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and inter-American systems, the bilateral The Director will adopt the measures agencies of developed countries, and the necessary to fulfill the Governing Bodies’ bilateral agencies in the countries of Latin mandates. These measures will relate to America and the Caribbean is critical. the roles to be played by the PAHO/WHO Country Representations, the Regional At the PAHO/WHO Level Programs, the coordinations, and other Headquarters units in the implementa- The Governing Bodies of PAHO/WHO tion of the plan and administration of the will guide and oversee the implementa- fund. An Executive Secretariat and a Co- tion of the plan and the preinvestment ordinating Group for the plan have been fund at the regional level, particularly in formed, made up of staff from various regard to the Organization’s participation Headquarters units and reporting di- therein. The frame of reference for that rectly to the Director. To the extent pos- participation is provided by the strategic sible, programming, monitoring, and orientations and program priorities for evaluation of the process as a whole will PAHO during the quadrennium 1991- 1994 be carried out through the mechanisms and by those resolutions relating to the already available in PAHO’s planning, plan or the fund that have been or may programming, monitoring, and evalua- be approved. tion system (AMPES). Health Services System in Dominica Each year the Governments of the countries of the Americas, acting through their repre- sentafives in the meetings of PAHO’s Governing Bodies, confer the PAHO Award for Administrafion in recognition of an outstanding contribution in the field of health services administration. The names of candidates are submitted by the Member Governments and the winner is selected by a three-member award committee at the first yearZy meeting of the Executive Committee. The 1992 award committee, composed of representatives of Barbados, Cuba, and Honduras, unanimously selecfed Dr. Desmond O.N. McIntyre, former Chief Medical Ofjicer, Minisfy of Health of Dominica, as the 18fk recipient of this award, which was presented on 23 September 1992 during the XXXVl Meeting of the Directing CounciI. The following is part of the text of Dr. McIntyre’s remarks on that occasion, describing recent innovations in his county’s health services system. The Ministry of Health in Dominica ment of an increasingly decentralized four- has made significant progress, particu- tier health system and community involve- larly since Hurricane David in 1979, in ment in health services, training and place- improving and expanding its primary ment of primary care nurses, development health care services. In the aftermath of of local programming and a health infor- the hurricane, the government commis- mation system, implementation of an sioned a task force (led by me) to prepare islandwide immunization program, and a a health plan for the next 10 years. The revolving drug fund for the provision of approach adopted focused on develop- essential drugs throughout the country. 86 Bulletin of PAHO 27(l), 1993 DECENTRALIZATION rectly to the Princess Margaret Hospital in the capita1, Roseau. Now a system [ex- Much innovation has occurred in the isted within the district to handle non- health services during the past decade. emergency cases]. The first major step taken by the Ministry of Health [was] a decentralization of the DISTRICT HEALTH TEAM health care system. The key strategy in the reorganization was a decentralization Effective primary health care delivery of personnel to enable functional health and integration of services at the com- teams at the district level to respond to munity level in Dominica is being achieved community needs. by a team approach. [Early on] it was In the old system inherited from the realized that additional in-service train- metropolitan country, each health ing would be needed to mold persons professional in the district worked inde- from different professional backgrounds pendently of his colleagues and reported into cohesive teams. Team-building ex- directly to a supervisor at headquarters. ercises were conducted in all health dis- The reorganization removed the vertical tricts. Members were trained to function lines of command along which programs together with a high degree of horizontal had previously been organized and man- communication, understanding each aged and substituted a team approach at other’s role. [Despite the challenges in- all stages and levels. volved in the process,] the decentraliza- Seven health districts have been cre- tion of the services is now well estab- ated, each one headed by a resident med- lished and multidisciplinary health teams ical officer. The District Medical Officer well developed, with responsibility and is professionally and administratively in authority for program execution. charge of all regular health services within This administrative innovation was the district and supervises the District buttressed by a number of village health Health Team. The district is the key level committees. These committees, working in Dominica’s primary care system and in close collaboration with the health serves as the base for Iocal programming, professional, became a dynamic frame- management, supervision, and financial work for change in people’s awareness control. about their health problems and appro- A network of some 42 clinics existed priate measures to solve them. It has be- around the island. It was thought that come a tradition in Dominica to have an some of these clinics could be upgraded annual consultation of district health teams to act as a focus of primary care activities with their village committees. At the con- in the area they served. One health clinic sultation, district health teams review the in each district was upgraded and classed progress in primary health care programs as a Type III Center, mainly [on the basis and set targets for the following year. of] the activities carried out there, the [The consultation affords] community category of staff at the center, and the health workers the opportunity to dis- population to be served by that facility. cuss and share experiences in the imple- The remaining clinics were classed as Type mentation of primary health programs, I and II facilities. [Therefore, several small [and its success is] due in part to the clinics were linked] up with a Type III feeling of importance [and the motivation center as the main referral center within engendered in] the health teams and the district. This was a new feature. Pre- community members . during this full viously, patients were being referred di- day of activities. Abstracts and Reports 87 PRIMARY CARE NURSE workers, but the program is now well PROGRAM integrated into the health care system of Dominica. The 65 graduates of this pro- One major obstacle to the govern- gram have been well received in the com- ment’s policy to extend health service inunities they serve, and patients as well coverage to the rural population through as senior officials are satisfied with their primary care was the shortage of nurses. performance and record of service. Health manpower development was, therefore, seen as a crucial factor. How- ever, the Ministry of Health also was LOCAL PROGRAMMING AND aware of the many constraints faced in THE HEALTH INFORMATION bringing about such manpower devel- SYSTEM opment. For example, merely retaining health personnel can be a problem. Fur- By 1983, with the nursing staff situa- ther, training and supporting vast man- tion well under control, attention could power resources was impractical given be directed to improving district health government’s financial difficulties at the service delivery through local program- time, and securing highly trained nurses ming coupled with the development of a to live and work in remote rural areas health information system (HIS) to sup- was virtually impossible. port it. The HIS developed had particular As a deliberate effort to ensure that relevance to health services program- health personnel were available to pro- ming. Rather than [merely recording] vide adequate coverage in all health dis- health activities, the system was de- tricts, a new nursing staff category-the signed to be a managerial tool and sup- primary care nurse-has been trained and ports the functions of planning, pro- introduced.. The program commenced gramming, monitoring, and evaluation. in 1981 and was designed to prepare a To facilitate district programming, a second level nurse within a 2-year pe- catchment area was defined for each riod. Traditional nurse education and health clinic within a district. As a first training, which focused on disease- step, in each village mapping, identifi- oriented care, has been replaced by a new cation, and numbering of houses and in- program specially designed to prepare the dividuals was completed by the local primary care nurse to deal with health health team collaborating with local vil- problems and needs of the community, lage councils and with assistance from particularly the rural population. The members of the community. As a result, training program consists of 1 year gen- sketch maps now exist for each village, eral and community nursing, 9 months delineating boundaries for blocks (50-90 midwifery exposure, and 3 months in- buildings within each block) and existing ternship period. tracks and roads. The program, which is unique to Dom- At the district level, the planning pro- inica, can be viewed as a reflection of the cess is effected through local program- commitment needed to achieve, within ming exercises conducted by the district economic reality, effective health cover- health team. The programming exercises age of underserved population groups. quantify the work to be done, using ex- Implementation of this program has en- isting norms, goals, and standards, and countered several challenges, including reprogramming is conducted annually acceptance of this new category of nurs- based on existing district data and staff ing personnel by local and regional health experiences.

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