The role of research in a technical assistance agency: the case of the 'German Agency for Technical Co-operation'.

Technical assistance agencies have a sustainable impact on the health systems of the countries they are operating in. As well as policy-makers at the national level, technical assistance agencies see themselves confronted that their interventions should be based on evidence, usually meaning the results of research. This study has the aim to analyse role of research in the implementation of technical assistance. We sent a questionnaire to all health project managers of the 'German Agency for Technical Co-operation' and performed a qualitative case study in one of the health projects. Forty-seven of 80 (58.8%) of the questionnaires were completed and sent back. The managers considered publications of International Organisations (IOs), scientific articles and local research as most important for their work. The case study showed application problems in the daily work. Research use not only depends on the relevance of the data but also on analytical skills, linguistic barriers and technical access to research by the potential users. The role of knowledge and information management has to be clearly defined in an organisation of technical assistance. The specific needs at the different levels have to be analysed so that skills and resources can be allocated adequately.

Sterilizing vaccines or the politics of the womb: retrospective study of a rumor in Cameroon.

In 1990 a rumor that public health workers were administering a vaccine to sterilize girls and women spread throughout Cameroon. Schoolgirls leapt from windows to escape the vaccination teams, and the vaccination campaign (part of the Year of Universal Child Immunization) was aborted. This article traces the origin and development of this rumor. Theories of rumor and ambiguous cultural response to new technologies shed some light on its genesis and spread, but explain neither its timing nor its content. For this task we need to examine the historical context of Cameroonian experience with colonial vaccination campaigns and the contemporary contexts of the turmoil of democratization movements and economic crisis, concurrent changes in contraceptive policy, and regional mistrust of the state and its "hegemonic project." Drawing on Bayart's politique du ventre and White's thoughts on gossip, we explore this rumor as diagnostic of local response to global and national projects. This response, expressed in this case through the idiom of threats to local reproductive capacity, reveals a feminine side to local-global relations, a politics of the womb.

Indigence and access to health care in sub-Saharan Africa.

Access to health care services for the poor and indigent is hampered by current policies of health care financing in sub-Saharan Africa. This paper reviews the issue as it is discussed in the international literature. No real strategies seem to exist for covering the health care of the indigent. Frequently, definitions of poverty and indigence are imprecise, the assessment of indigence is difficult for conceptual and technical reasons, and, therefore, the actual extent of indigence in Africa is not well known. Explicit policies rarely exist, and systematic evaluation of experiences is scarce. Results in terms of adequately identifying the indigent, and of mechanisms to improve indigents' access to health care, are rather deceiving. Policies to reduce poverty, and improve indigents' access to health care, seem to pursue strategies of depoliticizing the issue of social injustice and inequities. The problem is treated in a 'technical' manner, identifying and implementing 'operational' measures of social assistance. This approach, however, cannot resolve the problem of social exclusion, and, consequently, the problem of excluding large parts of African populations from modern health care. Therefore, this approach has to be integrated into a more 'political' approach which is interested in the process of impoverishment, and which addresses the macro-economic and social causes of poverty and inequity.

The distribution and spread of schistosomiasis in relation to water resources development in Mali.

Schistosomiasis prevalence is known to be high in water resources development projects. Data from 225 villages and 34,434 persons were used to compare areas with irrigation in agricultural development projects, villages in the vicinity of small dams, settlements around a large artificial lake, communities along the Niger river and places in savanna areas without any irrigation programmes. For ten villages the prevalence rates before and after the creation of the large lake were analysed. In irrigated areas the risk of schistosomiasis infection was found to be six times higher than in savanna villages. Even in the vicinity of natural bodies of water the prevalence of infection was three times less than in agricultural development projects employing irrigation. A pre-valence of intense infections above 5%, indicating that schistosomiasis requires specialized interventions was observed only in areas with irrigation. Therefore schistosomiasis may be considered a man-made health problem in rural Mali although the infection is endemic in the whole country.

Cost and effectiveness of different approaches to schistosomiasis control in Africa.

In order to analyze the cost-effectiveness of selected mass-chemotherapy, a model is used to compare the treatment of urinary schistosomiasis with metrifonate (3 dose regimen, fortnightly intervals) and praziquantel (one dose regimen). The model was applied to two situations. Setting I, based on experiences in the Peoples Republic of the Congo, assumes that the average distance between the project base and the area of intervention is 80 km, the other, setting II, based on the situation in Mali, assumes an average distance of 250 km. The aim of the project is defined as the reduction of a prevalence of 50% to less than 5% in the absence of reinfection. Using metrifonate, the cost per person rendered negative is calculated at DM 12.57 for the Congo and at DM 32.52 for Mali. Prevalence will be 4.2% after intervention. Using praziquantel, the costs are DM 8.36 and 11.47, respectively, and the prevalence reached at the end of the intervention will be 1.1%. The cost difference is mainly due to the high operational cost incurred by the 3 dose regimen. Once low prevalence levels are reached, operational cost further outweigh drug expenses.

Financially independent primary health care drug supply system in Cameroun.

The drug supply system in the North-west Province of Cameroun differs from 'simple' health financing projects in three important respects. Firstly, the system does not promote drug sales for cofinancing purposes but aims at supporting the prescribers to provide better medical care, and patients' access to the most essential drugs at fair prices. Secondly, the project guarantees equal prices and services throughout the Province regardless of distance from the central warehouse and sales at a given location. Thirdly, along with the revolving fund-financed drug supply system, a community-based legal framework has been established. Built-in management alert mechanisms helped the project resist common causes of collapse such as uneconomic behaviour and political interference. The drug supply system has gained full independence from subsidies and external authorities. Its strong community participation promotes good governance.

The influence of health sector reform and external assistance in Burkina Faso.

Despite health reform and increasing public investment in the health sector, utilization of curative health services, immunization coverage and patient satisfaction with the public health care system are steadily decreasing in Burkina Faso. It seems that the health care system itself is "ill". This paper examines the major symptoms associated with this illness. The central thesis suggests that any further improvement of health care performance in Burkina Faso will be subject to profound central reform in the area of human resources and financial management of the sector. Such a broad reform package cannot be achieved through the current project approach, but a sector-wide approach (SWAp) does not seem to be realistic at the present time. Policy discussions at a level higher than the Ministry of Health could be beneficial for achieving better donor coordination and increasing the commitment of the Ministry of Health to a sector-wide approach. Health sector reform issues and priorities and the role of international cooperation are reviewed and discussed.

The policy basis for community health financing in Cameroon: establishment of the North West Provincial Special Fund for Health.

National health systems in Africa and around the world have and are still undergoing reforms in response to the Alma Ata Declaration. In Africa, people centred, community based and locally managed strategies are widely accepted. And in many countries like Cameroon, revolving funds for essential drugs have been adopted as an entry point to the implementation of primary health care elements in community health centres. The current reforms are leading to a sharing of financing responsibilities between people and government, with catalytic support from external agencies. Economic, social and political crises in Africa in the past decade have earned the countries stiff structural adjustment policies with severe consequences on health budgets, health manpower, and health status. This paper describes the policy basis for community financing in Cameroon. It suggests that revolving essential drugs funds (as proposed in the Bamako Initiative) cannot be viewed in isolation, but as part of the community and national response to the crises situation; it also demonstrated the capacity of the health sector to fight back to overcome the ill effects of structural adjustment. And last but not the least, these funds have provided an opportunity for the exercise of democracy and the participatory management by these officials of public goods and services.