El Contexto actual y los desafíos de formar en la sociedad del Conocimiento

Calls for emergenc

y evacuation 1996 7 1997 8 1998 8 1999 9 2000 12 2001 12 2002a ₂₀₀₃ 14 Year

Bypassing health centres Originating from health centres

Hospital upgraded Radio- ambulance 0 50 100 150 200 250 300 350 400 450

Number of health centres

structures, they have shown credible and visible results, sometimes in very adverse circumstances, as in Guinea and the Democratic Republic of the Congo.

On balance, the experience of the last decade suggests that health districts still stand as a rational way for governments to roll out primary health care through networks of health centres, family practices or equivalent decentralized structures, backed up by referral hospitals. There are no real alternatives to serve as a vehicle for a continuum of integrated care for mothers, newborns and children. The challenge now is to scale up implementation in an adverse environment where exclusion is further fuelled by the rampant commercialization of the health sector, including within public and not- for-profit facilities. The second challenge is to tailor health care delivery strategies to the specific situation and exclusion patterns of each country. At the same time, it is no longer possible to experiment with district projects without looking at the wider context of cross-cutting, system-wide constraints. Without a real commitment to strengthening district health services, talking about the priority status of mothers and children is likely to remain mere lip service.

Part of the task ahead is political. Maternal, newborn and child health cannot be reduced to a set of programmes to be delivered to a target population. Rather, moth- ers and children must be in a position to claim a set of entitlements as their right. This implies an adjustment of macro-level health policies and resource mobilization, at country level and internationally. Three issues cry out for attention: the funding of the health sector, the human resource crisis, and the accountability of health systems and providers to their clients.

But the task ahead is also one of refocusing programme content. For too long at- tention has been directed towards the development of technologies, rather than to- wards embedding these in viable organizational strategies that organize and ensure a continuum of care. Given the complexity of expanding district health care systems, the temptation is to go back to vertical programmes built around disease control technologies. In the past this has led to a considerable amount of fragmentation, at the expense of ensuring the continuity of care from pregnancy throughout childhood. Much of the challenge, in fact, is to accommodate both programmatic and systemic concerns: an organizational rather than a technical problem. The next chapters relo- cate the technical strategies available for improving the health of mothers, newborns and children within health systems that are scaling up and facing an increasingly vocal demand for care.

In the mid 1990s Ouallam, one of the poorest districts in Niger with 250 000 inhabitants living at an average distance of 74 km from the hospital, had seven dysfunctional health centres and an almost empty district hospital. Emergencies could not be referred to the hospital in an area with no means of communication. Several measures were, however, put in place to change the situation. Some were general measures to solve problems in the district and others were specifically aimed at improving the referral system. Making the changes took eight years (see table below).

References

1. World development indicators 2004. Washington, DC, World Bank, 2004.

2. Human development report 2003 – Millennium Development Goals: a compact among nations to end human poverty. New York, NY, Oxford University Press for the United Nations Development Programme, 2004.

3. Chen S, Ravaillon M. How have the world’s poorest fared since the early 1980s? Washington, DC, World Bank, 2004.

4. Griffin K, Brenner MD, Kusago T, Ickowitz A, McKinley T. A strategy for poverty reduction in Mongolia. Report of a UNDP mission on the integration of equity and poverty reduction concerns into development strategy. Ulaanbaatar, United Nations Development Programme, 2001.

5. Human development report Mongolia 2000. Ulaanbaatar, Government of Mongolia/United Nations Development Programme, 2000.

6. Government of Mongolia/WHO. Mongolia health sector review. Ulaanbaatar, World Health Organization, 1999.

7. Janes CR, Chuluundorj O. Free markets and dead mothers: the social ecology of maternal mortality in post-socialist Mongolia. Medical Anthropology Quarterly, 2004, 18:230–257. 8. UNAIDS/WHO. AIDS epidemic update, December 2004. Geneva, Joint United Nations

Programme on HIV/AIDS, 2004.

9. De Cock KM, Fowler MG, Mercier E, de Vincenzi I, Saba J, Hoff E et al. Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice. JAMA, 2000, 283:1175–1182.

10. Zaba B, Whiteside A, Boerma JT. Demographic and socioeconomic impact of AIDS: taking stock of the empirical evidence. AIDS, 2004, 18(Suppl. 2):S1–S7.

11. The world health report 2004 – Changing history. Geneva, World Health Organization, 2004.

12. McIntyre J. Mothers infected with HIV. British Medical Bulletin, 2003, 67:127–135. 13. Sewankambo NK, Gray RH, Ahmad S, Serwadda D, Wabwire-Mangen F, Nalugoda F et al.

Mortality associated with HIV infection in rural Rakai District, Uganda. AIDS, 2000, 14:2391-2400.

14. Ahmed Y, Mwaba P, Chintu C, Grange JM, Ustianowski A, Zumla A. A study of maternal mortality at the University Teaching Hospital, Lusaka, Zambia: the emergence of tuberculosis as a major non-obstetric cause of maternal death. International Journal of Tuberculosis and Lung Disease, 1999, 3:675–680.

15. Monasch R, Boerma JT. Orphanhood and childcare patterns in sub-Saharan Africa: an analysis of national surveys from 40 countries. AIDS, 2004, 18(Suppl. 2):S55–S65. 16. Newell ML, Brahmbhatt H, Ghys PD. Child mortality and HIV infection in Africa: a review.

AIDS, 2004, 18(Suppl. 2):S27–S34.

17. Report on the global AIDS epidemic 2004. Geneva, Joint United Nations Programme on HIV/AIDS, 2004.

18. Walker N, Schwartlander B, Bryce J. Meeting international goals in child survival and HIV/AIDS. Lancet, 2002, 360:284–289.

19. Tawfik L, Kinoti S. Impact of HIV/AIDS on the health sector in sub-Saharan Africa: the issue of human resources. Washington, DC, United States Agency for International Development, 2001.

20. Evidence base for the impact of HIV upon health systems. London, John Snow International UK and Health Systems Research Centre, 2003.

21. Dambisya YM. The fate and career destinations of doctors who qualified at Uganda’s Makerere Medical School in 1984: retrospective cohort study. BMJ, 2004, 329:600–601. 22. Al Gasseer N, Dresden E, Keeney GB, Warren N. Status of women and infants in complex humanitarian emergencies. Journal of Midwifery and Women’s Health, 2004, 49(Suppl. 1):7–13. 23. Porignon D, Soron’gane EM, Lokombe TE, Isu DK, Hennart P, Van Lerberghe W. How robust

are district health systems? Coping with crisis and disasters in Rutshuru, Democratic Republic of Congo. Tropical Medicine and International Health, 1998, 3:559–565. 24. Pronk, J. Collateral damage or calculated default. The Millennium Development Goals and

the politics of globalisation. The Hague, Institute of Social Studies, 2003.

25. Jones G, Steketee RW, Black R, Bhutta, ZA, Morris S and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet, 2003, 362: 65–71.

26. Bryce J, el Arifeen S, Pariyo G, Lanata C, Gwatkin D, Habicht JP. Reducing child mortality: can public health deliver? Lancet, 2003, 362:159–164.

27. L’approche des besoins obstétricaux non couverts pour les interventions obstétricales majeures. Etude comparative Bénin, Burkina Faso, Haiti, Mali, Maroc, Niger, Pakistan et Tanzanie. [Tackling unmet needs for major obstetric interventions. Case studies in Benin, Burkina Faso, Haiti, Mali, Morocco, Niger, Pakistan and Tanzania]. Antwerp, Unmet Obstetric Needs Network, 2002:1–47 (www.uonn.org).

28. Matthews Z, Ramasubban R, Rishyasringa B, Stones WR. Autonomy and maternal health- seeking among slum populations of Mumbai. Southampton, Southampton Statistical Sciences Research Institute, 2004.

29. Reproductive health strategy to accelerate progress towards the attainment of international development goals and targets. Geneva, World Health Organization, 2004.

30. Bhan G, Bhandari N, Taneja S, Mazumder S, Bahl R, and other members of the Zinc Study Group. The effect of maternal education on gender bias in care-seeking for common childhood illnesses. Social Science and Medicine, 2005, 60:715–724,

31. Claeson M, Bos ER, Mawji T, Pathmanathan I. Reducing child mortality in India in the new millennium. Bulletin of the World Health Organization, 2000, 78:1192–1199.

32. Exclusion in health in Latin America and the Caribbean. Washington, DC, Pan American Health Organization, 2004.

33. Hulton L, Matthews Z, Stones RW. A framework for the evaluation of quality of care in maternal services. Southampton, University of Southampton, 2000.

34. Jaffré Y, Olivier de Sardan JP. Une médecine inhospitalière: les difficiles relations entre soignants et soignés dans cinq capitales d’Afrique de l’Ouest [Inhospitable medicine: difficult relations between carers and cared for in five West African capital cities]. Paris, Karlhala, 2003.

35. Ferguson BD, Tandon A, Gakidou E, Murray CJL. Estimating permanent income using indicator variables. Geneva, World Health Organization, 2003 (Global Programme on Evidence for Health Policy Discussion Paper No. 42).

36. Demographic and Health Surveys. Country statistics (http://www.measuredhs.com/ countries/start.cfm, accessed 16 December 2004).

37. Gwatkin D, Rutstein S, Johnson K, Pande R, Wagstaff A. Socio-economic differences in health, nutrition and population. Washington, DC, World Bank, 2000 (Health, Nutrition and Population Discussion Papers).

38. Gwatkin D. Who would gain most from efforts to reach the MDGs for health? An enquiry into the possibility of progress that fails to reach the poor. Washington, DC, World Bank, 2002. 39. Graham W, Fitzmaurice AE, Bell JS, Cairns JA. The familial technique for linking maternal

death with poverty. Lancet, 2004, 363:23–27.

40. Pangu KA. La santé pour tous d’ici l’an 2000: c’est possible; expérience de planification et d’implantation des centres de santé dans la zone de Kasongo au Zaïre [Health for all by the year 2000: it can be achieved; experience of planning and setting up health centres in the area of Kasongo in Zaire]. Brussels, Université Libre de Bruxelles, Faculté de Médecine, Ecole de Santé Publique, 1988.

41. Equipe du Projet Kasongo, Darras C, Van Lerberghe W, Mercenier P. Le Projet Kasongo: une expérience d’organisation d’un système de soins de santé primaires [The Kasongo Project: experience of organizing a system of primary health care]. Annales de la Société Belge de Médecine Tropicale, 1981, 61(Suppl.):1–54.

42. Knippenberg R, Soucat A, Oyegbite K, Sene M, Bround D, Pangu K et al. Sustainability of primary health care including expanded program of immunizations in Bamako Initiative programs in West Africa: an assessment of 5 years’ field experience in Benin and Guinea. International Journal of Health Planning and Management, 1997, 12(Suppl. 1):S9–S28. 43. Jancloes M, Seck B, Van de Velden L, Ndiaye B. Financing urban primary health services.

Balancing community and government financial responsibilities, Pikine, Senegal, 1975–81. Tropical Doctor, 1985, 15:98–104.

44. Pangu KA, Van Lerberghe W. Self-financing and self-management of basic health services. World Health Forum, 1990, 11:451–454.

45. Van Lerberghe W, Pangu K. Comprehensive can be effective: the influence of coverage with a health centre network on the hospitalisation patterns in the rural area of Kasongo, Zaire. Social Science and Medicine, 1988, 26:949–955.

46. Van den Broek N, Van Lerberghe W, Pangu K. Caesarean sections for maternal indications in Kasongo (Zaire). International Journal of Gynecology and Obstetrics, 1989, 28:337–342. 47. Van Lerberghe W, Pangu KA, Van den Broek N. Obstetrical interventions and health centre

coverage: a spatial analysis of routine data for evaluation. Health Policy and Planning, 1988, 3:308–314.

48. Better health in Africa. Washington, DC, World Bank, 1994.

49. Organisation for Economic Co-operation and Development. International Development Statistics on line (http://www.oecd.org/dataoecd/50/17/5037721.htm, accessed 15 December 2004).

50. The health sector human resources crisis in Africa: an issue paper. Washington, DC, United States Agency for International Development, Bureau for Africa, Office of Sustainable Development, SARA Project, 2003.

51. Bodart C, Servais G, Mohamed YL, Schmidt-Ehry B. The influence of health sector reform and external assistance in Burkina Faso. Health Policy and Planning, 2001, 16:74–86. 52. Dovlo D. The brain drain and retention of health professionals in Africa. A case study.

Paper presented at: Regional Training Conference on Improving Tertiary Education in Sub-Saharan Africa: the things that work! Accra, 23–25 September 2003.

53. Tawfik L, Kinoti SN. The impact of HIV/AIDS on the health sector in sub-Saharan Africa: the issue of human resources. Washington, DC, United States Agency for International Development, Bureau for Africa, Office of Sustainable Development, SARA Project, 2001. 54. Lambert D. Study of unofficial health service charges in Angola in two health centers

supported by MSF. MSF Medical News, 1996, 5:24–26.

55. Meesen B. Corruption dans les services de santé: le cas de Cazenga [Corruption within the health services: the case of Cazenga]. Brussels, Médecins Sans Frontières, 1997 (Repères: 1–20).

56. Parker D, Newbrander W. Tackling wastage and inefficiency in the health sector. World Health Forum, 1994, 15:107–113.

57. Asiimwe D, McPake B, Mwesigye F, Ofoumbi M, Ortenblad L, Streefland P, Turinde A. The private-sector activities of public-sector health workers in Uganda. In: Bennett S, McPake B, Mills A, eds. Private health providers in developing countries: serving the public interest? London, Zed Press, 1997.

58. Roenen C, Ferrinho P, Van Dormael M, Conceicao MC, Van Lerberghe W. How African doctors make ends meet: an exploration. Tropical Medicine and International Health, 1997, 2:127–135.

59. Macq J, Van Lerberghe W. Managing health services in developing countries: moonlighting to serve the public? In: Ferrinho P, Van Lerberghe W. Providing health care under adverse conditions: health personnel performance & individual coping strategies. Antwerp, ITG Press, 2000 (Studies in Health Services Organisation and Policy, 16:177-186). 60. Lowell G, Findlay A. Migration of highly skilled persons from developing countries: impact

and policy responses. Geneva, International Labour Office, 2001.

61. Awases M, Nyoni J, Gbary A, Chatora R. Migration of health professionals in six countries: a synthesis report. Brazzaville, World Health Organization Regional Office for Africa, 2003. 62. The international mobility of health professionals: an evaluation and analysis based on the

case of South Africa. Paris, Organisation for Economic Co-operation and Development, 2004 (Trends in International Migration Part III SOPEMI 2003).

63. World Health Organization/Ministry of Health and Social Welfare of the Government of Swaziland. A situation analysis of the health workforce in Swaziland. Geneva, World Health Organization, 2004.

64. Maiga Z, Nafo TF, El Abassi A. La réforme du secteur santé au Mali, 1989–1996 [Reform of the health sector in Mali, 1989–1996]. Antwerp, ITG Press, 1999 (Studies in Health Services Organisation & Policy, 12).

65. Bossyns P, Abache R, Abdoulaye MS, Van Lerberghe W. Unaffordable or cost-effective? Introducing an emergency referral system in rural Niger (submitted).

66. Bodart C, Servais G, Mohamed YL, Schmidt-Ehry B. The influence of health sector reform and external assistance in Burkina Faso. Health Policy and Planning, 2001, 16:74–86.