Showing papers in "Health Policy and Planning in 1994"

Reforming the health sector in developing countries: the central role of policy analysis

Abstract: Policy analysis is an established discipline in the industrialized world, yet its application to developing countries has been limited. The health sector in particular appears to have been neglected. This is surprising because there is a well recognized crisis in health systems, and prescriptions abound of what health policy reforms countries should introduce. However, little attention has been paid to how countries should carry out reforms, much less who is likely to favour or resist such policies. This paper argues that much health policy wrongly focuses attention on the content of reform, and neglects the actors involved in policy reform (at the international, national sub-national levels), the processes contingent on developing and implementing change and the context within which policy is developed. Focus on policy content diverts attention from understanding the processes which explain why desired policy outcomes fail to emerge. The paper is organized in 4 sections. The first sets the scene, demonstrating how the shift from consensus to conflict in health policy established the need for a greater emphasis on policy analysis. The second section explores what is meant by policy analysis. The third investigates what other disciplines have written that help to develop a framework of analysis. And the final section suggests how policy analysis can be used not only to analyze the policy process, but also to plan.

The elasticity of demand for health care in Burkina Faso: differences across age and income groups

Abstract: Like many other developing countries, Burkina Faso has been exploring how community resources can be tapped to co-finance health services. Although revenue generation is important for the viability of health services, effects on utilization and on equity of access to health care must also be considered. The authors present a logistic regression model to derive price elasticities of demand for health care based on cross-sectional survey data. While demand for health care appears inelastic overall (-0.79), subgroup analysis reveals differences in elasticity across age and income groups. Elasticities of demand for infants and children (-3.6 and -1.7) and for the lowest income quartile (-1.4) are substantially greater than overall elasticity. The method used is unusual in that it allows estimation of elasticities before the introduction of user fees. This increases the value of the information to policy makers.

The potential of health sector non-governmental organizations: policy options.

Abstract: Non-governmental organizations (NGOs) have increasingly been promoted as alternative health care providers to the state, furthering the same goals but less hampered by government inefficiencies and resource constraints. However, the reality of NGO health care provision is more complex. Not only is the distinction between government and NGO providers sometimes difficult to determine because of their operational integration, but NGOs may also suffer from resource constraionts and management inefficiencies similar to those of government providers. Some registered NGOs operate as for-profit providers in practice. Policy development must reflect the strengths and weaknesses of NGOs in particular settings and should be built on NGO advantages over government in terms of resource mobilization, efficiency and/or quality. Policy development will always require a strong government presence in co-ordinating and regulating health care provision, and an NGO sector responsive to the policy goals of government.

Carrot and stick: State mechanisms to influence private provider behaviour

Abstract: The relationship between private for-profit health care providers and the State which has a responsibility to ensue that health services are available to the people can be analyzed as a "principal-agent" problem. Thus the State as principal aims toward equitable service delivery and the private provider as agent wishes to maximize profits. While private providers are criticized for their emphasis on profit they may in fact provide much of the health care in a country especially in slum areas. The problems associated with private profit-making providers are that their objectives are geared to maximize profits they fail to address public health concerns they lack integration with government health services they attract professionals from the public sector and they provide poor quality or inappropriate services. When planners consider ways to improve overall health service provision they can uncover the existing relationship between the State and the private sector by examining the objectives of the provider; the regulations provided by the State; the balance between incentive options and regulations; which agents are responsible for setting monitoring and enforcing rules and for creating incentives; and whether regulatory agencies are active or passive. The various players in the State/private provider relationship can be depicted in a conceptual framework. The State achieves its influence from its power bases: legislative power power over resources and power over information and accountability. Different ministries of the State may also play different roles. Purchasing agents professional bodies consumers and community representatives are also important in this relationship. In addition there is a diverse array of actual providers of care including physicians midwives dentists pharmacies and hospitals. Suppliers of drugs and equipment also have an influence in this relationship. The political environment dictates how these various players interact for example in use of the media for information dissemination or in the use of prosecution and litigation to control the actions of providers. The State can regulate private providers by specifying minimum standards for premises setting price ceilings or by specifying a mandatory period of government service after training. Regulation commonly can be entrusted to professional bodies some created expressly for that purpose. Consumer activism is also playing a more important regulatory role. The problems encountered in regulation include professional self-interest a lack of information and the organizational structure of the governments themselves. Since regulation can be viewed accurately as a means to protect the professional and preserve the income of health care providers it should not be left to professional organizations alone. Incentives may prove useful in promoting public health. Priorities should focus first on areas where private practice is actually causing harm. Generating debate about the role of private providers may also be an important strategy. Research should focus on the potential benefits and dangers of using particular forms of incentives the value of accreditation schemes combined with quality assurance programs and the use of financial incentives to stimulate better quality care.

Behaviour of the private sector in the health market of Bombay

Abstract: The government of India has been unable to meet the health care needs of its people especially in rapidly expanding urban areas so private sector health services have proliferated. In 1990 for example the private sector in Bombay ran 87.9% of the 602 hospitals and provided 39.8% of the total beds. Members of all socioeconomic groups use the private facilities and the willingness of people to pay for health care heralds the expansion of private sector services yet there is no policy governing such an expansion. A study was undertaken therefore to document the different types of private services offered in Bombay analyze the private sector delivery of health services access the existing control regulations and consider policy options available for private sector regulation. Information was obtained from 15 individuals who hold key positions in the health sector including hospital executives medical school professors hospital managers private practitioners and a social activist. In addition information was obtained from the findings of a committee investigating conditions in private nursing homes as part of a law suit. This committee found that many of the nursing homes were substandard and were operating without regard to antiseptic procedures. Most of the individuals queried reported that private hospitals do not pose the same problems as private nursing homes since the private hospitals are situated outside of residential areas and have a proper waste disposal system. The respondents felt that the private facilities were well equipped and that the use of modern technology was justified in the hospitals but not in the nursing homes or clinics. Most respondents felt that the nursing homes and clinics lacked properly trained medical personnel. It was acknowledged that some private physicians abuse their honorary staff positions in public hospitals by using the facilities to treat private patients or by diverting public patients to their private practices. Charges of medical malpractice were also proffered with examples given of collusion to extort fees from patients or to provide people with false medical documentation for a price. These unethical practices are mirrored by negligent medical practices. Calls for regulation of the private sector have increased. The existing regulation dates from 1949 and its implementation has been far from satisfactory. Public confidence in the Maharashtra Medical Council and the Indian Medical Associations ability to regulate individual doctors has also dwindled. A regulatory policy should be directed toward the expansion of the private sector in Bombay and should include measures that will contribute to the overall improvement of public health. Once formulated the regulations should be implemented by the Public Health Department of the Municipal Corporation with the responsibility vested in a Deputy Executive Health Officer who should also be able to report unethical practices for action. A holistic approach to this problem will result in better health care for the citizens of Bombay.

Programming for safe motherhood: a guide to action.

Abstract: The Safe Motherhood Initiative has successfully stimulated much interest in reducing maternal mortality. To accelerate programme implementation, this paper reviews lessons learned from the experience of industrial countries and from demonstration projects in developing countries, and proposes intervention strategies of policy dialogue, improved services and behavioural change. A typological approach with three hypothetical settings from resource poor to resource rich environments is used to address the variability in health behaviours and infrastructure encountered when programming for safe motherhood.

Trends, priorities and policy directions in the control of vector-borne diseases in urban environments

Abstract: The habitats available in urban environments tend to be rather lacking in diversity compared to those in the countryside, and relatively few species are able to exploit them. Those that can, however, often find themselves relatively well provided with food and places to live, and relatively free of competitors and predators. This applies not only to such well-known species as the house-sparrow, but also to most of the important mosquito vectors of human disease in urban areas. Human city dwellers thus tend to be exposed to a different spectrum of disease than their rural counterparts. This review describes how the physical and social changes associated with urbanization have altered the transmission of vector-borne disease. It concentrates on the important mosquito-borne infections: malaria, dengue and filariasis. Dengue virus vectors breed in relatively clean water in man-made containers, while urban filariasis vectors breed in highly polluted water, and these mosquitoes have now been spread by man's activities to almost every tropical city. With important exceptions, anopheline malaria vectors have not generally succeeded in adapting to urban life, but malaria can still be a problem where there are rural pockets in the middle of town. Each of these problems requires control using different technologies and timing. The following policy implications are stressed. The areas of responsibility between different sectors of the local services (health, water supply, sanitation), and between these and the public, need to be clearly defined. Due to the biological complexities of vector-borne disease, decentralized primary health care systems are generally incapable of ensuring that control efforts are adequately targeted in time and space. Community support is essential but specialized technical skills are also required.

Contracting out of health services in developing countries

Abstract: Contracting out is emerging as a common policy issue in a number of developing countries. The theoretical case for contracting out suggests many advantages in combining public finance with private provision. However, practical difficulties such as those of ensuring that competition takes place between potential contractors, that competition leads to efficiency and that contracts and the process of contracting are effectively managed, suggest that such advantages may not always be realized. Most countries are likely only to contemplate restricted contracting of small-scale non-clinical services in the short term. Prerequisites of more extensive models appear to be the development of information systems and human resources to that end. Some urban areas of larger countries may have the existing preconditions for more successful large-scale contracting.

Managing the health care market in developing countries: prospects and problems.

Abstract: There is increasing interest in the prospects for managed market reforms in developing countries, stimulated by current reforms and policy debates in developed countries, and by perceptions of widespread public sector inefficiency in many countries. This review examines the prospects for such reforms in a developing country context, primarily by drawing on the arguments and evidence emerging from developed countries, with a specific focus on the provision of hospital services. The paper begins with a discussion of the current policy context of these reforms, and their main features. It argues that while current and proposed reforms vary in detail, most have in common the introduction of competition in the provision of health care, with the retention of a public monopoly of financing, and that this structure emerges from the dual goals of addressing current public sector inefficiencies while retaining the known equity and efficiency advantages of public health systems. The paper then explores the theoretical arguments and empirical evidence for and against these reforms, and examines their relevance for developing countries. Managed markets are argued to enhance both efficiency and equity. These arguments are analysed in terms of three distinct claims made by their proponents: that managed markets will promote increased provider competition, and hence, provider efficiency; that contractual relationships are more efficient than direct management; and that the benefits of managed markets will outweigh their costs. The analysis suggests that on all three issues, the theoretical arguments and empirical evidence remain ambiguous, and that this ambiguity is attributable in part to poor understanding of the behaviour of health sector agents within the market, and to the limited experience with these reforms. In the context of developing countries, the paper argues that most of the conditions required for successful implementation of these reforms are absent in all but a few, richer developing countries, and that the costs of these reforms, particularly in equity terms, are likely to pose substantial problems. Extensive managed market reforms are therefore unlikely to succeed, although limited introduction of particular elements of these reforms may be more successful. Developed country experience is useful in defining the conditions under which such limited reforms may succeed. There is an urgent need to evaluate the existing experience of different forms of contracting in developing countries, as well as to interpret emerging evidence from developed country reforms in the light of conditions in developing countries.

Bangladesh pharmaceutical policy and politics

Abstract: An analysis of the politics of Bangladesh pharmaceutical policy in the 1980s shows how significant health policy reforms in developing countries depend on political conditions both inside and outside the country. Bangladesh's drug policy of 1982 illustrates that governments can sometimes change public policy in ways unfavourable to multinational corporations, while the failed health policy reform of 1990 shows that reforms unfavourable to powerful domestic interest groups can be more difficult to achieve, even contributing to a government's downfall. The case provides evidence of basic changes in how the international agenda for health policy is set, especially the growing role of non-governmental organizations in international agencies and national policy debates. Understanding the political patterns of policy reform in Bangladesh has important implications for strategies to affect health policy in developing countries.

Donor funding for health reform in Africa: is non-project assistance the right prescription?

Abstract: During the past 10 years, donors have recognized the need for major reforms to achieve sustainable development. Using non-project assistance they have attempted to leverage reforms by offering financing conditioned on the enactment of reform. The experience of USAID's health reform programmes in Niger and Nigeria suggest these programmes have proved more difficult to implement than expected. When a country has in place a high level of fiscal accountability and high institutional capacity, programmes of conditioned non-project assistance may be more effective in achieving reforms than traditional project assistance. However, when these elements are lacking, as they were in Niger, non-project assistance offers nothing inherently superior than traditional project assistance. Non-project assistance may be most effective for assisting the implementation of policy reforms adopted by the host government.

Controlling schistosomiasis: the cost-effectiveness of alternative delivery strategies.

Abstract: In rural Kilombero District in the Morogoro Region of southeast Tanzania where urinary schistosomiasis is endemic in most villages a cost-effectiveness study was conducted to compare the costs and coverage of 2 forms of delivering chemotherapy to school children and then compared these options with chemotherapy integrated into the routine activities of the primary health care (PHC) system and targeted at anyone using the PHC facilities. The student-centered alternatives to control schistosomiasis included a mobile team treating all children at all 77 primary schools in the district with a single oral dose of praziquantel (40 mg/kg) (MMT = mass treatment by mobile team) and school teachers annually screening children using Sangur reagent strips and referring all positives to the nearest dispensary for treatment (RST = reagent strip testing). One teacher per school attended a workshop for training in reagent strip testing health education and materials needed for screening their school. The third option was passive case detecting using urine sedimentation and subsequent treatment of positives with a single oral dose of praziquantel (40 mg/kg) at the dispensary (PTT = passive testing and treatment). The indicator of effectiveness was number of infected persons treated (adults + children). The PTT option covered the most people. The analysis showed that the most cost effective option was indeed PTT (financial and economic costs per infected person treated were US$ 1.78 and 1.87 respectively; they were US$ 3.71 and 3.82 for RST and US$ 4.48 and 4.50 for MMT). It remained the most cost effective option even when the analysis considered only the number of children treated. All 3 options were more affordable and sustainable than vertical strategies examined in the literature. This report provides program managers with a framework to evaluate similar strategies in various epidemiological settings.

Assessing and planning home-based care for persons with AIDS.

Abstract: Any AIDS program should strive to strengthen the capacity of the home and community to care for people with AIDS by building on traditional family structures which support all chronically ill people. A rapid assessment tool has been developed to resolve potential conflicts and to facilitate the design of an AIDS program tailored to local needs. It was designed with developing countries in mind. It uses an assessment matrix for systematic community evaluation of the problems and resources with current home care. The 3 levels are individual household and community. The key categories are HIV prevalence and awareness perceived needs community capability and health and social system. For example community capability and its operation are examined at the individual household and community level. Each country or program must come up with its own process and outcome indicators. They should choose indicators based on data that will always be available and permit measurement of progress towards selected goals/objectives (e.g. percentage of HIV seropositive TB patients). After completion and review of the matrix the strengths weaknesses and barriers (which will become apparent) are used to develop an action plan. There are general guidelines for data analysis and the development of the action plan. Every program should be area-specific and community-based. Neither donors nor implementers should misjudge the obstacles to care within the community. Incremental steps will result in improved capacity of the community to cope with people with AIDS. All people who are involved in home care (e.g. prostitutes) must be included in the team to evaluate home care. Outside help (e.g. donors) must not undermine community initiatives to care for members with AIDS. The information and conclusions should be presented to the community and key informants for verification before implementing any interventions.

The public/private mix in the health care system in Malawi

Abstract: Herbalists traditional birth attendants and health counsellors make up the traditional subsector of health providers in Malawi while the government the Christian Health Association of Malawi and private for-profit providers comprise the modern subsector. This mix of public and private health care providers has in fact defined the provision of health care in Malawi from about 1930s to the end of the 1980s. The government however had long stifled the growth of the private for-profit sector through legislation and registration requirements. Recent policy changes easing the way for private health care provision date back largely to the 1987 Medical Practitioners and Dentists Act. The registration of medical practitioners has been liberalized and policies restricting private practice by government doctors have been relaxed along with early retirement. The concurrent emergence of a health insurance industry and the expansion of drug outlets have also helped to bring about the rapid expansion of the subsector. The Ministry of Health acknowledges the potential contributions of private providers and is reaching out to tap into their resources. This paper considers some of these developments and looks at the future of health care in Malawi identifying what is needed to continue a meaningful expansion of private health care services.

National health information systems in the Pacific Islands: in search of a future

Abstract: Health information is essential for proper management and deployment of limited resources in the health services of the Pacific Islands. There have been numerous efforts to establish and strengthen sustainable information systems but the common feature of these attempts has been the very limited achievement. Subsequently, the use of information as a management tool has been abandoned in favour of 'gut feeling', hearsay and adhocry. In the last decade health planning and primary health care activities have necessitated the re-emphasis of monitoring and surveillance of health and health service indicators. Therefore a revival of interest in health information systems is taking place. A review of national health information systems in the Pacific showed that routinely collected data remained largely untouched by human thought. The contributing factors to the current inertia are examined with suggestions on how to elevate health information from its current lowly status to its rightful place as an essential tool for management. The special problems of small island states, like limited resources, geographical isolation, natural barriers to technology, and diverse cultural milieu, will be examined in relation to an appropriate health information system for Pacific Island countries in the twenty-first century.

Thailand: private health care out of control?

Abstract: The mix of public and private health care providers in Thailand has been changing rapidly in terms of financing provision and human resources. Private payments by households represent the most important and growing source of health care financing (69.3% in 1984 71.2% in 1986 and 73.2% in 1987). These payments go to private providers and Ministry of Health (MOH) user fees and have shifted away from expenditures for self-medication. Private providers will benefit from the 1990 Social Security Act which provides extensive medical benefits and allows private facilities to compete equally with public providers for insured patients. The government coordinates 4 different insurance programs and is currently grappling with the difficulties involved in running coexistent schemes. As the role of insurers increases the role of the private sector will also increase. Data on the private health care providers is inadequate; however available data show a rapid growth in private hospitals and hospital beds as well as a successful effort from the MOH to increase access to public facilities particularly in rural areas (most of the private hospitals are in urban areas particularly Bangkok). The private hospitals show a low occupancy rate (58% compared to 99% in MOH facilities) which may dictate an aggressive admissions policy. Only 5 of the more than 100 hospitals in Bangkok are non-profit and even these recover costs through user fees. The for-profit private hospitals may be owned by individuals small companies or by publicly-limited stock companies. Privately-run clinics (over 2000 in Bangkok) are also extremely popular and offer convenient hours and locations for outpatient care. A percentage of the market is still given to drug stores (especially among poorer people) priests exorcists and traditional healers. More and more doctors now work in the private sector attracted by higher salaries and better working conditions (shorter hours). These factors lead to concern that a 2-tiered health care system will develop to cater to the rich and the poor. Initial surveys show that income and socioeconomic characteristics do affect the type of health care sought but the effect of insurance plans on use behavior has not been determined. A variety of insurance payment schemes is also affecting facility use. Unlike public facilities private providers have been able to procure high cost technological equipment with the assistance of government exemptions on import duties for medical equipment (x-ray equipment has been duty-free since 1988). Potential abuse of this equipment could drive up health costs. Public policy is needed to oversee the integration of the private health care sector into a national health development plan to control the procurement and use of this equipment address the oversupply of hospital beds and assure that the public facilities are able to attract adequate manpower.

Employer's willingness to pay: the case for compulsory health insurance in Tanzania.

Abstract: This article documents employers' expenditure on the arrangements for the health care of their employees in one of the least developed countries; Tanzania. The case for compulsory health insurance is considered in the light of the fact that only 3% of the population is employed in the formal sector and could be covered at first. It is shown from a survey of larger employers, outside government, that they were spending on average 11% of payroll on health care for their employees. This demonstrated their lack of satisfaction with the government health services. Nevertheless, those who could readily be covered by insurance were making considerable use of the more expensive government hospital services. It is argued that a compulsory health insurance scheme could be introduced for the formal sector of employment which would cover a wider range of health services at lower cost. The scheme would also have the desirable economic effect of lowering employers' labour costs while making it possible to improve the standards of the government health services.

Health of the elderly in a community in transition: a survey in Thiruvananthapuram City, Kerala, India.

Abstract: Results of a survey to assess the health and functional status of the elderly (defined as those who are 60 years or older) in Thiruvananthapuram city, the capital of Kerala state, India, are discussed. As the process of development results in longevity without concomitant economic success, traditional support systems break down. The differences in status of the elderly dependent on gender and socioeconomic class are highlighted. Women are poorer and generally suffer more morbidity than men in old age, even though their death rates are lower. The better-off among the elderly enjoy a quality of life much superior to their poor brethren. Thus, in transitional societies such as Kerala, socioeconomic status and gender play a significant role in determining the quality of life of the elderly, a finding which may have some policy implications.

The socioeconomic impact of malaria in Colombia and Ecuador.

Abstract: In-depth studies in three communities of Colombia and Ecuador, over a period of two to three months in each, were the basis of the economic analysis presented in this paper. In Santa Cruz, located at the rio Naya in Colombia, the average cost per case of malaria was US$17.30 (indirect costs US$15.80 and direct costs US$1.50); the loss corresponded to 20.1% of a minimum monthly wage (1986) or to a value of 5.6 days' work. In Perla de Sade, in the Cant6n Quininde of Ecuador, the average cost per case of malaria amounted to US$10.40 (indirect costs US$5.90 and direct costs US$4.50); the losses corresponded to 20.8% of a minimum monthly wage (1989) and to a value of 5.7 days' work. In Calder6n in the Cant6n of San Lorenzo in Ecuador, the average cost per case of malaria was US$4.80 (indirect costs US$3.50 and direct costs US$1.30); the losses corresponded to 16.0% of a minimum monthly wage (1991) with a value of 4.4 days' work. The results in these three communities, and in four additional ones, showed that the major economic impact of malaria is in the reduction of the labour force of families (indirect costs), and less so in the direct costs of care and cure. This emphasizes the economic importance of malaria because the rural familes with economies at subsistence level depend for survival particularly upon the maintenance of their labour force.

Indigenous perceptions and quality of care of family planning services in Haiti

Abstract: This paper presents a method for evaluating and monitoring the quality of care of family planning services. The method was implemented in Haiti by International Planned Parenthood Federation Western Hemisphere Region (IPPF/WHR), the managerial agency for the Private Sector Family Planning Project (PSFPP), which is sponsored by the USAID Mission. The process consists of direct observations of family planning services and clinic conditions by trained Haitian housewives playing the role of 'mystery clients', who visit clinics on a random basis without prior notice. Observations conducted by mystery clients during one year, from April 1990 to April 1991, are presented and illustrate the use of the method. In addition, measurements for rating the acceptability of the services were developed, providing a quantitative assessment of the services based on mystery clients' terms. Statistical results demonstrate that simulated clients ranked some criteria of acceptability higher than others. These criteria are: the interaction provider/client, information adequacy, and competence of the promoter. Likewise, simulated clients' direct observations of the services permitted the identification of deficiencies regarding the quality of care such as the paternalistic attitudes of the medical staff; the lack of competence of promoters; and the lack of informed choice. Based on its reliability since its implementation in 1990 the method has proven to be a useful tool in programme design and monitoring.

Community financing of drug supplies in rural Nepal: evaluating a ‘fee per item ’ drug scheme

Abstract: A new programme in rural Nepal was evaluated in which users partly fund the supply of additional drugs needed at health posts. Patients are charged a fee per item prescribed (FPI scheme). The scheme is administered by the District Public Health Office (DPHO). This scheme is compared with two established schemes: one charges patients a fee per prescription ('fee-per-script' or FPS scheme) and is administered by independently paid NGO (non-governmental organization) staff; the other uses local shops as a means of supplying drugs. The new scheme was associated with a rise in average daily attendance from nine to thirty-two patients a day (a 240% increase) when compared to a similar period the previous year. Fewer drugs were prescribed in the FPI scheme (average per patient 1.8 vs. 2.4, Chi square P <0.001). The average cost of a drug from the user's perspective was approximately 12% lower in the FPI scheme. These factors combined to make the average cost to the patient of a prescription half that of one in the FPS scheme. The new scheme was 24% cheaper to run on a 'cost per patient' basis when compared with the FPS scheme. However, the overall subsidy needed for the scheme to operate was higher because of the big increase in attendance. One-off stocktakes of ten essential drugs were used to assess the availability of drugs for patient use. The proportion of these drugs that were in low supply or absent was 24% in the FPI scheme. This was similar in the other two schemes. The government DPHO did not perform all the administrative tasks required. These tasks need to be simplified and different methods for involving DPHO staff in drug scheme management need to be explored. The rapid turnover of senior staff, however, will remain a major impediment. This preliminary evaluation shows that an FPI scheme promotes a more rational use of resources, compared to an FPS scheme. Administration of the scheme may, however, prove to be more difficult. A simple field-based comparative assessment of drug supply schemes can give a valuable insight into the strengths and weaknesses of a new programme.

The role of information in the planning, management and evaluation of community nutrition programmes.

Abstract: Protein-energy malnutrition has many diverse location-specific causes which make if difficult to solve through uniform interventions implemented through vertical programmes. This paper investigates the role of information in the planning, management and evaluation of several community nutrition programmes judged to be successful. The programmes come from Tanzania (Iringa), India (Tamil Nadu), Dominican Republic and Colombia. The review finds that the initial conceptualization and design of these programmes benefited from the results of earlier surveys and experience with similar programmes in the same or other countries. Strong capacity for operations research is important to assist with a myriad of small but important programme design details and larger mid-term re-orientations. The impact of this information depends upon the flexibility of the programme and receptivity of its management towards a learning-by-doing approach. Information for on-going programme management differs widely and conforms to the overall character of the individual programme. Thus, Iringa employs a simple system based on community growth monitoring, primarily to catalyze intervention planning and action at household and community levels. Tamil Nadu's system is far more complex and is primarily intended to assist in the delivery of centrally planned interventions. Programme evaluation benefited from information generated within the programme, but more rigorous impact evaluation requires stronger designs and more in-depth analysis than is usually provided. Overall, the review suggests that characteristics like community participation, empowerment and growth monitoring are less important in the short/medium term than strong management, a learning-by-doing approach, and the existence of some method for informing programme design and management about community needs and responses to the programme. The former characteristics may well be important for the longer-term sustainability of programmes.

Approaches to linking agriculture and nutrition programmes

Abstract: A review of literature on the effectiveness of nutrition intervention programs suggests that national food self-sufficiency will not in and of itself alleviate household malnutrition. Policy-makers must be aware of the factors affecting malnutrition. Programs with the potential for improving household malnutrition and food security include agricultural credit programs for women agricultural extension services for women combined health and social service programs with crop production plans and strategies for reducing seasonal effects of production consumption and labor requirements. The design of intervention programs should 1) rely on existing infrastructure and programs; 2) use effective agricultural strategies for achieving nutrition goals (cash crop production hybridization extension services and agricultural credit); and 3) pay attention to household level income and resources womens control of resources and income and household allocation. Future implementation of strategies linking nutrition and agriculture should test successful nutrition coping strategies and programs currently being implemented in developing countries. Typically intervention programs involve supplementary feeding weaning and formulated foods fortification targeted consumer price subsidies food stamps and increasing household income. Food must be distributed on a needs basis in order to improve nutrition at the household level. Provision of food and allocation of food both influence child nutrition. Womens labor demands may influence the number of meals the number of nutritious meals the cultivation of less nutritious crops with less labor input or decreased breast feeding and child care. Food policy research has been dominated by studies of how policies and programs affect consumption rather than by the income and household food links. Macro studies have shown that increased household income contributed to the quality and quantity of the household diet but household malnutrition may still persist depending on a variety of factors such as the expenditure on food items the distribution of food among members and the level of health and hygiene of members.

The impact of political transformation in South Africa on public / private mix policy debates.

Abstract: South Africa has experienced the change from apartheid and free market policies towards a nonracial democracy addressing poverty and inequalities. Changes also occurred in the private/public health care sector between 1980 and 1991. An explanation for the health sector changes and the nature of the policy debate are discussed. Private sources of health care have expanded while real per capita public expenditure on health declined private sources of finance increased and the distribution of health care providers changed. Private sector was directly affected by the pressures to reduce public spending s a means of adjustment to the debt crisis the influential ideology of monetarism and privatization lobbies and the growth in numbers of Black workers with health insurance. The proportion of private sector providers increased from 47.2% in 1979 to 57.8% in 1987 while public sector providers declined from 53% to 42%. In 1987 96% of private sector doctors were self-employed. Public health services deteriorated concomitantly with decreased expenditures and the shift of skilled personnel to the private sector. Rural health services declined due to the lack of supply of overseas doctors; this supply was affected by the anti-apartheid boycotts the perception of South Africa as politically unsafe the exits out of the country of military conscripts due to compulsory service requirements and higher incomes for doctors overseas. Currently the private sector has over 50% of the doctors serving over 20% of the population. The transitional end of the post-apartheid era will expose the greater demand for public spending while economic uncertainties prevail. A strong health lobby of medical professional groups and business interests has promoted privatization of health care as an economic advantage and an opportunity to deracialize the issues of access to health care. The opposition has rallied behind a demand for a National Health Service while the Black trade unions have helped to secure the fee for service in the private sector. After 1990 the policy debates changed markedly. Nationalizing private health care would increase the states liability to pay for care which opens up discussion of how the private sector can be regulated in order to control the more destructive impacts.

Partnership in rural water supply and sanitation: a case study from Bangladesh

Abstract: In 1990 a survey of 32 field sites and interviews with women users women handpump caretakers and trainers from participating nongovernmental organizations (NGOs) in Bangladesh was performed to evaluate the performance of the 2-year rural Water Supply and Sanitation (WSS) project conducted by the NGO Forum. 233 of 295 health-related NGOs affiliated with the Association of Development Agencies in Bangladesh took part in the water supply program and 153 took part in the sanitation program. WSS achieved 100% of its targeted activities: tubewell installation establishment of sanitation centers workshops seminars training courses and publications. 40 NGOs built sanitation centers which constructed and sold 8838 latrines out of a budget for 4000 latrines revolving their funds about 2.2 times. Project staff trained 335 field workers. 80% of trainees were male yet most field workers were female. Training did not include information on hygienic practices. 90% of women used the tubewell for drinking purposes. Around 90% of families used unsanitary latrines because the hygienic latrines filled too quickly when used. All community women knew that drinking tubewell water was linked to good health. 55% knew that sanitary latrines contribute to a clean environment. Women participated in site selection of only 15% of sites. At those sites where women did not participate their participation had not been invited by NGO workers. Only 3 of the 32 women caretakers could successfully maintain the tubewells. These 3 had been provided maintenance tools by the NGO. These findings indicate that a partnership approach can efficiently provide hand pumps and latrines to many unserved/underserved people (about 100000) but it cannot easily realize effective and sustainable use of the WSS supplies.

Obstetric transfers and maternal mortality: a study in Conakry, Guinea

Abstract: A retrospective study was made of 349 obstetric patients transferred from suburban maternity units to 2 referral maternity units in the capital city of Conakry Guinea from July 1 1989 to June 30 1990 in order to determine the influence of such a transfer on maternal mortality. Data collected from medical reports and transfer registries included sociodemographic data reproductive history time of transfer original diagnosis diagnosis at admission outcome and place of delivery and cause of death if applicable. The women had a mean age of 24 years. 96% were married or living as a couple 25% were engaged in a profession and 35% had less than 5 years schooling. Mean parity was 2.0; 40% were primigravida 27% had had 5 or more pregnancies and 11% had previous obstetric complications including 6% who had a previous Cesarean section. 161 of the women had a Cesarean section for this birth and 18 of these died. A total of 25 of the women died of infection (28%) ruptured uterus (12%) postpartum hemorrhage (19%) and hypertensive disorders (16%). Since there were 123 maternal deaths in Conakrys maternity units and suburban hospitals during this period 20% of the women who died had been transferred. There were no seasonal variations in the average of 27 women who were transferred each month (3% of the total deliveries). Reasons for the transfers were not given for 20% of the women but a third were transferred for nonprogression of labor and many were transferred for rupture of the uterus. An additional 60 women were transferred but were not usually resident in Conakry and were thus not included in the above analysis. Of these 5 had complications of abortion and 30 a previous Cesarean section. 11 of these women died. The rate of mortality due to ruptured uterus was high considering the short distance between the urban maternity units and the referral units and was most likely caused by the absence of both a partograph and a defined obstetric decision tree which delayed the transfer of women with real complications. The high death rate and the difference between original and admission diagnoses point to an urgent need for staff training in early detection of dystocial deliveries especially through the introduction and use of the partograph.

Developing countries' health expenditure information: what exists and what is needed?

Abstract: In the past decade, the scarcity of financial resources for the health sector has increasingly led countries to take stock of national health resources used, review allocation patterns, assess the efficiency of existing resource use, and study health financing options. The primary difficulties in undertaking these analyses have been 1) the lack of information on health expenditures and 2) not using existing information to improve the planning and management of health sector resources. The principle sources of available health expenditure information are reported by organizations such as the World Bank, WHO, UNICEF and OECD. Special studies and non-routine information are a second major source of information. This existing data has a number of difficulties, including being sporadic, inconsistency, inclusion of only national level public expenditure, high opportunity and maintenance costs, quantitative and qualitative differences across countries, and validity and interpretability problems. Reliable health expenditure data would be useful not only for in-country, national purposes, but also for cross-national comparisons and for development agencies. Country uses of health expenditure data include policy formulation and planning and management, while international uses would facilitate examination of cross-national comparisons, reviews of existing programmes and identification of funding priorities. Collaborative efforts between countries and international development agencies, as well as between agencies, are needed to establish guidelines for health expenditure data sets. This development must ensure that the resulting information is of direct benefit to countries, as well as to agencies. Results of such collaborative efforts may include a set of standardized methodologies and tools; standardized national health accounts for developing countries; and training to enhance national capabilities to actively use the information. The opportunities for such collaboration are unique with the issuance of the World Development Report 1993, to build on this work in clearly identifying what is needed and proposing a standardized data set and the tools necessary to regularly and economically gather such data.

Access policies and utilization patterns in prenatal and child delivery care in Mexico.

Abstract: In Mexico people utilize public private and traditional health providers interchangeably and in contrast to official access policies. Access policies for prenatal and child delivery services are evaluated using data from the National Health Survey of 1988. The study documents significant coverage gaps on the part of public providers with respect to their potential coverage and especially large cross-utilization of social security Ministry of Health and private providers by beneficiaries. Child deliveries in Mexico are attended by a physician in only 66% of cases. The percentages are 85% for social security affiliates 53% for women within reach of IMSS-Solidarity services (a relief program for the rural poor) and only 31% for women with official access to private or Ministry of Health care or beyond the reach of services. 78% of medical deliveries by women affiliated to social security occur at their pre-paid facilities while 14% deliver at extra cost with private physicians contributing to 32% of deliveries so offered. Even though only 7% of insured women deliver at Ministry of Health facilities this amounts to 20% of the Ministrys relief offer. In all only 66% of affiliates use social security delivery services. On the other hand 36% of deliveries by non-insured women are cared for by Ministry of Health providers and 39% by the private sector; 22% of such deliveries occur in social security institutions amounting to 18% of these institutions care offer. These results indicate a wide departure between policy and fact and the working of distributive and redistributive forces that impinge on the quality and efficiency of health care. Open access to the reproductive health services of all public institutions with coordination among them and private providers is suggested as a possible solution. (authors)

An operational evaluation of the Community Oral Rehydration Units in Peru.

Abstract: Since 1984, in Latin America donor agencies and national governments have extensively supported the implementation of the Community Oral Rehydration Units (CORUs) in an attempt to increase the access to oral rehydration therapy and improve the case management of diarrhoea at the community level. This study surveyed 40 CORUs in two regions of Peru to assess their operation, the number of patients with diarrhoea attended, and the knowledge of volunteers in charge. The results show that CORUs were mainly implemented close to existing health centres; the median of case load was 2.0 patients in the preceding month; and the volunteers' knowledge of case management was principally deficient in the diagnosis of hydration status, dietary management and in preventive measures. This lack of knowledge was replicated by professionals at the supervising health centres. Despite the fact that CORUs have been functioning for around four years, they exhibit numerous deficiencies which prevent them from fulfilling their objectives. A global review of the whole CORU strategy is called for.