medical centres 214 7253 under review are given in the following table : Maternity hospitals 3 564 Paediatric hospitals 10 2 226 Infectious diseases hospital 1 358 1969 1970 1971 1972 Tuberculosis hospitals 34 9 253 Mean population . . 2020900020371 0002057200020 772 000 Psychiatric hospitals 18 10 958 Number of live births . . 382 764 363 278 375 762 380 743 Orthopaedic hospitals 10 2 630 Birth rate Eye clinics 2 443 (per 1000 population) . 18.9 17.8 18.3 18.3 Hospital for dermatology and venereal Number of deaths . . . 188695 181 842 179113 190578 diseases 1 106 Death rate Hospital for rheumatic diseases . . 1 370 (per 1000 population) . 9.3 8.9 8.7 9.2 Hospital for allergic diseases 1 376 Natural Increase (%) . . 0.96 0.89 0.96 0.91 Rehabilitation centres 33 6 273 Number of Infant deaths . 21 928 20149 18 605 16 911 Oncology hospitals 5 719 Infant mortality rate Hospital for occupational diseases . 1 94 (per 1000 live births) . 57.3 55.5 49.5 44.4 Hospital for traumatology 1 171 Number of deaths, Spas and climatic resorts 17 2 799 1 -4 years 3 643 3 548 3 077 2 501 Death rate, 1 -4 years (per Ambulatory medical and preventive health care was 1000 population at risk) 2.5 2.5 2.1 1.7 Number of maternal available in 1972 at 3789 establishments for general deaths 283 207 185 141 Maternal mortality rate medicine, which recorded over 45 million attendances; (per 1000 live births) . 0.7 0.6 0.5 0.4 at 690 specialized establishments, which recorded over 17 million attendances; at 372 multipurpose home The communicable diseases most frequently notified visiting units, which recorded nearly 3.2 million visits; in 1972 were: dysentery, all forms (32 622), measles at 34 oncological X -ray units; at 124 emergency units; (22 288), scarlet fever (9988), whooping -cough (7932), and in 391 hygiene and epidemiology services. meningococcal infections (1788), typhoid and paratyphoid fevers (1435), smallpox (175), diphtheria (57), Medical and allied personnel and training facilities poliomyelitis (13). In 1972 Yugoslavia had 26 927 doctors, or one Hospital services doctor for 860 inhabitants.Other health personnel included : In 1972 there were altogether 122 106 beds in Dentists 1 632 government hospitals and inpatient care establish- Pharmacists 3 912 ments. The bed /population ratio was thus 5.9 per 1000 Pharmaceutical assistants 3 591 Veterinarians 4 069 inhabitants. These 122 106 beds, to which 2 114 641 Veterinary assistants 2 647 EUROPEAN REGION 235

Midwives 3821 Specialized units Assistant midwives 1630 Nurses 34877 Paediatric nurses 5436 In 1972 maternal and child health care was based on Assistant nurses 18093 Assistant sanitarians 2266 1325 maternal centres and 1328 child health centres. Physiotherapists 1480 Their services were provided during the year to 316 241 Occupational therapists 155 Laboratory technicians 6006 pregnant women and 347 615 infants.School health X -ray technicians 1286 services were provided at 628 school health centres to Other auxiliary medical technicians 3874 over 3 million schoolchildren, representing 44 % of the The arrangements for the training of medical and total school population. Dental treatment was given at health personnel were as follows: 2554 dental health units.Medical rehabilitation ser- Category DurationNumber of Number of Number of vices were provided at 212 rehabilitation outpatient and admission of study schools studentsgraduates centres, which recorded 325 854 patients during the requirements (years) (public) 1971/72 1972 year. Doctors : There were also 1081 establishments for the secondary education . 5 9 11 579 1 569 health care of workers, 438 tuberculosis clinics, 158 Dentists : secondary education 5 7 4 220 473 skin and venereal diseases clinics and 1682 public Pharmacists : health laboratories. secondary education 4 3 1849 267 Veterinarians: secondary education . 5 4 2 292 235 Nurses (senior level): Assistance from WHO secondary education . 2 4 2 508 552 Nurses (junior level) . . In 1972 WHO's assistance to Yugoslavia included primary education . . 4 28 6 321 1 422 Paediatric nurses: the following projects: primary education . 4 1 831 180 Midwives : primary education . . 4 8 1 310 321 Community water supply, wastes disposal and pollu- Physiotherapists (senior tion control, Kosovo (1972- ) UNDP: to develop a level) : secondary education . 2 2 283 108 programme for water pollution control, community Physiotherapists (junior water supply and wastes disposal in Kosovo Province. level): primary education . . 4 1 113 27 X -ray technicians: Public health administration (1962- ) UNDP: to secondary education . 2 1 31 1 provide training facilities and equipment for the federal Occupational therapists: secondary education . 2 2 91 27 and republic institutes of health. Sanitary technicians : secondary education. 2 2 249 76 Regionalization of health services and health insurance Saniped and laboratory in Serbia (1972- ): to establish a functional organi- technicians : primary education 4 1 392 120 zation of health services, backed by a suitable health Pharmaceutical technicians : insurance organization. primary education 4 2 677 149 Dental technicians : Chronic and degenerative diseases (1969 -1972) UNDP: primary education 4 3 1 061 254 to provide training facilities and equipment for the Dental assistants : primary education 4 1 188 80 chronic and degenerative disease centres to be set up in Students in polyvalent certain republics. schools : primary education . 4 38 19 876 4 546 Government health expenditure Immunization services In 1972 the following immunization procedures were In 1971 total government health expenditure on carried out: health activities amounted to 922 million dinars, of which about 65 % was contributed by the workers' Poliomyelitis 1736292 Smallpox 1503401 health insurance, about 10 % by the farmers' health Diphtheria, whooping -cough and tetanus 719783 Diphtheria and tetanus 677344 insurance, about 5 % by the government budget, and BCO 648253 the remainder by the citizens through a cost -sharing Measles 381099 Tetanus 271552 scheme, by work organizations, etc.

GIBRALTAR Population and other statistics 1969 1970 1971 1972

Mean population . . 28 537 29 320 28 694 29 254 At the last census, taken in October 1970, the civilian Number of live births . . 557 577 594 581 Birth rate population of Gibraltar was 26 833. Population (per 1000 population) . 19.52 19.68 20.70 19.86 estimates and some other vital statistics for the period Number of deaths . . . 246 215 238 244 Death rate under review are given in the following table: (per 1000 population). 8.62 7.33 8.29 8.34 236 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 Gibraltar has one nursing school attached to the Natural increase ( %) . . 1.09 1.24 1.24 1.15 Number of infant deaths . 15 5 15 10 St Bernard's hospital which organizes courses of three Infant mortality rate to five years for basic nursing and auxiliary nursing (per 1000 live births) 26.9 8.67 25.25 17.21 Number of deaths. training. During the school year 1971/72 these courses 1-4 years 4 2 0 0 were attended by 91 students, of whom 28 graduated Number of maternal deaths o o o o in 1972. Training for other health personnel is provided in the United Kingdom. Of the 244 deaths recorded in 1972, the main causes were: 1 chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease and other forms of Immunization services heartdisease(76),cerebrovasculardisease(43), The following immunization procedures were carried malignant neoplasms (38), pneumonia (16), nephritis out in 1971:

and nephrosis (9), congenital anomalies, birth injury, Cholera 6 216 difficult labour and other anoxic and hypoxic condi- Poliomyelitis 2 047 Smallpox 1 501 tions, other causes of perinatal mortality (7), bronchitis, Diphtheria, whooping -cough and tetanus 1 129 emphysema and asthma (6). Tetanus 702 Diphtheria and tetanus 531 Yellow fever 56 Organization of the public health services Typhoid and paratyphoid fevers 43 Diphtheria 2 The health services are the responsibility of the Minister for Medical and Health Services, who is Specialized units advised by a board of management for medical and In 1972 prenatal care was provided at the outpatient health services. The Director of Medical and Health department of the St Bernard's hospital where 400 Services is responsible for the overall organization and pregnant women attended during the year. A child administration of the health services.His deputy is welfare centre with a paediatrician and a team of also hospital administrator. health visitors looks after the health and medical needs of all children up to the age of 5, at which time they Hospital services come under the responsibility of the school health In 1971 Gibraltar had three hospitals with a total service. In 1972 this centre was attended by 327 bed complement of 252, equivalent to 9.3 beds per infants and 1022 children aged 1 -5 years. Domiciliary 1000 population. These beds, to which 3531 patients care was given to 3687 children aged 1 -5 years and were admitted during the year, were distributed as 906 visits were paid to infants. In 1972, 358 deliveries follows: 182 beds in one government general hospital were institutional.The school health service was 10 in one government infectious diseases hospital, and attended by 4420 children, 89 % of the total school 60 in one government psychiatric hospital. population.Dental care was provided at one dental Outpatient facilities were available in 1972 at one unit for adults, where 2080 persons were treated in hospital outpatient department which recorded 30 765 1972, and at one dental unit for schoolchildren, where attendances and at one dispensary which recorded 1781 children received treatment.Psychiatric out- 3821 attendances. patient consultations were given at two units, which recorded 198 new patients during 1972. The hospital Medical and allied personnel and training facilities rehabilitation outpatient department was attended by 558 patients. Gibraltar has one public health labora- In 1971 Gibraltar had 19 doctors of whom 17 were in tory where over 100 000 examinations were carried out government service. The doctor /population ratio was in 1972. thus one to 1590.Other health personnel included: Dentists 4 Environmental sanitation Dental laboratory technicians 2 Pharmacists 4 Pharmaceutical assistants 13 In 1972, 90 % of Gibraltar's population were served Midwives 5 with piped water, whereas the remaining 10 % had Nurses 55 Assistant nurses 131 water from public fountains; 96 % of the inhabitants Sanitary engineers 3 were living in houses connected to sewers. Sanitarians 7 Assistant health Inspectors 2 Physiotherapists 3 Government health expenditure Laboratory technicians 6 Assistant laboratory technicians 3 X -ray technicians 3 In the fiscal year 1971/72 total government health Medical records officers 3 expenditure amounted to £550 444, which represents 1 International Classification of Diseases, 1965 Revision. a per capita health expenditure of £19. EASTERN MEDITERRANEAN REGION

BAHRAIN

Population and other statistics Cardiology technicians 2 Health educator 1 Health statisticians 3 At the last census, taken in April 1971, the popu- Vaccinators 5 lation of Bahrain was 216 078.The following are population estimates for the period under review: Bahrain has a school for the training of nurses (three -year course) and practical nurses (18 -month Year Population course). 1969 197 575 In addition, a two -year course is organized 1970 215 000 for the training of assistant pharmacists. 1971 216 078 1972 222 000 In 1972 the registered crude birth rate was 32.8 per Immunization services 1000 population and the registered death rate 3.3 per The following immunization procedures were car- 1000. ried out in 1972:

Cholera 311722 Hospital services Smallpox 107676 Poliomyelitis 53205 In 1972 Bahrain had 11 hospitals with 961 beds, of Diphtheria, whooping -cough and tetanus 18554 Tetanus 18242 which 845 beds were in nine government- maintained BCG 5155

Diphtheria and tetanus 1 275 establishments. The bed /population ratio was 4.3 per Typhoid and paratyphoid fevers 887 1000. These beds were distributed as follows: Yellow fever 400 Category and number Number of beds General hospitals 4 494 Specialized units Health centres 3 34 Maternity hospital 1 124 In 1972 maternal and child health care was based Tuberculosis hospital 1 80 Psychiatric hospital 1 184 on six prenatal and six child health centres, which Geriatric clinic 1 45 were attended by 6135 pregnant women and 6114 Outpatient facilities were available at the hospital children aged 0 -5 years.Domiciliary care was given outpatient departments; at three health centres pro- to 14 082 children.In 1972, 4774 deliveries were viding inpatient facilities and staffed by three to 15 institutional.School health services were provided at doctors; at five small health centres staffed by one or four centres, which supervised the total school popu- two doctors and serving a population of about 10 000 lation. There were three dental health units for adults inhabitants; at five dispensaries staffed by a doctor and three for schoolchildren. During the year, dental and serving about 500 to 1000 inhabitants; and at treatment was given to 7209 schoolchildren and to four outpatientclinicsoperated by the Bahrain 16 340 adults. The four hospital rehabilitation centres Petroleum Company, the aluminium factory,the recorded 20 765 new outpatients in 1972.Psychiatric American mission hospital, and the Defence Force. outpatient consultations were given at two clinics to 528 new patients.Bahrain also had one tuberculosis Medical and allied personnel and training facilities and one leprosy outpatient clinic and a public health laboratory. In 1971 Bahrain had 116 doctors, of whom 102 were in government service.The doctor /population ratio Environmental sanitation was one per 1900. Other government health personnel included: In 1971, of the 64 communities in Bahrain, 61 had

Dentists 5 piped water systems, which served 99.6 % of their Pharmacists 4 inhabitants, the remainder having access to water Pharmaceutical assistants 56 Veterinarians 4 from public fountains. Three communities had a Veterinary assistants 3 sewerage system, serving 47 % of the inhabitants. Midwives 90 Assistant midwives 50 Nurses 517 Assistant nurses 259 Government health expenditure Sanitarians 2 Assistant sanitarians 26 In 1971 total government current expenditure was Physiotherapists 8 Laboratory technicians 19 20 708 000 Bahrain dinars, of which 3 030 628 were Assistant laboratory technicians 30 spent on health services. The per capita government X -ray technicians 8 Assistant X -ray technicians 16 expenditure on health was 14 Bahrain dinars. - 239 - 240 FIFTH REPORT ON THE WORLD HEALTH SITUATION

CYPRUS

Population and other statistics Hospital services At the last census, taken in December 1960, the In 1972 Cyprus had 132 hospitals and other estab- population of Cyprus was 577 615. Population lishments for inpatient care providing a total of 3488 estimates and some other vital statistics for the period beds, of which 2003 were in 27 government hospitals. under review are given in the following table : The bed /population ratio was 5.5 per 1000 inhabitants.

1969 1970 1971 1972 The 3488 beds were distributed as follows :

Mean population . . 611 600 616 500 622 700 630 000

Number of live births . . 11 920 11 810 11 640 11 620 Category and number Number of beds Birth rate General hospitals 80 1 783 (per 1000 population) . 19.5 19.2 18.7 18.4 Rural hospitals 16 117 Number of deaths . . . 5 950 6 000 5 980 6 040 Maternity clinics 28 548 Death rate Infectious diseases and leprosy hos- (per 1000 population) . 9.1 9.7 9.6 9.6 pitals 2 39 Natural increase (%) 1.04 0.95 0.91 0.88 Tuberculosis hospital 1 115 Number of infant deaths 360 347 339 355 Psychiatric hospitals 4 879 Infant mortality rate Other hospital establishment 1 7 (per 1000 live births) . 30.2 29.4 29.0 28.8 Number of maternal deaths 0 1 1 1 Outpatient care was available in 1972 at six hospital Maternal mortality rate outpatient departments, at 16 health centres, which (per 1000 live births) . 0 0.1 0.1 0.1 also had some hospitalization facilities, and at one Among the deaths reported in 1972, the main causes dispensary. were :1 symptoms and ill- defined conditions (895), chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease and other forms of heart Medical and allied personnel and training facilities disease (222), accidents (191, including 138 in motor - In 1972 Cyprus had 562 doctors, of whom 155 were vehicle accidents), malignant neoplasms (157), cerebro- in government service.The doctor /population ratio vasculardisease(92),pneumonia(66),diabetes was thus one to 1120. Other health personnel included: mellitus (41). The communicable diseases most frequently notified Dentists 185 Dental hygienist 1 in 1972 were: tuberculosis, all forms, new cases (104), Dental mechanics 12 Pharmacists 210 meningococcal infections (9), typhoid and paratyphoid Veterinarians 36 fevers (9), measles (8), scarlet fever (4), leprosy (4), Veterinary assistants 49 Midwives 99' bacillary dysentery (4), influenza (3), malaria, imported Nurses 351* cases (2). Assistant nurses 634* On- the -job trained nurses 395* Nursing aides 140' Health inspectors 94* Organization of the public health services Sanitary labourers 358' Physiotherapists 17* Medical laboratory technologists 37* The health administration in Cyprus is centralized X -ray technicians 52* at the Ministry of Health.The Minister of Health, Medical physicists 2* assisted by the Director -General, is responsible for * Data available from the Greek community only, which represented the health policy and the overall organization of the approximately 80% of the total population of Cyprus. public health services.Executive responsibility lies with the medical department, which is in charge of Cyprus has no medical school. Apart from nursing the delivery of medical care and of the preventive personnel, professional health workers aretrained and social health services. abroad. The arrangements for the training of nursing Although there is yet no national sickness insurance and midwifery personnel and sanitarians are as follows : scheme covering all citizens, the public health admin- Category DurationNumber of Number of Number of istration provides medical and health care free of and admission of study schools studentsgraduates charge, or at nominal fees, to all citizens of the lower requirements (years) 1971/72 1972 Nurses (basic nursing and middle income groups.Civil servants, including course) : 12 years' general edu- members of the armed forces and their dependants, cation 3 2 73 15 are also entitled to free medical and health care. Auxiliary nursing personnel : Some industrial undertakings and trade unions also 10 years' general edu- provide medical care to their employees. cation 2 4 186 71 Midwives(basic training): 10 years' general edu- 1 International Classification of Diseases, 1965 Revision. cation 2 1 31 14 EASTERN MEDITERRANEAN REGION 241

Category DurationNumber of Number of Number of a few education authorities have set up such a service and admission of study schools studentsgraduates requirements (years) 1971/72 1972 for their schools. Midwives(postgraduate In 1972 Cyprus had 43 public dental clinics and training): must be state register- three mobile dental units, which paid routine visits to ed nurses 1 1 18 12 schools in the rural areas.Dental treatment was Sanitarians : 12 years' general edu- given to 12 643 schoolchildren and to 28 384 adults. cation 2 1 26 - In the same year the two hospital rehabilitation outpatient departments recorded 3320 new patients. Communicable disease control and Psychiatric consultations were given at two public immunization services clinics to 1950 new patients.Only two industrial There are no "quarantinable" diseases in Cyprus. establishments offer full medical and health services. Malaria has been eradicated. Thetuberculosis Several other establishments provide only ambulatory prevalence is about 16 per 100 000. Venereal diseases medical care. Under the "Children and Young are on the increase. Hydatid disease, which has been a Persons Employment Law" every person under 18 serious health problem in Cyprus, is steadily declining. years has to undergo pre -employment and thereafter The higher standard of living of the population and annualmedicalexamination. Routineperiodic the improvement in environmental sanitation have examinations are compulsory for all workers exposed contributed to the control of most infectious diseases. to silica dust or to toxic substances such as lead. Other The following immunization procedures were car- specialized units included a public leprosy clinic, a ried out in 1972: public tuberculosis clinic, which was attended by

Smallpox 100963 2059 new patients in 1972, five chest clinics, which Poliomyelitis 36645 were attended by 8627 patients, and two miniature Diphtheria, whooping -cough and tetanus 31954 Tetanus 12247 radiography units, which were attended by 9511 Cholera 4573 BCG 92 patients. The three public health laboratories carried out over 315 000 examinations. Chronic and degenerative diseases Environmental sanitation Cyprus is faced with a growing prevalence of chronic and degenerative diseases (cardiovascular diseases, All urban and rural areas are supplied with safe cancer, mental disorders, and diabetes) and accidents, piped water for domestic purposes. In the rural areas which are important causes of sickness and death. only 88.7 % of the population was served with piped The programme for the prevention of these hazards water; the remaining 11.3 % obtained water from public is at present limited to health education of the popula- fountains.Public sewerage and sewage treatment tion. plants are being built in the towns of Nicosia and Famagusta. In the absence of these facilities individual Specialized units methods of sewage disposal are practised -i.e., the The expansion of maternal and child health services use of septic tanks and soak -away pit systems or the is the aim of one of the long -term programmes of the dry conservancy system. public health administration.In 1972 maternal and child health care was given at 174 public centres to Major public health problems 6964 pregnant women and 17 995 infants and children The main public health problem in Cyprusis up to 5 years.In addition to these centres, there are considered to be thalassaemia.It is estimated that child health centres maintained by the local authorities. about 14 % of the population carry the trait of this In the same year 5797 domiciliary visits were paid to hereditary disease and about one child out of 200 is pregnant women and 34 131 to infants and children born with the disease.Special units have been up to 5 years. In 1972 all deliveries were attended by established to promote preventive measures and for a doctor or a qualified midwife. A voluntary family the care of patients. planning association has been established recently for the purpose of expanding family planning activities Social and economic developments of significance in rural areas.Birth control methods are widely for the health situation used in the urban areas.However, family planning has not yet been established as a responsibility of the The period under review was marked by significant public health authorities within the general public developments in agriculture, industry, commerce, and health services. Because of staff shortages Cyprus has transport. The contribution of theagricultural not yetestablisheda coordinatedschool health sector to the national economy reached about 20 %, service covering the whole school population.Only whereas the contribution of medium -size industry 242 FIFTH REPORT ON THE WORLD HEALTH SITUATION was about 12 %. Investment in science and technology, (5) To intensify the health education of the public although on a limited scale, has been directed mainly with emphasis on such special aspects as smoking and towards educational and agricultural research.As protection of the human environment. population growth has been maintained at a low (6) Tostrengthenthepharmaceuticalcontrol level during thelast few years,family planning services in order to establish strict control over the activities have not been integrated into the national quality and price of pharmaceutical preparations. health services. However, a voluntary family planning association has been established recently. The literacy rate of the population aged 15 years and over is Assistance from WHO approximately 95 %. In 1972 WHO's assistance to Cyprus included the following projects: National health planning Sewage disposal (1971- ): to study environmental The year 1971 marked the end of the second five - health conditions, especially as regards waste -water year plan. A third five -year health development plan and solid wastes disposal. has been initiated for the period 1972 -1976. The main Public health laboratory (1970- objectives of this plan, which is aimed at strengthening ): to establish a cancer register and raise the standard of performance the public health services, are : of the histopathology department. (1) To improve the competence of health personnel at all levels, with particular emphasis on the postbasic National health services (1972): a consultant assisted and postgraduate training of doctors, nurses and in exploring the possibilities of introducing a national technicians. For this purpose, it is proposed to make health service and in reviewing the social, financial, use of long -term fellowship programmes established and technical implications. with national and international financial assistance. Pharmaceutical quality control (1967 -1969; New specialized services have already been set up 1971- ): to develop the laboratory for the quality including a neurosurgical unit, a thoracic surgery control of pharmaceutical preparations, and to provide unit, a cobalt unit, intensive care units, and haemo- the national pharmaceutical services with an efficient dialysis units. control system. (2) To improve themedical equipment of all basic hospitals. (3) To increase accommodation in all basic and Government health expenditure psychiatric hospitals. (New hospitals are planned for In1972totalgeneral government expenditure Nicosia and Kyrenia and for two selected rural areas. amounted to 55 493 000 Cyprus pounds, of which Substantial extensions to the district hospitals are £2 789 000 were spent on health services at the minis- proposed, and increased accommodation is expected terial level, including £2 568 000 on current account to become available in private hospitals.) and £220 684 on capital account.The Ministry of (4) To expand the school dental services to cover Health accounted for £2 682 000 and other ministries the whole school population. for £106 930.

DEMOCRATIC YEMEN

Population and other statistics cough (5247),measles(1114),infectioushepatitis (1089), gonorrhoea (933), cholera (908), pulmonary The estimated mid -year population of Democratic tuberculosis, new cases (853), typhoid fever (302), Yemen for the period under review was as follows : syphilis, new cases (137), schistosomiasis (87), meningococcal infections (69), poliomyelitis (31), leprosy (9), Year Population diphtheria (5). 1969 1398096 1970 1435940 1971 1474705 1972 1 514522 Organization of the public health services The communicable diseases most frequently recorded The Ministry of Health is responsible for providing in inpatient and outpatient establishments in 1972 the country's preventive and curative health services. were:amoebic andbacillarydysentery(14 900), It is headed by the Minister of Health, who is assisted influenza (11 902), malaria, new cases (5457) whooping- by an executive officer (the Permanent Secretary of EASTERN MEDITERRANEAN REGION 243

Health) and by a professional officer (the Director of Communicable disease control HealthServices). The following divisions come under the Director of Health Services: preventive Malaria iswidespread, existing throughout the medicine,curativemedicine,and administration. entire country.However, no detailed malariometric The country is divided into six governorates and 24 data are available to determine the prevalence of the districts. disease. The lack of trained personnel is one of the main difficulties in carrying out a malaria control programme. Although tuberculosis prevalence surveys Hospital services have not been conducted, the known high infection The Al- Joumhouria hospital in Aden, which has rates and the results of clinical examinations strongly 495 beds, is the largest referral hospital in the country. indicate that tuberculosis represents a serious public In 1968 other inpatient facilities in the first governorate health problem. Both urinary and intestinal schistosomiasis exist in the country.Trachoma ishighly included a private hospital with 130 beds.Whereas the sixth governorate had no hospital establishment, prevalent in the north -east. theotherfourgovernorateshadaltogether14 Specialized units government hospitals with a total bed capacity of 519. Additional inpatient facilities were provided In 1972 maternal and child health care was provided in 1972 at one mental hospital, six maternity clinics, at 33 centres, of which 21 had hospitalization facilities. one sickness hostel and one old people's home. The Other specialized outpatient establishments included number of hospital beds available in 1971 was esti- a school health service unit, a dental clinic, a psychi- mated to be 1733. atric outpatient clinic, two tuberculosis centres and a The outpatient establishmentsexistingin1972 leprosy outpatient clinic. included four health centres, five dispensaries, and 154 health units. National health planning The first national development plan for the years Medical and allied personnel and training facilities 1971 -1974 gave priority to economic development. It also gave particular emphasis to rural development In 1968 Democratic Yemen had 42 doctors, of and to the extension of community services, mainly whom 29 were working in the first governorate. centred in the first gevernorate, and to the rural Other health personnel included: areas of the other five governorates of the country. The health sector of the national development plan Dentists 5 Dental technicians 18 and the national health plan (1971 -1976) give priority Pharmacists 2 to the development of health services outside the Dispensers 21 Midwives 14 first governorate, particularly as regards development Registered nurses 28 and strengthening of the health infrastructure, com- Graduate nurses 23 Auxiliary nurses in training 637 municable disease control, development of maternal and child health care, training of health personnel, The Institute of Health Manpower Development and provision of safe water. The number of hospital in Aden provides training facilities for the following beds is to be increased by 30 %.Ten new health health personnel: centres will be built and 45 health units will be provided.Self -help building programmes by the com- Category DurationNumber of Number of and admission of study studentsgraduates munity will be encouraged. A number of rural requirements (years) 1971/72 1972 hospitals will be renovated and upgraded, and a Medical assistants : 9 years' general education . 3 46 leprosarium will be established in the first governorate. Dispensers: The budgetary allocation to the health sector in the 6 years' general education . 1''4 24 national development plan amounts to 751 000 dinars. Pharmacy technicians:

9 years' general education . 3 32 Laboratory assistants: Assistance from WHO 8 years' general education . 1 % 9 Sanitarians: In 1972 WHO's assistance to Democratic Yemen 9 years' general education . 3 11 11 included the following projects : Nurses: 9 years' general education . 3 29 27 Tuberculosiscontrol(1971- )UNICEF:to Auxiliary nurses: implement a comprehensivenationaltuberculosis 6 years' general education . 1 53 38 Midwives: control programme, integrated into the general health 3 years' basic nursing education 1 7 7 servicesinthe provinces and with a specialized Auxiliary midwives: service at the central level. 6 years' general education . . . 1 j 33 14 244 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Smallpox eradication(1969- ):to carry out Soil and water utilization and conservation in the mass vaccination against smallpox and to organize Wadi Tuban watershed area (health aspects) (1971 -1972) and intensify reporting and surveillance. UNDP /FAO: a consultant made an epidemiological Malaria control (1969- ) : to carry out antimalaria survey of health and sanitary conditions in the project measures and coordinate the development of the area and formulated recommendations for the pre- malaria service with that of rural health services. vention and control of health hazards. Parasitic disease survey (1972): a consultant made National health laboratory (1971- ): to establish a survey of the prevalence of parasitic diseases, advised a central public health laboratory. on control methods and helped to train personnel. Institute of Health Manpower Development, Aden Publichealthadvisoryservices(1968- ): to (1970- ) UNDP: toestablish an institutefor strengthen the administration of the health services training the technical personnel required for the health and develop health programmes. services.

EGYPT

Population and other statistics measles (1366), infectious hepatitis (572), typhoid fever (489), meningococcal infections (302), diphtheria (131), At the last census, taken in May 1966, the population poliomyelitis (64), rabies in man (53), leprosy (44), of Egypt was 30 075 858.Population estimates and whooping -cough (28). some other vital statistics for the period under review are given in the following table: Hospital services

1969 1970 1971 1972

Mean population . . 32501 000333290003407600034 839 000 In 1971 Egypt had 1418 hospitals and other inpatient Number of live births. . 1 197 245 1 161 539 1 186 350 1 188 000 establishments providing a total of 73 943 beds, of Birth rate

(per 1000 population) . 36.8 34.8 34.8 34.1 which 64 182 were in 1246 government establishments.

Number of deaths . . . 468 017 500 626 454 192 501 000 Death rate The bed /population ratio was 2.2 per 1000.The (per 1000 population) . 14.4 15.0 13.1 14.4 73 943 beds were distributed as follows : Natural increase ( %) 2.24 1.98 2.17 1.97 Number of infant deaths 142 506 135 067 122 517 135 432 Category and number Number of beds Infant mortality rate General hospitals 412 40 068 (per 1000 live births) . 119.0 116.3 103.3 114.0 Rural hospitals Number of deaths, 587 8448 Medical centres 204 432 1 -4 years 105 809 122 734 97149 Maternity hospitals 3 680 Death rate, 1 -4 years (per Paediatric hospitals 2 135 1000 population at risk) 24.9 28.3 22.5 Infectious diseases hospitals 69 6267 Number of maternal Tuberculosis hospitals 42 7 851 deaths 1 078 1 278 1 068 1 069 Psychiatric hospitals 8 Maternalmortalityrate 5688 Skin and venereal diseases hospital 1 75 (per 1000 live births) . 0.9 1.1 0.9 0.9 Ophthalmological hospitals 35 1 581 Hospitals for tropical diseases 29 305 Of the 454 192 deaths recorded in 1971, the main Leprosaria 20 1 869 causes were: 1 symptoms and ill- defined conditions Other hospitals 6 544 (91 333), chronic rheumatic heart disease, hypertensive Outpatient medical care was available in 1972 at disease, ischaemic heart disease, other forms of heart 356 hospital outpatient departments; at 22 urban disease (41 130), birth injury, difficult labour and other polyclinics; at 589 rural health centres, each serving anoxic and hypoxic conditions,othercauses of a population of 10 000 -15 000 inhabitants; at 1385 perinatal mortality (29 855), bronchitis, emphysema rural health units, each serving a population of 5000 and asthma (29 727), pneumonia (16 793), accidents inhabitants; at 483 dispensaries; at 171 medical aid (16 543, including 546 in motor -vehicle accidents), posts (ambulance services);andat3006 mobile malignant neoplasms (7294), cirrhosis of liver (4267), health units. nephritis and nephrosis (3621), tuberculosis, all forms (2896), diabetes mellitus (2028), bacillary dysentery Medical and allied personnel and training facilities and amoebiasis, enteritis and other diarrhoea) diseases (1873), avitaminosis and other nutritional deficiency In 1971 Egypt had 18 802 doctors, or one for 1810 (1760). inhabitants. Other health personnel included: The communicable diseases most frequently notified Dentists 2511 in 1971 were: tuberculosis, all forms, new cases (2897), Pharmacists 6665 Veterinarians 2620 Midwives 2336 1 International Classification of Diseases, 1965 Revision. Nurses 5192 EASTERN MEDITERRANEAN REGION 245

Assistant nurses 17336 Of all deliveries in 1972, 69.2 % were attended by a Physiotherapists 94 Assistant laboratory technicians 3335 doctor or a qualified midwife, either in hospital or at X -ray technicians 633 home.School health services were provided at 2178 The arrangements for the training of medicaland centres, which supervised 88.5 % of the total school other health personnel in Egypt are as follows: population. There were 184 dental clinics for school- Category DurationNumber of Number of Number of children, which recorded 528 025 patients, and 765 and admission of study schools studentsgraduates dental clinics for adults, which recorded 2 300 000 requirements (years) (public) 1971/72 1972 patients in 1972. Egypt had three independent medical Doctors : secondary school cer- rehabilitation centres and 21 hospital rehabilitation tificate 7 9 21 863 2 867 departments.Psychiatric consultations were given in Dentists : secondary school cer- 30 clinics, which were attended by 173 089 outpatients. tificate 5 2 2 353 406 Pharmacists : Outpatient facilities provided in specialized clinical secondary school cer- fields included 116 units for chest diseases and tuber- tificate 5 4 5 334 784 Veterinarians : culosis, 20 leprosy clinics, 69 infectious diseases units, secondary school cer- 35 ophthalmic diseases units, 27 endemic diseases tificate 5 3 4 058 597 Nurses (university units, and 50 venereal diseases units.There were degree) : also 153 public health laboratories. secondary school certificate 4 2 665 96 Nurses (basic training): preparatory school cer- Environmental sanitation tificate 3 26* 2 292 787 Assistant nurses: preparatory school cer- In 1971, of the 4193 communities in Egypt, 2485 tificate 1% 28** 937 450 (with a total population of 26 166 100) had piped Health visitors: preparatory school cer- water systems, which served 79 % of their inhabitants, tificate 3 9 1 637 551 a further 13 % having access to water from public Auxiliary midwives: preparatory school cer- fountains. In all,115 communities (with a total tificate 1 % 17 707 379 8 944 600) systems. Laboratory technicians : populationof had sewerage secondary school cer- It is estimated that 27 % of the inhabitants of these ficate 2 4 774 232 Sanitarians : communities were livingin houses connected to secondary school cer- sewers. tificate 2 4 966 268 X -ray technicians: secondary school certificate 2 4 239 64 Assistance from WHO Dental technicians: secondary school cer- In 1972 WHO's assistance to Egypt included the tificate 2 4 82 26 Sanitation assistants: following projects: primary schoolcerti- ficate 14 weeks 6*** 100 100 BCG vaccine production, Cairo (1972- ) UNDP: Laboratory assistants : primary schoolcerti- to establish a laboratory for the large -scale production ficate 18 weeks 6*** 310 310 of freeze -dried BCG vaccine. First aid workers : preparatory school cer- Shigella and Salmonella survey (1969- ):to ficate 3 3 125 establish a reference centre for the classification of *Including two private schools. ** Including one private school. Shigella and Salmonella. * ** These centres are to be replaced by secondary technical health schools that will provide three -year courses. Virusresearch,trainingand productioncentre, Agouza (1966- ) UNDP: to set up a vaccine pro- Immunization services duction centre for poliomyelitis, measles, and other virus vaccines. The following immunization procedures were carried out in 1972: Malaria eradication programme (1957- ) : to carry out studies on malaria in the country, and to Smallpox 17955667 Cholera 15057011 make studies of spraying equipment. Typhoid and paratyphoid fevers 1931729 Diphtheria 1555709 Schistosomiasis control pilot project and training Poliomyelitis 1271970 centre (1961- ) UNDP UNICEF: to test measures BCG 1086532 Measles 85113 for controlling schistosomiasis, so as to find the cheapest and most effective under conditions in the Specialized units country. In 1972 maternal and child health care was based Cairo sewage disposal (1969 -1972): to improve the on 2189 prenatal centres and 2187 child health centres. operation and management of the Zenein sewage 246 FIFTH REPORT ON THE WORLD HEALTH SITUATION treatment plant and of the Cairo sewerage system in content is below the desirable level, starting in certain general. districts of Alexandria. Central agricultural pesticideslaboratory,Cairo Nutrition Institute (1972- ) UNDP UNICEF (health aspects) (1971- ) UNDP /FAO: to evaluate (FAO) : to continue the development of the Nutrition the mammalian toxicity of new pesticide formulations, Institute, Cairo. develop application techniques and procedures, and Medical education (1970- ): to develop undergra- determine the measures needed to protect the health duate and postgraduate medical education, and scien- of agricultural workers and of the general population. tific research, in the medical schools. Health component in Lake Nasser Development High Institute of Public Health, University of Alexan- Centre (1966- ) UNDP /FAO: to examine the dria (1956- ): to develop the Institute, which pro- public health problems arising from environmental vides postgraduate training in public health for Egyp- changes associated with the comprehensive Lake tian graduates and WHO fellows from other countries Nasser development scheme in the Aswan region. of the Region. Concentrated sera production (1972- ): to estab- Pharmaceuticalqualitycontrol(1970- ):to lish a unit for the production and purification of con- develop specific aspects of drug control for locally centrated sera at the Agouza laboratories, Cairo. manufactured and imported pharmaceutical prepa- Intensive care unit, Alexandria University Hospital rations, and to carry out research and train specialists (1970- ): to develop an intensive care unit at the in this field. Hospital. Cancer Institute, Cairo (1967 -1972): to establish a Intensive care units (1972- ): to plan, organize, statistical service for the collection of epidemiological and manage intensive care units in the large hospitals information on cancer at the Cancer Institute, develop and train the necessary staff. techniques for the early detection and treatment of cancer, and undertake research and training of per- Postbasic nursingeducation(1961 -1972) UNDP sonnel in various aspects of cancer control. UNICEF: to assist in strengthening nursing education and services and to prepare qualified nurses as Neurosurgicalcentre,ShoubraHospital,Cairo teachers and administrators. (1971- ) UNDP: toestablish a neurosurgical centre in Shoubra Hospital, Cairo, and develop satel- High Institute of Nursing, Cairo University (1965-): lite centres in other governorates. to develop a basic four -year degree programme in nursing. Centre for allergic diseases of the respiratory system (1971- ) UNDP: to establish a centre for allergic Physical therapy department, Poliomyelitis Institute, diseases of the respiratory system. Cairo (1967- ): to develop the department. Family planning (1970- ) UNFPA: to implement Health data processing (1970- ): to improve the the health component of the national family planning use made of computers for vital and health statistics programme and traintechnical personnel for the and research, and to train national staff. programme. Prophylaxis of recurrence of rheumatic fever in schoolchildren (1972- ):to prevent and control Government health expenditure rheumatic fever in schoolchildren. During the fiscal year 1971/72 the expenditure of Fluoridation of water (1972- ):to carry out the Ministry of Public Health amounted to 43 860 000 fluoridation of public water supplies where the fluoride Egyptian pounds.

IRAN

Population and other statistics 1969 1970 1971 1972 Mean population . . 28264 000 29146 000 30056 000 30994 000

Number of live births. . 1088 053 1134 129 1263337 1122 264 At the last census, taken in November 1966, the Birth rate Population esti- (per 1000 population) . 38.5 39.2 42.4 36.2 population of Iran was 25 785 210. Number of deaths . . . 169 039 164 019 151 799 153 239 mates and some other vital statistics for the period Death rate (per 1000 population) . 6.0 5.7 5.1 4.9 1969 -1972 are given in the following table: Natural increase ( %) . . 3.25 3.35 3.73 3.13 EASTERN MEDITERRANEAN REGION 247

Of the 49 381 deaths recorded in 1972 in 12 selected Category and number Number of beds cities (Teheran, Meshed, Isfahan, Shiraz, Kerman, General and maternity hospitals 373 25 245 Rural hospitals 31 652 Kermanshah, Rizaiyeh,Tabriz,Resht, Hamadan, Maternity hospitals 50 3 522 Yezd, and Ahwaz), the main causes were: 1 chronic Paediatric hospitals 9 941 Infectious diseases hospital 1 84 rheumatic heart disease, hypertensive disease, ischae- Tuberculosis hospitals 13 3 680 Psychiatric hospitals 15 2 912 mic heart disease and other forms of heart disease Cancer hospitals 3 280 (7226), malignant neoplasms (3915), bacillary dysen- Clinics for narcotics addicts 6 285 Rehabilitation centres 5 633 tery and amoebiasis, enteritis and other diarrhoeal Leprosaria 2 987 diseases (3525), avitaminosis and other nutritional Outpatient care was provided in 1972 at 411 hospital deficiency (1318), bronchitis, emphysema and asthma outpatient departments, 154 health centres, 2752 dis- (885), tuberculosis, all forms (796), pneumonia (752), pensaries, 102 medical aid posts, 593 mobile health measles (450). units, and 5225 private doctors' clinics. The communicable diseases most frequently notified in 1972 were: influenza (517 011), sore throat and scarlet fever (95 280),bacillary dysentery (88 031), Medical and allied personnel and training facilities measles (52 745), whooping -cough (40 696), typhoid In 1972, Iran had 9470 doctors, of whom 8562 were and paratyphoid fevers (26 319), tuberculosis of the in government service.The doctor /population ratio respiratory system (13 548),gonococcal infections was one to 3250.Other health personnel included: (10 150), infectious hepatitis (8083), malaria (3901), Medical assistants 65 diphtheria (2498), syphilis, all forms (2350), tetanus Dentists 1 692 Dental assistants 995 (1204), poliomyelitis (554), leprosy (375). Pharmacists 3 316 Pharmaceutical assistants 780 Veterinarians 1 037 Midwives 1 589 Organization of the public health services Assistant midwives 630 Nurses and assistant nurses ( "behyars ") 10368 Sanitary engineers 74 The Ministry of Health is responsible for and super- Sanitary Inspectors 84 vises all health organizations in the country and their Assistant sanitarians 1 083 Physiotherapists 85 activities.Medical and health services are provided Laboratory technicians 799 by government, welfare, and private institutions. A Assistant laboratory technicians 998 X -ray technicians 221 number of organizations are under the direct authority Health technicians 1 717 of the Minister of Health -namely, the Narcotics Other paramedical technical personnel . . 2 455 Control Administration, the Pasteur Institute, the The arrangements for the training of medicaland State Pharmaceutical Institute, the Firouzgar Medical other health personnel in Iran are as follows: Research and Training Centre, the Health Corps Category Number of Number of Number of Organization, the Food and Nutrition Institute, and schools students graduates the Civil Servants' Insurance Organization. There are 1971/72 1972 Doctors 7 5357 693 five units in the Ministry, each supervised by an Dentists 4 776 141 under -secretary of state, who is directly responsible to Dental assistants 1 156 71 the Minister of Health. These units are for planning Pharmacists 3 685 162 Veterinarians 1 279 48 and programming,parliamentaryaffairs,medical Sanitary engineering aides 1 66 14 Sanitation assistants 3 60 48 and health care, family planning, and administration. Nutritionists 1 174 62 A provincialgeneraldirectoristheresponsible Physiotherapists 1 72 68 Nurses 18 1 742 513 authority in each of the provinces into which the Assistant nurses ( "behyars ") . 45 3569 958 country is divided. At the city level, there is a local Midwives 6 95 45 Assistant midwives 314 124 urban health council, which is in charge of all health Laboratory technicians 300 140 Laboratory assistants 1 200 280 activities. X -ray technicians 58 22 Radiographers 80 27 Health educators 40 20 Hospital services Hospital administrators 68 37 In 1972 Iran had 508 hospitals and other inpatient Communicable disease control and institutions providing a total of 39 221 beds, of which immunization services 21 939 were in 191 government establishments.The The smallpox control and eradication programme bed /population ratio was 1.3 per 1000.The 39 221 proved so successful that there are now no smallpox beds were distributed as follows: cases in the country.The malaria eradication programme progressed satisfactorily.The infection rate 1 International Classification of Diseases, 1965 Revision. has gradually decreased to less than 0.03 per 1000 248 FIFTH REPORT ON THE WORLD HEALTH SITUATION population in the consolidation areas, where nearly benefits, and requirements, thus ensuring the general 65 % of the country's total population lives, and to coordination of the plan. less than 0.24 per 1000 population in the areas in the During the period of operation of the fourth five - attack phase. There have been no deaths from malaria year plan effective measures were taken for the exten- in Iran since 1970.Leprosy, tuberculosis, and tra- sion of curative and preventive programmes. A net- choma and other eye diseases arestillimportant work of health corps organizations, rural insurance health problems in the rural areas. organizations, and other governmental and welfare The following immunization procedures were carried agencies promoted rural health and curative activities. out in 1972 (excluding those undertaken in private A countrywide network of health services providing clinics and dispensaries): 516 clinics and 11 200 additional beds was established and developed.The training of auxiliaries received Smallpox 21 123954 Cholera 11 000000 special emphasis. Diphtheria, whooping -cough and tetanus } The fifth five -year plan aims at the establishment Diphtheria and tetanus 4712283 Poliomyelitis 1 655332 of 640 new rural and urban health centres, 3040 rural Measles 1 056870 BCG 655663 and urban subcentres, the provision of prenatal care Typhoid and paratyphoid fevers 407735 and family planning services to 1 200 000 women, an increase in the number of hospital beds from an Specialized units average of 1.3 beds to 1.8 beds per 1000 population, the improvement and completion of hospitals, the In 1972 maternal and child health care was provided establishment of two medical schools and 36 schools at 242 prenatal centres and 249 child health units. At for nurses, nursing aides, and laboratory technicians, the end of that year Iran also had 1884 family planning and the development of technical manpower. clinics. There were 102 school health units, 235 dental health units, and 711 public health laboratories. Assistance from WHO

Environmental sanitation In 1972 WHO's assistance to Iran included the following projects: In 1972, 2400 of the country's main communities had piped water systems serving 14 000 000 of their Teaching of sanitary engineering, Pahlavi University, inhabitants.In the same year 13 communities had a Shiraz (1972- ) : to develop a programme of sanitary sewerage system serving 1 600 000 inhabitants. engineering education and research. Pre -investment survey of sewerage needs and facilities National health planning in Teheran (1970- ) UNDP: to undertake a pre - investment survey for sewerage and storm drainage The fourth five -year plan, which was initiated in in the Greater Teheran area and to draw up master 1968, was completed in 1972. In 1973 Iran embarked plans and first -stage feasibility studies to assist in on its fifth five -year plan covering the period 1973- securing investment for construction. 1978. The plan for the health sector is incorporated Health services development (1972): a consultant in both the fourth and the fifth five -year development assisted in carrying out a study of the decision -making plans. process in the Ministry of Health. The responsibility for Iran's development programming rests with the Plan and Budget Organization, High Institute of Nursing,Teheran (1967- ) which formulates national development plans in con- UNDP: to develop basic nursing education at univer- sultation with the technical ministries and state-affi- sity level. liated organizations entrusted with the execution of Postbasic nursing education (1967- ): to develop the projects. a two -year postbasic programme at the Department The Plan and Budget Organization consists of the of Nursing, College of Arts and Science, Pahlavi National Planning Board, which is composed of the University, Shiraz. Minister of Finance, the Minister of Economics, and Rehabilitation of the physically handicapped (1969- the Director -General of the Central Bank, under the chairmanship of the Prime Minister; and of the Ex- ) : to train personnel required for the development of rehabilitation services throughout the country at the ecutive Planning Board, under the chairmanship of the Executive Director of the Plan and Budget Organiza- school of physical therapy, University of Teheran, and the Shafa Yahayaian Rehabilitation Hospital. tion.The National Planning Board analyses and approves the various parts of the development plan, Medical education (1971- ): to develop training which have been prepared according topriorities, and research work in the medical faculties of the seven EASTERN MEDITERRANEAN REGION 249

universities, and to establish the radiotherapy depart- Healthaspectsof family planning(1971- ) ment at the University of Isfahan. UNFPA: to plan and implement the health compo- Postgraduate education in public health (1964- ): nents of the national family planning programme, to develop postgraduate training in public health and and to train technical personnel for the programme. allied fields at the faculty of public health, University of Teheran. Government health expenditure Laboratory for pharmaceutical quality control (1966- ) UNDP: to develop the quality control laboratory for the analysis and assay of pharmaceutical prepara- In the fiscal year 1972/73, total government expen- tions, chemicals, and dependence -producing drugs, diture amounted to 378 billion rials, of which 17 bil- liI were spent for health purposes, or approximately reviselegislationgoverning thetrade,and train 570 rials per capita. local staff. Of the total health expenditure, 144 000 000 rials were spent on capital account and Cancer control (1967- ):to develop the pro- 6 374 000 were devoted to the health activities of gramme of the Research Department of the Teheran social security schemes and other nongovernmental Cancer Institute. social welfare activities.

IRAQ

Population and other statistics dysentery and amoebiasis, enteritis and other diarrhoeal diseases (195), meningitis (169), anaemias (151). At the last census, taken in October 1965, the The communicable diseases most frequently notified population of Iraq was 8 047 415.Population esti- in 1972 were :trachoma (99 537), measles (38 272), mates and some other vital statistics for the period tuberculosis, all forms, new cases (19 776), whooping- 1969 -1972 are given in the following table: cough (16 299), influenza (8363), malaria, new cases

1969 1970 1971 1972 (6347), amoebic dysentery (1713), typhoid and para-

Mean population . . . . 9 148 846 9 440 098 9 749 59710 074 169 typhoid fevers(1498), gonorrhoea (1026), menin-

Number of live births 1 . 134 408 143 299 143 240 160 412 gococcal infections (897), diphtheria (790), infectious Birth rate hepatitis (534), scarlet fever (264), poliomyelitis (255), (per 1000 population) . 14.7 15.2 14.7 15.9

Number of deaths 1 . . 35 329 33 464 38 546 40 599 bacillary dysentery (156), syphilis, new cases (118), Death rate leprosy (12), rabies in man (9). (per 1000 population) . 3.9 3.5 4.0 4.0

Natural increase ( %) . . 1.08 1.17 1.07 1.19 Number of infant deaths . 2 826 2 826 3 647 4 515 Organization of the public health services Infant mortality rate (per 1000 live births) . 21.0 19.7 25.5 28.1 At the national level, the Ministry of Health is Number of deaths, responsible for preventive and curative medical work. 1 -4 years 1 2 136 2 171 Death rate, 1 -4 years (per Some other ministries and organizations, such as the 1000 population at risk) 1.6 1.6 Ministryof Labour andSocialAffairs,provide 1 Registered. special health programmes for specific population groups.The Minister of Health is assisted by the Of the 33 464 deaths recorded in 1970, the main Under - Secretary of Health. The Ministry of Health is causes were:symptoms and ill- defined conditions divided into six departments with a director -general (14 635), chronic rheumatic heart disease, hypertensive in charge of each.These departments deal with disease, ischaemic heart disease and other forms of preventive medicine, medical supplies, rural health heart disease (5217), accidents (2598, including 122 services, health services, medical services, and health in motor -vehicle accidents), tuberculosis, all forms inspection. (1648),pneumonia(1543),malignantneoplasms The country isdivided administratively into16 (1432),cerebrovasculardisease(630),congenital governorates (mohafadhas). Each governorateis anomalies, birth injury,difficult labour and other divided intodistricts(qadas), which in turn are anoxic and hypoxicconditions,othercausesof divided into subdistricts (nahiyahs). perinatalmortality(279),bronchitis,emphysema At the intermediate level (governorates) there is a and asthma (278), cirrhosis of liver (264), bacillary department of health, directed by a chief officer of health, who is in charge of all the health services and 1 International Classification of Diseases, 1965 Revision. institutions located within the governorate. 250 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Hospital services malaria exists in practically all the inhabited territory of Iraq. From the malarious territory can be excluded In 1971 Iraq had 152 hospitals with 18 593 beds, of the desert areas and the high mountain areas near which 18 097 were in136 government- maintained the borders of Iran and Turkey.Transmission is establishments.The bed /population ratio was 1.9 known to occur in Basra and may on occasion take per 1000. The 18 593 beds were distributed as follows : place in Baghdad.Of the various problems facing Category and number Number of beds the malaria eradication programme in Iraq, the most General hospitals 105 11 805 important and the one having the most serious effects Maternity hospitals 5 405 Paediatric hospitals 13 889 on the overall malaria situation is the persistence of Infectious diseases hospitals 7 379 transmission in the north of the country.Various Tuberculosis hospitals 8 2649 Psychiatric hospitals 3 1 733 malaria foci in the central region persisted and a few Maternal and child health institutes 6 175 more were detected during the period under review. Ophthalmological hospitals 3 205 Lep rosari u m 1 325 The situation in the southern region remained under Hospital for nuclear medicine 1 28 control. Outpatient care facilities were available in 1972 at Other major diseases in the country are schisto- 121 hospital outpatient departments, 65 polyclinics, somiasis,trachoma,tuberculosis,anddiarrhoeal diseases. The programme for the control and eradi- 620 health centres (of which six also provided inpatient facilities), 474 dispensaries, and 88 mobile health cation of some of these diseases has been in existence for several years. units. The following immunization procedures were carried out in 1972: Medical and allied personnel and training facilities Cholera 9484833 Smallpox 8224612 In 1971 Iraq had 3158 doctors, of whom 2847 were Poliomyelitis 387567 in government service.The doctor /population ratio Diphtheria, whooping -cough and tetanus 372355 Typhoid and paratyphoid fevers 170958 was thus one per 3090.Other health personnel BCG 143818 included:

Medical assistants 1 424 Specialized units Dentists 442 Dental laboratory technicians 94 Pharmacists 885 In 1971 there were 73 centres engaged in maternal Pharmaceutical assistants 308 and child health care. During the year, 53 950 pregnant Assistant and practical midwives 1 535 Nurses 2 011 women, 64 633 infants under one year, and 32 002 Health visitors 243 Dressers 2 649 children aged 1 -5 years availed themselves of these Sanitary engineers 10 services. Of all deliveries in 1971, 135 293 were Sanitary inspectors 396 Physiotherapists 129 attended by a doctor or a qualified midwife, either in Assistant laboratory technicians 671 hospital(31 368deliveries)or at home (103 925 X -ray technicians 227 Health statistician 1 deliveries). In 1972 there were 23 school health units, Health educators 4 eight psychiatric outpatient clinics,16 tuberculosis Medical records officers 2 outpatient clinics, 20 venereal diseases outpatient There are three medical colleges in Iraq, at the clinics, and a leprosy outpatient clinic. Universities of Baghdad, Basra and Mosul. The Universities of Baghdad and Mosul also have a Environmental sanitation college of pharmacy.In addition, the University of Baghdad has a dental college and a veterinary college. Between 3 500 000 and 4 000 000 rural dwellers There are five training schools for nurses.Training have yet to be served with a safe water supply. of auxiliary personnel is carried out at the High Throughout the rural areas of Iraq there are only Institute of Health Auxiliaries in Baghdad. 1400 tube wells, which serve a population estimated at between 500 000 and 1 000 000 living in villages. A Communicable disease control and comprehensive sewerage scheme is being constructed immunization services in Baghdad. Plans have been prepared for the construction of sewerage systems in six major towns in The countrywide malaria eradication programme, Iraq. The situation in the rural areas is still inadequate. based on residual spraying and surveillance operations, Solid waste collection and disposal is in operation in was launched in 1957.The total population at risk Baghdad and most large towns.In rural areas dis- protected by spraying was 5 300 000 in 1970.With posal of solid wastes is generally the responsibility the possible exception of some of the urban areas, of the individual householder. EASTERN MEDITERRANEAN REGION 251

National health planning Public health laboratory services (1969- ):to develop microbiological diagnostic facilities and also The main priorities and aims stated in the five year to develop the production of vaccines. plan of action and in the 10 -year plan are: control of the communicable diseases prevalent in the country, Hospital servicesadministration(1966- ):to maternal and child health, mental health and occupa- strengthen the administration of the Medical City tional health, and development of rural health services TeachingHospital,Baghdad, plan and organize and of medical care services.The Government has nursing services, establish an intensive care unit and given high priority to the improvement of health a central sterile supply department, and develop food servicesinrural areas through extension of the and dietetics services. network of primary health centres and subcentres. College of nursing, Baghdad (1962- ): to develop a university nursing education programme. Assistance from WHO Medical education (1971- ): to strengthen the departments of basic medical sciences and public In 1972 WHO's assistance to Iraq included the health at the colleges of medicine in Baghdad, Basra, following projects: and Mosul.

Malaria eradication programme (1957- ) Poison information centre (1972- ): to establish UNICEF. a poison information and treatment centre, and to organize procedures for dealing with cases of poisoning. Rural water supply programme (1971- ) UNDP: to appraise the community water supply situation in Cancer control (1968- ): to develop the radio- the rural areas, prepare a master plan for rural therapy department of the Institute of Radiation water supplies, and establish a national rural water and Nuclear Medicine, Baghdad, and to train radio- authority. therapy technicians. Comprehensivebasichealthservices: training Maternal andchildhealthand familyhealth (1964- ) UNDP UNICEF: to provide in- service (1970- ) UNFPA: to develop maternal and child training for professional and auxiliary personnel of health and family planning activities within the health the rural health services and field training for under- services, organize the family planning programme, graduate medical and nursing personnel. and train the necessary personnel.

ISRAEL

Population and other statistics The main causes of deaths recorded in 1971 were: chronic rheumatic heart disease, hypertensive disease, At the last census, taken in May 1972, the population ischaemic heart disease and other forms of heart of Israel was 3 124 000.Population estimates and disease (6757), malignant neoplasms (3751), cerebro- some other vital statistics for the period under review vascular disease (2724), congenital anomalies, birth are given in the following table: injury, difficult labour and other anoxic and hypoxic conditions, other causes of perinatal mortality (1328), 1969 1970 1971 1972 accidents(1184,including585inmotor -vehicle Mean population . 2 873 100 2 958 300 3045600 3 146 200

Number of live births. 73666 77601 85899 85544 accidents), symptoms and ill- defined conditions (732), Birth rate pneumonia (482), bronchitis, emphysema and asthma (per 1000 population) . 25.6 26.2 28.2 27.2

Number of deaths . . . 19767 20416 21415 22679 (223), diabetes mellitus (196), suicide and self- inflicted Death rate injuries (181), cirrhosis of liver (164), nephritis and (per 1000 population) . 6.9 6.9 7.0 7.2 Natural increase ( %) 1.87 2.04 2.12 2.00 nephrosis (130), enteritis and other diarrhoeal diseases Number of infant deaths . 1 733 1 765 1 977 2 068 Infant mortality rate (128). (per 1000 live births) . 23.5 22.7 23.0 23.7 The communicable diseases most frequently notified Number of deaths, 1 -4 years 270 270 276 in 1972 were: bacillary dysentery (4273), infectious Death rate, 1 -4 years (per hepatitis (2779), gonorrhoea (1192), scarlet fever (506), 1000 population at risk) 1.0 1.0 1.0 Number of maternal tuberculosis, all forms, new cases (424), measles (413), deaths 25 18 13 Maternal mortality rate

(per 1000 live births) . 0.34 0.23 0.15 'International Classification of Diseases, 1965 Revision. 252 FIFTH REPORT ON THE WORLD HEALTH SITUATION

typhoid and paratyphoid fevers (193), typhus (187), payments for specific purposes, if and as approved. syphilis,newcases(121),whooping -cough(61), The following persons are exempted from contribu- malaria, new cases, imported or induced by blood tions although they enjoy full membership rights: transfusion (56), meningococcal infection (33), cholera the spouse of an insured person, if he or she hasno (10), relapsing fever (9), poliomyelitis (8, including income; the children of an insured person up to the suspected cases). age of 14, and above if their income is not sufficient for their livelihood; persons entitled to social benefits, Organization of the public health services such as welfare cases, and recipients of oldage pensions. The Ministry of Health, which is entrusted with the A plan for the establishment of a network of administration of the Public Health Law, has three comprehensive community mentalhealthcentres main divisions: (a) a Division of Curative Services, has been approved and a model centre has been which is responsible for government -owned hospitals openedinJaffa,providingdiagnostic,curative, and health centres, for the supervision and licensing preventive, and promotive services.It is expected of all nongovernmental hospitals and for the allocation that once these centres become operative they will of grants -in -aid to all nonprofit hospitals, according help to reduce the pressure on psychiatric hospitals to bed strength; (b) the Regional Services Adminis- and change fundamentally the approach to mental tration,which dealswithpublic health proper, illness. operating through 14 public health offices in the field; The Government has set up a statutory authority and (c) the Division of Mental Health. Certain health to deal with.all aspects of the environment, including areas are under the jurisdiction of ministries other the health aspect. This authority is affiliated with the than the Ministry of Health -e.g., veterinary health National Council for Research and Development, in is under the Ministry of Agriculture, occupational the Prime Minister's Office.The Ministry of Health health under the Ministry of Labour, and custodial has reached an agreement with the Tel Aviv University care of the mentally deficient under the Ministry of Medical School on the establishment of a joint SocialWelfare. An interministerialcommittee environmental health research institute. The Office of comprising the directors -general of the social service the Chief Scientist has been established with a view ministries (or their representatives) has been set up to stimulating and promoting medical research within for the purpose of ensuring coordination. the various institutions of the Ministry of Health, to The country is divided into six districts and 14 ensuring proper distribution of available grants, and subdistricts.District health officers are charged with to supervising the evaluation of results. responsibility for the health services in their respective Because of the ever -increasing numbers of elderly districts; certain municipalities operate health services people in the population, a regional home service has of their own. been established.It is directed by doctors acting as regional geriatricians and is operated from the district Changes in the provisionofhealth services health offices by public health nurses, who are assisted A Health Insurance Bill, which provides for compul- by social workers. sory insurance for all residents of the country, has been approved by the Cabinet and is being submitted Hospital services to the Knesset (Parliament).In the first stage the In 1971Israel had 88 hospitals with a total of insurance will cover ambulatory treatment (including 17 369beds (8917in 30government- operated housecalls),hospitalization,laboratoryservices, hospitals), to which 423 947 patients were admitted. supply of medicaments, personal preventive medical These 17 369 beds -equivalent to a bed /population services such as care of pregnant women, mothers ratio of 5.8 per 1000 -were distributed as follows: and infants, preschool children and schoolchildren, Category and number Number of beds dentalhealthandoccupationalhealthservices, General hospitals 39 10275 Maternity hospitals 6 120 auxiliary medical appliances and medical rehabili- Paediatric clinic 1 50 tation services, and ambulance services.The health Leprosy clinic 1 30 Psychiatric hospitals 31 5 941 services to which an insured person is entitled under Hospitals for long -term care 5 508 the Insurance Law are to be provided by the existing General rehabilitation institutions 3 263 Ophthalmological clinic 1 82 voluntary sick funds, which cannot refuse a resident Geriatric clinic 1 100 applying for admission.All restrictions obtaining in Mosthospitalshaveoutpatientdepartments. the various sick funds (as to age, previous and chronic Ambulatory medical care is provided in the main by illness, etc.) are to be abolished.Budget allocations the Sick Fund of the General Federation of Labour. for these funds are derived from contributions by At the end of 1972 the 1092 polyclinics of this Sick the members, employers and the Treasury, and by Fund included 776 basic clinics (staffed by a nurse EASTERN MEDITERRANEAN REGION 253 and a resident or visiting general practitioner), 306 Category DurationNumber of Total Number of and admission of study schoolsenrolmentgraduates district clinics (staffed by a nurse, a resident or visiting requirements (years) 1971/72 1972 general practitioner, and a paediatrician), 14 regional Physiotherapists : 12 years' general edu- clinics, and three central clinics. cation 3 2 177 79 Occupational therapists : 12 years' general edu- Medical and allied personnel and training facilities cation 3 1 103 34 Sanitarians : 12 years' general edu- In 1970, Israel had 7281 doctors (including those cation 3 1 55 30 not professionally active), or one doctor for 400 X -ray technicians : 12 years' general edu- inhabitants. Other health personnel included: cation 2 4 100 51 Dentists 1 444* In the field of medical education, the Centre of Dental practitioners 699* Dental nonoperating assistants 70* Health Sciences at the University of the Negev in Pharmacists 1 705* Assistant pharmacists 639* Beersheba represents a new educational approach Midwives 514* that has a twofold aim: to integrate all existing health Nurses 5 087 ** Practical nurses 5 966 ** services in the Negev with a view to providing compre- Nursery nurses 2 868 ** hensive medical care to the entire population of the Sanitary engineers 60 (approx.) Sanitarians 260 regionthrough optimum useoforganizational, Municipal inspectors 170 (approx.) Physiotherapists 458* financial, and manpower resources; and at the same Occupational therapists 207* time to use this system in an attempt to orient medical Qualified medical workers 1 116* X -ray technicians 506* education towards the training of physicians who Electroencephalography technicians . 14* wish to work in both community hospitals and primary Medical records officers 63* health centres.The Centre will constitute a faculty * Licensed personnel, including those not professionally active. of the University.The clinical facilities available in * *Including those not professionally active but excluding those not trained in Israel. the region will be used for teaching purposes and the knowledge and experience of the Centre will be used The arrangements for the education and training for improving the health services.Thus the staff of of medical and other health personnel in Israel are as the Centre will be involved in both service and teaching. follows : Category DurationNumber of Total Number of Communicable disease control and and admission of study schoolsenrolment graduates requirements (years) 1971/72 1972 immunization services Doctors : 12 years' general educa- Throughout the period under review the previously tion andmatricula- tion certificate . . . 6 3 1 115 125 achieved malaria eradication status was maintained Dentists : within thecountry's boundaries and surveillance 12 years' general educa- tionandmatricula- activities were continued. However, malaria morbidity tion certificate . . 6 1 221 14 due to imported cases increased in the civilian popu- Pharmacists : 12 years' general educa- lation, especially in 1970 and 1971. In 1970 a cholera tion 4 1 108 35 outbreak with 185 cases and two deaths,strictly Dental assistants: 12 years' general edu- limited to the Jerusalem area, was reported. Reintro- cation 8 months 2 40 40 duction of cholera in 1972 resulted in a small outbreak Feldshers : previous experience . 8 months 1 23 with 11 cases, all in the Jerusalem area. About 50 -120 Dietitians : cases of rickettsiosis were reported annually, a consid- 12 years' general education 3 2 53 24 erable proportion of which, particularly in 1971 and Nurses (basic nursing 1972, were tickborne spotted fever. Infectious gastro- course) : 12 years' general edu- intestinal diseasesstill account for a considerable cation 3 17 1 617 321 proportion of the morbidity due to notifiable diseases, Practical nurses: Bacillary 1' 473 396 particularly in the young age groups. Public health nurses : dysentery continued to be the most frequently reported must be registered nurses 9 months 2 52 36 disease, followed by viral hepatitis, most of which is Psychiatric nurses: infectious hepatitis. Salmonellosis, not including typhoid must be registered nurses 1 1 12 10 and paratyphoid fevers, is still highly prevalent, with Midwives: 1700 -1900 reported cases annually.Typhoid fever must be registered nurses 9 months 3 23 13 morbidity has been decreasing in recent years, and Laboratory technicians : less than 150 cases were recorded in 1972, as compared 12 years' general education 2 3 304 200 with an annual morbidity of 250 -300 cases previously. 254 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Venereal diseases are on the increase, particularly Social and economic developments of significance among the young age groups. for the health situation Intensively conducted mass immunizations have progressively led to a high vaccination coverage of During the period under review there has been full the country's child population.It is estimated that employment and a definite rise in the standard of about 80 % of newborns are vaccinated against living. The loss through the outflow of medical smallpox, about 85 % are given BCG vaccine, and personnel is compensated by the immigration of about 90 % are immunized with DPT and trivalent doctors.The economic boom, however, has had an oral poliomyelitis vaccine.Mass vaccination against adverse effect on the recruitment of paramedical measles was introduced in 1967 and in 1971 covered manpower. A division of manpower and training about 60 % of newborns. The incidence of whooping - has been set up to deal with this problem. cough remained low, and only sporadic cases of paralytic poliomyelitis occurred during the period under National health planning review, mostly among unvaccinated or only partially vaccinated children. The incidence of measles and of There is no statutory national health planning pulmonary tuberculosis has decreased considerably authority in Israel and no comprehensive long -term since 1968. health plan has been evolved.There is, however, a The following immunization procedures were car- hospital planning and construction authority. Planning ried out in 1972: is done on an ad hoc basis in accordance with changing priorities. Poliomyelitis 187297 BCG 150137 Diphtheria, whooping -cough and tetanus . 115421 Measles 37566 Assistance from WHO Smallpox 24475 In 1972 WHO's assistance to Israel included the Specialized units following projects: At the end of 1972 there were 742 centres engaged National surveyonrefusedisposal(1967 -1970; in maternal and child health care; these are gradually 1972- ): to review the situation as regards solid being transformed into family health centres. During waste disposal, and to draw up and implement a the year 60 049 pregnant women and 86 965 children national refuse disposal plan. under one year availed themselves of these services, Nursing education (1965- ): to prepare plans for and 72 656 domiciliary visits were paid to pregnant the further development and strengthening of nursing women, 122 219 to children under one year and education and services. 129 930 to children aged 1 -5 years.In 1972, 98.3 Radiation protection (1970- ) :to improve the of all deliveries were attended by a doctor or a qualified dosimetryintherapeutic X -rayinstallationsand midwife. During the same year 452 599 schoolchildren, increase the protection of personnel occupationally representing 64.3 % of the total school population, exposed to ionizing radiation by the introduction of were under medical and health supervision at 1395 thermoluminescentdosimeters;totrainhospital school health service units.Other specialized units physicists; and to carry out surveys of environmental included 135 dental clinics serving schoolchildren, radioactivity. 72 psychiatric outpatient clinics, 18 pulmonary disease clinics,a leprosyclinic and seven public health Medical education (1957- ): to develop teaching laboratories. and research at the medical faculties. Cancer control (cytopathology) (1972- ) : to devel- Major public health problems op cancer control services and organize a course in the The major public health problems in Israel are techniques of exfoliative cytology for the early detec- similar to those encountered in Western countries - tion of cancer. namely, the growing importance of cardiovascular Coronary care unit (1969- ):to develop the diseases(inparticularischaemicheartdisease), coronary care unit of the Tel Hashomer Government cancer, road accidents, the problem of providing Hospital for use as a training centre. servicesfor theaged, and environmental health problems such as air, water, and soil pollution. The Government health expenditure main concernis,however, the organization and delivery of medical care.The search for ways to In the fiscal year 1971/72 the Government spent a remedy the present situation continues with due total of 408 600 000 Israeli pounds on health, which regard to local conditions and circumstances. is equivalent to 2.9 % of total government expenditure. EASTERN MEDITERRANEAN REGION 255

The share of the central Government was 364 100 000, health expenditure, 265 000 000 Israeli pounds were local authorities covering the rest. About 84 % of the spent on hospitals and 15 000 000 on health adminis- total health expenditure was spent on current account tration. In all, the per capita government expenditure and about 16 % on capital account. Of the government on health amounted to 134 Israeli pounds.

JORDAN

Population and other statistics Category and number Number of beds General hospitals 19 1 070

Rural hospital 1 63 At the last census, taken in November 1961, the Maternity hospitals 5 150 population of Jordan was1 706 226. Population Paediatric hospital 1 60 Tuberculosis hospitals 3 116 estimates and some other vital statistics for the years Mental hospital 1 100 1969 -1971 are given in the following table: Surgical clinic 1 123 Hospital for internal medicine 1 72 Ophthalmological hospital 1 34 1969 1970 1971 Ear, nose and throat hospital 1 28

Mean population 1600 000 1634 000 1695 500 Rehabilitation hospital 1 34 Number of live births 73 443 76 828 77 758

Birth rate (per 1000 population) . . . 45.9 47.0 45.9 Number of deaths 6 430 6 808 7 233 Outpatient care facilities were available in 1972 at Number of infant deaths 1 865 1 698 1 607 Infant mortality rate (per 1000 live the hospital outpatient departments, 12 polyclinics (of births) 25.4 22.1 20.7 which six had some hospitalizationfacilities),11 Number of deaths, 1 -4 years . . . . 901 860 691 Death rate, 1 -4 years (per 1000 popu- health centres, 309 dispensaries, 30 medical aid posts, lation at risk) 4.48 4.25 3.0 and five mobile health units. Number of maternal deaths 37 36 41 Maternal mortality rate (per 1000 live births) 0.5 0.47 0.5

East Bank only. Medical and allied personnel and training facilities

The communicable diseases most frequently notified In 1971 Jordan had 826 doctors, of whom 278 were in 1972 were: measles (1050), whooping -cough (286), in government service.The doctor /population ratio infectious hepatitis (221), influenza (220), dysentery, was one per 2090. Other health personnel included : allforms(188),meningococcalinfections(129), typhoid and paratyphoid fevers (70), poliomyelitis Dentists 117 Dental assistants 35 (59), scarlet fever (14), tickborne fever (11), diphtheria Pharmacists 241 (8). Pharmaceutical assistants 291 Veterinarians 3 Midwives 150 Assistant midwives 350 Organization of the public health services Nurses 355 Assistant nurses 1 376 Sanitary engineers 3 The overall responsibility for the public health Sanitarians 2 services in Jordan rests with the Ministry of Health. Assistant sanitarians 82 Physiotherapists 9 The Minister of Health isassisted by the Under - Laboratory technicians 10 Secretary of Health. The following directorates Assistant laboratory technicians 152 X -ray technicians 71 operate in the Ministry of Health: technicial services, pharmacy and supplies, dental health, nursing services, The University of Jordan is establishing the first health services, and administration. The Directorate medical school in the country.The first class of for Technical Services has three sections, dealing students started their training in basic medical sciences respectively with curative medicine, preventive medi- in the medical faculty in 1973. cine, and statistics.They are subdivided to cover The arrangements for the training of health per- most aspects of the health services in the country. sonnel in Jordan are as follows:

Category Duration Number of Number of Number of Hospital services and admission of study schools studentsgraduates requirements 1 (years) (public) 1971/72 1972

In 1971 Jordan had 35 hospitals and other inpatient Laboratory technicians . 2 1 18 18 establishments providing 1850 beds, of which 1250 Physiotherapists. . . 2 1 8 8 Radiographers 2 1 13 13 were in 20 government establishments.The bed/ X -ray technicians . . . 2 1 13 13 population ratio was 1.1 per 1000. The 1850 beds, to Laboratory assistants . 2 1 Dental auxiliaries . . . 2 1 which 67 442 patients were admitted during the year, were distributed as follows : 1 All categories must possess a certificate of secondary education. 256 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Immunization services Public health laboratory (1971- ): to set up an oncology register in the public health laboratory The following immunization procedures werecar- services, develop the production of bacterial vaccines, ried out in 1971: and establish a virology diagnostic section. Cholera 897985 Hospital planning and administration (1971- ) Smallpox 218580 Diphtheria, whooping -cough and tetanus . 43799 UNDP: to organize and develop a hospital adminis- Poliomyelitis 41643 Typhoid and paratyphoid fevers 4128 tration unit in the Ministry of Health and review the Measles 1 582 planning of facilities and the organization and management of hospitals. Specialized units Survey of thermal waters (1972): a consultant made In 1972, 34 centres were engaged in maternal and chemical analyses of the Azrak mineral water resources child health care.They were attended by 27 474 in order to ascertain the possibilities of their use for pregnant women, 29 076 infants under one year and curative purposes. 25 320 children aged 1 -5 years. Dental treatment was Nursing education (1965- ) UNDP: to strengthen provided at 19 dental clinics, which were attended by nursing services and develop professional and auxi- 109 311 schoolchildren.The hospital rehabilitation liary nursing education programmes. outpatient department recorded 13 765 new patients Rehabilitation services (1967- ): to develop the in1972.Psychiatric outpatient consultations were rehabilitation centre and introduce modern methods given in 1972 to 17 464 new patients. Jordan had 33 of physical therapy; also to plan and develop training public health laboratories, which carried out nearly programmes and establish a prosthetic workshop. 400 000 examinations in 1972. Health training institute (1972- ):to establish Assistance from WHO and develop an institute for training multipurpose health personnel for staffing health centres and dis- In 1972 WHO's assistance to Jordan included the pensaries in rural areas. following projects : Medical education (1971- ):to strengthen the Tuberculosis control (1963- ): to formulate and Faculty of Medicine and Pharmacy of the University implement a comprehensive nationaltuberculosis of Amman. control programme, integrated in the general health services. Government health expenditure Malaria eradication programme (1958- ) UNDP. In 1971 total government health expenditure on Municipalwastedisposal,Amman(1968- ) current account amounted to 6 607 220 Jordan dinars, UNDP: to provide for assistance to the Amman of which 2 957 220 were spent by the Ministry of municipality in operating and maintaining the new Health and 3 650 000 by other ministries.The per sewage works and in providing house connexions to capita government health expenditure was 3.9 Jordan the water mains and sewers. dinars.

KUWAIT

Population and other statistics 1969 1970 1971 1972 Infant mortality rate (per

1000 live births) . . . 33.2 39.5 37.4 38.5 At the last census, taken in April 1970, the popula- Number of deaths, tion of Kuwait was 737 908.Population estimates 1 -4 years 1460 1735 1 643 1 845 Number of maternal and some other vital statistics for the period under deaths 3 2 5 5 review are given in the following table: Of the 4149 deaths recorded in 1972, the main 1969 1970 1971 1972 causes were: ' accidents (519, including 274 in motor - Mean population . . 689 200 750 000 790 000 838 000 vehicle accidents), birth injury, difficult labour and Number of live births. . 35 135 33 842 35 558 37 688 Birth rate other anoxic and hypoxic conditions, other causes (per 1000 population) . 51.0 45.5 45.0 45.0 of perinatal mortality (480), symptoms and ill- defined Number of deaths . 3 378 3 735 3 832 4 149 Death rate conditions (447), bacillary dysentery and amoebiasis, (per 1000 population) . 4.9 5.0 4.9 5.0 4.61 4.05 4.01 4.00 Natural increase ( %) Number of infant deaths . 1 1G8 1 335 1 331 1 451 ' International Classification of Diseases, 1965 Revision. EASTERN MEDITERRANEAN REGION 257 enteritis and other diarrhoeal diseases (382), chronic Immunization services rheumatic heart disease, hypertensive disease, ischaemic heart disease and other forms of heart disease The following immunization procedures were carried out in 1971 : (360), pneumonia (350), malignant neoplasms (243), congenital anomalies (222), influenza (114), diabetes Cholera 619 593 mellitus (97). Smallpox 348 182 (1970) Poliomyelitis 155 094 Tetanus (simple and combined) 75640 Diphtheria (simple and combined) 60670 Whooping -cough (combined) 42637 Hospital services BCG 41 148 Typhoid and paratyphoid fevers 11 580 Measles 2 844 In 1971 Kuwait had 26 hospitals providing 4009 Yellow fever 87 beds, of which 3635 were in 18 government establishments.The bed /population ratio was 5.0 per 1000. Specialized units The 4009 beds were distributed as follows: In 1972 maternal and child health services were

Category and number Number of beds provided at 10 prenatal centres and at eight child General hospitals 11 1 764 health units.In the same year all deliveries were Medical centres 7 110 attended by a doctor or a qualified midwife, either in Maternity hospitals 2 758 Infectious diseases hospitals 2 241 hospital (32 597 deliveries) or at home (5091 deliveries). Tuberculosis hospitals 2 574 In 1972, 214 438 schoolchildren were under the medical Psychiatric hospital 1 452 Chronic diseases hospital 1 110 supervision of the school health service. Kuwait also had 16 dental clinics for schoolchildren and 29 Outpatient facilities were available in 1972 at 15 foradults,fivehospitalrehabilitationoutpatient hospital departments, 10 polyclinics, 33 health centres, departments, one psychiatric outpatient clinic, and six dispensaries, and seven medical aid posts. 18 public health laboratories.

Assistance from WHO Medical and allied personnel In 1972 WHO's assistance to Kuwait included the In 1971 Kuwait had 744 doctors, or one doctor for following projects : 1060 inhabitants. Other health personnel included: Nursing advisory services (1969- ) Funds -in- trust: to develop nursing education and nursing services, Dentists 67 Pharmacists 163 define standards of nursing care, and organize in- Pharmaceutical assistants 351 service education programmes for nursing personnel. Veterinarians 19 Midwives 177 Pollutioncontrolin theworkingenvironment Assistant midwives 30 Nurses 1 576 (1972- ) UNDP /ILO: to carry out an occupational Assistant nurses 1 223 Sanitarians 22 hygiene programme giving particular attention to Assistant sanitarians 165 the control of pollution in the working environment; Physiotherapists 47 Laboratory technicians 65 and to evaluate the effects on the health of the popu- Assistant laboratory technicians 129 lation, including workers, of air and water pollution X -ray technicians and assistants 99 Radiotherapy technicians and assistants 11 and implement measures for its control.

LIBYAN ARAB REPUBLIC

Population and other statistics 1969 1970 1971 1972* Death rate At the last census, taken in July 1973, the population (per 1000 population) . 7.4 7.7 8.3 8.0 Natural increase (%) . . 3.57 3.41 3.97 3.73 of the Libyan Arab Republic was 2 257 037.Popu- Number of infant deaths . 5 124 5 220 6 022* 6 515 lation estimates and some other vital statistics for the Infant mortality rate (per 1000 live births) . 63.6 64.5 62.4 69.0 period under review are given in the following table: * Provisional data. 1969 1970 1971 1972* The communicable diseases most frequently notified Mean population . . 1869 000 1938 000 2 010 000 2084000 in 1971 were: dysentery, all forms (1545), infectious Number of live births . . 80559 80914 96539 94377 Birth rate hepatitis(1148),measles(1039),tuberculosis,all (per 1000 population) . 43.1 41.8 48.0 45.3

Number of deaths . . . 13 850 14 915 16 738 16 653 forms, new cases(347),meningococcal infections 258 FIFTH REPORT ON THE WORLD HEALTH SITUATION

(159), typhoid and paratyphoid fevers (91), diphtheria A new faculty of medicine in Benghazi opened in (76), whooping -cough (61), leprosy (61), poliomyelitis September 1971. (59), gonorrhoea (36), scarlet fever (21), malaria, new The arrangements for the training of medical and cases (11). other health personnel in the Libyan Arab Republic are as follows : Organization of the public health services Category DurationNumber of Number of Number of 10 and admission of study schools studentsgraduates The Libyan Arab Republicisdivided into requirements (years) (public) 1971/72 1972 governorates, each of which has a directorate of Doctors : health services.Previously all the directorates of 12 years' general education 6 1 113 - health services were under the technical and adminis- Nurses : trative supervision of the Ministry of Health, but 9 years' general education 3 3 168 62 since April 1971 they have been transferred to the Auxiliary nurses: 6 years' general edu- administrative authority of the Ministry of Local cation 1'A 15 690 264 Government.The Ministry of Health retains only Laboratory technicians : 9 years' general edu- the responsibility for technical guidance. cation 3 1 44 12 The Minister of Health is assisted by an Under - Radiographers: 9 years' general edu- Secretary of Health. There are six major departments cation 3 1 43 17

Sanitarians : in the Ministry of Health, dealing respectively with 9 years' general edu- preventivemedicine,curativemedicine,endemic cation 3 1 63 29 Assistant pharmacists: diseases, medical equipment and supplies, planning 9 years' general edu- and follow -up and administration and finance. cation 3 1 11

Hospital services Communicable disease control and immunization services In 1971 the Libyan Arab Republic had 80 hospitals providing a total of 8487 beds, of which 8380 were in Tuberculosis occurs in all provinces of the Libyan 76 government hospitals.The bed /population ratio Arab Republic, with a high prevalence in the eastern was 4.2 per 1000.The 8487 beds were distributed as provinces, especially in the towns. Preventive, diagnos- follows : tic, and curative services are provided by a chain of Category and number Number of beds tuberculosiscontrol centres. The comprehensive General hospitals 31 5169 BCG vaccination programme is an integral component Medical centres 31 150 Maternity hospitals 3 330 of the national tuberculosis programme.Contacts Paediatric hospitals 2 183 are investigated.The diagnostic procedures include Tuberculosis hospitals 3 511 Psychiatric hospital 1 1 022 X -ray examination, examination of sputum specimens Emergency hospitals 2 577 Leprosaria 2 102 by direct microscopy, and culture examination.All Ophthalmological hospital 1 125 cases are given complete treatment. Hospitals for the mentally handicapped 2 200 Hospital for diabetics 1 43 Eye diseases are also common in all provinces. Physiotherapy centre 1 75 Trachoma is particularly widespread, mostly in the Outpatient care was available in 1972 at 26 hospital southern and eastern provinces.Treatment of com- outpatient departments, 74 polyclinics, 465 dispen- municable eye diseases through existing health units saries, and 31 medical aid posts. and maternal and child health centres is considered a priority programme in the interior of the country. Medical and allied personnel and training facilities Mass treatment in elementary schools was extended during the years 1970/72 to all schools in rural areas In 1971 the Libyan Arab Republic had 1336 doctors, and to urban schools located in congested areas and of whom 1313 were in government service. The in suburban quarters inhabited by newcomers from doctor /population ratio was one per 1500. Other villages. health personnel included : Diarrhoeal diseases are considered to be one of

Dentists 87 the leading causes of death among infants. Amoebic Dental technicians 48 dysentery is endemic in the country.Schistosomiasis Pharmacists 129 Pharmaceutical assistants 133 is prevalent mainly in the southern provinces and Midwives 382 Assistant midwives 37 gives rise to serious health complications in the pop- Nurses 2 516 ulation of the area. Antimalaria activities are carried Assistant nurses 1 306 Sanitary engineers 40 out in the southern provinces. The western and eastern Sanitarians 117 provinces appear to have been virtually free from Laboratory technicians 151 X -ray technicians 168 malaria since 1965.Malnutrition is considered to be EASTERN MEDITERRANEAN REGION 259

a common factor of infant and childhood mortality Assistance from WHO associated with the peak incidence of bronchopneumonia and measles in the winter months and gastro- In 1972 WHO's assistance to the Libyan Arab enteritis in the summer months. Republic included the following projects: The following immunization procedures were car- Epidemiological services (1971- ): to establish in ried out in 1970: the Ministry of Health a department of epidemiology.

Cholera 1400000 (approx.) Poliomyelitis 357691 Tuberculosiscontrol(1963- )Funds -in- trust: Diphtheria, whooping -cough and tetanus 326190 to implement a national tuberculosis control pro- BCG 149839 Smallpox 94519 gramme. Tetanus 11215 Measles 2126 Gommunicable eye disease control (1969- ) Funds - in- trust: to set up, within the public health infra- Specialized units structure,services for maintaining the control of communicable eye diseases on a permanent basis. There has been a rapid expansion of the maternal and child health services in recent years; in 1972 a Environmental health services (1968- ) Funds - total of 76 centres recorded 99 134 visits by pregnant in- trust: to develop a national environmental health women, 51 220 by children under one year and 45 596 programme and environmental health services. by children aged 1 -5 years.Domiciliary care was Publichealthlaboratory service (1972- ):to given to 5217 pregnant women and 21 590 infants establish a national laboratory service, starting with a and preschool children. central public health laboratory in Tripoli. Antenatal care is well established in most urban Nursing education, Benghazi (1967- ): to develop centres, which have full -time doctors and nurse - the nursing school in Benghazi. midwives.In smaller towns and desert areas attendances are still low, owing mainly to the lack of Maternal and child health, Benghazi (1965 -1972) health education to impart knowledge of the value Funds -in- trust: to train auxiliary maternal and child of antenatal care.The child health services are still health staff for maternal and child health and basic regarded as primarily curative in function.Of all health centres in the eastern provinces. deliveries in 1972, 52.5 % were attended by a doctor or Maternal and child health advisory and supervisory a qualified midwife, either in hospital (46 074 deliveries) activities (1965 -1972) Funds -in- trust: to improve and or at home.There is a school health dispensary in expand maternal and child health work as part of the the capital of each governorate.These dispensaries general health services. are engaged in curative work, mainly treatment of School health services (1972): a consultant advised minor ailments.Dental treatment was given in 1972 on the organization, development, and strengthening at 61 dental clinics and a mobile dental clinic, which of the school health services. together recorded over 430 000 visits.Other outpatient establishments for specialized medical care Healthtraininginstitute,Benghazi(1955- ) included seven psychiatric clinics,16 tuberculosis Funds -in- trust: to train health auxiliaries and sani- clinics and nine mobile tuberculosis units, 14 trachoma tarians, radiographers, laboratory technicians, and clinics, five eye disease clinics and a mobile eye disease male nurses for hospital and health centres, parti- unit, a malaria centre, two leprosy clinics, and three cularly in rural areas. schistosomiasis clinics.There were also 18 public Cancer control (1972- ): to plan a radiotherapy health laboratories. department for the treatment of cancer.

Environmental sanitation Government health expenditure In 1972, 46 communities had piped water systems In the fiscal year 1972/73, total government health serving 44 % of their inhabitants, the remaining 56 expenditure amounted to 43 400 000 Libyan dinars, having access to water from public fountains.In of which 29 700 000 were spent on current account and the same yearseven communities had sewerage 13 700 000 on capital account. The current expenditure systems and about 24 % of the population were living of the Ministry of Health amounted to 5 500 000 in houses connected to sewers. Libyan dinars. 260 FIFTH REPORT ON THE WORLD HEALTH SITUATION

PAKISTAN

Population and other statistics The arrangements for the training of medical and other health personnel in Pakistan are as follows: The following are population estimates for the period under review :' Category DurationNumber of Number of Number of and admission of study schools studentsgraduates Year Population requirements (years) 1971/72 1972 1969 57890000 Doctors : 1970 59990000 Inter -science examina- 1971 62170000 tion 5 71 1 129 1972 64420000 Dentists : Inter -science examination 3 3 78 The estimated crude birth rate is 29 per 1000 pop- Pharmacists ulation, the estimated death rate 11.8 per 1000, and Inter -science examination 2 1 10 the estimated infant mortality rate 130 per 1000 live Nurses : matriculation certificate 3 25 431 births. The rate of population growth during the last Midwives : 10 years has been over 4 %. 8 years' general education 1'A 44 132 The communicable diseases most frequently notified Lady health visitors : in 1972 were: dysentery, all forms (95 957), tuber- matriculation certificate 27 months 5 195 Dispensers: culosis, all forms (59 694), typhoid and paratyphoid matriculation certificate 1 733 Health laboratory techni- fevers(8717),smallpox(7053),whooping -cough cians: (2543), diphtheria (1253), poliomyelitis (911), measles matriculation certificate 1''A 3 110 Physiotherapists: (881), meningococcal infections (451), typhus, tick - Inter- science examina- borne (119), leprosy (51), relapsing fever, tickborne tion 3 1 12 Radiographers: (18), scarlet fever (13). 6 months 1 12 Sanitarians : matriculation certificate 9 months 1 55 Hospital services In 1972 Pakistan had 2690 hospitals and other Communicable disease control and inpatient establishments providing a total of 33 401 immunization services beds.The bed /population ratio was 0.5 per 1000. The 33 401 beds were distributed as follows: The main causes of death in 1972 were malaria, tuberculosis,cardiovasculardiseases,and cancer. Category and number Number of beds The incidence of communicable diseases, including General hospitals 447 23760 intestinal infections, remains high.An outbreak of Rural hospitals 87 390 Medical centres 2111 3217 poliomyelitis in Karachi called attention to the need Maternity hospitals 7 447 Infectious diseases hospitals 5 453 for immunization.Vaccination programmes are in Tuberculosis hospitals 16 2 468 force for smallpox, cholera, and tuberculosis.The Psychiatric hospitals 4 1 736 Ophthalmological hospitals 4 283 smallpox eradication programme is implemented by Hospital for plastic surgery 1 45 the provincial health departments. Leprosaria 5 500 Other establishments 3 102 The following immunization procedures were carried out in 1970: Outpatient facilities were available in 1972 at 496 hospital outpatient departments, 249 health subcentres, Smallpox 24598064 2137 dispensaries, 16 mobile health units, 87 rural BCG 1352162 health centres, and 249 rural health subcentres. National health planning Medical and allied personnel and training facilities A seven -year health scheme was announced in 1972 which aims at an integrated approach to health In 1970 Pakistan had 14 061 doctors, or one doctor problems, bringing together the preventive services, for 3810 inhabitants. Other health personnel included: medical care, and the relief services structure. Delivery Dentists 377 of health care will be effected through successive tiers Dispensers /compounders 5 476 Midwives 616 of health institutions. A planning and research unit Nurse/midwives 2 642 has been set up in the Ministry of Health and Welfare. Health inspectors 1 242 Lady health visitors 1 169 The Ministry with its attached departments formulates Rural health inspectors 296 and coordinates policies for the provincial govern- ' United Nations, Monthly Bulletin of Statistics, May 1974. ments. EASTERN MEDITERRANEAN REGION 261

Assistance from WHO Occupationaltherapyworkshop(1970- ):to In 1972 WHO's assistance to Pakistan included reorganize the work of the occupational therapy unit the following projects : of the Department of Physical Medicine and Reha- bilitation,JinnahPostgraduateMedicalCentre, Tuberculosis control (1962- ) UNDP UNICEF: Karachi, and to improve the orthopaedic workshop. to implement a national tuberculosis control programme integrated into the general health services. Occupational health(1972- ):todevelopa department of occupational health in the Institute of Smallpox eradication (1967- ): to implement a Hygiene and Preventive Medicine, Lahore, for teaching smallpox eradication programme. and research. Malaria eradication programme (1961 - (USAID). Nutrition Institute, Islamabad (1972- ) UNICEF (FAO): to organize a Nutrition Institute at Islamabad Teaching of sanitary engineering, Lahore (1968- ) and promote nutrition programmes and services. UNICEF: to strengthen the postgraduate sanitary engineering course at the University of Engineering Institute of Hygiene and Preventive Medicine, Lahore and Technology, Lahore. (1966- ):to develop postgraduate teaching in public health at the Institute. Communitywatersupplyandruralsanitation (1964- ): to develop the organization and manage- Pharmaceuticalqualitycontrol(1967- ):to ment of .community water supply programmes; and develop services for the quality control of pharmaceu- to improve rural sanitation. tical preparations through the establishment of a National health laboratories, Islamabad (1964- ): central laboratory and the training of staff. to establish national health laboratories in Islamabad, Family planning (1970- ) UNFPA: to plan and with a view to making them reference laboratories implement the health aspects of the national family for the whole country. planning programme and to train technical personnel.

QATAR

Population and other statistics director, who is responsible to the Minister of Health for the administration of the department, which Population estimates and some other vital statistics comprises the following sections reporting straight for the period under review are given in the following to the director: administration, Rumaillah General table: Hospital, Women's Hospital, Doha Hospital, poly- 1969 1970 1971 1972 clinics, dispensaries and clinics, the Health Training Mean population . . . 80 000 80 000 80 000 80 000

Number of live births. . 3 438 3 611 3 921 4 034 Institute, health services, specialist services, pharmacy, Birth rate medical stores, nursing services, and hospital main- (per 1000 population) . 26.2 26.6 30.0 31.0 Number of deaths . . . 422 454 428 593 tenance.Medical services are provided free to all Death rate Qatari nationals and to foreigners resident in the (per 1000 population) . 3.2 2.6 3.2 4.0 Natural increase (%) . . 2.30 2.40 2.68 2.70 country. Number of infant deaths . 178 159 164 170 Infant mortality rate

(per 1000 live births) . 52.0 44.0 42.0 42.0 Number of maternal Hospital services deaths 14 11 4 6 Maternal mortality rate In 1972 the medical care services run by the Govern- (per 1000 live births) 4.1 3.0 1.0 1.5 ment included the Rumaillah General Hospital, the The communicable diseases most frequently notified Doha Hospital, and the Women's Hospital, which in 1970 were : measles (107), influenza (98), tuberculosis, together provided over 600 beds.There were in all forms, new cases (89), bacillary dysentery (88), addition three rural hospitals, at Khor al Odeid, amoebic dysentery (42), whooping -cough (38), infec- Ruwais, and Umm Said.Ambulatory medical faci- tious hepatitis (21), typhoid and paratyphoid fevers lities were available at five hospital outpatient depart- (21), gonorrhoea (18), diphtheria (7), syphilis (6). ments, two polyclinics, five dispensaries, and three medical aid posts. Organization of the public health services Medical and allied personnel and training facilities The responsibility for the health services in Qatar rests with the Ministry of Public Health. The medical In 1971 Qatar had 78 doctors, of whom 68 were in and public health services directorate is headed by a government service. The doctor /population ratio 262 FIFTH REPORT ONTHE WORLD HEALTH SITUATION was one per 1030. Other government health personnel maternal and child health care services and of an included: organizational structure for health education, food control, industrial health, and malaria control. Food Dentists 4 Dental laboratory technicians 5 inspection is inadequate, since there are no relevant Pharmacists 3 Pharmaceutical assistants 12 public health laws. As agriculture is expanding, it is Veterinarians 2 probable that malaria willspreadinthe future; Veterinary assistants 6 Nurses 200 malaria vectors are present in the country and malaria Assistant nurses 28 cases are imported from neighbouring countries. No Nursing aides 130 Sanitarians 9 malariometric survey has yet been carried out. Rodents Physiotherapists 2 are also one of the major public health problems in Laboratory technicians 15 Laboratory aides 10 Qatar and a rodent control campaign is being planned. X -ray technicians 14 As industries are growing very fast in Qatar, there is Biochemist 1 Chemist 1 urgent need for the development of occupational Health educators 5 Health statistician 1 health measures. Medical records officers 10 Vaccinators 18 University education is obtained abroad. Training Social and economic developments of significance for the health situation coursesforsanitationassistants,sanitarians, and nurses are organized in Qatar at the Health Training The opportunities created by the oil industry led to Institute. a sizable immigration of manpower, resulting in a considerable population increase over the last two Immunization services decades.The Qataris at present form only 41 % of Vaccination against smallpox, poliomyelitis, and the total population. Moreover, the economic activity diphtheria is compulsory.A new programme for of the country is overwhelmingly dependent upon vaccinating infants with BCG after the first week of expatriates, who represent 83 % of the economically deliveryisunder consideration. The following active population.The economy of the country is immunization procedures were carried out in 1972: almost entirely dependent on income from oil.The Government, however, plans to diversify the economy. Cholera 80712 The expansion of agricultural land, which depends on Smallpox 31347 Measles 2180 groundwater for irrigation, has been a government BCG 1208 Typhoid and paratyphoid fevers 622 priority,with theresultthat,despiteitslimited Yellow fever 18 potential, Qatar is now a substantial exporter of fresh vegetables to other Gulf States.The educational Specialized units policy of the Government is aimed at achieving national self -sufficiency through a methodical process In1971 Qatar had one prenatal health centre attached to the Women's Hospital. One school health of "Qatarization" of all executive sectors. unit provided health and medical care to the total school population.Dental treatment was given in National health planning 1971to 7445 schoolchildren at two dental clinics for schoolchildren and to 26 269 adults at two clinics During the next five years it is proposed to implement for adults. The psychiatric outpatient clinic recorded a new health plan that provides for the construction 1599 new patients in 1971. Nearly 7000 examinations of a 600 -bed hospital, six health centres in Doha, a were carried out during the year by the public health social centre for the care of the aged, and a nursery laboratory. for orphans and illegitimate children.

Environmental sanitation Assistance from WHO In 1972, 85 % of Qatar's population were served with piped water, 25 % of its inhabitants were living In 1972 WHO's assistance to Qatar included the in houses connected to sewers, and 75 % had septic following project: tanks for sewage disposal. Training of health personnel (1969- ): to train auxiliary health personnel for staffing health services Major public health problems and hospitals; also to develop in- service and refresher Important health problems confronting the health training of health personnel already in government authoritiesinQatar arethelack of specialized employment. EASTERN MEDITERRANEAN REGION 263

SUDAN

Population and other statistics centres. The staff of these establishments is seconded from the Ministry of Health and Social Welfare, At the last census, taken in January 1956, the which is still responsible for the technical supervision recorded population of the Sudan, based on the results through the provincial medical officer.Coordination of a sample survey, was 10 262 536. The mean pop- between the Ministry of Health and Social Welfare ulation estimates and other estimated vital statistics and the Ministry of Local Government is secured by for 1971 and 1972 were: delegation of powers of both ministries to the provin- 1971 1972 cial medical officer of health.The health establish- Mean population 16087 00016489 000 Number of registered live births 700 000 742 000 ments are mainly financed by the Ministry of Local Birth rate (per 1000 population) 45.0 45.0 Government, the Ministry of Health and Social Number of registered deaths 300000 330 000 Death rate (per 1000 population) 20.0 20.0 Welfare providing a grant representing 20 % of the Natural increase (%) 2.5 2.5 total.Health plans, which are elaborated by the Number of infant deaths 91 000 96 000 Infant mortality rate (per 1000 live births) 130.0 129.4 provincial executive councils in collaboration with the provincial medical officers of health, are sub- The communicable diseases most frequently notified mitted for approval to the provincial authority and in 1972 were: malaria (713 392), influenza (172 405), subsequently to the Ministry of Health and Social meningococcal infections (4253), infectious hepatitis Welfare for scrutiny and technical evaluation and to (3574), diphtheria (1619), typhoid fever (957), small- theMinistry of Local Government forfinancial pox (827), relapsing fever (56). approval. In each province there is at least one provincial Organization of the public health services hospital, which until recently was run by the provincial medical officer of health and is now administered by a The overall responsibility for the health services in management board with the provincial medical officer the Sudan rests with the Minister of Health and of health as chairman and the senoir medical officer Social Welfare.The Permanent Under Secretary as secretary or executive officer. The district hospitals the civil service head of the Ministry. He is assisted are in the charge of medical inspectors, and the by five deputies dealing respectively with preventive dispensaries, located in rural areas, are run by medical medicine, curative medicine, finance and planning, assistants.Dressing stations, which are the most training and international health, and provincial affairs. outlying medical units, are supervised by a male Each deputy has an assistant. The Ministry comprises nurse. Child welfare centres are run by health visitors. the following divisions, each headed by a chief: vital Sanitation is the responsibility of a senior public health and health statistics, smallpox, nutrition, industrial inspector or a health officer, depending on the size of medicine, medical commission, communicable eye the provincial executive council concerned.Sanitary diseases, malaria, and medical stores.The teaching overseers or assistant sanitary overseers are responsible and specialized hospitals in Khartoum, Khartoum for sanitation at peripheral health posts. North, and Omdurman are run by directors, whose functions it was planned to transfer to management Hospital services committees. The central research laboratory is headed by a director. In 1972 the Sudan had 115 hospital establishments At the provinciallevel,the provincial medical with 13 962 beds (excluding the beds in the maternity officer of health is in charge of all health services in hospital), which is equivalent to 0.8 beds per 1000 his province. He is also a member of the provincial population. Outpatient services were available at executive council, a function that adds to his responsi- the hospital outpatient departments; at 124 health bility because of the passage of a new Provincial centres, staffed by medical assistants, nurses and, in Administration Act that gives increased authority in urban areas, sometimes by doctors; at 627 dispensaries, health administration to provincial authorities.The which have the same staffing pattern as health centres; provincial medical officer of health is assisted by an and at 1393 dressing stations, staffed by male nurses asssistant medicalofficerof health,a provincial only. public health inspector, a provincial medical assistant, and a superintendent nursing officer. Medical and allied personnel and training facilities The provincial authority is now responsible for environmental sanitation, hospitals, health centres, In 1972 the Sudan had 1168 doctors, of whom 1007 dispensaries,dressingstations,and childwelfare were in government service.The doctor /population 264 FIFTH REPORT ON THE WORLD HEALTH SITUATION ratio was one to 14100.Other health personnel reservoir by casedetection,treatment and mass included: prophylaxis, and antilarval measures including aerial spraying where feasible. Medical assistants 993. Dentists 81 It is estimated that tuberculosis occurs in the whole Dental assistants 59 Dental laboratory technicians 4 country, that the prevalence is high, and that infection Pharmacists 289 takes place early in life. Although less prevalent than Pharmaceutical assistants 12 Auxiliary midwives 3 501 formerly -mainly owing to health education, improv- Nurses 200 ed health conditions, and rising standards of living - Auxiliary nurses 8 252 Sanitary engineers 2 diarrhoeal diseases are still very common and remain Public health officers /public health inspectors 240 the commonest cause of morbidity and mortality Assistant sanitarians 251 Physiotherapists 6 among infants. Schistosomiasis occurs in all provinces Laboratory technicians 38 Assistant laboratory technicians 137 and is one of the most important causes of morbidity X -ray technicians 118 in the country. The problem has been aggravated by Cardiology technicians 8 the rapid development of agricultural schemes.In In government service. the Gezira irrigated areas the prevalence of Schistosoma The arrangements for the training of medical and mansoni infection is over 60 %.Control measures other health personnel in the Sudan are as follows : include snail control by sulfation, the use of mechanical barriers in canals, surveillance, treatment of cases, and Category DurationNumber of Number of Number of health education. and admission of study schools studentsgraduates requirements (years) (public) 1972 1972 During the period under review smallpox endemicity Doctors : continued to be heavy in the southern provinces and certificate of secondary education 6 1 180 60 major epidemics occurred, particularly in 1970. The Pharmacists : incidence remained low in the six northern provinces. certificate of secondary education 4 1 50 38 The first smallpox vaccination programme was carried Veterinarians : out by the Government between 1962 and 1964, certificate of secondary education 6 1 100 41 during which about 8 800 000 people were vaccinated Nurses (university course): in eight of the nine provinces. The second smallpox secondary education 3 1 16 16 vaccination programme, in combination with a BCG Laboratory assistants: certificateofprimary vaccination campaign, commenced in January 1969. education 2 1 48 48 The aim was to eradicate smallpox from the Sudan by Medical assistants : certificateofprimary vaccinating the entire population within as short a education 2 8 97 194 Dental auxiliaries: time as possible, to protect the population in the age certificateofprimary group 0 -19 years against tuberculosis, and to integrate education 2 1 26 26 Auxiliary nurses: BCG vaccination in the routine work of the basic certificateofprimary health services. education 3 41 1 095 892 Midwives : The following immunization procedures were car- nursing certificate and ried out in 1972: 3 nursing training . 1 119 110 Auxiliary midwives: Smallpox 2481529 9 months 9 296 286 BCG 105009 Laboratory technicians : Cholera 103772 certificate of secondary Yellow fever 14608 education 3 1 40 - X -ray technicians : certificate of secondary education 3 1 40 14 Specialized units Sanitary overseers: certificateofprimary In 1972 maternal and child health care was based on 6 months 1 20 20 education 124 maternal and child health centres, which were Communicable disease control and attended by 524 735 pregnant women and 616 876 children up to 5 years of age. In the same year 82 646 immunization services deliveries were attended by a doctor or a qualified Malaria isstill considered the most important midwife, either in hospital or at home. Dental care endemic disease in the country. The existing malaria was given to schoolchildren at 16 hospital dental control programme was reorganized in 1970 with health units and to adults at 25 dental clinics in health control operations integrated as a routine activity of centres. The 12 school health units provided medical the general health services. Initial efforts were concen- supervision to 54 158 schoolchildren.The hospital trated on reducing malaria in areas of economic rehabilitation department was attended by 130 554 importance. The principal control measures used are patients.Psychiatric consultations were available at insecticide residual spraying, depletion of the parasite seven clinics, where 44 599 patients were recorded EASTERN MEDITERRANEAN REGION 265

in 1971.Medical and health services were provided from neighbouring countries and from the jungle areas. in 419 industrial establishments.There were also The health infrastructure, which was severely damaged seven outpatient units for specialized medical care by the civil disturbances, is being reconstructed. and 128 public health laboratories. National health planning Environmental sanitation The national health plan is part of a comprehensive At the end of 1972 it was estimated that 90 % of the development plan for 1970 -1975.This plan places population of the Khartoum area (770 000) was particular emphasis on the development of preventive served by a piped water supply and 10 % had access to and social medicine. The control of endemic diseases, water from public fountains.However, the problem such as schistosomiasis, malaria, tuberculosis, leprosy, of rural water supply is very serious in Sudan and is gastrointestinal diseases, and kala -azar, the care of aggravated by the size of the country, of which a large mothers and children, nutrition, the health of school- area is desert. In many areas there is an acute water children,health education,vaccination,industrial shortage and, where water is available, itis often health, environmental sanitation, and the development unsafe for drinking.The planning of rural water of statistics are priority objectives of the health plan. supplies and the execution of the plans are the respon- Other main programmes of the plan are the develop- sibility of the Department of Land Use, which has a ment of rural health services through the improvement rural water supply and soil conservation board. Many of the health infrastructure -namely, the extension of artesian wells are drilled every year in priority areas the dispensary and health centre network, the intro- and geological surveys are carried out to locate duction of mobile health units for the care of the sources of potable water. Only Khartoum and nomadic population, which represents 25 % of the Khartoum North have public sewerage systems. The total population, and the training of village midwives sewerage system in Khartoum serves about 40 % of as multipurpose health workers in rural areas. With the population, while that in Khartoum North serves regard to health personnel training, the plan provides only industrial plants, no domestic sewage being for the establishment of a postgraduate medical collected. education board, and the opening of a new medical faculty and of a technical institute forspecialist training and auxiliary training. The programmes for Major public health problems the provision of specialist services to regional and The most important public health problems still district hospitals, and for the development of research to be solved are malaria, tuberculosis, schistosomiasis, related to the main health problems of the country diarrhoeal diseases, smallpox, and communicable eye are also given high priority. diseases.The deficiency of rural water supplies is another important problem. Assistance from WHO In 1972 WHO's assistance to the Sudan included the Social and economic developments of significance following projects: for the health situation Leprosy control (1972- ): to establish a pilot The period under review was marked by develop- demonstration area for testing the practicability of ments in the social, cultural, and economic fields. simple methods for leprosy control, and to draw up There was a considerable expansion in education and implement a leprosy control programme, inte- with the opening of 2177 schools of various grades. grated into the basic health services. Efforts were made to improve agricultural productivity Smallpox eradication (1967- ). and14 115 government and privateagricultural Malaria control programme (1963- ): to build up schemes were operating in the country. The country's the technical, administrative, and operational facilities industrial potential was increased during the period for a control programme as a step towards malaria under review with the establishment of 620 new eradication and at the same time to develop the rural industries. This overall development has been reflected health services. in a higher standard of living, in better health conditions, and particularly in lower infant mortality. Malaria eradication training centre (1963- ): to Unemployment has decreased to a comparatively train staff for the malaria service. low level.Following the settlement of the conflict Onchocerciasis control (1963- ):to carry out in southern Sudan at the end of 1972 and the end periodic surveys of onchocerciasis infection; to develop of the civil war, which had lasted for 17 years, thou- a programme for prevention and control of the disease; sands of refugees requiring medical care returned and to train personnel. 266 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Mycetoma survey (1969- ): to define the extent Occupational health (1969- ):to develop the of the mycosis problem. division of occupational health and draw up an Sanitary engineering course, University of Khartoum occupational health programme. (1967- ):to improve the teaching of sanitary Applied nutrition programme (1966- ) UNDP/ engineering subjects to students of civil engineering. FAO UNICEF: to develop nutrition services and Environmental health(1965- 1972):to plan and programmes. develop a national environmental health programme Medical education (1971- ): to develop medical and to organize, in the Ministry of Health, a sanitary education at undergraduate and postgraduate levels. engineering service to undertake it. Pharmaceutical quality control (1972): a consultant Community water supply in rural areas (1968- 1972): advised on the pharmaceutical industry in the Sudan to solve general problems of rural water supply. and on the services for quality control of pharma- Publichealthadvisoryservices,southernregion ceutical preparations, includingstaff requirements (1972- ) UNICEF: to strengthen the planning, and training needs. organization, and administration of the health services in the southern region. Government health expenditure National public health laboratory service (1971- ) In the fiscal year 1971/72 the central government UNDP: to establish a national public health labora- health expenditure amounted to 10 650 000 Sudanese tory service. pounds, of which 9 000 000 were current expenditure Training of X -ray technicians (1970- ). and1 650 000 were capital expenditure. Current government health expenditure included the following: Advisoryservicesinvitaland healthstatistics 245 000 Sudanese pounds for administration and (1970- ): to strengthen the vital and health statis- government personnel; 225 000 for mass campaigns tics unit in the Ministry of Health, develop a vital and against communicable diseases (200 000 for smallpox health statistics system, and train staff. and 25 000 for eye diseases); 30 000 for vaccination Teaching of paediatrics (1969- ) UNICEF: to and immunization of children; 47 000 for laboratory strengthen teaching and research work in the Depart- services, and 6800 for occupational health services. ment of Paediatrics, Faculty of Medicine, University The central government per capita expenditure on of Khartoum. health was 0.67 Sudanese pounds.

SYRIAN ARAB REPUBLIC

Population and other statistics 81in motor -vehicleaccidents), pneumonia (800), malignant neoplasms (545), cerebrovascular disease At the last census, taken in September 1970, the (517), bronchitis, emphysema and asthma (466), birth population of the Syrian Arab Republic was 6 304 685. injury, difficult labour and other anoxic and hypoxic Population estimates and some other vital statistics conditions, other causes of perinatal mortality (298), for the period under review are given in the following measles (241), meningitis (234). table : The communicable diseases most frequently notified 1969 1970 1971 1972 in 1971 were: measles (1585), whooping -cough (1133), Mean population . . 6050000 6 260 000 6 451 000 6 670 000

Number of live births . . 181 925 191 728 206507 241 505 dysentery, all forms (710), malaria, new cases (622), Birth rate typhoid and paratyphoid fevers (486), meningococcal (per 1000 population) . 30.1 30.6 32.0 36.2 Number of deaths . . . 26 327 29 783 29 014 27 629 infections (68), diphtheria (61), tuberculosis of the Death rate (per 1000 population) . 4.4 4.8 4.5 4.1 respiratory system, new cases (58), infectious hepatitis Natural increase ( %) . . 2.57 2.58 2.75 3.21 (49), influenza (34), poliomyelitis (27), trachoma (16), Number of infant deaths . 4 542 4 706 4 856 5 029 Infant mortality rate leprosy (14). (per 1000 live births) . 25.0 24.5. 23.5 20.8 Of the 27 629 deaths recorded in 1972, the main Hospital services causes were: 1 symptoms and ill- defined conditions In 1971 the Syrian Arab Republic had 79 hospitals (16 483), chronic rheumatic heartdisease,hypertensive disease, ischaemic heart disease and other and other establishments for inpatient care providing a total of 5945 beds, of which 4786 were in government forms of heart disease (3213), accidents (934, including establishments. The bed /population ratio was 0.9 per 1 International Classification of Diseases, 1965 Revision. 1000. The 5945 beds were distributed as follows : EASTERN MEDITERRANEAN REGION 267

Category and number Number of beds clinic, three schistosomiasis clinics, 13 malaria clinics, General hospitals 20 2 852 Maternity hospitals 13 330 and three public health laboratories. Infectious diseases hospitals 4 108 Tuberculosis hospitals 3 580 Psychiatric hospitals 2 710 Hospitals for internal medicine 3 343 Assistance from WHO Hospitals for general surgery 31 792 Ophthalmological hospitals 2 30 Leprosarium 1 200 In 1972 WHO's assistance to the Syrian Arab Republic included the following projects: Outpatient facilities were available in 1972 at the hospital departments, 101 health centres, 114 dispen- Advisory services in epidemiology (1972- ): to saries, and two mobile health units. set up, in the Ministry of Health, a department of epidemiology for the control or eradication of the most prevalent communicable and noncommunicable Medical and allied personnel and training facilities diseases.

In 1971 the Syrian Arab Republic had 1673 doctors, Tuberculosiscontrol(1965- )UNICEF:to equivalent to one doctor for 3860 inhabitants. Other implement a national tuberculosis control programme. health personnel included : Communicableeyediseasecontrol(1966- ) Dentists 445 UNDP: to carry out a study of the epidemiology of Pharmacists 874 Veterinarians 86 trachoma and related eye infections, develop methods Veterinary assistants 267 Midwives 873 for their control, train personnel, and set up services Assistant midwives 337 for maintaining the control programme permanently Nurses 1 130 Assistant nurses 517 and extending it. The arrangements for the training of medicaland Malaria eradication programme (1956- ) UNDP. allied personnel were as follows: Development of theTechnicalHealthInstitute Category DurationNumber ofNumber of (1971- ) UNDP: to develop the Institute in order and admission of study schoolsgraduates requirements (years) (public) 1972 toprovide trainedhealth personnel of different Doctors: categories for the health services and improve the baccalauréat 6 2 446 Dehtists: technical standards of health workers. baccalauréat 4 1 76 Pharmacists: Euphrates pilot irrigation project (health aspects) baccalauréat 4 1 95 Laboratory technicians: (1972) UNDP /FAO: a consultant advised on the baccalauréat 2 1 31 public health engineering aspects of the irrigation Sanitarians: baccalauréat 2 1 23 development scheme in the project area and made X -ray technicians: recommendations on water supply and waste disposal baccalauréat 2 1 16 Assistant anaesthetists: facilities for a pilot area comprising 14 villages. baccalauréat 2 1 25 Pharmacy assistants: Publichealthand endemicdiseaseslaboratory baccalauréat 2 1 28 Nurses: (1959- ): to develop the services of the public 9 years' general education 3 6 255* Midwives: health and endemic diseases laboratory, and partic- 9 years' general education and ularly the food microbiology section. basic nursing training 1 4 62* * Data incomplete. Nursing education, Damascus (1960- ): to develop a pattern of nursing education that will provide Immunization services graduate nurses to meet the needs of the health services. The following immunization procedures were car- School health services (1972): a consultant advised ried out in 1970: on and assisted in the preparation of a long -term BCG 224 020 programme for the strengthening and development of Smallpox 72 147 school health services, including training of personnel.

Specialized units Medical education (1972- ): to develop medical education,givingspecialattentiontoimproving In 1972 maternal and child health care was provided teaching of the basic medical sciences and community at 27 prenatal centres and 27 child health centres. medicine and to the further training of teachers in There were also 147 school health service units, 49 their subjects and in educational science and method- dental clinics, eight tuberculosis clinics, one trachoma ology. 268 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Community- oriented education, Faculty of Medicine, Government health expenditure Aleppo (1966 -1972) UNDP: a WHO consultative group In 1972 total government expenditure amounted to helped to draw up a request for UNDP assistance in 3188 million Syrian pounds, of which 48.5 million establishing a Faculty of Medicine at the University of were spent on health services. Per capita expenditure Aleppo. The Faculty enrolled its first students in 1967. by the Government for health purposes was thus Teachers are provided and fellowships awarded. 7.3 Syrian pounds.

TUNISIA

Population and other statistics public health administrator, is subdivided into medical districts (circonscriptions). There is a regional hospital At the last census, taken in May 1966, the population in each governorate and an auxiliary hospital in each of Tunisia was 4 533 351.Population estimates and medical district.At the local level there are multi- some other vital statistics for the period under review purpose dispensaries that serve a population of from are given below: 1000 to 10 000 inhabitants. About 90 % of the popu-

1969 1970 1971 1972 lation is entitled to free medical services, which are

Mean population . 5 027 000 5 137 000 5241 000 5 380 000 financed by social security funds. Number of live births 1 . 194 940 185 756 182 749 198 785 Birth rate (per 1000 population) . 38.8 36.2 34.9 36.9 Number of deaths' . . . 52872 45435 48762 40053 Hospital services Death rate (per 1000 population). 10.5 8.8 9.3 7.4 Natural increase ( %) 2.83 2.74 2.56 2.95 In 1971 Tunisia had 90 hospitals and other inpatient Number of infant deaths 1 15156 13 344 13 934 ... Infant mortality rate establishments providing a total by 12 571 beds - (per 1000 live births) 77.7 71.8 76.2 equivalent to 2.4 beds per 1000 population.These Number of deaths, 1 -4 years 1 11 063 7 758 8 044 12 571 beds were distributed as follows:

Registered events only (it is estimated Category and number Number of beds and 73% of all deaths are registered). General hospitals 19 7631 Local or rural hospitals 54 2 272 The communicable diseases most frequently notified Medical centres 8 76 Paediatric hospital 1 300 in 1972 were: early syphilis (1154), infectious hepatitis Blood transfusion institute 1 29 (952), typhoid and paratyphoid fevers (904), menin- Cancer hospital 1 141 Ophthalmological hospital 1 131 gococcal infections (536), tuberculosis, all forms, new Orthopaedic hospital 1 95 amoebiasis(62), Tuberculosis hospitals 3 878 cases(216),poliomyelitis(67), Mental hospital 1 1 018 diphtheria (33), malaria, new cases (19), leprosy (17), cholera (4), typhus (4). Ambulatory medical care was provided at hospital outpatient departments and at 388 dispensaries. Organization of the public health services Medical and allied personnel and training facilities The Ministry of Public Health is responsible for all health and medical activities in the country. The In 1971 Tunisia had 1004 doctors -equivalent to Minister of Public Health is assisted by the Higher one doctor for 5220 inhabitants. Other health person- Public Health Council and by the Public Health nel included: Inspectorate- General, which includes a programming and planning service. At the central level the Ministry Dentists 76 Pharmacists 163 of Public Health comprises the Directorate of Technical Veterinarians 34 Services and the Directorate of Administrative and Midwives 225* Medical supervisors 196* Financial Coordination.The subdirectorates under Senior male nurses 321* Nurses 2 989' the control of the Directorate of Technical Services Nursing aides 4 361* are responsible for public health and epidemiology, Technical personnel 392' preventive and social medicine, and pharmacies and Social assistants 51' laboratories. In government service. The country is divided into 13 governorates, which correspond to the health regions. Each governorate, The arrangements for the training of medical and the health services of which are supervised by a other health personnel in Tunisia are as follows: EASTERN MEDITERRANEAN REGION 269

Category DurationNumber of Number of Number of and admission of study schools studentsgraduates 42 % of the population. In the same year 77 commu- requirements (years) (public) 1971/72 1972 nities with 688 000 inhabitants had sewerage systems Doctors : and about 13 % of the population lived in houses baccalauréat plus 1 preparatory year 6 1 connected to sewers. Pharmacists : baccalauréat 5 Nurses : 5 years' secondary edu- National health planning cation 2 3 316 271 Midwives : The Ministry of Public Health is responsible for 7 years' secondary education 3 3 31 21 national health planning. There is, however, no special Laboratory technicians : 5 years' secondary edu- unit in charge of health planning. A four -year plan cation 2 1 28 23 for the development of basic health services was Physiotherapists : baccalauréat 3 7 7 prepared for the period 1969 -1972. Sanitarians : baccalauréat 3 1 Training given in medical faculty. Assistance from WHO In 1972 WHO's assistance to Tunisia included the Communicable disease control and following projects: immunization services Malaria eradication programme (1966- ) UNDP. Although the available data are incomplete, itis Schistosomiasis control (1970- estimated that 50 -60 % of all patients attending rural ): to carry out an epidemiological andmalacologicalsurveyof dispensaries are treated for intestinal parasitoses and schistosomiasis, intensify control measures, and train gastrointestinal infections.Tuberculosis is the most personnel. important communicable disease, followed by syphilis, gastrointestinal infections, infectious hepatitis, cere- Environmental health services (1962- ) UNDP: brospinal meningitis, helminthiasis, trachoma, and to develop a national environmental health programme schistosomiasis.Malaria was a major public health and train personnel. problem until1968, but owing tothesuccessful Liquid and solid wastes disposal (1971- 1972): two malariaeradicationcampaign,thecountryhas consultants carried out surveys of the system for reached the consolidation phase. disposal of liquid and solid wastes and made recom- The following immunization procedures were car- mendations for improvements. ried out in 1972: Health planning (1972- ): to analyse available Cholera 1 400813 select health Smallpox 724995 information on the health situation, Poliomyelitis 663578 programmes, projects and strategic areas that should BCG 329029 Typhoid and paratyphoid fevers 104392 be developed, review the sectoral plan for health Tetanus, whooping- cough, diphtheria. . 91467 within the context of the fourth national socioeconomic Tetanus 2876 Yellow fever 325 development plan, and develop health and medical care services. Specialized units Nursing education (1964- ) UNDP: to strengthen the nursing services and nursing schools. In 1971 maternal and child health care was based on 96 centres, which recorded 53 563 prenatal consul- Advisory servicesinvital and healthstatistics tations, 313 160 consultations for infants under one (1968- ) UNDP: to develop a system of vital and year and 446 995 consultations for children aged 1 -5 health statistics through the establishment of a per- years.The total school population was under the manent statistical service in the Ministry of Public medical and health supervision of 13 school health Health and the training of national staff. units. Other specialized units included a hospital Medical education (1961- ): to develop medical rehabilitation outpatient department, three psychiatric education. outpatientclinics,threetuberculosisclinics,an Cancer control (1972- ) : to develop the program- ophthalmological clinic, and a cancer clinic.There me of the National Cancer Institute. were 28 public health laboratories in 1971. Family planning aspects of maternal and child health Environmental sanitation (1971- ) UNFPA: to develop integrated maternal and child health and family planning services as part In 1971, 258 communities with a total population of the health services, train personnel, and develop of 2 100 000 had piped water systems serving about biomedical research. 270 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Government health expenditure were spent for health purposes, including 1 900 000 dinars on central administration and 12 700 000 on In1971totalgovernment currentexpenditure hospitals. The per capita government expenditure on amounted to 154 000 000 dinars, of which 14 600 000 health was 2.8 dinars.

FRENCH TERRITORY OF THE AFARS AND THE ISSAS

Population and other statistics which 823 were in 10 government establishments. The bed /population ratio was 9.4 per 1000. The 943 beds Population estimates and some other vital statistics were distributed as follows: for the period under review are given in the following table: Category and number Number of beds General hospitals 2 820 1969 1970 1971 1972 Rural hospitals 4 78 Medical centres 5 45 Mean population . . 90 000 100 000 100 000 100 000

Number of live births . . 3 767 3 664 3 918 3 838 Birth rate Outpatient facilities were available in 1971 at eight (per 1000 population) . 41.9 36.6 39.2 38.4 hospital outpatient departments, one polyclinic, 15 Number of deaths . . . 603 707 1 343 988 Death rate dispensaries (of which four had inpatient facilities), (per 1000 population) . 6.7 7.1 13.4 9.9 20 medical aid posts, and four mobile health units. Natural increase ( %) . . 3.52 2.95 2.58 2.85 Number of infant deaths . 177 189 324 198 Infant mortality rate 82.7 51.6 (per 1000 live births) . 47.0 51.6 Medical and allied personnel and training facilities Number of deaths, 1 -4 years 53 39 213 80 In 1971 the Territory had 44 doctors, of whom 41 The communicable diseases most frequently notified were in government service.The doctor /population in 1972 were :influenza (3989), tuberculosis of the ratio was one per 2200.Other health personnel respiratory system, new cases (1151), bacillary dysen- included: tery(484),measles(359), whooping -cough (259), Dentists 4 typhoid fever (150), smallpox (93),malaria, new Dental mechanics 2 Pharmacists 5 cases (25, of which 24 were imported cases), meningo- Pharmaceutical assistants 6 coccal infections (24), poliomyelitis (11), leprosy (9), Veterinarian 1 Veterinary assistant 1 diphtheria (9), amoebiasis (9), trachoma (8). Midwives 4 Assistant midwives 9 Nurses 68 Organization of the public health services Assistant nurses 220 Assistant sanitarians 9 Physiotherapist 1 Following the law of July 1967, public health has Laboratory technicians 7 become the responsibility of the territorial authorities. Assistant laboratory technicians 8 X -ray technicians 6 The Ministry of Public Health and Social Affairs, which was established within the Government Council A training and professional education centre in of the Territory, is in charge of all health activities. Djibouti organizes a one -year course for the training The two main divisions in the Ministry are the Direc- of nurses. This course was attended by 21 students torate of Public Health and the Service for Public in 1971. Hygiene and Epidemiology. The Directorate of Public Health is responsible for the organization and Communicable disease control and administration of both the urban and the rural health immunization services establishments, for medical supply, for education and training of health personnel and for the control of The French Territory of the Afars and the Issas is communicable diseases. free from most of the tropical diseases.Malaria, The Territory is divided into four administrative amoebiasis, schistosomiasis, filariasis, trypano- areas, each of which has a medical centre headed by a somiasis, and yaws do not occur in the Territory, medical officer.Six rural dispensaries are attached to except as imported cases.There was an epidemic the four medical centres. outbreak of cholera in 1971 with 346 cases. Smallpox also occurred in epidemic form during the period under review, with 27 cases in 1971 and 79 cases in Hospital services 1972. Tuberculosis is the only important endemic In 1971 the French Territory of the Afars and the disease in the Territory.This disease is aggravated Issas had 11 hospitals with a total of 943 beds, of by malnutrition, particularly among children. Bacillary EASTERN MEDITERRANEAN REGION 271 dysentery and other gastrointestinal infections are of khat, deficiencies in environmental sanitation in common Djibouti, and the need to develop rural health and The following immunization procedures were car- maternal and child health services, the health author- ried out in 1972: ities are faced with problems of organization. These include the need to formulate a more coherent policy Cholera 147365 BCG 27714 with a view to establishing better coordination between Smallpox 26660 Diphtheria 3891 the various health sectors, a more suitable hospital Tetanus 2712 structure, and better qualified health administration Typhoid and paratyphoid fevers 2400 Whooping -cough 971 and nursing manpower. Yellow fever 843

Specialized units National health planning In 1971 there were five prenatal centres and one The period under review has been covered by the child health centre.Domiciliary care was given to fifth French five -year plan (1966 -1970) and by the 3036 pregnant women. Of all deliveries in 1971, 2534 sixth French plan (1971 -1975).In the fifth plan the were institutional. The five school health units provided main emphasis was placed on improvement and exten- medical and health services to the total school pop- sion of the medical infrastructure in the rural areas, ulation. The three dental health units were attended organization of tuberculosis control, and extension of in 1971 by 6850 patients.During the year 443 new hospitalfacilities. The improvement of hospital outpatients were recorded at the independent medical facilities in Djibouti, the reorganization of maternal rehabilitation centre.Psychiatric consultations were and child health care, and increased accessibility of given at two clinics to 197 new outpatients.The the health services are given first priority in the sixth tuberculosis clinic recorded 2373 patients. There were plan. also three public health laboratories.

Environmental sanitation Government health expenditure In 1971, 12 communities had water supply systems. In 1971 total government expenditure amounted to None of the communities had a sewerage system.In 2 490 000 000 Djibouti francs, of which 375 700 000 Djibouti, 65 % of the inhabitants were served with were spent on health services. The per capita govern- piped water and 35 % with water from public fountains. ment health expenditure was 3757 Djibouti francs. In the other communities, between 10 % and 25 % of Government health expenditure included the following the inhabitants had piped water. outlays : 205 900 000 Djibouti francs for government administration and personnel, 13 200 000 for environ- Major public health problems mental health services, and 156 700 000 for hospitals. An additional sum of 50 700 000 Djibouti francs for In addition to the health problems of the Territory, tuberculosis control activities was charged to the among which are tuberculosis, malnutrition, chewing metropolitan budget.

WESTERN PACIFIC REGION

AUSTRALIA

Population and other statistics the local authorities.The powers of the Federal Government in the health field are limited to general At the last census, taken in June 1971, the popula- supervision, tion of Australia was 12 755 638. Population estimates quarantine, and the payment, under and some other vital statistics for the period under statutory authority, of certain benefits which, broadly review are given in the following table: speaking, help to defray the cost of medical care to the individual. 1969 1970 1971 1972 Each of the six states has a minister of health who

Mean population . 12263 00012507 300 12755 600 12959 100 is responsible to the government of the state for the

Number of live births. 250176 257516 276362 264969 Birth rate administration of the health department, and for the (per 1000 population) 20.4 20.6 21.7 20.4 proper functioning of the state hospital commission. Number of deaths . . . 106 496 113 048 110 650 109 760 Death rate This latter body consists of a government- appointed (per 1000 population) . 8.7 9.0 8.7 8.5 board that supervises the administration and manage- Natural increase ( %) . . 1.17 1.16 1.30 1.19 Number of infant deaths . 4 482 4 604 4 777 4 430 ment of the public hospitals. The state health depart- Infant mortality rate

(per 1000 live births) . 17.9 17.9 17.3 16.7 ment is responsible for the provision of a wide range Number of deaths, of public health services, including maternal and child 1 -4 years 837 882 842 883 Death rate, 1 -4 years (per welfare, health education, mental hospitals, tubercu- 1000 population at risk) 0.9 0.9 0.9 0.9 Number of maternal losis sanatoria, and environmental sanitation. Certain deaths 44 66 51 33 of these functions are shared with the health depart- Maternal mortality rate ments of the local government bodies and are the (per 1000 live births) . . 0.2 0.3 0.2 0.1 executive responsibility of a medical officer of health The communicable diseases most frequently notified and his staff.In one of the most populous states - in 1972 were: gonorrhoea (11 017), infectious hepatitis New South Wales -the Minister of Health is assisted (6118),tuberculosis,all forms, new cases (1221), by the chairman of the New South Wales Health syphilis, new cases (1215), diphtheria (61), menin- Commission.Under this officer the Commission is gococcal infections (encephalitis) (48), leprosy (39), organized in the following four bureaux, each of typhoid and paratyphoid fevers (21), poliomyelitis (7). which is headed by a commissioner: the bureau of manpower and management services; the bureau of Organization of the public health services personal health services, which isresponsible for public and psychiatric hospitals; the bureau of environ- The national health services in Australia are con- mental and special health services, which is responsible trolled by the Federal Government in Canberra. The for maternal and child health, epidemiology, immu- organization provides for a Federal Minister of State nization, care of the physically handicapped, nutrition, for Health, who exercises political control of the health education, occupational health, etc. ; and the Australian Department of Health, which is headed by bureau of finance and physical resources. The Com- a Director -General.The Australian Department of mission is at present establishing 14 regional offices in Health hasfunctionaldivisionsfor management New South Wales, each to be under the control of a services, national health and medical research, medical regional director.Eventually, many of the central services, policy and planning, therapeutics, public activities will be delegated to each region. health, and a national biological standards laboratory. The Department directly administers 17 pathology Hospital services laboratories in various parts of Australia, and certain laboratoriesforspecialpurposes -e.g.,radiation, In 1972 Australia had 2197 hospitals and other accoustics, and serology. The School of Public inpatient establishments providing a total of 160552 Health and Tropical Medicine, the Institute of Child beds, or 12.4 beds for 1000 population. Health, and the Institute of Anatomy are also con- With a view to promoting the regionalization and trolled by this Department. The Australian Depart- modernization of hospital services,linkedto the ment of Health has offices in each state and is also development of community -based health services and represented overseas. Inthe Australian Capital preventive health programmes, the Australian Govern- Territory and the Northern Territory itis charged ment hasestablishedan InterimCommittee on with certain duties that in the states are carried out by Hospitals and Health Services.This Committee has - 275 - 276 FIFTH REPORT ON THE WORLD HEALTH SITUATION

proposed a major community health programme to course of community -based surveys is compulsory. In develop facilities and services in a coordinated manner addition, routine chest X -rays of migrants are carried for the provision and planning of prevention, treat- out prior to their leaving for Australia. ment and rehabilitation, and related welfare aspects of Poliomyelitis has ceased to be a problem in Aus- community health. tralia following the use of Salk vaccine and, more The Australian Government is establishing com- recently, Sabin vaccine.There were seven non -fatal munity healthcentresintheAustralianCapital poliomyelitis cases in 1972, as compared with 1144 Territory and the Northern Territory for which it cases and 57 deaths in 1956.Infectious hepatitis has direct responsibility.Community health centres remains one of the most prevalent infectious diseases are considered to be an important mechanism for in Australia and presents one of the most difficult shifting emphasis away from hospital inpatient care problems owing to the inability to isolate or culture to community care, reducing the fragmentation and the organism. The disease continues at a high level, duplication of services, and offering a means of although there was an apparent decline in incidence achieving better coordination between health services during the period under review, with 6118 cases in and related welfare services. 1972 as compared with 8143 cases in 1968. Since 1970 542 150 doses of rubella virus vaccine have been made Medical and allied personnel available to the states by the Federal Government for public health compaigns aimed at the immunization of In1971Australia had 16 107 doctors, or one nonpregnant women of childbearing age and of girls doctor for 790 inhabitants.Other health personnel aged 12 -14 years in particular. included: The following immunization procedures were car-

Dentists 3 477 ried out in 1972: Pharmacists 8 046 Professional nurses (including midwives) . 56646 Poliomyelitis 1636490 Other nurses 12 413 Tetanus 1 196478 Trainee nurses 20461 Diphtheria, whooping -cough and tetanus . 1012581 Hospital and nursing auxiliaries 32 839 Cholera 577952 Veterinarians 1 375 Smallpox 456179 Physiotherapists 1 865 Diphtheria and tetanus 440884 Radiographers 1 049 Typhoid and paratyphoid fevers 313670 Chiropodists- 287670 Optometrists 636 Rubella 230560 Other professional medical workers 1 917 Measles 108850 Typhoid fever and cholera 92567 Yellow fever 7686 Communicablediseasecontrolandimmunization Plague 7218 Typhoid and paratyphoid fevers and tetanus 7008 services Diphtheria 4941 Whooping -cough 1 738 The growth of air travel has increased the risk of Epidemic typhus 128 importing diseases into Australia.Nevertheless, as a Number of doses released. result of the work of the quarantine service, the country has remained free of "quarantinable" infec- Chronic and degenerative diseases tious diseases, with the exception of 41cases of cholera reported in 1972, all arising from one incident, Chronic and degenerative diseases continue to be traced to contaminated food served during a plane the major causes of death in Australia. In 1971 flight. These cases were the first notifications of arteriosclerotic heart disease caused 3O.34°ó of all cholera since the occurrence of a single imported case deaths in that year, or 262.6 deaths per 100 000 in 1969. During 1972, 189 cases of imported malaria inhabitants. In 1971, 47 deaths per 100 000 inhabitants were diagnosed. Leprosy occursinthe tropical were due to malignant disease of the digestive organs regions, particularly in the Northern Territory and and peritoneum.The number of deaths from lung thenorthernpartofWesternAustralia,where neoplasms continues to increase and accounted for altogether 26 cases were notified during the year. 3.08 % of all deaths in 1971.The National Heart The number of notifications of new tuberculosis Foundation of Australia, founded in 1961 and opera- cases continued to decrease, falling from 14.9 per ting in all states of Australia, provides advice on the 100 000 inhabitants in 1969 to 11.4 per 100 000 in 1972. prevention of cardiac disease and rehabilitation of The tuberculosis mortalityrate has also declined those who have suffered an attack. Educational steadily, from 14.9 deaths per 100 000 inhabitants in programmes through the media of radio, television, 1952 to 1.4 per 100 000 in 1971. The control of tuber- newspapers, and booklets and pamphlets prepared by culosisisastateresponsibility,but considerable statehealthauthorities and cancer organizations encouragement and support is given by the Federal have played a prominent role in informing the general Government. Attendance for chest X -ray during the public of the dangers of cancer and of its prevention WESTERN PACIFIC REGION 277 and early detection.Services for cervical cytology Administration of the present system of voluntary are available in all states. health insurance hasbeentransferred from the Australian Department of Health to the Department of Major public health problems Social Security. Under the present system the public may obtain financial aid in defraying the cost of Owing to geographical variations and to differences hospital and medical services.Persons who insure in the degree of urbanization the public health prob- themselves are eligible, after obtaining treatment, for lems of country areas differ from those of major cities. Australian Government hospital and medical benefits The latter must contend with the growing problems of that supplement amounts payable by a health organi- noise, accidents, and environmental pollution, whereas zation known as Fund Benefit. The patient is required, the problems of rural areas are caused by the remote- however, to meet a small portion of the cost of the ness of these areas from medical services.Radio medical services he receives.In 1970 the Australian communications and flying doctor services have been Government introduced the Subsidized Health Benefits created. Plan to assist the following persons in meeting the In general, however, the health problems of Aus- costsofhealthinsurance:low- incomefamilies, tralia are similar to those of other industrialized persons receiving unemployment, sickness or special Certain infectious diseases, such as infec- countries. benefits, and newly arrived migrants.Families with tious hepatitis, venereal diseases, and tuberculosis, two or more dependants are eligible for assistance are still considered to be public health problems, but under the Plan.The medical benefits scheme was compared with the chronic degenerative diseases, revised and medical benefits were more closely related mental illness, and accidents, they are of lesser impor- to thefees most commonly charged by medical tance. practitioners. More recently, the Government has developed a Social and economic developments of significance national health insurance plan that is designed to for the health situation bring comprehensive health care within the reach of During the period under review, much attention every citizen. The new programme will cover medical was given to road safety and air pollution from motor services on a fee -for -service basis, free standard ward vehicles.The number of automobile accidents, and hospital treatment, and some provision for community of persons killed and injured thereby, increased in health centres, ancillary health services, and domi- 1969 -1970 but decreased in 1971 -1972.In 1970 the ciliary services. The health insurance scheme will be Federal Government set up an Expert Group on Road funded by a health insurance fund financed by a 1.35 Safety to advise the then Minister of Shipping and levy on taxable incomes, a matching government Transport and to initiate research into the road subsidy, and other sources.The programme will accident problem.The Expert Group conducted a provide for the exemption of low- income families national review of Australia's road accident situation. and ceilings will be fixed for contributions from persons A publicity advisory committee on education in road with higher incomes. safety was established in 1970.During 1971 /72 the Since 1970 the Government has provided financial Australian Government provided $A 450 000 for assistance for a national drug education campaign. promotion of road safety practices.Measures were also taken to overcome vehicle engine emissions. Medical and public health research During the years 1969 -1972 the Government gave great emphasis to science and technology and their A wide range of research in the basic medical application to economic development. Increasing sciences, clinical medicine, and public health is carried attention was also given to their social implications out in the universities, hospitals, and other medical and use in solving social problems.A separate institutions. Ministry of Science was created in 1972 to coordinate The Federal Government supports medical research existing scientific and technological developments and by triennial disbursements to the Medical Research to formulate new policies. New Ministries for Environ- Endowment Fund from which grants are made on the ment and Conservation and for Urban and Regional advice of the National Health and Medical Research Development were also established. The responsibil- Council.During the financial year 1971/72 grants ities of these ministries include aspects that are directly totalling 2 689 204 Australian dollars were awarded relevant to national health -e.g., support for bio- for the support of research projects, postgraduate and medical research and population control. In the area undergraduate scholarships, and overseas travelling of employment, an employment policy for handicapped fellowships. These grants make up some 25 % of the persons was established during the period under total identifiable medical research expenditure and review. enable the Council to exercise a leading influence in 278 FIFTH REPORT ON THE WORLD HEALTH SITUATION

the development of research.The largest of these Medicine at the University of Sydney is part of the grants in 1971/72 amounted to $A 354 323 and was Australian Department of Health. made to the Walter and Eliza Hall Institute of Medical Other funds for medical research are provided by Research in Melbourne. TheGovernment also the state governments and a number of nongovern- indirectly supports medical research through general mental organizations, such as the National Heart grants to universities and special departmental insti- Foundation, the Life Insurance Medical Research tutions and laboratories.Thus, the John Curtin Fund of Australia and New Zealand, the Australian School of Medical Research in Canberra is entirely Post -graduate Federation in Medicine, and a number supported by grantstothe Australian National of anticancer councils.Additional funds are also University. The School of Public Health and Tropical provided by private bequests.

JAPAN

Population and other statistics whooping -cough (206), meningococcal infections (49), leprosy (49), malaria, new cases (13), amoebiasis (11), At the last census, taken in October 1970, the popu- typhus (tsutsugamushi) (8), poliomyelitis (6). lation of Japan was 103 720 060. Population estimates and some other vital statistics for the period under review are given in the following table : Hospital services

1969 1970 1971 1972 In 1971 Japan had altogether 39 171 hospitals and Mean population . . 103160 000104330 000105600 000106960 000 other inpatient establishments providing a total of Number of live births . . 1889815 1934239 2022 204 2038 678 Birth rate 1 338 056 beds, of which 376 699 were in 2627 govern- (per 1000 population) 18.5 18.8 19.1 19.3 ment establishments. The 1 338 056 beds -equivalent Number of deaths . 693 787 712 962 689 542 683 760 Death rate to 12.7 beds per 1000 population -were distributed (per 1000 population) . 6.8 6.9 6.5 6.5 Natural increase (%) . . 1.17 1.19 1.26 1.28 as follows: Number of infant deaths. 26874 25412 25035 23777 Infant mortality rate Category and number Number of beds 13.1 12.4 11.7 (per 1000 live births) 14.2 General hospitals Number of deaths, 8026 856836 Medical centres 30 062 255 409 1 -4 years 7 374 7 467 7 237 7 493 Infectious diseases hospitals . 30 2510 Death rate, 1 -4 years (per Tuberculosis hospitals 139 21 689 1000 population at risk) 1.1 1.1 1.0 1.0 Psychiatric hospitals 900 188 395 Number of maternal Leprosaria 14 13 217 deaths 1 094 1 008 905 818 Maternal mortality rate (per 1000 live births) . 0.58 0.52 0.45 0.40 Outpatient care was available in 1971at 6943 Of the 689 542 deaths recorded in 1971, the main hospital establishments, 30 062 medical centres, and 39 795 polyclinics. causeswere: 1cerebrovasculardisease(176 952), malignant neoplasms (122 850), chronic rheumatic heart disease, hypertensive disease, ischaemic heart Medical and allied personnel and training facilities disease, other forms of heart disease (102 915), symptoms and ill- defined conditions (45 684), accidents In 1971 Japan had 121 254 doctors, or one doctor (42 433, including 21 101 in motor -vehicle accidents), for 860 inhabitants. Other health personnel included: pneumonia (23 102), suicide and self -inflicted injuries Dentists 38143 (16 239), tuberculosis, all forms (13 609), bronchitis, Dental hygienists 9887 emphysema and asthma (13 583), cirrhosis of liver Dental technicians 6973 Pharmacists 57945 (12 994),birthinjury,difficultlabour and other Veterinarians 21214 anoxic and hypoxic conditions (12 409), nephritis and Midwives 27811 Nurses 148418 nephrosis (8567),diabetesmellitus(7647),peptic Assistant nurses 156591 Auxiliary nurses 137320 ulcer (7388). Sanitary engineers 3955 The communicable diseases most frequently notified Sanitarians 23664 Physiotherapists 1983 in1971 were: tuberculosis,all forms, new cases Occupational therapists 404 (157 684), influenza (39 474), measles (22 153), scarlet Orthoptists 202 Laboratory technicians 18038 fever (9597), gonorrhoea (7299), bacillary dysentery X -ray technicians 12822 (5822), syphilis, new cases (5105), trachoma (5071), Other health auxiliaries 178282 diphtheria (433), typhoid and paratyphoid fevers (329), The arrangements for the training of medical and 1International Classification of Diseases, 1965 Revision. other health personnel in Japan are as follows: WESTERN PACIFIC REGION 279

Category DurationNumber of Number of of study schools students Specialized services (years) 1971 Doctors : In 1972 maternal and child health care was based on premedical 2 53 4 540 university 4 595 centres.In 1971,1 943 002 confinements took Dentists : predental 2 19 1 700 place in hospital. Almost all deliveries were attended university 4 by a doctor or a qualified midwife. In the same year Pharmacists : prepharmaceutical 2 32 5 290 there were 15 752 school health service units, 30 317 university 2 dental clinics,1171 Veterinarians : rehabilitation departments at- preveterinary 2 16 680* tached to hospitals, about 4700 psychiatric outpatient university 2 clinics, and 905 public health laboratories. Nurses 2 -4 500 18 004 Assistant nurses 2 -3 772 32 779 Public health nurses (university) 4 51 1 510 Midwives 4 48 1 150 Radiology technicians 3 22 785 Assistance from WHO X -ray technicians 2 9 695 Health laboratory technicians . 2 61 2 560 In 1972 WHO's assistance to Japan included the Clinical laboratory technicians . 3 15 840 Dental hygienists 1 -2 65 2 235 following project: Dental technicians 2 37 1 330 Physical therapists 3 8 140 College of Health Sciences, University of the Ryukyus Occupational therapists 3 3 60 (1970- 1970 data. ): to strengthen the College, which was set up in 1969 to train nurses, midwives, medical technol- Immunization services ogists, biostatisticians, health education workers, and epidemiologists. The following immunization procedures were carried out in 1972:

BCG 4489083 Government health expenditure Diphtheria, whooping -cough and tetanus 3614326 Smallpox 3360739 Poliomyelitis 2839498 During the fiscal year 1972/73, central government Diphtheria 1949926 health expenditure amounted to181 563.3 million Diphtheria and whooping -cough 543616 Cholera 155300 yen, of which 181 235.2 million were spent by the Whooping -cough 16948 Ministry of Health and Welfare and 328 000 000 by Tetanus 6189 Typhoid and paratyphoid fevers 44 other ministries.

KHMER REPUBLIC

Population and other statistics Organization of the public health services At the last census, taken in April 1962, the popula- Responsibility for the health services in the Khmer tion of the Khmer Republic was 5 728 771. Population Republic rests with the Ministry of Public Health. estimates for the period under review are as follows: The Higher Council of Health acts in an advisory capacity to the Ministry.The Director -General of 1969 6 701 000 Health is the executive head of the health administra- 1970 6 818171 1971 6 968169 tion.The Directorate -General of Health has four 1972 7 121 468 directorates dealing respectively with public health In 1969 the birth rate was estimated at 45 per 1000 and preventive medicine, public health laboratories, inhabitants, the death rate as 17 per 1000, the infant pharmaceutical and chemical services, and hospitals mortality rate at 80 -120 per 1000 live births, and the and health establishments. natural increase at 2.8 %. The provincial health structure is being progressively The communicable diseases most frequently notified reorganized.Each province will be supervised by a in 1970 were: influenza (28 142), gonorrhoea (13 978), provincial director of health. Three to five provincial tuberculosis, all forms, new cases (6279), amoebiasis health directorates will form a regional health direc- (5761), scarlet fever and streptococcal sore throat torate, at the head of which will be a public health (5638), malaria, new cases (5616), syphilis, new cases physician with the title of regional health director. (5527), trachoma (3139),measles (1528), bacillary dysentery (1244), typhoid and paratyphoid fevers (317), Hospital services infectious hepatitis (160), leprosy (113), diphtheria (83), In 1971 the Khmer Republic had 94 hospitals and poliomyelitis (15). other inpatient establishments providing a total of 280 FIFTH REPORT ON THE WORLD HEALTH SITUATION

7500 beds, of which 5448 were in 54 government - in hypoendemic or in hyperendemic form, the latter maintained establishments. The bed /population ratio form obtaining in the forest areas. The malaria pre - was 1.1 to 1000. The 7500 beds were distributed as eradication programme, which commenced in 1963, follows: became in 1969 a malaria control project with the aim Category and number Number of beds of protecting the population at risk, particularly in General hospitals 33 5 922 areas of special socioeconomic importance.Control Rural hospitals 27 379 Maternity centres 32 479 activities included spraying operations, active and Psychiatric hospital 1 666 passive case -detection, followed by treatment. When Ophthalmological clinic 1 54 hostilities broke out in 1970, control operations were Outpatient facilities were available in 1971 at 35 curtailed and field activities were limited to safe areas. hospital establishments, 10 polyclinics with hospital- Spraying operations and active case -detection were ization facilities, 27 health centres with hospitalization sharply reduced. facilities, 19 dispensaries, and 485 infirmaries.The The following immunization procedures were car- staff of the dispensaries, which serve municipal or ried out in 1972: suburban areas, consists of two or three nurses and Cholera 730907 one or two midwives.The infirmaries, located in Smallpox 319397 BCG 57538 rural areas, are staffed by a male nurse, often assisted Plague 61 by an auxiliary midwife. Yellow fever 10

Medical and allied personnel and training facilities Specialized units In 1971 the Khmer Republic had 438 doctors, of While maternity care has been considerably ex- whom 381 were in government service. The doctor/ panded, the health care of children is still generally population ratio was one to 15 910.Other health limited to curative services. In 1971, 69 180 pregnant personnel included: women, 39 468 infants under one year, and 80 096

Dentists 71 children aged 1 -5 years attended the maternal and Pharmacists 79 child health centres. School health servicesare Midwives 478 Auxiliary midwives 948 provided by the Ministry of Education in cooperation Nurses 2 786 with the Ministry of Public Health. One hundred and Auxiliary nurses 853 Sanitary engineer 1 twenty -three school first -aid posts have been established Assistant sanitarians 463 in the provinces and 27 in Phnom Penh. Of the total Laboratory technicians 46 school population, 36 % had access to these services. The arrangements for the training of medical and The psychiatric hospital outpatient department re- other health personnel in the Khmer Republic are as corded 6584 new patients in 1971.The 16 public follows : health laboratories carried out 479 490 examinations. Category DurationNumber of Number of and admission of study schools students requirements (years) (public) 1971/72 Environmental sanitation Doctors : 14 years' general education . 6 1 1085 In 1972, about 8 % of the country's population were Dentists : served with piped water to their dwellings, approxi- 14 years' general education . 5 1 61 Pharmacists : mately 39 % were living within reasonable distance of 5 1 540 14 years' general education. . a water supply, and about 3 % were living in houses Nurses : 1 250 12 years' general education . . 3 connected to sewers. Auxiliary nurses: 10 years' general education . . 1 1 200 Midwives : Assistance from WHO 12 years' general education. . 3 1 100 Auxiliary midwives: 10 years' general education . 1 2 In 1972 WHO's assistance to the Khmer Republic Laboratory technicians: included the following projects: 12 years' general education . 3 1 60 Sanitarians : 12 years' general education . 1 1 80 Tuberculosis control (1965 -1972) UNICEF: to set up the nucleus of a national tuberculosis control Communicable disease control and service, with emphasis on preventive measures, and to immunization services carry out a control programme. The number of people at risk from malaria infection Malaria control (1962- ) UNDP: to extend in the Khmer Republic in 1969 was estimated at antimalaria activities progressively in order to protect 2 200 000. There is no malaria in the towns or in the the 2 3 million people living under malaria risk; and central plains. Elsewhere the disease is present either to promote the development of an integrated health WESTERN PACIFIC REGION 281

service by training malaria personnel and involving Trainingoflaboratorytechnicians(1968- ) the rural health services in malaria case detection and UNDP: to train laboratory technicians for the health treatment. laboratory services in Phnom Penh and the provinces. Epidemiology and health statistics (1966- ): to Organization and operation of healthlaboratory establish in the Ministry of Public Health an epidemio- services (1972- ): to organize laboratory services, logical and health statistical service; to study local strengthen and develop the resources of the Institute epidemiological patterns of causes of morbidity and of Biology, improve health laboratory services in the mortality; to réorganize the health statistics systems in hospitals and dispensaries, and train laboratory staff. health care institutions; and to train personnel. Medicalservicesadministration(1971- 1972):a Environmental health advisory services (1968- ): consultant assisted in assessing the urgent health needs to establish a public health engineering unit in the of the population during the present emergency and Ministry of Public Health; and to draw up and imple- recommended measures for improving the situation. ment countrywide environmental health programmes. Rehabilitationof thephysicallyhandicapped Water supply for Kompong Som (1970 -1972) UNDP: (1971- ) UNDP: to establish a unit that could to study and implement a medium -term water supply later become a school for training therapists and set development programme that would meet the needs up a national rehabilitation service. of the population until 1980. Educationandtrainingofhealthpersonnel Water supply and sewerage, Phnom Penh (1972 -1973) (1971- ) : to develop and strengthen the centres for UNDP: two consultants assisted the Government in the training of all categories of health personnel and formulating a project request for a programme of to develop a community health centre to serve as a improvement and development of the water supply, model for centres to be established in other parts of sewerage, and drainage systems of Phnom Penh. the country. Irrigation and drainage networks of the Prek Thnot Government health expenditure River (1972) UNDP /FAO: WHO advised on the public health measures to be considered in planning In 1972 the total government health expenditure for the population affected by the FAO -assisted amounted to 707 100 000 riels. The per capita govern- irrigation and drainage project. ment health expenditure was thus nearly 100 riels.

LAOS

Population and other statistics Organization of the public health services

Population estimates for Laos for the period under The responsibility for health services in Laos rests with the Ministry of Public Health, which comprises review were as follows: the Cabinet of the Minister, the Higher Public Health Year Population Council, the National Health Council, the Health 1969 2893 000 Services Inspectorate, and the Directorate -General 1970 2962000 1971 3033000 of Public Health. The Directorate -General is respon- 1972 3106000 sible for all technical health matters and is divided into the directorate for administrative affairs, the In 1971 the birth rate was 45.9 per 1000 population, directorate for hospitals and personnel training, and the death rate 22.5 per 1000, and the natural increase the national public health services. These last -named 2.34%. services deal with maternal and child health, hygiene The communicable diseases most frequently notified and preventive medicine, pharmacies, laboratories, in 1971 were: malaria, new cases (21 243), influenza and the school of public health. Each province in Laos (16 541), amoebiasis (3197), gonorrhoea (2807), bacil- has a medical officer. lary dysentery (1700), whooping -cough (1518), rabies in man (1017), trachoma (976), syphilis, new cases Hospital services (905), measles (575), pulmonary tuberculosis, new cases (496), typhoid and paratyphoid fevers (159), In 1971 Laos had 17 general hospitals with a total leprosy (37), meningococcal infections (26),polio- of 2283 beds, and eight rural hospitals.Outpatient myelitis (25). medical care was provided in 1972 at 15 hospital 282 FIFTH REPORT ON THE WORLD HEALTH SITUATION

establishments, four health centres, and 135 rural graphic reconnaissance, spraying operations in limited dispensaries. areas, epidemiological survey and assessment, ento- mological observations, and drug distribution. Medical and allied personnel and training facilities Tuberculosis also represents a very serious health problem. Systematic BCG vaccination campaigns have In 1971 Laos had 228 doctors and assistant doctors, been organized to cover the population aged 0 -15 of whom 14 were in government service and 64 served years. Rabies is endemic in dogs in the Vientiane area the armed forces. The doctor and assistant doctor/ and human beings are exposed to the disease with population ratio was one to 13 290.Other health marked frequency. Leprosyisfairlyprevalent. personnel included: Schistosomiasisis common on the banks of the Mekong River and on Khong Island. Other prevalent Dentists and assistant dental surgeons 15* endemic diseases are dysentery, typhoid fever, and Dental mechanics 5 Pharmacists 15* venereal diseases. Pharmaceutical aides 26 The following immunization procedures were car- Veterinarian 1 Assistant veterinarians 19 ried out in 1972: Veterinary nurses 133 Midwives 22 Auxiliary midwives 147 Cholera 369444 Nurses 770 Smallpox 265391 Assistant laboratory technicians 35 BCG 51211 X -ray operators 10 Diphtheria, whooping -cough and tetanus . 9181 Tetanus 4514 Health statistician 1 Poliomyelitis 1 551 * Including 4 serving the armed forces. The arrangements for the training of medical and Specialized units other health personnel in Laos are as follows: In 1972 maternal and child health care was provided Category DurationNumber ofNumber of Number of at 59 centres, which were attended by 14 941 pregnant and admission of study schools students graduates requirements (years) (public) 1971/72 1972 women and 32 972 children. A family planning policy Doctors : was adopted by the Government in 1972.Other 3 DEPC 1 or BEPC 5 1 227 8 Dentists : specialized health care establishments included a DEPC or BEPC . 5 1 30 2 school health service unit, a medical rehabilitation Pharmacists : centre, and a public health laboratory. DEPC or BEPC . 5 1 42 3 Nurses :

DEPC 3 1 49 11 Auxiliary nurses: CEPCEL3 2 2 88 81 Major public health problems Auxiliary midwives : CEPCEL 2 4 53 18 Laboratory technicians: The main health problems are connected with CEPCEL 2 1 8 8 deficient environmental sanitation- namely, inade- X -ray operators : CEPCEL 2 1 7 7 quate waste disposal and lack of water supply and Pharmaceutical aides: sewerage systems in urban areas. CEPCEL 2 1 6 5

1 Diplôme de fin d'études du premier cycle de l'enseignement secon- daire (certificate of secondary education). National health planning 2 Brevet d'études secondaires du premier cycle (secondary education, first phase). 3 Certificat d'études primaires complémentaires de l'enseignement A High Commissioner for Planning is in charge of lao (certificate of primary education). formulating, controlling and coordinating the implementation of national plans. The goals set out in the Communicable disease control and master plan for 1969 -1974 gave first priority to major immunization services projects such as the international airport and to the production sector (which includes agriculture), and Only limited information isavailable regarding the Vientiane Plain development scheme. Aspects of a communicable diseases, partly because of the restric- national health policy were reflected in the master plan tion of movement as a result of the hostilities. From document. The health plan comprised the following available information it is evident that the greater projects: development of public health services in the part of Laos is malarious, with varying degrees of Vientiane Plain, malaria control, tuberculosis control, endemicity. However, for security reasons, the opera- remodelling of the hospital of Luang Prabang, estab- tional areas are restricted to the plains of Vientiane lishment of a pharmaceutical control laboratory, and Province, which have a rural population of nearly construction of a maternal and child health centre in 200 000.The main activities have consisted of geo- the Mahosot hospital, Vientiane. WESTERN PACIFIC REGION 283

Assistance from WHO Vitalandhealthstatisticsadvisoryservices In 1972 WHO's assistance to Laos included the (1968- ): to establish a vital and health statistics following projects: service in the Ministry of Public Health and to train staff. Malaria control (1969- ) : to build up the administrative and operational facilities of the central malaria Nutrition advisory services (1968- ) UNICEF: to service to the level required to carry out an antimalaria improve nutritional levels in the community and to programme, in the first place in the Vientiane Plain. coordinate all food and nutrition work. Development of health services (1968- ) UNDP Royal School of Medicine (1967- ) : to strengthen UNICEF: to develop and strengthen the general the faculty of the Royal School of Medicine. healthservices,beginning in Vientiane Province, Workshop in medical education (1972) : WHO assisted which will serve as a pilot area; to organize a central in organizing a workshop to acquaint medical teachers advisory body to review the organization, programmes with the latest advances in teaching and learning and coordination mechanism of the health services; methods. and to formulate and carry out a programme for training health manpower. Maternal and child healthlfamily welfare (1971- ) UNFPA UNICEF: to provide effective maternal and Health laboratory services,Vientiane (1953- ) child health care and advise on family planning. UNICEF :to establish a public health laboratory service and train laboratory personnel. Government health expenditure Nursing education(1962- ) UNDP UNICEF (USAID) (Asia Foundation) (Colombo Plan): to set During the fiscal year July 1971 -June 1972 total up a school of nursing and midwifery for training government health expenditure amounted to personnel for the country's hospital and health services. 544 355 000 kips, which was equivalent to a per capita Rehabilitationof thephysicallyhandicapped government health expenditure of K. 178. The expen- (1967- ) UNDP (United Nations Office of Tech- diture on general public health services included nical Cooperation) : to assess the extent of the problem K. 243 788 000 for education and training of health of the physically handicapped, plan and operate personnel and K. 77 859 000 for environmental health rehabilitation facilities and train staff, and review services.The government expenditure on hospitals legislation dealing with the physically handicapped. amounted to K. 107 990 000.

MALAYSIA

In 1963 Malaysia came into being, replacing the 1969 1970 1971 Infant mortality rate (per 1000 live Federation of Malaya.The states of the former births) 43.2 40.8 38.5 Number of deaths, 1 -4 years. . . . 5 653 4 837 4 572 Federation of Malaya are now referred to as Peninsular Death rate, 1 -4 years (per 1000 popu- Malaysia, Sabah, and Sarawak. lation at risk) 4.92 4.20 4.00 Number of maternal deaths . 469 411 383 Maternal mortality rate (per 1000 live births) 1.57 1.4 1.24 PENINSULAR MALAYSIA 1 Of the 64 304 deaths recorded in 1971, the main causes were :1 congenital anomalies, birth injury, Population and other statistics difficult labour and other anoxic and hypoxic condi- At the last census, taken in August 1970, the populations,other causes of perinatal mortality (3386), tion of Peninsular Malaysia was 8 780 728.Popula- symptoms and ill- defined conditions (3137), accidents tion estimates and some other vital statistics for the (2911,including77inmotor -vehicleaccidents), period 1969 -1971 are given in the following table: chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease and other forms of heart 1969 1970 1971 disease (2634), malignant neoplasms (1598), cerebro- Mean population 9018 836 9244 848 9487 510 Number of live births 297 963 297 358 309 378 vascular disease (1380), pneumonia (1090), tubercu- Birth rate (per 1000 population) . 33.0 32.2 32.6 Number of deaths 65 378 64 035 64 304 losis, all forms (977), bacillary dysentery and amoe- Death rate (per 1000 population) 7.2 6.9 6.8 biasis, enteritis and other diarrhoeal diseases (493), Natural increase (%) 2.58 2.53 2.58 Number of Infant deaths 12 872 12130 11 915 suicide and self -inflicted injuries (458), nephritis and 1 See also under Malaysia (p. 287). 1 International Classification of Diseases, 1965 Revision. 284 FIFTH REPORT ON THE WORLD HEALTH SITUATION

nephrosis (323), diabetes mellitus (289), anaemias The arrangements for the training of medical and (273), bronchitis, emphysema and asthma (241). other health personnel in Peninsular Malaysia are as The communicable diseases most frequently notified follows : in 1972 were :pulmonary tuberculosis, new cases Category DurationNumber of Number of Number of (6658), dysentery, all forms (1680), typhoid and para- and admission of study schools studentsgraduates typhoid fevers (1149), poliomyelitis (765), amoebiasis requirements 1971/72 1972 (592), leprosy (412), diphtheria (344), cholera El Tor Doctors : higher school certificate 6 years 1 264 110 (287), yaws, new cases (268), bacillary dysentery (152), Dentists : higher school certificate 5 years 1 62 37 typhus (35), meningococcal infections (11). Pharmacists : higher school certificate 4 years 1 - - Laboratory assistants : middle schoolcertifi- Hospital services cate 3 years 1 90 - Radiographers : middleschoolcertifi- In 1971 Peninsular Malaysia had altogether 214 cate 2 years 1 69 25 Staff nurses : hospitals and other inpatient establishments providing middle schoolcertifi- a total of 30 695 beds, of which 25 243 were in 63 cate 3 years 4 1 373 267 and 4 government hospitals. The bed /population ratio was months 3.2 to 1000.The 30 695 beds, to which 625 626 Hospital assistants : middleschoolcertifi- patients were admitted, were distributed as follows : cate 3 years 1 14 13 and 4 Category and number Number of beds months Assistant nurses: General hospitals 63 18 266 7 -8 years' general edu- Medical centres 132 3 784 cation 2 years 16 903 484 Surgery hospitals 2 35 Nurse /midwives : Maternity hospitals 6 218 must be qualified staff Ophthalmological hospital 1 7 nurse 1 year 4 193 179 Tuberculosis hospitals 3 622 Midwives : Ear, nose and throat hospital 1 4 7 -8 years' general edu- Psychiatric hospitals 2 4218 cation 2 years 19 363 137 Chronic diseases hospital 1 77 Dispensers: Leprosarla 2 3 399 middleschoolcertifi- 1 65 Convalescent home cate 1 year 1 163 53 Public health inspectors: lower school certificate 1 year 1 125 79 Outpatient facilities were available in 1972 at the Dental nurses: followingestablishments:thehospitaloutpatient middleschoolcertifi- cate 3 years 1 186 186 departments and medical centres, which recorded and 4 months nearly 8 000 000 attendances; 301 dispensaries, which Dental technicians: recorded over 3 500 000 attendances; and 240 travelling middle schoolcertifi- cate 28 months 1 39 39 dispensaries, which recorded over1 000 000 atten- Malaria inspectors: dances. middle schoolcertifi- cate 3 months 1 42 42

Medical and allied personnel and training facilities Immunization services

In 1971 Peninsular Malaysia had 1881 registered The following immunization procedures were car- doctors, of whom 1029 were in government service. ried out in 1972: The doctor /population ratio was one to 4770 inhabitants. Other health personnel included: Diphtheria, whooping -cough and tetanus . 443324 BCG 352765 Smallpox 404836 Dentists 579 Diphtheria 262785 Dental technicians 108* Dental nurses 512* Pharmacists 250 Midwives 3 012 Specialized units Nurses (registered) 5 499 Assistant nurses 2 372 Sanitary engineers 3* In 1972 Peninsular Malaysia had a total of 1631 Public health inspectors 425* Public health overseers 393* centres for the care of mothers and children, which Physiotherapists 21* Medical laboratory technicians 787* recorded over 4 800000 attendances and 2000000 home Laboratory assistants 213* visits. The entire school population has access to the Radiographers 124* Biochemists 6* general health establishments but there are no separate Entomologists 5* school health services.There were 624 dental health 150* Malaria inspectors units, of which 252 were for schoolchildren, 154 for In government service. adults, and 218 for preschool children. In 1972, 433 011 WESTERN PACIFIC REGION 285 schoolchildren and 304 648 adults received dental treat- mentation of health programmes and policies in the ment. Medical rehabilitation outpatient services were State. He is assisted by a deputy director, a principal available at one independent centre and 14 hospital medical officer (health), a principal dental officer, a rehabilitation departments. There were five government principal matron, a principal medical officer (tubercu- psychiatric outpatient clinics, and 81 state mining hos- losis), a government malariologist, and a chief health pitals offering health and medical services to workers. superintendent. Other specialized outpatient facilities included six The State of Sabah is administratively divided into tuberculosis clinics, five venereal diseases clinics, 57 four residencies with Labuan Island, and 22 adminis- leprosy outpatient clinics (which recorded 633 new trative districts, two to four of which form an area patients in 1971), six filariasis control teams, and a health unit or health district under the direction and yaws team.Peninsular Malaysia also had 64 public supervision of an area medical officer. health laboratories.

Hospital services SABAH 1 In 1972 Sabah had 14 hospitals and other inpatient establishments providing a totalof 2013 beds - Population and other statistics equivalent to 2.7 beds per 1000 population. There were At the last census, taken in August 1970, the popu- an additional 384 beds in 37 dispensaries. During the lation of Sabah was 651 304.Population estimates year, 60 869 patients were admitted to the inpatient and some other vital statistics for the period under establishments. review are given in the following table: Outpatient facilities were available in 1972 at 14 hospitaldepartments,37dispensaries,andfive 1969 1970 1971 1972* travelling dispensaries. Mean population . . 636 566 663 647 694 989 733 253

Number of live births . . 24 473 24 558 24 127 25 959 Birth rate (per 1000 population) . 38.4 37.0 34.7 35.4 Medical and allied personnel and training facilities Number of deaths . . . 3 251 3 805 3 734 3 553 Death rate (per 1000 population). 5.1 5.7 5.4 4.8 In 1972 Sabah had 84 doctors, of whom 46 were in Natural increase ( %) . . 3.33 3.13 2.93 3.06 Number of infant deaths . 663 804 751 661 government service. The doctor /population ratio was Infant mortality rate thus one to 8950.Other health personnel included, (per 1000 live births) . 27.1 32.7 31.1 25.5 Number of deaths, in 1971: 1 -4 years 394 441 362 358 Death rate, 1 -4 years (per Dentists 69* 1000 population at risk) 4.5 Dental nurses 27 Number of maternal Dental laboratory technicians 11 deaths 47 22 Pharmacists 3 Maternal mortality rate Pharmaceutical assistants 7 (per 1000 live births) . 1.9 0.9 Veterinarians 17 Veterinary assistants 36 * United Nations data. Midwives 183* Assistant midwives 261 The communicable diseases most frequently notified Nurses and hospital assistants 571* Assistant nurses and assistant nurses in training 326* in 1971 were: malaria, new cases (21 834), influenza Sanitarians 43 (8579), tuberculosis, all forms, new inpatients (1273), Assistant sanitarians 16 Physiotherapists 2 gonorrhoea (239), bacillary dysentery (98), infectious Laboratory technicians 20 (88),amoebiasis(69), (26), Assistant laboratory technicians 23 hepatitis diphtheria X -ray technicians 7 typhoid fever (26), syphilis, new cases (12), cholera (10), leprosy (9). 1972 data. The arrangements for the training of health personnel Organization of the public health services in Sabah are as follows:

Category DurationNumber of Number of Number of The Federal Ministry of Health, which assumed and admission of study schools studentsgraduates responsibility for the Medical and Health Department requirements (public) 1971/72 1972 of Sabah in 1971, determines major health policies of Hospital assistants and nurses: the State.The Department of Medical and Health Senior Cambridge 3 years and Services,Sabah, however, continuestoenjoya school certificate . 3 months 1 132 17 Midwives: considerable degree of autonomy.The Director of Junior Cambridge 1 year and

school certificate . 3 months 1 9 5 Medical Services of Sabah is responsible for the imple- Rural health nurses: Senior Cambridge 1 See also under Malaysia (p. 287). school certificate . . 2 years 3 255 196 286 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category DurationNumber of Number of Number of 1989 1970 1971* 1972* and admission of study schools studentsgraduates Death rate requirements (years) (public) 1971/72 1972 (per 1000 population) . 4.8 4.9 4.9 4.7 General assistant Natural increase (%) . 2.37 2.54 2.38 nurses : Number of infant deaths . 913 907 907 951 Junior Cambridge Infant mortality rate school certificate . 2 years 49 10 (per 1000 live births) . 33.9 30.6 32.0 31.3 Psychiatric assistant Number of deaths, nurses : 1 -4 years 397 486 450 Junior Cambridge 6 months Number of maternal school certificate . and service deaths 24 26 training 2 10* Maternal mortality rate

(per 1000 live births) . 0.9 0.9 * 1970 data. * Sarawak Bulletin of Statistics, 3rd quarter, 1973. Communicable disease control and immunization services The communicable diseases most frequently notified As a result of the malaria eradication programme, in1972 in government hospitals and dispensaries the number of malaria cases was reduced from an were:tuberculosis,allforms, new cases(1546), estimated 250 000 in 1958 to 11 000 in 1972.Trans- dysentery, all forms (362), typhoid fever (336), infec- missionstillcontinuesin certain problem areas, tious hepatitis (237), malaria, new cases (129), cholera though on a lesser scale.The tuberculosis control (118), leprosy (21), diphtheria (17), poliomyelitis (4). programme started in 1960 with a mass X -ray and BCG campaign.By the end of 1969 the control Organization of the public health services activities had already covered 70 % of the population. At present case -detection is carried out by mass X -ray The Medical and Health Department of Sarawak is and sputum examination.Direct BCG vaccination an integral unit of the Federal Ministry of Health, is given to persons aged 19 years and below.There which determines major policies.The Director of was an outbreak of cholera El Tor in November 1972. Medical and Health Services is responsible to the The following immunization procedures were car- Federal Minister of Health for the implementation of ried out in 1972: health programmes and projects in the State.He is assisted by a deputy director of medical services, an Cholera 188428 (health),a Poliomyelitis 100510 assistantdirectorof medical services BCG 39919 principal matron, a superintending pharmaceutical Diphtheria 39289 Tetanus 39289 chemist, a medical officer (training), a senior dental Whooping -cough 29703 officer, and a medical officer in charge of the Central Smallpox 29000 Medical Laboratory. Each of the five divisional offices is headed by a divisional medical officer, who Specialized units is responsible for the direction and supervision of the In 1971 Sabah had 127 part -time maternal and child health services in the division. While each divisional health clinics. There were 28 dental clinics for school- area is divided into districts, there is no administrative children and adults, one hospital rehabilitation out- unit at the district level responsible to the divisional patient department, one psychiatric outpatient clinic, medical officer.District local councils are responsible 52 state and mining hospitals providing occupational for maternal and child health services rendered in health services, five tuberculosis clinics, one leprosy health centres. outpatient clinic, and 15 public health laboratories. Under the second Malaysian development plan (1971 -1975) the rural health service will be developed according to the pattern of the Peninsular Malaysian SARAWAK infrastructure. The State will be divided into health districts, each district under a district health officer. A Population and other statistics health centre with its subcentres will be able to provide a well -supervised, integrated rural health service for At the last census, taken in August 1970, the popula- 25 000 inhabitants.It is intended to establish 200 tion of Sarawak was 887 292.Population estimates health subcentres to cover the entire State by the end and some other vital statistics for the period under of 1980. review are given in the following table:

1969 1970 1971* 1972* Hospital services

Mean population . . . 945 061 968 997 994 535 1 017 887 30 340 Number of live births . . 26 959 29 612 28 772 In 1972 Sarawak had 20 hospitals and other in- Birth rate (per 1000 population) . 28.5 30.3 28.9 29.8 patient establishments providing a total of 2287 beds, 4 924 4 751 Number of deaths . . . 4 515 4 775 of which 2133 were in 13 government establishments. ' See also under Malaysia (p. 287). The bed /population ratio was thus 2.2 to 1000 inhab- WESTERN PACIFIC REGION 287 itants.The 2287 beds were distributed as follows: Immunization services Category and number Number of beds The following immunization procedures were car- General hospitals 12 t 509 ried out in 1971: Rural hospital 1 30

Maternity hospital 1 16 BCG 83278 Psychiatric hospital 1 300 Poliomyelitis 33715 Leprosarium 1 400 Diphtheria, whooping -cough and tetanus . . 20885 Medical and maternity centres . . 4 32 Smallpox 16436 Outpatient facilities were available in 1972 at 16 hospitaloutpatientdepartments,whichrecorded Specialized units 619 897 attendances, and at four health subcentres, 83 In 1971 maternal and child health care was provided dispensaries and 31 travelling dispensaries. at 120 centres run by local councils.There are no separate school health service units, but the whole Medical and allied personnel and training facilities school population has access to medical and health care, which is available in outpatient departments. In 1972 Sarawak had 103 registered doctors, of Dental care was provided at 67 dental health units, of whom 57 were in government service. The doctor/ which 60 served schoolchildren.In 1971, 190 894 population ratio was one to 10 070. Other government persons received services at these dental units. There health personnel included: were three hospital rehabilitation outpatient depart- Dentists 16 ments and one independent medical rehabilitation Dental nurses 56 Dental technicians 9 centre.Other specialized outpatient units included Pharmacists 5 five tuberculosis centres, a leprosy clinic, and a malaria Dispensers 37 Occupational therapists 3 centre. Sarawak also had 17 public health laboratories. Dietitians 2 Midwives 44 Nurses 281 Assistant nurses 161 Hospital assistants 171 MALAYSIA Health superintendents 4 Health Inspectors 4 Rural health supervisors 57 Assistance from WHO Physiotherapists 2 Laboratory technicians 33 Radiographers 2 In 1972 WHO's assistance to Malaysia included the X -ray technicians 12 following projects: The arrangements for the training of health person- Malaria eradication programme, Peninsular nel in Sarawak are as follows: Malaysia (1967- ). Category DurationNumber of Number of Number of and admission of study schools studentsgraduates Malaria eradication programme, Sabah (1961 - requirements (years) (public) 1971/72 1972 UNDP. Hospital assistants : Senior Cambridge Malaria eradication programme, Sarawak school certificate . 3 1 28 8 Nurses : (1961- ) UNDP. Senior Cambridge

school certificate . 3 1 97 41 Epidemiological services (1971- ):to establish, Psychiatric nurses and in the Division of Communicable Disease Control, psychiatric hospital assistants: Ministry of Health, an epidemiological and statistical Hospital assistant service responsible for planning and guiding national certificate 6 months 1 7 7 Midwives : diseasecontrol programmes;tostudythelocal Sarawak junior school

certificate 2 1 36 9 epidemiology of causes of morbidity and mortality; Assistant nurses: and to train staff. Sarawak junior school certificate 2 3 49 18 Environmental health advisory services (1966- ) Dispensers : Senior Cambridge UNICEF: to develop a national environmental health school certificate . . 3 1 6 3 Laboratory technicians : scheme, to implement sanitation projects, and to Senior Cambridge train sanitation staff. school certificate . . 3 1 13 5 Junior laboratory techni- Development of health services -advisory services cians : Sarawak junior school (1964- ) UNICEF: to strengthen and expand the certificate 1 1 4 4 Health inspectors: basic health services in Malaysia and train personnel Senior Cambridge according to a consolidated plan. school certificate. 3 1 16 10 Rural health supervisors: Development of health services -operational research Sarawak junior school

certificate 9 months 1 15 15 (1971- 1972): to undertake health practice research 288 FIFTH REPORT ON THE WORLD HEALTH SITUATION with a view to developing methods for the efficient education and supplementary feeding programmes, organization and administrationof localhealth and train personnel. services, and, from the knowledge and experience University of Malaya (1965- ): to strengthen the gained, to establish a health policy and programme teaching staff of the Faculty of Medicine of the for local health service development under the second University of Malaya. five -year development plan. Public Health Institute (1970- ) UNICEF: to Organization of medical care (1972) : A consultant develop the Public Health Institute; to undertake surveyed patterns of hospital design, assessed needs studies in public health; to assist the Ministry of and resources and drew up guidelines for hospital Health in the coordination of itsvarious health alteration.Another consultant made a survey of training programmes. hospital management and recommended measures for improving anddevelopinghospitalmanagement Government health expenditure practices. Health education advisory services (1971 -1972): to In 1972 the estimated total government expendi- develop the health education components in various ture was 4069.4 million Malaysian dollars, of which special programmes, establish a one -year certificate M$ 1334.3 million were spent on capital account and course for health education personnel, develop the M$ 2735.1 million on current account. The govern- school health programme, and expand the health ment health expenditure amounted to M$ 273 300 000, education services in Sabah and Sarawak. including M$ 36 200 000 on capital account and M$ 237 000 000 on current account. The government Mental healthadvisoryservices(1971- 1972):a consumption health expenditure included the following consultant helped to plan and implement an in- outlays: M$ 9 500 000 for general administration, service education programme for a group of nurses. M$ 42 000 000 for general health services, M$ 18 400 000 Applied nutrition (1967- ): to plan and carry out for the control of major diseases, and M$ 153 900 000 nutritional surveys in a pilot area, develop nutrition for medical care services.

NEW ZEALAND

Population and other statistics eluding 674 in motor -vehicle accidents), pneumonia (1195),bronchitis, emphysema and asthma (987), At the last census, taken in March 1971, the popu- congenital anomalies, birth injury, difficult labour and lation of New Zealand was 2 862 631.Population other anoxic and hypoxic conditions (811), diabetes estimates and some other vital statistics for the period under review are given in the following table : mellitus (372), suicide and self -inflicted injuries (237), nephritis and nephrosis (128),peptic ulcer (107), 1969 1970 1971 1972 cirrhosis of liver (104). Mean population . . . . 2784 032 2819 602 2853 254 2904 871 The communicable diseases most frequently reported Number of live births . . 62564 62207 64460 63 482 Birth rate in 1972 were: infectious hepatitis (3868), tuberculosis, (per 1000 population) . 22.5 22.1 22.6 21.9 all forms, new cases (830), bacillary dysentery (587), Number of deaths . . . 24161 24840 24309 24 801 Death rate meningococcal infections (39), typhoid and paraty- (per 1000 population) . 8.7 8.8 8.5 8.5 phoid fevers (13), malaria, new cases (7), leprosy (4), Natural increase ( %) . . 1.38 1.33 1.41 1.34 Number of infant deaths . 1 057 1 040 1 066 cholera (3 imported cases). Infant mortality rate

(per 1000 live births) . 16.9 16.7 16.5 Number of deaths, 1 -4 years 237 233 225 Organization of the public health services Death rate, 1 -4 years (per 1000 population at risk) 1.0 1.0 0.8 Number of maternal The direction, planning, and supervision of health deaths 14 20 14 services in New Zealand is the responsibility of the Maternal mortality rate (per 1000 live births) . 0.2 0.3 0.2 Minister of Health, operating through the Department of Health, which is administered by a medical director - Of the 24 309 deaths recorded in 1971, the main general of health. The Minister and the Department causes were: 1 chronic rheumatic heart disease, hyper- are advised by a variety of statutory bodies and com- tensive disease, ischaemic heart disease and other forms mittees, and also utilize for this purpose the services of heart disease (8416), malignant neoplasms (4504), of other government departments, and of universities, cerebrovascular disease (3310), accidents (1569, in- technical institutes,local bodies, and professional 1 International Classification of Diseases, 1965 Revision. organizations. WESTERN PACIFIC REGION 289

The Department of Health consists of three bureaux : was established to advise the Government and improve cooperation between departments. In 1972 a Commis- (1) The Bureau of Public Health Services, which is sioner for the Environment was appointed to act as headed by the Deputy Director -General of Health coordinator of all government matters related to the (Public Health), comprises the divisions of public environment.Since 1970 an improved scheme for health and dental health, the national health institute, subsidizing local authorities' water supply and sewer- the national radiation laboratory, the national audio- age works has been administered by the Department logy centre, and the national health statistics centre. of Health.The Clean Air Act 1972, which became (2) The Bureau of Medical Services, which is headed effective in April 1973 and which is administered by the by the Deputy Director -General of Health (Medical Department of Health with local authority assistance, Services),comprises thedivisionsof hospitals, is expected to improve the control of air pollution in mental health, clinical services, and nursing. New Zealand. A food standards committee under the (3) The Bureau of Administrative Services, which Food and Drugs Act was formed to advise the Depart- is headed by the Deputy Director -General of Health ment and the Minister on food standards. (Administration), groups general administrative, fi- In 1971 the Department of Health's branch of mater- nancial, personnel, and legal functions. nal and child health was transformed into a family health branch.In 1971 the Government introduced In 1970 an advisory social work service was esta- an extended family planning policy designed to pro- blished in the head office of the Department of Health. vide educational services for the purposes of raising It is primarily concerned with forward planning and health standards and improving the quality of family with investigating, advising on, and assessing the devel- life in the population groups that had not previously opment of policy and practice in respect of social used the existing services. work in all forms of medical care. The objective is to The main purpose of the new Nurses Act 1971 was achieve a fully professional social work service in all to establish the Nursing Council of New Zealand as a branches of the health field, and thus the emphasis is corporate body concerned with the registration of at present on improving education and training oppor- nurses and standards and competence within the nur- tunities. sing profession. Changes in the provision of health services Hospital services The Royal Commission of Inquiry intoSocial Security, which reported early in 1972, made a number In 1970 inpatient medical care was available in 331 of recommendations concerning health benefits and hospitals and other health establishments providing several of these have been implemented. a total of 28 554 beds, of which 24 925 were in 182 Increasing attention has been given to ways of streng- government- maintained establishments. The bed/ thening and improving medical services. In particular, population ratio was 10.1 to 1000.The 28 554 beds the development of group medical practice and health were distributed as follows: centres is being encouraged by the Government.In 1970 the Hospital Act was amended to enable hospital Category and number Number of beds boards, with the prior approval of the Minister, to General hospitals 225 17281 Maternity hospitals 82 1 750 establish health centres integrating preventive and Mental hospitals 10 7939 curative care as well as rehabilitation services.The Hospitals for chronic diseases 12 1 440 Rehabilitation centre 1 26 capital cost of health centres is to be financed by grants Clinic for functional nervous disorders . 1 118 to hospital boards from government funds. All major hospital boards have been requested to Ambulatory medical care was provided in 1972 at 90 set up geriatric assessment and rehabilitation wards hospital outpatient departments and at 25 industrial under the direction of a specialist regional geriatrician. health centres established in areas where there is an This programme is aimed at adequately and promptly aggregation of industrial workers amounting to more assessing all aged patients admitted to hospitals and than 2000 workers within a half -mile radius from the at instituting an effective rehabilitation programme. centre. Several measures have been taken for the control of drugs and narcotics, in order to prevent drug abuse Medical and allied personnel and training facilities and dependence. They include the establishment of assessment and treatment centres and restrictions on In 1971 New Zealand had 3375 doctors, of whom the dispensing of narcotics by private practitioners. 2402 were in government service (including part-time The portfolio of Minister for the Environment was government service). The doctor /population ratio was created in 1971 and a cabinet committee of ministers thus one to 850. Other health personnel included: 290 FIFTH REPORTON THE WORLD HEALTH SITUATION

Dentists 1 097 Communicable disease control and School dental nurses 1 341 Pharmacists 2 343 immunization services Veterinarians 620 Livestock instructors 252 There has been no case of poliomyelitis since 1970, Midwives 9 460 Nurses 17 500* and, in 1971 and 1972, for the first time, there were Community nurses 3 856 no cases Pulmonary tuberculosis Rural practice nurses 99 of diphtheria. Hospital nursing aides 2 509 ** continued to decline and in 1971 reached the lowest Sanitary engineers 50 Health inspectors 341 incidence ever recorded.In 1972, however, the inci- Physiotherapists 675 dence rose again. In 1971, 37 918 BCG vaccinations Occupational therapists 195 Radiographers 236 ** were carried out.During 1970 the Department of Health educators 20 Health commenced a school rubella vaccination cam- Health statisticians 5 Physicists 17 ** paign for children aged 5 -10 years.This campaign Number of annual practising certificates issued. initially covered children reaching the age of 4 -5 years ** In government service. and women of childbearing age. It was extended to all primary schoolchildren in 1971.Congenital rubella The arrangements for the training of medical and was made notifiable in 1972, but no case has been other health personnel in New Zealand are as follows : recorded so far. Approximately 80 % of all infants in Category DurationNumber of Number of Number of New Zealand are vaccinated against diphtheria, whoo- and admission of study schools students graduates requirements (years) (public) 1971/72 1972 ping- cough, and tetanus. Infectious hepatitis continues Doctors : to be the most prevalent notifiable disease.In 1971 university entrance examination plus 1 serum hepatitis was made notifiable as a separate precribed interme- entity; most of the cases notified have been associated diate year 6 4* 907 123 Dentists : with drug abuse and tattooing. university entrance examination plus 1 prescribed interme- Specialized units diate year 5 1 194 44 Pharmacists (university The Royal New Zealand Society for the Health of level) : Women and Children runs a nationwide network of university entrance examination plus 2 clinics to which mothers bring their children for routine years' prescribed checks and advice.Prenatal services were provided science course . . 4 1 31 11 Pharmacists : in 1972 at 88 hospitals. With very few exceptions, all university entrance School health services examination . . 3 1 227 50 births take place in hospital. Sanitary engineers : are based on 18 district health offices, where a consulta- basic engineering 1 full -time ; qualification . . . . 2 part -time 1 18 6 tive medical service is provided to primary and post - Veterinarians : primary schools. A routine examination of all children university entrance examination plus 1 is carried out on their first attendance at school, as prescribed interme- well as a routine inspection of the school environment diate year 4 1 340 38 Nurses : to ensure a reasonable standard. Public health nurses school certificate . . . 3 38 plusi 5 251 1 053 and health inspectors also assist in this responsibility. Community nurses . . 18 months 2 private 1 787 740 Midwives : Dental care for schoolchildren was provided in 1972 registration as general nurse and maternity at 1332 dental health units. There were also five inde- nurse 6 months 3 73 174 pendent medical rehabilitation centres and 34 rehabili- Laboratory technologists : university entrance 50 plus 22 tation outpatient departments in general hospitals and examination . . 5 private 687 Physiotherapists : 11 in psychiatric hospitals.Psychiatric outpatient university entrance consultations were available at 42 units. In 1972, 135 examination . . 3 1 171 46 Radiographers : industrial establishments offered medical and health university entrance 3 ** 7 32 8 services to their workers. New Zealand had also one examination 2 * ** 7 167 73 Health Inspectors: outpatient clinic for rheumatic diseases and 53 public university entrance health laboratories. examination or endorsed school certificate 16 months 1 36 22 Environmental sanitation Health educators: university entrance In 1971 New Zealand's population lived in 696 com- examination . . . . 1 1 5 3 Dental auxiliaries: munities, of which 519, with a total of 2 212 068 inha- . . . 176 school certificate 2 3 417 bitants, had piped water systems serving nearly 80 * Including two clinical schools (Christchurch and Wellington). ** Academic years; correspondence course conducted by Joint of the population. In the same year, 423 communities, Committee of the New Zealand Society of Radiographers on behalf of with 2 113 889 inhabitants, had sewerage systems the Australian Institute of Radiographers. * ** Course conducted in major hospitals. serving approximately 74 % of the population. WESTERN PACIFIC REGION 291

Major public health problems supported and private services.In 1971 the Govern- ment introduced a new policy that included the im- With its extensively organized health services, New provement of existing family planning services, the Zealand has only a few residual public health problems. development of further services, and educational pro- There is, however, a constant need to maintain the grammes to raise general health standards. services in line with population growth. A continuing An active manpower policy is being developed by education programme is also required to keep up the the recently established Manpower Planning Unit of control of the communicable diseases, particularly the Department of Labour.The policy emphasizes those that can be averted by immunization.The the need to forecast manpower supply on the one chronic diseases,such as cardiovascular diseases, hand and likely manpower requirements on the other, diabetes, and cancer, are becoming increasingly signi- with a view to equating the two where necessary by ficant, as is the problem of traffic accidents. A growing means of relevant manpower plans. shortage of doctors is making it difficult to achieve adequate coverage in some areas of the country. Medical benefits in the form of rural practice bonu- ses and other incentives became operative in October However, various incentives to practice in rural areas 1969 and were initiated under the Social Security Act. have, in recent years, halted the decline in the number In 1970/71 total expenditures for these services were of rural practitioners.Pollution control and drug 292 000 New Zealand dollars, and by 1971/72 they had abuse are other fields where further study and resour- increased to NZ$ 337 000.The increasing use of ces are necessary, although in these fields problems chemicals in agriculture has contributed to health are much smaller than in some other countries. hazards in farming. The Department of Agriculture undertakes an educational programme toreduce Social and economic developments of significance for accident rates. the health situation The 1971 Report on Rural Education stimulated A major feature of government policy since late interest in the provision of improved educational 1972 has been the emphasis on promoting the develop- facilities for post -primary pupils in rural areas.The ment of local industry, particularly in regions where concept of the area school is being developed.It is population, employment, and industrial opportunities a unified school providing education from primary to are declining. General industrial expansion on a post -primary levels for all children in the immediate nationwide scale is also being promoted. A further vicinity and for post -primary students drawn from policy objective is to institute procedures to restrain contributing schools in a wider area. increases in costs and prices.In 1970 the Industrial The drift of population to the north -particularly Research and Development Grants Act was passed, to the northern part of the North Island-ha s con- providing for the payment of grants based on expendi- tinued over several decades, resulting in a population ture on researchconducted by corporationsor concentration in the major urban centres, where, at individuals. the last census in 1971, the combined growth rate No population pressure exists in New Zealand at was shown to be double that of the New Zealand present, or is envisaged in the immediate future.In population as a whole. There was a downward trend order to investigate the most desirable pattern of future in the population of rural areas and of many of the development, the Government hopes to initiate re- smaller towns. As part of its general policy the Govern- search into the relationship between the size and rate ment has recently introduced measures tofoster of growth of population, the use of environmental greater regional growth so as to curb or halt the ad- resources and the maintenance and improvement of verse effects of declining areas and indirectly the decline the quality of life.The Government has taken steps in population in such areas.During the changes in to improve the coordination of departmental research the economy of the country during the period under on population and demography by establishing a review, New Zealand experienced a large net outflow committee comprising several government depart- of manpower at the beginning of the period but, by ments, whose responsibilities include the setting up 1972, the flow had been reversed. of a New Zealand Demographic Society and the task of encouraging the specialized training of demo- National health planning graphers. Family planning has received much attention in New Zealand has no detailed health plan, but the recent years in New Zealand, with the emphasis not principal objectives for the 1970s are progress in so much on the need for population control, but rather environmental health, the health of pregnant women, as a health measure based on the concept of responsible infants and children, disease control, with emphasis parenthood. Family planning services available in the on chronic diseases, accident prevention, and medical field have been and are a combination of government- care programmes. The 10 areas chosen for particular 292 FIFTH REPORT ON THE WORLD HEALTH SITUATION attention are: environmental pollution, water supply, Other private foundations and societies in New maternal and child health, disease control, accident Zealand also provide funds for medical research. The prevention, hospital care, community medical care sixprovincialmedicalresearchfoundations each services, problems of aging, medical education, and support specific research projects of their own, as do medical research. A National Development Council such bodies as the National Heart Foundation and keeps under review the targets and objectives set as a the Cancer Society of New Zealand and numerous result of the National Development Conference held smallergrantingorganizations. Otherresearch in 1969. Health is covered by the broad plan and the projects are supported from Golden Kiwi lottery Department of Health is represented on two of the profits by the Medical Research Distribution Com- sector councils -namely, the environmental and social mittee. councils working under the National Development Council. Government health expenditure

Medical and public health research During the fiscal year 1971/72 total general government expenditure amounted to1 493 000 000 New The Medical Research Council isthe principal Zealand dollars, of which NZ$1 001 000 000 were organization supporting medical research in New spent on current account and NZ$ 492 000 000 on Zealand.It is responsible for the administration of capital account. The total central government health government funds provided for research, and acts as expenditure amounted to NZ$ 293 000 000, of which the national coordinating body for medical research. NZ$ 286 000 000 were on current account, and the This Council was established in 1937 as a committee local government total health expenditure amounted of the Department of Health and became an auto- to NZ$ 28 000 000.Altogether, general government nomous body in 1951. The Council supports research health expenditure per capita amounted to NZ$111. through the establishment of units and laboratories, The breakdown of the total expenditure on general and the provision of project grants, scholarships, and public health services includes the following: NZ$ fellowships. Research activities are carried out in 3 948000 on administration and government personnel, universities and hospitals. Epidemiological studies NZ$ 497 000 on mass campaigns against communicable with emphasis on cardiovascular diseases and related diseases,including vaccination, NZ$ 472 000 on metabolic disorders, and on the social and physical laboratory services, NZ$ 2 730 000 on environmental effects of migration, are being made of Maori and health services, NZ$ 87 000 on occupational health European communities in New Zealand, of Tokelauans services, and NZ$ 1 554 000 on education and training in the Tokelaus, and of Tokelauans settled in New of health personnel. Government expenditure on Zealand. A wide range of research activities has been hospitals included NZ$ 169 108 000 on all public undertaken in clinical medicine, in obstetrics and hospitals, NZ$ 27 572 000 on psychiatric hospitals, gynaecology,etc., and in basic medical sciences. and NZ$ 6 836 000 on private hospitals. Government Government grants, which amounted to 1 016 300 New contributions to the health activities of social security Zealand dollars in 1971 and 1972 and to NZ$ 2 100 000 schemes and other nongovernmental social welfare in 1973, are the Council's main source of finance. systems amounted to NZ$ 64 000 000.

PHILIPPINES

Population and other statistics 1969 1970 1971 1972 Infant mortality rate

(per 1000 live births) . 67.3 60.0 62.0 67.9 At the last census, taken in May 1970, the population Number of deaths, of the Philippines was 36 590 068. Population estimates 1 -4 years 38 007 32 814 39 292 47 883 Death rate, 1 -4 years (per and some other vital statistics for the period under 1000 population at risk) 6.3 5.4 6.5 9.6 review are given below: Number of maternal deaths 1 768 1 276 1 261 Maternal mortality rate 1969 1970 1971 1972 (per 1000 live births) . 1.9 1.3 1.3

Mean population . . 37158 00036849 000 37919 000 39041 000

Number of live births . . 946 753 966 762 963 749 968 385 Birth rate Of the 250 137 deaths recorded in 1971, the main (per 1000 population) . 25.5 26.2 25.4 24.8 causes were: 1 senility without mention of psychosis, Number of deaths . . . 241 678 234 038 250 137 285 761 Death rate ill- defined and unknown causes (36 017), pneumonia (per 1000 population) . 6.5 6.4 6.6 7.3

1.98 Natural increase ( %) 1.90 1.88 1 75 Number of infant deaths . 63 719 57 279 59 730 65 719 1 International Classification of Diseases, 1955 Revision. WESTERN PACIFIC REGION 293

(35 908), birth injuries, postnatal asphyxia and atelec- Category and number Number of beds tasis, infections of the newborn and other diseases General hospitals 651 29 745 Maternity hospitals 83 2 001 peculiar to early infancy and immaturity (26 466), Paediatric hospitals 10 622 Infectious diseases hospital 1 900 tuberculosis,all forms (26 021), chronic rheumatic Ophthalmological and otorhinolaryngo - heart disease, arteriosclerotic and degenerative heart logical hospitals 6 97 Orthopaedic hospitals 2 730 disease and other diseases of the heart (14 526), Tuberculosis hospitals 6 1 597 gastritis,duodenitis,enteritisandcolitis,except Psychiatric hospitals 5 7 800 diarrhoea of the newborn (11 755), avitaminoses and other deficiency states (10 374), malignant neoplasms Medical and allied personnel (9480), bronchitis (8199), hypertension (5263), vascular lesions affecting the central nervous system In 1970 there were 4051 doctors working in govern- (4552), accidents (4096, including 1040 in motor - ment service.Other health personnel in government vehicle accidents),nephritis and nephrosis (3591), service included:

measles (3264), tetanus (3183). Dentists 626 The communicable diseases most frequently notified Dental assistants 342 Pharmacists 378 in 1970 were: influenza (388 769), tuberculosis, all Veterinarians 149 forms, new cases(136 035),malaria, new cases Midwives 2 761 Nurses 4 522 (28 594), measles (20 446), whooping -cough (19 946), Assistant nurses 2 319 Sanitary engineers 79 dysentery, all forms (11 946), gonorrhoea (11 514), Sanitarians 1 918 infectious hepatitis (3592), typhoid and paratyphoid Laboratory technicians 649 X -ray technicians 147 fevers (2466), diphtheria (1770), cholera El Tor (1039), Health educators 70 meningococcal infections (635), poliomyelitis (581), Nutritionists 234 Chemists 34 leprosy (218), syphilis, new cases (27). Social workers 98

Organization of the public health services Communicable disease control and The Secretary for Health is in charge of the Depart- inununization services ment of Health and is responsible for the health The public health importance of malaria in the services in the Philippines.He is advised by the Philippines has declined considerably over the last National Advisory Board of Health and by a number 20 years.Prior to the initiation of countrywide anti - of other boards and committees.The Office of the malaria measures (1955), morbidity from malaria was Undersecretary for Health and MedicalServices comprises the following bureaux: health services, estimated to vary between 1 000 000 and 2 000 000 cases per year in a population of 23 000 000 (giving medical services, and disease control.The Office of the Undersecretary for Special Health Services has a rate of between 4.3 % and 8.7 %). In 1971 the reported cases numbered 37 113 in a population of 38 000 000 three bureaux dealing respectively with quarantine, (0.1 %). Several factors have contributed to this dental health services, and research and laboratories. The Office of the Undersecretary for Health and impressive decline in malaria prevalence.Among Medical Services is also in charge of the regional them can be cited the development of health and medical facilities,better housing, improvement of health offices, under which come the provincial health offices, the regional hospitals, and the city health agricultural techniques, deforestation, water pollution control measures, and urbanization. The major offices.The following bodies operate directly from factor, however, has been the eradication activities, the Office of the Secretary for Health: stream and air which have succeeded in bringing down to a very low pollutioncontrolcommittee,malariaeradication level or in totally eliminating the transmission of the service, national schistosomiasis control committee, disease in a large part of the previously malarious area. disease intelligence services, office of health education But this success has been rather limited in the fringe and personnel training, food and drug administration, areas, or pioneer lands. In general, the level of trans- national nutrition programmes, projectofficefor mission is highest in the foothill areas, decreasing, in maternal and child health, and office of administrative many instances very abruptly, towards the adjacent services. plains. Thus the largest number of malaria cases is found in the forest -fringe and hilly areas. In 1971, out Hospital services of a total of 37 113 positive cases detected, 18 573, or In 1969 the Philippines had 764 hospitals and other 50 %, were found in such areas, which are inhabited by inpatient establishments providing a total of 43 492 only 13 % of the total population at risk. The popu- beds, or 1.2 beds per 1000 population.These beds lation at risk from malaria in the Philippines was were distributed as follows: estimated to be 11 800 000 in 1972. 294 FIFTH REPORT ON THE WORLD HEALTH SITUATION

The national tuberculosis programme consists of Laguna de Bay water quality laboratory design direct BCG vaccination of primary school entrants (1972) UNDP: a consultant assisted in detailed design and preschoolchildren;case -findingby sputum and planning of a water quality laboratory. microscopy among persons with symptoms of tuber- Study of the Laguna de Bay water resources develop- culosis; free ambulatory chemotherapy for bacterio- ment (1972) UNDP /Asian Development Bank: a logically confirmed cases and suspects with specific consultant advised in the environmental implications lesions on X -ray examination; follow -up of patients of the project. during and after treatment; and training of medical, General healthservicesdevelopment (1969- ) nursing, and other personnel. UNICEF: to improve the organization and adminis- Gastrointestinal diseases account for a high morbid- tration of the health and medical care services, under- ity and mortality in the country. take national health planning, and review health Rabies is widespread throughout the Philippines. In 1971 the number of deaths attributable to this manpower education and training schemes. disease was 201, giving a mortality rate of 0.5 per National health planning (1972- ): to develop a 100 000.The only reservoir of rabies virus in the comprehensive national health plan and train health Philippines is the dog, though sporadic outbreaks personnel. of rabies have been reported in other animals following National seminar on public health nursing education exposure to rabid dogs. Despite the widespread (1972): a consultant assisted in organizing a seminar endemicity of rabies in the country, there is no orga- to consider thesituation regarding public health nized national programme foritscontrol;only nursing in the country and its probable development. occasional campaigns are conducted at the local level Maternal and child health advisory services (1971- in selected areas. 1972) : a consultant assisted in reviewing the prevailing The following immunization procedures were car- causes of maternal and child mortality and morbidity ried out in 1970: and in making recommendations on maternal and

Cholera 6275100 child health care provided as part of the general Smallpox 2139552 health services. Typhoid and paratyphoid fevers 1768320 BCG 1639363 Occupational health (1970 -1972) UNDP /ILO: to Diphtheria 323863 Tetanus 297651 establish the legal, administrative, and operational Whooping -cough 287661 framework for a coordinated national programme of Poliomyelitis 137023 occupational health and safety, develop all the tech- Environmental sanitation nical components of the programme, and plan for future expansion. It was estimated that during the period under review Dental health advisory services (1972) UNICEF: a there were 1377 water supply systems of all sizes, consultant reviewed the progress made since 1969, 20 840 wells, and 2081 springs serving a population in evaluated the integrated dental services system of the both urban and rural areas of between 14 900 000 and Departments of Health and of Education in Rizal 17 650 000, or between 38 % and 45% of the total Province, and assessed the feasibility of introducing population. The remainder of the population did not the system in other provinces. have access to a safe water supply. University of the Philippines (1970- ): to strength- Assistance from WHO en the staff of the University of the Philippines, in particular that of the Institute of Public Health. In1972 WHO's assistancetothePhilippines Food and drug administration (1972): a consultant included the following projects: reviewed the quality control programmes in the food Tuberculosis control (1972) UNICEF: a consultant processing and pharmaceutical industries and the evaluated the operation of 10 provincial tuberculosis extent of the food pollution problem, and made programmes and made recommendations concerning recommendations concerning a long -term plan to the feasibility of extending control programmes to improve the quality control programmes. other provinces. Maternity- centredfamily planning (1971- ) Malaria eradication programme(1958- ) UNFPA UNICEF: to develop the staff and facilities (USAID). of 25 teaching hospitals and associated teaching Rabies control (1972): a consultant studied the institutions with a view to the inclusion of maternity - feasibility of undertaking a programme for eradicating centred family planning training and service in their rabies from the country. work. Community water supply (1969 -1972) UNDP: to Nursing education in family planning (1971- ) improve and extend provincial water supply systems. UNFPA: to organize national workshops to prepare WESTERN PACIFIC REGION 295 faculty members to introduce family planning in family planning, human reproduction and population basic nursing curricula. dynamics (1971- ) UNFPA: to expand the teaching facilities and activities of the Institute of Public Health Assistance to the teaching programme of the Institute in family planning and to strengthen the long -term of Public Health,University of the Philippines,in academic programme in family planning.

REPUBLIC OF VIET -NAM

Population and other statistics Medical and allied personnel and training facilities No population census has ever been taken in the In 1971 the Republic of Viet -Nam had 2000 doctors, Republic of Viet -Nam, although some sampling of whom 419 were working with the Ministry of Health. surveys were conducted in 1956. Population estimates There was one doctor for 9400 population.Other for the period under review are as follows : health personnel included:

1969 17867000 Dentists 300 1970 18332000 Dental auxiliaries 20 1971 18809000 Pharmacists 2 200 1972 19213000 Pharmaceutical assistants 293* Pharmaceutical aides 8* Birth registration remains incomplete, but from Veterinarians 130 Health technicians 273 available data the Ministry of Health has calculated Nursing technicians 1 157 Midwives 1 179 a national crude birth rate of 42.7 per 1000, while the Nurses 1 817 crude death rate is assumed to be 12.7 per 1000. The Assistant nurses 2 994* Auxiliary nurses 147* estimated rate of population growth is thus 3 % per Nursing aides 103* annum. The infant mortality rate in the rural areas is Sanitary engineers 5* Sanitarians 57* probably over 100 per 1000 live births. District health workers 289* The communicable diseases most frequently notified Rural health aides 3 544* Malaria eradication agents 290* in 1971 were: malaria, new cases (39 981), tuberculosis Health educators 8* Assistant laboratory technicians 203* of the respiratory system, new cases (28 816), influenza Laboratory assistants 230* (26 708), trachoma (12 668), measles(10 563), Other health aides 287* whooping -cough (9355), gonorrhoea (7062), plague *In government service. (3479), leprosy (3099), typhoid and paratyphoid fevers (2995), syphilis, new cases (2218), infectious hepatitis The arrangements for the education and training (1561),amoebiasis(1330),poliomyelitis,paralytic of medical and other health personnel in the Republic cases (602), meningococcal infections (585), diphtheria of Viet -Nam are as follows:

(554), bacillary dysentery (205), rabies in man (116), Category Duration Number of Number of Number of cholera (31). and admission of study schools studentsgraduates There were 146 cases of cholerain1972 and requirements (years) (public) 1971/72 1972 Doctors : 250 cases in 1973. baccalauréat 7 2 plus 1 1 267 204 private Dentists : Hospital services baccalauréat 5 240 64 Pharmacists : baccalauréat 5 1 734 293 In 1971 the Republic of Viet -Nam had 4874 hospitals Nurses: and other inpatient establishments providing a total 11 years' general education 3 3 plus 10 529 124 of 39 731 beds, of which 30 870 were in 4223 govern- private Assistant nurses: ment establishments.The bed /population ratio was 9 years' general edu- 2.1 to 1000 inhabitants.The 39 731 beds were dis- cation 1 8 630 553 Midwives: tributed as follows: 11 years' general education 3 3 421 66 Category and number Number of beds Assistant midwives: General hospitals 107 20 882 9 years' general educa- Rural hospitals 4 363 tion 1 18 391 339 Medical centres 4 755 14 886 Laboratory technicians: Maternity hospitals 2 787 11 years' general edu- 1 78 Paediatric hospital 1 276 cation 3 Infectious diseases hospital 1 511 Physiotherapists : Tuberculosis hospital 1 508 11 years' general edu- 1 20 Psychiatric hospital 1 1 312 cation 3 Hospital for dermatology and venereo- Sanitarians : logy 1 100 11 years' general edu- 1 119 Cancer hospital 1 106 cation 3 296 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category DurationNumber of Number of Number of objectives, the plan proposes 39 programmes dealing and admission of study schools studentsgraduates requirements (years) (public) 1971/72 1972 with seven operational targets, in addition to three Dental technicians: special programmes, for the Pasteur Institute, the 11 years' general education 3 1 30 National Institute of Rehabilitation, and the National Anaesthesia techni- Institute of Public Health.The implementation at cians : 11 years' general edu- regional level is covered by 55 regional plans, one for cation 3 1 13 Dental auxiliaries: each province or municipality. Planning officers have 9 years' general educa- been appointed for each province, to serve as assistants tion 1 1 19 19 Laboratory assistants : in charge of regional planning under the provincial 9 years' general educa- medical officers. tion 1 2 191 191 Pharmacy assistants: The four -year health plan gives priority to the 9 years' general educa- following main areas: training and education for tion 1 4 155 144 Public health assistants: health; methodology and planning for health services; 9 years' general educa- basichealthservices;controlof communicable tion 1 1 100 79 diseases; protection of the family; and improvement Immunization services of living conditions. The targets for health manpower callfor the The following immunization procedures were carried recruitment and training of 60 % of the number of out in 1972: qualified nurses and midwives required by the public Cholera 2725717 health services; 90 % of the number of health auxiliaries Smallpox 2304701 with one -year training; and 50 % of the required num- Plague 1864085 BCG 800338 ber of health technicians. With regard to the develop- Diphtheria, whooping -cough and tetanus 757016 Typhoid and paratyphoid fevers 493926 ment of basic health services, it is proposed to emphasize Diphtheria and tetanus 295169 the development of the rural health service network. The number of hospital beds will be increased, but Specialized units only to the extent of maintaining the present bed/ population ratio.Within the hospital system the In 1972 maternal and child health care was based quality of medical and nursing care will be enhanced on 1072 prenatal services and 883 child health services. and its scope extended, outpatient departments will These establishments were attended by 382 815 preg- be improved, and emergency services made more nant women, 62 540 infants under one year, and 39 976 efficient. It is planned to establish one maternity children aged 1 -5 years. Domiciliary visits were paid infirmary for about 50 000 population and to open to 17 199 pregnant women and to 13 258 children. 16 health centres for districts with approximately In 1972, 81 % of all deliveries were conducted under 100 000 population. In the control of communicable qualified professional care, in hospitals (320 958 deliv- diseases, the most intensive drive and sustained effort eries) or at home (2621 deliveries). Three school health will be made against those diseases that are of special service units supervised the health of 557 831 school- importance in the economic and social fields, such as children, representing 21.35 % of the total school malaria, tuberculosis, leprosy, and trachoma. A more population. There were six dental health units for systematic approach will also be adopted in smallpox schoolchildren and 61 for adults, which were attended surveillance and the control of plague and cholera, in 1972 by 40 756 schoolchildren and by 547 582 adults. and the requisite organizational procedures will be The five independent rehabilitation centres recorded improved.As regards communicable diseases that 6754 new outpatients. can be controlled by simple and effective vaccines, such as diphtheria, pertussis, tetanus, and poliomyelitis, Environmental sanitation extensive immunization campaigns will be organized In 1971, of the Republic of Viet -Nam's total popu- in order to protect 70 % of the children in the suscep- lation, 25 % were served with piped water and 6 tible age groups. Besides the traditional activities for had access to water from public fountains. the prevention and treatment of diseases of mothers and children, more emphasis will be given to pro- National health planning grammes for the promotion of family health, which will include advice on family planning and provision The broad objectives of the four -year national health for family planning services considered as an integral plan for 1972 -1975 are to improve and extend medical part of maternal and child health care services.The care and health services, to meet the specific health programme for the improvement of living conditions problems of the postwar period, and to orient the covers activities dealing with nutrition, environmental health sector towards development. To achieve these sanitation, and occupational health. WESTERN PACIFIC REGION 297

Assistance from WHO Health, formulate a national health policy and a national health and manpower plan, and train staff. In 1972 WHO's assistance to the Republic of Viet - Nam included the following projects: Health laboratory services (1964- ) UNICEF: to establish a central health laboratory service and Venereal disease control (1966- ) UNICEF: to train health laboratory workers; and later, to organize reduce the incidence of the venereal diseases, and regional and peripheral health laboratory services. strengthen and improve the syphilis serological work Production and control of biologicals (1972- ): carried out in national laboratories. to improve the production and control of biologicals. Tuberculosis control (1958- ) UNDP UNICEF: Medical education (1972- ) : to strengthen various to set up a national tuberculosis control programme aspects of the curricula of schools of medicine, with as a permanent part of the basic health services. particular attention to preventive medicine and public Malariapre -eradicationprogramme(1959- ) health. (USAID): to train national staff and make prepa- National Instituteof Public Health (1969- ) rations for the implementation of a malaria eradication UNFPA: to build up a national institute of public programme. health which will serve as a centre for the planning, standardization,organization, coordination, imple- Epidemiological surveillance and quarantine (1970- mentation, and evaluation of training programmes ):to develop epidemiological services at the for various categories of medical and health workers. central and regional levels, strengthen the application of the International Health Regulations and train staff. Government health expenditure Environmental health advisory services (1966- ): In 1972 total government expenditure amounted to strengthen the environmental sanitation service to 324 231 million Vietnamese piastres, of which 7870 in the Ministry of Health and introduce improvements million were spent on health services. Of this sum in urban and rural areas. 6857 million piastres were spent on current account National health planning (1972- ): to strengthen and 1013 million on capital account.The per capita the national health planning unit in the Ministry of government health expenditure was 410 piastres.

SINGAPORE

Population and other statistics forms of heart disease (1802), malignant neoplasms (1758), symptoms and ill- defined conditions (1270), At the last census, taken in June 1970, the popula- cerebrovasculardisease(1077),pneumonia(939), tion of Singapore was 2 074 507. Population estimates congenital anomalies, birth injury, difficult labour and and some other vital statistics for the period under other anoxic and hypoxic conditions (662), accidents review are given in the following table: (581, including 338 in motor -vehicle accidents), tuber- 1969 1970 1971 1972 culosis, all forms (489), bronchitis, emphysema and Mean population . . 2042 500 2674 500 2110 400 2147 400 asthma (434), suicide and self -inflicted injuries (235), Number of live births . . 44 562 45 934 47 088 49 598* Birth rate diabetes mellitus (207), nephritis and nephrosis (166), (per 1000 population) . 21.8 22.1 22.3 23.1 cirrhosis of liver (146). Number of deaths . . . 10224 10717 11 329 11 521 Death rate The communicable diseases most frequently notified (per 1000 population) . 5.0 5.2 5.4 5.4 Natural increase ( %) . . 1.68 1.69 1.69 1.77 in 1972 were: malaria, new cases (302), typhoid and Number of infant deaths . 930 942 948 954 paratyphoid fevers (167), leprosy (149), cholera (114), Infant mortality rate

(per 1000 live births) . 20.9 20.5 20.1 19.2 diphtheria (7), poliomyelitis (2), typhus (2). Number of deaths, 1 -4 years 273 277 201 Death rate, 1 -4 years (per Organization of the public health services 1000 population at risk) 1.3 1.4 1.1 Number of maternal The responsibility for the health services in Singapore deaths 17 11 8 8 Maternal mortality rate rests with the Minister of Health, who is a member of (per 1000 live births) . 0.6 0.3 0.3 0.3 the Cabinet. The Director of Medical Services, who * Provisional data. is also Permanent Secretary (Health), is assisted by a Of the 11 521 deaths recorded in 1972 the main Deputy Director of Medical Services (Hospitals) and by the Assistant Director of Medical Services (Tuber- causes were: 1 chronic rheumatic heart disease, hypertensive disease, ischaemic heart disease and other culosis), the Assistant Director of Medical Services (Dental Services), the Chief Pharmacist, the Senior International Classification of Diseases, 1965 Revision. Pathologist, and the Principal Matron. The Permanent 298 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Secretary for Special Duties (Health) is assisted by The University of Singapore has a facultyof the Deputy Director of Medical Services (Health). medicine (five -year course), a faculty of dentistry The divisions under his control include the following: (four -year course), and a faculty of pharmacy (three- maternal and child health, school health, quarantine year course).During the academic year 1971, the and epidemiology, legal affairs, vector control, health following numbers of students enrolled and graduated education, training, nutrition, family planning, and respectively: 136 and 124 in medicine; 38 and 47 in the statistical and research unit. dentistry; and 23 and 25 in pharmacy.In- service In 1972 the newly established Ministry of the training for nurses is organized by the schools of Environment was put in charge of the functions of the nursing run by the Ministry of Health.In- service former local authorities -e.g., control of markets and training is also provided for laboratory technicians, hawkers, the municipal cleansing services, and the radiographers, X -ray technicians, dental auxiliaries, sections on quarantine and epidemiology concerned and laboratory assistants. with airport and port health services. The section on industrial health was transferred to the Ministry of Communicable disease control and Labour. immunization services Hospital services The pattern of diseases in Singapore has changed In 1971Singapore had 21 hospitals and other markedly and many of the major communicable establishments for inpatient care providing a total of diseases have lost their public health importance. 8251 beds, of which 7368 were in 14 government Since 1963 minor outbreaks of cholera El Tor have recurred; the largest, with 114 reported cases, took establishments. The 8251 beds -equivalent to 3.9 place at the end of 1972.The importance of tuber- beds for 1000 inhabitants -were distributed as follows : culosis as a public health problem is declining in Category and number Number of beds Singapore. From 1961 to 1967 the annual incidence General hospitals 10 2 935 Rural hospital 1 34 of notified tuberculosis patients fell from 373 per Maternity hospital 1 554 100 000 to 187 per 100 000 and tuberculosis mortality Infectious diseases hospital 1 272 Tuberculosis hospital 1 1 304 fell from 38 per 100 000 to 28 per 100 000 in the same Psychiatric hospital 1 2 029 period.For 1970, the corresponding rates were 159 Hospital for the mentally defective . 1 45 Chronic diseases hospital 1 100 and 20. The case -detection programme includes mass Venereal and skin diseases hospital . . 1 51

Orthopaedic hospital for children . 1 120 radiography campaigns, which have covered about Leprosarium 1 785 65 % of the population at risk.Over 5000 leprosy 1 22 Drug rehabilitation centre patients are on the active case register and about 10 Ambulatory medical care was available in 1972 at of them were hospitalized at the only leprosarium in the hospital outpatient departments, which recorded Singapore. It is estimated that 4000 -6000 leprosy 1 164 807 attendances, at 28 outpatient clinics, which patients have not yet been detected. The prevalence of recorded 2 216 550 attendances, and at two mobile infectious syphilis is tending to increase; about 300 health units. cases a year are reported. Enteric diseases are fairly common; in view of their recognized importance, the Medical and allied personnel and training facilities Government intends to initiate surveillance activities, In 1971 Singapore had 1681 doctors of whom 648 to assess the problem, and to formulate a nationwide were in government service.The doctor /population programme for their control. About 200 -250 cases of ratio was one to1260. Other health personnel typhoid fever are reported each year.Poliomyelitis included: is seen only occasionally. There is at present a steady importation of malaria cases into Singapore from Dentists 406 Pharmacists 257 surrounding countries. These are the source of Pharmaceutical assistants 153 occasional episodes of local transmission, which are Veterinarians 25 Veterinary assistants 60 rapidly brought under control. Such outbreaks Midwives 469 usually occur in areas where the population is highly Nurses 3174 Assistant nurses 1429 vulnerable. Sanitary inspectors 157 Assistant sanitarians 663 The following immunization procedures were car- Physiotherapists 27 ried out in 1972: Laboratory technicians 180 Assistant laboratory technicians 10 Laboratory assistants 43 Poliomyelitis 195814 X -ray technicians 84 Diphtheria, whooping -cough and tetanus . 131356 Biochemists 6 Cholera 126610 Physicists 12 BCG 70229 Entomologists 6 Diphtheria and tetanus 55738 Health educators 3 Diphtheria 4 WESTERN PACIFIC REGION 299

Specialized units standard of living has only slightly influenced the pace of population increase. The previously declining birth In 1972 maternal and child health care was based on rate rose in 1970 for the first time since 1956, and in 46 centres, which recorded 30 990 attendances by 1972 population growth also increased. The popula- pregnant women, 402 852 attendances by infants tion density in the small island of Singapore, which under one year, and 269 207 attendances by children is already one of the highest in the world, is expected aged 1 -7 years.During the same year, 41 890 home to increase even more by 1975.Immigration is also visits to pregnant women, 77 358 to infants under one becoming a significant factor in population projections. year, and 75 317 to children aged 1 -7 years were Previous unemployment has turned into full employ- recorded. In 1972, 88.2 % of all deliveries were atten- ment in all sectors, with large numbers of foreign ded by a doctor or a qualified midwife, either in govern- workers seeking employment in Singapore. The need ment hospitals (40 324 births)or at home (3764 for controlling the rate of population growth has births).The total school population was under the become very urgent.The national family planning supervision of the school health services, the main programme has been able to reach about 60 % of the activities of which are periodic medical examination, eligible women. As family planning campaigns and treatment of schoolchildren with defects, and system- availability of family planning services alone proved to aticimmunizationagainstsmallpox,diphtheria, be not entirely effective, social incentives and deterrents tetanus, and poliomyelitis, Dental care was available have accordingly been introduced. The laws on at 69 dental clinics for schoolchildren, at which 436 132 abortion and sterilization were liberalized in 1970. schoolchildren were treated, and at 22 dental clinics The number of legal abortions was equivalent to 7 for adults, at which 160 582 persons were treated. of all births in 1972. There were eight hospital rehabilitation outpatient departments, which recorded 17 560 new patients during the year, and an independent government rehabilitation clinic.Psychiatric consultations were National health planning given to 1632 new outpatients at six psychiatric clinics, Two five -year development plans were drawn up, of which five operate on a part-time basis. The public health laboratory carried out over 100 000 for the periods 1959 -1964 and 1965 -1969.Health planning in these two development plans examinations in 1972. restricted to solving immediate problems, without embarking on comprehensive long -term planning. In Environmental sanitation 1972 a comprehensive plan for the development of all hospital services over the next 20 years was drawn In1972 the piped water system of Singapore up by a British team of consultants.The initial served 99 % of the population. part of the plan, covering a period of 10 years, has been accepted by the Government and its implementation is proceeding. The primary objective of the Social and economic developments of significance for plan isto provide for a much -needed increase in the health situation hospital capacity and facilities to match the rapid population increase, and to achieve a bed /population The momentum of economic developmentin ratio of 4.5 to 1000. Another objective of the plan is Singapore was maintained during the period under manpower development, with the expansion of the review.Singapore's gross national product (GNP) at training capacity of existing schools.Whereas basic currentpricesreached7917.5millionSingapore training of medical personnel isavailable locally, dollars in 1972. This represents an annual growth of specialist training still has to be acquired abroad. 13 %. Per capita GNP improved from S$ 3321 in 1971 to S$ 3687 in 1972. Public housing schemes have progressed; over one -third of the population are now Medical and public health research housed in public estates and eventually two -thirds of the population will be accommodated inpublic A modest research grant is now available and admin- housing. The improved standards of living, particu- istered under a Medical Research Council.For the larly the better housing conditions, have been res- present, the allocation of funds is mainly for projects ponsible for reducing the incidence of tuberculosis, that may have some practical application in disease leprosy, and diphtheria; but these achievements have control or where baseline information is required. brought new problems.Strict measures have been The following research projects have been undertaken against environmental pollution, particularly taken: anthropometric studies of children; surveys of air and water pollution.The improvement in the streptococcal infections related to rheumatic fever 300 FIFTH REPORT ON THE WORLD HEALTH SITUATION and research on its prevention; investigation of dietary Ministry of Labour, in the assessment and control of factors in the epidemiology of coronary heart disease; environmental hazards in industry.He also advised research on Australian antigen in blood donors; on the formulation of an industrial hygiene laboratory treatment of bladder infections and malfunctions of and training programme. the bladder to prevent subsequent kidney disease; National seminar on the organization of industrial screening for hypertension in the population; a survey health services for small industries (1972): two con- of food handlers for enteric infections, and screening sultants assisted in the organization of a seminar of typhoid carriers. during which the health situation in small industries was reviewed and the possibility was studied of providing them with health services. Assistance from WHO Nutrition advisory services (1972- ) UNICEF In 1972 WHO's assistance to Singapore included the (FAO) :to plan the development of public health following projects: nutrition services. Communicable diseases advisory services (1972- ): Development of medical specialties (1971- ): to to develop and strengthen the epidemiological service establish and organize specialist units in hospitals and of the Ministry of Health, study the epidemiology of to train in advanced techniques staff to man these units. the main causes of morbidity and mortality, develop University of Singapore (1972- ): to strengthen procedures for the investigation, prevention, diagnosis the teaching staff of the Faculty of Medicine of the and control of certain diseases, and train staff. University, particularly in the fields of preventive Planning forseweragedevelopmentandwater medicine, public health, and organization of medical pollution control (1970- ) UNDP: to prepare a care. long -term master plan for the development of sewerage facilities; and to conduct studies on river and coastal Government health expenditure water pollution, with a view to developing a programme for its abatement and control. In the fiscal year 1971X72 the total health expenditure of the Ministry of Health amounted to 89 025 166 Management of hospital services(1972- 1973):a Singapore dollars. The outlay on administration and consultant assessed the administration of the govern- government personnel amounted to S$ 48 267 428 ment hospital services. and on laboratory services to S$ 969 641. Gross Occupational health advisory services (1971- 1972): a expenditure on hospitals and clinics was reported to consultantassistedtheIndustrialHealthUnit, be S$ 48 287 428.

WESTERN SAMOA

Population and other statistics Of the 540 deaths recorded in 1972, the main causes At the last census, taken in November 1971, the were: 1symptoms and ill- defined conditions (223), population of Western Samoa was 143 547 (prelimi- accidents (32, including 18 in motor -vehicle accidents), nary data). Population estimates and some other vital pneumonia (31),chronic rheumatic heart disease, statistics for the period under review are given in the hypertensive disease, ischaemic heart disease and other following table : forms of heart disease (27), cerebrovascular disease 1969 1970 1971 1972 (23), bacillary dysentery and amoebiasis, enteritis and

Mean population . . 139 170 142 187 145 204 148 398 other diarrhoeal diseases (22), intestinal obstruction Number of live births . . 4 330 4 719 4 714 4 017 Birth rate and hernia (19), birth injury, difficult labour and other (per 1000 population) . 31.0 33.0 32.5 27.1 anoxic and hypoxic conditions (18), malignant neo- Number of deaths . . . 652 771 558 540 Death rate plasms (15), avitaminoses and other nutritional defi- (per 1000 population) . 4.7 5.4 3.8 3.6 ciency (14). Natural Increase ( %) . . 2.63 2.76 2.87 2.35 Number of infant deaths . 120 166 90 109 The communicable diseases most frequently notified Infant mortality rate (per 1000 live births) 27.7 35.2 19.1 27.1 in 1970 were: influenza (4724), measles (2159), infec- Number of deaths, tious hepatitis (573), whooping -cough (128), typhoid 1 -4 years 88 93 71 49 Number of maternal and paratyphoid fevers (53), tuberculosis, all forms, deaths 5 4 1 5 Maternal mortality rate (per 1000 live births) 1.2 0.8 0.2 1.2 1 International Classification of Diseases, 1965 Revision. WESTERN PACIFIC REGION 301 new cases (21), gonorrhoea (19), leprosy (15), bacillary Western Samoa has no facilities for training health dysentery (6). workers at university level. The nursing training school at the Apia general hospital provides a three -year course, which, during the academic year 1971/72, was Organization of the public health services attended by 144 students, of whom 18 graduated. All medical and health services in the country are provided by the Government through the Health Communicable disease control and Department, which is under the Director of Health, immunization services who is responsible to the Minister of Health.The department has sixdivisions, dealing with public Because of the importance of the tuberculosis pro- health, the Apia general hospital, nursing, dental blem in Western Samoa, two nationwide tuberculosis health, health laboratory services, and administration. campaigns were conducted between 1961 and 1968. The chief of the division of public health is also in The first campaign (1961- 1963), which covered the charge of all the health services in the 16 health districts, entire population, included tuberculin testing for those including 14 district hospitals and eight subcentres. under 15 years of age and X -ray examination for those The district medical officer is responsible for all pre- above 15 years.During the second campaign (1966- ventive and curative health services in his district. He is 1968) a successful attempt was made to detect all assisted by district nurses and other nursing personnel. active tuberculosis patients and to vaccinate the popu- The women's health committees play an important lation at risk. The tuberculosis control services were role in assisting the district nurses in health and welfare integrated into the general public health services in a activities.Most of the health services rendered are pilot area in 1970 and into the general health services free of charge and drugs are sold at a minimum price. in 1972. Each district hospital is now responsible for its BCG programme. Vaccination schedules are systematically organized for the vaccination of newborns, Hospital services preschool children in the villages, and school entrants. In 1972, 8946 persons were vaccinated with BCG. In 1971 Western Samoa had 15 hospitals providing Case -finding is carried out systematically and continu- a total of 630 beds, to which 13 621 inpatients were ously in the health districts. It is estimated that during admitted during the year.The bed /population ratio the period under review the annual tuberculosis death was 4.4 to 1000.The 630 beds were distributed as rate varied between 15 and 28 per 100 000 population. follows : Thefilariasiscampaign, which commenced its Category and number Number of beds activities in 1965, is assisted by WHO and UNICEF. General hospital 1 294 Surveys showed that 19.06 % of Western Samoa's Rural hospitals 14 336 population was infected with bancroftian filariasis. Outpatient facilities were available in 1972 at the Assessment after the first mass drug administration Apia general hospital, at the rural hospitals, and at showed an infection rate of 1.63 %.Typhoid fever eight health centres. became prevalent in the years 1966 and 1967 with a case rate of more than 140 per 100 000 population. Following a mass immunization programme in 1968, Medical and allied personnel and training facilities the case rate dropped to 31.3 per 100 000 in 1969 and to 20.2 per 100 000 in 1970. In 1971 a typhoid control In 1971 Western Samoa had 51doctors,allin programme was launched, with emphasis on water - government service. The doctor /population ratio was seal latrine construction and immunization of the one to 2800 inhabitants.Other health personnel high risk population groups. included :

Dentists 13 Dental hygienists 10 Specialized units Pharmacist 1 Pharmaceutical assistants 9 Maternal and child health care services are provided Pharmacy helpers 2 Midwives 8 at the Apia general hospital, at the rural hospitals, Nurses 205 and by the women's health committees. Student nurses 112 In 1972, Nursing auxiliaries 53 1836 pregnant women and 2915 infants and preschool Health inspectors 3 Health inspector trainees 9 children availed themselves of these services. In 1972, Physiotherapist 1 2023 (approximately 50 %) of all deliveries were con- Medical laboratory technologists 2 Medical laboratory assistants 16 ducted in hospital.Dental treatment was provided Laboratory aides 5 in 1971 in five dental health clinics to 1740 school- X -ray technicians 7 Health educators 2 children and 8233 adults. The hospital rehabilitation 302 FIFTH REPORT ON THE WORLD HEALTH SITUATION outpatient department recorded 282 new patients in public health research programme was initiated to 1972. Psychiatric consultations were given at one survey and analyse the workload and activities of the outpatient clinic to 185 new patients. Western Samoa district health personnel, in order to formulate a also had a tuberculosis clinic and a leprosy clinic. reasonable staffing pattern for the rural health services The two public health laboratories carried out nearly and to improve the work programme in the health 150 000 examinations during the year. districts.

Environmental sanitation Assistance from WHO In 1972, of the 16 health districts, 14, with a total In1972 WHO's assistanceto Western Samoa population of 133 319, had piped water systems. None included the following projects: of the communities in Western Samoa had a sewerage Tuberculosiscontrol (1971- ):to consolidate system. and assess the tuberculosis control service in the demonstration area of Leulumoega; to standardize the Major public health problems methods and procedures used by all districts; and, ultimately, to integrate the tuberculosis control ser- The most important health problems in Western vices into the general health services throughout the Samoa are gastrointestinal infections associated with country. poorenvironmentalsanitation,andrespiratory diseases.The nutritional status of the inhabitants is Filariasis control (1972) UNICEF: a consultant also causing concern. reviewed the survey data obtained through the project, made an epidemiological assessment, assessed the vector mosquito density in the area of drug dis- National health planning tribution, evaluated the field trials of vector control, Western Samoa's first five -year economic develop- and made recommendations on future activities. ment plan covered the period 1966 -1970. The second National healthservices development (1967- ) five -year development plan was formulated for the UNICEF: to develop and strengthen the organization period 1971 -1975.In the second five -year economic and operation of the general health services, partic- development plan, the Government laid emphasis on ularly atdistrict and local levels; to improve the increasing agricultural, fishery, and forestry products, operation of the rural health programme; to organize developing small -scale industries, encouraging interna- in- service training; to conduct epidemiological studies; tional trade, and constructing roads, ferries and tele- and to plan disease control programmes as part of the communication systems. The plan also laid emphasis general health services. on the reorientation of the education and training Publicadministrationand managementadvisory system. services (1972): a consultant advised the Health Depart- Although there is no national health planning unit ment on the organization and maintenance of a record- in the Health Department, planning is done by the ing and filing system and helped to train staff for this National Health Advisory Committee under the chair- work. manship of the Director of Health and with the parti- Hospital administration (1971- 1972): a consultant cipation of the chiefs of the six divisions of the Depart- helped to assess the medical care services, advised on ment. Their decisions are subject to the approval of and assisted in strengthening hospital management the Minister of Health. The health sector of the second practices and procedures and assisted in establishing five -year development plan calls for the improvement referral systems. He also participated in the formu- of preventive and curative health services and the lation of a building programme for hospital services initiation of a family planning programme to be inte- and in the organization of training programmes for grated into the general health services. Much attention hospital staff, and advised on legislative measures for is also paid to the strengthening of rural health services. ensuring the effective delivery of medical care services. Nursing education (1972- ) UNDP: to improve Medical and public health research the standard of nursing and midwifery education and Since 1969 the surgical service of the Apia general services. hospital has been engaged in clinical research on Maternal and child health /family planning (1971- ) filariasis, particularly with a view to finding effective UNFPA UNICEF: to organize a family planning ways of correcting the deformities of filarial elephan- programme, including advice on the spacing and tiasis.This project is supported by WHO and by the limitation of births and the treatment of subfertility, New Zealand Medical Research Council.In 1972 a and train the necessary staff. WESTERN PACIFIC REGION 303

Government health expenditure on laboratory services, $WS 24 377 on environmental health services, $WS 24 406 on mass campaigns against In 1972 the total government expenditure on current communicable diseases, (WS 12 124 on education and capital accounts amounted to 11 042 430 talas, and training of health personnel, $WS 9000 on occu- of which $WS 1 170 844 were spent on health ser- pational health services, and $WS 8000 on vaccination vices. The per capita expenditure for health purposes activities.Government contributions to health acti- was $WS 8.Government health expenditure on vities of social security schemes and other nongovern- currentaccountincludedthefollowingitems: mental social welfare systems amounted to $WS $WS 718 683 on hospitals and clinics, $WS 42 318 397 244.

BRITISH SOLOMON ISLANDS PROTECTORATE

Population and other statistics Health Inspector, who provide advisory services to district health personnel and who are involved in At the last census, taken in February 1970, the popu- training at various levels; the malaria eradication lation of the British Solomon Islands Protectorate programme, which is administered by the government was 160 998.Population estimates and some other malariologist; and the community health division, vital statistics for the period under review are given which is concerned with the development of rural health in the following table: services and the control of endemic diseases and which

1969 1970 1971 1972 consists of the medical officer (community health) Mean population . . . 158 540 160 998" 166 290 173 510 and the public health sister. Number of live births . . 5 720 6 211 Birth rate In each of the above -mentioned four medical dis- (per 1000 population) . 36.1 38.6 tricts there is a district medical officer.The district Number of deaths . . . 2 060 Death rate health services consist of the district hospital and of (per 1000 population) . 13.0 a series of local authority, mission, and commercial Natural increase ( %) . . 2.31 Number of infant deaths . 300 clinics.Church hospitals are also maintained in the Infant mortality rate (per 1000 live births) 52.4 Western and Malaita Districts. In addition, there are various endemic disease control programmes, admi- " Census figure. nistered by the medical headquarters, of which the The communicable diseases most frequently notified district medical officer is the local manager (as in the in1970 were: influenza (10 708), tuberculosis,all case of the tuberculosis and the leprosy control pro- forms, new cases (338), leprosy (33). grammes), or the local coordinator (as in the case of the malaria eradication programme), or the local representative (as in the case of the rural water supplies Organization of the public health services project, which is managed by the chief health ins- The Government Medical Department is responsible pector). The district medical officer leads a team con- for the administration and organization of all public sisting of a district sister, one or two medical officers, health activities in the territory.It has three main an assistant health inspector, the malaria field opera- components -namely, the medical headquarters, the tions officer, and supervisory nurses. He is also res- central hospital (with the school of nursing), and the ponsible for the management of the district hospital rural medical services in the four medical disctricts and of the rural hospitals in his district. (Malaita District, Eastern District, Western District, and Central District).The medical headquarters Hospital services comprise the Directorate of Medical and Nursing Services headed by the Director of Medical Services, the In 1971 the British Solomon Islands Protectorate Deputy Director of Medical Services, and the Super- had 74 hospitals and other establishments for in- intendent of Nursing Services, who formulate the patient care providing a total of 1414 beds, of which health policy of the territory, in accordance with the 469 were in 25 private establishments.The bed/ directives of the Governing Council and taking account population ratio was thus 8.5 to 1000. The 1414 beds of the recommendations of the Community Health were distributed as follows : Operations Committee and of the annual Conference Category and number Number of beds of District Medical Officers and Nursing Sisters; a General hospital 1 171 number of nonclinical specialist officers, including Rural hospitals 9 529 Medical and maternity centres 63 626 the Senior Health Education Officer and the Chief Leprosy hospital 1 88 304 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Ambulatory medical care was available in 1972 at and in some areas of the Central District the incidence ninehospitaloutpatientdepartments,88health of malaria is now extremely low. Mass drug adminis- centres (of which 78 had some hospitalization facilities), tration as a supplementary measure covered some 25 medical aid posts, and one mobile health unit. 4000 inhabitants in problem areas on Guadalcanal north coast and Nggela, and in certain villages of the Medical and allied personnel and training facilities Western District.Good coordination between the general health programme and the malaria eradication In 1971 the British Solomon Islands Protectorate programme has been promoted through the public had 38 doctors, of whom 33 were in government health operations committee and the existing malaria service. The doctor /population ratio was one to 4370. operations committee. However, the peripheral rural Other health personnel included: health structure was found to be still inadequate to

Medical assistants 118 give full support to the malaria eradication programme, Dentists 3 mainly because of understaffing of rural health units, Dental assistant 1 Dental mechanics 2 inadequate supervision at the intermediate level, lack Pharmacists 2 of provision for in- service training of the staff, and Dispensary attendants 8* Veterinarians 2 limited transport facilities. Veterinary field assistants 7 With an average of some 386 new cases notified Assistant midwives 75 Nurse/midwives 174 each year since 1964, tuberculosis remains the second Dressers 39 Sanitary engineers 3 most serious public health problem. Notifications Sanitary inspector 1 for 1972 totalled 338 new cases, indicating little change Health assistants 17 Physiotherapist 1 in the overall picture. The tuberculosis problem seems Laboratory supervisors 3 most acute in the Malaita District. A contact regis- Medical laboratory assistants 2 Laboratory attendants 11 tration system to encourage the active search for and X -ray technicians 4 examination of contacts was instituted in April 1972. Entomologist 1 Malaria microscopists 15 The proportion of pulmonary cases has fallen from Entomology technicians (malaria) 10 Epidemiology technicians (malaria) 80 the previous steady level of about 80 % to 70 %. Facil- ities for bacteriological confirmation have been much In government service only. improved in the central hospital laboratory.BCG There isone government establishment for the vaccination of all babies, children, and young adults, training of health assistants, which provides a one - treatment of cases, case -finding among contacts, and year practical course for candidates who have com- other case -finding by surveys are the main control pleted primary education.The school of nursing measures adopted by the health authorities. attached to the central hospital organizes a three -year There has been little change in the epidemiological course for candidates with four years' secondary situation of leprosy, with the number of new cases education. In 1972 the total enrolment of this school notified annually remaining around 35. An intensive was 60 students, of whom 20 graduated. The school leprosy survey was begun in September 1972 and was of nursing at Fauabu hospital has been integrated conducted chiefly in the endemic area of Malaita. with the central hospital school of nursing. During the period under review, a fifth of the cases have been classified as lepromatous, a proportion which has remained fairly constant over the last 10 Communicable disease control and years.Most of the leprosy patients are treated suc- immunization services cessfully on a domiciliary basis after an initial period The major endemic diseases are malaria, tuberculosis, in hospital for stabilization by means of chemotherapy. helminthiasis, skin conditions, eye infections, and The following immunization procedures were car- leprosy. Malaria is still the principal cause of morbid- ried out in 1971: ity in those islands that are not covered by spraying Poliomyelitis 8 982 operations. In 1968 the malaria eradication policy for Smallpox 6 987 BCG 2 808 the period 1969 -1975 was officially defined, and in Diphtheria, whooping -cough and tetanus . . 2 364 Tetanus 1 592 1970 the malaria eradication programme was launched Diphtheria and tetanus 333 with WHO assistance.The entire population, with the exception of the inhabitants of a few small islands where transmission of the disease does not occur, is Specialized units covered by the programme. Most areas have proved fully responsive to spraying, as measured by the In 1972 maternal and child health care was provided declining incidence of the disease, assessed by blood at one urban centre and at 31 rural health units.It surveys in the various islands. In the Western District is estimated that, in the same year, 78 % of all deliveries WESTERN PACIFIC REGION 305

were conducted under professional medical supervision. A survey of the organization and distribution of A policy statement on family planning was approved the rural health and hospital services has been car- by the Governing Council and an application for ried out in the context of suggestions for a national assistance from UNFPA has been prepared.The medical service formulated at the request of the social territory has only one properly equipped dental services committee of the Governing Council.As a surgery, which isat the central hospital.Dental result, it is proposed to rationalize existing government, officers tour the districts extensively, paying particular local council, and church institutions into a four - attention to schoolchildren. tiered structure involving a network of registered staff clinics as the lowest level, which are to be grouped Environmental sanitation under the supervision of area health centres.Each of the latter will be staffed by a nursing officer and an The capital city, Honiara, has a piped water system assistant health inspector and have access by radio to which, in 1972, served 85 % of its inhabitants with the district medical officer and facilities for referring piped water, the remaining 15 % having access to patients to the district hospital. The central hospital, water from standpipes.In the same year 10 % of which provides specialist services, represents the highest Honiara's population were living in houses connected level. to sewers. Of the rest of the Protectorate's population, 82 % had piped water. Medical and public health research

Major public health problems There is no formal research organization in the British Solomon Islands Protectorate.Much infor- The major public health problems are the communi- mation of research interest has been accumulated cable diseases already mentioned :malaria, tubercu- through the programmes for malaria eradication and losis and leprosy. Environmental sanitation, nutrition for tuberculosis and leprosy control. Work continues education, and population control are also becoming on methods to improve the collection of vital statistics increasingly important.

Social and economic developments of significance for Assistance from WHO the health situation In 1972 WHO's assistance to the British Solomon High inflation, depression in the copra and timber Islands Protectorate included the following projects: markets, and the destruction of valuable crops by Malaria eradication programme (1970- ) UNDP. cyclones have caused serious setbacks to the develop- Health education advisory services (1971 -1972): to Since the beginning of the ment of the Protectorate. strengthen the health education service in the Medical sixth development plan, however, there has been Department, establish a pattern for health education spectacular progress in fisheries, which has brought activities to be carried out at village level, and improve immediate benefit to the national economy with much the teaching of health education. promise for the future. The gradual growth of tourism has continued. Following the establishment of a statisticalofficein1970, more basic information Government health expenditure necessaryforplanned development has become available. In1971totalgeneral government expenditure amounted to 10 491 285 Australian dollars, of which National health planning $A 1081 855, or approximately 10 %, were used for health purposes.The per capita health expenditure The sixth development plan, which was adopted in thus amounted to $A 7 during 1971.The Medical 1971 and extended into 1974, called for an expansion Departmentaccountedfor$A1 048 730,other of the malaria eradication programme to give country- departments for $A 5225, and the local health author- wide coverage;forcontinuedeffortstocontrol ities for $A 27 900.Approximately one -third of the leprosy, tuberculosis, and other communicable diseases; government health expenditure was disbursed on for a modest programme of rural water supply and administration and government personnel, one -third water -seal latrine construction; for an improvement in on general hospitals and clinics, and the rest on dental services; and for the maintenance of existing various programmes, the largest of which isthe curative services, subject to a review of their distri- malaria eradication programme, which represented bution and organization. an expenditure of $A 183 750. 306 FIFTH REPORT ON THE WORLD HEALTH SITUATION

BRUNEI

Population and other statistics inhabitants. These beds, to which 10 535 patients were admitted during the year, were distributed as follows: At the last census, taken in August 1971, the popu- 438 beds in three general hospitals, and 18 beds in a Population estimates lation of Brunei was 136 256. rural hospital. and some other vital statistics for the period under Outpatient care was provided in 1972 at the hospital review are given below: departments, at nine health centres and nine mobile 1969 1970 1971 1972 health units, and through a flying doctor service. Mean population . . 124650 130260 136256 141 500 Number of live births . . 4 614 4 823 5181 5 008 Birth rate (per 1000 population) . 37.02 37.03 38.02 35.39 Medical and allied personnel and training facilities Number of deaths . . . 691 716 801 742 Death rate In 1971 Brunei had 38 doctors, of whom 31 were in (per 1000 population) . 5.54 5.50 5.88 5.24

Natural increase (%) . . 3.15 3.15 3.21 3.01 government service. The doctor /population ratio Number of infant deaths 198 163 199 177 Infant mortality rate was thus one to 3550. Other health personnel included: 42.91 33.80 38.41 35.34 (per 1000 live births) Number of deaths, Hospital assistants 34 1 -4 years 79 64 64 Dentists 7 Death rate, 1 -4 years (per Dental assistants 6 1000 population at risk) 3.66 Dental nurses 24 Number of maternal Dental laboratory technicians 7 deaths 6 4 Pharmacists 3 Maternal mortality rate Dispensers 5 (per 1000 live births) . 1.25 0.78 Veterinarian 1 Veterinary assistants 11 Midwives 25 Of the 742 deaths recorded in 1972, the main causes Assistant midwives 67 were :1 symptoms and ill- defined conditions (279), Nurses 127 Assistant nurses 66 congenital anomalies, birth injury,difficult labour Health inspectors 14 and other anoxic and hypoxic conditions, other causes Junior health inspectors 12 Physiotherapists 3 of perinatal mortality (91), chronic rheumatic heart Laboratory technicians 16 disease, hypertensive disease, ischaemic heart disease X -ray technicians 2 Medical records officer 1 and other forms of heart disease(69),bacillary dysentery and amoebiasis, enteritis and other diar- Training facilities for health personnel in Brunei rhoeal diseases (55),cerebrovascular disease(34), are limited to nursing and midwifery training, for pneumonia (32). which there are the following arrangements: The communicable diseases most frequently notified Category DurationNumber of in 1971 were: measles (544), tuberculosis, all forms, and admission of study schools new cases (242), gonorrhoea (47), bacillary dysentery requirements (years) Nurses (basic course) : (32), typhoid and paratyphoid fevers (30), malaria, lower certificate of edu- new cases (15), infectious hepatitis (6). cation 3 1 Assistant nurses: 6 years' primary education 2 1 Organization of the public health services Midwives (basic course) : lower certificate of edu- The Medical and Health Department, which is cation andnursing training 3 1 headed by the Director of Medical Services, is pri- Assistant midwives . . 2 1 marily responsible for the organization and administration of public health activities in Brunei.It is subdivided into two departments, one for general Communicable disease control and medical services and the other for public health immunization services preventive medicine.Brunei has four districts, of There is no indigenous malaria in Brunei as a which only two at present have direct health represen- result of the control work carried out under the malaria tatives. eradication project.A few cases of malaria occur annually, however, mostly among immigrant labourers. Hospital services Continuous antimalaria vigilance is maintained, with In 1971 Brunei had four hospitals providing a special emphasis on spraying in border areas. Filariasis total of 456 beds, equivalent to 3.3 beds for 1000 is present in a number of small areas. A countrywide tuberculosis survey has commenced. All infants 1 international Classification of Diseases, 1965 Revision. attending the maternal and child health clinics are WESTERN PACIFIC REGION 307

immunized with BCG vaccine as well as against Social and economic developments of significance for poliomyelitis and smallpox. Very few trachoma the health situation cases are seen in Brunei's ophthalmological clinics. The following immunization procedures were car- The main industrial activity of Brunei is the produc- ried out in 1972: tion of oil and liquefied natural gas. Communications within Brunei have improved very considerably since Cholera 108425 Smallpox 17077 the completion of a number of good roads. Similarly, Diphtheria, whooping -cough and tetanus . 15543 the use of short -wave radio has made it possible for Typhoid and paratyphoid fevers 1 782 Tetanus 594 the medical services to assist inhabitants in remote Yellow fever 56 areas.Surgical and medical emergencies, notified by radio, are transported to hospital by helicopter. There Specialized services is also a regular flying medical service to all remote In 1972, eight maternal and child health centres areas. recorded 28 204 attendances by pregnant women, 4302 by infants under one year and 364 by children National health planning aged 1 -5 years.In 1972, 3068 (about 60 %) of all deliveries were conducted under medical supervision. A five -year national development plan now in The school health service supervised the health of preparation will include a plan for medical services. 1631 schoolchildren.Dental treatment was given at 12 school dental clinics to 11 447 schoolchildren and at three dental clinics for adults to 36 084 patients. Government health expenditure The two hospital outpatient rehabilitation departments recorded 509 new patients in 1972.Consultations In1972totalgovernmenthealthexpenditure were given at the psychiatric clinic to 30 new out- amounted to 9 928 062 Brunei dollars. The per capita patients. expenditure on health was thus Brunei $ 70. Govern- ment expenditure on general public health services Environmental sanitation included the following items: Brunei $ 614 557 on administration and government personnel, $ 87 480 In 1972 three communities of Brunei with a total on mass campaigns against communicable diseases, of 100 000 inhabitants had a piped water supply includingvaccinationprocedures,$ 190 000on system serving 71 % of the population, and two environmental and occupational health services, and communities with 67 000 inhabitants had a sewerage $ 200 000 on education and training of health person- system. Of the total population, 50 % were living in nel. Government health expenditure on hospitals houses connected to sewers. amounted to Brunei $ 3 305 025.

GILBERT AND ELLICE ISLANDS

Population and other statistics hepatitis (24), gonorrhoea (18), meningococcal infections (14), typhoid and paratyphoid fevers (8), leprosy At the last census, taken in December 1968, the (5). Gilbert and Ellice Islands had a population of 53 517. Population estimates and some other vital statistics Organization of the public health services for the period under review are given in the following table: All government medical and public health activities are carried out by the Medical Department under the 1969 1970 1971 1972 supervision of the Director of Medical Services. He Mean population . . 54 226 56 390 58 417 59 760 Number of live births. . 1 287 1 268 is assisted by two senior medical officers, who are Birth rate responsible for curative and preventive services respec- (per 1000 population) . 22.8 21.7 Number of deaths . . . 329 414 tively, while a senior dental officer is responsible for Death rate dental health services.There is also a small health (per 1000 population). ... 5.8 7.1 Natural Increase ( %) . . 1.70 1.46 inspectorate under the direction of a medical officer. The nursing services are not yet fully developed at The communicable diseases most frequently notified the central level. in 1970 were: influenza (19 893), bacillary dysentery Apart from the main island of Tarawa, which has (229), tuberculosis, all forms, new cases (67), infectious approximately one -fifth of the total population of the 308 FIFTH REPORT ON THE WORLD HEALTH SITUATION territory and in which the central hospital is situated, Communicable disease control and healthservicesare mostly provided by nursing immunization services staff,employed by thecentral government and posted to the scattered outer islands. A few islands Tuberculosisisstillthe most important public health problem in the territory and a control program- withlarger populations have a resident medical Maternal and child health aides, resident in me, in operation since 1961, continues with WHO officer. assistance.By the beginning of 1970 all the islands island villages, are given rudimentary training by the Medical Department, and are employed by island had been covered by a tuberculin testing and BCG vaccination campaign. Difficulties of inter -island councils under the supervision of nursing staff. transport, distance between islands, and a shortage of adequately trained staff on the islands have increased Hospital services the costs of the campaign and exacerbated the problems of follow -up of registered cases and supervision of In 1971 the Gilbert and Ellice Islands had 28 domiciliary treatment. The number of notified tuber- hospitals and other establishments for inpatient care culosis cases declined from 433 in 1961 to 136 in 1972. providing a total of 539 beds, of which 479 were in 27 Diarrhoeal diseases are common and only likely to government- maintained establishments. The bed/ be reduced as environmental sanitation is improved population ratio was 9.2 to 1000. The 539 beds were and safe water supplies and hygienic waste disposal distributed as follows: are provided. The number of patients suffering from

Category and number Number of beds diarrhoea continues to increase every year. Leprosy is General hospitals 2 219 endemic in the Gilbert Islands but rare in the Ellice Rural hospitals 10 120 Islands. The number of new leprosy cases decreased Medical centres 16 200 from 75 in 1961 to 7 in 1971. Patients are confined to Outpatient facilities were available in 1971 at two leprosaria only ifactively infectious or otherwise hospital departments, which recorded 27 406 atten- needing hospital care. Filariasis is a health problem in dances; at 10 health centres, which are staffed by a the Ellice Islands and, to a lesser degree, in some of the physician and provide limited inpatientfacilities; Gilbert Islands. A filariasis control programme was and at 19 dispensaries, which are outer island nurse initiated in the Ellice Islands in 1972. No cases of yaws stationsproviding both outpatient and inpatient have been reported since the mass treatment campaign services to island populations ranging from 300 to 2000. in 1958. Venereal diseases do not at present constitute a major health problem, practically all cases being confined to the port area of South Tarawa; the Medical and allied personnel and training facilities number of reported cases totals less than 100 per annum. In 1971 the Gilbert and Ellice Islands had 30 The following immunization procedures were car- physicians, of whom 26 were in government service. ried out in 1971: The doctor /population ratio was thus one to 1900. Other health personnel included: Smallpox 4 936 Poliomyelitis 3 981 BCG 1 245 Dentists 3 Cholera 140 Dental assistant 1 Typhoid and paratyphoid fevers 104 Pharmacist 1 Pharmaceutical assistant 1 Nurse/midwives 104 Nursing auxiliaries and maternal and child health Specialized units aides 110 Assistant health inspectors 5 Maternal and child health services are provided at Assistant laboratory technicians 2 110 prenatal and child health service units.In 1972, Assistant radiographers 2 740 deliveries were attended by a doctor or a qualified The only professional health training available in midwife, either in hospital or at home. The promotion the islands is given at the Nurse Training School at of family planning, which is integrated in maternal the Central Hospital, Tarawa, which organizes a and child health work, was given top priority between three -year course. In 1972 the total enrolment of this 1970 and 1972 and results have been good, with school was 42 students, of whom 12 graduated. one -third of the female population aged between 15 There are also two training schools for maternal and and 44 years now using reliable methods of family child health aides, which provide a six -month course. planning. Trained maternal and child health aides are A total of 18 students were enrolled in the two schools employed by island councils to extend the basic in the year 1971/72. coverage of MCH services. A school health service All other training in the health field is acquired for all schools on Tarawa is provided by the maternal abroad, mainly in Fiji and New Zealand. and child health team. Dental treatment was given in WESTERN PACIFIC REGION 309

1971 to 4348 patients at two dental clinics.Other followed by the plans for 1971 -1973 and 1973 -1976. specializedfacilitiesincluded a leprosy outpatient The health objectives of the 1973 -1976 development clinic and a public health laboratory. plan are to develop unified and effective preventive health services in all islands; to maintain curative Environmental sanitation services at the present per capita level in real terms; and to establish an influential national body to advise is territory Fresh water scarce throughout the on matters affecting population growth. except in the extreme north and south, where rainfall A Medical and Public Health Policy Paper has been is normally plentiful.Piped water supplies are avail- prepared for the years 1970 -1979, which is subject to able on one outer island; elsewhere in the rural areas, review at two- yearly intervals. This Policy Paper has drinking -water is taken from open wells or caught been taken into account in the preparation of the from metal roofs. General -purpose water comes from development plans. The basic principles and aims of open wells. The urban areas of South Tarawa have no the islands' medical and public health policy are: to Potable water is delivered by piped water supply. undertake a territorywide family planning campaign; tanker. Water supply development has been hampered to concentrate on preventive as opposed to curative by the droughts of 1968 and 1970.In some villages, medicine and on health education; to develop the and throughout the urban areas, increased population rural health services, especially maternal and child densities have made traditional methods of human health services; to raise the standard of environmental waste disposal unsafe. Flyborne diseases are common sanitation throughout the territory; to integrate the and the risk of serious epidemic infection through various preventive health services; and to maintain polluted water supplies is increasing. The most urgent and improve existing hospital and curative services. problem is in the most densely populated areas. A programme to provide each household with safe Assistance from WHO sanitation through the construction of septic tanks In 1972 WHO's assistance to the Gilbert and Ellice was launched in 1972 as a British aid project. Provision is being made for the construction of piped sewerage Islands included the following projects: systems in each of the town areas in a five- to six - Nursing education (1964 -1968; 1970 -1972) UNDP year programme that was scheduled to begin in 1973. UNICEF : to establish programmes for training nursing personnel for the hospital and health services; to Major public health problems strengthen the public health nursing aspects of the basic curriculum of the school of nursing, increase Apart from the communicable diseases already the number of nursing personnel, and improve their mentioned the most important public health problems quality. in the Gilbert and Ellice Islands are poor water Family health (1971- ) UNFPA UNICEF: to Urgent measures supply and inadequate sanitation. organize and make available to the whole population are being taken to improve the situation in South services related to human reproduction and fertility, Tarawa, where overcrowding in urban areas and air including services for spacing and limitation of births and sea communications increase the threat of epidemic and for treatment of subfertility, and to carry out a High priority is being given to improve- diseases. programme of information and education of the public. ment of sanitation in the outer islands, which should result in an appreciable reduction in infant mortality, Government health expenditure and in gastrointestinal and other waterborne and In 1971 total government health expenditure amoun- flyborne diseases. ted to 477 875 Australian dollars of which $A 442 975 were spent on current account and $A 34 900 on National health planning capital account. The per capita expenditure on health Formal development planning began in the Gilbert was thus $A 8.18.The government expenditure on and Ellice Islands with the 1970 -1972 plan, which was hospitals amounted to $A 276 271.

HONG KONG

Population and other statistics 1969 1970 1971 1972

Mean population . . . 3863 900 3959 000 4045 300 4078 400 At the last census, taken in March 1971, the popu- Number of live births. . 79329 77465 76818 80337 Birth rate lation of Hong Kong was 3 948 179.Population (per 1000 population) . 20.5 19.6 19.0 19.7 estimates and some other vital statistics for the period Number of deaths . . . 18730 20763 20253 21301 Death rate under review are given in the following table: (per 1000 population) . 4.8 5.2 5.0 5.2 310 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 bed /population ratio was 4.1 to 1000.These 16 406 Natural Increase (%) . . 1.57 1.44 1.40 1.42 beds, to which 345 745 patients were admitted during Number of infant deaths . 1 731 1 521 1 410 1 394e Infant mortality rate the year, were distributed as follows: (per 1000 live births) . 21.8 19.6 18.4 17.4 Number of deaths, Category and number Number of beds 1 -4 years 341 407 314 302 Death rate, 1 -4 years (per General hospitals 28 11 753 1 15 1000 population at risk) 0.93 1.18 0.95 0.95 Rural hospital Number of maternal Medical centres 88 785 Maternity hospital 1 301 deaths 12 15 11 16 Maternal mortality rate Infectious diseases hospital 1 88 Tuberculosis hospitals 3 1 282 (per 1000 live births) . 0.15 0.19 0.16 0.20 Psychiatric hospital 1 1 242 United Nations data. Cancer hospital 1 120 Children's orthopaedic hospital . . 1 200 Medical rehabilitation clinic 1 80 Of the 21 301 deaths recorded in 1972, the main Leprosari u m 1 540 causes were:malignant neoplasms (4375), chronic rheumaticheartdisease, hypertensive disease, In 1972 outpatient services were available at nine ischaemic heart disease and other forms of heart hospital departments, which recorded over 2 000 000 disease (3035), pneumonia (2359), cerebrovascular attendances during the year; at eight polyclinics, which disease (1892), symptoms and ill- defined conditions recordedover3 100 000attendances and which (1813), tuberculosis, all forms (1312), accidents (1192, include specialist clinics, general outpatient clinics including 419 in motor -vehicle accidents), bronchitis, and sometimes a rehabilitation unit for the disabled; emphysema and asthma (1012), congenital anomalies, at 32 health centres, which recorded over 3 900 000 birth injury, difficult labour and other anoxic and attendances and which provide general outpatient hypoxic conditions, other causes of perinatal mortality services, and, in some cases, maternal and child health (926), suicide and self -inflicted injuries (463), cirrhosis services; at five police medical posts (81 500 atten- of liver (309), nephritis and nephrosis (255), diabetes dances); at nine mobile health units (29 400 atten- mellitus (179), peptic ulcer (165). dances); at two family clinics (45 300 attendances); The communicable diseases most frequently notified and at 14 prison hospitals and their family clinics and in 1972 were: tuberculosis, all forms, new cases (8420), other special centres. measles (783), typhoid and paratyphoid fevers (466), bacillarydysentery(462),leprosy(101),amoebic Medical and allied personnel and training facilities dysentery (35), meningococcal infections (10), malaria, new cases, imported (6), poliomyelitis (4). In 1971 Hong Kong had 2342 doctors (including 181provisionally registered house physicians),of whom 649 were in government service.The doctor/ Organization of the public health services population ratio was one to 1730.Other health per- The organization of the health services in Hong sonnel included: Kong is based on the Government Medical and Health Unregistrable doctors 1 456 Dentists 480 Department, which establishes and controls clinical Dental nurses 13 and laboratory institutions and preventive medical Dental technologists 2 Dental technicians 35 activities.Services are provided free or at a nominal Dental surgery assistants 78 Pharmacists 186 charge. Government subsidies continue to support a Dispensers 131 number of voluntary organizations that supplement Veterinarians 9 Midwives 747 government services, particularly hospital facilities. Nurses 5 472 The Medical and Health Department works closely Psychiatric nurses 215 Nursing auxiliaries 141 with other departments holding statutory responsibility Psychiatric nursing auxiliaries 32 for safeguarding the public health. These departments Health inspectors /Student health inspectors 384 Physiotherapists 60 are the Urban Council, the Urban Services Depart- Laboratory technicians 68 Laboratory assistants 22 ment, the Labour Department, and the New Territories Radiographers 106 Administration. Medical officers are seconded to Biochemist 1 Physicists 8 some of these departments. Chemists 14 Health visitors 92 Health auxiliaries 126 Hospital services 1 Persons with 6 years' training in medical schools not recognized by Commonwealth countries. In 1971 Hong Kong had 127 establishments for In government service. inpatient care providing a total of 16 406 beds, of The arrangements for the training of professional which 6566 were in 36 government institutions. The and auxiliary health personnel in Hong Kong are as 1 International Classification of Diseases, 1965 Revision. follows: WESTERN PACIFIC REGION 311

Category DurationNumber of Total Number of Diphtheria 516096 and admission of study schoolsenrolment graduates Smallpox 441067 requirements (years) (public) 1971/72 1972 Cholera 350511 Doctors : Poliomyelitis 315478 Matriculation certifi- BCG 135545 cate 5 1 690 128 Typhoid and paratyphoid fevers 89969 Dental technicians: Measles 35622 5 -6 years' secondary Yellow fever 1901 Plague education 3 2 75 - - Epidemic typhus Laboratory assistants: 38 5 -6 years' secondary education or matricu- Chronic and degenerative diseases lation certificate . 2 -3 1 - - Dispensers : 5 -6 years' secondary The noncommunicable diseases are becoming an education 3 1 58 10 General nurses: increasing problem in Hong Kong, where the leading 5 -6 years' secondary causes of death are cancer, heart diseases and hyper- education 3 2 726 138 Psychiatric nurses: tensivediseases,pneumonia, and cerebrovascular 5 -6 years' secondary diseases.The control of this group of diseases is education 3 1 90 4 General nursing auxilia- concentrated on health education for prevention, ries : and on early detection and treatment. 3 years' secondary education (3rd form) . . 2 1 147 38 Psychiatric nursing auxiliaries : Specialized units 3 years' secondary education (3rd form). . 2 1 21 11 In 1972 maternal and child health care services were Midwives : must be general nurses available at 33 prenatal centres and 35 child health or have completed 4 centres.During the year, 24 440 pregnant women, years' secondary edu-

cation (4th form) . . 1 -2 2 169 94 73 979 children under one year and 34 454 children Health auxiliaries: aged 1 -5 years attended these units. Home visits were 5 -6 years' secondary education 2 1 19 8 paid to 35 953 infants and to 49 104 children aged Medical laboratory tech- 1 -5 years.In 1972, 33 822 deliveries, or about 43 nicians : 5 -6 years' secondary of the total, were conducted in government hospitals education 3 1 17 or maternity homes. The school medical service pro- Physiotherapists : 6 years' secondary edu- vided medical and health supervision to 68 837 school- cation 3 1 42 13 children, representing approximately 5.4 % of the total Radiographers: 6 years' secondary edu- school population.Dental treatment was given at cation 3 1 36 8 30 dental clinics to 271 554 patients. In 1972, the seven Health Inspectors: 5 years' secondary edu- independent medical rehabilitation centres were atten- cation 3 1 90 23 ded by 5313 new outpatients and the four hospital Prosthetists : 5 -6 years' secondary rehabilitation departments by 23 353 new outpatients. education 3 1 4 3 During the same year, 2856 new patients attended the seven psychiatric outpatient clinics. Other specialized Communicable disease control and units included 23 tuberculosis centres with 42 238 new immunization services outpatients, 14 venereal disease clinics with 38 203 new outpatients, eight leprosy clinics with 303 new There have been considerable improvements in the outpatients, 18 ophthalmological clinics with 81 571 control of communicable diseases.The incidence of new outpatients, nine dermatology clinics with 14 784 diphtheria, poliomyelitis, and measles remained at a new outpatients, and eight ear, nose, and throat clinics. low level as a result of immunization campaigns. Between July and October 1969 Hong Kong had a Environmental sanitation short cholera outbreak.The disease was quickly brought under control by the application of vigorous All the water supply in Hong Kong is surface water, public health measures and intensive vaccination. collected and stored in reservoirs. There is a central Although there was no further outbreak, precautionary water supply authority that supplies water to con- measures were maintained.Routine sampling of sumers through metered piped water connexions and night soil for cholera vibrio was carried out on a year - to some 4 % of the population through public stand- round basis as part of the surveillance programme. pipes, of which about 1000 are dispersed throughout Tuberculosis, with a prevalence of 0.8 % in 1972, the rural areas and within the urban areas to meet the remains the principal community health problem. needs of the population living on boats and on squatter The following immunization procedures were carried sites. An estimated 75 % of the total population live out in 1972: in houses connected to sewers. 312 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Major public health problems Medical and public health research

Tuberculosis remains a serious public health prob- Research activities are carried out by the various lem. Hong Kong is also facing increasing problems units of the Medical and Health Department and in due to the rising incidence of cancer and cardiovascular collaboration with local and international agencies. diseases.Attention is also being directed to special Such investigations during the period under review care for the aged and disabled and to the improvement related to viral hepatitis, lung cancer, salivary gland of the environmental and housing conditions of the tumours,tuberculosis,nasopharyngeal carcinoma, community as a whole. and cancer of the breast.Clinical, biochemical, and bacteriological studies are also being carried out on different therapeutic and anaesthetic agents. Social and economic developments of significance for the health situation Assistance from WHO Economic growth has been rapid in the period under In 1972 WHO's assistance to Hong Kong included review, raising the level of living in Hong Kong. There the following project: were improvements in housing facilities, and public Epidemiology and health statistics (1972): a con- assistance and free primary education were introduced. sultant reviewed the epidemiological and statistical In 1972 a "Keep Hong Kong Clean" campaign was organized with special attention to environmental work of the Medical and Health Department and advised on measures for strengthening and improv- pollution on land and water. ing the relevant services.

National health planning Government health expenditure The development programme of the Medical and In 1971/72 total government expenditure amounted Health Department has made rapid progress. Between to2939.1million Hong Kong dollars,of which 1969 and 1972, 37 projects were completed, under HK$ 304 700 000 were spent on the public health construction, or being planned for the improvement services. HK$ 267 200 000 were spent on current and expansion of the health and medical services in account and HK$ 37 500 000 on capital account. The urban and rural areas. per capita expenditure on health was thus HK$ 75.

MACAO

Population and other statistics disease, ischaemic heart disease, other forms of heart disease (256), malignant neoplasms (243), tuberculosis, At the last census, taken in December 1970, the all forms (204), cerebrovascular disease (154), bron- population of Macao was 248 636.Population esti- chitis, emphysema and asthma (68), accidents (67, mates and some other vital statistics for the period including 20 in motor -vehicle accidents). under review are given in the following table: The communicable diseases most frequently notified 1969 1970 1971 1972 in 1971 were: tuberculosis, all forms, new cases (1304), Mean population. . . . 244 100 248 636 248 553 251 206 infectious hepatitis(409), influenza (227), measles Number of live births. . 2 878 2 670 2 637 2 750 Birth rate (89), typhoid fever (24), diphtheria (13). (per 1000 population) . 11.8 10.8 10.6 10.9 Number of deaths . . . 1 474 1 516 1 543 1 539 Death rate (per 1000 population) . 6.0 6.1 6.2 6.2 Hospital services Natural increase ( %) . . 0.58 0.47 0.44 0.47 Number of infant deaths . 62 96 65 81 Infant mortality rate In 1971 Macao had 7 hospitals and other inpatient (per 1000 live births) . 21.5 36.0 24.6 29.5 establishments providing a total of 1345 beds, of Number of deaths, 1 -4 years 28 25 24 24 which 392 were in three government hospitals.The Death rate, 1 -4 years (per bed /population ratio was 5.4 to 1000. The 1345 beds 1000 population at risk) 1.6 1.4 1.4 1.4 were distributed as follows:

Of the 1539 deaths recorded in 1972, the main causes Category and number Number of beds were: 1 chronic rheumatic heart disease, hypertensive General hospitals 4 1 263 Rural hospitals 2 12 1 International Classification of Diseases, 1965 Revision. Paediatric hospital 1 70 WESTERN PACIFIC REGION 313

Medical and allied personnel and training facilities health service, a dental health unit, a hospital rehabilitation outpatient department, a tuberculosis clinic, In 1971 Macao had 141 doctors, or one doctor for an ophthalmological clinic, a venereal diseases clinic, 2280 inhabitants.Other health personnel included: and three public health laboratories. Dentists 2 Operating dental auxiliaries 57 Pharmacists 3 Pharmaceutical assistants 24 Environmental sanitation Midwives 22 Assistant midwives 2 Nurses 170 In 1971, 83 % of Macao's inhabitants were served Assistant nurses 43 Veterinarian 1 with piped water to their dwellings, while the remaining Auxiliary sanitarians 11 17 % had access to water from public fountains.In Auxiliary laboratory technicians 15 X -ray technicians 3 the same year about 64 % of the population lived in houses connected to public sewers. The health and welfare services of Macao operate a technical school for the training of nurses, assistant nurses, midwives, assistant midwives, laboratory tech- Government health expenditure nicians, X -ray technicians, and pharmaceutical assistants. There is also a nursing training school run by In 1972 the total government health expenditure missionaries. amounted to 7 552 527 patacas, of which 5 309 698 patacas were charged to current account and 2 242 829 Immunization services patacas to capital account. Accordingly, the per capita The following vaccination procedures werecarried government expenditure on health was 30 patacas. out in 1972: The expenditure on general public health services included the following items: 3 639 646 patacas for Cholera 41737 administrative and government personnel,175 627 Smallpox 10972 Diphtheria 5852 patacas for mass campaigns against communicable Poliomyelitis 5118 BCG 2652 diseases, 19 970 patacas for immunization and vacci- Tetanus 478 nation activities, 5935 patacas for laboratory services Typhoid and paratyphoid fevers 24 and 120 438 patacas for education and training of health personnel.The government expenditure on Specialized units hospitals included 1 255 200 patacas for general hos- In 1972 Macao had one prenatal and two child health pitals, 28 979 patacas for specialized hospitals, and centres. Other specialized units included a school 63 900 patacas for other health establishments.

NEW CALEDONIA AND DEPENDENCIES

Population and other statistics gococcalinfections(12),bacillarydysentery(4), typhoid and paratyphoid fevers (3). At the last census, taken in March 1969, the populationof New Caledonia and Dependencies was Organization of the public health services 100 579. Population estimates and some other vital statistics for the years 1969 -1971are given in the The health services in New Caledonia are under the control of the Director of Public Health and Hygiene, following table: who is directly responsible to the Governor of the 1969 1970 1971 territory. He is assisted by a medical officer and an Mean population 102 450 109411 117387 Number of live births 3 545 3 922 4 126 administrative officer. New Caledonia is divided into Birth rate (per 1000 population) . . 34.6 35.8 35.1 16 medical districts. A medical officer is in charge of Number of deaths 944 1 047 1 044 Death rate (per 1000 population) 9.2 9.6 8.9 each district. Natural increase ( %) 2.54 2.62 2.62 Number of infant deaths 127 161 131 Infant mortality rate (per 1000 live Hospital services births) 35.8 41.1 31.7 Number of deaths, 1 -4 years . . . . 101 98 86 In 1971 New Caledonia had 32 hospitals and other inpatient establishments providing a total of 1296 beds, The communicable diseases most frequently notified of which 1191 were in 30 government -maintained in 1972 were: influenza (5457), whooping -cough (1240), establishments. The bed /population ratio was 12.1 to measles (1125), pulmonary tuberculosis, new cases 1000 inhabitants. The 1296 beds were distributed as (152), leprosy (27), infectious hepatitis (25), menin- follows : 314 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Category and number Number of beds Diphtheria, tetanus, and poliomyelitis 2 533 Tetanus General hospitals 3 628 618 Poliomyelitis Rural hospitals 15 230 605 Medical centres 12 82 Typhoid and paratyphoid fevers 420 Diphtheria, tetanus and whooping -cough . 271 Psychiatric hospital 1 165 Yellow fever 131 Leprosarium 1 191

Ambulatory medical care was available in 1971 at Specialized units the outpatient department of the Gaston Bourret Hospital, 21 dispensaries, and one mobile health unit. In 1971 maternal and child health care was provided In addition there were two polyclinics,15 health at a prenatal centre and a child health centre. During centres, and 12 dispensaries that also provided hospi- the year, 3651 pregnant women, 7115 infants under talization facilities. one year and 7101 children aged 1 -4 years availed themselves of these services.In 1971 approximately 70 % of alldeliveries were attended by qualified Medical and allied personnel and training facilities personnel (2910 in hospital and 18 at home).The In 1971 New Caledonia had 83 doctors, of whom 49 entire school population (i.e., 21 237 children) were were in government service.The doctor /population under the medical supervision of the school health ratio was one to 1290 inhabitants.Other health service. New Caledonia also had two dental health personnel included: clinics, a rehabilitation hospital outpatient department a psychiatric outpatient clinic, which recorded Dentists 28 Pharmacists 20 1026 patients during the year, a tuberculosis outpatient Pharmaceutical assistants 11 Veterinarians 5 clinic and a leprosy clinic.The two public health Veterinary assistants 10 laboratories carried out over 210 000 examinations Midwives 7 Assistant midwives 14 during the year. Nurses 81 Assistant nurses 228 Assistant sanitarlans 3 Environmental sanitation Physiotherapists 7 Laboratory technicians 3 In 1972, of New Caledonia's 452 communities, 300 Assistant laboratory technicians 8 X -ray technicians 4 (with a total of 86 426 inhabitants) had a piped water A nursing school providing a two -year course was system.Thus, 81.5 % of the territory's population opened in 1969.In 1971/72 it had 16 students and were provided with this amenity; a further 7.2 % had eight graduates. access to water from public fountains. Three communities (with a total of 20 600 inhabitants) had a Immunization services sewerage system and 20.5 % of the total population were living in houses connected to sewers. The following immunization procedures were carried out in 1972: Government health expenditure

Smallpox 10248 BCG 9229 In 1971 total government expenditure amounted to Diphtheria and tetanus 4269 7329 million CFP francs, of which 579 277 000 CFP Cholera 3896 Diphtheria,whooping- cough,tetanus,and francs were spent on health services. The per capita poliomyelitis 3281 government expenditure on health was thus 4935 CFP Typhoid and paratyphoid fevers, diphtheria, and tetanus 2679 francs.

NIUE Population and other statistics

Natural increase ( %) . 3.20 3.02 2.50 2.27 At the last census, taken in September 1971, the Number of Infant deaths . 7 5 6 3 Infant mortality rate population of Niue was 4990.Population estimates (per 1000 live births) 33.65 25.64 38.46 19.5 and some other vital statistics for the period under Number of deaths, 1 -4 years 1 3 6 review are given in the following table: Death rate, 1-4 years (per 1000 population at risk) 1.3 3.8 7.6 1969 1970 1971 1972

Mean population . . 5 323 5 250 5 115 4 541 Of the 51 deaths recorded in 1972, the main causes Number of live births . . 208 195 156 154 Birth rate were: 1symptoms and ill- defined conditions(16), (per 1000 population). 39.1 37.1 30.5 33.9 infective and parasitic diseases (13), pneumonia (5), Number of deaths . . . 38 36 28 51 Death rate (per 1000 population) . 7.1 6.9 5.5 11.2 i International Classification of Diseases, 1965 Revision. WESTERN PACIFIC REGION 315

cerebrovascular disease (4), accidents (3, including 2 Niue has one nursing school, which organizes a in motor -vehicle accidents), malignant neoplasms (2), course lasting two and a half years.There were 11 bronchitis, emphysema and asthma (2), nephritis and students in 1971/72, of whom two graduated. nephrosis (2). The communicable diseases most frequently notified Communicable disease control and in 1971 were influenza (1591), measles (39), bacillary immunization services dysentery (5), tuberculosis, all forms, new cases (3), gonorrhoea (2), meningococcal infections (2), amoe- During the period under review, a dengue epidemic biasis (2), infectious hepatitis (1). affected about 75 % of the population and 11 deaths were directly attributable to the severe form of the Organization of the public health services disease. A filariasistreatment programme was initiated in 1973. The health and medical services are based on the The following immunization procedures were car- Health Department, headed by the Director of Health. ried out in 1972: He is assisted by a health inspector, an assistant health inspector, a public health sister and two staff nurses. Poliomyelitis 542 Diphtheria, tetanus and whooping -cough . 527 The health inspectorsare responsible forvillage Diphtheria and tetanus 392 Tetanus 327 hygiene, the supervision of food handlers, and the Smallpox 12 inspection of food premises. They are also in charge of water supply and waste disposal.The public Specialized units health sister is in charge of the maternal and child health programme and the care of the elderly and the In 1972 Niue had one prenatal centre and one child infirm. health centre, which were attended by 150 pregnant women, 147 infants under one year, and 378 children Hospital services aged 1 -5 years.Domiciliary care was given to 147 In 1971 Niue had one hospital with 30 beds, to children under one year and 352 children aged 1 -5 which 501 patients were admitted during the year. The years. Of all deliveries in 1972, 83 % were conducted bed /population ratio was 5.9 to 1000 inhabitants. by a doctor or a qualified midwife (109 in hospital Ambulatory medical care was provided in 1972 at and 17 at home). During the same year 1400 school- the hospital outpatient department, which recorded children -the entire school population -were under 21 371 attendances, at two medical aid posts, and at a the medical and health supervision of the school health mobile health unit (the latter recording 1358 atten- service.The two mobile school dental health units dances). recorded 3279 attendances and the dental clinics for adults 1073. Niue also had a public health laboratory. Medical and allied personnel and training facilities Government health expenditure In 1971 Niue had 5 doctors, or one doctor for 1000 inhabitants. Other health personnel included: During the fiscal year 1972/73 total government

Dentists 3 health expenditure amounted to 181 794 New Zealand Dental laboratory technicians 2 dollars of which NZ$ 175 229 were spent on current Dental chairside assistants 2 Dispenser 1 account and NZ$ 6565 on capital account. The per Nurses 4 capita expenditure on health was thus NZ$ 40. The Staff nurses 12 Senior nurses 2 currentgovernmenthealthexpenditureincluded Sanitary Inspector 1 Assistant sanitary Inspector 1 NZ$ 84 514 for administration and government per- Physiotherapist sonnel, NZ$ 5000 for environmental services, and Assistant laboratory technician X -ray technician NZ$ 27 000 for general hospitals and clinics.

PORTUGUESE TIMOR

Population and other statistics 1969 1970 1971 1972

Mean population . . . 593 300 607 600 621 767 626 000 At the last census, taken in December 1970, the Number of live births . . 11 893 13 607 12 764 17 846 population of Portuguese Timor was 609 477. Popu- Birth rate (per 1000 population). 20.0 22A 20.5 28.5 lation estimates and some other vital statistics for the Number of deaths . . . 6 217 7 592 5 360 8 303 Death rate period under review are given in the following table: (per 1000 population). 10.5 12.5 8.6 13.3 316 FIFTH REPORT ON THE WORLD HEALTH SITUATION

1969 1970 1971 1972 Laboratory technicians 5 Assistant laboratory technicians 14 Natural increase ( %) . 0.95 0.99 1.19 1.52 X -ray technician 1 Number of infant deaths . 251 499 446 Infant mortality rate Physiotherapist 1 Entomologist 1 (per 1000 live births) . 21.1 36.7 34.9 The technical school run by the health services of Hospital services Portuguese Timor organizes training courses for nurses In 1971 Portuguese Timor had 74 hospitals, with a (three -year course), assistant nurses (18 -month course), total of 1590 beds, equivalent to 2.6 beds for 1000 assistant midwives, laboratory technicians, pharma- population.These beds were distributed as follows: ceutical assistants, and microscopists.

Category and number Number of beds General hospitals 10 818 Immunization services Rural hospitals and medical centres . 64 772 The following immunization procedures were car- Outpatient facilities were available in 1972 at 12 ried out in 1971: hospital departments, the health centre in Dili, 47 Smallpox 209112

medical aid posts, and one mobile unit for the control Diphtheria,whooping -cough and tetanus . 4101 of endemic disease. BCG 4001 Cholera 1 670 Tetanus 2562 Typhoid and paratyphoid fevers 242 Medical and allied personnel and training facilities Yellow fever 95 In 1971 Portuguese Timor had 24 doctors, or one Specialized units doctor for 26 000 inhabitants. Other health personnel included : In 1972 maternal and child health care was based on one prenatal centre and one child health centre. Dentist 1 Dental technician 1 Other specialized units included a school health unit, Pharmacists 3 Midwives 2 a dental health unit, a hospital rehabilitation out- Assistant midwives 12 patient department, a psychiatric clinic, and a public Nurses 28 Assistant nurses 110 health laboratory.

WALLIS AND FUTUNA

Population and other statistics influenza (106), pulmonary tuberculosis, new cases At the last census, taken in March 1969, the popu- (26), amoebic dysentery (2), leprosy (1). lation of Wallis and Futuna was 8546. Population Organization of the public health services estimates and some other vital statistics for the period under review are given below: The health service, which is part of the territorial 1969 1970 1971 1972 administration, is organized in a directorate, a medical Mean population . . . . 8574 8600 9000 10000 care service, and a case -finding service.There is no Number of live births. . 392 372 352 362 Birth rate private medical practice on Wallis and Futuna. (per 1000 population) . 45.7 43.3 39.2 36.2 Number of deaths . . . 68 91 70 87 Death rate Hospital services

(per 1000 population) . 7.9 10.6 7.8 8.7

3.78 3.27 3.14 2.75 Natural increase ( %) In 1970 Wallis and Futuna had altogether 150 Number of infant deaths . 16 20 10 24 Infant mortality rate hospital beds, of which 40 were in the general hospital (per 1000 live births) . 40.8 53.8 28.3 66.3 Number of deaths, at Sia on Wallis, 30 in the hospital at Sigave on Futuna, 1 -4 years 6 12 6 14 and 80 in three medical centres. Outpatient care was Of the 87 deaths recorded in 1972, the main causes provided at a hospital department, five health centres were: 1 birth injury, difficult labour and other anoxic with hospitalization facilities, four dispensaries with and hypoxic conditions(18),heartdisease(10), hospitalization facilities, and a mobile health unit. pneumonia (8), avitaminoses and other nutritional deficiency (7), malignant neoplasms (5), symptoms Medical and allied personnel and ill- defined conditions (5), congenital anomalies (4). In 1971 Wallis and Futunahad four doctors, all The communicable diseases most frequently notified of whom were in governmentservice.The doctor/ in 1972 were: measles (274), whooping -cough (113), population ratio was one to2250. Other health 1 International Classification of Diseases, 1965 Revision. personnel included: WESTERN PACIFIC REGION 317

Assistant midwives 3 one year, and 87 children aged1 -5 years availed Nurses 3 Assistant nurses 22 themselves of these services.Domiciliary care was given to 462 pregnant women, 367 infants under one Specialized units year, and 294 children aged 1 -5 years.All deliveries took place in hospital. The entire school population Maternal and child health care is given at the had access to the school health services.There was hospital outpatient departments and the dispensaries. also a dental health unit. The public health laboratory During 1972, 105 pregnant women, 120 infants under carried out 4407 examinations in 1972.

INDEX TO COUNTRIES AND TERRITORIES

Afars and the Issas, French Terri-Grenada, 104 Paraguay, 115 tory of the, 270 Guatemala, 106 Peninsular Malaysia, 283 Angola, 68 Guiana, French, 130 Peru, 118 Anguilla, St Kitts, Nevis and, 132 Guinea -Bissau, 57 Philippines, 292 Antigua, 125 Guyana, 108 Poland, 203 Argentina, 77 Portugal, 207 Australia, 275 Haiti, 110 Portuguese Timor, 315 Austria, 159 Hong Kong, 309 Hungary, 187 Qatar, 261 Bahamas, 79 Bahrain, 239 Republic of Viet -Nam, 295 Barbados, 80 Iceland, 191 Romania, 209 Belgium, 161 India, 141 Belize, 126 Iran, 246 Sabah, 285 Bolivia, 83 Iraq, 249 St Kitts, Nevis and Anguilla, 132 British Solomon Islands Protecto-Ireland, 192 St Lucia, 135 rate, 303 Israel, 251 Sao Tomé and Principe, 71 British Virgin Islands, 128 Italy, 196 Sarawak, 286 Brunei, 306 Scotland, 228 Bulgaria, 165 Japan, 278 Senegal, 66 Burundi, 53 Jordan, 255 Singapore, 297 Solomon Islands Protectorate, Bri- Caicos Islands, Turks and, 138 Khmer Republic, 279 tish, 303 Canada, 86 Kuwait, 256 Spain, 211 Cape Verde Islands, 69 Spanish Sahara, 72 Central African Republic, 54 Sri Lanka, 147 Chile, 91 Laos, 281 Sudan, 263 Colombia, 94 Liberia, 58 Surinam, 136 Comoro Archipelago, 70 Libyan Arab Republic, 257 Sweden, 213 Congo, 56 Switzerland, 217 Cuba, 96 Macao, 312 Syrian Arab Republic, 266 Cyprus, 240 Madagascar, 60 Czechoslovakia, 167 Malaysia, 283 Thailand, 150 Mali, 62 Timor, Portuguese, 315 Democratic Yemen, 242 Martinique, 131 Tunisia, 268 Denmark, 172 Mexico, 111 Turkey, 219 Dominican Republic, 100 Monaco, 198 Turks and Caicos Islands, 138 Mongolia, 145 Egypt, 244 Montserrat, 132 Union of Soviet Socialist Republics, El Salvador, 102 222 England and Wales, 226 United Kingdom of Great Britain Netherlands, 198 and Northern Ireland, 226 Falkland Islands (Malvinas), 130 Nevis and Anguilla, St Kitts, 132 Upper Volta, 67 Finland, 175 New Caledonia and Dependencies,Uruguay, 121 France, 179 313 French Guiana, 130 New Zealand, 288 Venezuela, 123 French Territory of the Afars andNiger, 63 Viet -Nam, Republic of, 295 the Issas, 270 Nigeria, 64 Virgin Islands, British, 128 Niue, 314 German Democratic Republic, 183 Northern Ireland, 229 Wallis and Futuna, 316 Gibraltar, 235 Norway, 200 Western Samoa, 300 Gilbert and Ellice Islands, 307 Great Britain and Northern Ireland,Pakistan, 260 Yemen, Democratic, 242 United Kingdom of, 226 Panama, 113 Yugoslavia, 234

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CURRENCIES

A list of national units of currency and US dollar equivalents is given below. The rates are those that prevailed at 31 December 1972, the end of the period covered by the report. Owing to variations in exchange rates any attempt to express national expenditures overthe whole of the four -year period covered by the report in terms of a single currency might give rise to certain anomalies.Inreviews by countries and territories, therefore, expenditures are expressed in the national currencies.

Units of currency Units of currency Country or territory per US dollar Country or territory per US dollar (December 1972) (December 1972)

Angola 26.80 escudos Hungary 27.63 forints Antigua 2.04 East Caribbean dollars Iceland 98.56 kroner Argentina 9.93 pesos India 7.63 rupees Australia 0.7843 dollar Iran 76.25 rials Austria 23.20 schillings Iraq 0.335 dinar Bahamas 0.97 dollar Ireland 0.426 pound Bahrain 0.437dinar Israel 4.20 pounds Barbados 2.04 East Caribbean dollars Italy 582.00 lire Belgium 44.00 francs Japan 301.00yen Belize 1.57 British Honduras dollars Jordan 0.3571 dinar Bolivia 20.00 pesos Khmer Republic 55.50rids BritishSolomonIslands Kuwait 0.3289 dinar Protectorate 0.7843 Australian dollar Laos 605.00 kips British Virgin Islands 2.04 East Caribbean dollars Liberia 1.00 dollar Brunei 2.82 dollars Libyan Arab Republic 0.329dinar Bulgaria 1.85 leva Macao 5.85 patacas Burundi 87.50 francs Madagascar 255.00 francs Canada 1.00 dollar Malaysia 0.8396 dollar

Cape Verde Islands . . 26.80 escudos Mali 510.00 francs

Central African Republic 255.00 CFA francs Martinique 5.11 French francs Chile 46.00 escudos Mexico 12.50 pesos Colombia 22.45 pesos Monaco 5.11 francs Comoro Archipelago . 255.00 CFA francs Mongolia 3.68 tughrik Congo 255.00 CFA francs Montserrat 2.04 East Caribbean dollars Cuba 0.92 peso Netherlands 3.24 guilders Cyprus 0.383 pound New Caledonia and Czechoslovakia 13.10 korunas Dependencies 93.00 CFP francs Democratic Yemen . 0.373South Arabian dinar New Zealand 0.8396 dollar Denmark 6.88 kroner Niger 255.00 CFA francs Dominican Republic . 1.00 peso Nigeria 0.6578 naira Egypt 0.4348 pound Niue 0.8396 New Zealand dollar El Salvador 2.50 colones Norway 6.60 kroner Falkland Islands (Malvinas) 0.426 pound Pakistan 11.00 rupees Finland 4.13 markka Panama 1.00 balboa France 5.11 francs Paraguay 124.00 guaraníes French Guiana 5.11 French francs Peru 43.30 soles French Territoryofthe Philippines 6.70 pesos

Mars and the Issas . . 198.00 Djibouti francs Poland 22.08 zlotys German Democratic Portugal 26.80escudos Republic 3.18 marks Portuguese Timor 26.80escudos Gibraltar 0.426 pound Qatar 4.37 riyals Gilbert and Ellice Islands 0.7843 Australian dollar Republic of Viet -Nam 425.00 piastres Grenada 2.04 East Caribbean dollars Romania 16.00 lei Guatemala 1.00 quetzal St Kitts, Nevis and Anguilla 2.04 East Caribbean dollars Guinea- Bissau 26.80 escudos St Lucia 2.04 East Caribbean dollars Guyana 2.20 dollars Sao Tomé and Principe . . 26.80 escudos Haiti 5.00gourdes Senegal 255.00 CFA francs Hong Kong 5.58 dollars Singapore 2.82 dollars - 321 - 322 FIFTH REPORT ON THE WORLD HEALTH SITUATION

Units of currency Units of currency Country or territory per US dollar Country or territory per US dollar (December 1972) (December 1972)

Spain 63.50 pesetas Union of Soviet Socialist Spanish Sahara 63.50 pesetas Republics 0.824 rouble Sri Lanka 6.70 rupees United Kingdom of Great Sudan 0.3482 pound Britainand Northern Surinam 1.77 guilders Ireland 0.426 pound Sweden 4.75 kronor Upper Volta 255.00 CFA francs Switzerland 3.80 francs Uruguay 725.00 pesos Syrian Arab Republic 4.30 pounds Venezuela 4.40 bolívares

Thailand 20.83 baht Wallis and Futuna . . . . 93.00 CFP francs Tunisia 0.484 dinar Western Samoa 0.6758 tala Turkey 14.00 liras Yugoslavia 16.70 new dinars Turks and Caicos Islands 0.85 Jamaican dollar