W. Van Lerberghe

How African doctors make ends meet: an exploration

This paper is an attempt to identify individual coping strategies of doctors in sub‐Saharan Africa. It also provides some indication of the ‘effectiveness’ of these strategies in terms of income generation, and analyses their potential impact on the functioning of the health care system. It is based on semi‐structured interviews of 21 doctors working in the public health sector in sub‐Saharan Africa and attending in 1995 an international Masters course in Public Health in Belgium or in Portugal.

Monitoring unmet obstetric need at district level in Morocco

Unmet obstetric need was assessed in Taounate province (Morocco) during the year 1995 by monitoring rates of major obstetric intervention for absolute maternal indications. We report results in terms of spatial distribution of the failures of the health care system to provide women with essential emergency obstetric care. An estimated 135 women with life‐threatening conditions did not benefit from the obstetric interventions they required. The paper documents the effects of the monitoring process on the way the provincial team changed their way of dealing with deliveries. Assessment of unmet obstetric need in Taounate province proved feasible and affordable without external budgetary inputs. It provided the team with information on the magnitude of a previously ignored problem. The results were so dramatic as to lead the team to look for causes and solutions. These were clearly not merely technical but systemic in nature.

Hospitals in sub-Saharan Africa : why we need more of what does not work as it should

This paper analyses the origins of todays crisis in the hospital sector in sub‐Saharan Africa. Present trends in availability of hospital services are extrapolated to the future in order to provide a low‐end estimate of the need for expansion of first referral level hospitals. This will not be possible without giving due priority to this sector, a commitment to considerable investments and reorientation of resources from tertiary to first referral level hospitals. It is to be feared that if this is not done, the backlog will increase, and, given the time lag before investments translate into operational services, there will be a major shortage of hospital services in sub‐Saharan Africa within a decade.

Voluntary health insurance in Bwamanda, Democratic Republic of Congo. An exploration of its meanings to the community

An insurance scheme covering hospital care in the rural district of Bwamanda in the North‐west of the Democratic Republic of Congo, which locally is called the mutuelle, was conceived and developed in 1986 on the initiative of Belgian doctors working in the district under the arrangements for bilateral Belgian aid. After more than 10 years of operation the Bwamanda scheme has achieved a high rate of coverage, contributed to a significant improvement in access to hospital‐based in‐patient care, and constitutes a stable source of revenue for the operation of the hospital. We present an investigation conducted through focus groups in 1996 of the populations social perceptions of this risk‐sharing scheme to identify ways to improve it. The findings pertain to the reasons for people to subscribe to the scheme; to the perception of its redistribution effects; to peoples frustrations and questions; and finally to the relationships between the insurance scheme and traditional mutual aid arrangements. The difference between a hospital insurance scheme (a logic of contract) and the traditional systems of mutual aid (a logic of alliance) is highlighted, and the impact of the hospital insurance scheme on social inequalities is discussed. The implications of this study on the management of the Bwamanda health insurance scheme are reviewed, and this study may be useful to health managers working in similar contexts.

How robust are district health systems? Coping with crisis and disasters in Rutshuru, Democratic Republic of Congo

background Since the eighties, the North Kivu Province socio‐economic environment has been deteriorating. This province also faced an influx of Rwandan refugees in July 1994. The objective of the paper is to show how a rural health district has been able to adjust and maintain its medical activities under unfavourable conditions.

Assessment of appropriate child care at district level: how useful are mortality rates?

: Where financial resources are sharply limited, routine process and health care output data could be used to assess district level child health care system appropriateness better than mortality data. The rural district health system serving Kasongo, Zaire was studied in reaching these conclusions. Appropriate systems were defined as affordable, acceptable, flexible, and effective. Each of these four characteristics should be met where a primary health care package of techniques and activities truly meets the needs of a given sociocultural setting. The authors do not accept mortality rates as the most suitable tools needed to determine if a system meets these criteria for appropriateness. Particular attention is called to the complexity of measuring system effectiveness. A decline in mortality rate may be an implicit system objective, but not the only goal of the program recognized by its users and workers. There is also a clear need for immediate care and relief from suffering in the community. Use of mortality rates as principle indicator of system effectiveness would not fully reflect positive steps in meeting the broader objectives of the system. Moreover, mortality rates lack sensitivity and specificity, lack relevance to indicators needed by decision-makers at the district level, and are otherwise costly and complex to accurately obtain. Instead of mortality rate determination and analysis, the authors call for a comparison of hospital admission rates between regions which do and do not have properly functioning rural health units accordingly. If health unit operations are conducted as effectively and efficiently as designed, hospital admission rates for illnesses readily treated at the rural level should decline over time. this information is readily and cheaply examined, and allows local decision makers to respond quickly and accurately to local needs.