The poorest first: WHO's activities to help the people in greatest need.

Through its Division of Intensified Cooperation with Countries and Peoples in Greatest Need, WHO is giving special attention to the relationship between poverty and ill-health. The work of the Division is outlined in the present article.

PIP: Poverty is the main reason why babies are not vaccinated, clean water and sanitation are not provided, curative drugs and other treatments are not available, and mothers die in childbirth. It is the main cause of low life expectancy, handicap, disability, and starvation, and a major factor in mental illness, stress, suicide, family disintegration, and substance abuse. Poverty is spreading, just as the gap between rich and poor is growing in both developed and developing countries. In 1989, the World Health Assembly asked the World Health Organization (WHO) to pay attention to the special needs of the most poor countries, a request which led to the development and launching of the Intensified Cooperation with Countries and Peoples in Greatest Need initiative. The goals of the initiative are to enable poor countries to develop public policies and implement strategies for improving the health status of their populations, to promote innovative intersectoral action, and to make the best possible use of international cooperation in health matters. The main task has been to develop and implement community-based strategies for primary care in approximately 30 countries. In-country actions are described for Angola, Bangladesh, Bolivia, Burkina Faso, China, Guatemala, Guinea-Bissau, Moldova, Myanmar, Vietnam, and Yemen. Lessons learned are presented and future requirements considered.

Towards new partnerships for health development in developing countries: the contractual approach as a policy tool.

What roles for government but also for society's groups in the advancement of public health in developing countries? This paper focuses on the need to adopt the contractual approach as a powerful policy tool and sketches the contours of a policy framework for good contracting. A short historical review of health system changes leads up to a discussion of the current emergence of a multitude of actors, the forging of alliances between the various partners, examples on how significant health policy benefits might be secured through contracting, and the implications of building alliances, such as defining and assigning accountability to the contracting partners.

Attacking poverty and improving health: a report on the WHO/State of Maryland International Health Congress, Baltimore, September 1997.

An international meeting, 'Investment Strategies for Healthy Urban Communities', in Baltimore in September 1997 called on the the business community, city authorities and the health professions to reduce poverty and its adverse health consequences, especially in urban areas, in both the industrialized and developing world. In addition to issuing the Baltimore Charter on partnership for a healthy urban future, the meeting had two main outcomes: the innovative concept of Business for Health, championed by progressive business leaders from Australia, Europe and the United States, to promote business principles to reduce poverty, create enterprises and improve people's health, especially in developing countries; and the establishment by health professionals of an information network between cities and countries on poverty and ill-health. Two follow-up meetings in London in December 1997 resulted in an action plan to create networks of health professional groups and representatives of the business community.

Financing urban primary health services. Balancing community and government financial responsibilities, Pikine, Senegal, 1975-81.

It is difficult to prejudge a community's capacity to satisfy its basic human needs, because no satisfactory method has been developed to predict the potential resources of a poor community. To improve their health conditions, all people, even poor, have some resources available. When they can manage themselves and be involved in decision making, they can become very efficient and contribute many material and human resources needed to organize health facilities in situations where the government fails to provide for wide-ranging needs, especially in the new cities. This was demonstrated by our experiment in Senegal between 1975 and 1981. This paper discusses the respective roles and responsibilities of the communities and the government in terms of: the process of setting up and carrying out the project in Pikine and the stages of community participation; and the pre-conditions for successful co-management in a primary care organization financed in a large part by the community.

Selected economic issues in helminth control.

This paper examines four main economic issues in the formulation of helminth control policies: whether, what, how and with whose resources to control helminthiasis. The paper argues that (i) although helminth control would have a negligible impact on mortality, its nutrition-mediated effects on improved labor productivity and intellectual performance may be significant; (ii) that reduction of helminth disease rather than infection should be the target of control policy, although the preferred intervention may still be eradication rather than continuous control; and (iii) that although the case for public subsidy of helminth control interventions is strong, the existence of serious fiscal constraints and some evidence of private willingness-to-pay for anthelminthic chemotherapy indicates a potential for partial cost recovery which should be explored.

Epidemiology of seasonal falciparum malaria in an urban area of Senegal.

A 15-month longitudinal survey was carried out to examine entomological and parasitological aspects of human malaria transmission in Pikine, a city located in the Sudan savanna zone on the Cap Vert peninsula in the west of Senegal. The anopheline population was sampled twice weekly indoors by night human bait capture. During the same period, thick and thin blood films were collected from 296 children at 2-month intervals. Anopheles arabiensis was the only species responsible for transmission of Plasmodium falciparum. The parasite rate showed a positive correlation with both the entomological inoculation rate and the vectorial capacity. In Pikine, malaria is epidemic and probably unstable, and the population enjoys a variable degree of immunity.

[Priority health care finances and joint control by the population and the state (Pikine - Senegal) 1975-1981]. / Soins de santé prioritaires financés et contrôlés conjointement par les populations et par l'état (Pikine - Sénégal) 1975-1981.

Where the government cannot meet wide-ranging health needs of the population and when people are given the opportunity to manage their own affairs and to be involved in decision-making, they can become very efficient. This was demonstrated by an experiment in a senegalese town (450 000 inh.) between 1975 and 1981. A strategy for priority health care with the active participation of the local community was developed to provide a network of acceptable and accessible health services. This was with government support. --The government provides the basic structure of its health services to which the community contributes. It provides the medical staff, technical guidance and logistic support and helps the community volunteers to develop sound accounting procedures. --The community contributes financial and human resources to improve the coverage of the health units. Based on a self-financing system controlled by a health committee per each health unit, communities are in decision making concerning the utilization and management of the community's resources. Procedures to control the community's financial contribution are especially well detailed in the paper. In view of this successful experiment, the minister of public health with the agreement of the government, has recommended that community participation in financing health care services be extended to all regions of the country.

[Epidemiological control of intestinal nematodoses in a rural area of Zaïre (author's transl)]. / Contrôle épidémiologique des nématodoses intestinales dans une zone rurale au Zaïre.

In order to establish the rational organization of a mass campaign intended to control intestinal parasites in villages of a rural zone in Lower Zaïre, a prevalence study was made of a total population of 3,056 inhabitants. Coprologic examination allowed to determine the following mean levels of prevalence: Ascaris, Lumbricoides 57 per cent, ankylostoma 51 per cent, Stronglyoides stercoralis 14 per cent and Trichuris trichiura 11 per cent. In a prospective survey of nine months allowed to determine the optimal therapeutic coverage to be realized in the municipalities concerned using the epidemiological date as a reference.

Mass control of ascariasis with single oral doses of levamisole. A controlled comparison in 3,056 subjects between three incomplete population coverages.

Ninety-, 60-, and 40-percent population coverages with levamisole 2.5 mg/kg of body weight were compared for their effects on Ascaris lumbricoides, ancylostoma, Strongyloides stercoralis, and Trichuris trichiura infections. They were shown to be effective in maintaining a reduced prevalence of A. lumbricoides in the treated subjects for 9, 6, and 3 months, respectively. Nine months after treatment, the prevalence of ascariasis was still lower than before treatment both in the levamisole and in the control subjects, regardless of the population coverage. This was probably because the egg output had been reduced. It is concluded that mass treatment with single oral doses of levamisole repeated at 3-month intervals might help control ascariasis, and that population coverages between 60 and 90% might be appropriate. No clear-cut effects against hookworms could be shown, possibly because the first follow-up examinations were performed three months after treatment. No changes in the prevalence of S. stercoralis and T. trichiura could be demonstrated. There were no adverse exp