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BMJ. British Medical Journal. 1993 Sep 18; 307(6906):729-30.The former Minister of Health responds to an earlier, inaccurate article about the dispute between some emergency ward physicians and the public sector in Chile. Even though the economy appears to be healthy, 38% of the population are poor. Chile has had a longterm social policy addressing socioeconomic problems in health and in education, resulting in impressive health indicators (e.g., in 1990, 97% immunization rate for children under 5 years of age. The Pinochet regime whittled away at the strong national health service, however, including a large reduction in staff in the mid-1970s and a 40% reduction in expenditures (and a response to the economy adjustment crisis). These actions became time bombs which exploded in May 1990, 2 months after the inauguration of the 1st democratically chosen president in years. The health unions and, later, physicians asked for higher wages. In late 1992, the government increased salaries by 35% in real terms and 100% in nominal terms. Between 1990 and 1993, 6000 people, which included 1200 physicians for rural areas, were added to the public sector staff. The government increased investment in equipment (around 10,000 pieces of equipment, including 10 CAT scans) and in infrastructure by 240%. 190 public hospitals are undergoing repair and renovation. 2 small hospitals have opened. 4 large regional hospitals are scheduled for completion in 1993 and 1994. During the 3 years of democracy, the public sector budget increased 50% in real terms. The World Bank has provided assistance for a health sector reform project to meet the challenges that accompany the demographic and epidemiologic transition, transitions from a planned to a market economy and from dictatorship to democracy, a cultural transition, and behavioral changes. Politicians and physicians do not necessarily support reforms, however, sometimes resulting in changes in ministers, such as the author of this article.
IPPF COUNTRY PROFILES. 1992 Aug; SAR 19-24.In 1984 in Pakistan, the government's Council of Islamic Ideology banned contraception unless pregnancy would jeopardize a woman's life. The government soon realized that its 2.9% population growth rate was too high to achieve social and economic development, so it implemented a national population policy, hoping to reduce population growth to 2.5% by 2000. The policy calls for a multisectoral approach, emphasizing mobile services to promote birth spacing and maternal and child health and providing family planning services through the public and private sector and family welfare centers. The policy also aims to increase literacy, reduce unemployment, and improve health care. It targets rural areas where 72% of the population lives. In 1989, only 9.1% of 15-49 year old married women used contraceptives and 58.6% wanted to control their fertility but did not have access to family planning information and services. Pakistan depends greatly on the family planning services of the nongovernmental organization. Family Planning Association of Pakistan (FPAP). FPAP introduced family welfare centers, social marketing, and reproductive health centers to Pakistan. It continues to introduce new contraceptives. FPAP's major projects include educational programs in population, family planning, and nutrition; family planning training; promotion of family planning and maternal and child health; programs emphasizing male involvement in family planning; information, education, and communication; and lobbying Parliament for more funding for family planning and for improvement in women's status.
New York, New York, UNFPA, . v, 36 p. (Report)The former government of Romania sought to maintain existing population and accelerate population growth by restricting migration, increasing fertility, and reducing mortality. The provision and use of family planning (FP) were subject to restrictions and penalties beginning in 1986, the legal marriage age for females was lowered to 15 years, and incentives were provided to bolster fertility. These and other government policies have contributed to existing environmental pollution, poor housing, insufficient food, and major health problems in the country. To progress against population-related problems, Romania most urgently needs to gather reliable population and socioeconomic data for planning purposes, establish the ability to formulate population policy and undertake related activities, rehabilitate the health system and introduce modern FP methods, education health personnel and the public about FP methods, promote awareness of the need for population education, and establish that women's interests are served in government policy and action. These topics, recommendations, and the role of foreign assistance are discussed in turn.
[Unpublished] 1990 May. , 12 p. (PRITECH Field Implementation Aid)Control of Diarrheal Disease (CDD) programs need to move more and more toward self-sufficiency. Thus they want a reliable supply of low cost, locally produced oral rehydration salts (ORS). 2 obstacles hinder the process: low demand and an inadequately developed pharmaceutical industry. It takes about US$200,000 to begin ORS production. In 1987, pharmaceutical plants in developing countries made 75% of all ORS produced. In Indonesia, for example, 12 private and parastatal manufacturers can produce ORS, but low demand is forcing some to decrease production. In Bangladesh, however, only 1 parastatal and 1 private company produces all ORS used in the country, but they cannot keep up with demand. Other developing countries producing their own ORS include Costa Rica, Tunisia, Zambia, Mali, Egypt, and Ghana. Any group that considers local ORS production must first examine various factors including an assessment of potential demand, the extent that diarrhea is treated with oral rehydration therapy (ORT), and the government's position on ORS production and distribution. The group should contact the local UNICEF office to gain its support and guidance. It should also work with WHO and Ministry of Health officials and speak with the chief pharmacist or head of the pharmacy board. This group also needs to consider economic factors such as pricing and costs of importing raw materials. It should also see to a detailed cost analysis and market research. The group also needs to determine production capability in the country which includes the ability of companies to adhere to the international Good Manufacturing Practices code. In the beginning of project development, the group must consider ORS promotion with ORS production, e.g., it should scrutinize the potential producer's record for marketing and organize field research. The group can obtain technical assistance from UNICEF, UNIDO, and USAID funded projects such as PRITECH, PATH, HEALTHCOM, and SOMARC.
HEALTH POLICY AND PLANNING. 1992 Dec; 7(4):364-74.The Director of WHO's Regional Office for Africa presents a health development framework based on the primary health care (PHC) concept. the government should review national health policies, national health strategies, and national heath services to resolve basic issues. Then it should define the framework for health development by breaking down the goal into operational target-oriented subgoals for individuals, families, and communities, by creating health districts as operational units, and by organizing support for community health. Once this framework has been decided, the government should use it to restructure the national health systems. At the district level, health and development committees, helped by community health workers, and district health teams would be responsible for community health education and activities. The provincial health offices would oversee district activities, select and adapt technologies, and provide technical support to communities. A board would manage the provincial hospitals (public, private, and voluntary). These hospitals would work together to organize secondary medical care programs. A public health office wold link them with the provincial health centers. Other sectors would also be involved, e.g., departments of education and water. The national health ministry would set national policies, plans, and strategies. A suprasectoral health council would coordinate cooperation between universities and other sectors and external agencies. National capacity building would involve establishing management cycles of health development, using national specialists as health advisors, and placing health as a priority in development. To implement this framework, however, the government needs to surmount considerable structural economic, and social obstacles by at least decentralizing and integrating health and related programs at the local level, fostering a national dialogue, and promoting social mobilization.
Arlington, Virginia, John Snow, Inc. [JSI], Resources for Child Health Project [REACH], 1987.  p. (USAID Contract No. DPE-5927-C-00-5068-00)In 1987, consultants went to Niger to prepare the plan of operations for the national Expanded Programme on Immunization (EPI). US$ 6 million from the World Bank Health Project and around US$ 5 million from the UNICEF EPI Project were available for EPI activities. Low vaccination coverage prevailed outside Niamey. Outbreaks of diseases that EPI can prevent continued to kill children. The cold chain was not maintained, especially at the periphery. Mobile teams continued to use inadequate strategies. Record keeping did not exist. The central level did not supervise the periphery. EPI staff at departmental and division levels did not have current written guidelines. Not only did poor working communications exist between the central level and the periphery, but also between the EPI Director and the other Minister of Health divisions, between WHO and UNICEF, and between both UN agencies and EPI. The EPI Director did have a good relationship with the USAID office, however. No one took inventory of EPI resources or monitored temperatures at any point in the cold chain. Even though the World Bank Health Project intended to five EPI 50 ped-o-jets, 46% of the existing 88 ped-o-jets were in disrepair and no one knew how to repair and maintain them. Thus EPI should not routinely use ped-o-jets. The consultants recommended that USAID stay involved with EPI in Niger since the EPI Director considered it an acceptable partner. EPI staff at each level should take a detailed inventory of all material resources. Effective and regular supervision should occur at the central, regional, and peripheral levels. A health worker needs to record the temperature of the refrigerator twice a day. Technical grounds should determine the standardization and selection of all equipment. Someone should maintain an adequate supply of spare parts and technicians should undergo training in maintenance.
INTERNATIONAL NURSING REVIEW. 1991 Mar-Apr; 38(2):31.A brief report summarizes issues and concepts discussed by participants from Malawi, Tanzania, and Zambia at the 2nd ICN/WHO intercountry conference in Lusaka, Zambia. Broadly discussing nursing care of people with HIV/AIDS and their families, counseling and case/family support should be considered major components of local initiatives in Africa. While local constraints must be recognized in diagnosing, counseling, caring for, and supporting cases and families, programs may also build upon community strengths. Present official health services are often unable to accommodate the needs of all patients with HIV/AIDS. Participants therefore examined innovative, new home-based approaches to care and case/family support. Examples of community-based support programs tailored to meet local needs are mentioned. The role of counseling in both case/family support and for behavioral change is also voiced. A multidisciplinary approach carried out by open, flexible, and understanding personnel is required. Nurses must provide clinical care to cases while also working to facilitate behavioral change.
INFECTIOUS DISEASE CLINICS OF NORTH AMERICA. 1991 Jun; 5(2):221-34.Public and private domestic expenditures for health in a total 148 developing countries for 1983, were estimated to be $100 billion. 1986 external donor health expenditures totalled $4 billion, a small percentage of overall health expenditure for developing countries. U.S. direct donor assistance for development was 0.5% of the federal budget for 1988, with approximately 10% of all U.S. development assistance allocated for health, nutrition, and population planning. As such, the U.S. accounts for 13% of total health contributions from external donors to developing countries. Approximate at best, private and volunteer organizations are estimated to contribute 20% of all such health assistance. Developing countries are therefore required to efficiently use their own resources in the provision of national health services. Technical assistance and donor experience also counting as external assistance, the overall supply of health financing is far greater than developing country demand in the form of well-articulated, officially approved proposals. Reasons for this imbalance include health ministry unfamiliarity with potential donor sources, passive approaches to external financing, unfamiliarity with proposal preparation, increasing competition from other sectors of developing nations, limited numbers of trained personnel, and lack of an international system of support to mobilize financing. The paper discusses 6 years of Pan American Health Organization interventions for resource mobilization in Latin America and the Caribbean, and suggests World Health Organization regional extension backed by U.S. encouragement and support.
WORLD HEALTH. 1988 Jan-Feb; 10-11.In 1979 WHO invited its member states to participate in a global strategy for health and to monitor and evaluate its effectiveness using a minimum of 12 indicators. Members' 1982 implementation reports and 1985 evaluation reports form the basis for evaluating each measure. Indicators 1-6 have strong political and economic components in both developed and developing countries and are not complete. Indicator 7, for which rates of reply are satisfactory, asks whether at least 5 elements of primary health care are available to the whole population. The 8th gauge seeks information on the nutritional status of children, considering birth weight (a possible indicator of risk) and weight for age (a monitor of growth). Infant mortality rate and life expectancy at birth, indicators 9 and 10, are difficult to estimate in developing countries, and health services are not always kept informed of current estimates. Indicator 11 asks whether the literacy rate exceeds 70%; it can provide information on level of development and should emphasize literacy for women, for whom health information is critical. The last global measure yields information about the gross national product, which is not always the most recent, despite the trend of countries to publish their gross domestic product. Failure to make use of the best national sources, such as this, is one of several problems encountered by WHO's member states in collecting accurate data. Other problems include lack of universally acceptable definitions, different national accounting systems, disinterest of health authorities in economic matters, lack of staff, lack of financial resources in developing countries, and inadequately structured health system management. Each country must choose the most appropriate methods for collection of data. If an indicator cannot be calculated, the country is encouraged to seek and devise a substitute. WHO must produce more precise and reliable indicators. It must respond to requests for ways of improving or strengthening national systems.
REVIEWS OF INFECTIOUS DISEASES. 1983 May-Jun; 5(3):546-53.Control of measles in tropical Africa has been attempted since 1966 in 2 large programs; recent evaluation studies have pinpointed obstacles specific to this area. Measles epidemics occur cyclically with annual peaks in dry season, killing 3-5% of children, contributing to 10% of childhood mortality, or more in malnourished populations. The 1st large control effort was the 20-country program begun in 1966. This effort eradicated measles in The Gambia, but measles recurred to previous levels within months in other areas. The Expanded Programme on Immunization initiated by WHO in 1978 also included operational research, technical assistance, cooperation with other groups such as USAID, and development of permanent national programs. Cooperative research has shown that the optimum age of immunization is 9 months, and that health centers are more efficient at immunization, but mobile teams are more cost-effective as coverage approaches 100%. 53 evaluation surveys have been done in 17 African countries on measles immunization programs. Some of the obstacles found were: rural population, underdevelopment of infrastructure, and exposure of unprotected infants contributing to the spread of measles. Measles surveillance is so poor that less than 10% of expected cases are reported. People are apathetic or unaware of the importance of immunization against this universal childhood disease. Vaccine quality is a serious problem, both from the lack of an adequate cold chain, and lack of facilities for testing vaccine. The future impact of measles control from the viewpoint of population growth and health of children offers many fine points for discussion.