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Notes from the Field. 2002 Jan; (12): p..Paraguay is usually overlooked by international donors because it's geographically isolated and dwarfed by its large, high-needs neighbors like Bolivia, Brazil and Argentina. But the reproductive health needs in Paraguay are as great if not greater than in other countries. It has the highest fertility rate in South America, 4.7 [children per woman], teen pregnancy is high, and maternal mortality is also high. CEPEP is managing to do a lot with few resources. In addition to four of its own clinics, it works with independent "associated clinics," institutions and professionals to increase access to sexual and reproductive health services and contraceptives. When looking at quality, CEPEP distinguishes between "calidad" and "calidez," and emphasizes both. "Calidad" refers to the quality of clinical procedures, infection prevention, etc., and "calidez" [warmth] refers to client satisfaction issues like courtesy, expedience and clinic environment. Through this focus on quality, CEPEP hopes to increase clinic attendance and sustainability. It seems to be working: One of the clients I spoke with had traveled four hours to get to the clinic. She said there was a Ministry of Health clinic closer, but she chose to come to CEPEP. (excerpt)
Project appraisal document on a proposed loan of US $10.0 million and a proposed credit of SDR 36.8 million to the People's Republic of China for a Health Nine project.
Washington, D.C., East Asia and Pacific Region, Human Development Sector Unit, 1999 Apr 14. , 63 p. (Report No. 19141-CHA)This project appraisal document of the World Bank details the proposed loan of US $10 million and a proposed credit of special drawing right for nine health projects in the People's Republic of China.
Addis Ababa, Ethiopia, Pathfinder International, .  p.This booklet describes how Pathfinder International is collaborating with the Ethiopian government and nongovernmental organizations (NGOs) to expand the availability of high-quality family planning (FP) and reproductive health services. The introduction notes that Ethiopia is struggling to overcome poverty and that the government has instituted a progressive population policy to overcome the country's high rate of maternal, infant, and child mortality and high population rate. Next, various aspects of the services and leadership offered by Pathfinder since it began work in Ethiopia in 1964 are reviewed, especially the first community-based reproductive health services program in the country and specific integrated reproductive health and FP projects carried out in partnership with several local nongovernmental organizations. The introduction of community-based service delivery methods as a way to improve access to services is then discussed as is Pathfinder's commitment to quality and program sustainability. The booklet also relays Pathfinder's response to the fact that the reproductive health needs of adolescents require a different approach, which once again relies on collaboration with NGOs through the creation of three new youth centers that offer recreational activities as well as reproductive health services and information. Throughout the booklet, case histories are presented of individuals helped by activities supported by Pathfinder. The booklet closes with a look at an effort to train former prostitutes to generate income as hairdressers and tailors and to become community-based reproductive health agents.
London, England, Earthscan Publications, 1995. 218 p.This book reports the findings of a 3-year research project conducted by Save the Children Fund UK, which used a variety of case studies to document and analyze how health systems in low-income countries develop in response to internal and external influences and how these influences affect the sustainability of the health systems. After an introduction that defines sustainability as "the capacity of the health system to function effectively over time with minimum external input," chapter 1 considers the sustainability problem by looking at the donor's dilemma and at definitions and measures of sustainability, providing a conceptual framework that emphasizes the quality of the process of health system development, and noting contradictions that occur in the development process, such as those that exist between immediate needs and capacity building, between dependency and self-reliance, and between the goals of effectiveness and continuity/self-reliance. Chapter 2 describes the contextual hostility created by economic conditions, the international aid system, the local political climate, and the health care market. This chapter also includes a note on the history of legacies and investment trends. Chapter 3 explores the quality of investment through an exploration of the role of government, the constraints faced by donors as investors, and the investment dynamic that emerges from the interaction between governments and donors. The final chapter links investment and sustainability by addressing the contradictions between investment practice and sustainability and considering strategies for securing sustainability. It is concluded that the two basic requirements for health system sustainability are a renewable resource base and an institutional capacity for effective and efficient resource use.
Lancet. 1995 Jul 29; 346(8970):301.The World Bank, in "India's Welfare Programme: Towards a Reproductive and Child Health Approach," a review done with the Ministry of Health and Family Welfare, makes the following recommendations: 1) eliminate method-specific contraceptive targets and incentives, and replace them with broad reproductive and child health goals and measures; 2) increase the emphasis on male contraceptive methods (which account currently for only 6% of contraceptive use); 3) improve access to reproductive and child health services; 4) increase the role of the private sector by revitalizing the social marketing program; and 5) encourage experimentation with an expanded role for the private sector in implementing publicly funded programs. Since the launch of the family planning program in 1951, mortality has fallen by two-thirds, and life expectancy at birth has almost doubled. However, the population has almost doubled since 1961. By 2025, it is expected to be 1.5-1.9 billion. By 1992, India had achieved 60% of its goal for replacement fertility (2.1 births per woman), decreasing from 6 births per woman in 1951-1961 to 3-4 births per woman. Meeting India's unmet need for family planning would allow the replacement fertility goal to be reached. Female education and employment would add to the demand for smaller families and assure continuing declines in fertility and population growth rate. The report also highlights problems in implementation of the program, including program accessibility and quality of care. The report cites National Family Health Survey data which shows that only 35% of children under 2 received all six vaccines in the program, while 30% received none. The bank's "1993 World Development Report" recommended spending $5.40 per head for maternal and child health and family welfare programs; India spends $0.60. Massive borrowing will be required.
Arlington, Virginia, John Snow [JSI], Resources for Child Health [REACH], 1988 Sep. , 99,  p. (USAID Contract No. DPE-5927-C-00-5068-00)Building upon smallpox and measles immunization campaigns originally supported by USAID, the Centers for Disease Control, and the World Health Organization, the African region Combatting Childhood Communicable Diseases (CCCD) Project began providing immunizations, oral rehydration therapy for children with diarrhea, and malaria prophylaxis services in 1982. The project was approved in September, 1981, for spending of $47 million through fiscal 1988, and was designed to be implemented through existing publicly operated health service delivery systems with recipient CCCD project countries helping to finance recurrent costs and providing human resources for project implementation. Accordingly, almost all country project agreements were written to ensure that country governments would provide financial support for activities through direct budget allocations, user fees, or some combination of the 2. Regular analyses of service provision were also agreed upon. The development and implementation of user fees have taken place, but the overall theoretical financial strategy has yet to be met in any country project. This document discusses financing achievements and what more is needed to ensure longer term project financial sustainability. Sections review country-specific agreements to spell out original USAID/country terms on financing components; consider the capacity of CCCD project governments to finance recurrent costs in their respective macroeconomic contexts; present highlights of a review of CCCD project financing activities; summarize an evaluation of alternative health financing options; give conclusions of analyses on the financial sustainability of CCCD project activity; and make recommendations for future USAID CCCD project support with respect to financing and economics.
[Unpublished] 1992. Presented at the 120th Annual Meeting of the American Public Health Association [APHA], Washington, D.C., November 8-12, 1992. 27,  p.In the mid 1980s, USAID started nonproject assistance, mainly in the economic sectors, to African countries. The countries received nonproject assistance after they fulfilled conditions which influence institutional and/or policy reforms. The longest running health sector reform program in Africa was in Niger and was slated to receive portions of the funds after fulfilling 6 specific predetermined reform activities. Yet, between 1986 and 1991, Niger had implemented only 2 of them. It did accomplish the population/family planning reforms: expansion of family planning services, a national population policy, analyses and implementation of improvements in the pricing and distribution of contraceptives, and legalization of use and distribution of contraceptives. Continuing economic deterioration during the 1980s and political upheavals after 1989 somewhat explained why the other reform activities were not implemented. Other equally important factors were a very complex sector grant design (more than 20 reforms in 6 policy/institutional areas) with little incentive to realize the reforms, insufficient number of staff (limited to senior personnel) to implement the reforms, and just 1 USAID staff to monitor and facilitate activities. The nonproject assistance for the primary health care (PHC) system in Nigeria had a simpler design than that in Niger. The reform goals were shifting responsibility for PHC from curative care to preventive health services. After USAID and the Nigerian government signed an agreement, they included policy reforms promoting privatization of health services. Only 1 reform was implemented. Factors which could lead to success of nonproject assistance include host government needs to perceive it owns the objectives and building financial and institutional sustainability. In conclusion, nonproject assistance can be effective when implementing policy reforms that the host government has already adopted.