Vertical vs horizontal health programmes in Africa: idealism, pragmatism, resources and efficiency

Argument still rages over whether vertical health programmes--attacking one or a few health problems--should still be set up in developing countries, or whether all their efforts should be devoted to establishing a horizontal multiproblem approach such as primary health care. This paper argues that the debate can be made rather more informed firstly by a consideration of the technologies available to improve health and the methods of delivery to which they are most suited; secondly by a consideration of their effectiveness and the organisational feasibility of different strategies of delivery, and finally, by investigation of the total costs and cost-effectiveness of different delivery systems. Particular attention is given to the contribution of economic analysis to elucidating these issues, and a variety of cost-effectiveness studies are reviewed to see what information is available on the way in which particular health programmes such as malaria control and immunisation activities can be organised in order to maximise their cost-effectiveness.

Preservation of fetal brain blood flow relative to other organs during hypovolemic hypotension

The asphyxiated newborn is particularly vulnerable to hypotension, which contributes to hypoxic brain damage by reducing cerebral perfusion. During asphyxia, cerebral blood flow (CBF)( is pressure passive, that is, CBF autoregulation is abolished. It is important to know if the nonasphyxiated fetus and newborn are similarly vulnerable to hypotension. In the present study, we have measured acute responses of organ blood flow to a hypovolemic/hypotensive stress in the normoxic near term sheep fetus. Changes in brain flow were compared to changes in other organs. Eight chronically prepared fetal lambs were studied. Organ blood flows were measured by the microsphere technique during a control period, after a 20% blood volume reduction, and again after reinfusion of that volume. Hypovolemia was accompanied by a 21% decrease in blood pressure and a 4 torr increase in PCO2; after reinfusion blood pressure increased 16% above control. Control measurements of organ perfusion were similar to those reported by other investigators. Cardiac output and flow to all organs, with the exception of the brain, were reduced 30-56% during hypovolemia. Brain blood flow was insignificantly reduced by 9%. If a correction is applied for the increase in PCO2, CBF corrected to control PCO2 would have have been significantly reduced by 18%. After reinfusion, flow to all organs increased to near control levels. We conclude that the normoxic fetal lamb shows evidence of CBF autoregulation, and is able to preserve relative constancy of CBF within a blood pressure range of +/- 20% of normal. However, the evidence presented in this study suggests that autoregulation may be less effective in response to a hypotensive stress, even though CBF is better preserved than flow to most other organs.

The contribution of economics to health service planning

The increased emphasis on the need consciously to plan the future development of the NHS has, in recent years, focused attention on the availability of skills and techniques which might help planners in their attempts to elucidate objectives and the best way of achieving them. This paper sets out the contribution economics can make to health service planning and reviews some of the recent developments in this field.

Measuring the outcome of contact tracing. 1. A description of the patient and contact populations studied

A standard system for health workers to record and handle information on patients and contacts was introduced to five clinics. Information on all the patients interviewed during the first quarter of 1975 was collected and analysed. An analysis of the characteristics of these patients showed variation between the clinics. However, regardless of what was being measured, there were always differences between men and women. It was found that not all infected patients were interviewed about their contacts. Unless or until contact tracing includes all infected patients, the effect of contact tracing on the control of the sexually transmitted diseases will be of limited value and difficult to assess.

Measuring the outcome of contact tracing. 2. The responsibilities of the health worker and the outcome of contact investigations

The previous paper (Satin and Mills, 1978) concerned information on patients who were interviewed by health workers in five selected clinics; information on the contacts named by these patients was similarly analysed. This paper describes and evaluates the activities of the health workers and the outcome of contact investigations. At all stages of the contact tracing process, differences were observed between men and women. It was found that more than half of the male contacts and half the female contacts were known to have been examined. Of those contacts examined, at least two-thirds of them attended the same clinic as the patient who had named them, and 85% of these contacts were found to have a treatable condition. It will be seen that the concept of success or effectiveness of contact tracing is complex in definition and measurement.