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Health Policy and Planning. 2005; 20(1):1-13.National governments and international agencies, including programmes like the Global Alliance for Vaccines and Immunizations and the Global Fund to Fight AIDS, Tuberculosis and Malaria, have committed to scaling up health interventions and to meeting the Millennium Development Goals (MDGs), and need information on costs of scaling up these interventions. However, there has been no systematic attempt across health interventions to determine the impact of scaling up on the costs of programmes. This paper presents a systematic review of the literature on the costs of scaling up health interventions. The objectives of this review are to identify factors affecting costs as coverage increases and to describe typical cost curves for different kinds of interventions. Thirty-seven studies were found, three containing cost data from programmes that had already been scaled up. The other studies provide either quantitative cost projections or qualitative descriptions of factors affecting costs when interventions are scaled up, and are used to determine important factors to consider when scaling up. Cost curves for the scaling up of different health interventions could not be derived with the available data. This review demonstrates that the costs of scaling up an intervention are specific to both the type of intervention and its particular setting. However, the literature indicates general principles that can guide the process: (1) calculate separate unit costs for urban and rural populations; (2) identify economies and diseconomies of scale, and separate the fixed and variable components of the costs; (3) assess availability and capacity of health human resources; and (4) include administrative costs, which can constitute a significant proportion of scale-up costs in the short run. This study is limited by the scarcity of real data reported in the public domain that address costs when scaling up health interventions. As coverage of health interventions increases in the process of meeting the MDGs and other health goals, it is recommended that costs of scaling up are reported alongside the impact on health of the scaled-up interventions. (author's)
Social Science and Medicine. 1985; 21(1):41-53.This paper explores the emergence of an international fad aiding and monitoring community participation efforts and projects its future outcome based on lessons from previous experiences in other than the health sector. The analysis suggests that the promotion of community participation was based in all cases on 2 false assumptions. 1) The value system of the peasantry and of the poor urban dwellers had been misunderstood by academicians and experts, particularly by US social scientists, who believed that the traditional values of the poor were the main obstacle for social development and for health improvement. However, the precolumbian forms of organization that traditional societies had been able to maintain throughout the centuries were not only compatible with development but had many of the characteristics of modernity: the tequio guelagetza minga and even the cargo system stress collective work, cooperation, communal land ownership and egalitarianism. 2) Another misjudgement was the claim that the peasantry was disorganized and incapable of effective collective action. In Latin America historical facts do not support this contention. A few examples from more recent history show the responsiveness and organizational capabilities of rural populations. The Peasant Leagues in Northeastern Brazil under the leadership of Juliao is perhaps 1 of the best known example. The question is thus raised as to why international and foreign assistance continues to pressure and finance programs for community organization and/or participation. It is suggested that the experience in Latin America (except perhaps Cuba and Nicaragua) indicates that community participation has produced additional exploitation of the poor by extracting free labor, that it has contributed to the cultural deprivation of the poor, and has contributed to political violence by the ousting and suppression of leaders and the destruction of grassroots organizations. Information presented on community participation in health programs in Latin America illustrates that they have followed closely the ideology and steps of community participation in other sectors. A country by country examination indicates that health participation programs in Latin America in spite of promotional efforts by international agencies, have not succeeded. The real international motivation for participation programs was the need to legitimeize political systems compatible with US political values. Through symbolic participation, international agencies had in mind the legitimation of low quality care for the poor, also known as primary health care and the generation of much needed support from the masses for the liberal democracies and authoritatrian regimes of the region. Primary health care delivery can be successful without community participation, in contradiction to what international agencies and governments maintain.
In: Potts M, Bhiwandiwala P, eds. Birth control: an international assessment. Baltimore, Maryland, University Park Press, 1979. 71-91.The planning, implementation, achievements, and existing problems facing a pilot community-based distribution (CBD) family planning program in Thailand are described. The program was begun in 1973-74 under auspices of IPPF following the Thai government decision to allow trained midwives to dispense oral contraceptives. Experience with the program has shown that such programs can provide adequate levels of medical supervision, be culturally acceptable, and have a decided impact on national fertility within 2 years. Administrative, financial, and structural elements of the program are summarized. The program was started to provide an alternative to existent clinical services and provide more complete coverage in rural areas. The IPPF donor relationship was useful to the launching of the program. The program has concentrated on training local nonmedical personnel for distribution of oral contraceptives and condoms. Both local doctors and field supervisors are available for advice to the distributors. The program now extends to all areas of the country. Communications activities play a large role in the program. Demographic effects of the program to 1977 are tabulated. The pilot project also involved an institutional and a private sector distribution program. There is need for a greater variety of contraceptive methods available through the program sources. Integrated family planning/development projects are now being tried.