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.

Defining essential information needs and indicators.

The management capabilities and performance of a health system can be improved by strengthening the information system it uses. This involves determining the strengths and weaknesses of the health system itself and focusing on its least functional areas. The first step is to analyse services so as to ascertain requirements for information and indicators, with particular reference to the management of clients, health units and the health system as a whole.

Recovery of recurrent health service costs through provincial health funds in Cameroon.

This article describes the Provincial Health Funds pioneered in two Provinces of Cameroon. These funds are non-profit associations and financed by the community through drug fees and--to a lesser extent--through fees for services. The financial objective of the Funds is the full coverage of both the costs of the drug supply and the recurrent non-salary costs of the entire public health services in the province. In addition the funds are channels for community participation in the management and improvement of health services. Following a discussion of the institutional and legal framework, the paper examines the cost recovery targets and the mark-up necessary to achieve them. Comparison is made with mark-up and prices of private for-profit pharmacies. In its third year of operation, the Fund currently covers 62% of recurrent health service costs, up from 22% in the first year. With increasing number of health centers joining the fund full coverage of recurrent costs is projected to occur at the earliest in year four of operations. The authors argue that the appropriate role of donor assistance is not only to finance investment but also to subsidize recurrent costs, until the fund has reached its optimal anticipated size, thus realizing economies of scale. While the final word on sustainability can only be said years after the funds have reached their final size, the consistent trend towards full cost recovery is encouraging.

Lamellar body secretion: ultrastructural analysis of an unexplored function of synoviocytes.

The intra- and extracellular distribution and relative density of lamellar bodies (LBs) were determined by electron microscopy in synovial biopsies from 20 non-rheumatoid arthritis (RA) patients. LBs were found on the synovial surface, in intimal cells, throughout intimal matrix, in blood vessel walls, in endothelial cytoplasm and within vascular lumena. Lamellar profiles were observed in type B synoviocytes within rough endoplasmic reticulum (RER), in association with the Golgi apparatus, and embedded in electron dense matrix (projection cores) in multivesicular bodies. Exocytotic release of mature LBs into intimal matrix was observed. In type A synoviocytes the outer lamellae of LBs were frequently found in contiguity with the limiting membrane of lysosomes. An in vitro investigation of the ultrastructural features of LB formation in cultured type B synoviocytes (from 3 non-RA patients) gave results similar to those obtained in biopsies. These studies provide ultrastructural evidence of synoviocyte activity in secreting and degrading phospholipid lubricant in a sophisticated system whose function and pathological derangements are largely unknown.

Lamellar bodies in synoviocytes, mesothelium and specific epithelia as possible site of auto-antigen in rheumatoid disease.

Intracytoplasmic lamellar organelles identical in ultrastructure to surfactant-containing lamellar bodies found in type II pneumocytes, have been demonstrated in other tissues, in synoviocytes and mesothelial cells, in a distribution pattern which reflects the systemic expression of rheumatoid disease. Antibodies raised against surfactant protein A (SP-A), exhibit a ranking of tissue reactivity in area, intensity and density of cells which also parallels the frequency and degree of pathological involvement characteristic of rheumatoid disease, showing in ascending order of immunopositivity, lacrymal and salivary epithelia, pulmonary parenchyma, mesothelium and synoviocytes. Maximal tissue reactivity to anti-SP-A antibodies was found in the synovium of 55 rheumatoid patients exhibiting classical histopathological appearances of RA, in a pattern of immunostaining identical to that obtained with ML30, an antibody to mycobacterial heat shock protein 65kDa which, in turn, cross-reacted with SP-A in dot blot testing.

User fees plus quality equals improved access to health care: results of a field experiment in Cameroon.

Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people. A "pretest-posttest controlled" experiment was conducted in five public health facilities in the Adamaoua province of Cameroon. Three health centers which were to introduce a user fee and quality improvement (i.e. reliable drug supply) policy were selected as "treatment" centers and two comparable facilities not yet phased into this policy were selected as "controls". Two rounds of household surveys were conducted (each to 800 households in 25 villages surrounding the five study sites) to measure the percentage of ill people seeking care at the health center before and after the implementation of the policy. The experiment was tightly controlled by conducting monthly observations at each study site. Results indicate that the probability of using the health center increased significantly for people in the "treatment" areas compared to those in the "control" areas. Travel and time costs involved in seeking alternative sources of care are high; when good quality drugs became available at the local health center, the fee charged for care and treatment represented an effective reduction in the price of care and thus utilization rose. Moreover, contrary to previous studies which have found that the poorest quintile is most hurt by user fees, this study found that probability of the poorest quintile seeking care increases at a rate proportionately greater than the rest of the population. Since the poor are most responsive to price changes, they appear to be benefitting from local availability of drugs more than others.

Cloning of a gene expressed in human breast cancer and regulated by estrogen in MCF-7 cells.

Messenger RNAs (mRNAs) were prepared from MCF-7 breast cancer cells grown in the presence of estradiol. Complementary DNAs (cDNAs) were inserted into pBR322 plasmid and a library of 4400 recombinant bacterial clones was prepared. The clones were screened by in situ differential hybridization with cDNAs prepared from RNAs of MCF-7 cells grown either in the presence or absence of estradiol. Several estrogen-induced or estrogen-repressed clones were identified. One of them corresponded to a relatively frequent mRNA (0.8% of recombinant plasmids) of 650 nucleotides. The concentration of this mRNA was increased by estradiol (half maximal induction approximately 0.05 nM) but not by progesterone, dexamethasone, or dihydrotestosterone. Tamoxifen inhibited the effect of estradiol but was devoid of any agonistic activity when administered separately. This messenger was present in biopsies of breast cancer, but not in endometrium or liver. The cloned cDNA was sequenced. An open reading frame was found corresponding to a protein of less than 100 amino acids. A search of data banks showed no identity or marked similarity to previously published DNA or protein sequences, particularly to those of growth factors evoked by some characteristics of the coded polypeptide. The cloned cDNA probe was used to screen a library of Charon 4A phage containing human genomic fragments. Screening of 300,000 phages yielded two different recombinants hybridizing to the cDNA. Southern blot experiments using DNA from recombinant phage, MCF-7 cells, and placenta showed the presence of a unique gene exhibiting a similar restriction pattern in DNAs from malignant and nonmalignant tissues.

Development and application of homologous radioimmunoassays for porcine gonadotrophins.

Antisera were raised against highly purified preparations of porcine luteinizing hormone (pLH) and follicle-stimulating hormone (pFSH). Highly specific and sensitive radioimmunoassay systems were developed. The antisera to LH and FSH were used at working dilutions of 1:500,000 and 1:200,000 respectively and the sensitivities of the assays were 0.1 ng LH/ml serum (3 x 10(-12) mol/l) and 0.5 ng FSH/ml serum (1.5 x 10(-11) mol/l). The LH and FSH preparations used as standards were 1.2 and 81 times as potent as NIH-LH-S15 and NIH-FSH-P1 respectively. Both assays were validated and adapted for the measurement of the gonadotrophin content of porcine serum. The concentrations of LH and FSH in blood were measured simultaneously in prepubertal sows throughout a 24 h period, in adult sows during the oestrous cycle and in both prepubertal and adult animals after treatment with LH releasing hormone.