[Between scientific management and research-action: the problem of overconsumption of drugs in Kasongo (Zaire)]

A Primary Health Care (PHC) system may be effective and efficient to the extent that essential drugs are available in health services and financially accessible to the population. In developing countries, besides the difficulties related to supplying health services with adequate amounts of drugs, the control of drug consumption is one of the frequent problems encountered by health authorities. Literature is relatively abundant in the field of rationalization of the diagnosis and drug prescription processes, and also in the field of drug financing mechanisms; publications are however rather scarce when topics related to corruption or drug misappropriation are concerned. The case study submitted hereafter reports a drug overconsumption problem in the health centres (HC) of the Kasongo district (Zaire). Despite the existence of direct control mechanisms as well as indirect ones (monitoring of drug consumption by HC), the problem has been identified belatedly. The district staff then used a step-by-step analysis of the HC drug consumption profiles; this analysis allowed to demonstrate that misappropriation would be the most plausible hypothesis. In order to solve the misappropriation problem-the consequences of which jeopardized the functioning of the very health system-the district staff chose to involve the nurses, in charge of the HC, in the entire problem-solving process. This participative approach, involving different actors as partners, allowed to deepen the situation analysis and to elaborate solutions congruent with PHC principles and acceptable to all concerned.

A prepayment scheme for hospital care in the Masisi district in Zaire: a critical evaluation

In most developing countries, government funding allocated to the health services is not sufficient to allow these services to provide appropriate health care accessible to all. Consequently, community financing has received much more attention in recent years and innovative schemes are being explored throughout the developing world. Risk-sharing schemes, like prepayment, are interesting because of their potential redistributive effects. At the end of the eighties, a prepayment scheme for hospital care was experimented with in the Masisi health district in Eastern Zaire. In the present paper, the experiment is described in a chronological way and the results are analyzed and discussed in detail. Although this particular case-study was not successful, it yields important lessons concerning the design, implementation and evaluation of prepayment schemes for hospital health care in developing countries. More specifically, phenomena like adverse selection and moral hazard are discussed. Finally, conditions for success of similar experiments are discussed. These conditions relate mainly to the organization pattern of the district health services system. The Masisi experiment is a nice illustration of the fact that prepayment is not a 'magic bullet': the lessons drawn from it may be of relevancy to health planners intending to implement hospital prepayment schemes in similar settings.

Principles of health infrastructure planning in less developed countries

This article proposes a number of key principles for health infrastructure planning, based on a literature review on the one hand, and on a process of internal deduction on the other. The principles discussed are the following: an integrated health system; a thrifty planning of tiers within that health system; a specificity of tiers; a homogeneity of the tiers' structures; a minimum package of activities; a territorial responsibility and/or an explicit and discrete responsibility for a well-defined population; a necessary and sufficient population basis; a partial separation of administrative and public health planning bases; and, finally, rules for a geographical division and integration of non-governmental organizations. The definition of two strategies, primary health care and district health systems, is also revisited.

The strategy of risk approach in antenatal care: evaluation of the referral compliance

The main goal of antenatal care in developing countries is to identify women whose pregnancy or delivery is likely to raise problems and to refer them at the appropriate time to a hospital facility where the necessary medical equipment and expertise (vacuum extractors, cesarian sections, human skill, etc.) is available. This approach, which is known as the Risk Approach (RA) strategy, is expected to significantly reduce maternal morbidity and mortality. However, the RA will function properly only if the women identified at risk agree to give birth in a hospital on the one hand, and if they can indeed reach this hospital on the other hand. In this article the authors assess to what extent women with a risk of difficult labor (nulliparous or primiparous women under 150 cm, history of previous difficult delivery or stillbirth, women with transverse lie) agreed to give birth in a hospital. This descriptive survey, which covered 5060 pregnancies monitored in the Kasongo District, Maniema, in eastern Zaire, showed that the referral success rate in this socioeconomically very disadvantaged region was only 33%, despite some favorable conditions, such as a strong emphasis on community participation, a complementarity of health centers and hospital, and the absence of financial barriers within the health services system. Of the various hypotheses tested, the geographic accessibility of the hospital and the parturient's perception of the risk status were the two most important factors determining the compliance rate. A stratified analysis shows that the intensity of the parturient's perception has a different impact on compliance whether rural or urban situations are considered.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening for Trypanosoma brucei gambiense antibodies with the Indirect Fluorescent Antibody Test (IFAT). Effect of age and previous treatment

This paper reports on some of the findings of a longitudinal multi-round investigation into the predictive power of early signs and symptoms of human African trypanosomiasis caused by T.b. gambiense, in the Rural Health Zone of Kasongo (Maniema, Zaire). It assesses the importance of the effect of age and a history of previously treated sleeping sickness on serological positivity as measured by the Indirect Fluorescent Antibody Test (IFAT), used as a screening test. The impact of including age and a history of previous sleeping sickness as part of the screening process is discussed in terms of sensitivity and positive predictive value. Including weak serological positivity among the screening criteria does not appear to improve the sensitivity of the IFAT test in this setting.