Health Policy and Planning

TAYEH, AHMED; CAIRNCROSS, SANDY

doi: 10.1093/heapol/8.3.191pmid: N/A

Dracunculiasis continues to be a major public health problem among many rural communities in Africa and the Indian Sub-continent which depend upon unprotected water sources for drinking. It is a painful and debilitating disease which is exclusively transmitted through drinking water from contaminated open sources. Various risk factors are implicated in dracunculiasis transmission which are related to water sources. Dracunculiasis is highly seasonal, with most of the cases appearing in the eariy dry season, end of dry season or early wet season depending upon local conditions. Its social, educational and economic cost to the individual, the household and the community is considerable and well documented. Unfortunately, no drug has been effective for its treatment, but prevention is attainable through water supply provision, when affordable, or health education promoting the filtering of drinking water and avoidance of water sources by sufferers of the disease. Such interventions are presently used as a strategy for its eradication.International awareness of dracunculiasis has been growing recently as a result of the International Water Decade (1981–1990). It was targeted for eradication by 1995 by several international organizations and by national governments in endemic countries.This paper concludes by discussing the different strategies used in its eradication and the prospect of achieving the eradication goal by 1995 as planned.

KACHONDHAM, YONGYOUT; CHUNHARAS, SOMSAK

doi: 10.1093/heapol/8.3.208pmid: N/A

Over the past twenty years, Thailand has undergone rapid economic and health (demographic, epidemiological) transitions. While on the one hand the economic outlook is bright, even to the extent of Thailand's emerging status as a Newly Industrialized Country, persisting health development challenges remain as targets for future research and international support. This paper documents Thailand's current economic and health development situations, their transitions and challenges. Special reference is made towards emerging post-transitional health/epidemiological problems, reorientation of health services and the referral system, community participation, health care financing, public-private health care partnerships, decentralization of the health service system and essential national health research.

SANDIFORD, PETER

doi: 10.1093/heapol/8.3.217pmid: 10128376

In recent years Lot quality assurance sampling (LQAS), a method derived from production-line industry, has been advocated as an efficient means to evaluate the coverage rates achieved by child immunization programmes. This paper examines the assumptions on which LQAS is based and the effect that these assumptions have on its utility as a management tool. It shows that the attractively low sample sizes used in LQAS are achieved at the expense of specrficity unless unrealistic assumptions are made about the distribution of coverage rates amongst the immunization programmes to which the method is applied. Although it is a very sensitive test and its negative predictive value is probably high in most settings, its specificity and positive predictive value are likely to be low. The implications of these strengths and weaknesses with regard to management decision-making are discussed.

HARNMEIJER, JOANNE

doi: 10.1093/heapol/8.3.224pmid: N/A

Success, and indeed sustainability, of water supplies stands to gain from careful selection that gives priority to villages that have an apparent need for improved and more convenient water supplies. Water supply planners should thus insist on more objective and painstaking selection procedures through refined selection criteria. As the justification for village selection differs between villages, the expected impact of improved water is also different. It is argued that a conceptual link should be made between village selection and expected village impact. Both selection and prediction of impact at village level could become part of baseline studies, which would then take on a wider purpose than such studies have at present. The baseline study envisaged should thus form a basis for need-oriented planning, and make a connection between selection and impact.

ESSOMBA, RENE OWONA; BRYANT, MALCOLM; BODART, CLAUDE

doi: 10.1093/heapol/8.3.232pmid: N/A

The reorientation of primary health care (PHC) that was begun in Cameroon in 1989 is presented as a natural response to the economic and health environments prevailing at that time. A brief discussion of the original PHC policy introduced following the Alma-Ata declaration identifies a lack of effective communication between the community and the health services as a major problem. The basic elements of the reorientation are presented and the obstacles and constraints encountered since beginning the reform process in 1989 are described. These have been identified as: an inadequate legal framework; incompatibilities between the political structure and the new health structure; incompatibilities between the goals of the new health policy and the organizational chart of the Ministry of Health; the lack of trained personnel in health management; a highly centralized system of management with poor coordination of human resource management; the slowness of the extension of PHC coverage; the inability of the system to ensure that medicines are available and easily accessible; an inadequate health information system; poor promotion of the new PHC policy; and poor coordination of research activities.

UNGER, JEAN-PIERRE; YADA, ADAMOU

doi: 10.1093/heapol/8.3.240pmid: N/A

Drug distribution by pharmacies is fraught with difficulties in Africa. These include: improper use of medication by health professionals; by-passing health services leading to irrational serf-medication; the inevitable fee-for-service payment scheme; and finally inadequate management. In this article, a health centre in Burkina Faso is evaluated for these problems using quantitative and qualitative methods. The reality of the problems justifies consideration of an alternative drug distribution arrangement, perhaps via the health services.

FOSTER, SUSAN

doi: 10.1093/heapol/8.3.247pmid: N/A

The 1992 Southern African drought focused the world's attention on the precarious food security situation of that region. In Monze District, southern Zambia, in addition to the drought there was also a serious epidemic of East Coast fever among the cattle, which resulted in the deaths of a large percentage of the district's herd causing further impoverishment among some of the district's poorer households. At the same time, AIDS and HIV disease are increasingly making an impact on the productivity of the district's population, with as many as one in 6.5 households already having experienced illness or a death due to AIDS. This paper describes the history of maize in Zambia, the impact of the 1992 drought and of the epidemic of East Coast fever, and the likely impact of AIDS on agriculture in the district.

HANSON, KARA; MCPAKE, BARBARA

doi: 10.1093/heapol/8.3.247-apmid: N/A

The Bamako Initiative was launched in September 1987 as a means of increasing access to essential drugs through community participation in revolving drug funds. The response of the public health community was highly critical of the Initiative. Issues raised included equity and access; problems of integration, management and logistics; the relative importance given to drugs; and sustainability and dependency.The Initiative has evolved in part in response to these criticisms, now focusing on increased accessibility and quality of services, and the strengthening of health system management. An evaluation carried out in 1991 reviewed the main areas of criticism. In all areas, a relative approach was found to be useful. For example, while substantial problems of equity and affordability exist, in some cases, services of a given quality have been made available more cheaply than before.The most important outstanding policy issues were considered to be: the need to strengthen community support mechanisms for those without economic access to services and to develop payment mechanisms compatible with seasonal income patterns; the feasibility of regional cross-subsidization of revenues; the development of an improved model of community participation; and the nature and extent of external support to the programme.

GREEN, REGINALD HERBOLD

doi: 10.1093/heapol/8.3.255pmid: N/A

Drought by itself does not lead to famine. That requires severe economic weakness, very poor national and/or external response and/or war. In practice, mass starvation does not happen in Africa in the absence of war. However, the degree of hunger and, perhaps even more, the speed of affected household livelihood recovery depend heavily on domestic and international strategic responses. The present standard donor political economy of response to crisis is one-off, short term, not incorporating livelihood rehabilitation or future vulnerability reduction. Further, it is usually managed in a way fragmenting national response and frequently decapacitating national structures. This ‘Good Samaritan’ approach provides no link back to ‘normal development’ which also tends to exclude post drought reconstruction by livelihood rehabilitation.National responses vary in coherence, degree of sophistication, capacity and relationship to sustaining or rehabilitating livelihoods. In part this reflects governing coalition political priorities - in the absence of war even a very poor state can mount programmes averting mass migration and famine (e.g. Tanzania). Both normative and efficiency criteria suggest more coherent/nationally owned responses within ongoing donor and national emergency response structures; greater expedition in action to avert people being forced to leave their homes, and building livelihood rehabilitation and future vulnerability reduction components into drought responses as integral components.

GREEN, REGINALD HERBOLD

doi: 10.1093/heapol/8.3.256pmid: N/A

Drought by itself does not lead to famine. That requires severe economic weakness, very poor national and/or external response and/or war. In practice, mass starvation does not happen in Africa in the absence of war. However, the degree of hunger and, perhaps even more, the speed of affected household livelihood recovery depend heavily on domestic and international strategic responses. The present standard donor political economy of response to crisis is one-off, short term, not incorporating livelihood rehabilitation or future vulnerability reduction. Further, it is usually managed in a way fragmenting national response and frequently decapacitating national structures. This ‘Good Samaritan’ approach provides no link back to ‘normal development’ which also tends to exclude post drought reconstruction by livelihood rehabilitation.National responses vary in coherence, degree of sophistication, capacity and relationship to sustaining or rehabilitating livelihoods. In part this reflects governing coalition political priorities - in the absence of war even a very poor state can mount programmes averting mass migration and famine (e.g. Tanzania). Both normative and efficiency criteria suggest more coherent/nationally owned responses within ongoing donor and national emergency response structures; greater expedition in action to avert people being forced to leave their homes, and building livelihood rehabilitation and future vulnerability reduction components into drought responses as integral components.