The World Bank.

The control of human onchocerciasis (river blindness) is one of the most successful global partnerships ever supported by the World Bank. Mectizan mass treatments have greatly contributed to this success and have shaped the strategies of the programmes in which the World Bank has been involved - the Onchocerciasis Control Programme (OCP), which covered onchocerciasis control in West Africa until 2002, and the African Programme for Onchocerciasis Control (APOC), which is currently working in 30 countries, to protect millions of people from onchocerciasis. Through the strategy of community-directed treatment with ivermectin (CDTI), onchocerciasis control in Africa was transformed from a technologically-driven and vertical health initiative to a community-directed process of treatment and empowerment. Together, CDTI and the donation of Mectizan also reduced costs, producing one of the most effective and affordable disease-control schemes ever seen, and the CDTI strategy is now being applied to other disease-control initiatives. The onchocerciasis programmes have also been exemplary in shaping partnerships with communities, countries, the World Health Organization, governments, non-governmental development organizations, and the private sector. The Bank's involvement in onchocerciasis control has helped mobilize funds, giving confidence to other donors. More than U. S.$800 million was raised for both the OCP and APOC (excluding the initial costs of Mectizan). With these funds and the commitment of the partners involved, high coverages have been achieved in the Mectizan distributions. The Bank is confident that, during the years to come, the partners will continue their success, and that the APOC will achieve its goals by the target date for its closure, in 2015.

Ethnobotanical survey and antibacterial activity of some plants used in Guinean traditional medicine.

A total of 418 healers have been interviewed in Guinea, a coastal country of West Africa, ranging between 7 degrees 30 and 12 degrees 30 of northern latitude and 8 degrees and 15 degrees of western longitude. Plant species used by the local inhabitants to treat infectious diseases were identified using ethnobotanical, ethnographic and taxonomic methods. During these investigations, 218 plants were registered, of which the following were the most frequently used: Erythrina senegalensis, Bridelia ferruginea, Crossopteryx febrifuga, Ximenia americana, Annona senegalensis, Cochlospermum tinctorium, Cochlospermum planchonii, Lantana camara, Costus afer, Psidium guajava, Terminalia glaucescens, Uapaca somon and Swartzia madagascariensis. Most plants, and especially the leaves, were essentially used as a decoction. In order to assess antibacterial activity, 190 recipes were prepared and biologically tested, among which six showed activity (minimal inhibitory concentration<125 microg/ml) against Bacillus cereus, Mycobacterium fortuitum, Staphylococcus aureus, or Candida albicans, i.e., Entada africana, Chlorophora regia, Erythrina senegalensis, Harrisonia abyssinica, Uvaria tomentosa, and a mixture of six plants consisting of Swartzia madagascariensis, Isoberlinia doka, Annona senegalensis, Gardenia ternifolia, Terminalia glaucescens and Erythrina senegalensis.

The cost-effectiveness of forty health interventions in Guinea.

Addressing diseases of a high burden with the most cost-effective interventions could do much to reduce disease in the population. We conducted a cost-effectiveness analysis of 40 health interventions in Guinea, a low-income country in sub-Saharan Africa, using local data. Interventions were selected from treatment protocols at health centres, first referral hospitals and national programmes in Guinea, based upon consultation with health care providers and government plans. For each intervention, we calculated the costs (comprising labour, drugs, supplies, equipment, and overhead) in relation to years of life saved, discounted at 3%. The results show that the per capita costs and effectiveness of any intervention vary considerably. Average costs show no clear pattern by level of care, but effectiveness is generally highest for curative hospital interventions. Several interventions have a cost-effectiveness of US$100 per year of life saved (LYS) or less, and address more than 5% of total years of life lost. These include health centre interventions such as: treatment of childhood pneumonia ($3/LYS); rehydration therapy for diarrhoea ($7/LYS); integrated management of childhood pneumonia, malaria and diarrhoea ($8/LYS); short-course treatment of tuberculosis ($12/LYS); treatment of childhood malaria ($13/LYS), and childhood vaccination ($25/LYS). Outreach programmes for impregnated bed nets against malaria cost $43/LYS. Maternal and perinatal diseases, have slightly less cost-effective interventions: integrated family planning, prenatal and delivery care at health centres ($109/LYS) or outreach programmes to provide prenatal and delivery care ($283/LYS). A minimum package of health services would cost approximately $13 per capita, and would address a large proportion (69%) of major causes of premature mortality. This minimum package would cost about three times the current public spending on health, suggesting that health spending needs to rise to achieve good health outcomes.

Affordability, cost-effectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea.

Since 1986 two West African countries, Benin and Guinea, have been actively reorganizing their peripheral health systems according to strategies subsequently called the "Bamako Initiative". Two preceding articles described the strategies implemented and the increased effectiveness of primary health care (PHC) witnessed over a period of six years. This article presents an analysis of cost and coverage data from biannual monitoring sessions between 1988 and 1993 in approximately 200 health centres in Benin and 214 in Guinea. In order to assess affordability, the total and per capita recurrent costs for operational health centres are analysed and then compared. The cost analysis reveals a mean total cost per health centre per year of slightly over US+11,000 in Benin and nearly US+9,000 in Guinea. The median cost per capita per year is approximately US+1.0 in Benin and between US+0.60 and US+0.80 in Guinea. Comparisons of these costs between regions, health centres and over time (as coverage levels evolved) show very little variation in either country. Cost-effectiveness is estimated by allocating these costs to immunization, antenatal and curative care and comparing them to the coverage achieved with these interventions. First, the cost-effectiveness of the Bamako Initiative (BI) system as a whole is analysed. The cost per fully vaccinated child is calculated at US+10.9 in Benin and US+8.8 in Guinea. The cost per woman receiving at least three antenatal visits is US+7 in Benin and US+4.7 in Guinea. For curative care, cost per full treatment is US+1.6 in Benin and half this amount in Guinea. Cost-effectiveness is variable between regions, health centres reveals that these differences in cost-effectiveness are mainly caused by the coverage levels achieved, since total costs are relatively stable. Finally the efficiency of drug management and prescriptions as well as of outreach for the expanded programme of immunizations (EPI) is estimated by relating specific drug and outreach activities costs to the number of beneficiaries. The average cost of drugs per treatment is around US+0.5 in Benin and around US+0.3 in Guinea. Cost analysis of outreach activities undertaken for EPI in Guinea revealed a similar average cost per child completely vaccinated for health centres with different intensities of outreach (approximately US+10) and an additional cost per child vaccinated attributable to outreach of US+1-2.