In many countries, reliable morbidity, mortality and coverage rates cannot be determined because notification is defective or nonexistent. For this reason, sample-based surveys are beginning to be used as a valid resource for producing the figures needed as a starting point for calculating the goals of the diarrheal disease control program and for subsequently evaluating that program.
By adopting an integrated concept, epidemiological data can also be obtained on other aspects of primary healthcare, such as the Expanded Program on Immunization, nutrition, acute respiratory infections and others, as well as much of the descriptive information needed for interventions aimed at reducing specific morbidity, for example, breastfeeding campaigns, school hygiene and environmental hygiene.
Consequently, during the first part of 1984, an integrated study instrument for diarrheal disease control and primary healthcare, with a systematic set of analyses, will be designed and tested in two countries: Suriname and Ecuador.
In the Region, an increasing number of countries have achieved relatively high coverage of the diarrheal disease control program. To help identify initial effects and detect and correct any obstacles to program activities, WHO has prepared methods for evaluating national programs for the control of these diseases.
In this Region, evaluations of such programs were carried out in October and November 1982. Based on that experience, a small working group met at PAHO headquarters in March 1983 to further refine the methods. With some modifications, a third evaluation of diarrheal disease control was carried out in Jamaica in July 1983, together with the Expanded Program on Immunization. A fourth evaluation took place in Belize in November 1983.
Although the results have been satisfactory, the methods still need improvement. At least three additional evaluations of diarrheal disease control have been planned for 1984.
The evaluations, together with growing operational experience in the countries, have helped identify the main limitations of national programs against diarrheal diseases. Most of the problems in these programs are administrative in nature; others will require detailed operational research to identify the optimal program designs for each country, or even for each specific culture.
It is clear that new procedures are needed to improve the administration of national diarrhea programs. One possibility lies in establishing and using microcomputer-based systems. In several countries, such systems are already routinely used, although not specifically for diarrheal disease control.
During 1985, a priority activity will be the production and testing of standardized programming support for diarrheal disease control to be used with microcomputers in the countries. This system will not only improve the internal administration of national diarrheal disease control programs, but will also make it possible to easily gather and compare compatible information on national control activities at the regional and global levels.
Toward a Holistic Concept of Primary Healthcare
Like the teaching materials, all instruments and interventions of the diarrheal disease control program have been designed with the purpose of later integrating them with other programs that make up primary healthcare, such as immunizations, maternal and child hygiene, acute respiratory infections, nutrition and others.
Most experts believe that this integration is necessary in order to obtain the greatest possible impact from scarce health resources. Although conceptually and technically simple, the real integration of primary healthcare is often difficult to achieve for several reasons.
Like WHO itself, health services in most countries have traditionally been organized vertically. The inevitable result has been unnecessary duplication and even competition among the various programs that together constitute primary healthcare.
Many countries still need to clearly define their primary healthcare priorities. Budgets are stretched without a sense of reality in an attempt to support each health program equitably. Worse still, disproportionate amounts continue to be allocated to costly secondary or tertiary hospitals, while basic primary healthcare services, such as diarrheal disease control and immunizations, whose cost-effectiveness is fully proven, receive very little consideration.
The integration of specific primary healthcare interventions is also necessary for the simple reason that the same agent who provides that care must ultimately deliver all services within a joint program to the same target groups.
Many opportunities to integrate primary healthcare services have been lost, but many more remain to be identified and used as new knowledge and experience are obtained.
The diarrheal disease control program represents one of the main vehicles through which a holistic concept of primary healthcare is expected to develop, a concept that will make it possible to achieve the goal of health for all by the year 2000.
