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Population, Health and Nutrition (PHN)
Human Development Department (HDD

HDDFLASH (formerly PHNflash) is a bimonthly electronic newsletter and archiving service produced by the Human Development Department (HDD) of the World Bank. We have expanded our service PHNFLASH which covered ISSUE’s on population, health and nutrition to include other human development ISSUEs such as education, reproductive health and poverty. The newsletter serves as a bulletin to announce breakthrough technology, new publications, project updates, conference and training information, job vacancies, grant opportunities, and information on other related electronic resources available on the Internet. The archive provides subscribers with on-line access to over 400 documents in English, French and Spanish.

For more information about this newsletter see PHNFLASH no 1 further.

Introduction - Subscription Info

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HDDFLASH (formerly PHNFLASH) is a bimonthly electronic newsletter and archiving service produced by the Human Development Department (HDD) of the World Bank. We have expanded our service PHNFLASH which covered ISSUEs on population, health and nutrition to include other human development ISSUEs such as education, reproductive health and poverty. The newsletter serves as a bulletin to announce breakthrough technology, new publications, project updates, conference and training information, job vacancies, grant opportunities, and information on other related electronic resources available on the Internet. The archive provides subscribers with on-line access to over 400 documents in English, French and Spanish.

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Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Integrated childhood development

Dr. Mary Eming Young
Public Health Specialist

The following document was prepared for Bank's World by Dr. Mary Eming Young, Public Health Specialist in the Population, Health & Nutrition Department. It draws from staff appraisal reports on child health and education projects in Bolivia, Colombia and Mexico with additional information from The Twelve Who Survive, by R. Myers and M. Alva's Children's First.

"A child is born without barriers. Its needs are integrated and it is we who choose to compartmentalize them into health, nutrition, or education. Yet the child itself cannot isolate its hunger for food, from its hunger for affection or its hunger for knowledge" Alva, 1986

Three specific international events have given new visibility to the child which cast institutional and organizational challenges facing early childhood programs at the national levels: (a) the Convention on the Rights of the Child was adopted by the United Nations General Assembly in November 1989; (b) the World Conference on Education for All, held in March 1990 under the sponsorship of the World Bank, UNDP, UNESCO, and UNICEF, placed special emphasis on the expansion of early childhood care and development through family involvement and community interventions, especially for poor and disadvantaged children; and (c) the World Summit for Children, held at the UN in September 1990, brought together 158 presidents and prime ministers. These meetings have expressed a new awareness of the importance of early education on the part of international donors and given additional impetus and commitments on the part of governments in favor of early childhood development.

Today at least 12 of every 13 children born will live to see their first birthday, compared with the 1960 figure of five for every six children born. What happens to the "12 who survive"? Many of the same conditions of poverty and stress that previously put children at risk to die now put them at risk of impaired physical, mental, social and emotional development in their earliest months and years. Delayed or debilitated development in the early years can affect all of later life. It can also be prevented.

Not only are more children surviving but social changes create conditions that require new ways of thinking about child care and development. We need to look beyond mere survival to a program of early childhood care and development. More women are entering the labor force. Family structures are changing, urbanization requires some different skills than those in the past. The highest level of labor participation is in Southeast and East Asia where 50 to 60 percent of the women aged 15 and over are economically active. In sub-Saharan Africa, the percentage is slightly below 50 percent. In contrast, in Latin America and the Caribbean 32 percent of women are economically active. With changing family structures more women have sole responsibility for supporting their families. In Latin America and the Caribbean almost 30 percent of households are headed by women, over 20 percent in sub-Saharan Africa and 15 percent in East and South East Asia.

There is increasing evidence that early investments in development of the "whole child" can bring improvements in the life of the child and benefits to the larger society. Cumulative research evidence continues to indicate that most rapid mental growth occurs during infancy and early childhood and that, on the whole, the early years are critical in the formation and development of intelligence, personality and social behavior. Fifty percent of development of intelligence is established by age 4. Furthermore, inadequate intellectual stimulation and affective care, as well as early malnutrition, are likely to result in severe and possibly irreversible damages to physical and emotional capabilities, which are crucial to further learning. In this sense, elementary and even kindergarten can be too late an opportunity to develop these capacities in children.

Why should we invest in early childhood development?

·Efficiency·. Early childhood education increases the return on primary and secondary school investments, contributes to human capital formation, raises participants' productivity and income levels and reduces public expenditures (i.e. lower welfare, health and education costs). In the U.S. Perry Preschool Program, in operation since 1962, a $1 investment yielded $6 in eventual savings due to lower educational and welfare expenditures and higher productivity among participants. In the U.S. Head Start Program, $1 spent is worth $4 in costs saved later. Similarly, studies carried out in Asia, the Middle East and particularly Latin America suggest that early childhood education increases school readiness skills, promotes timely school enrollment, lowers primary repetition and dropout rates, and improves overall academic skills. The beneficial impact of early education is particularly pronounced among the traditionally disadvantaged groups (e.g., girls and children with rural, indigenous, and lower-level socio-economic backgrounds).

Furthermore, increased primary school attendance decreases the availability of older siblings to act as supplementary caretakers. Where sibs have been forced to drop out of school to provide such care, there is strong argument for child care.

Evidence suggests that health- and nutrition-related programs are positively associated with physical growth, basic cognitive abilities, school readiness and positive classroom behavior. A 10-year study in Mexico shows the negative effect on school readiness of severe malnutrition and lack of home stimulation, evident in delayed language development. Child care and development programs are potentially useful as vehicles for extending primary health care. Child physical growth can be influenced by not only the food intake but also by how well a child is developing socially and psychologically and by how free a child and the child's care-giver are from stress and illnesses.

·Social equity·. A large part of cognitive achievement differentials between lower socioeconomic and higher income groups can be attributed to low levels of psychological stimulation among poor children, malnutrition and lack of sanitation, all of which are directly associated with, or can be positively affected by, education. Early childhood education can help reduce societal inequalities rooted in poverty, by giving children from disadvantaged backgrounds a fair start, especially those living in rural and urban-marginal areas.

·Intersecting needs of women and children·. Increased numbers of women-headed households and of women who must work create a major need for complementary child care. If care is available, the earnings of these women are more likely than would be the earnings of men to go toward improving and helping distressed families with very young children. There is a kind of vicious circle particularly in the cities in which low paying jobs prevent mothers from purchasing adequate child care, and the absence of adequate child care prevents mothers from seeking more stable, higher paying employment. This circle is particularly acute in resource poor households where the effect on families of not working is highest. Provision of subsidized care that meets women's need could help to break this circle, raising earnings and productivity and benefiting both women and children.

What can we do?

Non-formal early childhood education has been a major area of innovation worldwide. The Bank has already invested in several such projects-for example, in India, the Integrated Child Development Services and the Tamil Nadu Nutrition Projects; in Colombia, the Community Child Care and Nutrition Project; in Mexico, the Initial Education Project; and in Bolivia, the Integrated Child Development Project. This fiscal year, Viet Nam is preparing a project on early childhood development project this fiscal year. Other multinational agencies, UNICEF and UNESCO, and non-governmental agencies, such as the Bernard van Leer Foundation and the Aga Khan Foundation, have had extensive experiences on implementation of early child care and development projects.

Early child care and development projects can be carried out through two modalities, formal and nonformal (center-based or home-based). The non-formal modality has received increasing attention in recent years because formal educational programs have failed to reach the population most in need, are costly and do not address specific community needs. However, there are also problems with the non-formal strategies. The ISSUEs are: insufficient institutional capacity, inadequate targeting mechanisms, poor educational inputs, loosely defined supervision, inadequate incentives for community educators, inconsistent community support, and sporadic linkages with complementary programs (health and nutrition). Moreover, we need proper and ongoing evaluation of the non-formal programs in developing countries to assess their cost-effectiveness and determine what are the minimum inputs of such programs.

Finally, we do have an emerging strategy for going to scale in programming for early childhood care and development. This involves a rather deliberate, focused, phased approach. It requires not only political commitment and resources but flexibility and continuous leadership and supervision capable of fitting programs to existing environmental, organizational and material resources. It would also be well to remember that the primary school graduates of the year 2000 have already been born and are being prepared for their lives. What seems so far away is being influenced now. Child development, growth, and the struggle to survive are simultaneous, inseparable and mutually reinforcing processes. We need to re-examine policies and approaches to enhancing early childhood care and development. We need not only sustain our effort to increase child survival but also enhance the development potential of the child with a smile.

[Reprinted with the author's permission from Bank's World, Volume 12/Number 10 October 1993]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Women, Health, and Development

Here are excerpts from a paper presented by Anne Tinker, Senior Health Advisor during a conference on Women's Health and Nutrition held last May at the Rockefeller Foundation Center in Bellagio, Italy:

Since the 1960's several initiatives have influenced women's health status in developing countries. Understanding of the important, but previously largely undervalued, role of women has increased greatly during the past 15 years, stimulated in large part by the United Nations Decade for Women. The Safe Motherhood Initiative, launched in Nairobi in 1987, successfully focused world attention on the magnitude of maternal mortality in developing countries and the need to improve maternal care.

Family planning efforts are increasingly oriented toward providing women with reproductive choice and the ability to avoid unwanted and poorly timed pregnancies. Recently, child survival efforts have recognized the significant impact of maternal health and nutritional status on infant outcome; this is reflected in the inclusion of maternal mortality goals in the recommendations of the World Summit for Children, held in 1990. While the family planning and child survival initiatives have been successful in bringing about dramatic reductions in fertility and infant mortality, there has not been comparable progress in improving women's health and nutrition, not even in reducing maternal mortality, which has received specific attention. Since the Nairobi Safe Motherhood Conference, over three million women have died from pregnancy-related causes. The annual number of maternal deaths has actually increased; although women's risk of dying as a result of pregnancy or childbirth has fallen by five percent during the past five years, the number of births has increased by seven percent over the same period.

It is appropriate that development policies and programs to improve women's health place special emphasis on pregnancy and childbirth in developing countries, due to the proportion of the life span spent in reproduction, its associated risks, and the high mortality and morbidity that result from largely preventable and/or manageable pregnancy-related complications. At the same time, these activities need to be increasingly complemented over the longer term by efforts to improve women's health and nutritional status more broadly. This requires attention to problems that often begin in infancy due to the lower status of girls, such as poor nutritional status due to discrimination in the allocation of food. Reproductive health problems include unplanned pregnancy and sexually transmitted diseases (STDs).

Several other gender-specific health ISSUEs will require increased attention in certain cultures, such as chronic diseases in transition societies where older women form a growing proportion of the population, occupational hazards that place women at particular risk, and violence in societies where physical or sexual abuse are prevalent.

Women's Health: A Neglected Development Issue

That women's health has received scant attention in development programs is reflected in high levels of persistent, but largely preventable, morbidity and mortality. In sub-Saharan Africa, a woman runs a one in 21 risk of dying from pregnancy-related causes during her lifetime; in Asia, it is one in 54; and in Latin America, it is one in 73. This compares to one in 10,000 in Northern Europe. Over 50 million women in developing countries are estimated to suffer acute pregnancy-related complications every year, and an uncounted number of women suffer pregnancy-related disabilities long after delivery. In addition, some of the deleterious effects of infectious diseases common to both men and women, such as malaria and hepatitis, are exacerbated by pregnancy.

The majority of women in the developing world go through pregnancy with no prenatal care and deliver without the assistance of appropriately trained health care providers. Most women of reproductive age also lack regular access to a range of modern methods of contraception. This frequently results in poorly timed or unwanted pregnancies [which] lead to between 36 and 53 million abortions around the world every year. Pregnancy termination under unsafe conditions is the cause of 115,000 to 200,000 maternal deaths each year. In Latin America, the complications of unsafe abortion are the main cause of death among women between the ages of 15 and 39 and absorb as much as 50 percent of some hospital maternity budgets.

In addition to problems associated with pregnancy, other conditions such as anemia, malnutrition, AIDS and other sexually transmitted diseases, and reproductive cancers impose a high toll on women's health and productivity. The number of women with HIV/AIDS is accelerating rapidly. In Africa alone, nearly four million adult women were already infected by the end of 1992.

Current estimates are that equal numbers of women and men are infected in Africa, and predictions suggest that more women than men will be infected by the end of the decade. Women with HIV risk passing the virus to their newborns, and they themselves usually die while their children are still growing up. Cervical cancer is the leading cause of death from all cancers (affecting both men and women) in developing countries-about half a million new cases are diagnosed each year worldwide, more than three-quarters of which are found in developing countries. Virtually only women are affected by breast cancer, yet it is the third most common cancer worldwide.

It is estimated that less than 20 percent of government health budgets are allotted to maternal and child health and family planning, and most of that amount is for child health. The resources allocated for women's health are not commensurate with the clearly demonstrated need.

Women's Status and Women's Health

Women's poor health is a reflection of their low status in many developing countries. Worldwide, women have a longer life expectancy than men [but] despite this, females have higher morbidity and physical disability levels than males throughout the life cycle. The differential in health status often begins in childhood, when girls receive less nutrition and health services than their brothers.

Women's lack of education and disadvantaged social position help perpetuate poor health and high fertility, as well as a continued cycle of poverty. Because women tend to be less educated and have less access to information, they are less apt to recognize problems or understand the value of or seek out preventive and curative care. Among other benefits, female education, especially through the secondary level, is associated with greater use of contraception and increased age of marriage, both of which improve women's health by reducing their exposure to pregnancy and early childbearing.

Families and communities also frequently underestimate the social and economic worth of women, and, therefore, their health needs. In Senegal, for example, a study which examined the low utilization of maternal health services found that only two percent of the women interviewed said they would decide for themselves to seek care in the event of pregnancy-related complications.

A number of other health problems associated with women's low socioeconomic status must also be addressed by health and development programs. Gender-specific violence provides an example. In Papua New Guinea, a survey found that 67 percent of rural women were victims of wife abuse. Dowry deaths and bride burning in India and female circumcision in parts of Africa and the Middle East are further examples of gender-specific cultural practices deleterious to women's health. Occupational health hazards are also an increasing concern. Women's low status, particularly lack of education, exacerbated by economic hardship, is leading to increasing prostitution, for example. This, in turn, is contributing to the rapid spread of STDs, including AIDS.

The health of women is integrally related to their overall status in society. Expanded opportunities in health and education will allow women greater control over their health and lives and enable them to exercise more productive and visible roles in socioeconomic development.

The Effects of Women's Ill Health on the Family, Community and Economy

A woman's ill health or death affects not only her own opportunities and potential but those of her children. A mother's death in childbirth is a virtual death knell for her newborn, and it often has severe consequences for her other young children. At least 60 percent of women who die from pregnancy-related complications are already mothers, and a study in Bangladesh found that when a mother died, the chances that her children up to the age of 10 would die were sharply increased-by more than three times for her girl children.

Women's poor health also affects the welfare and productivity of their households and communities. Ironically, the poorer the family, the greater its dependence on women's economic contribution. Women are the sole breadwinners in some 30 percent of the world's households, and at least 25 percent of other households depend on female earnings for more than 50 percent of total income.

Women also play a critical role in their national economies, and their physical well-being determines their ability to be productive. Data on women's contribution to development, while still tentative, indicate that women are responsible for up to three-quarters of the food and cash crops produced annually in the developing world. In Africa, women produce 80 percent of the food consumed domestically and at least 50 percent of export crops. Women also constitute one-third of the world's wage labor force and one-fourth of the industrial labor force. However, women's wages for the same or similar work are substantially lower than men's. In parts of Asia and Africa, women earn 50 percent less than men. Women work longer hours than men in every country except Australia, Canada and the United States. Therefore, female ill health has a substantial impact on productivity and economic development.

Ill health impedes women's ability to work and earn money, and burdens them and the economy with increased health care costs. Investments in women's health programs not only improve a woman's health status and the survival and health of her family, such investments increase the labor supply, productive capacity and economic well-being of communities.

Cost-Effective Interventions to Improve Women's Health

Improvements in women's health are not only critical to development, they are feasible and affordable. Of the many health sector interventions discussed in the World Development Report, safe motherhood interventions were found to be among the most cost-effective. Safe motherhood interventions include family planning to raise age at first delivery, space births, and prevent unwanted pregnancy, tetanus toxoid immunization, micronutrient supplementation, and improved prenatal and delivery care.

Strategies to protect women from sexually transmitted diseases can also have a cost-effective impact. Biologically, women are more susceptible to STDs; the probability of transmission in a single contact of unprotected vaginal intercourse is greater from infected male to uninfected female than the reverse. Moreover, because the duration and severity of STDs (other than HIV) are greater in women than in men, preventing a single case of an STD in a woman is estimated to be 20 percent more effective than preventing a single case in a man. Preventing and curing STDs in women also helps to reduce prenatal transmission. The most cost-effective strategy is to combine information, education, and communication with condom subsidies and STD treatment targeted to core groups of males or females who engage in unsafe sex with multiple partners.

The evidence suggests that improving women's health is a sound investment. Women's health programs are not only feasible and cost-effective, but their broader benefits stretch far beyond the woman and have important effects on the household and community development.

Women's Health and Development: Priorities for Action

Despite their higher life expectancy, women suffer from more health problems than men. Beginning in infancy, females often receive less and lower-quality food and, when sick, receive treatment less often and at a more advanced stage of disease. Because of their reproductive function, women run risks of morbidity and mortality which men do not face. Their health is also adversely affected by gender-specific cultural practices, such as female circumcision and physical abuse.

The development response must be a life cycle approach to women's health. Policies and programs need to address both the biological and cultural determinants of women's poor health status. To address gender discrimination that begins in infancy and childhood, education, communications and health service outreach strategies will be needed to promote more equitable intra-household food allocation and health service use. To reduce the prevalence of early childbearing and improve adolescents' productive potential and reproductive health, strategies must be developed to target them with information and services on reproductive health, family planning and nutrition, as well as to expand educational opportunities and postpone age of marriage.

Innovative approaches are needed since traditional maternal and child health and family planning programs have had limited impact on adolescents. For all women of reproductive age, an integrated approach is necessary to ensure protection against unwanted pregnancy, AIDS and other sexually transmitted diseases. Appropriate food and micronutrient supplementation, prenatal health services, safe delivery and referral care are essential services for pregnant women. Detection and treatment of cervical cancer (and in some countries, breast cancer) will need to be considered as a priority for older women.

Improvements in women's health, while beneficial in their own right, contribute to development through improved productivity, reduced costs of medical care, and a healthier generation to follow. At the same time, development leads to improved health of women if the benefits of development are shared equitably.

Women comprise over one-half the human race. Investing in their health is an investment in development today; it is also an investment in the generations of tomorrow.

[Reprinted with the author's permission from Bank's World, Volume 12/Number 11, November 1993]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Lessons From Health Care Reform

The debate over NAFTA tore fissures through the US public and blasted chasms through the Democratic and Republican parties, but the impending dispute over health care reform "will make trade look like a tea party," warns a prescient New York Times article, November lath. To prepare HP leaders for the storm ahead, Bernard Liese (Health Services Dept.) and Phil Musgrove (Pop. Health, Nutrition Dept.) look at the politics of health care reform in the US and elsewhere, and comment on the merits and weaknesses of the Clinton health plan. But first, an update on where the 1342 page Health Security Act bill stands today and its main ingredients:

-The Thanksgiving holidays in end-November marked the beginning of a renewed campaign by the Clinton Administration to build public support for the bill while Congress is in a two month recess. "They have planned a relentless exercise in retail politics: town meeting by town meeting, hospital by hospital, videotape by videotape," reports the New York Times, Nov 23. Every bit of effort is crucial to wooing employers, families and individuals who, since the plan was first released to glowing reviews in September, have become increasingly worried about how the reforms will affect their budgets and the quality of care available to them. Congress is unlikely to vote on the bill before the autumn of 1994, by which time the bill will probably have been significantly re-shaped.

-The bill, according to the Lancet's Daniel Greenberg, rewrites the "fundamental rules for the entire American health care industry, a $1 trillion a year enterprise with 10 million employees and 250 million patients...(as) the biggest business in America..(it is little wonder) that the prospect of change introduces economic anxieties."

-The Clinton plan aims at ensuring universal health coverage and reining in the runaway costs of health care. Currently, health care costs total over 14 percent of GDP -far higher than any other country-even though some 37 million Americans are thought to lack health insurance. Key elements of the plan are insurance for all and "managed competition" among physicians and hospitals that would be fostered by regional purchasing alliances of health-care services. The standard benefits package would cover most illnesses, preventive techniques and prescription drugs. Employers would bear 80 percent of the costs, with individuals and government paving for the rest. The plan proposes that no firm pay more than 7.9 percent of its payroll toward the cost of workers' health premiums and that employees not be required to pay more than 3.9 percent of their wages. Most features of the system would in place by the end of the century.

-Government subsidies for small employers. Low income workers and non-working people would he financed by Medicare-Medicaid cuts, a 75 cents-a-package cigarette tax and higher taxes on alcohol. a one percent payroll tax on large employers, and limits on tax deductions for premiums beyond a certain amount.

-Competition will drive down the cost of care says the Clinton Administration. but if it does not, the plan imposes limits on the amount health premiums can go up until the year 2000. Yet the task of lowering health-care costs is likely to prove more difficult than that of ensuring universal coverage, notes the Lancet in an editorial.

-The Clinton plan allows states flexibility in designing the mechanisms by which they will provide the federally mandated basic package. Thus, states could even choose to adopt the Canadian single-payer system, the leading competitor to managed competition.

-The anticipation of federal reforms has already sparked consolidation amongst health-care providers and pharmaceutical companies keen to position themselves to negotiate with the regional purchasing alliances, reports Oxford Analytica, Nov 19. One three way merger of the country's largest hospital chains is aimed at creating the "Wal-Mart of health care." In the pharmaceutical sector, Merck, the largest US drug firm, has purchased Medco, the largest US drugs distributor, while other large manufacturers have purchased generic drug firms. "The new wave of acquisitions is signaling drug companies' ambitions to gain a competitive edge through controlling different areas of the market," notes the report.

Bernard Liese writes: "When Germany's national health insurance was launched in 1883, just 110 years ago, the design was influenced by a tremendous political struggle. Businessman feared that general revenue financing of the health insurance would give the military agricultural class too much influence over the economy, the representatives of the workers wanted higher benefits, the agrarian traditionalists wanted everything through mutual aid organisations-the predecessors of the alliances-and so on.

The Clinton proposal will face quite a few obstacles of a similar nature. But I am confident that there will be national health insurance when the dust has settled. And it is overdue. No industrialized nation has ever had to deal with a situation like the US-it is really a Wild West in the health sector, with the insurance companies playing at being the railways barons and landowners.

It is here where the battle line is drawn already. This is interesting, because in many countries it was organized medicine-alias the physicians- which put up fierce resistance. Not so in the US. The plan is in my view the most significant social legislation the US has ever introduced since the days of the Social Security Act of 1935, but there the times were very different-the great depression was just about to end and FDR was unchallenged.

The plan which is proposed tries to find a consensus, but below the surface it is fairly hard core social insurance. It will give the states real power to design their own health care system, including the option to set up a system a la Canada (Quebec) or similar ones that are entirely Government run. Other states May want to follow the more central European tradition of an association of sickness funds bargaining with providers; these are called Alliances here.

There is however one crucial difference between Germany's sickness funds in 1880 and the proposed alliances. Designers of the system in 1880 could count on a general shared objective-social solidarity was accepted as an overriding public concern by nearly all of them, but today maximizing profits at the expense of the public seems to be the primary concern of their cousins. Well one might want to say that "redistributive political struggles have always contaminated the introduction of social insurance." The difference I guess is here in the US the struggle will be a battle. I do hope the public concern wins; I am somehow confident it will."

And according to Phil Musgrove: "It has looked for a long time as though the US could save a lot of money and improve health care coverage, whether or not anyone's health got better as a result, simply by copying the Canadian system-that is, by allowing complete competition among providers on quality and on the advice they give -patients, and letting the system be run by the states (provinces), while (I) having the federal government set the most important rules because of its contribution, (2) disallowing price competition, and (3) paying for the system out of general revenues with no link to employment.

It May be that the Clinton Plan didn't go for that approach because the Canadian system has been unjustly smeared by the opponents of health care reform in the US-they make a big deal of the fact that people sometimes don't get the care they want, and that rich Canadians sometimes come to the US for care. The first of these problems is already vastly worse in the US, and anyway not getting something you want is the essence of controlling costs. As for the second, NO proposal for reforming the US system has ever included a prohibition on people getting extra care for themselves, provided only that they pay for it themselves or by non-subsidized private insurance. After any reform, Americans would be just as free to get such care as Canadians are today.

Nonetheless, the Canadian model isn't the Clinton Plan. Two differences seem particularly important. One looks like being unfortunate, a second-best choice that is a long way from first best: that is to keep insurance tied to people's jobs, which complicates administration and raises all the difficulties of which employers are to subsidize which others, given that people's wages differ so much. The other difference May be an improvement over the Canadian model-since it hasn't been tried yet on a national scale, there is no way to be sure. That is the reliance on "alliances" to shop for insurance, to give buyers at least as much clout as sellers and to rely on competition not only for service provision, as Canada does, but also for financing arrangements. Of course, one can imagine a single-payer system with some such competition, but since it would require payment through the insurance industry and that industry is superfluous under a single-payer system, that hardly looks worthwhile.

So the US proposal is a second-best, presumably designed to minimize political damage and to keep as many features as possible of the present system. It seems too bad, but (I) it May be the best the US political system can do, for now, and (2) by relying more on managed competition and prying the insurers' hands off the health system's throat, it May in one respect improve a lot over the current mess and even outdo the Canadian model on cost control."

Box US.: causes of death

In a major new study, US government researchers have concluded that tobacco is the country's primary cause of death contributing to the deaths of 400,000 people in 1990, larger than the combined toll of drug use, firearms, sexually transmitted disease and car accidents. The first US study to analyze the "root causes" of death rather than the "primary pathophysiological conditions," the report by Michael McGinnis, deputy assistant secretary in the Department of Health and Human Services, and William Forge of the Carter Center, was published in JAMA, Nov 10.

Along with tobacco, other leading contributors to mortality are diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000). Though important, infections are no longer the leading killer in the US, notes the study, but emphasizes that HIV "now represents one of the most rapidly increasing causes of death," with a 20 percent increase between 1990 and 1991. The authors stress that the figures are first approximations, and that "socioeconomic status and access to medical care are also important contributors, but difficult to quantify independent of the other factors cited."

The implications of these findings, says the report, are, one, that & greater investments in prevention are called for, as nearly half of the 2,148,000 deaths in 1990 could have been prevented through behavioral changes such as stopping smoking, eating more healthfully, exercising more, shunning alcohol and practicing safe sex; and two, that providing universal health care will not be enough to shrink the nation's medical bill.

[Reprinted from Health Policy, Number 5, December 1993 Population, Health, and Nutrition Department, World Bank


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Health Updates Oral Rehydration Therapy

Is ORAL REHYDRATION THERAPY based on glucose or on cereals more effective in reducing stool output? A hospital-based study by Fayad et al. in the Lancet, Sept 25, argues that glucose-based ORT was more effective than rice-based ORT in reducing stool output-both are equally effective in preventing dehydration-but an editorial by Abhay Bhang in the same ISSUE says the conclusion is premature, noting that the study population does not represent diarrhea cases in the community and that the rice-based ORT was commercially prepared. This is an important debate, and readers are urged to read this article.


Malaria buffs take note: the latest ISSUE (volume 37, number 9) of Social Science and Medicine focuses on this protozoan plague, including a review of economic and demographic research and several studies of malaria's effect in different regions of the world.

Visceral Leishmaniasis

WHO and UNICEF ISSUEd an emergency appeal. Oct 26, for $4.4 million to help fight an epidemic of kale azar (visceral leishmaniasis) in Sudan that has killed thousands this year, according to a WHO press release. A fact-finding mission reports that the majority of cases are in children and that war and the shortage of drugs discourage people from trekking to clinics. The mission concluded that the epidemic is expanding rapidly, probably because of the movement of infected people to non-infected areas and wider distribution of the sand fly vector following the breakdown of vector control measures.

Smoking and Tobacco

"When Smoking Is a Patriotic Duty" is the headline of a New York Times article, Oct 17, which reports on the Japanese government's profitable tobacco monopoly, Japan Tobacco Inc, the nation's largest corporate taxpayer. The company had net sales of $23.8 billion last year, and provided $15 billion in taxes. "With the tobacco industry enjoying state support," Japan has the highest smoking rate in the industrialized world, 36.1 percent, well above the US's 25.7 percent, the article notes.

However, life expectancy is significantly higher for Japanese than for Americans, and rates of tobacco related disease have still to reach US levels .

And in India, the Indian Council of Medical Research, a government advisory body, has told the government that the cost of treating patients suffering from tobacco-related conditions is set to exceed the revenue earned from the tobacco industry, reports the British Medical Journal.

India is the world's third largest producer of tobacco, with the industry employing thousands of people and paying nearly $500 million in taxes annually. The burden of tobacco-related disease has grown exponentially in recent decades, and the Council estimates that one-third of all new cancer cases are related to tobacco. While the health ministry says it is considering requirements for more stringent warnings on cigarette packets, doctors and non-governmental organizations are pushing for stronger action, including phasing out tobacco production .

Speaking at the All Africa Conference on Tobacco Control in Harare, Nov 14, Howard Barnum (Population, Health & Nutrition Dept.), stressed that tobacco consumption was a global economic problem that Africa had so far avoided, "but it is coming if international tobacco companies have their way." Prompt action by governments -particularly by Finance Ministries- is needed to avoid the loss of many years of lives and of billions of dollars, said Barnum. The conference brought together over 100 representatives from African governments, bi- and multi-lateral agencies, anti-tobacco groups, and tobacco growers.

[Reprinted from Health Policy, Number 5, December 1993, published by Population, Health, and Nutrition Dept. World Bank]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

HIV/AIDS: Summary of Publications

· African Women's Control Over Their Sexuality in an Era of AIDS", by Orubuloye et al., from Social Science and Medicine, is the kind of complex and thought-provoking article that defies being reviewed in a few sentences. But readers are urged to study it. The article highlights the paucity of information on the extent to which African women have control over their sexual relations, compares the situation of women in East and Central Africa to their relatively more independent counterparts in West Africa, and reports on a detailed study of the Yoruba in southwestern Nigeria. One conclusion-with crucial policy implications-is that "most Yoruba women have undisputed control of their sexuality when their partner suffers from STDs or AIDS. The refusal of sex May result in the breakup of a marriage but is unlikely to result in a continuing marriage dominated by violence or forced sex, or by pressure from their own relatives for the husband to be allowed his conjugal rights or for the wife to stay with him." Why are matters so much worse in most other societies? Just what will it take to reduce the risks of HIV transmission faced by women? This article offers leads.

· The risk of HIV transmission is multiplied by the preference for "dry, tight" vaginas in communities in Zaire and other parts of central Africa, write Judith Brown et al. in a recent ISSUE of Social Science and Medicine, noting that both sex workers and married women commonly use intravaginal drying substances and washing procedures because it increases pleasure for both partners during coitus. But these practices often cause lesions in the vagina and cervix, while both the vagina and the penis can be traumatized because of the lack of lubrication. Both partners face higher risks of transmission of HIV and other sexually-transmitted infections, say the authors, citing other studies in Africa that show higher rates of HIV in people using these practices. The preference also means that women are unwilling to use slippery spermicide, and that the risk of condom breakage is multiplied.

The October ISSUE of the American Journal of Public Health is devoted to AIDS. Important articles are reviewed here briefly. Highly recommended.

a) In an editorial, Zena Stein of the HIV Center for Clinical and Behavioral Studies makes a plea for rapidly expanding use of the prophylactic methods currently available to women for HIV prevention. "We already have a battery of largely untried barrier methods-nonoxynol-9, the diaphragm, the cervical cap, the female condom," writes Stein. "What we need to discover is how to overcome behavioral obstacles to using these barriers." Stein also stresses the importance of developing a microbicide that will spare sperm but inactivate HIV, given the enormous value placed on reproduction in many cultures.

b) Should clinical care for the millions of developing country people infected with HIV be a top health sector priority? Kevin de Cock et al. argue yes, noting that "reluctance on the part of donors to deal with AIDS care is widening the divergence between the approach to AIDS in developing countries and that in industrialized ones, where there is an increasing emphasis on secondary prevention and treatment for those already infected with HIV." They note that providing clinical care could also enhance the credibility of prevention efforts, and will raise the likelihood of early voluntary HIV testing and counseling.

· The topic is taken up by Charles Gilkes in the Lancet, October 23. in an article which usefully complements de Cock's. Gilkes makes the crucial point that little is known about what is causing most HlV-related disease and death in Africa and other areas of the developing world, and that "without such data the ISSUE of care-what to provide and to whom; what is affordable and sustainable-cannot be addressed." In the absence of such information most researchers erroneously focus on AIDS, "an approach (that) invites powerlessness and hopelessness (because) how can poorly equipped hospitals reliably diagnose opportunistic infections and then afford to treat them?" But non-AlDS disease with common high-grade pathogens such as tuberculosis, pneumonia and the salmonellae is far more common in developing countries, notes Gilkes, suggesting that efforts to improve treatment of such diseases for both seropositive and seronegative persons would be far more effective than adopting "any specific HlV-driven vertical clinical initiative".

· Readers should also look at "AIDS in Africa: Can the Hospitals cope?" by Jorge Cabral, in Health Policy and Planning, who argues that hospital management needs to be improved and curative cure decentralized to forestall the collapse of rural and urban health services. Cabral calls for expanding the number of intermediate level urban hospitals, defining strict rules for the type of clinical follow-up, and for therapeutic schemes for opportunistic infections.

· A dissenting view comes in an editorial from Robert Biggar of the US National Cancer Institute. Biggar argues, one, that prevention of HIV is by far the most cost-effective approach: two, that developing country health budgets are too small to undertake even the prevention effort: and three, that most developing courier- health policies are already biased towards clinical care. with hospitals consuming between 40 to 80 percent of health budgets.


Have We Become Surrogates for Failure? Proposing a New Nutrition Education
by Richard K. Manoff

Martin J. Forman Memorial Lecture
Sixth Annual June 21, 1993
sponsored by Helen Keller International
90 Washington Street, New York, NY 10006, U.S.A.
National Council for International Health Conference, Arlington, Virginia
Helen Keller International wishes to thank the staff of Emmerling-Post for their assistance in the publication of this lecture.

Have We Become Surrogates for Failure?

Friends, colleagues and admirers of Martin Forman: I remember Marty in many ways. First, as the man who rescued me from the wicked wiles of Madison Avenue and led me into the wondrous world of nutrition. He changed my life, infusing it with his sense of passionate mission. I also remember Marty, obsessed with objectives, for whom process and strategy were time-consuming encumbrances. Had he lived longer, he might have discovered a way to attain nutrition s objectives by decree. Instead, in his short but full life, Marty seized upon any promising strategy. Inside the academic trappings was a maverick of Herculean courage. Who else would have gambled on me? The bizarre notion of using the mass media for nutrition education intrigued him from the start. But my Madison Avenue credentials proved more than mildly threatening to the scholarly sensibilities of the praetorian guard at USAID in Washington. Marty prevailed with an ingenious compromise. I would be accompanied by a communications professor from Stanford University whose academic mantle was apparently large enough for both of us. From India, to Ecuador, to Nicaragua and beyond, I learned that nutrition was more than a matter of food. It sometimes led to embarrassment. The development of the Nicaragua Oral Rehydration Therapy program brought word from Marty that the Health Office at AID was upset. I was overstepping their territory. But, I explained meekly, I was told diarrhea was the No. 1 nutritional problem.

Will it work? They think so. So do I.

OK, he said and I could hear the smile in his voice.

What about the overstepping? I wanted to know. Not to worry, he replied. Just don't trip. Whatever I have managed to contribute would have been improbable without Marty. In that sense, he was social marketings pioneer, not I. What I learned early on was that malnutrition is more than a problem of food, nutrient composition and food habits. Malnutrition is also: An income problem, A water problem, A sanitation problem, A problem of public policy barriers, A problem of contradictory health practices, A problem of women s inequities, A land-tenure and land-use problem, An agricultural technology problem, A food production and distribution problem, A problem of antagonistic marketing practices, A problem of appropriate credit and fiscal policies, And more.

In the course of my remarks I will propose four broad initiatives for the new nutrition education:

1. How to make deliberate country demonstrations in implementation of the 1992 International Conference on Nutrition (ICN) Plan of Action

2. How to achieve more rigorous application of social marketing principles

3. How to mobilize the mass media for greater access

a. Media Workshops for media authorities
b. An International Nutrition News Service
c. The Time Bank

4. How to mobilize the private commercial sector for nutrition education

a. The Provita Plan for micronutrient fortification
b. The Nutrition Social Marketing Board

These initiatives are the outgrowth of the changing dynamics of malnutrition and their possible implications for nutrition education. Let me set the stage by sharing with you the thinking from which they emerged. Today, we know that more than one in five people in the developing world 780,000,000 people still do not have access to enough food to meet their basic daily needs for nutritional well-being.... More than two billion subsist on diets that lack the essential vitamins and minerals. 1 Bad water, sanitation, chronic diarrhea, other infectious diseases and the whole array of wrongful socio-economic policies and practices in the public and private sectors are major causes of malnutrition. Many other behaviors obviously need changing, but that will not happen unless we nutrition and health educators undertake to change our own. Clearly, nutrition education is due for a major behavior overhaul.

This is not to gainsay the progress we have made. There is a ready appreciation of social marketing disciplines and the power of the mass media. But the focus of our attention is still too narrow. When we talk behavior change, it is almost always on the woman and the members of her household. For example, the 1992 International Conference on Nutrition resolved: Programmes should be directed at household leaders, with particular focus on women. How much chance does the old nutrition education have to improve individual behavior when so many other behaviors are working against it? Have we become surrogates for their failure? Doesn't this outmoded conception of nutrition education become a convenient cover-up for the failure of others? Here is how the old nutrition education perceives its target:

The target is almost always the woman. She is in an open field, untrammeled by circumstance. She is easily accessible. If we carefully design the nutrition message and aim it well, the theory is that we will motivate her to respond with the desired behavior change. But this perception is inaccurate. A more literal symbolization of this target, given the meaning of the word target, would look like this: (Illustration)

She is the center of a context, a bull's eye. The concentric rings make her seem even more accessible. In that sense we have badly chosen our metaphor, for in fact, she is not so accessible at all.

She is held hostage in a closed system of environmental forces of malnutrition beyond her control bad water, worse sanitation, chronic infection, poor education, etc. each a massive restraint on her ability to respond to nutrition education. Breaking through those restraints is a nutrition education objective: to help free the individual to respond more readily to our nutrition education and to release the energy that is now wasted on her unequal struggle against these other causes of malnutrition.

Response Capability: A New Objective

In the past, our concern was to improve our communications capability. The insights of social marketing have made a big difference. But we now know communications capability is not enough. Large-scale successes will still defy our best efforts if the response capability of target populations to nutrition education remains suppressed. While we should not assume responsibility for failure not our own, we have an obligation to help prevent it. Effective local intersectoral collaboration, so hard to accomplish, is nevertheless indispensable. Educating other sectors as to their importance in eliminating malnutrition is mandatory. If we do not work toward it, do not achieve it, give up on it, then we will resort to making rationalizations for it. For example, one would think that increasing the income of the poor would reduce poverty and malnutrition. History shows that economic improvement of individuals leads to improvements in social infrastructures better water, sanitation, education, health care and the like. That s why the subject is important to nutrition. We need those improvements to increase the response capability to nutrition education. But now this truism has been rationalized into an enigma. Some recent reports from various sources have begun to stress that increasing income is not enough. We should be concerned. The Agency Coordinating Committee, Subcommittee on Nutrition (ACC/SCN), collaborating with the International Food Policy Research Institute, has reported that: Increasing GNP per capita from around $300 to $600 is associated with a decline in the prevalence of underweight children from around 34% to 17% or a reduction of about 50%. Beyond the $900 income per capita level, the effect of increasing incomes on malnutrition diminishes.

First of all, we all know that GNP per capita is not the same as household income per capita. Secondly, data on household income per capita are sparse and do not exist at all for many countries. The World Bank Development Indicators show mostly blank spaces, even for percentage share of household income. Third, even if it were available, household income per capita is a deceptive measure. In developing countries the vast majority 70%, 80% and more live well below that average. Eduardo Galeano, the Latin American writer, once asked sarcastically of his readers, Have you ever known anyone who earns a per capita income?

IFPRI reports that when incomes of poor families rise, malnutrition persists in households even with more food whose value exceeds the energy requirements. The conjecture is that something strange is going on there. The inclination is to focus on behaviors inside the family the inequities of the feeding chain, the need for nutrition education and the urgency for individual behavior change. This inclination attracts others and the conjecture spreads. Income is devalued, as we can see in a recent monograph by a nutrition specialist at the World Bank unfortunately titled Ending Malnutrition: Why Increasing Income Is Not Enough. The Xerophthalmia Club Bulletin, in reviewing it, said, This study suggests that increases in income of the poor cannot on its own be expected to raise food intake, but its effect on nutritional status May be enhanced by other measures such as more advantageous ways of paying people, offering nutrition education and providing women with functional literacy classes, etc.(italics mine). 4 But the monograph also recommends other measures such as improvements in health, sanitation, and water facilities, etc. Then why the almost exclusive emphasis on nutrition education for behavior change in the individual? This could create the perception that nothing else is as important. Yet other behaviors, including our own, need changing just as urgently. Why trivialize the importance of increased income? This leaves the perception that other factors May be more important. Malnutrition demands a concerted intersectoral behavioral collaboration on all fronts and with many different kinds of people. Then why single out income? Why not Ending Malnutrition: Why Good Water Is Not Enough; or Why Sanitation Is Not Enough; or Why Nutrition Education Is Not Enough; or even reductio ad absurdum Ending Malnutrition: Why Food Is Not Enough. You can pick your own enigma if you don't care and merely want to play this nutritional version of Trivial Pursuit. But since we do care, we ought not to behave by pitting one strategy against another not even hint at it. Here is the opening paragraph in the introduction of this monograph:

This paper examines, through a brief review of the literature, the impact of increased income on nutrition status and the factors that mitigate this influence. Since access to food is largely determined by household income, food security projects often aim to increase or diversify the source of income.

But simply ·increasing household income is not enough·. Many factors mitigate the effect that an increase in income has on access to food and on any subsequent nutritional benefits (see Figure 1). By taking these factors into account when designing food security projects, ·the impact of increased income on nutritional status can be greatly improved·.

Notice the bolded and underlined words: But simply increasing household income is not enough ; and the impact of increased income on nutritional status can be greatly improved. Now, these phrases represent two clear choices for titles. Here is how the same publication with not a word changed inside might have appeared with a more appropriate title using the latter statement: Ending Malnutrition: How the Impact of Increased Income Can Be Greatly Improved.

(Illustration) One publication. Two different titles. Two different points of view, leading to two different attitudes, two different behaviors. I suspect that the millions of disadvantaged around the world whose incomes we are talking about would resoundingly reject the first in favor of the second.

This enigma is all the more perplexing at a time when schemes for generating increased income for women are high on everyone s agenda the same women who are being told in the name of nutrition that their behavior change is more important. This is not precisely how to win friends and influence people. This little exercise also reminds us of the awesome power of communications and the caution we must exercise in using it. Our points of view and the messages they engender can have a deadly impact on our prospects for changing others behavior when we ignore the need to change our own.

Now that I have almost certainly excoriated the sensibilities of some friends and colleagues, I am reminded of Voltaire on his death bed. His priest pleads with him to denounce the Devil. Voltaire feebly brushes him aside and asks: Is this a time for me to make enemies? This is no time for me to make enemies either, but it is a time for candor which May be perceived as enmity. I hope you will not so view my remarks. Almost twenty years ago, The World Food Conference of 1974 recommended that each country formulate integrated food, nutrition and prevention policies and pledged to eliminate within a decade hunger and malnutrition. Two decades have since passed and last December the ICN swore the same pledges for still another, with no more assurance that the institutional and sectoral behaviors that failed before have changed.

We have a poor institutional memory. We know that prevention programs are not possible without political will. Political Will: Rhetoric or Reality?

Only four months ago, IFPRI declared that the world s current approach to the problems of hunger and malnutrition is very shortsighted. Governments and aid agencies tend to focus on crises ... at the expense of sustainable solutions to persistent hunger, ... of incentives to expand production of ... food crops, improvement of rural infrastructure ...job programs and ... basic health and sanitation services. 6 In plain talk this means lack of political commitment. Yet we hear reports that there is a good deal of political commitment, that many governments are interested in large new nutrition programs.

Our defenses should be aroused. Is the reported interest real or feigned? Is it motivated by an unwillingness to confront what Urban Jonsson of UNICEF refers to as the more basic, more costly causes of malnutrition? Walter Santos, some 20 years ago when he was the health minister for the State of Sao Paulo in Brazil, told a Pan American Health Organization representative in my presence that nutrition education for behavior change can be the tool of rascals. It can be a way, he said, of dropping the burden onto the individual when the intersectoral programs needed to combat malnutrition call for sizable economic investments.

Unfortunately, intersectoral collaboration exists mostly in the halls of global meetings. What emerges in the field are trickle-down intersectoral emanations from these deliberations. And the abstract rhetoric of this summitry defies translation to the realities of the village. This is the Funnel Syndrome: too much wishful thinking goes in at the top with too little action coming out below. Or, to put it more kindly good intentions globally, meager outcomes locally.

We have to turn things upside down. What we need at the top is more focus on local initiatives and then mobilizing global capacity to help make them happen. Our few successes have certain things in common. The inspiration is local; the leadership is local; the execution, local; the inputs, local.

(Illustration) If intersectoral collaboration is to be achieved, it will have to be by local governments with the support of global organizations acting together to make the opportunities for local initiatives more propitious. This was eloquently endorsed at the 1992 ICN by The Ministers and Plenipotentiaries of 159 states and the EEC when they declared their determination to eliminate hunger and to reduce all forms of malnutrition in an International Decade of Food and Nutrition.

What would happen if the ordinary people had it in their power to hold them to account? To ask: What happened to our decade or to any of the other decades declarations that have come and gone with pledges unfulfilled? Ordinarily they would have grounds to sue in class actions for damages incurred from broken contracts. When governments and quasi-governmental organizations break their social contracts, shouldn't they be held to account under the same laws to which they hold others accountable? Meanwhile we squander our credibility which, as social marketing teaches us, is everything in nutrition education.

Initiative for Deliberate Demonstrations

What is to be done with the rhetoric of the ICN? It must be transformed into deliberate demonstrations of the ICN Plan of Action in selected countries. But the planning process must be turned upside down, formulated from the bottom up with the people in the villages and the neighborhoods. This is the doctrine from Alma Ata.

Deliberate demonstrations of the ICN Plan of Action include all the interventions necessary to create a hospitable environment for peoples response capability. All U.N. resources are mobilized at country level with those of international aid organizations, the mass media, NGOs, the private sector and community groups. If almost 160 nations can pledge a decade for the world, they should be eager to deliberately demonstrate its feasibility in a handful of countries, one for each U.N. region. We need to authenticate in every region the possibilities inherent in the interdependence of local institutions. If the sum of the parts is indeed greater than the whole, let us proceed to prove it. It would set the example for all countries and help establish nutritions proper place high up on the public agenda.

The deliberate demonstrations will not be complete unless their progress is recorded on video for annual TV and radio specials in-country and out. The mass media and their authorities must be key players in this collaboration. The mass media are crucial. Note the following quotes from focus groups: If it s not on TV it doesn't exist. It s true, I heard it myself on the radio. It says so in the (newspaper). My faith in the mass media has deep roots, particularly in their potential to promote new norms of behavior. The victory against smoking in the United States could not have happened without aroused anti-smoking constituencies that took the ISSUE to scale through the mass media. This social marketing activity eventually created a critical mass of public support for bans on smoking in offices, on planes and in public places. The smoking population has fallen to below 30% and is still falling. This social pressure would have been impossible without the mass media.

As recently as 35 years ago, food manufacturers in the U.S. spurned nutrition as the narrow interest of food fanatics. But all that changed when nutrition advocates began clamoring against empty calories, high sodium, fat and cholesterol. We carried this social marketing war onto the mass media. A critical mass of the public began to demand more nutrition information. Nutrition claims inundated the airwaves. Nutrition imperatives dominated new product development. Neither the behavior of the food industry nor of the American consumer would ever be the same.

Prevention through proper dietary behavior became the new covenant. Prevention needs to achieve a critical mass. Creating that critical mass is social marketings prime function. The mass media are its first-line weapons. UNICEF s State of the World s Children for 1993 declares that the task of informing hundreds of millions of parents about the where and why of immunization could not have been achieved without ... the mass media, the schools, the religious leaders and many non-governmental organizations. But the schools, the religious leaders, the NGOs would not have responded so vigorously if the mass media had not given immunization its public voice and raised a critical mass of awareness.

In New York, some days after the Clinton-Gore inauguration, one teacher replayed the videotape of the ceremony in class. When Maya Angelou reached these lines in her poem for the occasion, the kids began to cheer:

So say the Asian, the Hispanic, the Jew
The African and Native American, the Sioux
The cheers for each ethnic reference were from the kids who identified with it.

Familiarity, says Anna Quindlen of The New York Times, breeds content. She quotes Roger Wilkins, a noted civil rights leader: If there's nobody who looks like you, you have the sense that you can't do it- if there s somebody who's something like you, it seems possible.

But this beginning of behavior change would not be possible without social marketing and the mass media to deliver that image and the message it conveys.

Women, our favorite target, could be our most powerful change agents. The challenge is to help women win a public voice. The historian Simon Schama reminds us that in the French Revolution, public diction was public power. 9 All that those revolutionaries had at their command was an open forum and the limited reach of their voices. We have the mass media and social marketing to work with. We can work miracles. In Bangladesh, in 1982, we projected new images of women by radio in a popular Bengali soap opera. The objective was to portray the more than 20,000 female family planning workers as heroines. Din Badolar Pala was a social marketing conception of Manoff International executed by two famous Bangladeshi writers. The strategy was strictly social marketing: the story had to be an engrossing drama no didactic family planning tract. The heroine of the drama had to be Laila, a young modern married woman who chooses to be a family planning worker. She is revealed as a beloved and respected person to whom all turn for understanding. In this orthodox Muslim society this was a new image of women for the millions of men and women who tuned in. Husbands of real life Lailas wrote to recant old antagonisms to their wives work. Letters from many real-life Lailas told how their morale was bolstered.

Anna Quindlen reminds us: Life magazine ran a photograph of 98 women and two men on the steps of the Capitol to dramatize the unequal composition of the Senate.... It took some time to find the men in that photograph. They were insignificant. 10 But that powerful image without the mass circulation of Life is a picture without a public, a light bulb in a dead socket.

One soap opera, one picture in Life, one black poet s roll-call of ethnic pride do not a revolution make. But these are beginnings and stirrings. With social marketing they are multiplied by continuing inputs to reach a critical mass of support for new norms of behavior in people, institutions and whole societies.

A More Rigorous Application of Social Marketing Principles

Harnessing the power of the mass media to affect behavior change requires rigorous observance of social marketing disciplines regarding target audience identification and analysis, innovative research for community inputs, problem identification and analysis, message design and validation, media analysis and selection and total situation assessment (of health care, infrastructural services, marketing systems, food and agricultural policy, health care practices and the like). Motivating deep-seated behavior changes in tradition-bound cultures is a lot more complicated than promoting brand-switching in purchases of food, soft drinks or hair sprays. Invention is the mother of necessity. Social marketing was to have its inevitable beginning.

Perception is the only reality. This is a basic social marketing premise. We need to know how target populations perceive a situation and to understand how and why the view May be different from their side. Such insight makes for more reliable messages, materials and media strategies. But the chains of behavioral bondage are still evident in our work, particularly in how we go about defining problems and deciding on strategies. In Bangladesh, the government's family planning campaign theme had been: A small family is a happy family. But villagers could point to the largest family (also the richest) and say there is the happiest family. Others could point to unhappy small families. If social marketing disciplines had prevailed, up-front feed-forward qualitative research like focus groups would have revealed that strategy was confused with objective. A small family May be a good objective but it makes a non-strategy for getting there.

Objectives are clearer than problems. Unclear problems produce uncertain strategies leading to unhappy outcomes. This is not a quantitative challenge. Research denies the existence of what it cannot measure. And what it cannot measure May be critical to what we need to know. The search is for new insights, not the shifting measures of old ones; for new questions in peoples minds, not updating responses to the familiar in ours.

Knowing why May be more important than knowing what. We need diagnostic, not merely descriptive information. Focus groups turn people into self-inquirers. They are askers of questions as well as answerers. But much of this value of focus groups is diluted by behavioral bondage. Focus group information cannot should not be quantified. Yet some researchers cannot overcome the compulsion to codify, quantify, to manufacture data out of it. Others cannot resist using questionnaires instead of discussion guidelines. The value of this unstructured technique is wasted. It is the free interaction among the group, facilitated by the moderator, that produces its rich discoveries. Focus groups can also be a useful management tool. After conducting focus groups with health care clients, it can be illuminating to repeat them with the providers using the same discussion guidelines, and then match the insights. How do the clients feel about their providers? How do the providers feel about their clients? The results have led to substantial changes in training, supervision and operations.

We must learn to listen with an open ear. In Lesotho in 1990, investigators of villagers attitudes reported widespread ignorance and misunderstanding about family planning. 11 One in four women believed family planning caused illness. Contraception was perceived as causing dilution of mother's milk. But both of these could be true. The contraceptive pill has been known to affect blood pressure, the IUD to cause bleeding, the high-dose contraceptive pill to inhibit lactation. These are not ignorance and misunderstanding. They are real risks exaggerations perhaps, of minor fears but they must be dealt with and resolved and not dismissed out of hand. This is why qualitative research like the focus group is essential for behavioral diagnosis. But we have to do a better job of it.

Research has a tendency to dominate programs, with regrettable results. This has been true, for example, of a once popular question: the capability of mass media to affect behavior. Mass media s impact is as good or as bad as the messages. Measurements of mass media effectiveness, therefore, are really measurements of message quality. This serves to explain their contradictory conclusions. Researchers thought they were measuring one thing but were really measuring another. This can also be true of cost/benefit analyses. When we set out to measure the cost/benefits of strategies, we May actually end up measuring the performance of people, and that can vary widely. The same strategy implemented by two separate teams of people May have wildly divergent benefits for the same cost.

So we need caution not to fall prey to what I call The Sandbag and the Bicycle Switch. The customs inspector at the Canadian border accuses the man of smuggling in a mysterious bag of sand on the back of his bicycle when in fact the article being smuggled by the cyclist is the bicycle.

The dominance of research over action often leads us to research sandbags instead of bicycles with far too many studies not carefully matched to problems. One project in Peru presented at the 1991 International Nutrition Planners Forum (INPF) May very well have overlooked its bicycle problem and created a sandbag in its stead. Because it was judged difficult to change weaning practices, it was decided not to attempt it. Instead, a good weaning food recipe was converted to a diarrhea food on he assumption, not altogether clear, that parents would accept it more readily under pressure from the illness. But the planners of this otherwise seemingly well-organized effort ought to ponder three questions:

1. Do you believe nutrition education and its social marketing applications are capable of motivating behavior change?

2. Then, was it right to walk away from changing weaning practices merely because it was pre-judged difficult to do so?

3. Was it right to associate a good weaning food recipe only with diarrhea episodes?

Very often the problem is not the problem. When the problem is that new mothers are not breastfeeding, the problem is not that new mothers are not breastfeeding. The problem is hospital practices (no rooming in). Or, the problem is the pediatrician. Or, the problem is the manufacturer of artificial milks.

When the problem is the low level of contraceptive practice, the problem is not the low level of contraceptive practice. The problem is the male. Husbands do not discuss family planning with their wives. When the problem is diarrhea, the problem is not diarrhea. The problem is poor sanitation, poor sanitary practices, poor water supply. When the problem is lack of diarrheal management, the problem is not lack of diarrheal management. The problem is rehydration management. When the problem is goiter, the problem is not goiter. The problem May be that goiter is not perceived as a disease. When a program falters, the problem is not with the program.

The problem is in the message. Or, audience targeting. Or, research design. Or, in our expectations, our promises. The problem is strategy, strategy, strategy. If the problem is strategy, the problem is with us, with our failure to challenge, to pose questions of every fact, every opinion, every conventional wisdom. The peril in every innovative endeavor is its premature embalming in ceremony. The unique experience becomes routine, the unusual becomes commonplace. We May learn our social marketing lessons well, master the formula, recite the social marketing litany. We nimbly manage every step as though it were a dance. The more we enter into it, the more skilled we become until, finally, it is pure ceremony graceful and comely, yet glacial in its style.

Social marketing of nutrition education is a strategy, a means to an end. But nutrition education as ceremony becomes unresponsive to its ends mummified, rigid, sterile. We know the ropes, but we are tied up in them. We can recite the sophomoric four Ps of marketing, or dozens of formulaic Ps and As to Zs until we are anesthetized by this checklist thinking. We wait for evaluations to explain our lack of success, blind to the fault in ourselves, in our compulsion to formularize, to make dance routines of ingenuity, imagination and enterprise. We lose faith. We thrash around for new ceremonies to rescue us from the doldrums.

Social marketing is a new enterprise each time. Our ends are dynamic. If our imagination fails us in the setting and resetting of ends, our means will stultify. This is the challenge we face: to go beyond ceremony, beyond the well-worked forms of our last experience. To look at the new task ahead, the new end to be achieved, and ask how to determine the necessary creative inputs. I was invited three years ago to consult with The European Society for Social Pediatrics (ESSOP) in Bern, Switzerland.

These pediatricians from all over Europe had come to realize the limitations of the doctor/patient relationship in the face of the social dimensions of our major health risks. They had concluded that to be effective, disease prevention had also to deal with large population groups. Hence the name, Social Pediatrics. They perceived in social marketing a means to achieve scale. But not all of us are available to such innovative developments.

At the Sixth International Conference of the International Nutrition Planners Forum (INPF) in 1991, eight nutrition education case histories were presented. All eight were deliberate social marketing efforts. The local people are committed. But authorities at the top can be ambivalent about social marketing. For in the glow of such shining efforts the ghosts of orthodoxy still stalk, their chains of behavioral bondage clanging in the mists. The published report of the conference is entitled, Effective Nutrition Communication for Behavior Change.

Those responsible should be charged with the crime of deceptive labeling. In nutrition circles there can be no more heinous offense. Three more words would have set matters right: Effective Nutrition

This is a more truthful description of the contents. But the chains of behavioral bondage are often hard to break. John Maynard Keynes once declared: The difficulty lies not in new ideas but in escaping from old ones. 14 Despite the resistance, social marketing's acknowledgments proceed apace. The World Bank reports that "an increasing number of projects use a variety of qualitative research techniques: (like) focus group interviewing....Social marketing is being introduced to the human resource work of the African Region.... [Other social marketing components] have assisted ... projects in Bolivia, Mali and Zaire among others."

Alan Berg, in recommending the social marketing approach, refers to it as the new style nutrition education pioneered in Indonesia. That is precisely what social marketing accomplished in Indonesia which, in turn, became the model for Tamil Nadu in India and what it can do everywhere with more rigorous cultivation of its possibilities. Social marketing's usefulness extends to previously untried areas. Training offers an example.

Training is communication. It should be designed according to social marketing principles for all communications. The training of village health workers (VHWs) and community health workers (CHWs) is really nutrition education designed for health workers. The typical procedure for training starts at the top. Training materials and manuals are produced at a central training department of the health ministry where regional trainers receive their orientation. Then district trainers receive theirs from the regional trainers and, finally, the VHWs, CHWs, etc., receive theirs in the districts. This trickle-down training is not precisely providing the village with a voice.

We ought to reverse the process: start with the district workers meeting with regional trainers to give their insights into nutrition problems and aims, their critiques of the last training experience the materials, the manuals, the unnecessaries, the omissions. How do they think the next training could be improved? Regional trainers then share these insights with the people at the national training center before the actual training curriculum is carved in stone. These bottom-up inputs reflect the realities of village life and provide health workers with a voice in their own training.

This is the social marketing approach to training. If community participation is valid for nutrition education, it is valid for all its aspects. It is not divisible whether for the outside communications job with the public or the inside communications job with health workers that we call training. Even social marketing s mass media messages serve as a continuing in-service training for health workers, reminding them of the gospel to which they must keep faithful when in contact with their clients. This assures message harmony. Given the valuable use social marketing can make of the mass media, governments must be pressed to re-examine media policies so that the public media are made more available to nutrition education. But our minds are not altogether clear on this matter. Once again we must summon the 1992 ICN Plan of Action to the witness stand.

Analyzing the ICN Plan of Action

The ICN Plan of Action contains six sections. The first is an introduction. The second consists of 13 Major Policy Guidelines. Not one is devoted to nutrition education. There is a reference to it in the guideline entitled Focus on Women and Gender Equality. It merely offers advice that the nutrition education of men and boys should be enhanced. Period. The third section sets forth six major intersectoral Issues. Two of them one-third clearly acknowledge the importance of nutrition education. One refers to using mass media and the other to strengthening educational systems and social communications mechanisms. The fourth section is a discussion of nine Strategies and Actions.

Nutrition education does not rate either as a Strategy or an Action. Every one of these nine contains disuniform references such as mass media, social communications, increasing awareness, education and communications programmes, nutrition education, health information, promotion or community awareness. Only one, "Improving Household Security, deals importantly with nutrition education, devoting a 17-line paragraph to the subject. But the view is narrow. It declares that programmes should be directed at household leaders with particular focus on women (italics mine). Sections five and six the last two deal with Responsibility for Action and Recommendations for the Follow-Up of the Conference. The one pertinent statement is that the mass media should be mobilized by governments to help individuals and population groups achieve nutritional well-being. But no guidelines. The role of social marketing or anything remotely resembling it is notable by its absence.

All in all, one cannot escape the inference that among the Ministers and Plenipotentiaries representing 159 States and the EEC, nutrition education is not clearly understood, is considered peripheral, is paid a ceremonial respect but is not held in high regard. It is easy to read the lip service. But why? How can a Plan of Action for Nutrition deal so indifferently with nutrition education, potentially the most effective if not the only strategy for behavior change? The Plan should have had a tenth strategy, namely: Employing a New Nutrition Education Based on Social Marketing Disciplines. It would recommend new policy initiatives for mobilizing the mass media as recommended by ICN.

Mobilizing the Mass Media

With possibly the lone exception of The United States, governments control the airwaves. Where commercial channels are licensed, they are rigidly controlled. Public access to the air even for government-sponsored programs is obtained by special permission of the authorities and is doled out inadequately. The media authorities are clearly in need of a behavioral overhaul. They do not appreciate either the significance of the mass media to health and nutrition aims or the importance of nutrition to the national interest.

Media Workshops

Therefore, media decision-makers and programming officials are an ideal target audience for a special kind of nutrition education initiative in the form of Media Workshops. The objectives would be: 1) to sensitize them to the importance of nutrition to the nation's security; 2) to raise their awareness of the role mass media can play in nutrition education; and 3) to demonstrate the programming potential of nutrition for panel discussions, dramas and news programs. The new nutrition education deserves this acknowledgment of its importance and of the need to raise the nutrition profession's self-esteem. The ISSUE is often put to me: How can social marketing improve nutrition s status in the sectoral hierarchy? USAID s Richard Seifman has a short, pointed answer: Resources plus policy plus a public constituency equal power.

The success of the family planning movement is often cited as proof of this equation. But it is not an apt analogy. Family planning has one big advantage: a single, clearly defined objective lowering the birth rate and a relevant, single-minded, sharply defined behavioral strategy contraceptive practice. Family planning is defined by that and little else (except, perhaps, in developed countries where it more prominently offers fertility services).

Nutrition has no such single-mindedness in which to luxuriate. By the time we are through defining nutrition (if we can ever be through), we are enmeshed in a maze of interwoven problems like breastfeeding, diarrheal management, vitamin A, iron, iodine and other micronutrient deficiencies, protein/calorie insufficiencies, growth monitoring, immunization, food scarcity and/or security, agricultural, environmental, water and sanitation policies, and others almost ad infinitum.

Unlike family planning, the term nutrition is an abstract catch-all. Beyond its traditional food relationship, the meaning becomes unclear. Nutrition is a construct from which the component elements must be disaggregated. These are the nutrition ISSUEs or nutr-ISSUEs, to coin a word. They are the only means by which nutrition can be defined not nutrition but nutr-ISSUEs.

The word nutrition is fine inside the profession. But our messages to our publics are concerned with disease-specific nutr-ISSUEs and the behavior changes needed to prevent them. Dealing competently with each nutr-ISSUE builds respect for the nutrition profession.

International Nutrition News Service

That is why a second mass media initiative would also help: the organization of the International Nutrition News Service (INNS). INNS would provide the mass media in each country with news and feature releases for the press and ready-to-use scripts as inserts for radio/TV programs and newscasts. It would provide suggestions for panel discussions, offer supporting material questions and answers for panel participants, for example as well as material for other broadcast and telecast formats.

INNS will gather its material from USAID, The World Bank, WHO, FAO, UNESCO, NGOs, international foundations, advisory and consulting groups, publications and universities. It should be a joint effort of international aid agencies with its own staff of news writers and editors to provide a flow of media material so that the nutr-ISSUEs become a regular news beat.

There is no need to envisage the start of INNS as a full-blown news and information structure. Given the existence of other news gathering and disseminating organizations, INNS could enter into arrangements for hitching onto their networks. The explosion of new information dissemination technologies the fax, satellite transmissions, the digital revolution makes this initiative a timely one for nutrition.

The combination of the two initiatives the Media Workshops and the INNS will help to give nutr-ISSUEs a presence with the mass media that nutrition currently does not enjoy. Increased awareness among the media is the beginning of a higher level of esteem. This, in turn, leads to greater access.

This should prepare the ground for a third initiative to establish a mandated share of air time.

The Time Bank

The Time Bank represents the ultimate acknowledgment of health and nutrition s role in the national interest. Mobilizing the mass media, as recommended by ICN s Plan of Action, must provide for mandatory share-of-air. A proposed 10% of all radio and TV time periods is deposited in The Time Bank. It is administered by a quasi-public agency independent of political control.

The administrators of The Time Bank, in consultation with nutrition and health authorities, budget the radio and TV time to be reserved for each nutrition education program. Drafts are presented to national and local media authorities for withdrawals of time as needed.

The Time Bank acts as a social marketing agency in behalf of the nutrition section of the Health Ministry, the national nutrition institute or some equivalent body. In time, other agencies with public-agendas will seek their fair share. This is not to be discouraged. A critical mass of demand will fortify this new media policy. It could also harmonize intersectoral collaboration. This involvement of mass media authorities could well serve to cement relationships and minimize dissonant messages.

The Time Bank is consistent with public policies affecting land use, national seashores, waterways, incomes and even man- and woman-power in times of threat to national security. The principle of public claim to a share of property, income, service, is deeply rooted in every nation's purpose. None could function without it. As the concept of national security expands to embrace the health and nutrition of the nation for which the mass media are indispensable, then sane public policy demands that a fair share of media time be mandated for their benefit.

This is an initiative calling for vigorous political action. Government officials, legislators, regulators, must be lobbied with forceful presentations linking The Time Bank and nutrition education to national security. Community groups are needed to take up the cudgels. It will take time to effectuate The Time Bank and in some countries maybe never. But even the advocacy activity for the idea is bound to make for a more hospitable media environment for nutrition education.

All three mass media initiatives comprise another opportunity for which a critical mass of public opinion cannot indefinitely be denied. And this time it would be targeted at the media whose traditional behavior is inimical to the health of nations. Changing that behavior represents one of nutrition education s major opportunities.

Mobilizing the Private Commercial Sector

We need true leadership because from the beginning to the end our firmest assurance is in dedicated, motivated, inspired people at all levels. In 1987, the Rockefeller Foundation called a conference at Bellagio, Italy, to explore Why Things Work in family planning programs. Nine reasonably successful country ventures had been identified and their teams invited to present. I was a member of an expert panel assembled to identify the common elements that could explain their successes. After ten days we concluded that the only decisive common element we could discern was good people. Good people make good leaders and they can be overlooked. One of the frequently overlooked sources is the private sector the business sector which can be both ally and antagonist. Our responsibility is to differentiate potential friends from enemies and to mobilize their support. Let me suggest two business sector initiatives that illustrate how good business people would be likely to help serve nutrition s ends.

The Provita Plan

I call the first The Provita Plan for micronutrient fortified foods. The premise of The Provita Plan is a government/business collaboration. Government s job is to set standards for these products composition, quality, pricing, packaging and the like. Then it persuades manufacturers to make and market them. It is not unusual for their cost of marketing to exceed their cost of goods. They May be willing to accept a lower profit, but the possibility of a non-profit or a loss will tax their patriotism unduly.

The Provita Plan is designed to fix that problem. Provita is a brand name, a seal of approval. The government designs it, owns it and licenses it to selected manufacturers who agree to produce the fortified food in accordance with prescribed standards. In exchange, the government undertakes aggressively to promote the brand name on both radio and TV at no charge to the producers. In effect, the government says: You make the product. We'll make the market. You distribute it. We'll sell it.

The manufacturer s license is good indefinitely so long as all contractual arrangements are observed. The manufacturer May put his own name on the product along with the Provita brand name, so that, for example, it might be called:

Manoff's Provita Salt. Nutrition Fortified with Iodine. Or, Forman s Provita Cereal. Nutrition Fortified with Iron. Or, Keller s Provita Sugar. Nutrition Fortified with Vitamin A. This is the Provita Family of nutritionally fortified products. Separate radio and TV commercials would be prepared for each product. Advertisers are relieved of a major business cost, a very attractive incentive. The government owns a brand name under licensing arrangements that effectively provide enforcement. A good arrangement for both.

Nutrition Social Marketing Board

A second business sector initiative in every country, and one in which business is more than likely to participate, is the formation of a Nutrition Social Marketing Board (NSMB). The NSMB s function would be to provide interdisciplinary participation in the planning and execution of nutrition social marketing programs. It is comprised of executives of food companies, advertising agencies, the mass media, consumer research firms, nutritionists and nutrition educators; key government officials from agriculture, education, media, water and sanitation; and representatives of international aid agencies and NGOs.

The nutrition educators request the Board to form pro-bono teams of specialists in the planning and execution of nutrition social marketing ventures. Business executives would volunteer their marketing specialists; the ad agency, its planning and creative services; the media, pro-bono radio and TV time (from The Time Bank, if established); the research firm, the special social marketing field investigations; the various government sectors, an agreement on their respective collaborative roles.

An International Nutrition Social Marketing Board serves as an advisory body. It lends an international cachet to the initiative. It is composed of executives of international marketing firms, advertising agencies and related sectors. It meets periodically to assess progress of country programs and serves as an exchange for ideas and programs through seminars, award ceremonies and published reports. At both international and national levels, the NSMB would confer considerable esteem on the nutrition function with governments and sectoral officials. The new nutrition education does not need nutrition educators to do all the tasks that need doing. Instead, the need is for them to know what needs doing and how and where to find the best people. The need is for them to know how to work with the NSMB and the specialists it makes available.

Creativity and the Message

From the start, creativity is a must and creativity cannot be taught. In developing countries, there are talented people in research, marketing, communications, creative writing and design. The NSMBs and the new nutrition educators must ferret them out and offer them a window on the nutrition world. We need their skills and their talents. We should also give nutrition candidates a window on all these other worlds at the same time.

We are more likely to find promising talents that way than to try to build them all into the same individuals. The future nutrition educator will have to be more of a manager, and more of a nutrition
education program producer. It will minimize the risk and increase the likelihood of fresh ideas. This is especially important in regard to message design.

The message is the crucial intersection for all the program inputs the research, the problem analysis, the strategy decisions, the product development, the marketing, the community mobilization, and the intersectoral collaboration. They all come together at the intersection where we pick up the crossroads to our target audiences. The only passage is the message, whether the target is policy maker, farmer, water and sanitation officials, doctors, school officials, families or the Ministry of Health.

Until the advent of social marketing, message design had been an indifferently assigned responsibility. There are private sector communications and marketing entities advertising agencies and radio/TV program producers in which the importance of message design is properly acknowledged and assigned to their most talented people.

Such individuals will be available from NSMBs to lend their craft to nutrition education s purposes. It takes individuals to make movements. It takes inspired individuals to lead them. The challenge is to find them.

One day in 1975 or 1976, a spirited, highly unconventional young woman came to see me. Her name was Leah Margulies. She arrived in my office a few days later accompanied (much to my amused surprise) by three nuns in the orthodox garb of the Sisters of the Precious Blood. They were token stockholders in Bristol-Myers. They were the instigators of an organized stockholder initiative to force change in the company's marketing of infant formula. These four impassioned women, three of them Catholic nuns, the other a Jew, were among the handful of people around the world who by 1981 were able to move some 160 nations to adopt the International Code for the Marketing of Breastmilk Substitutes.

When Robert Choate stood up in Congress in the mid-sixties and assailed the empty calories of the cereal makers, he started a nutritional revolution in the United States that eventually spawned an extended family of equally inspired nutrition advocates. The revolution rolls on. These are not the exceptions to the rule of revolutions, of making a difference. They are the rule. But the demand for revolutions is greater than the supply. We need more inspired people to lead another worldwide nutrition education revolution. Leadership is more an emergence than a selection. The workers at every level know and can identify future leaders. They are the ones they go to for advice. The ones who will listen. The ones to turn to for example. The process thrusts up the leaders. They are creative, example-setting, inspiring, with vision, disciplined yet not tradition-bound, listeners, articulators, hard- working, principled collaborators. Their co-workers know who they are the women and the men. Directors can be appointed. Managers can be appointed. But leaders emerge.

They are in business, in government, in NGOs, in the neighborhoods, the barrios, and the villages. We need local constituencies to turn up the local temperatures, to take Nutr-ISSUEs public with social marketing initiatives so that the energies of people are released. This is really what we are about: to release the energy of the people, for leadership to emerge from among them, for generating behavior change in their institutions, their social structures, their governments and in themselves.

Richard K. Manoff

June 21, 1993


1. ICN. World Declaration and Plan of Action for Nutrition. Rome, Dec. 1992.

2. ACC/SCN. Second Report on the World Nutrition Situation. Vol. 1, Washington DC, Oct. 1992.

3. World Bank. World Development Report 1992. New York: Oxford University Press, Inc., 1992.

4. Xerophthalmia Club Bulletin. No. 52, London, March 1993.

5. Marek, Tonia. Ending Malnutrition: Why Increasing Income Is Not Enough. Washington, D.C.: World Bank, Oct. 1992.

6. IFPRI. IFPRI Report, Vol. 15, No. 1, Feb. 1993.

7. Angelou, Maya. On the Pulse of the Morning. New York: Random House, 1993.

8. Quindlen, Anna. Looking for Someone Who Looks Just Like You. International Herald Tribune,

9. Schama, Simon. Citizens. New York: Knopf, 1989.

10. Quindlen, ibid.

11. Salmen, Lawrence F. Reducing Poverty. Washington, D.C.: World Bank, 1992.

12. Verzosa, Cecelia C. Effective Nutrition Communication for Behavior Change. Report of Sixth Annual Conference of International Nutrition Planners Forum, Sept.4-6, 1991, UNESCO, Paris, France.

13. Report of the Sixth International Conference of INPF. Sept. 4-6, 1991, UNESCO, Paris, France.

14. Keynes, John M. The General Theory of Employment, Interest and Money. New York: Harcourt and Brace, 1936, p. viii.

15. Salmen, ibid.

16. Manoff, Richard K. Social Marketing: New Imperative for Public Health. New York: Praeger, 1985.

Contributors to the Sixth Annual Martin J. Forman Memorial Lecture


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Population and Reproductive Health News

Approved Project in Population and Reproductive Health
· Nicaragua - Health Sector Reform. Nicaragua has not been immune to the winds of reform blowing through the health sectors of many other countries, both developed and developing. The objective of this project is to support the implementation of the government's new health sector strategy, which emphasizes primary health care. Family planning is one of the government's eight priority interventions addressed through vertical programs. However, the redefined primary health care model highlights the need to integrate family planning with other maternal and child health services for reasons of efficiency and effectiveness. The project finances staff training in counseling and method selection. It will also include activities in institution building, service delivery, pharmaceuticals, hospital rehabilitation, and financing mechanisms. Total project costs are $20.1 million, including the equivalent of $15.0 million in credits from the International Development Association (IDA).

Project under Preparation
· Vietnam - Population and Family Planning Project Preparation). The population of Vietnam is over 70 million and is growing at an annual rate of 2.2 percent, prompting the government to consider slowing the rate population growth a priority. In addition, the results of a recent Demographic and Health Survey suggest a great interest in controlling fertility, with total fertility rates substantially higher than desired fertility. The high abortion rate - about one abortion per birth - also suggests the need for greater access to other forms of fertility regulation. This project will seek to improve the provision of family planning and family health services at the lowest levels, build management capacity in primary health, and strengthen population policy formulation. The activities to be financed include providing a range of family planning services for women and men, implementing social marketing of contraceptives, providing mobile and outreach family planning services, IEC, training, selected safe motherhood interventions, and facilities upgrading.

Learning from Project Completion Report (PCR)
· Bangladesh - Third Population and Family Health Project. The well- known lesson of the Bangladesh family planning program experience is its indication that fertility decline can take place even in countries with poor socioeconomic conditions. Part of the program's positive impact can be traced to this project. The PCR cites many factors as contributing to project success, including strong government commitment and extensive donor coordination that also involves government participation to ensure that project activities support the broader national strategic and project goals. A number of lessons learned in Bangladesh target specific Bank practices, and are especially germane to the current emphasis on implementation and supervision outlined in the Wapenhans report. Among them are the value of a strong IDA (International Development Association) presence in the field to guide project activities and the benefits of the greater-than-usual staff time allotted for supervision. The project was approved in 1986 and closed in 1992.

Demographic and Health Survey Results (preliminary)
· In the Philippines, fertility has not changed much since the early 1980s, with the total fertility rate (TFR) declining only gradually to 4.1 children per woman from a level of 4.3 in 1988. Contraceptive use has similarly remained flat.

· In contrast, the results from Kenya indicate significant fertility declines, with the TFR falling to 5.4, as opposed to the figure of 6.7 calculated from the 1989 survey. It is estimated that 33 percent of Kenyan women are using contraceptives, with 28 percent using modern methods.

· A similar decline was not seen in Senegal, where the TFR has fallen only gradually, from 7.1 in 1978 to 6.0 in the current survey. Increases in contraceptive use have also been limited, with only 7.4 percent of married women using any form of contraception. This does represent an increase from the 4.6 percent measured in 1986 and the 1.3 percent from 1978.

Publications of Note

Cost Recovery and User Fees in Family Planning, Karen G. Foreit and Ruth E. Levine, the Options Project, Policy Paper No. 5, September 1993. As health and family planning budgets become tighter and demand for services grow, many programs have adopted cost recovery schemes. Others have found that modest fees improve their clients' perception of the services. This policy paper provides guidelines for program managers on how to initiate cost recovery efforts and/or rationalize the existing fees charged to individual users of subsidized family planning outlets. Among the conclusions of the paper are that fees should be kept and used at the operational level where they are collected and charged for all services provided in a facility, not just family planning services. In all cost recovery schemes, adequate mechanisms for protecting the poor should be put in place; the two basic approaches discussed in the paper are means testing for sliding fee scales and adjusting fees by location and time of service to achieve self-selection.

Contact: The Futures Group, tel. (202) 775-9680


The National Council for International Health's (NCIH) 21st Annual International Conference, Population and the Quality of Life: A Dialogue on Values, will explore the linkages among population dynamics, health, and quality of life ISSUEs; review policies and programs aimed at influencing population dynamics; and clarify perspectives and values linking population, women's health, and human rights ISSUEs. The conference will be highly relevant to the upcoming 1994 International Conference on Population and Development. For further information, please contact the NCIH Conference Department, tel. 202-800-5903.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Population/Reproductive Health News


The Brazil AIDS and STD Control Project was approved by the Bank's Board this fiscal year. Brazil is estimated to have the fourth largest number of AIDS cases in the world. The available data suggest that Brazil suffers from between 40,000 and 70,000 cases of AIDS and from 300,000 to 425,000 cases of HIV infection. To address the threat of continued spread of the disease, the project will target prevention, treatment and surveillance, and research and evaluation activities. It will also build the institutional capacity of the National AIDS and STD Control Program, charged with leading Brazil's efforts to combat AIDS in coordination with state and municipal health authorities.

Prevention activities will include mass media campaigns, workplace education, and targeting of high risk populations - including intravenous drug users, commercial sex workers, and homosexuals - through financing of NGO projects. Over the life of the project, 200 million condoms are expected to be procured. Total project costs will be $250 million, supported by a $160 million World Bank loan.

The Chad Population and Health Project is under preparation, currently in the appraisal stage. Appraisal, which is carried out by the Bank, provides a comprehensive review of the project and lays the foundation for implementing the project and evaluating it when completed.

The government of Chad has recently confirmed its commitment to addressing the low health status and high fertility of its population (life expectancy of 47 years, maternal mortality of 700 deaths per 100,000 live births and infant mortality of 124 per 1,000 live births). This first IDA (soft loan) health sector project in Chad will strengthen the ability of the government to act on this commitment by providing family planning and basic health services to its population. It will assist the government in the design and implementation of a population policy, finance improved training and IEC programs, and upgrade service delivery in two regions.

<TOC3>> Lessons of Experience: Learning from Project Completion Reports (PCRs).

As the final step in supervision, regular projects staff-and usually the borrower-prepare a completion report on each project at the end of the disbursement period. PCRs are a central part of the Bank's project evaluation system.

Indonesia - Fourth Population Project. As one in a series of Bank projects in Indonesia, the Fourth Population Project further strengthen the ability of the National Family Planning Board (BKKBN) to carry out its major activities of service delivery, IEC, and research. A second project beneficiary was the Ministry of Population and Environment (KLH), which developed a long-term population plan of action and supported activities in universities and with NGOs. The project, which was approved in 1985 and closed in 1992, was seen to have a positive impact, achieving most of its stated objectives. While there were many lessons drawn from this experience, two stand out as salient to almost all Bank projects: the need for careful design of technical assistance, and the importance of ensuring ownership. The report notes that the project could have been more effective if the design of technical assistance components had been more thoroughly thought out, with specific consideration of the intended outcome and the capacity of recipient institutions to utilize it. In addition, the report noted that having two beneficiaries requires special efforts to build ownership on the part of both agencies and to coordinate their activities.


Contraceptive News

A new polyurethane condom will soon be marketed by the London International Group. The polyurethane condom is less likely to be affected by heat and humidity than the more common latex condom and unlike the latex variety is compatible with oil-based lubricants, as well as those with a water base. While the strength of the polyurethane condom is similar to latex, it has other advantages, being thin, clear, and odorless. It is, however, expected to cost more than latex condoms.

A recent update article in Network (October 1993) cites studies showing that progestin-only methods of contraception are safe for breastfeeding women and their infants. In addition, they generally do not affect milk production. Common progestin-only methods include progestin-only oral contraceptives known as "minipills", Norplant, and DMPA, an injectable. Given the proven safety of progestin-only contraceptives, WHO experts consider them appropriate for women who are breastfeeding.


The East-West Center Program on Population has announced its 25th Summer Seminar on Population, to be held in Honolulu, June 6 to July 3, 1994, and in Taiwan, July 4 to July 8. The program, intended to provide an opportunity for professionals in population-related fields to share and expand their knowledge of population and its relation to social and economic change, will have four different workshops followed by a field trip.

The workshop topics are:

· Advanced Methods for Family Planning Program Impact Evaluation
· Evaluating Policy Implications of the HIV/AIDS Epidemic in Asia
· Family Planning Program Accomplishments and Challenges: Analytical and Presentation Tools
· Population Aging and Inter-generational Transfers

The competitive selection of participants requires applications to be received by February 18, 1994. For more information contact the East-West Center, tel. 808-944-7444.


Labor and the Emerging World Economy, David E. Bloom and Adi Brender, Population Bulletin, Vol. 48, No. 2, October 1993. Even though population growth rates have leveled off in many countries, the number of people of working age will increase from 3 to 5 billion between 1990 and 2025. Over 90 percent of the increase will occur in developing countries, which already account for 75 percent of the world labor force. This paper examines the extent to which recent trends toward economic integration between countries has benefited workers in developing countries, and the extent to which it May do so in the future. The paper concludes that while recent integration has been lopsided - favoring the industrial world - the potential for mutually beneficial economic integration remains great.

Contact: Population Reference Bureau, tel. (202) 483-1100.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Population/Reproductive Health News


Comoros Population and Human Resources was approved by the Bank's Board this year. Comoros is one of the most densely populated countries in Africa. Its rapid rate of population growth, currently at 3.1 percent annually, contributes to the country's high ratio of dependents to the working age population and significant level of unemployment. As a result of these and other factors, a public consensus is emerging that the country is fast becoming overpopulated. Nevertheless, contraceptive prevalence is low (approximately 4 percent). Among other activities, this project attempts to increase access to and demand for family planning. It will finance in-depth studies to be used in the design and implementation of IEC and family planning programs; training of service providers; and provision of commodities. The project will also target AIDS control and improve regional health management capacity. The project takes a unique participatory approach. It includes a Community Development Support Fund to finance sub-projects developed by communities themselves with the participation of beneficiaries.

India Family Welfare (Assam, Rajasthan and Karnataka) Project is under preparation, currently in the appraisal stage. Appraisal, which is carried out by the Bank, provides a comprehensive review of the project and lays the foundation for implementing the project and evaluating it when completed.

The Indian Family Welfare program is principally responsible for providing family planning and maternal and child health services. Recognizing many problems with program organization and service delivery, the government proposed an Action Plan for improvement in 1992. Key elements of the plan include service quality improvements, expanded method mix to provide more temporary methods, and modification of the sterilization targeting and incentives systems to remove rigid, centrally-imposed targets, discontinue payments to motivators, and devolve responsibility to the states. This project will assist three states, Assam, Rajasthan, and Karnataka, to implement the action plan. Project activities include extending and upgrading infrastructure, strengthening outreach and community linkages, improving the quality of services, upgrading IEC, and improving program management. The project will include efforts to involve private voluntary organizations (PVOs).


Contraceptive News

A recent ISSUE of Outlook (Volume 11, No. 3, September 1993, published by the Program for Appropriate Technology in Health) provides a summary of the current thinking on the benefits and risks of oral contraceptives (OCs). Studies examining the links between OC use and cardiovascular disease, breast cancer, and HIV infection are reviewed. The piece concludes that while some small increased risk of cardiovascular disease exists among some women, other risk factors must also be present, such as smoking, diabetes, or hypertension. In addition, lower dose OCs available today decrease the risk due to the decreased amount of estrogen.

In the case of breast and cervical cancer, there is some evidence of slight increased risk, although the relationship between OC use and these cancers remains controversial. Amid recent concern about a possible association between use of OCs and HIV infection, the article notes insufficient evidence exists to establish a link. It is true, however, that OCs provide no protection against transmission of the AIDS virus. In general, the authors consider OCs to be a safe and highly effective contraceptive, with positive benefits - including protection against endometrial and ovarian cancer and reduction of menstrual cycle problems - outweighing any risks. The relative safety of OCs implies that family planning programs could reduce some of the barriers to access, such as allowing prescription only by medical doctors and requiring women to return monthly or quarterly for refills. A recent editorial in the Lancet suggests that OCs should be available over the counter.


· Who Gets Primary Schooling in Pakistan: Inequalities Among and Within Families, Zeba A. Sathar and Cynthia B. Lloyd, The Population Council Working Paper No. 52. Using data from the 1991 Pakistan Integrated Household Survey, this paper explores the factors affecting household decision-making on sending children to school. The results indicate that income and parental education, especially that of the mother, are key determinants, with poor and uneducated parents less likely to send their children to school. Within households, boys are more likely to be educated than girls. Also, larger numbers of siblings reduce the probability of primary school completion for children in urban areas and significantly reduce average education expenditures. This finding suggests an emerging quality-quantity trade-off between fertility and education.

Contact: The Population Council, tel. (212) 339-0500.

· Fertility, Family Size, and Structure: Consequences for Families and Children, Proceedings of a 1992 Population Council Seminar, edited by Cynthia B. Lloyd. This seminar was conducted as part of a research project on the consequences high fertility at the family level and its implications for the next generation. The proceedings include 14 papers covering the broad topics of: the costs and benefits of children; the parents' perspective; child health and nutrition; children's education and work; and consequences of sustained high fertility. Regionally, the results represent primarily South and Southeast Asia and sub-Saharan Africa.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank
Population/Reproductive Health News


Pakistan - Social Action Program Project is under preparation, currently in the appraisal stage. Appraisal, which is carried out by the Bank, provides a comprehensive review of the project and lays the foundation for implementing the project and evaluating it when completed.

The government of Pakistan has designed a Social Action Program (SAP) designed to strengthen basic social services - primary education, primary health care, family planning, and rural water supply and sanitation - during the Eighth Five Year Plan (1993/94 -1997/98). The SAP project aims to help relieve poverty, improve the well-being of families, and slow population growth in Pakistan by supporting the SAP.

In the population sector, the SAP seeks to dramatically increase service availability, with targets of 100 percent coverage in urban areas and 70 percent coverage in rural areas. The plan also calls for a near doubling of the contraceptive prevalence rate, which now stands at 12 percent, and a ten percent fall in the population growth rate, which is currently 3 percent annually. Specific activities under the project will be expanded village outreach, increased service delivery points, staff and management training, and strengthened IEC efforts.

Lessons of Experience: Learning from Project Completion Reports (PCRs).

As the final step in supervision, regular projects staff-and usually the borrower-prepare a completion report on each project at the end of the disbursement period. PCRs are a central part of the Bank's project evaluation system.

India - Third Population Project (Kerala and Karnataka). The third population project, approved in December 1983 and closed in March 1992, was implemented in two states, Kerala and Karnataka. In countries where the Bank has been involved in multiple projects, as is the case in India, learning from past experiences is crucial. Recognizing this, the PCR noted the extent to which this project resolved ISSUEs occurring in the preceding projects and commented on ways in which later projects incorporated the lessons learned in Karnataka and Kerala. For example, the report found that the success and sustainability of the third project was hampered by taking a project approach that targeted districts, rather than a program approach that also addresses management ISSUEs at the state level. Later India population projects, including the upcoming Family Welfare project (see page 2), focus on the state level. They also build on the highly successful in-service training and IEC programs begun under Population III. A cautionary note arises from this project, however, in regards to external evaluations: unless the evaluation is presented as an opportunity for learning and improvement, it is likely to have a negative impact by raising defensive reactions.


· Population and Land Use in Developing Countries, summary of a workshop, edited by Carole L. Jolly and Barbara Boyle Torrey, National Research Council (1993). The link between population growth and environmental degradation generally hinges on two factors: the environmental impact of large-scale urbanization and the changes in land use patterns and populations growth. This volume provides a synthesis and condensed versions of papers on the second set of interrelationships. The report considers the existing empirical research and notes the difficulties encountered in finding reliable date. One general theme drawn from the papers is agreement that in the long run, population growth almost certainly affects land use patterns through the extensification and intensification of agricultural production. However, given the numerous factors involved in this relationship, specific case studies are needed that clearly delineate the relative roles of markets, land tenure systems, soil quality, climate, and other factors affecting land use, in addition to those of population growth and density.

Contact: Committee on Population, Commission on Behavioral and Social Sciences and Education, National Research Council, tel. (202) 334-3167.

[The following articles are reprinted from Population Network News (PNN), No. 6, Winter 1994. PNN is a quarterly round-up of news and information relevant to Bank staff working in the population field. PNN is edited by Chantal Worzala.]


The following announcement was forwarded by the National Public Health and Hospital Institute (NPHHI). The Department of International Projects at the National Public Health and Hospital Institute (NPHHI) currently maintains a collection of three public electronic forums on Health and Medical Care in the New Independent States of the former Soviet Union (NIS) and the US. These electronic forums are sponsored by the American International Health Alliance (AIHA) which coordinates partnerships between hospitals in the United States and the former Soviet Union.

Projects currently being developed for the conferences include a directory of users in the NIS and around the world who are involved with health care in the NIS. Also, NPHHI is creating a directory of institutional and individual research grants available in the international health field.

NPHHI electronic services

· aiha. info-various directories of information relating to health and medical care in the NIS (includes a US-NIS drug equivalency index, a directory of health-related assistance projects in Eastern Europe and the NIS, and almost any other type of information related to health care)

· aiha, med-treat-articles and discussion relating to clinical medical treatment in the US and the NIS

· aiha, med-pol-articles and discussion relating to ISSUEs of health policy in the US and the NIS

We are offering free subscriptions to these three conferences, and we encourage participation and contributions from anyone. In order to subscribe, just send a message to (World Bank staff should add @INTERNET at the end). You will be able to post messages by using this address and messages posted by other participants will be forwarded to you as e-mail messages.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Success in a Challenging Environment: Fertility Decline in Bangladesh

Based on the World Bank sector study Bangladesh - The Determinants of Reproductive Change, this booklet highlights the successes and lessons of the Bangladesh case, where fertility has fallen from a total fertility of seven births per woman in 1975 to well below five in 1990. At the same time, contraceptive prevalence has correspondingly increased dramatically.

The study shows that a high level of political commitment to family planning, combined with a strategic program approach, can have a significant impact on reproductive behavior, in spite of considerable economic, social and cultural obstacles that are generally thought to preclude fertility decline, such as low levels of education and female status.

The Bangladesh case also highlights the value of gradual development of family planning programs building on in-country experience. The Bangladesh program tested a variety of approaches, including strong IEC (Information, Education, & Communication) efforts and door-to-door services. The resulting system of service delivery is well adapted to the country's needs and cultural realities.

Moreover, the donor consortium approach used in Bangladesh has proven instrumental in mobilizing substantial financial resources for the sub-sector and in coordinating external donors' support for the Government's program. This approach facilitated the dialogue and partnership between the government and donors for program development and for monitoring and evaluation, thereby contributing to the success of the program.

Contact: Population Reference Bureau for the booklet, which is written in style appropriate for policy makers in both developed and developing countries. The full study, written by John Cleland and James Phillips, will soon be published in the World Bank's Regional and Sectoral Studies series.

1994 International Conference on Population and Development (ICPD '94)

Recent Events....

The annotated outline of the document to result from the ICPD, commonly know as the Cairo document, was debated at the UN General Assembly on November 4-5, 1993. Over 40 delegates from around the world provided feedback on the outline, as well as a representative of the NGO community. At the meeting, Dr. Nafis Sadik, ICPD General Secretary, stressed that while the conference will discuss the interrelationships between population, resource use, the environment and sustainable development, "we must keep firmly in our minds the centrality of population ISSUEs as we prepare for Cairo."

Other ISSUEs raised at the General Assembly included the respective roles of both developed and developing countries in the achievement of sustainable development; the need for increased attention to special groups such as adolescents and indigenous peoples; and vigilant respect for the rights of individuals in all discussions of population and development.

In addition to the General Assembly discussion, a number of Round Table discussions have taken place on specific topics, such as the demographic impact of AIDS, women, and population and development strategies. They will result in specific recommendations to the Cairo conference.

Currently, the ICPD Secretariat is preparing its first draft of the Cairo document, to be completed by February 1994. The next step in the ICPD process is the third session of the Preparatory Committee, to take place in New York from April 4-21, 1994. The Conference will take place in Cairo, 5-13 September.

...And Bank Involvement

The Bank has been involved in the lead-up to the Conference in a number of ways. Bank representatives have been present at all but one of the expert group meetings, as well as at every regional meeting and the first preparatory committee meeting. The Vice President for the Middle East and the North Africa region addressed the Arab Regional Conference. Other Bank contributions to conference activities include:

· Providing a grant to the Center for Population Options(CPO) to ensure that the special needs and concerns of adolescents are given adequate attention in Cairo, including funding the attendance of adolescents and leaders of groups addressing their concerns at the Conference.

· Granting funds to the Center for Economic Development and Population Activities (CEDPA) to sponsor the attendance of women NGO leaders at the conference.

· Allocating additional monies to sponsor NGO delegate participation at the ICPD, potentially to include funding of the NGO Committee organizing the NGO Forum.

· Cosponsoring with the Rockefeller Foundation, the Population Council, and the Group of Non-Aligned Nations a Forum on Population and Development in Bellagio. The purpose of the meeting was to encourage high-level political and financial support for population work. It was attended by representatives of both the donor community and developing countries.

In addition to these activities, the Bank is currently preparing a population sector overview, examining the history and future of Bank involvement in the sector in light of recent changes in the field. The document will be available at the Conference to provide background and guidance on trends in the sector and the Bank's role in addressing the ISSUEs of population and sustainable development.

[The following articles are reprinted from Population Network News (PNN), no. 6, Winter 1994. PNN is a quarterly round-up of news and information relevant to Bank staff working in the population field. PNN is edited by Chantal Worzala.]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

The how-to of health reform

Health reform: It May be an obvious priority, and to many a seemingly straightforward concept. But planners across the world often stumble when trying to implement reform, foiled by nitty-gritty realities that wreck their best-laid plans.

Given this frustrating record and the urgent need to learn how to be more effective, PHN (Department of Population, Health and Nutrition) brought together roughly 30 interested Bank staff for a day-long discussion of Planning and Implementing Health Reform, January 10. The first in a series to be held in the coming months on this ISSUE, the meeting focused on learning from the experience of Bank task-managers in aiding health sector reform efforts across the globe.

Julie McLaughlin and Jean-Louis Lamboray, both of PHN, report in brief on main themes that emerged in the discussion: (participant list found below)

·· We know WHAT needs to be done. But we need to understand the HOW: how people "produce" health; how to ensure technical efficiency of health care systems; how to change corporate culture in bureaucracies dealing with health; how to adapt health policy making to the momentous changes that have swept the globe.

·· We need to develop our understanding of the determinants of health. We agree that health is broader than health care. Yet, we find ourselves confined to discussing only health care reform. We agree that people, not health services, produce health. But beyond that statement the mystery remains: how do peoples' interactions within the household and the community, with service providers, and with their physical, biological, cultural, economic and political environment determine their health? We have yet to develop a common language that would allow us to analyze and act upon micro, meso and macro determinants of health.

·· We have to focus much more on understanding the kinds of health systems required for ensuring effective utilization of health, population and nutrition interventions. For people to enjoy music they need both records and a record player. For people to be in good health they need cost-effective interventions delivered by a performing health care system. We are literally flooded with experts advertising "records": the EPI record, the MCH/FP record, the TB record, the STD/AIDS record....

Unfortunately the record player itself is often broken. Very few people know how to repair it, and the repair manual remains to be written.

Epidemiology and intervention research tells us what needs to be done. But the simple availability of the intervention does not guarantee its effective use at the lowest cost. Improving the delivery of services is essential to increasing coverage and utilization.

The need for greater emphasis on quality assurance was brought up repeatedly. Poor quality of care was emphasized in discussions on Russia, Brazil and Indonesia, but it is a problem that afflicts virtually every country. Improved quality of services are a precondition to increasing utilization of services and efficiency.

·· We must address the question of how to foster attitudes that provide caring service to clients. Throughout the world, clients complain about health provider attitudes. AIDS, a disease without an effective cure, has reminded the international health community that people want to be cared for - even when no cost-effective cure is at hand. Why don't people utilize cost-effective interventions such as EPI and ORT? The major reason is probably that providers don't care. And providers don't care because they have no incentive to do so. Too often, Ministry of Health staff care more about their powers than about the quality and equity of health services - a flaw shared by international multi- and bilateral agencies.

The role of incentives - more correctly, determinants of motivation - demand attention. Poor quality can cripple a system's ability to improve health status, and hence monitoring and evaluation needs to be an integral part of the planning and feed-back process. Yet, standards and targets should be tailored to what can be achieved by that particular country, or client governments and donors will quickly become discouraged with the reform process. We were cautioned not to let the "optimal" become the enemy of the "practical".

Must read article

The public-private debate: Stumped by the complexities of judging whether the private sector needs to play a bigger role in health services in the country you work on? Can't think of ways to raise the quality and coverage of publicly-delivered health services?

Need a thoughtful review of the relative strengths and weaknesses of the private and public sector in health delivery and finance?

For any of these needs, turn to Julio Frenk's "The public/private mix and human resources for health," published in Health Policy and Planning. Too complex to be usefully reviewed, Frenk's work is untainted by dogmatism and will challenge many people at the Bank.

Task managers will find particularly useful his analysis of ways to make publicly-delivered and financed health services work better, of which Frenk writes, "the general point of these various innovations is that, before rushing to dismantle public systems which have been constructed over long periods of time, we should imaginatively look for the manifold ways in which they can be improved." (Editor)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Dear PHNFLASH Subscribers:

PHNFLASH was developed to serve as an electronic broadcast medium which would provide our colleagues with information relevant to population, health, and nutrition ISSUEs. PHNFLASH complements the World Bank's Public Information Center (PIC), an electronic service which provides access to World Bank publications via the Internet (contact

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Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Dear PHNFLASH Subscribers:

Thank you for your time in filling out the survey. We will do our best to incorporate your comments and suggestions in our future activities. If you tried sending back the survey to our office and received an error message, please contact us by sending a message to and we will correct the mismatch in your e-mail address. We have attached the survey at the end for those who did not have the opportunity to fill it out last week.

Thank you very much.

Project: Nicaragua: health sector reform

[IDA $15 ml, total $20.1 ml; approved Dec 16 '93. Pop 4.3 ml; GNP per cap $422; life exp 67; U5MR 66; MMR 159; TFR 5.1]

In January 1993, the Government appointed a new management team at the Ministry of Health, which started to radically transform the management of the sector. This new team, including the Minister, came from the Ministry of Finance. Their analysis of the sector placed emphasis on the management and financing of the health sector, an approach differing from that of most health ministers in Latin America who are usually doctors, thus more technically oriented. The Government requested the Bank to help design and support a reform of the health sector. Building upon sector work undertaken in 1992, the Bank helped the Government design a clear strategy for the sector.

This strategy is to increase efficiency in the use of existing resources, provide incentives for cost savings by delegating more decisions on resource allocation to local levels, and stimulate the increased participation of the private sector in the financing and delivery of health services. Increased cost recovery at the secondary level, principally through the sale of health services to the Social Security Institute, would be used to improve service at the primary level. The Ministry would enter into management agreements with the departmental health units, which would receive funds from the center. The Government explained its new strategy to the population and various interest groups through the staging of meetings and seminars that helped build consensus.

To support the strategy, a project was prepared that includes institutional strengthening of the Ministry of Health, support for an integrated primary health care delivery model, strengthening of the pharmaceutical supply and distribution system, rehabilitation and maintenance of hospitals, and technical assistance to the Social Security Institute. The project had to be carefully thought out as the Government wanted to undertake bold reforms, but there was a lack of institutional capacity in the country. Based on experience of other Bank projects, the project was designed to be implemented gradually so as to allow the Ministry to build up institutional capacity and demonstrate results in an initial phase before implementing a broader reform.

Policy brief: malaria

Not only can bed nets treated annually with insecticide sharply lower childhood mortality and sickness from malaria, but the intervention is highly cost effective, comparing "very favorably with measles vaccination and the use of oral rehydration fluids," reports Brian Greenwood, director of a large-scale trial in The Gambia, in "Transactions of the Royal Society of Tropical Medicine and Hygiene". The intervention is likely to work equally well in other parts of the Sahel, though it remains to be seen whether it can be replicated in other regions. (Recommended; editor) A wealth of excellent studies on malaria control are available - including a chapter in the Bank's "Disease Control Priorities" series - and a welcome new addition is "Implementation of the Global Malaria Control Strategy", number 839 in the WHO Technical Report Series. This 50-odd page report "gives guidance for the implementation of the Global Strategy," laid out in another WHO document, "A Global Strategy for Malaria Control", published last year. Major constraints on cutting the toll taken by malaria include low coverage and poor quality of existing health services, the lack of managerial and epidemiological capability to bring programs in line with WHO's Global Strategy, and the dire lack of financial and technical resources needed to implement malaria control programs.

The US Agency for International Development is planning deep cuts in its $2.5 million annual funding of the UNDP/Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), reports the New York Times, Feb 13, a move that could derail the development of a promising new malaria vaccine and encourage other donors to pull out. D.A. Henderson, currently an US assistant secretary of health, is quoted as saying, "Once you kill the research it is dead." Despite a budget of only $30 million a year, TDR is widely respected for advancing the development of drugs for the neglected tropical diseases.

[The following is reprinted from Health Policy, Number 6, March, 1994 ISSUE. Health Policy is edited by Siddharth Dube]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Dear PHNFLASH Subscribers:

Attached is an announcement by the American Public Health Association Clearinghouse on their recent acquisitions of articles that May be of your interests. We thank Ms. Virginia Yee of the Clearinghouse for making this information available.

PHNFLASH Moderator

American Public Health Association Clearinghouse

New Acquisitions

For the last fourteen years, the Clearinghouse on Infant Feeding and Maternal Nutrition has been providing information to practitioners and policymakers in developing countries. Based at the American Public Health Association, the Clearinghouse database includes more than 17,000 books, documents and education materials. Materials in the collection are computer-referenced for easy access. The project is supported by the Office of Nutrition, Agency for International Development.

The following is a bibliography of some recent acquisitions. This listing includes articles about adolescence, anthropology, breastfeeding, child development, education materials, evaluations, growth monitoring, information, education and communication, maternal health, maternal and child health, micronutrients, nutrition, and women.


Barker, G. Adolescent fertility in Sub-Sahara Africa: strategies for a new generation. The Center for Population Options, International Center on Adolescent Fertility, Mar 1992. (Doc #14304).

Address: International Center on Adolescent Fertility (ICAF), The Center for Population Options, 1025 Vermont Avenue, NW, Suite 210, Washington, DC 20005, USA.

Elster, A. B. Confronting the crisis in adolescent health: visions for change. Journal of Adolescent Health, 14:505-508, 1993. (Doc #14316).

Address: Arthur B. Elster, MD, Department of Adolescent Health, American Medical Association, 515 North State Street, Chicago, IL 60610, USA.

Marques, M.; et al Gente joven/young people: a dialogue on sexuality with adolescents in Mexico. The Population Council, 1993. [booklet] (Doc #14347).

Address: Ann Leonard, Quality/Calidad/Qualite, The Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA.


Dettwyler, K. A. Biocultural approach in nutritional anthropology: case studies of malnutrition in Mali. Medical Anthropology, 15:1, 17-39, 1992. (Doc #14296).

Address: Katherine A. Dettwyler, Assistant Professor, Department of Anthropology, and Graduate Faculty of Nutrition, Texas A&M University, College Station, TX 77843-4352, USA.


Cumming, R. G.; Klineberg, R. J. Breastfeeding and other reproductive factors and the risk of hip fractures in elderly women. International Journal of Epidemiology, 22:4, 684-691, 1993. (Doc #14344).

Address: Robert G. Cumming, Department of Public Health A27, University of Sydney, Sydney 2006, Australia.

Harrison, G. G.; et al Breastfeeding and weaning in a poor urban neighborhood in Cairo, Egypt: maternal beliefs and perceptions. Social Science Medicine, 36:8, 1063-1069, Apr 1993. (Doc #14302).

Address: Gail G. Harrison, Division of Population and Family Health, School of Public Health, University of California, Los Angeles, CA 90024, USA.

Hills-Bonczyk, S. G.; et al Women's experiences with combining breastfeeding and employment. Journal of Nurse-Midwifery, 38:5, 257-266, Sep-Oct 1993. (Doc #13184).

Address: Laura Duckett, RN, PhD, University of Minnesota, School of Nursing, 6-101 Unit F, 308 Harvard Street, Minneapolis, MN 55455, USA.

Kramer, F. M.; et al Breastfeeding reduces maternal lower-body fat. Journal of the American Dietetic Association, 93:4, 429- 433, Apr 1993. (Doc #14301).

Address: F.M. Kramer, Research Psychologist, U.S. Army Natick Research, Development and Engineering Center, Natick, MA 01760- 5020, USA.

Natural family planning: what health workers need to know. World Health Organization, 1993. (Doc #14322).

Address: Unit of Family Planning and Population, Division of Family Health, World Health Organization, 1211 Geneva 27, Switzerland.

Taren, D.; Chen, J. Positive association between extended breastfeeding and nutritional status in rural Hubei Province, People's Republic of China. American Journal of Clinical Nutrition, 58:862-867, 1993. (Doc #14335).

Address: D. Taren, University of Arizona, College of Medicine, Department of Family and Community Medicine, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.

Valaitis, R. K.; Shea, E. Evaluation of breastfeeding promotion literature: does it really promote breastfeeding? Canadian Journal of Public Health, 84:1, 24-27, 1993. (Doc #14349).

Address: Ruta Valaitis, School of Nursing, HSC 2J28, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5.

Yang, C. P.; et al History of lactation and breast cancer risk. American Journal of Epidemiology, 138:12, 1050-1056, 1993. (Doc #14342).

Address: Richard P. Gallagher, Division of Epidemiology, Biometry, and Occupational Oncology, British Columbia Cancer Agency, 600 West 10th Avenue, Vancouver, British Columbia, Canada V5Z 4E6.


Black, M. Street and working children: Innocenti global seminar summary report. UNICEF International Child Development Centre, 1993. (Doc #14348).

Address: UNICEF International Child Development Centre, Piazza Santissima Annunziata, 12, 50122 Florence, Italy.

Salach, S. In first person plural: growing up with a disadvantaged community. Bernard van Leer Foundation, Oct 1, 1993. [book] (Doc #14331).

Address: Bernard van Leer Foundation, P.O. Box 82334, 2508 EH The Hague, The Netherlands.


Bendezu G., A.; et al Educacion en sexualidad para jovenes y adultos, 1992. [book] (Doc #14339).

Address: Asociacion Peru Mujer, Apartado Postal 11-0206, Lima 11, Peru.

Safe motherhood/Child's play/Johnny sad boy. UNICEF, 1993. [3 animated films on video] (Doc #14338).

Address: George McBean, Communications Officer, UNICEF, Caribbean Area Office, Box 1232, Bridgetown, Barbados, West Indies.


Feuerstein, M. T. Participatory evaluation: the Patna experience. Contact, Issue No. 132, 1-15, Aug 1993. (Doc #14350). Address: Contact, Christian Medical Commission, World Council of Churches, 150, route de Ferney, 1211 Geneva 2, Switzerland.


Censo de talla en escolares. Ministerio de Educacion, Republica del Peru; UNICEF; Programa Mundial de Alimentos (PMA); Apr 1993. [book] (Doc #14276).

Address: Programa Mundial de Alimentos, Av. Canaval y Moreyra 590 San Isidro, Apartado 4480, Lima, Peru.

Msefula, D. How can growth monitoring and special care of underweight children be improved in Zambia? Tropical Doctor, 23: 3, 107-112, Jul, 1993. (Doc #14315).

Address: Derrie Msefula RGN MRM MSc, Orthopaedic Directorate, Royal Liverpool University Hospital Trust, Prescot Street, Liverpool L7 8XP, U.K.

Thaver, I. H.; Husein, K.; Cara, N. B. "P" in GMP - a major shift in growth monitoring program of a primary health care project. Southeast Asian Journal of Tropical Medicine and Public Health, 24:1, 23-27, Mar 1993. (Doc #14300).

Address: Department of Community Health Sciences, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan.


Beauvais, D. Portable video production: a training kit, 1990. [3-book manual and video] (Doc #14332).

Address: Video Tiers-Monde Inc., 3680 rue Jeanne-Mance, bureau 430, Montreal, Quebec, H2X 2K5, Canada.

Fryer, M. L. Health education through interactive radio: a child-to-child project in Bolivia. Health Education Quarterly, 18:1, 65-77, 1991. (Doc #14351).

Address: Michelle L. Fryer, Education Development Center, 55 Chapel Street, Newton, MA 02160, USA.

Hawes, H.; et al Children for health: children as communicators of "Facts for Life". The Child-to-Child Trust; UNICEF, 1993. [book] (Doc #14330).

Address: TALC, P.O. Box 49, St. Albans, Herts AL1 4AX, U.K.

Wells, D. Introducing computers into development programmes: some problems and suggested solutions. Development in Practice, 3:1, 36-43, Feb 1993. (Doc #14306).

Address: Duncan Wells, Informatics Development Coordinator, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, U.K.


Bianco, M. Por una maternidad sin riesgos. Fundacion para Estudio e Investigacion de la Mujer, Junio 1992. [book] (Doc #14329).

Address: Fundacion para Estudio e Investigacion de la Mujer, Parana 135 3ro. "13", (1017) Buenos Aires, Argentina.

Graham, W. J.; Filippi, V. G. Monitoring maternal health goals: how well do the indicators perform? Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, 1994. [booklet] (Doc #14341).

Address: Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, U.K.

Kinoti, S. N.; Mpanju-Shumbusho, W.; Mati, J. K. Policy implications of reproductive health research findings in East, Central and Southern Africa: summarized outline results. Reproductive Health Research Programme of Commonwealth Regional Health Community Secretariat (Tanzania), 1993. [booklet] (Doc #14340).

Address: APHA Clearinghouse, 1015 15th Street, NW, Washington, DC 20005, USA.

Shiferaw, T.; Tessema, F. Maternal mortality in rural communities of Illubabor, Southwestern Ethiopia: as estimated by the "sisterhood method". Ethiopian Medical Journal, 31:239-249, 1993. (Doc #14346).

Address: Dr. Tesfaye Shiferaw, Department of Community Health, Jimma Institute of Health Sciences, P.O. Box 378, Jimma, Illubabor, Ethiopia.


Chelala, C. Planting the seeds: binational efforts to improve maternal and child health care in the United States-Mexico border area. Pan American Health Organization (PAHO), 1993. [booklet] (Doc #14337).

Address: Dr. Solis, Regional Advisor, Division of Maternal and Child Health and Family Planning, Pan American Health Organization, 525 23rd Street, NW, Washington, DC 20037, USA.

Victora, C.; et al Pastoral da crianca e a saude materno- infantil em dois municipios do maranhao. UNICEF, Nov 1991. (Doc #14317).

Address: Oscar Castillo, Oficial de Saude, UNICEF, SBS - Edificio Seguradoras - 13 Andar, Caixa Postal 04,0084, Brasilia, DF, CEP 70072, Brasil.


Dunn, J. T.; van der Haar, F. Practical guide to the correction of iodine deficiency. WHO; UNICEF; International Council for Control of Iodine Deficiency Disorders (ICCIDD), 1990. [manual] (Doc #10073). Address: World Health Organization, Nutrition Unit, 1211 Geneva 27, Switzerland. Gorstein, J.; et al Global prevalence of iodine deficiency disorders. WHO; UNICEF; International Council for the Control of Iodine Deficiency Disorders (ICCIDD), Jul 1993. [booklet] (Doc #14363).

Address: World Health Organization, Nutrition Unit, 1211 Geneva 27, Switzerland.

Guerra, E. M.; et al Prevalencia de deficiencia de ferro em gestantes de primeira consulta em centros de saude de area metropolitana, Brasil. Etiologia da anemia. Revista Saude publica, S. Paulo, 26:2, 88-95, Apr 1992. (Doc #14299).

Address: E.M. Guerra, Av. Dr. Arnaldo, 355 - 01246-902, Sao Paulo, SP, Brasil.

Rankins, J.; et al Undernutrition and vitamin A deficiency in the Department of Linguere, Louga Region of Senegal. American Journal of Clinical Nutrition, 58:1, 91-97, 1993. (Doc #14298).

Address: J. Rankins, NFMS, College of Human Sciences, The Florida State University, Tallahassee, FL 32306-2033, USA.

Smitasiri, S.; et al Social marketing vitamin a-rich foods in Thailand. Office of Nutrition, Bureau of Research and Development, A.I.D.; Institute of Nutrition, Mahidol University, 1993. [book] (Doc #14333).

Address: The Institute of Nutrition, Mahidol University (INMU), Salaya, Phutthamonthon, Nakhon Pathom 73170, Thailand.


Alderman, H.; Garcia, M. Poverty, household food security, and nutrition in rural Pakistan. International Food Policy Research Institute, 1993. [book] (Doc #14327).

Address: International Food Policy Research Institute, 1200 17th Street, N.W., Washington, D.C. 20036-3006, USA.


Linnecar, A.; Yee, V. Maternity leave legislation. World Alliance for Breastfeeding Action, Nov 1993. (Doc #14308).

Address: World Alliance for Breastfeeding Action, P.O. Box 1200, 10850 Penang, Malaysia.

Morna, C. L.; et al When women learn, everyone benefits. African Farmer, 8, 15-21, Mar 1993. (Doc #14307).

Address: Carol Coonrod, The Hunger Project, Global Office, One Madison Avenue, New York, NY 10010, USA.

Norsigian, J. Women and national health care reform: a progressive feminist agenda. Journal of Women's Health, 2:1, 91- 94, 1993. (Doc #14345).

Address: Judy Norsigian, Boston Women's Health Book Collective, 240A Elm Street, Somerville, MA 02144, USA.

Women in development report, FYs 1991 and 1992. Office of Women in Development, Bureau for Research and Development, A.I.D., Dec 1993. [book] (Doc #14336).

Address: Publications Manager, Office of Women in Development, Room 714, SA-18, U.S. Agency for International Development, Washington, D.C. 20523-1816, USA.


Gill, G. J. O.K., the data's lousy, but its all we've got (being a critique of conventional methods). Sustainable Agriculture Programme, International Institute for Environment and Development, 1993. (Doc #14303).

Address: International Institute for Environment and Development, Sustainable Agriculture Programme, 3 Endsleigh Street, London WC1 HODD, U.K.

Randel, J.; German, T. Reality of aid: an independent review of international aid. Actionaid, Jun 1993. [book] (Doc #14334).

Address: Actionaid, Hamlyn House, Macdonald Road, Archway, London N19 5PG, U.K.

Tumwine, J. K. Zimbabwe's success story in education and health: will it weather economic structural adjustment? Journal of the Royal Society of Health, 112:6, 286-290, Dec 1992. (Doc #14297).

Address: James K. Tumwine, MB, ChB, MMed, FRSH, 23 Edinburgh Drive, Kidlington, Oxford, OX5 2JF, U.K.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Peru: Basic Health and Nutrition Project

[IBRD $34 ml, total $44.5 ml; approved Feb 3 '94. Pop 21.9 ml; GNP per cap $1070; life exp 64; U5MR 69; MMR 165; TFR 3.4]

Polly Jones, task manager, writes: "Peru faces serious health and nutrition problems. Infant and maternal mortality rates are among the highest in Latin America. A major share of morbidity and mortality could be prevented by increased coverage of basic services such as attended deliveries. Levels of child malnutrition have not declined significantly over the last two decades. Slightly over a third of children under the age of 5 suffer from chronic malnutrition (short for age) and about 10 percent from global malnutrition (underweight for age). Weaknesses in the provision of basic health and nutrition services, particularly in rural areas, include: low and uneven coverage; poor quality due to the lack of equipment and drugs and poorly trained staff, among other factors; and inadequate attention to prevention, particularly with regard to health and nutrition education and community outreach.

The project supports the Government's poverty alleviation strategy because it encompasses rural and indigenous people among whom the incidence of extreme poverty is highest. It also focuses on vulnerable groups such as pregnant and lactating women, children and the chronically ill. The objective of the project is to improve health and nutritional status in the project area, particularly among poor women and children, by: (a) increasing use of maternal and child health and nutrition services by extending access and improving the quality of services; and (b) promoting better health and nutritional practices, with an emphasis on preventive care and education.

The project will be carried out in three regions, in addition to Lima: Grau, Nor Oriental del Maranon and Inka. In all, 15 provinces are included in the project area, of which all but 2 are classified by the Government as "most deprived". Within Lima, the project covers the district of San Juan de Lurigancho, one of the poorest areas of the city. The project has five components: maternal and child health; nutrition; tuberculosis treatment; information, education and communications; and management and evaluation.

The project design does not include new construction, but instead aims to improve the functioning of available infrastructure through the provision of basic equipment and medicine. Community outreach is emphasized, including the participation of existing community health workers. The project envisages the use of experienced NGOs to supplement the Government's capacity, and steps have been taken to facilitate their participation. The project aims to improve the effectiveness and targeting of the Government's current food assistance programs by expanding child growth monitoring, strengthening education activities, particularly to improve breast-feeding and weaning practices, and by providing micronutrients. No food is being financed under the project. Malnourished children identified through growth monitoring would be enrolled in existing food assistance programs."


Is exclusion of high-risk blood donors a reliable and low-cost method of cutting the risks in Africa of transfusion-transmitted HIV infection? So far, the consensus has been no, based on the argument that risk groups are hard to identify in Africa because of high rates of HIV infection in the general population. But in Excluding blood donors at high risk of HIV infection in a west African city, "British Medical Journal", Richard Schutz et al. report on a trial in Abidjan where behavioral risk factors had a high predictive value in identifying sero-positive donors. They write, "Even in areas with high rates of HIV infection not everyone is at equal risk." Important risk factors included contact with women prostitutes, a history of sexually transmitted diseases, and being between 30-39 years in age; exclusion criteria are likely to differ in other cultural settings, the authors note. Using the first risk factor - a history of contact with prostitutes - "at a cost of less than one third of the total units of blood donated almost three quarters of infected units could have been excluded, and over a quarter of units excluded would have been from donors who were infected with HIV," the authors note. They conclude, "Although the priority must remain to extend HIV testing to all units of blood transfused, donor deferral merits investigation in resource poor areas."

[The following is reprinted from Health Policy, Number 6, March, 1994 ISSUE. Health Policy is edited by Siddharth Dube]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Project: Malaysia-Health Development

[IBRD $50 ml, total $101.3 ml; approved 9th Dec '93. Pop 18 ml; per cap GNP $2520; life exp 71; U5MR 18; MMR 0.39; TFR 3.7]

"Amongst the SE Asian Tigers, Malaysia stands out for its success in improving health conditions, and this project helps the country deal with its own success - literally, second-generation challenges like occupational and environmental health, the need to upgrade primary health care through the introduction of new technologies, and to improve regional equity in health care standards," says Jo Martins, task manager. "The project maintains the illness-prevention emphasis of the Malaysia health system." A historical stress on primary health care, coupled with over a decade of prosperity, have helped make Malaysia's health indicators rival those of South Korea, an acknowledged regional leader in health conditions.

The bulk of project costs will go towards increasing the number and capacity of laboratories - under the Ministry of Health and the Department of Chemistry - to monitor public health and environmental hazards, respectively. New data show rising age-specific rates of behavioral, environmental and occupational health problems, stoked by the country's rapid urbanization and industrialization. Particularly worrisome trends, says Martins, are the increase in industrial accidents and in environmental pollution from households, industry, motor vehicles, and agriculture. HIV/AIDS is also an emerging problem.

On the technological side, the project will upgrade blood transfusion services - including establishing a national blood service center - and encourage greater use of blood products instead of whole blood. This will help contain the spread of hepatitis and HIV.

A third component focuses on improving the primary health care system in three states that have lagged behind in health conditions. An important feature of the project is that quality assurance activities have been integrated in the service component.

A final component of the project will help strengthen the Ministry of Health's policy development capacity, an essential task given the need for increased attention to questions of health finance, new medical needs, and the expanding role of the private sector in providing specialized health care in the country.


Do counseling and testing work in African settings? Another crack at this crucial question, "Impact of HIV counseling and testing among child-bearing women in Kinshasa, Zaire," William Heyward et al. in AIDS, reports that "HIV counseling and testing led to higher rates of contraceptive and condom use, although the actual level was lower than the intended use." Major obstacles to behavior change, says the study, were, one, the "apparent reluctance of many women to inform their sex partners of their infection status," and two, the cultural pressures on African women to bear children, which resulted in only a "very modest impact" on reduction of pregnancy among HIV-positive women. Finally, the report emphasizes the need to counsel the male partner as well, as this has been shown to increase use of condoms in HIV-discordant couples. The stumbling-block, of course, is how to do this, since many sero-positive women fear that their husbands will divorce them on knowing they are infected.

[The following is reprinted from Health Policy, Number 6, March, 1994 ISSUE. Health Policy is edited by Siddharth Dube]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Costa Rica: Health sector reform project- Social security system

[IBRD $22 ml, total $33 ml; approved 22nd Oct '93. Pop 3.1 ml; per cap GNP $1940; life exp 75; U5MR 15; MMR 2; TFR 3]

Carmen Hamann, task manager, writes: "This project can serve as an excellent road map for health projects in countries undergoing a health sector reform, as well as provide valuable lessons in inter-institutional arrangements and cooperation - in this case, amongst the Ministry of Health (MOH), the Social Security System (CCSS) and external financing agencies such as the Inter-American Development Bank (IDB) and the World Bank. by allocating 7 to 10 percent of GDP in the past 30 years to providing health care for all its citizens, Costa Rica has brought about significant improvements in the health status of its population. Indeed, key health indicators place Costa Rica in a highly advantageous position compared to other countries with similar income in Latin America. In recent years, however, inefficiencies have emerged in health care utilization patterns, caused by distortions in both the supply and demand for health care. On the supply side, poor resource mobilization, a lack of financial planning and management, and inefficient allocation of existing physical, financial and manpower resources have undermined the quality of health care administration and services provision. On the demand side, the changing health needs of an aging population and the low price of public health services have fueled the volume and complexity of demand for health services. These pressures have led to a noticeable deterioration in the quality of services and a growing operating deficit in the Social Security System (Cava Costarricense de Sequro Social (CCSS)), which had gradually taken over the role of health care provider from the Ministry of Health (MOH).

As a critical part of its long term development plan, the Government has made a firm commitment to improving the efficiency, effectiveness, and quality of health services and to increasing coverage to under-served and uninsured people, within the constraints of public resources. The principles underlying this policy are stated in the National Reform Plan of the Health Sector. The plan redefines the respective roles of the MOH and the CCSS as follows: the MOH will play a leadership role in defining policies, priority programs, and in monitoring and evaluating the use of resources in the health sector; while the CCSS will be restructured to assume the role of health care provider. This will entail a fundamental reorganization in these two institutions, shifting of MOH resources to the CCSS to avoid duplication of efforts, and decentralization of the CCSS's management and operational functions to the regional level. The plan also proposes the establishment of regulations and quality control of the provision of health care by the public and private sectors.

This is the first Bank lending operation in the health sector in Costa Rica. The Bank loan will complement parallel reforms in the MOH financed by the IDB. The project will support the Government's efforts to implement critical policy, institutional and operational reforms which aim at improving the efficiency, effectiveness, and quality of the delivery of the CCSS health care services and improve the quality control and surveillance system in the health sector.

The project has five main components:

(a) CCSS Institutional Reform and Development - would (i) support the design and implementation of policy and institutional reforms by organizing the CCSS in three main systems (Pensions, Health Care and Financial Management) to achieve greater transparency in the use of resources and avoid cross-subsidies; (ii) strengthening the management information system; and (iii) design human resources development and manpower planning programs;

(b) Redefined Primary Health Care Model which addresses the need for reforms and of innovative technical approaches for the delivery of primary health care programs; this also includes well-defined referral systems and functions and the establishment of a quality assurance system for monitoring and evaluating primary care actions;

(c) Resources Management and Pilot Testing of Alternative Models of Health Care Financing which would address: (i) design of a decentralized budget system; (ii) conducting studies to improve CCSS resource mobilization, premium collection, and auditing capabilities; (iii) carrying out and expanding pilot tests of alternative financing and administration mechanisms for provision of health care;

(d) National Health Surveillance and Quality Control Laboratory, for early detection of biological, chemical and psycho-social risks factors and quality control of food and biological products; and

(e) Project Administration, organization of a project coordination unit, responsible for project implementation.

The project preparation process had several innovative features, such as:

(a) the CCSS organized a high-level committee to define policy directions and guidelines for the project preparation groups and review their output;

(b) the CCSS organized specific working groups responsible for the preparation of each of the components;

(c) each group had the support of local and international consultants, and resource persons from the University. The groups were formed with staff from both the MOH and the CCSS and worked almost full time on this tasks. The Bank visited Costa Rica periodically, and reviewed in detail the output of each of the groups. In addition, the Bank had several meetings with the Board of Directors of the CCSS and senior managers, Ministers of Planning and Health to discuss the reforms proposed by the working groups, in order to get their views and enlist their support to the proposed reforms. In each of the project preparation phases (first draft of each component until the final product), the CCSS organized specific seminars with the participation of the CCSS Board of Directors, CCSS senior managers, and representatives from other agencies or interest groups (Ministries of Health, Planning, Finance, private sector, legislators from main political parties, university and private sector), to discuss the output of the working groups, to engage them in the project preparation process and get their technical and political support and commitment for implementing the reform process. As a result of this process, the reforms proposed by the project have enjoyed the support of the highest levels in the government, political parties and staff from both the MOH and the CCSS. Project preparation efforts were greatly facilitated by resources from the Japanese Grant Fund which was used throughout the project preparation process. This project preparation process resulted in strong commitment from the government and political parties to implementing the reform, but most importantly, was seen by the technical staff as a great learning experience and reinforced their commitment to implementing these actions.

For the Bank, some lessons can be drawn from this process: project preparation needs to be well planned and critical phases need the input from Bank staff on a systematic manner; the Bank team was the same throughout the project preparation process which provided continuity and developed excellent working relationship and trust between the Bank and the local team. Because of the high local involvement, there is a great sense of project ownership and commitment among the senior managers in the CCSS who are responsible for project implementation. Furthermore, the government and the CCSS are extremely satisfied with the Bank strategy, which will facilitate implementation."


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Sector Work-India Health Sector Financing: Coping With Adjustment, Opportunities for Reform

Yellow cover. Main authors are Damianos Odeh, SA3PK; Kalanidhi Subbarao, ESP; Charles Griffin, AF2PH; and consultants Peter Berman, Ruth Levine and Stace Birks. Technical advice provided by Richard Skolnik, SA2PH.

The problem - "In the face of budgetary pressure and the start of the adjustment process, the health sector faces a critical decision point today. The health system must cater to a large population that is quickly approaching the one billion mark. It must struggle to contain more than half the known cases of major endemic disease in the world. It must operate within states with marked variability in economic and social progress. In doing so, it operates an infrastructure that stretches existing budgets very thin and results in inefficiencies so marked that outreach of services to margins of the health system is hampered almost to the point of ineffectiveness."

"Health and family welfare received slowly declining shares of total spending after 1970, with a recipitous decline occurring in the 1980s. The main result of the combination of a declining share of public budgets for health and contemporaneous expansion of infrastructure has been increasingly inadequate support of recurrent costs."

And "although it is less than six percent of public expenditure on health, the central plan budget is important because it provides a demonstration effect and has leverage over state patterns of spending. For 1992/93, this budget was shocked by significant cuts."

Preferred solutions -

·· "The years of expanding the health system to reach to the village level, educating personnel to operate the system, establishing a logistics system to support it, and simultaneously funding both hospitals and traditional communicable disease programs is a phase that is completed...A new phase of consolidation and adequate support of recurrent costs is called for."

·· "There is an urgent need for additional central funds for the health sector."

·· "It will require very strong analytical work to argue for higher budgets and a stronger policymaking role for the Department of Health during the adjustment process and after...Action should quickly be taken to develop a Health Economics Unit in the Department."

·· "Higher health budgets are essential, but spending should be targeted toward programs with greater country-wide health impacts. Without doubt, the end result will be lower public spending on hospitals and medical education, two areas where the private returns are high and the social returns relatively low. However, these programs lend themselves, for the same reasons, to cost recovery."

·· "Additional spending is merited for communicable disease control. Communicable disease problems in India are far from solved, and they precipitate high government and private out-of-pocket expenditures for curative cure to treat preventable problems. Furthermore, it is the poor who benefit disproportionately from spending on communicable disease control."

·· "Since 1986, primary health care services have deteriorated. These facilities, which are key to many programs, such as communicable disease control, immunization, prevention, health education and family welfare should be enhanced. It is important that the central government place the highest priority on assisting states, especially the poorer states, to increase spending on non-salary inputs, such as drugs. Otherwise efficiency of primary health care will sink so low that, in many of the more poorly served areas, the service will collapse altogether."

The report has useful annexes on health insurance, cost recovery and the scope for using the private sector in health care delivery.

Task manager Damianos Odeh notes that the report was prepared with the active participation of the central and state governments and represents a joint statement of the Government of India and the Bank. "The process of producing this report ensured 'ownership' on the part of the government of India, and this has paid dividends," says Odeh.

Books on health financing in India are rare. Just out is "Paying for India's Health Care", edited by Peter Berman and M.E. Khan, Sage Books, 1993.

Must Read Article

Evaluating child survival: How well do child survival programs work? What are the strengths and weaknesses of the selective primary health care approach? The contentious fifteen-year debate over these ISSUEs has been marked by the virtual absence of hard data by which to measure the real-life impact of these new technologies and program designs. While the 11 papers in "Monitoring Child Survival Programmes in Africa: The Africa Child Survival Initiative", a special supplement in the "International Journal of Epidemiology",(volume 22, supplement 1, 1993) do not provide the data either, they offer crucial lessons for health planners.

The supplement reports on data collected in Liberia and Zaire under the Centers for Disease Control's CCCD projects - the acronym stands for Combating Childhood Communicable Diseases. The supplement includes three articles each on Liberia and Zaire that detail baseline studies of mortality, levels and changes in health service provision brought about through the project, and post-intervention data on mortality. In a background paper, Stanley Foster notes that the supplement is "presented to share one technical assistance programme's experience in assessing the effectiveness of national child survival strategies in providing selected primary health care services and reducing infant and child mortality." The studies employ a CDC-developed strategy for measuring the levels of infant and child mortality and community use of immunization, ORT, and chemotherapy for fever/malaria.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Dear Subscribers:

This week's ISSUE contains a list of articles from Mothers & Children Bulletin, Volume 12, published by the Clearinghouse of the American Public Health Association. Articles in English, French, and Spanish have been archived and are available for your retrieval.

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Mothers and Children Volume 12:3, 1993

Video as a community empowerment tool Information on Communications: CD-Rom (Latin America) Using Drama for Health Communications: Report from Burkina Faso, Mali and Niger Asia-Pacific Resource and Research Center for Women (ARROW) Ecuador: Breastfeeding Campaign mce12f Information Exchange: Computer Networking and E-mail mce12g Programs: Information for Action, Strengthening Capacity in the Field/Workshop Report mce12h Resources on communications mce12i Education Materials insert: reviews of videos, training kits, information packets, booklets, pamphlets, newsletters, manuals and games on health and nutrition topics Meres et Enfants Volume 12:3, 1993 mcf12a La video comme outil au service de l'autonomie des communautes mcf12b CD-ROM en Amerique latine: les defis de la diffusion de l'information mcf12c Burkina Faso, Mali et Niger: l'art dramatique a l'appui des programmes de communication en sante mcf12d Asia-Pacific Resource and Research Center for Women (ARROW) mcf12e Promotion de l'allaitement maternel en Equateur mcf12f Reseaux informatiques et courrier electronique mcf12g Programmes: Information pour agir, Renforcement des atouts sur le terrain/rapport d'atelier mcf12h Ressources sur les communications mcf12i Supplement des supports pedagogiques: analyses des videos, jeux educatifs, livrets, tableaux, manuels, cassette audio et des revues sur des themes de sante et nutrition Madres y Ninos Volume 12:3, 1993 mcs12a La videocinta como instrumento de habilitacion de la comunidad mcs12b Informacion sobre comunicaciones: el disco compacto (America Latina) mcs12c Empleo de la dramatizacion en los programas de salud: Informe de Burkina Faso, Mali y Niger mcs12d Centro de Recursos e Investigacion sobre la Mujer de Asia y Pacifico (ARROW) mcs12e Promocion de la lactanciao=A2ptima en el Ecuador mcs12f Redes de computadores y correo electronico mcs12g Programas: Informacion en accion, Fortalecimiento de la capacidad existente en el terreno/reportaje de taller mcs12h Recursos sobre comunicaciones mcs12i Suplemento de materiales de educacion: resenas de video,juegos de ensenanza, folletos, manuales, audiocasetes y revistas sobre temas de salud y nutricion


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Update on the Cairo ''Population and Development'' Conference

As PNN (Population Network News) goes to press, New York City is awash with population and development experts and advocates-all of whom have an opinion. You've got it: PrepCom III is in full swing. As the last chance to shape the Cairo Document before the International Conference on Population and Development (ICPD) starts, PrepCom III has attracted thousands of delegates from national governments, NGOs, international development agencies (including the World Bank), and the Holy See to debate a variety of ISSUEs encompassed by the theme "population and sustainable development." Some participants are interested in increasing the attention paid to breastfeeding; others want more funding for literacy campaigns. But the "hot" ISSUEs at the conference concern two areas: reproductive rights and "sustainable development."

While PrepCom II witnessed some moments of acrimonious debate between women's health advocates and the traditional population community, PrepCom III has been the stage for considerable reconciliation. A consensus has emerged that while slowing population growth is an important development objective, it cannot override the reproductive health needs and rights of individuals. The various actors in this arena are also joining forces to protect language regarding family planning and reproductive health in the face of criticism from conservative religious groups.

Conference attendees and articles in the Earth Times newspaper covering the PrepCom report that the Vatican has invested many resources into influencing the language of the Cairo document and making its conservative voice heard. In addition, many right-to-life NGOs are attending the PrepCom to advocate their opposition to abortion. A representative of one such group was quoted in the Earth Times as saying that the draft document "promotes abortion-on-demand as a method of limiting family size and therefore increases maternal and child death and injury in the developing world."

On the charged ISSUE of "sustainability," a move is underfoot to broaden the definition of "population" ISSUEs to encompass a wide range of development and environmental concerns, including verconsumption in the North, debt reduction, human rights, and other ISSUEs. New topics potentially to be included in the Cairo document include forest conservation, water conservation, and coastal protection. In this area, the conference is echoing debates heard at the 1992 United National Conference on the Environment and Development (UNCED). While most delegates at the conference seem sympathetic to these views, some also worry that the focus on family planning and reproductive health ISSUEs could be lost in the broader debate and resources devoted to these topics could be diluted.

When the PrepCom wraps up on April 22, the agenda for discussion at Cairo will be set in place. And the thousands of participants will have a few months to regroup before the debate begins anew at ICPD this September.

Population Network News (Spring, 1994, Editor: Chantal Worzala)

OMNI (Opportunities for Micronutrient Interventions) Network and PHNFLASH

Developed and funded by the U.S. Agency for International Development's (USAID) Office of Nutrition in Washington, D.C., the Opportunities for Micronutrient Interventions Project (OMNI) is a comprehensive five-year effort to control and prevent micronutrient deficiencies in developing countries. OMNI consists of the following members: John Snow, Inc. (JSI) (will provide overall project management); Helen Keller International (HKI); Emory University School of Public Health, Center for International Health, Program against Micronutrient Malnutrition (PAMM); The Manoff Group; Johns Hopkins University, Department of International Health; The International Life Sciences Institute (ILSI), Nutrition Foundation; Program for Appropriate Technology in Health (PATH); The University of Arkansas; and The University of California at Davis.

OMNI's approach to reducing micronutrient malnutrition includes: micronutrient program development to assist host countries in designing, implementing and evaluating multi-faceted, integrated micronutrient intervention programs; field support; information dissemination through workshops, seminar, and conferences; and training.

In the future, look for more information about OMNI on the "PHNFLASH."

OMNI will be providing material on new innovations in micronutrient interventions, on relevant international conferences and training events, on project activities and on available technical materials as they are developed.

For information regarding OMNI or requests for financial or technical assistance, please contact:

John Snow, Inc., 1616 North Fort Myer Drive, Suite 1100, Arlington, VA 22209. Telephone: (703) 528-7474; Fax: (703) 528-7480; Internet:

Publication Notice by Family Health International (FHI):

"Costing Manual for Family Planning"

A manual that describes procedures for estimating the economic costs of family planning services has been published by Family Health

International (FHI) and the United Nations Population Fund (UNFPA).

Methods for Costing Family Planning Services is an 86-page paperbound manual designed to help managers assess the costs of all resources used by their programs, regardless of who pays for them. Information on economic costs of services can help managers to decide which family planning methods to provide, how to provide them, and, if the program charges for services, how much to charge. To obtain a copy, please contact: Ms. Debbie Wade, Publications Coordinator, Family Health International, P.O. Box 13950, Research Triangle Park, NC, 27709, USA. (919) 544-7040 [Family Health International is a non-profit research and technical assistance organization dedicated to contraceptive development, family planning, reproductive health and AIDS prevention around the world.]


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· "Explaining Fertility Decline in Indonesia" (Population Network News [PNN], No. 7, Spring 1994)

· World Bank Population and Reproductive Health-Related Project: Peru-Basic Health and Nutrition Project and Social Development and Compensation Fund Project

· Publication

NOTICE: If you are still using the old index or subscribed to PHNFLASH recently and have not used our archive system, May we suggest that you retrieve an updated index by sending a message to: and type: get-PHNFLASH index

Instruction for retrieving archived articles can be found at the end of this ISSUE.

Explaining Fertility Decline in Indonesia

In the midst of the debate over the relative impact of family planning programs versus socioeconomic change in bringing about fertility decline, a newly published article by Paul J. Gertler and John W. Molyneaux provides clear and compelling guidance. Using a combination of economic and demographic modelling techniques, the authors attempt to explain how socioeconomic development and family planning program effort combined to reduce fertility in Indonesia during the period 1982 to 1987.

Indonesia has witnessed one of the most dramatic declines in fertility. The total fertility rate has fallen from 5.6 children per woman in 1970 to 4.1 in 1980, and 3.2 in 1985. What factors explain this drop? The analysis shows that 75 percent of Indonesia's fertility decline was the result of increased contraceptive use. The other 25 percent was due to changes in marriage patterns and other proximate determinants. But why did contraceptive use increase? Was it due to improved family planning programs? Did economic growth play a role? What about increased levels of education?

The Gertler-Molyneaux study determined that it was a combination of socioeconomic change and family planning program effort that motivated and allowed Indonesian couples to increase their contraceptive use. The analysis estimates that changes in wages and education explained 87 percent of the increase in contraceptive use during the period under study, while increased program effort explained only 7 percent.

At the same time, the authors note that the analysis is "based on a fixed-effects model that relates changes in family planning inputs and in the socioeconomic variables to contemporaneous changes in contraceptive use and fertility. At the start of the period of analysis, the supply of family planning facilities and services was already widespread in Indonesia."

"[T]he dramatic impact of the changes in demand-side factors (education and economic development) on contraceptive use was possible only because there already existed a highly responsive contraceptive supply delivery system."

"How Economic Development and Family Planning Programs Combined to Reduce Indonesian Fertility" appeared in the February 1994 ISSUE of Demography.

Project: Peru-Basic Health and Nutrition Project and Social Development and Compensation Fund Project.

The Board has approved two projects which seek to improve the health and well-being of Peruvians. The health and nutrition project targets the needs of regions inhabited by large numbers of indigenous people and the extremely poor. With estimated total costs of $44.5 million, including a $34 million Bank loan, the project will work through the public health system to improve access to and the quality of basic maternal and child health and nutrition services. There is also a component promoting better health and nutrition practices, with an emphasis on preventive care and education. Family planning services will be provided as an integral part of the basic package of maternal and child health services.

The social development fund will complement these activities by supporting FONCONDES, an agency which funds a range of community-based, labor-intensive projects. FONCONDES has been operating since 1991 to alleviate poverty through the financing of small-scale, short-term investment projects proposed by communities and NGOs. The activities sponsored by FONCONDES fall into the categories of social assistance (education and health services, including family planning); social infrastructure; economic infrastructure; and credits to small-scale farmers and entrepreneurs. Total project costs are estimated to be $495 million, including $100 million in financing from the Bank.

Task managers: Polly Jones, health and nutrition, and Alexandre Abrantes, FONCONDES.

Publication: Ross, John A., W. Parker Mauldin, and Vincent C. Miller: Family Planning and Population: A Compendium of International Statistics. This volume is the fruit of a series of three questionnaires sent to about 100 developing countries since 1987. It compiles statistics from large-scale family planning projects together with basic socioeconomic and demographic data. It also rates the programs with effort scores based on the survey data. The compendium represents a valuable reference volume for anyone interested in finding data on a specific program or attempting a comparative analysis.


Electronic newsletter on population, health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Announcement by OMNI on "Food-based Approach to Eliminate Hidden Hunger" Workshop
· A Canadian Society for International Health Seminar Announcement
· Profile of a Recent PHNFLASH Subscriber

Announcement by OMNI (Opportunities for Micronutrient Interventions)

Using food as a weapon against micronutrient malnutrition

Food-based approaches to eliminate micronutrient malnutrition (MM) are the best long-term solutions but often the most difficult to implement. They require the coordination and cooperation of industry, government, scientists and technologists in the private and public sectors, as well as acceptance from the population. The need for a refined strategy to advance a food-based program is imperative in winning the war against hidden hunger. At the request of former participants of the Program Against Micronutrient Malnutrition (PAMM) and with the participation of other members of the OMNI consortium, PAMM's third annual follow-up workshop will focus on "Food-Based Approaches to Eliminate Hidden Hunger." The workshop will be held at the Papendal Sports Center, near Arnhem, The Netherlands, on June 12 to 24, 1994.

The primary purpose of the workshop is to give participants an opportunity to sharpen skills, share experiences, and discover and correct the flaws in theoretical program design while enmeshed in the day-to-day reality of managing micronutrient activities.

Hosted by the Wageningen Agricultural University and the International Agricultural Center in Wageningen in The Netherlands and PAMM, the workshop will focus on the initiation and management of food-based programs. It will include the promotion of under-utilized foods; the enhanced agricultural production and marketing of foods with limited availability; and the creation and marketing of fortified foods. Strategies such as these are needed to replace the current "quick fix" solutions that are in place in many countries, with solutions that are more sustainable over the long-term.

The workshop will be divided into three sections. The first week (June 12-19) will include "Trouble Shooting Clinics," where participants and PAMM and OMNI technical experts will work together on the problems that impede progress in moving food-based solutions forward and on designing solutions that can be immediately incorporated into country programs.

The second section of the workshop will consist of an Agricultural and Industrial Contributions Conference. This three-day (June 20-22) meeting will examine the agricultural and industrial approaches to eliminating MM. The three major micronutrients (iodine, vitamin A and iron) will be the focus of presentations, discussions and proposal formulation to devise specific recommendations that can be applied by agriculture and industry. The challenge for each of the one-day forums is to formulate a plan of action with tasks for government (i.e., implementation of appropriate laws or regulations, improved food quality control); agriculture (breeding of nutrient-dense varieties of common foods); industry (processing of new or better products), international organizations (assistance or incentives to national programs); NGOs (effective extension to most affected populations); and the research community (development of better communication techniques).

Specific presentations will expose global micronutrient problems, with special reference to Europe. The recommendations of the forums will be an important part of the Advocacy Meeting on June 24. The forums are organized by the Department of Nutrition of the Wageningen Agricultural University, which is headed by Clive E. West, Ph.D., D.Sc., a visiting professor of international nutrition at Emory University's Center for International Health.

The third portion of the workshop (June 23-24) will include a Micronutrient Fair and Advocacy Meeting. National programs, information on food systems, agency concepts, progress on support programs, and innovative research and designs will be featured at the Fair. The results of the Agricultural/Industrial Conference will be presented as well. The Advocacy Meeting will also allow leaders from government, agencies and industries to cultivate alliances. This event May enable participants to identify additional technical and donor resources to revitalize their MM programs.

For more information on the workshop, please contact:

The OMNI Project, c/o John Snow, Inc., 1616 N. Ft. Myer Drive, Suite 1100.
Telephone: 703-528-7474; Fax: 703-528-7480; Internet:
A Canadian Society for International Health Seminar Announcement

A Dialogue On The 1993 World Development Report And Beyond

May 30, 1994: Coast Plaza Hotel, Vancouver

Featured Speaker

Dr. Dean Jamison, Professor of Public Health
Director, Centre for Pacific Rim Studies, UCLA

The morning will be devoted to a keynote presentation by Dean Jamison, a reaction panel, and discussion. Those outside Vancouver interested in participating via audio-conferencing for the morning session 8:30am-12:30pm PST (11:30am-3:30pm EST) should contact the numbers below.

To register contact: (Fax is best) Wood and Associates
Tel: (604) 688-3787
Fax: (604) 688-5749

Sponsor: Canadian Society for International Health

[Posting provided by: CANCHID Listserv at]
Profile of a Recent PHNFLASH Subscriber

Following up on requests regarding the profile of PHNFLASH subscribers, we will periodically share with the group some of the messages sent to us by new subscribers. We hope that this section will provide a glimpse of the diversity of PHNFLASH readership. Today's message is from Ms. Gerry Clare from British Columbia.

"I am a full-time teacher-librarian in a Senior High School (Grades 10-12) of 650 students in northeastern British Columbia. My major role is to support the instructional goals of teachers by offering co-operative planning and teaching of units. As a long-time Social Studies teacher before become a librarian, I am particularly interested in supporting the Social Studies curriculum. At the Grade 11 level, that includes a major section dealing with the concept of the Global Village, with population and nutrition and with the distribution/exploitation of resources. A major problem is always that of getting current data.

Recently, students ran into a real problem finding information about diseases common to tropical areas of the world. I would be very interested in receiving information about world population, nutrition and health as I get many requests for current data from my Social Studies teachers. Thank you."

Gerry Clare, Teacher-librarian (
Peace River South School District
British Columbia


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this Issue...

· Fertility Decline in Egypt
· Nepal-Population and Family Health Project
· Note from the Moderator

Closing the Gap Between Supply and Demand: Fertility Decline in Egypt

The 1992 Demographic and Health Survey for Egypt documents a recent, dramatic decline in fertility. The trend in the total fertility rate (TFR) for the country falls from 5.5 children per woman of reproductive age in 1976 to 4.4 in 1988, and 3.9 for the period 1989-1992.

The overall decline in fertility masks considerable variations by geographic region. For example, the metropolitan areas had already reached the current national fertility level by 1980, while in rural Upper Egypt the TFR is still about 6 children per woman, but is beginning to decline slowly.

Explaining the decline. Some of the decline in fertility, particularly in urban areas, has resulted from an increase in the age of marriage. Among women with little schooling and in rural areas, however, the age at marriage has changed relatively little. Contraceptive use, on the other hand, has played a major role in reducing fertility. By 1976, about a quarter of women in Egypt were contracepting, increasing to about one-third by 1980, and reaching 38 percent in 1988. By 1992, contraceptive prevalence had increased dramatically to 47 percent. The changes in contraceptive use since 1980 resulted from both changes in demand for fertility control and supply of family planning services to meet those demands.

Demand factors. Reductions in mortality, expansions in female education, and urbanization have all decreased demand for children. However, there seem to have been additional changes in the social climate not entirely explained by these factors that have caused desired family size to diminish. In metropolitan areas, the desired family size changed little between 1980 and 1988, but in rural Lower Egypt, it fell by one child, and, in rural Upper Egypt, it fell by more than two children. After controlling for declines in infant and child mortality, there are still unexplained decreases in desired family size occurring primarily among women with no schooling or those with less than complete primary schooling. At least part of this change in the "climate of child bearing" May have resulted from the mass media efforts undertaken by the Government of Egypt and supported in part by USAID and UNFPA. Other modernizing influences and communication messages probably played a role as well.

Supply factors. In addition to the effects of the demand factors noted above, Egyptian women responded to an increase in access to family planning services. In 1980, only 40 percent of those who wanted no more children were contracepting. By 1988, two-thirds of such women were using contraception. Thus, contraceptive use increased faster than the demand to limit fertility in the period 1980 to 1988, implying that access to, or the quality of services increased. The evidence indicates that the major factors in the expanded access were a substantial increase in the availability of IUDs, particularly in the rural areas of Lower Egypt, and expanded access to pharmacies, the preferred source of pills, throughout the rural areas. This expansion of family planning services was a concerted effort on the part of the government and was supported by donors. Social marketing received special attention by the government and donors, resulting in an increased role for the private, commercial sector.

Prospects. In the period between 1988 and 1992, improvements in service provision made substantial inroads into unmet need. Overall unmet need dropped from 47 percent of fecund women to 20 percent. However, the future prospects for expanded contraceptive usage are uncertain. Further increases will depend on the extent to which services reach rural and uneducated women. The quality of those services will affect both the adoption and continuation rates of contraceptive use. Improved counseling by clinics and pharmacies and a broader range of methods are therefore imperative.

[Based on a draft sector paper by Susan Cochrane (PHN), et. al. Article extracted from Population Network News, No. 7, Spring, 1994]

Nepal: Health and Family Health Project (Approved)

The population of Nepal is 20 million strong and is growing at a rate of 2.5 percent annually. Social indicators paint a difficult picture of high infant mortality (197 per 1,000 live births), high maternal mortality (830 per 100,000 live births), and low contraceptive prevalence (23 percent). Improvements in conditions are hampered by the mountainous terrain and the remote location of many inhabitants.

The project will attempt to improve the health status of the population and decrease fertility by supporting the government's family planning and maternal and child health program. To address the remote nature of the Nepali population, the vast majority of project funds will finance outreach services, including training and salaries for female maternal and child health workers, construction and renovation of health posts, and field operation support and supervision. Other activities include the establishment of five clinical units, support to the logistics and supplies system, and institutional development. The project has estimated total costs of $39.0 million, including an IDA credit of $26.7 million. [Task manager: Badrud Duza; Article extracted from Population Network News, No. 7, Spring 1994]

Note from the Moderator

We need help from you in expanding PHNFLASH readership.

If you correspond with colleagues in Africa, Asia, Eastern Europe, and Latin America through e-mail who May be interested in receiving PHNFLASH, could you forward their e-mail addresses to us by replying back to this message? Alternatively, they can contact our office at: for subscription.

Thank you for your help.


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

<<<TOC4>> In this Issue...

· World Bank Project: Burkina Faso-Population and AIDS Control Project
· Announcement from IVACG (International Vitamin A Consultative Group)
· Comment from a Subscriber
· What's New in PHNFLASH Archive

Thank you to those of you who forwarded e-mail addresses of your colleagues who might be interested in receiving PHNFLASH. We would welcome in the future names of potential PHNFLASH subscribers. Please forward them to

Burkina Faso: Population and AIDS Control Project (Under Consideration)

In 1991, the government of Burkina Faso ISSUEd a Population Policy Statement that introduced targets of increasing contraceptive prevalence from about 4 percent currently to 60 percent in the year 2005. Clearly, this is an ambitious goal which will require considerable investments and political commitment. It responds, however, to the country's demographic situation: the population is growing at a rate of about 3 percent each year, and almost half of the population is under the age of fifteen. A recent Demographic and Health Survey shows that there is potential demand for family planning services, with about 19 percent of women stating a desire to stop bearing more children and approximately 50 percent interested in spacing future births.

The spread of HIV/AIDS has become an important ISSUE in Burkina Faso, where the national statistics estimate that between 4 and 7 percent of the population is seropositive. While these rates are low in comparison to countries of East Africa, they place Burkina Faso second after Cd'Ivoire among West African countries most affected by the epidemic.

The Board will soon consider the Population and AIDS Control project, which would finance improvements in the quality of and access to family planning and maternal and child health services, including contraceptive supplies. IEC activities in family planning and HIV/AIDS awareness and support for social marketing of condoms are meant to provide information and motivate the public. The proposed project would also contain institution building activities at the national level for both population policy and HIV/AIDS surveillance and monitoring, including blood screening. Total project costs are estimated to be $25.1 million, including an IDA credit of about $21.1 million.

Expected cofinanciers include the government of Norway and Canadian CIDA.

[Task manager: Bruna Vitagliano; Article extracted from Population Network News, No. 7, Spring 1994]

Ivacg meeting to be held in Thailand

"Two Decades of Progress: Linking Knowledge to Action" will be the theme of the XVI International Vitamin A Consultative Group (IVACG) Meeting, 24-28 October 1994, in Chiang Rai, Thailand. Commemorating IVACG's 20th anniversary, the program will include invited presentations on this topic and national plans of action developed as follow-up to the December 1992 International Conference on Nutrition, in Rome. The meeting will include more than 120 oral, poster, and video presentations (most of which were selected from submitted abstracts) on various topics related to vitamin A deficiency, such as:

· Linking Vitamin A to Development
· The Global Imperative to Prevent and Control Vitamin A Deficiency
· Food-based Interventions
· Information, Education, and Communication
· Home Gardening
· Assessment of Vitamin A Status by Dietary Methods and Other Methods
· Epidemiology and Ecology of Vitamin A Deficiency
· Health Implications of Vitamin A Deficiency
· Country Surveys
· Recent Advances in Vitamin A-related Biochemistry and Molecular Biology
· Managing Multiple Micronutrient Deficiencies

To allow full consideration of the many developments in the field, the conference program has been expanded to include eight workshops and several informal discussion groups. Summaries from all workshops will be presented at the meeting's plenary sessions, providing new opportunities for information sharing.

Among the more than 300 participants likely to attend the XVI IVACG Meeting are policy makers, program managers, planners, and scientists in health, nutrition, biochemistry, agriculture, horticulture, and development, from international agencies, national ministries, educational institutions, and non-governmental organizations.

The meeting will be sponsored by the International Vitamin A Consultative Group (IVACG) and a local organizing committee that has its secretariat at the Institute of Nutrition at Mahidol University. IVACG receives funds through the Office of Nutrition of the U.S. Agency for International Development and others.

IVACG guides international activities for reducing vitamin A deficiency in the world. Through its international meetings, the group provides a forum for new ideas, encourages innovations, recognizes important research findings, increases awareness of the latest survey data, and promotes action programs. The published conclusions of these meetings reflect the perspectives of those addressing vitamin A ISSUEs in varied settings.

For more information about the XVI IVACG Meeting, please contact:

Laurie Lindsay Aomari, IVACG Secretariat, ILSI Research Foundation, 1126 Sixteenth Street, N.W., Washington, D.C. 20036, USA. Telephone: 202-659-9024; Fax: 202-659-3617; Internet:

You May also contact The OMNI Project, c/o John Snow, Inc., 1616 N. Ft. Myer Drive, Suite 1100. Telephone: 703-528-7474; Fax: 703-528-7480; Internet:
Comment from a PHNFLASH Subscriber on "Fertility Decline in Egypt"
(from PHNFLASH Issue 21)

"This article is very interesting, but strengthen my belief that population ISSUEs can be more effectively solved through improvement of health and education, especially women's education. Improvement of women's education will generate the demand for fertility reduction. Mass media efforts and social marketing May have strengthened the demand, but evidence is not clear.

Supply factors need to be analyzed further and should show evidence. Only 40% of those who wanted no more children were using contraceptive. Then does this mean that 60% of those could not have access to contraceptive due to supply constraint? The burden of proof is on the other side."

Kye Woo Lee
World Bank


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· World Bank Project
· Publication of Note
· Note from the Moderator
· What's New in PHNFLASH Archive?

Guinea: Health and Nutrition Sector Project (Approved)

The project will seek to improve the quality and access of health services in the project area, which covers about 1 million people. Health service activities include rehabilitation and maintenance of facilities; financing of essential drugs, including contraceptives; and targeting of essential programs, including maternal and child health and family planning. A second component will seek to strengthen sector organization and management at the national level through technical assistance, training, and support for equipment and operating costs.

[Task manager: Sergiu Luculescu; Extracted from Population Network News, No. 7, Spring 1994.]

Publication of Note

Piotrow, Phyllis T., et. al.: Strategies for Family Planning Promotion, World Bank Technical Paper No. 223. This overview covers the lessons learned over the last two decades about designing and developing programs that promote family planning. The importance of good counseling is emphasized, since interpersonal communication influences whether, when, and how couples will use family planning. In successful programs, this one-on-one contact generally interacts with efficient and effective use of mass media, which can be used to convey convincing family planning messages that educate and motivate the public. While IEC campaigns are often quite expensive, the paper outlines ways of decreasing the costs through income-generating activities and accessing free media coverage.

The paper also recommends appropriate steps for designing effective IEC programs, with emphasis on integrating evaluation criteria into the design. Among the program ISSUEs highlighted as important for the 1990s are: building institutional capacity and in-country technical skills; linking IEC and family planning services; using private-sector expertise; handling opposition and controversy; and financially supporting IEC at a realistic level. [World Bank Technical Papers are available from the World Bank Bookstore, tel. (202) 473-2941.]

Note from the Moderator...

As you know, PHNFLASH was originally designed to distribute weekly newsletter and provide archive service on various population, health, and nutrition ISSUEs. We currently have approximately 600 direct subscribers in 30 countries but the circle of PHNFLASH readership is much wider when considering those who receive PHNFLASH ISSUEs through their contacts within their organizations or countries.

Some of you suggested that we make the list of subscribers available in order to create an opportunity for you, the subscribers, to network among yourselves. The list of subscribers changes from day to day and it May not be the wish of the majority to publicize the list. The list contains e-mail addresses and names of the subscribers broken down by types of organizations and countries. Would you like us to archive the list for electronic retrieval? We would like to ask you to help us brainstorm on the idea of creating an opportunity of networking among PHNFLASH subscribers. For example, you are working on a certain topic related to population, health, or nutrition and would like to know whether other subscribers are doing similar work. We could post your message in PHNFLASH regular ISSUE and include your e-mail address for contact.

For ideas and suggestions, please send a message to: or simply reply back to this message. Thank you very much.


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

The following two pieces of job announcement are made by the Department of Population, Health, and Nutrition, World Bank. Please circulate them to your colleagues.

Job announcement #1: Population, Health and Nutrition Department

The World Bank

Assistant to Nutrition Team

Job description: As assistant to the nutrition team in the Population, Health and Nutrition Department, the incumbent will provide support to four higher level nutrition staff and technical assistance to regional nutrition operations. Included are the following tasks: tracking and analysis of Bank lending for nutrition, research and text preparation for Bank documents produced in the PHN department, general administrative tasks such as preparation of consultant requests, organization of meetings, and assistance with seminars, dissemination of articles and reports produced by the nutrition staff, assistance with the production of a quarterly nutrition newsletter, liaison with bi/multi-lateral development agencies, management of external consultants, technical review of Bank projects, and direct operational support to regional mission activities in the field (on the order of 9 weeks/year).

Required experience and skills: Exceptional organizational skills and follow-through on many simultaneous activities, personal flexibility and a solid sense of humor to undertake a broad range of tasks utilizing technical nutrition knowledge, as well as good administrative skills, ability to work easily with a variety of personalities and their individual work styles, strong writing skills, ability and willingness to travel.

Preferable experience and skills: Graduate level nutrition/public health training, one or more languages in addition to excellent English, area of focused technical expertise (e.g. monitoring and evaluation), field experience with nutrition programs.

Non-United States citizens and women encouraged to apply.

Preferred starting date: August 1, 1994

Contact: Leslie Elder
World Bank
Room S-11-056
1818 H Street, NW
Washington, D.C. 20433
202-522-3234 (fax)

Job announcement #2: Population, Health and Nutrition Department

The World Bank

Coordinator: Nutrition Advisory Service

Job description: The Nutrition Advisory Service (NAS) coordinator provides support to Bank Operations staff in Washington D.C. through identification and management of external consultants for technical nutrition assistance to Bank projects as well as providing direct technical support in the field. The range of tasks includes dialogue with task managers to establish need, development of terms of reference for consultants following identification of suitable candidates, preparation of consultant and travel request forms, review/quality control of final reports, and tracking of regional technical support activities. Direct technical assistance, in addition to field work (9-12 weeks/year), involves research and text preparation of nutrition sections of project strategies and technical review of Bank-generated documents.

In addition, the consultant will prepare reports on specific technical areas to be determined based on successful candidate's background and expertise, maintain the NAS database of consultants, and generate semi-annual reports on the NAS.

Required experience and skills: Technical knowledge of nutrition, ability to oversee many activities at once and keep them on schedule, personal flexibility and a solid sense of humor, good organizational and administrative skills, ability to work easily with a variety of personalities and their individual work styles, excellent technical writing skills, ability and willingness to travel.

Preferable experience and skills: Graduate level nutrition/public health training, one or more languages in addition to excellent English, area of focused technical expertise (e.g. monitoring and evaluation, nutrition education), field experience with nutrition programs, working knowledge of Paradox.

Non-United States citizens and women encouraged to apply.

Preferred starting date: August 1, 1994

Contact: Judith McGuire
Room S-11-067
World Bank
1818 H Street, N.W.
Washington, D.C. 20433
202-522-3234 (fax)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Announcement from Helen Keller International
· Publication Announcement from Family Health International
· Note from a Subscriber in Kenya

We still have our ears open to listen to your ideas on promoting networking among PHNFLASH subscribers. Thank you to those of you who shared interesting ideas. Our ears can be reached at Thank you.

Announcement on Martin J. Forman Seventh Annual Lecture

''Time for a Change? A field's-eye view of donor agency support for nutrition''

What lessons have we learned about donor support to nutrition programs over the past two decades? One conclusion by Julia Tagwireyi, the Director of Nutrition for Zimbabwe, is that we cannot continue with "business as usual." As the seventh Martin J. Forman Memorial Lecturer, Ms. Tagwireyi will share her "field's-eye view" and her suggestions for improving nutrition programs. She is internationally known as one of the most prominent Africans working on nutrition. In addition to leading the outstanding nutrition program in Sub-Saharan Africa, she played a key role in overseeing her country's effective drought relief program.

Ms. Tagwireyi will speak at 7 p.m. on Monday, June 27th, 1994, at the Hyatt Regency Crystal City in Arlington, VA, USA. The lecture is free and open to the public. A reception immediately follows. Sponsored by Helen Keller International in honor of Dr. Martin J. Forman, the former nutrition director for the U.S. Agency for International Development, this annual lecture is held in conjunction with the annual conference of the National Council for International Health. Copies of Ms. Tagwireyi's remarks will be available for those unable to attend.

For more information, contact Helen Keller International, 90 Washington Street, New York, NY 10006, USA.

Quality of Care Publication Announcement

A publication on quality of care in family planning programs is available in English, Spanish or French from Family Health International (FHI). It appears as a theme ISSUE of Network, FHI's quarterly health bulletin, free upon request.

Health care experts agree that good quality care is essential to the acceptance and continued use of contraceptive methods. Adequate counseling for contraceptive methods is one of the factors family planning programs should examine when reviewing the quality of care.

FHI is a non-profit research and technical assistance organization dedicated to contraceptive development, family planning, reproductive health and AIDS prevention around the world.

To obtain a copy of the quality of care ISSUE of Network, write:

Publications Coordinator, FHI, PO Box 13950, Research Triangle Park, NC 27709, USA.

Note from a Subscriber in Kenya

The following message is from Mr. Shem Ochuodho, Director of the African Regional Centre for Computing, who describes current activities involving electronic network in Kenya.

"As you will probably be aware, we are involved in an initiative to start an African HLMNet (Health Learning Materials) with WHO HLM offices (c/o Dr. Dowling). Besides, in collaboration with our Ministry of Health, we propose to start a national "health network" called AFYANET to link key hospitals, health administrators and researchers. As a start, we already operate a mailing list called AFYANET, whose subscribers include institutions interested in health and related ISSUEs, eg. population, water and sanitation, etc. The National Council for Population Development (NCPD) is one of the more active participants. We also have on AFYANET UNFPA and KNACP (National Aids Control), but the two are yet to become really active. Other active participants include UNICEF, Kenya Medical Research Inst (KEMRI), Kenya-based Centres for Disease Control (CDC), Walter Reed Programme (WRP, together with CDC, based at KEMRI), African Medical Research Foundation (AMREF/NETWAS), WHO-HLM Kenyan office (arrangements to have country office on-line nearly concluded), university medical faculties and libraries, and the MoH HQ itself. Membership is fast growing, and in the coming weeks/months, expect to have all the 8 provincial hospitals nationwide on-line. At a separate level, we have recently been involved in a general computer sensitization and training at the Ministry.

Clearly, our users are a group who would be very much interested in PHNLINK work - PHNFLASH, QCARE, and any other list that May be open to them. Mail to reaches all of them. We also do post to them any information of interest that comes our way."

Shem Ochuodho

African Regional Centre for Computing (ARCC, Nairobi)

P.O. Box 58638

Nairobi, Kenya

Email: or


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

Clearinghouse of the American Public Health Association

New Acquisitions

For the last fourteen years, the Clearinghouse on Infant Feeding and Maternal Nutrition has been providing information to practitioners and policymakers in developing countries. Based at the American Public Health Association, the Clearinghouse database includes more than 17,000 books, documents and education materials. Materials in the collection are computer-referenced for easy access. The project is supported by the Office of Nutrition, Agency for International Development.

The following is a bibliography of some recent acquisitions. This listing includes articles about adolescence, breastfeeding, gender, information, education and communication, maternal and child health, micronutrients, nutrition, training, and women.

These documents should be ordered directly from the author or publisher. Addresses are provided.

For more information, contact APHA Clearinghouse, 1015 15th Street, NW, Washington, DC 20005, USA. Telephone: 202-789-5600; Fax: 202-789-5661; e-mail: or


1. Hamburg, D. A. Crucial opportunities for adolescent health. Journal of Adolescent Health, 14:7, 495-498, 1993.
Address: David A. Hamburg, MD, Carnegie Corporation, 437 Madison Avenue, New York, NY 10022, USA.

2. Perez, L. M. Embarazo en adolescentes rurales: Provincia de Curico. Corporacion de Salud y Politicas Sociales (CORSAPS), 1994. [booklet]
Address: M. Teresa Marshall, Corporacion de Salud y Politicas Sociales (CORSAPS), Vina del Mar No. 12, Providencia, Casilla 296, 22 Santiago, Chile.


1. Erwin, P. C. To use or not use combined hormonal oral contraceptives during lactation. Family Planning Perspectives, 26:1, 26-30, 33, Jan-Feb, 1994.
Address: Paul Campbell Erwin, Regional Health Officer, East Tennessee Region, Tennessee Department of Health, 1233 Southwest Avenue, Johnson City, TN 37604, USA.

2. Mennella, J. A.; Beauchamp, G. K. Beer, breastfeeding, and folklore. Developmental Psychobiology, 26:8, 459-466, 1993.
Address: Dr. Julie Mennella, PhD, Monell Chemical Senses Center, 3500 Market Street, Philadelphia, PA 19104-3308, USA.

3. Temboury, M. C.; et al Influence of breastfeeding on the infant's intellectual development. Journal of Pediatric Gastroenterology and Nutrition, 18:32-36, 1994.
Address: Dr. C. Temboury, Centro de Salud de Tres Cantos, Sector Oficios, parcela 11, Tres Cantos 28760, Madrid, Spain.


1. Bryson, K. R.; Mueller, R. D. Gender and generation in the world's labor force, module one: international and national trends. Office of Women in Development, Bureau for Research and Development, USAID, 1993. [booklet]
Address: Publications Manager, Office of Women in Development, Room 714, SA-18, U.S. Agency for International Development, Washington, D.C. 20523-1816, USA.

2. Fernandez Kelly, M. P. Political economy and gender in Latin America: the emerging dilemmas. The Johns Hopkins University Institute for Policy Studies and Department of Sociology, Oct 29, 1993.
Address: M. Patricia Fernandez Kelly, The Johns Hopkins University Institute for Policy Studies, 3400 N. Charles Street, Shriver Hall, Baltimore, MD 21218, USA.

3. Gomez Gomez, E. Genero, mujer y salud en las Americas. PAHO, 1993. [book]
Address: Pan American Health Organization, 525 23rd Street, NW, Washington, DC 20037, USA.


1. Coghlan, S. E.; Khan, S. I. Harnessing health information in the Third World. World Health Forum, 14:301-304, 1993.
Address: Sally E. Coghlan, Health Information Specialist, 45 Hillcrest Road, N. Chatham, MA 02650, USA.

2. Communication for rural development to improve planning, participation, and training. FAO, 1988. [booklet]
Address: Food and Agricultural Organization of the United Nations, Viale delle Terme di Caracalla, 00100 Rome, Italy.

3. Dawson, S.; Manderson, L.; Tallo, V. L. Manual for the use of focus groups: methods for social research in disease. International Nutrition Foundation for Developing Countries (INFDC), 1993. [manual]
Address: International Nutrition Foundation for Developing Countries (INFDC), Charles Street Station, P.O. Box 500, Boston, MA 02114-0500, USA.

4. Estrada, S. Connecting to the Internet: an O'Reilly buyer's guide. O'Reilly & Associates, Inc., 1993. [book] Price: US$15.95
Address: O'Reilly & Associates, Inc., 103-A Morris Street, Sebastopol, CA 95472, USA.

5. Harnessing the power of ideas - communication and social mobilization for UNICEF- assisted programmes: a case study. United Nations Children's Fund (UNICEF), Apr 1993. [booklet]
Address: UNICEF, 3 United Nations Plaza, New York, NY 10017, USA.

6. Klensin, J. C.; Bush, R. Expanding international email connectivity: another look. Baobab Electronic BBS (originally published in ConneXions, 7:8, Aug 1993), 1993.
Address: Baobab Electronic Bulletin Board (202) 296-9790, USA.

7. Mda, Z. When people play people: development communication through theatre. Humanities Press International, May 24, 1993. [book] Price: US$25.00
Address: Humanities Press International, 165 First Avenue, Atlantic Highlands, NJ 07716-1289, USA.

8. Patrikios, H. A.; Levey, L. A. Survival strategies in African university libraries: new technologies in the service of information. University of Zimbabwe Library; Sub- Saharan Africa Program, American Association for the Advancement of Science, Jan 1994. [book]
Address: Sub-Saharan Africa Program, American Association for the Advancement of Science, 1333 H Street, NW, Washington, DC 20005, USA.

9. Population communication: research, mass media and instructional materials (Vol. Two). Regional Clearing House on Population Education and Communication, UNESCO PROAP, 1993. [book]
Address: Regional Clearing House on Population Education and Communication, UNESCO Principal Regional Office for Asia and the Pacific, P.O. Box 967, Prakanong Post Office, Bangkok 1011 Thailand.

10. Using video in the field: guidelines for the use of video communication technology within FAO field projects. Development Support Communication Branch, Information Division, FAO, 1991. [book]
Address: Development Support Communication Branch, Information Division, Food and Agricultural Organization of the United Nations, Viale delle Terme di Caracalla, 00100 Rome, Italy.


1. Tonks, A. Pregnancy's toll in the developing world. British Medical Journal, 308:353-354, Feb 5, 1994.
Address: Alison Tonks, Assistant Editor, British Medical Journal, 42 Bedford Square, London WC1B 3SL, U.K.

2. Whiteford, L. M. Child and maternal health and international economic policies. Social Science and Medicine, 37:2, 1391-1400, 1993.
Address: Linda M. Whiteford, Department of Anthropology, Soc 107, University of South Florida, Tampa, FL 33720, USA.


1. Micronutrients: increasing survival, learning, and economic productivity. Nutrition Communication Project, Academy for Educational Development, 1993.
Address: Cindy Arciaga, Nutrition Communication Project, Academy for Educational Development, 1255 23rd Street, NW, Washington, DC 20037, USA.


1. ESN apercu nutritionnel. Food Policy and Nutrition Division, FAO, 1994. Recently published nutrition country profiles include Cambodia, Guinea Bissau, Tunisia, Burundi, Cameroon, Guinea, Laos, Madagascar, Mali, Mauritania, and Swaziland. Profiles of 89 more countries available.
Address: FAO - Food Policy and Nutrition Division, Nutrition Planning, Assessment and Evaluation Service, Nutrition Country Profiles Office C-251, Via Terme di Caracalla, 00100 Rome, Italy.

2. Jonsson, U. Nutrition and the United Nations Convention on the Rights of the Child. International Child Development Centre, UNICEF, Nov 1993.
Address: UNICEF, International Child Development Centre, Piazza S.S. Annunziata, 12, 50122 Florence, Italy.


1. Dennerstein, L.; Astbury, J.; Morse, C. Psychosocial and mental health aspects of women's health. Division of Family Health and Division of Mental Health, World Health Organization, 1993. [booklet]
Address: WHO, Division of Mental Health, CH-1211 Geneva 27, Switzerland.

2. Lovera, S.; Villar, I.; Vickery, K. Women and population policies. ISIS Internacional, Jul 5-9, 1993. [book]
Address: ISIS Internacional, Casilla 2067, Correo Central, Santiago, Chile.

3. Mackenzie, L. On our feet: taking steps to challenge women's oppression. Centre for Adult and Continuing Education (CACE), University of the Western Cape (UWC), 1993. [book]
Address: CACE Publications, Centre for Adult and Continuing Education (CACE), University of the Western Cape, Private Bag X17, Bellville, 7535 South Africa.

4. WAH! - women and health training programme India. Centre for Health Education, Training and Nutrition Awareness (CHETNA), 1993. [book]
Address: "WAH!" Secretariat, Centre for Health Education, Training and Nutrition Awareness (CHETNA), Lilavatiben Lalbhai's Bungalow, Civil Camp Road, Shahibaug, Ahmedabad- 380 004, Gujarat, India.


1. Brouwer, J.; Martinic, S. Selecting and training community promoters in Latin America. Bernard van Leer Foundation, Feb 1994. [booklet]
Address: Bernard van Leer Foundation, P.O. Box 82334, 2508 EH The Hague, The Netherlands.

2. Family planning: saving children, improving lives. United Nations Population Fund (UNFPA), 1993. [booklet]
Address: U.N. Population Fund, 220 East 42nd Street, New York, NY 10017, USA.

3. Reimers, F. Challenges for early childhood education policy in Latin America and the Caribbean. International Journal of Educational Development, 13:4, 303-314, 1993.
Address: Fernando Reimers, Harvard Institute for International Development, Harvard University, Cambridge, MA 02138, USA.


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· World Bank Project: Vietnam-Population and Family Health
· News from OMNI Network
· Job Announcement

Vietnam -Population and Family Health Project (Pre-Appraisal).

The Bank resumed lending to Vietnam in fiscal year 1994. Given its relatively low level of economic development, Vietnam has achieved considerable progress in improving the health of its population. For instance, the infant mortality rate is 36 deaths per 1,000 live births, which is lower than the average for middle-income countries. However, some of these indicators are beginning to deteriorate. In addition, fertility remains high-the TFR was 3.7 in 1992.

The government is very committed to reducing the rapid rate of population growth, and has requested assistance from the Bank. The proposed population and family health project plans a two-stage approach. The first phase of the project would include five provinces chosen on the basis of geographical representation, large rural population, commitment by provincial authorities, and above average management capacity; phase 2 interventions would be based on the results of phase 1.

The project would address both the government's demographic concerns and the maternal and child health needs of the population. In the area of family planning, the main method in use today is the IUD. The project would seek to increase the range of contraceptives available, provide mobile and outreach services, initiate an IEC program, and refurbish and equip selected health facilities. In addition, safe motherhood and institution-building activities would be included.

A number of ISSUEs need to be resolved, several of which are germane to other countries and projects. One example is providing services to the most disadvantaged groups, including ethnic minorities; another is to ensure provision of a wide range of contraceptive services based on informed choice and voluntary adoption; a third is putting in place a monitoring and evaluation system.

(Population Network News, Number 7, Spring 4)

Omni project participates in Sri lankan iron fortification workshop

As part of Sri Lanka's National Nutrition Week activities, an OMNI (Opportunities for Micronutrient Interventions Project) representative participated in an Iron Fortification Workshop that was held on June 9th. Approximately 40 representatives from government, university and private sector institutions involved in wheat flour production and distribution, and anaemia research attended the workshop.

The purpose of the workshop was to discuss whether or not food fortification would be a viable option to reduce micronutrient malnutrition in Sri Lanka. Various presenters pointed out that there are a number of possible interventions to address iron deficiency anaemia (IDA) one of which is food fortification.

Data was presented by the Nutrition Unit of Sri Lanka's Medical Research Institute on a number of studies on anaemia among pregnant women, preschool, school age and adolescent children. Using hemoglobin as the indicator, all studies suggest that 60% or more of the sample are anemic. This has important implications in terms of cognitive development, worker productivity, morbidity levels and maternal mortality, and thus the economic development of the island.

In Sri Lanka, the only centrally processed food eaten by a large number of people (including a large segment of the poor) on a regular basis is wheat flour. Although this seems the logical vehicle of choice, there are a number of technical, economic and social factors that need to be considered, which OMNI will assist the Sri Lankan government to address. Activities during the remainder of the year will include pilot phase trials and, in early 1995, field trials will start to determine the biological impact of fortification on the iron status of Sri Lanka. An anaemia prevalence survey funded by USAID/Colombo also will be incorporated as part of the National Nutrition Survey program in early 1995.

For more information, contact The OMNI Project, c/o John Snow, Inc., 1616 N. Ft. Myer Drive, Suite 1100, Arlington, VA 22209. Telephone: 703-528-7474; Fax: 703-528-7480; Internet:

Job Announcement

"I picked up the query below from PROFNET, a service that helps journalists to find experts. Any PHNFLASH subscribers who fit this description and would like to be interviewed by CNN - or at least provide them some guidance on the ISSUE - should contact the reporter directly at the Internet address listed." Lawrence MacDonald, Editor, Policy Research Department

FAMILY PLANNING IN EL SALVADOR: I'm looking for someone who's spent time in El Salvador recently and is well versed in population/family planning ISSUEs. This special someone should know something about USAID funding and how much progress is being made there on the population front.


Brad Abramson

CNN Network Earth


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Clearinghouse of the American Public Health Association

New Acquisitions no. 33, May - Jun, 1994

For the last fourteen years, the Clearinghouse on Infant Feeding and Maternal Nutrition has been providing information to practitioners and policymakers in developing countries. Based at the American Public Health Association, the Clearinghouse database includes over 20,000 books, documents and education materials. Materials in the collection are computer-referenced for easy access. The project is supported by the Office of Nutrition, Agency for International Development.

The following is a bibliography of some recent acquisitions. This listing includes articles about adolescence, breastfeeding, health education, information, maternal and child health, women's health and others.

These documents should be ordered directly from the author or publisher. Addresses are provided.

For more information, contact APHA Clearinghouse, American Public Health Association, 1015 15th St. NW, Washington, DC 20005. Telephone: 202-789-5610; Fax: 202-789- 5661; email: or


1. Macieira, M. M. Funding the future: resources for adolescent health programs in developing countries. International Center on Adolescent Fertility (ICAF), Center for Population Options (CPO), 1994.
Address: International Center on Adolescent Fertility, Center for Population Options, 1025 Vermont Avenue, NW, Suite 200, Washington, DC 20005, USA.


1. Learning to be baby-friendly. Office of Public Policy and Government Relations, U.S. Committee for UNICEF, 1994. [video] Cost: US$18.00
Address: Alan Chertok, PDR Productions, Inc., 219 East 44th Street, New York, NY 10017, USA.
2. Protect breastfeeding: making the code work. World Alliance for Breastfeeding Action (WABA), 1994. (Also available in French, Spanish and Portuguese)
Address: WABA, P.O. Box 1200, 10850 Penang, Malaysia.

3. State of the code by country. International Baby Food Action Network (IBFAN), 1994.
[survey chart] Cost: US$3.00
Address: International Code Documentation Centre, P.O. Box 19, 10700 Penang, Malaysia.

4. Gray, S. J. Comparison of effects of breastfeeding practices on birth-spacing in three societies: nomadic Turkana, Gainj, and Quechua. Journal of Biosocial Science, 26:69-90, 1994.
Address: Sandra J. Gray, Department of Anthropology, University of Kansas, 622 Fraser Hall, Lawrence, KS 66045-2110, USA.

5. Morrow, M.; Barraclough, S. Breastfeeding and public policy in Australia: limitations of a nutritional focus. Breastfeeding Review, II:9, 408-416, May 1994.
Address: Martha Morrow, Department of Health Administration and Education, Lincoln School of Health Sciences, LaTrobe University, Carlton 3053, Victoria, Australia.

6. Torre, P. Los sucedaneos de la leche materna en la seguridad social Mexicana durante 1990. Salud Publica de Mexico, 35:6, 700-708, Nov-Dec 1993.
Address: Lic. Pilar Torre, Investigadora del Instituto Nacional de la Nutricion "Salvador Zubiran," Vasco de Quiroga 15, colonia Tlalpan, 14000 Mexico, D.F., Mexico.

7. Girls' Education

8. Giracca de Castellanos, A. Yo puedo ser ... Instituto de Linguistica, Universidad Rafael Landivar, Guatemala, 1993. [storybook] (This is one in a series of brief books which promote girls' education.)
Address: U.S. Agency for International Development/Guatemala (USAID/G), 1a. calle 7-66 zona 9, Guatemala ciudad, Guatemala.

9. Piedra Santa, I.; et al Las vidas de Marta y Rosa: si nuestras hijas estudian, todos mejoramos. U.S. Agency for International Development/Guatemala, Guatemala, 1993. [flip chart/rotafolio] Address: U.S. Agency for International Development/Guatemala (USAID/G), 1a. calle 7-66 zona 9, Guatemala ciudad, Guatemala.


1. Capoor, I.; et al People for their health: the CHETNA experience. Center for Health Education, Training and Nutrition Awareness, Jan 1994.
Address: CHETNA, Lilavatiben Lalbhai's Bungalow, Civil Camp Road, Shahibaug, Ahmedabad - 380 004, Gujarat, India.

2. Parker, E.; et al Health education planning and management for child survival programs: a training program guide. U.S. Department of Health and Human Services, 1994. [book]
Address: ACSI-CCCD Technical Coordinator, International Health Program Office, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.


1. List of descriptors on the theme of women. Isis Internacional, Jan 1994. [book]
Address: Isis Internacional, Casilla 2067, Correo Central, Santiago, Chile.

2. Model science and technology information networks in Sub-Saharan Africa: report of a feasibility study carried out by a panel of the Board on Science and Technology for International Development. Panel on Scientific Networking in Africa, BOSTID, 1993. [book]
Address: Board on Science and Technology for International Development (BOSTID), National Research Council, 2101 Constitution Avenue, NW, Washington, DC 20418, USA.

3. Akman, J.; Boivin, L. International Women's Network of AMARC: Resource Directory. The World Association of Community Radio Broadcasters (AMARC), 1992. [booklet]
Address: The World Association of Community Radio Broadcasters (AMARC), 3575 boul. St-Laurent, Suite 704, Montreal, Quebec, H2X 2T7, Canada.

4. Box, L.; et al Culture and communication: the forgotten dimension in development cooperation. Royal Tropical Institute, 1993. Cost: Dfl.$15.00
Address: Royal Tropical Institute, KIT Press, Mauritskade 63, 1092 AD Amsterdam, The Netherlands.

5. Compton, A.; et al CD-ROM for African research needs: some basic guidelines. Sub-Saharan Africa Program, American Association for the Advancement of Science, Nov 1993. [booklet]
Address: Sub-Saharan Africa Program, American Association for the Advancement of Science, 1333 H Street, NW, Washington, DC 20005, USA.

6. Hornik, R.; et al Communication for child survival: synthesis of basic results (evaluation of Healthcom projects in eight countries). Center for International, Health and Development Communication, Annenberg School for Communication, University of Pennsylvania, 1993. [booklet]
Address: Center for International, Health and Development Communication, Annenberg School for Communication, University of Pennsylvania, 3620 Walnut Street, Philadelphia, PA 19104-6220, USA.

7. LaPorte, R. E.; et al Towards a global public health internet. Ronald E. LaPorte, PhD, Pittsburgh, PA, USA, Apr 25, 1994.
Email Address:, USA.

8. Levey, L. A. Profile of research libraries in Sub-Saharan Africa: acquisitions, outreach, and infrastructure. Sub-Saharan Africa Program, American Association for the Advancement of Science, May 1993. [booklet]
Address: Sub-Saharan Africa Program, American Association for the Advancement of Science, 1333 H Street, NW, Washington, DC 20005, USA.

9. Levey, L. A.; Rosenberg, G. Confronting the demand for scientific and scholarly literature in Portuguese: an assessment of African needs and how to meet them. American Association for the Advancement of Science, Dec 1992.
Address: American Association for the Advancement of Science, 1333 H Street, NW, Washington, DC 20005, USA.

10. Menou, M. J. Measuring the impact of information on development. International Development Research Centre (IDRC), 1993. [book] Cost: US$25.95
Address: International Development Research Centre, P.O. Box 8500, Ottawa, ON, Canada K1G 3H9.

Maternal and Child Health

Final Report: kangaroo motherhood method program - neonatal care of low birthweight newborns in the Isidro Ayora Maternity. Mother-Care project, 1993.
Address: Mother-Care, 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, USA.


Gopalan, C.; Kaur, H. Towards better nutrition: problems and policies. Nutrition Foundation of India, 1993. [book]
Address: Nutrition Foundation of India, B-37 Gulmohar Park, New Delhi, India.

Iunes, R.F.; Monteiro, C.A. Improvement in child nutritional status in Brazil: how did it occur? Center for Epidemiological Studies in Health and Nutrition, University of Sao Paulo (NUPENS/ USP), Sep 1993. [booklet]
Address: Dr. John B. Mason, Technical Secretary, ACC/SCN, c/o World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland.

Kachondham, Y.; Winichagoon, P.; Tontisirin, K. Nutrition and health in Thailand: trends and actions. Institute of Nutrition, Mahidol University, Dec 1992. [book]
Address: Dr. John B. Mason, Technical Secretary, ACC/SCN, c/o World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland.

Renqvist, U.H.; et al Nutrition in primary health care: experiences in Pahou, Benin. Centre Regional pour le Developpement et la Sante, 1993. Cost: Dfl.$15.00
Address: Centre Regional pour le Developpement et la Sante (CREDESA), B.P. 1822, Cotonou, Republique du Benin.

Tagwireyi, J.; Jayne, T.; Lenneiye, N. Nutrition-relevant actions in Zimbabwe. National Nutrition Unit, Ministry of Health and Child Welfare, Zimbabwe, Dec 1992. [booklet]
Address: Dr. John B. Mason, Technical Secretary, ACC/SCN, c/o World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland.

Uvin, P. Hunger report: 1993. Alan Shawn Feinstein World Hunger Program, Brown University, 1994. [booklet]
Address: Peter Uvin, Alan Shawn Feinstein World Hunger Program, Brown University, Box 1831, Providence, RI 02912, USA.

Zulkifli, S.N. Nutrition promotion: the role of monitoring physical growth. Asia-Pacific Journal of Public Health, 6:4, 210-216, 1992-1993.
Address: Siti Norazah Zulkifli, ScD, Social Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia.


Madzou, G.; et al Etude de l'alimentation de sevrage du nourrisson a Brazzaville. Medecine Tropicale, 53:3, 325-329, Jul-Sep 1993.
Address: G. Madzou, Assistant a la Faculte de Medecine, Institut Superieur des Sciences de la Sante, Departement de Sante Publique, Brazzaville, Congo.


Black, M. Girls and women: a UNICEF development priority. UNICEF, 1993.
Address: Programme Publications, United Nations Children's Fund, 3 UN Plaza, New York, NY 10017, USA.

O'Connell, H. Women and the family. ZED books, Mar 28, 1994. [book] Cost: US$17.50
Address: ZED Books, 7 Cynthia Street, London N1 9JF, U.K.


Creating common ground in Asia: women's perspectives on the selection and introduction of fertility regulation technologies. Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1994.
Address: Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, 1211 Geneva 27, Switzerland.

Information kit: women's perspectives on population ISSUEs. Health Networking Team, Isis International, 1994.
Address: Isis International, P.O.Box 1837 Main, Quezon City, 1100 Philippines.

Kanani, S.; Consul, P. Women's views matter: an overview of qualitative research methods in women's health and some experiences from India. Women, Households and Development Studies Information Centre, Department of Human Development and Family Studies, Faculty of Home Science, M.S. University of Baroda, India, 1993.
Address: Women, Households and Development Studies Information Centre, M.S. University of Baroda, Baroda 390 002, Gujarat, India.

Khanna, R.; et al Action linked research methodologies for women's health. Women, Households and Development Studies Information Centre, M.S. University of Baroda, India, May 1993.
Address: Women, Households and Development Studies Information Centre, M.S. University of Baroda, Baroda 390 002, Gujarat, India.

Sinclair, M. R.; Klugman, B. Reproductive health policy and programs: reflections on the African experience. The Henry J. Kaiser Family Foundation, Jul 1993. [report]
Address: Michael R. Sinclair, PhD, Vice President, The Henry J. Kaiser Family Foundation, 1450 G Street, NW, Suite 250, Washington, DC 20005, USA.

Winnard, K. Applying social marketing to maternal health projects: the MotherCare experience. MotherCare project, 1993. [book]
Address: MotherCare, 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, USA.


Meeting basic learning needs through programmes of early childhood care and development. The Consultative Group on Early Childhood Care and Development, Sep 1993.
Address: Dr. Robert Myers, Secretariat, The Consultative Group on Early Childhood Care and Development, Insurgentes Sur 4411, Ed 25-202, Tlalcoligia, D.F. 14430, Mexico.

Plano emergencial de acao para o setor saude. Ministerio da Saude, Brazil, Dezembro 1993.
Address: Ministerio da Saude, Gabinete do Ministro, 70.099-999, Esplanada dos Ministerio, Bloco 11-5o. Andar, Brasilia, DF, Brasil.

Moore, F. Beyond development cooperation: toward a new era of global and human security. International Development Research Centre (IDRC), Mar 1994.
Address: International Development Research Centre (IDRC), P.O. Box 8500, Ottawa, ON, Canada K1G 3H9.

Peck, M. G. Improving urban maternal and child health linkages: highlights of the 1993 Urban MCH Leadership Conference. CityMatCH, 1993. [book]
Address: National Maternal and Child Health at the Clearinghouse, 8201 Greensboro Drive, Suite 600, McLean, VA 22102, USA.

Vernooy, R.; Kealey, K. M. Food systems under stress in Africa: African-Canadian research cooperation. International Development Research Centre (IDRC), Mar 1994. [book]
Address: International Development Research Centre (IDRC), P.O. Box 8500, Ottawa, ON, Canada K1G 3H9.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Please Read The Following ANNOUNCEMENT!
· World Bank Sector Report: Better Health in Africa
· Announcement from EDI (Economic Development Institute)


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World Bank Sector Report: Better Health in Africa

Better Health in Africa was ISSUEd in gray cover on Dec 14th 1993, and will be available to the public in its final form late summer. Amongst the Africa Technical Department's most important reports to date, Better Health in Africa complements the 1993 World Development Report, Investing In Health, by offering a regional, operationally-oriented perspective on how health gains can be realized despite tight financial constraints.

The bottom line, argues the report, is "that the health status of Africans can be significantly improved despite binding financial constraints." Thus: "Other countries are achieving better health at low levels of per capita income, why not countries in Africa? Though cultural and political differences are involved, many of the lessons learned are generalizable and transferable."

Major obstacles and deficiencies:

·· "Despite commitments to the principles of primary health care (PHC) most governments have been slow to facilitate community-oriented and intersectoral approaches to planning and operating systems of health care.

·· Equally problematic is the lopsided way that private and public systems of health care have evolved. In many African countries 45 percent of the population does not have access to quality health care. Moreover, a large share of public funds for health - as much as 80 percent - goes to urban-based curative care.

·· Inefficiencies in systems of health care are rampant, with the result that households get too little quality care for the scare resources they have...Poorly trained personnel and inadequate supplies within several of the bottomtiers. prompts residents at the community level to by-pass lower levels to seek basic care from intermediate-level facilities and hospitals.

·· Ministries of health tend to be inappropriately staffed with inadequately trained health professionals and managers, and personnel at all levels tend to be underpaid and de-motivated. Publicly owned and operated infrastructure and equipment tend to be poorly managed and are visibly in decline in many countries. Stock-outs of drugs and supplies are frequent.

·· Broader societal conditions such as political instability, macro-economic shocks linked with the international economy, and national disasters, affect health outcomes in a major way...When poor economic performance and fiscal mismanagement (combined with mounting indebtedness) mandate budgetary reforms, governments have too often reduced the priority for health. Between 1975-89, for example, government health expenditures (as a share of total government expenditures) fell for 13 of the 22 countries for which time series data are available." Recommendations for action: "Admitting that some obstacles are more stubborn than others, this study targets constraints most amenable to change from a national perspective.

It recommends a restructuring of systems of health care to the effect that:

·· Governments would attach priority to creating an enabling environment for health through financing and provision of public health goods and services which benefit society at large, as well as subsidizing access to health care among the poorest segments of the population....the need to concentrate limited public sector capacity on these ISSUEs, and the prevailing tendency of private-for-profit health services to concentrate in large urban areas, means that private voluntary providers of health care and community autonomy in the financing and management of health services merit maximum encouragement.

·· Systems of health care would be decentralized.

·· Emphasis would be placed on basic services, provided in a cost-effective manner, featuring essential drugs and supporting community services...These would meet the needs of the most vulnerable groups - the newborn, children under 5, and women of reproductive age - as well as major diseases. This would aim to accommodate up to 98 percent of problems that can be treated clinically.

·· Cost-sharing would be practiced on a wide scale at the community level.

·· Beyond first referral hospitals, central, national, and teaching hospitals would continue to offer tertiary level care and focus on training, with the caveat that patients seeking care would proceed through an orderly referral system. Full cost recovery would be justified for tertiary care on both cost-effectiveness and equity grounds. Public budgetary support for large public hospitals would be hard to cut but would be frozen at current levels.

·· Indicative estimates included in the study suggest that a basic package of health care services, plus incremental, multi-sectoral services can be provided for approximately $13 per capita, per year in low income African countries. This has been disaggregated into costs for health care and facilities ($7.74 per capita), intersectoral interventions including safe drinking water and sanitation ($3.98), and institutional support ($1.50 per capita). No pretense is made, however, that an universally applicable cost or a single recipe for an essential package of health care services can be derived.

·· Establishing an indicative figure of $13 per capita for a basic package of services in low-income Africa is valuable as a means of prompting reflection on what people are getting now for the amount they pay; how resources might be allocated to usher in a more cost- effective approach; and additional resource requirements to assure that the poorest countries and poorest groups within countries could afford such a package.

·· Assuming the public sector - governments and donors - were willing to increase their resource commitments in ways suggested in the study, an additional $1.6 billion per year would be mobilized for better health in low-income Africa. Governments would contribute almost one billion dollars...the donor share, comprising about $650 million per year, would be about 50 percent more than the amount now provided from external sources in assistance for health improvement in Africa."

Announcement from Economic Development Institute, World Bank

The Studies and Training Design Division of Economic Development Institute (EDIST), World Bank, is seeking information on academic or other institutions which have prepared AIDS-related case studies in French. EDIST is trying to put together case studies on various facets of ISSUEs on AIDS including prevention, pharmaceuticals, financing, etc and need help in identifying available case studies. For more information, please contact Ms. Anuja Adhar through e-mail (


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· World Bank Project: Nepal-Population and Family Health
· Seminar on New Strategy to Combat Mineral-Micronutrient Deficiencies

Nepal: Population and Family Health

[IDA $26.7 ml, total $39 ml; approved April 12 '94. Pop 20 ml; per cap GNP $180; life exp 53; U5MR 197; MMR 833; TFR 5.5]

The first World Bank credit for the health and population sector in Nepal, the project is directed at increasing contraceptive prevalence, lowering fertility rates, and reducing maternal and child mortality and morbidity.

Progress on these fronts is a core element of the government's current poverty alleviation efforts, the project appraisal report notes, but "the attainment of these goals has so far proved formidable in view of the rudimentary health service delivery in most parts of the country, the limited access of the population even to the inadequate facilities available, and the constrained institutional, personnel, and financial resources in the population sector." At present, Nepal's family planning and mother-child health (MCH) program lacks momentum, emphasizes sterilization to the neglect of temporary contraceptive methods, and has given too little attention to MCH services.

The project's primary emphasis is on expanding outreach service delivery. On the MCH front, the project will help to substantially raise client access to an improved and expanded network of clinical facilities, including district hospitals, health posts and sub-health posts. A cadre of female MCH workers will be developed; they will be based at the sub-health posts. The family planning and MCH activities are to be integrated with the country's primary health care system. Targets set in the project include holding 50,000 outreach clinics per month by the end of the project period in the year 2000.

The project also supports the development of a field-based, integrated Management Information System that will facilitate record-keeping of service delivery, as well as monitoring, evaluation and planning.

Seminar - New Strategy to Combat Mineral-Micronutrient Deficiencies:

Food-Based Strategies To Combat Micronutrient Malnutrition in Developing Countries

Breeding for Mineral-Dense Seeds: A Means to Better Human Nutrition and Improved Crop Yields?

Tuesday, August 9, 1994

9:30 a.m. to 12:30 p.m.

World Bank "H-Building," Conference Room H-2-300, 600 19th Street, Washington, D.C.

Breeding for staple food plant varieties which load high amounts of iron and zinc in their seeds holds great promise for making a significant, low-cost, and sustainable contribution to reducing iron and zinc deficiencies in humans in developing countries. Because mineral-dense seeds turn out to be good for plant nutrition as well, this strategy also May well have important spin-off effects for increasing farm productivity in developing countries in an environmentally-beneficial way. Zinc-efficient wheat varieties have already been released on a commercial basis in Australia.

Screening for germplasm variability will commence soon for rice, wheat, maize, beans, and cassava under a project organized by the International Food Policy Research Institute with funding from the United States Agency for International Development. A collaborative effort to develop high-yielding, mineral-dense seeds will be undertaken initially at three CGIAR Centers (IRRI, CIMMYT, and CIAT), the Plant, Soil, and Nutrition Laboratory (USDA-ARS) in Ithaca, New York, and the Waite Agricultural Research Institute, University of Adelaide in Australia.

The seminar will provide information on project activities and will lay out the scientific basis for pursuing this approach to combating mineral deficiencies (see below for program). A multi-disciplinary panel will evaluate prospects for eventual success of the project.

All are welcome to attend. However, non-World Bank employees must R.S.V.P. to Howarth Bouis of IFPRI at 202-862-5641 or so that your name May be placed on a list for admittance to H-building.


International Food Policy Research Institute (IFPRI)

Consultative Group on International Agricultural Research (CGIAR)

Office of Health and Nutrition, USAID

Population, Health, and Nutrition (PHN), World Bank



Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Job Announcement from Medicines Sans Frontiers (MSF)
· Announcement on Three World Bank Discussion Papers

Two Positions with Medicines Sans Frontiers (MSF-CIS):

Food Security Analyst and Nutritionist

MSF CIS, a national food security and nutritional health monitoring system in Mozambique, seeks two international staff, one Food Security Analyst and one Nutritionist, to contribute to the production of a monthly bulletin through the collection and analysis of country-wide data. The positions are based in Maputo and require 50% travel to the field.

The Food Security Analyst will have a demonstrable specialization in one or more of the relevant disciplines: anthropology, public health, agronomy, geography or agricultural economics; practical and theoretical knowledge of food security and/or health information systems; and the capacity to conduct household health, nutrition and socio-economic surveys.

The Nutritionist will have practical and theoretical knowledge of food security and early warning systems; statistical and epidemiological methodologies; field experience of nutritional surveys; and nutrition programme design and evaluation.

Both candidates will posses: Proficient Portuguese or fluent Spanish; English, spoken and written; Willingness and ability to travel, sometimes under difficult conditions; Masters degree (or +/- 5 years of field experience) in relevant field or discipline; Strong communication and interpersonal skills necessary to work on a small, interdisciplinary team; Theoretical and practical knowledge of spreadsheet, word-processing, and statistical packages; MSF and/or NGO experience in developing countries; Knowledge of quantitative and qualitative assessment/analysis skills; Experience in the development and implementation of training programmes.

The application deadline for the Food Security Analyst is September 7, 1994 with a starting date of no later than October 1, 1994. The application deadline for the Nutritionist is October 7, 1994 with a starting date of no later than November 1, 1994. The minimum contract period for both posts is one year or until the completion of the project at the end of ´95. Salary consists of a monthly stipend, per diem, shared housing and transportation, medical benefits and travel. Send CV, 3 references, and a brief statement of purpose in English or Portuguese to: Human Resources, MSF Belgium, attn: Seco, 24/26 Rue de Schampheleer, B-1080, Brussels, Belgium, tel: [32- 2] 414-0300; fax: 411-8260. Local contact: Pierre Poivre, Coordinator; MSF CIS, CP 1653, Maputo, MZ; tel: [258-1] 42-36-03 or 42-59-95; fax: 42-21-40; email:

Three World Bank Discussion Papers:

"Women's Health and Nutrition"; "Violence Against Women"; "Making Motherhood Safe"

The following three papers published as part of a series of papers related to the women's health ISSUEs are available at no charge (while supplies last) to PHNFLASH subscribers. Please send your request to Odell Shoffner at (World Bank staff, please send an All-in-1 message to Odell Shoffner)

· Women's Health and Nutrition-This paper examines women's health problems from infancy to old age and sets forth a strategy for developing countries and their partners to improve women's health and nutrition through a set of cost-effective essential health services that address the major causes of death and disability among women in developing countries. [#256]

· Violence Against Women-This paper was prepared to raise awareness of the extent and consequences of violence against women. It also examines the implications of gender violence for health and development and suggest practical steps that can be taken toward eliminating violence against women. [#255]

· Making Motherhood Safe (also available in Spanish)-This paper was prepared to facilitate policy dialogue and program design, implementation and evaluation in maternal health and family planning. Although primarily intended for the use of World Bank staff, the paper will serve as a guidance to governments, other international agencies, and non-governmental organizations in the design and implementation of programs to reduce maternal mortality and improve the status of women. [#202]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Note from OMNI (Opportunities for Micronutrient Interventions)

Twenty-two Developing Countries Launch Industry-Government Partnerships to Achieve World Summit Goals

As the Year 2000 quickly approaches, a new level of global effectiveness is required to eliminate vitamin A and iodine deficiencies and reduce iron deficiency. These problems affect up to 2 billion people worldwide, limiting their ability to learn, resist illness, and, particularly in the case of children, survive.

The Opportunities for Micronutrient Interventions (OMNI) Project, funded by USAID's Child Survival Division of the Global Bureau for Population, Health and Nutrition, worked closely with the Wageningen Agricultural University and the International Agricultural Center as well as the Micronutrient Initiative to conduct back-to-back workshops strengthening international micronutrient programs. During the week of June 13th, 45 international micronutrient program managers worked with OMNI team specialists and field officers from UNICEF to analyze operational problems in salt iodization, iron supplement delivery, community-based strategies to enhance consumption of foods rich in vitamin A and iron, as well as surveillance, monitoring and mass communication.

Recommendations from diagnostic sessions and problem-solving clinics were used to revitalize national programs, and contributed to the June 20th - 24th Agro-Industrial conference, organized primarily by the Dutch agencies with additional technical support from OMNI, the U.S. Centers for Disease Control and Prevention (CDC), UNICEF, WHO and FAO with European corporate sponsorship.

The Agro-Industrial conference attracted as many as 180 food and nutrition researchers, corporate representatives and program officers from international agencies and private foundations (such as the Thrasher Research Fund, the Keystone Center, Kiwanis, and IFPRI). Following technical presentations, OMNI, Dutch and MI specialists facilitated working groups on social marketing, agricultural innovation, total quality management and monitoring. The challenge was to develop a framework by which government, the food sector and international organizations can interact in a climate of mutual trust and confidence to develop and responsibly market products with the potential of improving the health of children and women.

Innovative products - ranging from high iron strains of wheat and rice and genetically improved vegetables, fortified foods in every category, processing and packaging improvements, as well as supporting technologies of laboratory, data management and communications - were examined for their potential contribution to sustainable development.

Participants also described new health sector strategies linked to reproductive health and family planning, including jump-starting child survival by improving adolescent and women's health.

Many products and approaches were featured at a half-day Fair; and the multinational and European companies who attended the final "Advocacy Day" shared their vision of how micronutrient program managers could think "outside of the box" to achieve impact beyond traditional health or agricultural approaches. Program Officers from WHO, FAO and UNICEF - as well as the many government health sector representatives - focused on serving the needs of the most needy women and children first. The Undersecretaries of Health from Egypt, Indonesia, Pakistan and the Philippines kept the policy dialogue focused on pragmatics, and promised that immediate steps to reshape policies and programs would be taken. Representatives from Unilever, Proctor and Gamble and Heinz explored possibilities of contributing to new product development, training and trouble-shooting efforts in East and Southern Africa, the Pacific Rim and the SARC region with participants from these countries.

This would be accomplished by working through local subsidiaries of multinational companies, and stimulating local supporting businesses, ranging from national to micro-enterprises. All participants stressed the need for institutional capacity building and the need for countries to share human resources on a regional basis. Preliminary plans were made to strengthen training for francophone and anglophone Africa, Latin America, SARC and Southeast Asia.

For more information on the workshop, please contact The OMNI Project, c/o John Snow, Inc., 1616 N. Fort Myer Drive, Suite 1100. Telephone: 703-528-7474; Fax: 703-528-7480; Internet:


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Job Announcement from OMNI (Opportunities for Micronutrient Interventions
· World Bank AIDS Workshop

Job Announcement from OMNI

International public health consulting firm seeks Associate Nutritionist/Food Technologist for its USAID-funded Opportunities for Micronutrient Interventions (OMNI) Project. The Associate Nutritionist/Food Technologist will provide technical support to the Nutrition/Research Advisor and Food Technologist in a variety of areas related to micronutrient project activities. Candidates must have a broad knowledge and understanding of nutrition and food technology ISSUEs, some experience with micronutrients, at least a master's degree in one of the fields with a strong knowledge of the other; at least five years of international development field experience; excellent writing and computer skills; and working knowledge of French or Spanish.

Please send resumes and salary requirements by September 9, 1994 to:

Project Administrator, OMNI Project, John Snow, Inc., 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209, FAX Number: 703-528-7480. No phone calls please.

World Bank AIDS Workshop

The AIDS Workshop organized by the Training Division and the Africa Technical Department on April 6th focused on core prevention indicators and evaluation of national AIDS programs; a review of the Bank's support for AIDS-related work in Africa; and the World Vision-Government of Uganda Program of Assistance to Orphans. The workshop was designed and chaired by Wendy Roseberry and Elisabet Dennis.

Evaluation of national AIDS program has been a low priority over the past decade because of the pressure to take speedy and visible action, said Thierry Mertens of WHO's Global Programme on AIDS. But evaluation is anything but a luxury, he said, as "unless plans are made early enough for evaluation, programs run the risk of facing unfulfilled expectations, frustration and disillusionment for lack of feedback on the effects of hard work already carried out. Carefully conducted periodic surveys provide reliable information for long-term trends to determine the progress and future direction of the program." Ideally, evaluation should be an "on-going, operationally-oriented feedback system," said Mertens, and not the "threatening, one-time assessment by experts" that it is most often. And at most evaluation work should require 5 percent of a project's budget. An Evaluation Package developed by WHO/GPA, USAID and the World Bank focuses on 10 prevention indicators - including both process and outcome indicators - that range from knowledge of preventive practices and condom availability at the central level to reported STD incidence in men and HIV prevalence in women. A loose-leaf binder with the protocols is available from the editor, Wendy Roseberry or WHO/GPA.

In a presentation on the Uganda Orphans Program, a collaborative effort of the Ugandan Government, World Vision International and the World Bank, Joe Muwonge of World Vision noted that "the orphans problem is so widespread that orphanages alone would never be able to cope with the number." Some 1.2 million Ugandan children under the age of 18 are estimated to be orphans, while projections suggest that 50,000 new orphans are being created each year. Hence, the thrust in Uganda is on assisting communities in caring for their own by providing training in health care and counseling, providing tuition support and vocational training, and furnishing credit and agricultural inputs to raise food production by foster families. Motivating people at the grassroots so that they get to look at themselves as the principal resource is a key element, added Kofi Hagan and Edward Mubiriu, also with World Vision. The program has been operational for three years, making it "too early to speak of success or failure," said Muwonge. He can be contacted at 202-547-3743 for more information.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this Issue

· World Bank Sector Report: Brazil-The Organization, Delivery and Financing of Health Care

Brazil: The Organization, Delivery and Financing of Health Care

Coming at the end of a decade in which the Brazilian government undertook sweeping reforms of the public health sector - the "Reforma Sanitaria" - this report "is meant to inform the policy debate about marginal adjustments and new initiatives" that are still needed if the goals of reform are to be secured. Maureen Lewis (Latin American Human Resources) is the principal author, with contributions from Philip Musgrove (Population, Health, Nutrition). The report, ISSUEd in green cover in January this year, draws heavily on several background papers prepared for the World Bank.

The Reforma Sanitaria, begun in 1984, involved a "massive institutional, organizational, and financial reform of the public health sector," notes the report. It had three main objectives: Shifting the responsibility for health care provision from the center to the periphery, consolidating public sector provision and finance, and improving the equity of access to health services.

"Although the reforms were successful in expanding access to health care, improved equity has placed an enormous strain on government health care resources, which due to high inflation and recession in the 1980s and 1990s, have not kept up with increases in patient demand," says the report. "The eroding value of government reimbursements (under the prospective payment system) to hospitals and clinics, and fees to physicians has resulted in a decline in quality of care."

The report details the structure of health care in Brazil, the pattern of public and private expenditures on health, and institutional changes made under the recent reforms. Key points emerging from the report include:

· Brazil's health system differs markedly from those of most other developing countries in the heavy reliance on a prospective payment system that - along the lines of the US Medicare system - entails public reimbursement of privately provided services. Only a small proportion of care is provided by public facilities.

· In 1990, Brazil spent roughly 4.8 percent of GNP on health care, less than that spent by other middle income countries in the region. But the lack of management, oversight and accountability of both government programs and privately delivered and financed services is more pressing an ISSUE than the low level of spending.

· Roughly 66% of health expenditures were made by public entities and the rest by private citizens; half of the private expenditures were made by third party payers.

· The decentralization process has focused on transferring all functions and the bulk of funds to the 5000-odd municipalities, many of which have neither the capability nor capacity to oversee, finance and regulate health care.

· Regulation and enforcement of performance standards for public and private providers and facilities, and for private payers is virtually non- existent.

The report emphasizes the need to:

· Consolidate institutional reforms by defining the roles and functions of each level of government, ensuring transparent transfers of funds, and allowing states to experiment with alternative models of finance and delivery drawing on the experiences of Europe, Canada, the US and particular US states.

· Develop a capacity for health policy research to guide policy development and to provide an avenue for overseeing and regulating health care service delivery.

· Strengthen cost containment through reforms that take advantage of the in-built incentives for cost-containment in the prospective-payment system; efforts to discourage over-consumption by users; streamlined service options through the introduction of a basic package of eligible services that limit the scope of government's financing; and incentives to contain the volume of services provided by both the public and public-reimbursed system.

· Measure, monitor and improve quality of care through public-private oversight measures.

· Improve the regulation and enforcement of performance among providers (hospitals, physicians, nurses), payers (insurance companies) and training institutions (medical and other professional schools.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Notice to subscribers
· Essential Drugs

Notice to subscribers from futures group

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Essential Drugs:

...Are important drugs in developing countries of good quality, stable and safe at point of use? How far do adverse climatic or storage conditions affect these attributes? Do locally manufactured drugs perform less well on these counts? Quality of Selected Drugs at the Point of Use in Developing Countries, a joint UNICEF and WHO study of nine important drugs widely used in developing countries, is a first stab at studying these concerns. The drugs studied include amoxicillin, paracetamol and quinine. Five African, two Asian and two Latin American countries were studied. Major conclusions reached by the study are, one, that syrups have the highest failure rate and tablets the lowest; two, that though a large proportion of failures are associated with local manufacture, the difference is not statistically significant; and finally, that there is currently a "reasonable" level of quality. But the study cautions that the drug samples were largely collected at the central level - not at peripheral private sector distribution points - and that the very small size of the survey means that these results should be treated as an "approximation." Also just published is an external evaluation (in French) of the UNICEF- and WHO- led Bamako Initiative in Rwanda. Both are available from the editor.

...To its legion supporters, the Bangladesh National Drug Policy
was not just the first of its kind - based on public health concepts such as primary health care and the need for essential drugs - but has also in the past fourteen years brought about remarkable improvements in drug availability, pricing, quality, and elimination of hazardous and non-essential products. To its detractors, the policy has driven away foreign investment, limited access to life-saving drugs, hampered the growth of the Bangladesh pharmaceutical industry, and unfairly restricted multinational companies. For an informed assessment of this debate -but one clearly from the side of the boosters - turn to From Policy to Practice: The Future of the Bangladesh National Drug Policy, by Andrew Chetley, 1992, which is available from the Sectoral Library.

[Extracted from HEALTH POLICY, Number 7, June, 1994]


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Announcement: International Society of African Scientists (ISAS) Tenth Technical Conference
· Call for Papers for The Third Interdisciplinary Conference on Occupational Stress and Health
· World Bank Report for Cairo
· New Publications


International Society of African Scientists (ISAS) Tenth Technical Conference


September 20, 1994
McLean Hilton at Tysons Corner, McLean, Virginia
(Hotel Phone #: 703-847-5000)
The objectives of the conference are:

· to bring participants up-to-date on prevention, care and coping strategies.
· to examine the impact of socio-cultural factors on AIDS education and prevention programs.
· to share experience from various public health programs.
· to encourage collaboration and the exchange of scientific information on HIV and AIDS.

For additional information, please contact Dr. Kwaku Temeng at 302-695-1070 (Fax mail: 302-695-3347) or Dr. John Kilama at 302-451-0873 (Fax mail: 302-366-5738).

Work, stress, and health '95: creating healthier workplaces.

The Third Interdisciplinary Conference on Occupational Stress & Health.
September 13-16, 1995
Hyatt Regency Hotel, Washington, D.C.

Sponsored by American Psychological Association (APA), National Institute for Occupational Safety and Health (NIOSH), U.S. Department of Labor

(DOL) and U.S. Office of Personnel Management (OPM)

Workshop proposal deadline: January 3, 1995
Paper, poster, and symposium proposal deadline: January 27, 1995

Researchers, health and mental health practitioners, managers, and human resources personnel are invited to submit proposals for paper/poster presentations, workshops, and symposia on new research findings, prevention/intervention programs, and policy that address any of four major conference themes:

1. Stress, Health, and the Changing Nature of Work and Organizations: with special emphasis on organizational restructuring, realignment, downsizing, and the impact on individuals, families, and the workforce.

2. Social and Environmental Equity in the Workplace: with special emphasis on the contingent workforce, child labor, ISSUEs of diversity and the changing workforce, and lifestyle and privacy ISSUEs.

3. Workplace Violence: including job stress risk factors; prevalence; effects on workers, families, and organizations; prevention practices, and policies.

4. Health Effects, Policy, Prevention, and Intervention: including job stress intervention strategies; healthcare costs of stress; international policies, legislation and standards; and evaluation methods.

NOTE: Submissions must be made in printed form. Submissions by fax and electronic mail are not possible at this time. Refer inquiries to:

Lynn A. Letourneau Tel: 202-336-6124
Occupational Health Conference Fax: 202-336-6117
American Psychological Association
750 First St., NE
Washington, DC 20002-4242
Internet address:

World Bank Report for Cairo

"Population in Developing Countries: Implications for the World Bank," a report prepared for the International Conference on Population and Development reviews the progress made and the challenges still facing the international community in the area of population and reproductive health. The report also evaluates the Bank's past experiences in the sector and provides guidance on future strategies.

The following preface by Armeane Choksi, Vice President for Human Resources and Operations Policy, introduces the volume.

The 1994 International Conference on Population and Development is an occasion to reflect on the challenging population ISSUEs of this decade and beyond. For the World Bank, "Population in Developing Countries: Implications for the World Bank" is the first major review on population since the 1984 World Development Report, which was prepared for the last world population conference.

The report recommends population policies that integrate investments in reproductive health and family planning information with other human resource investments, including those that will reduce the continued high levels of maternal and child mortality in developing countries, increase women's education, and raise their economic and social status. Such investments are beneficial in their own right and will also help to slow rapid population growth.

While financial and technical support needs depend on country-specific conditions, much could be accomplished if governments and aid donors would allocate the resources needed to achieve these goals and if they would place greater emphasis on successful implementation of their projects and on undertaking effective social sector reforms.

The pursuit of sustainable economic growth is also a very important prerequisite for human development and for completion of the demographic transition. Raising of living standards for the large numbers of people being added to the populations of developing countries will not be possible without economic growth. Economic integration, openness in trade and technology transfer, as well as environmental preservation are essential to bring about sustainable economic development.

Population In Developing Countries: Implications for the World Bank is now available at the World Bank Bookstore. Tel. (202)473-2941.

(extracted from Population Network News, no. 8, Summer 1994).

New Publications

The following booklets published by the Department of Population, Health and Nutrition are available in French, English and Spanish upon request (while supplies last):

· Population and Development: Implications for the World Bank
· Family Planning: A Development Success Story (please specify language in your request)
· A New Agenda: For Women's Health and Nutrition

Please send request with your name, affiliation and mailing address via e-mail to Odell Shoffner at:


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Request for Proposals by Opportunities for Micronutrient Intervention (OMNI) Research
· World Bank's Regional Initiatives on Aids Prevention
· New publication by Family Health International (FHI)

Request for Proposals by OMNI Research

Theme: To identify practical approaches that will increase the bioavailability of iron, carotenoids and retinyl esters from diets typically consumed in developing countries. The goal is a documented improvement in absorption and in iron and vitamin A status, using locally appropriate, sustainable and practical alterations in the usual dietary pattern, types of foods consumed, or food preparation practices.


(i) Projects must be realistically completed within two years of receiving the award
(ii) Proposal budget, including indirect costs, should be less than US$200,000.

Proposal deadline: November 30, 1994 (funding to begin in February 1995).

For more information, please contact OMNI Research, ILSI Human Nutrition Institute, 1126 Sixteenth Street N.W., Washington, D.C. 20036. Fax: (202) 659-3617. Ph: (202) 659-0789.

Regional Initiatives on Aids Prevention

The World Bank's Special Grants Program has approved funding for two regional initiatives on Aids Prevention. Both initiatives will complement ongoing and proposed national programs, many of which are being supported by IDA credits.

The Sahel ...

The Sahel is perhaps the last frontier in Sub-Saharan Africa in the spread of the AIDS epidemic. Nevertheless, HIV is already preading rapidly in the region. Short-term projections suggest a tripling of the number of HIV-infected persons from about 782,000 in 1992 - out of a total population of 42.8 million - to approximately 2 million by 1997. According to the Sahel AIDS Strategy paper, "The late arrival of HIV/AIDS in Sahelian countries provides governments an unique opportunity to draw upon the lessons learned about the disease and experience gained in combating it and to take action now and implement cost-effective AIDS prevention interventions before the epidemic takes hold in the general population."

The Regional Advocacy and Capacity Building Program for AIDS

Prevention will focus on (i) establishing a full-scale IEC program at the regional level to widely disseminate information on HIV/AIDS and its prevention, and (ii) fostering regional cooperation and exploring innovative approaches to controlling the spread of HIV. Given the substantial migration to and from neighboring coastal countries with high seroprevalence, the program will work to develop ways of dealing with cross-border ISSUEs. Administered by WHO, this three-year program is estimated to cost $6 million; a third of which will come from the Special Grant the remaining share from donors.

South East Asia ...

HIV is spreading rapidly in South East Asia; with Thailand and Myanmar being the most severely affected. The Regional HIV/AIDS Facility for South East Asia will be based in Bangkok and will be administered by WHO/GPA. It will serve seven countries: Thailand, Myanmar, Malaysia, Laos, Cambodia, Viet Nam and the Philippines.

The Facility will ensure regular and systematic consultation among the seven countries on policy and implementation ISSUEs that need resolution at the regional and multi-sectoral level. The consultations will be underpinned by analytical work that deals with important regional aspects of the HIV problem including the management of legal and illegal labor movement, social policies, drugs and the roles of the region's international business community and NGOs. The Facility will support the efforts of the national level programs through implementation assistance, training, research, networking, studies, information exchange and promotion of NGO activities.

(extracted from Health Policy, no.7, June 1994)

New Publication

" Modern Barrier Methods: Effective Contraception and Disease Prevention" by Paul Feldblum and Carol Joanis of FHI; a comprehensive guide for health care providers and family planning program managers on the safety, effectiveness and acceptability of barrier methods, the only contraceptives that provide significant protection against unwanted pregnancy and disease.

This publication is available at no cost to developing country agencies (upon written request ONLY) and a charge of $13.95 for others. Refer requests to: Debbie Crumpler ,Publications Coordinator, Family Health International, P.O. Box 13950 , Research Triangle Park, NC 27009, USA Tel: (919)544-7040

Dear Subscribers:

We would like to thank the many of you who responded to our question "How are we doing and how can we better serve you?" We appreciate your comments and suggestions. We would like to continue this two-way communication and welcome further suggestions on improving PHNLINK's services.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Health Sector Reform in Mexico

Health Sector Reform in Mexico

According to Julio Frenk, director of the study Health and the Economy at the private Fundacion Mexicana Para la Salud, there is an overwhelming consensus in Mexico, where universal health coverage has recently been made a Constitutional goal, that the health system- now half a century old - must be reformed. The objective of this pioneer study which focuses on assessing the national burden of disease and the cost-effectiveness of interventions is to define a basic package of essential interventions.

Presently, the health system is dogged by insufficient coverage, especially in rural areas; inequitable distribution and inefficiency. As a result, Mexico's population is split into three groups in terms of access to adequate health services: the insured, who are covered by the Government's social security system; large segments of the middle class who lack health insurance but seek recourse in the private sector health services; and the poor, who are doubly vulnerable because they lack insurance coverage and the resources for private health services.

Major recommendations made by the study - to be published later this year - include guaranteeing universal health coverage by the end of the decade, separating finance and provision of care, diversifying sources of health care provision, promoting competition between private sector health service providers in cities and towns, and encouraging cooperative schemes for financing and service delivery in rural areas. The study recommends that the Ministry of Health's responsibilities not be diminished, but rather be redefined to emphasize system development, coordination, regulation, and consumer protection.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Job Announcements for Health Policy Advisor in Tajikstan and Chief of Party in Latin America
· What's on Internet?
· Reproductive Health Defined
· What's New in PHNFLASH archive?

Job Announcements

··· Health Policy Advisor in Tajikistan ···

The Aga Khan Foundation (AK) is recruiting a health policy advisor to work for a minimum of two years in the mountainous Gorno-Badakhshan region of eastern Tajikistan. The individual will be working with the local ministry of health in reforming the current health system, in particular to:

· liase with local health and government officials on allocation of medical resources
· work with national public health professionals in developing a sustainable health system
· identify training needs and contribute to the upgrading of technical skills in key areas of health management

The candidate must have a medical degree with a public health focus or a PhD in public health and have demonstrated technical expertise in public health.

A degree in health policy/planning will be helpful. Candidates should have ten years field experience in developing countries working with both health ministries and NGOs on health program design and policy. A working knowledge of Russian or Farsi is essential. Salary will be based on qualifications and experience. Candidates should be able to live and work in a remote location where living conditions are sometimes difficult and should be willing to begin their assignment as soon as possible.

Interested applicants should send their curriculum vitae to:

Chief Executive Officer

Aga Khan Foundation USA
1091 L Street, N.W. Suite 700
Washington, D.C. 20036
Fax: (202)785-1752

Urgent need for a Chief of Party for a multi-year USAID contract in Latin America. Candidates must have a PhD in public health or related field with at least 5 years experience as a supervisor of technical teams on maternal and child health ISSUEs in developing countries. Fluency in Spanish is required.

Interested applicants should reply by e-mail:
tel: (301)572-0899 (weekdays) or (410)461-5236 (evenings and weekends)

What's on Internet?

Epidemio-L is now available on the Internet. You May subscribe by sending the following message:

SUBSCRIBE EPIDEMIO-L YourFirst-name YourLast-name

This is a discussion group on methodological ISSUEs that are relevant to epidemiology and related to population studies which address health problems and questions. The discussions are therefore not restricted to approaches and procedures relevant to studying determinants of health/illness and outcome of interventions, but include approaches relevant to the organization of the health care deliver system.

If you would like more information, please contact:

Pierre Philippe, Ph.D.
Univ. of Montreal, Quebec, Canada
email: philipp@ere.umontreal,ca

Reproductive Health Defined

While the concept of reproductive health has taken hold in the international population and health communities, the exact meaning of the term is still being refined. In its recently-published Biennial Report 1992-1993, the Special Programme of Research, Development and Research Training in Human Reproduction at the World Health Organization (WHO HRP) outlined the following definition:

" Within the framework of WHO's definition of health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity, reproductive health addresses the reproductive processes, functions, and system at all stages of life. Reproductive health therefore implies that people are able to have a responsible, satisfying, and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this last condition are the right of men and women to be informed of and to have access to safe, effective, affordable, and acceptable methods of fertility regulation of their choice, and the right of access to appropriate health care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant."
(Population Network News no.8, Summer 1994)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Postdoctoral Research Training Program in Health Informatics
· Call for Papers for the Conference on Health and Communications in the Americas
· Social Indicators of Development for Bangladesh

Postdoctoral position

Health Informatics Research Training

The Biomedical Information Communication Center (BICC) at Oregon Health Sciences University (OHSU) is seeking qualified applicants (U.S. citizens and U.S. residents only) for its National Library of Medicine-sponsored postdoctoral research training program in health informatics. The BICC is one of the country's leading institutions in health informatics research wit seven full-time faculty. Its health informatics training program is designed to prepare individuals for many types of careers in the application of information technology in health care.

Curriculum: The primary focus of the program is to provide a structured research experience in one or two of the areas listed below (under Faculty Interests), along with course work in informatics. Fellows will survey the field broadly during their two to three year fellowship and will be expected to complete research projects. Upon completion of their training, they should be able to describe their results clearly in both oral and written form. The overall goals are to prepare trainees to: (a) direct their own health informatics research efforts at medical centers that actively embrace the Integrated Advanced Information Management Systems (IAIMS) agenda, or (b) take leadership positions in the growing number of hospital and/or commercial efforts in health informatics.

The faculty offers courses in introductory informatics course and advanced courses on information retrieval and medical decision making. Most fellows have availed themselves to a seminar series for fellows in the Division of General Internal Medicine and/or formal courses in statistics, computer science, and decision science at nearby universities. There is a degree option for a Master of Public Health with a specialization in health informatics.

Faculty Interests: clinical information systems and computer-based patient records; information retrieval; outcomes research; clinicians' information needs; telemedicine; medical decision making; patient information systems and neural networks.

For more information, please contact:


Oregon Health Sciences University
3181 SW Sam Jackson Park Rd.
Portland, OR 97201-3098
Kent A. Spackman, M.D., Ph.D.
Associate Director
Voice: 503-494-4502 /Fax: 503-494-4551
William Hereto, M.D.
Assistant Professor of Medicine and Medical Informatics
Voice: 503-494-4563 / Fax: 503-494-4551

Call for papers


Ryerson Polytechnic University
Toronto, Canada
March 27-29, 1995

Ryerson Polytechnic University in Toronto, Canada is hosting a conference on Health and Communications in the Americas with sponsorship from the

Inter-American Organization for Higher Education (IOHE).

Theme: The role of academics and the use of communications and information networks to enhance the quality of health delivery. Presentations will focus on the development of curricula, research initiatives, and the interaction of faculty with the broader community (NGO's, Official Health Agencies, Community Development Groups).

Submissions should exemplify creative and innovative courses, programs and research or outreach initiatives that reflect the growing awareness that development communication is a necessary component of health activities in universities in the Americas.

Please submit a two page abstract/proposal (two copies or email/file copy) by December 10, 1994 to:

Ruth Nesbitt
Ryerson Polytechnic University
350 Victoria Street
Toronto, Ontario,
FAX: (416) 979-5352 email:

Latin American presents will be eligible for a partial subsidy to help defray costs. If you would like a copy of this announcement in Spanish, send a message to:

Social indicators of development (sid)

The following table is a SID country data sheet for Bangladesh. SID country pages consist of: (a) the Bank's Priority Poverty Indicators (PPIs) such as poverty lines, mortality, malnutrition, and life expectancy (see table below) and (b) indicators on human and natural resources, expenditures and investment in human capital (not shown here). International comparisons are made easier by a summary table of a selected array of indicators, by countries in the same region and same income groups. Data for SID are gathered from governments, specialized international agencies, and from the World Bank data files.

SID is published annually by the International Economics Department of the World Bank. The 1994 edition of the SID is a compilation of social data for over 190 economies.

SID's print edition (416 pages) includes data for three time periods:
o the most recent estimate (1987-92)
o the 1980s (1980-85)
o the 1970s (1970-75)

SID is also available in time series on 3.5 inch diskettes in the World Bank's ·STARS· retrieval system. Users of DOS 2.1 or higher operating systems can view the data in their personal computers and extract data in a variety of electronic formats.

To order SID in the U.S., call (202) 473-1155, or fax: (202) 676-0581. The print edition is $24.95, and the electronic edition is $70.00. Outside the U.S., contact your local World Bank distributor. For a list of distributors, send a written request to:

The World Bank
1818 H St. N. W.
Department T-8051
Washington, D.C. 20433


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Positions Available: Essential Health Intervention Team
· Poverty and Gender Discrimination: An Exchange of Views
· Simple "How To" instructions

Essential health intervention team: Tanzania

CUCHID (Canadian University Consortium for Health in Development) is collaborating with the IDRC in the project: Essential Health Interventions Project (EHIP). This is an East Africa-based project to evaluate some of the recommendations of the recent World Bank report (Investing in Health), regarding "essential" public health and clinical interventions. The first participating country will be Tanzania.

An assessment team will be visiting Tanzania from Nov 21-Dec 9th. There is a need for someone with developing country experience to join the team in order to evaluate the state of the "physical infrastructure" (buildings, equipment, etc.) of the primary health care facilities in four districts. CUCHID is seeking for any Canadian universities with expertise in this area (either in health sciences faculties, or possibly in architecture or engineering) and individuals with experience who might be available on short notice to join this assessment team.

Please forward any suggestions, and preferably names of individuals (include phone, fax, E-mail) to:

Vic Neufeld, M.D. Internet:
Faculty of Health Sciences, Voice: (905) 525-9140 x 22033,22067
McMaster University, HSC 3N44 Fax: (905) 525-1445
Hamilton, ON, Canada L8N 3Z5

Poverty and gender discrimination: an exchange of views

Is poverty the primary cause of "excess" mortality and morbidity in female children in developing countries? Barbara Miller, associate professor of anthropology and international affairs at George Washington University argues that the relationship May seem a near-tautology in development circles, but it does not stand up to scrutiny.

In her article "On Poverty, Child Survival and Gender: Models and Misperceptions" in Third World Planning Review (Aug 1993), she chastises development analysts for remaining wedded to the "assumption that poverty drives discrimination against female infants and children ... in the face of contrary data." In particular, she cites two World Bank reports that uncritically link poverty in India with the gender gap in child health. The poorest people in India are not generally characterized by the greatest disparities in male and female child health. True, the poor have higher overall rates of infant and child mortality and morbidity. But it is the better-off (propertied) people of the Northwestern plains who are most implicated in patterns of daughter discrimination (and daughter 'elimination' through prenatal sex- selection);these groups experience overall lower rates of infant and child mortality and morbidity, but their female children are far behind their male children in experiencing health advantages."

Miller proposes a redefinition of how economic pressures affect household allocations of resources, writing that allocation decisions "that favor boys over girls, within particular patriarchal contexts, are poverty avoidance practices." This is no academic debate; Miller underscores the point that policies and programs concerning gender biases need to focus on propertied people in Northwestern India, while the poor need poverty alleviation programs.

(The following is a rebuttal by Meera Chatterjee, women-in- development officer with the Bank's New Delhi office and author of the 1990 Discussion Paper on Indian Women: Their Health and Economic Productivity)

In contending that Gender and Poverty (G&P) and Indian Women: Their Health and Economic Productivity (IWHP) "uncritically link poverty in India with the gender gap in child health", Miller has missed the "true relationship" between economic levels and gender differentiation. According to Miller, the true relationship is manifested in the greater gender discrimination practiced by the 'propertied' people of Northwest India, rather than among the poor. Alas, Miller has either not read the reports carefully, or has chosen to overlook several important aspects of our work on gender and poverty. Both reports state that the relationship between poverty and gender discrimination is, indeed, imperfect, and substantiate this with evidence from available studies, including Miller's earlier work.

The essential argument in the reports linking poverty and gender differentials in health is that where resources are scarce, they are preferentially allocated to males (sons) rather than females (daughters). This occurs, for example, in intra-household food distribution and in the use of household resources to support schooling (i.e. meet the direct costs, or offset the opportunity costs). We have discussed the social bias against females that pervades Indian society as a whole, and argued that poverty works in the presence of this gender bias to severely jeopardize young girls and women in matters of nutrition, health, education, and employment.

While Miller considers child health as a single entity, we have looked separately at the effects of economic levels on mortality, nutritional status, morbidity and access to health care, and found that the direction of effects is not the same in each of the cases. Miller's work on ´propertied' and ´unpropertied' groups in the North found that gender differentials in mortality were higher among the better-off. This, however, contrasts markedly with the direction of the effect of poverty on nutritional status. For example, Levinson found greater gender differentials in nutritional status among the poorer Scheduled Caste children compared with the better-off Jabs in the Punjab. The findings cited in our reports are from more recent studies on nutritional status in India. Miller is either not acquainted with these data on "health inequalities", or prefers to wear blinders to them and to our secondary analysis.

To explain the ´contradictory' effects of socioeconomic status on mortality and malnutrition, we proposed that while the poor May discriminate against daughters by preferentially allocating their meager food resources to sons, they have a greater stake in keeping daughters alive because of the importance of female labor to the survival of the household. Conversely, the better-off have less interest in keeping daughters alive because of their ´net negative' value on account of the high dowries they require. As higher mortality in this group is not mediated by worse nutritional status, one can impute other pernicious practices. Both in the North and South, high dowry demands have been linked to the practice of female infanticide or sex-selective abortion among the better-off, but such practices are also increasing among the poor.

A central message of both reports is that poor women are saddled with the dual burden of economic deprivation and social (gender) discrimination, and that "poverty programming" must deal with both these problems squarely and simultaneously, so that the potential for economic improvements exacerbating gender inequalities is minimized. We disagree with Miller's final contention that "the bulk of the (sex ratio) problem belongs to the more developed Northwest and most firmly to the propertied people there", and we would certainly not advocate that all development activity be focused on the 'propertied' of North India! While "female elimination" among this class is certainly more morally indefensible than "poverty avoidance practices" among the poor, in quantitative terms the major portion of excess female mortality unfortunately occurs among the poor. Thus, there is much to be done, and more to be gained, under the aegis of "poverty programming" and "gender equality", among and for the poor.'

Simple ''HOW TO'' Instructions

The following are simple instructions to commonly asked questions on PHNLINK services. Please save the following message for future reference. Thank you.

How to Subscribe to PHNFLASH or QCARE

If you are not a subscriber but wish to receive PHNFLASH, send a message to:

(World Bank staff ONLY May send message to: @list).

In the body of the text, type:
subscribe PHNFLASH email address YourFirst-name YourLast-name or subscribe QCARE email address YourFirst-name YourLast-name

For example: subscribe PHFLASH Jane. Doe

(NOTE: Do not add @Internet in your email address)
If you received an error message, please send a message to:

How to retrieve PHNFLASH Archive

To retrieve documents in the archive, please send a message to:

(World Bank staff May send message to: @list)
In the body of the text, type: get-PHNFLASH filename
For example: get-PHNFLASH hrn024
If you prefer to view the list of documents in the archive, in the body of the text, type: get phflash index


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Call for Papers for the Third National Conference of The Canadian Council on Multicultural Health
· Slowing Population Growth and Accelerating Sustainable Development: A Call to Action
· American Public Health Association (APHA) Clearinghouse: New Acquisitions

Call for papers

" Innovating in Hard Times "
Third National Conference of The Canadian Council on Multicultural Health
Montreal, Canada
May 17-20, 1995

The conference will focus on ISSUEs and implementation strategies within our present economic situation. Building on the experience of the previous conferences, it will focus on developments and strategies that have been successfully implemented and the progress made since the 1992 conference. Those submitting presentations are encouraged to do so within the context of the conference sub-themes:

· Accessibility of services (meeting the challenges)
· Partnerships and collaboration (the shape of the future)
· Innovation in action.

Submission deadline is October 31, 1994.

For more information, contact:
Innovating in Hard Times,
The Conference Committee, CCMH-CCSM,
Suite 400, 1017 Wilson Avenue, Downsview, ON, M3K 1Z1.
Tel: (416) 630-8835. Fax: (416) 638-6076.

Slowing Population Growth and Accelerating Sustainable Development: A Call to Action

Excerpts from an Address By Mr. Lewis T. Preston, President, The World Bank Group

...The Cairo Program of Action offers us the proper perspective on rapid population growth: it is a symptom of poverty-and an obstacle to poverty reduction. We know that as incomes increase and people lead longer, healthier lives-fertility decreases. Rapid fertility declines in East Asia, for example, went hand in hand with steady economic growth and improved living standards. In Sub-Saharan Africa, by contrast, the population growth rate of more than 3 percent over the past decade has been running far ahead of the economic growth rate of less than 2 percent. Africa's people have paid the price in terms of declining incomes and increasing poverty.

Our approach to population policy, therefore, must be part of a broader strategy to reduce poverty-through sustainable growth and investments in people. Three types of investment are particularly important:

First is basic health care, especially for women and children. In many of the poorest nations, one in every ten children dies before its first birthday. Reducing these appallingly high infant mortality rates-so that parents do not have to worry so much about their children's survival-is essential to reducing fertility rates.

Second, we know that birth rates decline when women are given access to education. An educated woman is more likely to delay marriage, space her pregnancies, and have fewer and healthier children. She is also likely to learn more if she works and to invest more in her children's education. Yet, nearly 100 million girls are currently denied education. The goal of universal primary education is something that we can-and must achieve within the next generation.

Access to family planning services is a third critical investment. Combined with economic growth and social investment, access to family planning has shown remarkable results in countries as diverse as Indonesia, Mexico, and Zimbabwe. Even in very poor countries where income growth and investment in people have lagged, family planning has made a big difference. Average fertility rates in Bangladesh, for example, have declined from seven births per woman in the mid-1970s to close to four in the 1990s.

These kinds of investments are highly cost-effective, but not high cost. The Bank estimates, for example, that a basic preventive health care package-including maternal and child care-can be provided at an annual cost of about $8 per person in the poorest countries. Raising girls' primary school enrollment rates to equal boys' would cost just under $1 billion-or only 2 percent of annual education spending by the developing world. Resources needed for family planning services are also relatively modest. Around $5 billion per year is currently spent on family planning in the developing countries-which is less than 5 percent of military expenditures.

Clearly, financing is not the main ISSUE. Much of the money required can be generated through redirecting resources toward priorities-and making sure that they are used efficiently. Nor need all the additional investment come from government budgets. There is ample evidence that people are willing to pay for family planning services, provided they have access to them.

Donor support, of course, remains important, particularly in the poorest countries. But it must be better tailored to meet individual country needs-and to offer people a range of appropriate choices. The proportion of couples using some kind of fertility regulation has increased from 10 percent thirty years ago to more than 50 percent today. Further and faster progress depends on making those services even more responsive to people's needs. That means listening even more to what people want-and we donors are not always very good at listening.

The World Bank's support for poverty reduction focuses on the same investments required for a broad approach to fertility reduction. About half of the projects that we finance, for example, now include specific components aimed at empowering women. Last year, we committed almost $2 billion for education alone- much of it focused on keeping girls in school. Over the last five years, the Bank has also become one of the largest financiers of family planning and reproductive health services. Close to $200 million was committed last year-and this is projected to increase by 50 percent over the next three years.

Quality, however, matters more than quantity. The Bank-and all of us-must do more to ensure the effective implementation of the programs we support: by better targeting our resources, so that they reach the poor; by strengthening partnerships among all those engaged in this effort to enhance overall impact; and by keeping population ISSUEs at the forefront of the policy dialogue.

New Acquisitions

American Public Health Association (APHA) Clearinghouse

For the last fourteen years, the APHA Clearinghouse has been providing information to practitioners and policymakers in developing countries. Based at the APHA, the Clearinghouse database includes over 20,000 books, documents and education materials. The project is supported by the Office of Health and Nutrition, U.S. Agency for International Development.

Their most recent acquisitions includes articles about adolescence, breastfeeding, child development, food security, growth monitoring, information, maternal and child health, micronutrients, research, women's health. A listing of the bibliography is available in the PHNFLASH archive (filename mcu0001).


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Twins Study: Heredity Plays a Minor Role in Lung Cancer
· New Publications

NCI twins study: heredity plays a minor role in most lung cancer

In the largest study of twins, on the role of heredity in the development of lung cancer, researchers from the National Cancer Institute (NCI) have found that heredity plays a role in no more than a small fraction of lung cancer cases. (Results of the study published in the August 13, 1994 ISSUE of the Lancet)

For the purposes of lung cancer prevention, "The message is that smoking-induced lung cancers in men greater than 50 years of age should be attributed to smoking cigarettes - not to the genes they inherit from their parents," said M. Miles Braun, M.D., a senior research investigator in NCI's Division of Cancer Etiology and the study's principal investigator. "It could be a fatal mistake for a smoker to believe that he will not develop lung cancer just because he has close relatives who smoked for a long time and did not develop lung cancer."

The study looked at lung cancer mortality in 15,924 pairs of male twins registered in The National Academy of Sciences-National Research Council Twin Registry in Washington D.C., one of the few large twin registries in the world. All of the twins were born in the United States between 1917 and 1927, and served in the armed forces during World War II. According to the researchers, a genetic role in the development of lung cancer would be likely had pairs of identical twins died more often of the disease than pairs of fraternal twins, which in fact was not observed in the study. Identical twins share a virtually identical genetic make-up while fraternal twins share roughly 50 percent of the same genes.

In the twin registry, lung cancer deaths occurred in approximately 5 percent of the twin pairs. As of 1990, 282 identical twins had died of lung cancer, including ten pairs, compared to 399 fraternal twins and 21 pairs. The researchers also examined lung cancer risk in a smaller group of 47 pairs of identical twin smokers, in which both twins had similar smoking habits. After the first twin's death from lung cancer, his brother was followed up for an average of 6.4 years. In the 47 smokers whose identical twin brothers had died of lung cancer, there were no lung cancer deaths. Because neither of these complementary studies found that inherited predisposition contributes to lung cancer risk, the researchers concluded, "for lung cancer - the leading cancer killer in the United States - inherited predisposition will probably be of limited predictive value."

[CancerNet News, National Cancer Institute Bulletin, September 1994]

New publications

Basic Concepts of International Health Module

... a new health and development manual produced by the Canadian University Consortium on Health & Development (CUCHID), is in module form. The modules provide a hands-on approach to a 10-day participatory workshop designed as an introduction to working internationally. The materials included in the modules are also suitable for a university course in health and development. It includes cross-cultural exercises and illustrations to capture key points. Gender, environment and development ISSUEs are interwoven through the text. Tips, feedback, detailed instructions, examples, a how-to-use section and general notes for facilitators are provided for each session. There are additional pointers and assistance for first-time facilitators.

The cost is $25 and funds from the sales of the book will finance workshops overseas to test and promote the use of the resource and will allow the book to be sold at a reduced rate in developing countries. Available from:

CUCHID, 170 Laurier Ave. W., Ste 902,
Ottawa, ON, K1P 5V5.

Training Module on Postpartum Contraception

... a slide presentation training module, was published in September as part of Family Health International's Contraceptive Technology Update Series. The module focuses on contraceptive needs of women who have recently given birth, appropriate family planning options for breastfeeding women, and features of successful postpartum programs. The module targets a broad audience, including physicians, nurses, administrators and policy-makers, and can be adapted to suit particular audiences. Thirty-nine 35mm color slides, an accompanying text, six related journal articles and a list of recommended readings make up the module. Spanish and French translations will be completed soon.

Single copies of the module are available at no charge to family planning trainers in the developing world, and to others for a small fee. Contact:

Vana Prewitt
Senior Health Communication and Training Coordinator
Family Health International
PO Box 13950,
Research Triangle Park, NC 27709.
Acta Tropica

Elsevier Science has published a social science special ISSUE of Acta Tropica, their international journal covering biomedical and health sciences with particular emphasis on topics relevant to human and animal health in the tropics and sub-tropics.

The special ISSUE entitled "Institutional Strengthening and the Development of Research Capacity in the Social Sciences" is available to non-subscribers from:

Elsevier Science
P.O. Box 1527,
1000 BM Amsterdam,
The Netherlands.
Tel: (+31) 20 5803 911.
Fax (+31) 20 5803 375.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Women's Health and Development

Women's health and development

Investing in women's health is now being recognized as an essential component of social and economic growth. Investments in women's health can be argued on several grounds. First, equity and human rights, which emphasizes redressing gender disparities. Second, the multiple benefits of women's improved health, which emphasizes increased productivity and the impact of a mother's health on her offspring. Third, the cost-effectiveness of reproductive health interventions compared to other health interventions. These arguments are policy and supply driven arguments, geared mostly to central planners. An increasingly compelling argument is that policy commitment must be complemented by a more participatory, enabling approach which involves women in decision-making and implementation if sustainable growth is to be achieved. This was the important message from the Population Conference in Cairo - that for population stabilization and overall development goals to be achieved, more emphasis must be given to improving women's health and women's empowerment.

To date, women's health has received little attention in development programs. This is reflected in the high levels of persistent, but largely preventable, morbidity and mortality. Among human development indicators, maternal mortality rates represent the widest gap between developed and developing countries.

A review of women's health today show that:

- About 6,000 girls are subject to genital mutilation each day

- In many developing countries, one third to one half of women become mothers before the age twenty

- One in every twenty-two women in Africa dies of pregnancy related complications

- Women are at a greater risk than men of contracting HIV/AIDS

- Cervical cancer causes more deaths in developing countries than any other cancer

- Studies show that twenty to sixty percent of women have been beaten by their partners

These statistics show that investing in women at different stages of life could save millions of women in developing countries from needless suffering or premature death. However, the resources allocated for women's health do not reflect the clearly demonstrated need. For example, it is estimated that less than twenty percent of government health budgets are allocated to maternal and child health and family planning; most of which goes to child health. Poor health is a reflection of the low status of women in many developing countries. Some cultures can also limit a women's access to health services.

Women's health is affected by complex biological, social, and cultural factors. Therefore, to reach women effectively, policies and programs must take into account the biological factors that increase health risks for women and such sociocultural determinants of health as age at marriage and status in the family, as well as psychological factors, such as low self-esteem and depression arising from discrimination and gender violence. Women's lack of education and disadvantaged social position help perpetuate poor health and high fertility, as well as the continued cycle of poverty.

Because women tend to be less educated and have less access to information, they are less apt to recognize problems or understand the value of or seek out preventive and curative care. For example, female education, especially through the secondary level, is associated with greater use of contraception and increased age of marriage, both of which improve women's health by reducing their exposure to pregnancy and early child bearing.

A number of health problems associated with low socioeconomic status are emerging as concerns that need to be addressed by health and development programs. These include gender specific violence and occupational health hazards. In Papua New Guinea, for example, a Law Reform commission survey found that 67 percent of rural women were victims of wife abuse. Women's low status, particularly lack of education, exacerbated by economic hardship, is leading to increasing prostitution. This, in turn, is contributing to the rapid spread of sexually transmitted diseases, including AIDS.

A woman's ill health or death affects not only her own opportunities and potential but those of her children. A mother's death in childbirth is a virtual death knell for her newborn, and it often has severe consequences for her other young children. A study in Bangladesh found that a mother's death sharply increased the chances that her children up to age ten would die-particularly for her girl children-whereas a father's death had no significant effect on his children's mortality rates. Women's poor health also affects the welfare and productivity of their households and communities, since they play critical roles in the welfare of their families and of their national economies. Data on women's contribution to development, while still tentative, indicate that women are responsible for:

- growing 80% of the food consumed domestically and in parts of Africa at least 50% of the export crops

- earning 40 to 60 % of household income, if home production is valued

- providing 70 to 80% of the health care in developing countries

- heading at least 20% of all households in Africa and Latin America

Investments in women's health programs not only improve a woman's health status and the survival and health of her family, such investments increase the labor supply, productive capacity and economic well-being of communities. Improvements in women's health are not only critical to development, they are feasible and affordable. Improving health care for children and for women aged 15-44 offers the biggest return on health care spending. Some health interventions for females in developing countries are highly cost-effective interventions and improving women's health is a sound investment. Women's health programs are not only cost-effective, but their broader benefits stretch far beyond the woman and have important effects on the household and community development.

Despite their higher life expectancy, women suffer from more health problems than men. Beginning in infancy, females often receive less and lower- quality food and, when sick, receive treatment less often and at a more advanced stage of disease. Because of their reproductive function, women run risks of morbidity and mortality which men do not face. Their health is also affected by gender-specific cultural practices, such as female circumcision and domestic abuse, which are not a consequence of their behavior. Several recent development trends affect women's health. The development response must be a life cycle approach to women's health. Policies and programs must address both the biological and cultural determinants of women's poor health status.

A new agenda for women's health and development calls for:

- A more comprehensive approach to improving women's education, health and employment opportunities which emphasizes listening to women and enabling their participation.

- Looking at family planning in the context of women's reproductive health and particular life circumstances.

- Moving beyond maternal and child health to give more attention to adolescents and older women. Interventions during adolescence are critical and can help break the cycle of poverty, unwanted pregnancy, and limited educational and economic opportunity. To a large extent, adolescence sets the stage for health and nutritional status in the later years, yet health policies and programs have not been oriented toward addressing the needs of this group.

- Emphasis should also be placed on early prevention of life cycle problems such as discriminatory practices and the health problems of older women, such as cervical cancer.

Improvements in women's health, while beneficial in their own right, contribute to development through improved productivity, reduced costs of medical care, and a healthier generation to follow.

Women comprise over one-half the human race. Investing in their health is an investment in development today. It is also an investment in the generations of tomorrow.

(taken from a presentation by Anne Tinker, Senior Health Specialist, Population, Health and Nutrition Department, The World Bank, at the 122nd American Public Health Annual Meeting, Washington, DC, November 1994)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Conference Announcement
· A New Look on Mortality
· New Publication: The Essential Package of Health Services in Developing Countries

Conference announcement

Health, Economics and Development: Working Together for Change
World Federation of Public Health Associations (WFPHA)
Seventh International Congress
December 4 - 8, 1994
Bali, Indonesia

Co-sponsored by: World Health Organization, Pan American Health Organization, United Nations Children's Fund, United Nations Population Fund, United Nations Development Programme


· examine the linkages among health, economic growth and human development
· identify the barriers to intersectoral planning and implementation
· highlight successful strategies and models for making health concerns more central to economic and development policies and programs

Participants include Dr. Hiroshi Nakajima, Director-General of the World Health Organization, Dr. Nafis Sadik, Executive Director of the UN Population Fund, officials from UNICEF, UNDP, World Bank, and other international organizations; and representatives of non-governmental health and development organizations.

For additional information:

Jl. Abdul Muis 68
Jakarta 10160 Indonesia
Tel: 62-21-3861207 or 3861208
Fax: 62-21-3851588, 3145583, 7270014, 7401148 or 7401107

WFPHA Secretariat:

Dianne Kuntz, Executive Secretary
c/o APHA
1015 15th Street, NW Suite 300
Washington, DC 20005
Tel: (202)789-5696
Fax: (202)789-5681

A new look on mortality

The bottom line of one of the most talked about papers in nutrition circles in recent years is that malnutrition has a far more powerful impact on child deaths than is typically recognized. Conventional methods of classifying cause of death suggest that roughly 70 percent of child deaths worldwide are due to diarrhea, acute respiratory infection, malaria and immunizable diseases. "Wrong," some now say or, at least, misleading. The paper by David Pelletier and colleagues from Cornell (presented at the 1994 annual federation meetings for experimental biology) applies a freshly-developed epidemiological method to estimate the percentage of child deaths caused by "the potentiating effects of malnutrition in infectious disease." With nationally representative data on weight-for-age of 6-to-59 month olds for 53 developing countries (an earlier paper by the authors, published last year in The American Journal of Public Health, had looked at six countries), the model indicates that a full 56 percent of child deaths are due to malnutrition's potentiating effects. Particularly noteworthy is the finding that 83 percent of these deaths are due to mild-to-moderate, not to severe, malnutrition. These yet-to-be published results (the methodology itself is discussed in the October ISSUE of the Journal of Nutrition) hold obvious implications for the design of child survival strategies.

New publication

The World Development Report 1993: Investing in Health Background Paper Series no. 1 entitled: "The Essential Package of Health Services in Developing Countries" by Jose-Luis Bobadilla, Peter Cowley, Philip Musgrove and Helen Saxenian has recently been published. Limited copies are available by contacting:

Odell Shoffner
Population, Health and Nutrition Department
World Bank
1818 H St., NW
Washington, DC 20433
Tel: (202)473-7023
Fax: (202)522-3234


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· HIV Conference Announcement and Call for Papers
· ASEAN Travel Grants for Graduate Students

Note to Subscribers

Starting next week, PHNFLASH will be ISSUEd on Wednesdays.


Dear PHNFLASH Subscribers:

PHNFLASH was developed to serve as an electronic broadcast medium to colleagues in the fields of population, health, and nutrition. Because PHNFLASH does not facilitate a dialogue, we have not had the opportunity to hear from you. To ensure that we continue to serve you appropriately, we would appreciate it if you could take a moment to fill out the following survey and return it to us at:

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Conference announcement and call for papers

Reversing the Trend: Strategies for HIV Prevention Among Minority Women
April 6-7, 1995
Texas A&M University, College Station, Texas

Primary Goals:

· To increase understanding of the cultural, socio-economic, and psycho-social barriers to HIV prevention among minority women.

· To facilite the development of research-informed HIV prevention strategies through discussion between researchers and practitioners.

· To enable community providers to complete and implement population-specific prevention strategies.

Call for Papers:

The format for this conference will include a series of panels addressing the major barriers to effective HIV prevention followed by interactive prevention planning workshops. Panel sessions will address ISSUEs on:

· Cultural, Psycho-social, Socio-economic and Gender Barriers/Strategies
· HIV and childbearing.
· The role of gangs in HIV transmission.
· Adolescent development and HIV prevention education.
· Reframing the language and images of Machismo.
· Trust and communication in the African American Community.
· Women in the sex industry.
· The political challenges to effective HIV prevention.
· Sexual Abuse, Self-Steem & HIV
· Prevention project or research for migrants, the Border population (US-Mexico), rural, handicapped, adolescents, & runaway.

Submissions should be one-page, typed, double-spaced proposals for papers that will be presented during the panel sessions. Please include TWO copies of your proposal. One copy should include your name, address, tel., fax, e-mail address, and any audio-visual equipment needs.

The second copy should not contain any identifying information. The deadline for receipt proposals is December 2, 1994.

For submissions or additional information, please contact:

Attn: S. Griswold, Conference Coordinator
BVCAA: Health
401 S. Washington
Bryan, TX 77803
Tel: 409/ 260-AIDS
Fax: 409/ 775-3475

Travel grants for graduate students

The Canada-ASEAN Centre in Singapore and the Asia-Pacific Foundation of

Canada have been mandated to serve as catalysts linking Canada with a wide range of interest groups in ASEAN (the Association of Southeast Asian

Nations). These include the strengthening of academic links to increase knowledge and understanding by Canadians of the ASEAN region (Brunei, Indonesia, Malaysia, Philippines, Singapore and Thailand) and its neighbour states of Vietnam, Cambodia, and Laos. Travel grant awardees will be part of our efforts to promote understanding and broader awareness.

Travel grants of $Can 5,000 will be awarded to 20 Canadian scholars to fund the cost of their travel to the region to:

· pursue study-related field research focused on the Southeast Asian region
· strengthen the capability and competitiveness of Canadian graduate students by increasing their knowledge and understanding of the region

Applicants are encouraged to submit applications for visits (minimum 8 weeks duration) and grants must be used by March 31, 1996.


Applicants must be

· Canadian citizens or landed immigrants, already holding an undergraduate degree, and registered as full-time graduate students at an accredited post-secondary educational institution in Canada.

· registered as full-time Masters or Doctoral candidates, whose focus of research is Southeast Asia in the areas of health, population, politics, history, environment, sciences, economics, language and religion


· registered as full-time graduate students in International Business programs at universities or community colleges

Preference will be given to applicants:

· whose referrals from the Canadian academic advisor best attest to the suitability of the assignment and of the applicant for a future academic/business career in the study area.

· whose proposed research reflects highest academic merit, and relevance to their future career plans.

· who are not holding another grant award or similar funding in the same time frame.

· who have an acknowledged sponsoring institution in Southeast Asia.

Awardees will be notified in March 1995.


· should be a maximum of three double-spaced typed pages and MUST provide the following information IN THE FORMAT AND ORDER LISTED BELOW.


PAGE ONE should list:

> applicant's name, position and full mailing address
> name and full address of faculty advisor
> concise statement of research to be undertaken

PAGE TWO should outline the research plan which consists of:

> objectives
> methodology
> rationale
> overall significance of the research

PAGE THREE should describe:

> relevance of applicant's proposed activity to the objectives of the

Travel Grant Fund

> applicant's interest in Southeast Asia and how grant would contribute to the applicant's future involvement in the region

> the host institution in the ASEAN region The following attachments MUST be submitted with application:

> Letter of referral from academic advisor

> Transcripts showing full-time status of student and academic record

> Brief CV

Deadline for applications is January 10, 1995.

Applications and requests for further information should be sent to:

Office of the Coordinator

Canada-ASEAN Centre/Academic Travel Grant Fund

Joint Centre for Asia-Pacific Studies
York Lanes, Room 270N, York University
4700 Keele Street, North York, Ontario M3J 1P3
Tel: (416) 736-5787
Fax (416) 736-5688


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Training Advisor Position
· The Follow-Up to The International Conference on Population and Development (ICPD)

OMNI: training advisor position

The Opportunities for Micronutrient Intervention (OMNI) project is a USAID- supported collaborative effort to assist countries with the elimination of micronutrient deficiencies in their populations through comprehensive and integrated strategies and programs. A major emphasis of OMNI's approach is on strengthening institutional capacities and problem solving skills of the public and private sectors in health, agriculture, education, food industry and micro-enterprises. The OMNI project is managed by a core team at John Snow Inc.(JSI), based in Arlington, VA.

The Emory University School of Public Health, Program Against Micronutrient Malnutrition (PAMM) is a subcontractor of OMNI, responsible for human resource development (HRD). PAMM and JSI are requesting applications by qualified individuals for the position of Training Advisor to complete the core team in Arlington, VA.


· Provide overall guidance in the development and delivery of training according to the needs of OMNI

· Review OMNI country strategies and work-plans to ensure HRD is adequately represented

· Design, coordinate, and manage the implementation, monitoring and evaluation of OMNI HRD activities. This includes identifying and co-ordinating the work of HRD consultants.

· Work with other OMNI core team members, subcontracting partners, and counterparts to build institutional training capacity in OMNI-assisted country programs

· Coordinate with OMNI subcontractors and collaborators as appropriate to work on OMNI-assisted HRD activities

· Provide other conceptual, programmatic or technical expertise


· At least a Masters degree in training, food and nutrition, public health, or a related field.

· Minimum 5 years working experience in food and nutrition or related field in international settings, with involvement in designing and conducting community- or university-based training activities (preferably both).

· Working level French and/or Spanish ability. Excellent interpersonal skills, with ability to work with a variety of experts from other sectors, and work well in a team setting.

Interested applicants should send their resume or inquiries to:

Att: Frits van der Haar
Emory University School of Public Health
Center for International Health
1599 Clifton Road NE
Atlanta GA 30329
Fax: (404) 727-4590,
No phone calls please.

The Follow-Up to The International Conference on Population and Development (ICPD)

In her address on the Follow-Up to the ICPD conference, Dr. Nafis Sadik, Executive Director of United Nations Population Fund (UNFPA) and Secretary-General of the September 1994 ICPD in Cairo, charged everyone to maintain the momentum from Cairo.

The Program of Action (PA) adopted by the ICPD is viewed by many as "a major breakthrough in conventional thinking on population and development." The international community is at long last acknowledging that investment in people, health and education is the key to sustainable growth and development. The PA approaches macro problems by addressing micro needs, taking into account individual perspectives and needs in policy formulation and implementation, without undermining the responsibilities and sovereignty of government.

The ICPD PA is different from previous documents in six ways:

I. The PA sees population as an integral part of development policy. Efforts to slow population growth and development strategies are mutually reinforcing.

II. The empowerment of women through education. The PA acknowledges the equal participation of women in ALL aspects of development. Given that
discrimination of gender begins at the earliest stages of life, the PA stresses the importance of special programs for girls.

III. The PA recognizes the need to integrate family planning into the wider context of reproductive health; particularly for women. It also reaffirmed the basic human right of all couples and individuals to decide freely and responsibly the number and spacing of their children, with the information, education and means to do so.

IV. In its commitment to improving the quality of life of all, the PA stipulates 20-year goals related to reducing infant, child and maternal mortality; provision of education, particularly for girls; and provision of reproductive health care and family planning services.

V. A conscious effort to include NGOs in the ICPD and calls for strengthening and future partnerships of NGOs in the formulation, implementation and evaluation of population and development programs.

VI. The international community's agreement on new financial investments in the areas of reproductive health care and family planning. The costs for the comprehensive package of in the developing world (including economies in transition) is estimated to be US$ 17 billion per year in the year 2000 and US$21.7 billion in 2015; up to two-thirds of the costs to be met by the developing countries and the remainder to come from external sources (US$ 5.7 billion in 2000 and US$ 7.2 billion in 2015).

Many countries, including the United States, Japan, United Kingdom, Germany and the Netherlands, have increased their support. In addition, the UNDO, UNICEF, UNFPA, and others are currently working on a proposal -the 20/20 initiative- which calls upon governments and donor countries to allocate at least 20 percent of their development assistance to the social sector. Discussion on this initiative will resume at the upcoming Social Summit in Copenhagen.

The success of the ICPD depends on the willingness of Governments, local communities, the non-governmental sector, the international community and all concerned organizations and individuals to put the recommendations into tangible and effective action. At the national level, the Program of Action calls on all governments, with the assistance of NGOs and the UN to disseminate the results of the ICPD. It recommends that countries establish appropriate Follow-Up mechanisms, and communication with parliamentarians, NGOs, community groups and representatives of the media and the academic community. In addition, national ICPD committees will monitor and evaluate the progress in achieving the goals and objectives.

At the international level, international agencies should collaborate to increase the efficiency and effectiveness of population and development programs, and promote the exchange of information.

Implementation of the ICPD recommendations will be monitored in three ways:

I. All organizations involved in the field of population and development should review their existing policy and program guidelines to ensure that they are consistent with the ICPD recommendations.

II. The UN General Assembly, at its current session, and subsequently at the ECOSOC High Level Session in June 1995, will review the implications of ICPD for the UN system as a whole, and in particular, UNFPA and establish a framework for an appropriate global monitoring system. The outcome of these discussions will have a major impact on international population-related assistance.

III. To ensure that the ICPD goals are adequately reinforced in other conferences, the ICPD Secretariat and UNFPA are working closely with the Secretariats of The Social Summit and the Fourth World Conference on Women, as well as in the preparations for 1996 Second United Nations Conference on Human Settlements (Habitat II),

In closing, Dr. Nafis stressed the role the Bank and IMF can play by (i) creating an economically favorable environment for social investment (ii) ensuring the infrastructure exist in ICPD priority areas of education and primary health care and (iii) in keeping the goals of ICPD in our health and sector reform projects. She called for a more regular and systematic information-sharing and communication among the international agencies. "The international community has every reason to be optimistic; let us make our optimistic is justified."

(taken from Dr. Nafis Sadik's address to the World Bank and the IMF on "After Cairo: The Follow up to the ICPD." You May retrieve the complete document from the PHNFLASH archive)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Health Policy Advisor Position - Tajikistan
· AIDS Conference
· The Economic Burden of Global Trade in Tobacco
· New Publication

Health policy advisor position in Tajikistan

The Aga Kahn Foundation Canada is seeking a health policy advisor to work for a minimum of two years in the mountainous Gorno-Badakshan region of eastern Tajikistan. The successful candidate will help the local health ministry make its current health system sustainable.

Qualifications needed:

· A medical degree with a public health focus or a Ph.D in public health. degree in health policy/planning would be helpful.

· 10 years field experience in developing countries, working with both government health ministries and NGOs on health program design and policy.

· A working knowledge of Russian or Farsi.

For more information, contact:

Chief Executive Officer
Aga Khan Foundation Canada
350 Albert Street, Suite 1820
Ottawa, ON, K1R 1A4.
Tel or Fax: (613) 237-2532.

Conference announcement and call for papers

September 17-21, 1995
Pang Suan Kaew Hotel, Chiang Mai, Thailand
Call for Papers:
This conference will include a series of panels sessions, workshops, symposiums and round table discussions.

For submissions or additional information, please contact:

Chanpen Choprapawon, Secretary General
THRI, 1168 Phaholyothin Soi 22, Phaholyothin Road,
Ladyao, Jatujak, Bangkok 10900
Tel: 66-2/ 939-2143
Fax: 66-2/ 939-2122
e-mail: OR

Registration package available after December 10, 1994. Registration (before June 30, 1995): $300.00; $350.00 thereafter.

New publication

Enriching Lives; Overcoming Vitamin and Mineral Malnutrition in Developing Countries. The World Bank. Development in Practice Series. 88 pages. Stock no. 12987. $6.95

Vitamin and mineral (micronutrient) deficiencies impose high economic costs on virtually every developing country. But programs for alleviating these deficiencies are among the most cost-effective of all health programs-with high rates of return in terms of human resources. World Development Report

1992: Investing in Health highlighted both needs and opportunities in this area. The report provides detailed arguments for addressing malnutrition and practical advice drawn from program experience. It suggests three main strategies:

· Educate consumers so that they fully appreciate and understand the importance of micronutrients in their diet.

· Encourage the fornication of foodstuffs by combining market incentives and regulatory enforcement

· Distribute, as a last resort, micronutrient capsules and other supplements, using all public and private channels available.

World Bank-assisted projects in 30 countries now have micronutrient components. This number could grow, but the effort will require stronger partnerships with non-governmental organizations, private industry, bilateral and international organizations.

To obtain a copy, please contact The World Bank Bookstore: (202) 473-3193.

For a mail order copy, contact:

The World Bank Bookstore
1818 H St. N. W.
Department T-8051
Washington, D.C. 20433
Tel: (202)473-1155 or Fax: (202)676-0581.

For orders of 50 copies or more at a discounted price, please contact:

Ms. Judy McGuire
Tel: (202)473-3452
Fax: (202)522-3234 or (202)522-3235

The economic burden of the global trade in tobacco

Tobacco is too great a problem to be left to the health sector. Last year alone, tobacco claimed 3 million lives worldwide and is expected to claim 10 million lives by the year 2025. Annually, one in every 8 deaths in developing countries are caused by tobacco; two times that in the developed world.

The Global Economic Burden of Tobacco

FAO estimates show that the global consumption of tobacco is expected to increase by over fifty percent; with all the increase coming from the developing world.

Cost-benefit analysis show that the global net loss resulting from 1,000 additional tons of consumption is US$ 27.2 million. The estimated benefits to consumers and producers in the form of immediate pleasure and profits are US$ 2.6 million (in 1990 prices). However, the cost of treating tobacco-induced diseases such as cancer, cardiovascular, cerebrovascular and chronic obstructive pulmonary diseases are estimated at US$ 5.6 million. In addition, there are "indirect costs" measured as the economic value of the years of life lost to morbidity (US$ 11 million) and premature mortality (US$ 13.2 million). With extrapolation, the world tobacco market is estimated to produce an annual global loss of US $200 billion; about one-third of the loss in developing countries.

Situation in the developing world

Until now, the developing world has felt only a small part of this economic loss. But, with international tobacco companies increasingly targeting the developing world market, the future could be very different. The projected growth rate of tobacco consumption in developing countries is expected to be about 3% for 1995-2000 and is expected to cause an inevitable increase in lung cancer and other tobacco-related illnesses in the future.

Fortunately, there are low cost and effective policies to, control tobacco use, and if implemented now these policies can avoid the waste of billions of dollars in developing countries in the future.

· Cigarette prices, greatly effected by excise taxes, have strong effects on the number of new starters and lesser effects (but positive) on smoking cessation. Some estimates suggest that a ten percent increase in cigarette prices reduces new starts by almost 15 percent. The price responsiveness of teenagers is expected to be even greater in the lowest income countries.

· Government health information campaigns, regulation and other policies can help to offset efforts by tobacco companies to expand tobacco markets.

The Cost Effectiveness of Tobacco Policy

WHO has developed a set of booklets that outline effective anti-tobacco policies in detail. In general, anti-smoking campaigns are the next most cost-effective measures to improve health after childhood immunizations. An anti-smoking campaign costs between 20 and 40 US$ per year of life gained, compared to 18,000 US$ per year of life gained from lung cancer treatment. By spending less on treatment and more on anti-smoking efforts many more years of life can be saved with the available resources.

Three years ago, the Bank's board of directors confirmed a policy which had become de facto over the previous ten years. (a) Bank operations include anti-tobacco activities in sector work, policy dialogue and lending operations (b) The Bank does not lend for tobacco production, processing, imports, or marketing, whether for domestic consumption or for export.

[Presented by Howard Barnum, Senior Health Economist, Population, Health and Nutrition Department, The World Bank at the 9th World Conference on Tobacco and Health, Paris, 10-14 October 1994]

The complete report is available in the PHNFLASH archive (filename: oth0004)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

Quality of care

QUALITY OF CARE was typically defined in terms of the shortage of structural inputs, such as dilapidated buildings and pervasiveness of drug shortages. De Geyndt notes that structural inputs are necessary but not sufficient condition for measuring quality. He proposes a conceptual model based on structure, process and outcome. Process measures what is actually done to and for the patient in giving and receiving care. Project design should emphasize process measures and incorporate the philosophy and methods of quality improvement to assess and improve the service delivery processes purposefully and continuously. Outcomes which are the end results of the correct process of patient care and of the timely availability of the necessary inputs May be measured using indicators of mortality, morbidity and functional impairment. Because outcomes can and are often affected by exogenous factors, it is therefore more effective to improve the health care delivery process continuously and to ensure the availability of critical inputs. [extracted from Health Policy no. 8, November 1994]

"Managing the Quality of Health Care in Developing Countries" by Willy de Geyndt is a forthcoming World Bank Technical Paper

Agtmaal Director Prof. Junkerslaan 3 1185 JL Amstelveen THE NETHERLANDS
Phone: 31-20-6473879 Fax: 31-20-6432490
International Graduate Program, Thailand

PHNFLASH 50 December 21, 1994

Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Chad: Health and Safe Motherhood Project

Chad: Health and Safe Motherhood Project

How can one ensure government and broad donor support for a national health project? In Chad, Eva Jarawan, task manager in Western Africa Population and Human Resources Department (AF5PH), relied on asking the Government to prepare a detailed national health development plan, which was then agreed to by donors at a pledging round-table. This kind of process May lengthen the time needed for project preparation, but for Jarawan the rich benefits reaped in design and implementation were well worth the extra effort. The need to have the full support of other donors is self-evident in a country like Chad where 80 percent of recurrent and investment health expenditures are met by donors. The preparation of the national health development plan was financed from IDA's ongoing Social Action Development Project.

The Bank's first freestanding health project in Chad, the Health and Safe Motherhood project will be complemented by a parallel IDA operation - appraisal is scheduled for this month - to support implementation of the Government's AIDS prevention and family planning efforts. This project focuses on improving Chad's inadequate, under-staffed and under-funded health services, which have deteriorated sharply as a consequence of years of economic and political turmoil. Major components of the project include efforts to strengthen central capacity to support regional health services; to provide assistance for health, nutrition and family planning services to two regions; and to support the development and implementation of a national drug policy.

Successful implementation is a challenge in Chad, notes Jarawan, as the government lacks the infrastructure and personnel to deliver services. Given these constraints, the project contracts out important areas to donor agencies active here. UNICEF, for instance, will assist the government in the management of efforts to promote community participation in local health services planning, implementation and monitoring, while WHO will help in developing training modules and in reinforcing the planning and management capacity of the Division of Pharmacy. Few areas of Chad's health sector as desperately need to be improved as does the public pharmaceutical sector, which is currently "disorganized, non-operational and impoverished," says Jarawan. The national budget for drugs is equal to only 5 percent of total expenditures on drugs - little wonder that public hospital pharmacies and health facilities rely almost entirely on donors for their pharmaceutical supplies, while those that fall outside areas where donors work suffer from chronic shortages. In response, the project establishes a Central Purchasing Agency to ensure an adequate and timely supply of essential drugs and supplies to all NGO and public health facilities at affordable prices. The Agency is being developed as an autonomous, national, not-for-profit institution, but it will not be granted a monopoly on drug purchases by the public sector. Donors have confirmed their willingness to purchase drugs from the agency.

In this ISSUE...

· Turkey: Second Health Project
· Health Economics Program in Thailand
· Note to subscribers

Turkey: Second Health Project

"In Turkey, the number of children who die before the age of five from preventable conditions such as improper deliveries, poor feeding practices, uncomplicated diarrhea, pneumonia and accidents indicates that the country has not yet maximized the potential advantages of its economic development, nor benefited fully from investments made in the health sector," says Alexander Preker, task manager for Europe and Central Asia Country Department II Human Resources Operations (EC2HR). Thus, despite rapid economic growth over the past three decades has placed Turkey 69th globally in per capita income, it ranks 91st in terms of under-five mortality rates. The failure to invest in cost-effective interventions - less than 18 percent of total public health expenditures is spent on essential health services - as well as persisting regional inequities in income, education, the health and status of women, and in access to basic health and water/sanitation services, underlie Turkey's poor performance in health.

Given these characteristics, the government's priorities are to increase spending on cost-effective interventions and to remedy regional inequities in access to health services. The project supports these goals by focusing on expanding access to highly cost-effective health interventions in the 23 eastern provinces that are the most burdened by poverty and disease and most disadvantaged in terms of health services. These provinces account for 16 percent of the nation's population.

Over seven-and-a-half years, the project will focus on implementing two major components. The Primary Health Care Component, which accounts for about four-fifths of project cost, will improve equity in access to essential health services by upgrading the training of primary health care personnel, expanding basic health care interventions known to be cost-effective, and strengthening the network of health care facilities. The Health Policy and Management Component will improve the quality of health care management in selected institutions nationwide by upgrading staff skills in planning and management, by decentralizing and restructuring management responsibility in six pilot hospitals, and by conducting pre-investment studies to support a broader reform of the health sector. The pre-investment studies will concentrate on ensuring that future reforms focus on reducing the burden of disease due to preventable and treatable causes; the National Burden of Disease estimation techniques developed in the Bank's 1993 Investing in Health report and cost-utility studies will be used to identify the most highly cost-effective health interventions for Turkey.

Health Economics program, Thailand

An international training program in health economics has been developed by the faculty of Economics at Thammasat University in Bangkok, Thailand with support from the International Health Policy Program (IHPP). The program is usually offered twice a year and consists of 2 courses.

In 1995, the course on Economic Evaluation of Health Services and Programs and will be offered from April 3-8 (deadline: January 31, 1995). The objective of the course is to provide intensive training in using the techniques of project evaluation to determine the desirability and economic feasibility of social investment projects.

The course on Health Economics and Policies in Developing Countries will be offered from May 15-26 (deadline: March 31, 1995). The objective of the course is to enable participants to use economic tools in making better decisions regarding health, so that limited resources are more efficiently utilized.

For further information and application materials, please contact:

Dr. Plearnpit Satsanguan
Faculty of Economics,
Thammasat University,
Bangkok 10200,
Tel: 66-2-2216111 ext. 2408.
Fax: 66-2-2249428.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Reproductive Health and the Role of Family Planning Programs
· Conference on Structure and Delivery of Health Services

Reproductive Health and the Role of Family Planning Programs

Reproductive Health and the Role of Family Planning Programs

The World Bank estimates that one-third of the total burden of disease in developing country women of reproductive age (15 to 44) is linked to health problems related to pregnancy, childbirth, abortion, human immunodeficiency virus (HIV) and reproductive tract infections (RTI). Reproductive health (RH) problems account for the majority of the disease burden for women in this age group among all cost-effective interventions. There is a clear need for greater access to reproductive health services.

With limited resources available, family planning services are increasingly being viewed as appropriate mechanism for improving women's reproductive health. Some key reasons for providing a broader array of RH services through family planning include:

- the incidence of induced abortion is integrally linked to access and availability of safe and effective contraception. Furthermore, women who visit family planning clinics seek abortion counseling, treatment of abortion complications and post-abortion family planning.

- family planning services that provide pregnancy testing, prenatal and delivery care are often integrally linked to provision of appropriate care for pregnant, postpartum and breastfeeding women.

- appropriate provision of contraception based on a woman's risk category and reproductive goals.

Many countries have to some extent integrated reproductive health interventions in their family planning programs. Some examples include:

- Bangladesh Women's Health Coalition which runs a network of clinics in Dhaka began with offering contraceptives and have gradually expanded their services to include general gynecologic/prenatal care and routine infant and child health care.

- In Tunisia, the Sfax post-partum project developed a program that integrate postpartum care, family planning and well-baby care in one visit. During the visit, both mother and infant receive complete examination. In addition, the infant receives routine immunizations, and the mother receives counseling on breastfeeding and birth-spacing and contraception upon request. Four years after the program was launched, over 80 percent of new mothers had made this visit and over half had decided to practice contraception.

- The Colombian Welfare Association (PROFAMILIA) now provides a wide array of RH services, often on a fee-for-service basis, including infertility services, pap smears, general gynecology and urology services and diagnosis and treatment of STDs.

Information on the successes or failures of integrated family planning programs is limited. Two major concerns regarding the feasibility of integrating RH in family programs are: the difficulty of providing STD management (diagnosis, treatment and follow-up). Many STDs can be asymptomatic in women and complicates clinical management. Implementing limited STD screening and/or management services can require significant commitment of resources. and damage to the reputation and credibility of family planning programs if STD/AIDS prevention and services are offered. Many programs, with the exception of PROFAMILIA have found a negative impact on their programs.

The level of RH services to be provided should be determined on a case-by case basis, taking into account the client needs and program capabilities. At the minimum, family planning programs should provide a broad range of contraceptive choices, STD prevention and linkages with safe birth and abortion care. A full package should include a range of key health services appropriate to women throughout their reproductive lives.

(based on the report "Women's Reproductive Health: The Role of Family Planning Program, Outlook Special Issue on Family Planning and Reproductive Health, volume 12, no. 2 August 1994).

Third Universal Health Conference

MicroHospital Workshop and Exhibition
Almaty, Kazakhstan
Commonwealth of Independent States
April 24-28, 1995

An International Conference on the Structure and Delivery of Health Services

The goals of this conference is to promote the creation of professional links between colleagues who worked together until the collapse of the Soviet Union who have grown apart but have a lot to learn from each other's experiences with change, in addition to links with the rest of the world.

Conference will include lectures on Health Care Reform and Financing Alternatives, Maternal and Child Health, Diseases related to Ecological Problems, Non-Infectious Chronic Diseases, Health Awareness and Health Education and a MicroHospital Workshop that will focus on review of new technologies and their application.

For more information, please contact:

in the US: Ms. Ruth Winter
MDS Associates, Inc.
1525 E. 53rd Street, Suite 1004
Chicago, IL 60615
Tel: (312)752-2650
Fax: (312)752-7620

in Kazakhstan: Ms. Laura Yergesgeva
Universal Health Conference
53-12 Rozyabakieva
Almaty, Kazakhstan
Tel: 7(3272)416763


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· National Tuberculosis Program
· Conference Announcement: Fourth Asia Pacific Conference on Tobacco or Health - Thailand
· Request for Proposal - Opportunities for Micronutrient Interventions (OMNI)

National Tuberculosis (TB) Program

Alan Hinman and Nancy Binkin of the US Centers for Disease Control and Prevention addressed the crucial question: "What constitutes a good national tuberculosis program?" at a seminar held at the Bank on June 23, 1994. They emphasized the need for comprehensive programs. Key elements in a national strategy to control TB must include efforts to improve socioeconomic conditions, case finding and treatment, preventive therapy of people exposed to infectious cases, and BCD vaccination of young children. Counter-intuitively, poor national programs May do more harm than good, Hinman warned. Poor treatment May raise the number of chronic or relapsing patients over that expected in a no-treatment scenario, leading to greater public spread and raising the risks of drug resistance.

Clearly, the reasons for tackling TB on a war-footing are manifold: it is among the top three causes of lost disability-adjusted life years in adults; an explosion in dual-infection cases of TB and HIV is emerging in parts of Sub-Saharan Africa, as well as in South and South East Asia; and TB short-course treatment is amongst the most cost-effective health interventions available today.

Operationally, good national TB programs are likely to combine elements of vertical and horizontal programs, said Binkin. They must be based on short-course treatment, while supervision by a health care worker or family worker is crucial to ensuring patient compliance, she noted. Initially, programs should focus on high-incidence areas, on passive case-finding, and on treating smear positive cases, as these are the most infectious. Only after achieving high cure rates should programs expand to cover other areas, introduce active case finding, and treat smear-negative cases. Other essential elements include training of health care and laboratory staff, and ensuring that the health infrastructure can maintain an uninterrupted supply of drugs and diagnostic materials.

For copies of the paper or other queries, contact Nanny Binkin at fax 404-639-8604 or E-mail:
[extracted from Health Policy no. 8, November 1994]

Conference announcement and call for papers

Fourth Asia-Pacific Conference on Tobacco or Health
November 22-24, 1995
Pang Suan Kaew Hotel, Kad Suan Kaew
Chiang Mai, Thailand

Early registration and abstract submission deadline (June 30, 1995). Topics for abstracts include epidemiology, health burdens, economic burdens, data collection, public education, legislation, smoking cessation and TTC's invasion/tactics.

For more information, please contact:

Dr. Chanpen Choprapawon
Fourth Asia-Pacific Conference on Tobacco or Health
Thailand Health Research Institute, National Health Foundation
1168 Soi Phaholyothin 22, Phaholyothin Road
Ladyao, Jatujak, Bangkok 10900, Thailand
Tel: (66-2)939-2239
Fax: (66-2)939-2122

Request for proposal opportunities for micronutrient interventions (OMNI)

Research Topics

The objective of this request for proposals is to encourage applicants to develop and test new, creative, and effective approaches to increase intake of micronutrient-rich foods. Projects May explore one or more of the following ISSUEs:

· development and testing of methods to increase demand for micronutrient-rich foods; to promote consumption of micronutrient-rich foods produced by the household; to sustain behavior change(s) after a communication program has been implemented; for choosing the most effective communication channels for reaching audiences of different ages and needs

· development and testing of measurement tools for evaluating behavior change.

· systematically testing of behavior change models as evaluation tools for assessing the impact of a communication intervention(s) at individual and community levels

Award Criteria

The project must be carried out in a country eligible for assistance by USAID funds. The proposal should specify: a target food or foods, specific target audience, evaluation tools and plans. Proposed budget should not exceed $50,000.

OMNI Research is particularly interested in receiving applications from multidisciplinary teams presently conducting field operations research. Teams comprised of program practitioners, communicators and field-oriented researchers are encouraged to apply. All documents must be written in English.

Proposal Submission Deadline: Applications must be received at the OMNI Research office no later than March 31, 1995. Transmission via facsimile is NOT acceptable.

For more information, please contact: Dr. Paula Trumbo, OMNI Research at the ILSI Human Nutrition Institute, 1126 16th Street, N.W., Washington, DC 20036. U.S.A. Tel: (202)659-0789; Fax: (202)659-3617.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· The Willingness to Pay for Health Services
· New journals and clinical lists
· Epidemiologist Position - Ontario, Canada

The Willingness to Pay for Health Services

The following is a review of a presentation at The Workshop on Effects of Service Quality and Cost on Education and Health sponsored by the Policy Research Department (PRD) and the Human Resources Development Vice-Presidency (HROVP).

The merits and downsides of levying user fees for public health services have been debated furiously in recent years, noted Victor Lavy, professor of economics at the Hebrew University of Jerusalem, and consultant to the World Bank's Policy Research Department. His talk entitled "Household Responses to Public Health Services: Costs and Quality Tradeoffs" focused on the crucial question of whether quality improvements are attractive enough to patients - especially to persons in high health risk categories - to maintain levels of health care utilization when user fees are increased.

Lavy's conclusions come prefaced with the warning that there is not enough data on willingness to pay to make conclusive policy recommendations. His findings show that consumers in developing countries respond to quality differences in the health care provided, suggesting that the market could efficiently allocate resources and services. New or increased user fees in public health facilities - when accompanied by an improvement of services - can increase utilization. The increase is positive for both the poor and the non-poor, with a greater increase for the non-poor.

The indirect costs of medical care, such as transport and the opportunity cost of time, are a major component of the overall costs faced by consumers, and hence charging fees for more accessible services by reducing indirect costs is well received by consumers. Low-income households value this expansion of services relatively more and will be willing to pay non- negligible fees in user charges for this benefit. Drug supply is another major characteristic of consumer-perceived quality, and keeping the stock of drugs at appropriate levels should be a priority. Finally, the effect on utilization and the willingness to pay for quality improvements is greater when multiple characteristics of quality are improved simultaneously.

Mr Lavy can be reached by E-mail at

New journals and clinical lists

··· Journal of Health and Place ···

Journal of Health and Place is a new quarterly interdisciplinary journal dedicated to the study of all aspects of health and health care in which place or location matters. The journal brings together international contributors from geography, social policy and public health. It offers readers comparative perspectives on the difference that place makes in the incidence of ill-health, the structuring of health-related behaviour, the provision and use of health services, and the development of health policy.

For information regarding submissions and subscriptions contact:

Editor: Dr. Graham Moon, School of Social and Historical Studies, Univ. of Portsmouth, Milldam, Burnaby Road, Portsmouth, P01 3AS, UK.
tel +44(0)705 842232, fax +44(0)705 842174, email MOONG@CV.PORT.AC.UK

Associate Editor: Dr. Michael V. Hayes, Department of Geography, Simon Fraser Univ., Burnaby, British Columbia, V5A 1S6, Canada. tel (604)291 4426, fax (604) 291 4455, email MHAYES@SFU.CA

Published by Butterworth-Heinemann, Linacre House, Jordan Hill, Oxford, 0X2 8DP,
UK. Contact: Alison Wynn, tel +44(0)865 310366, fax +44(0) 310898.

··· Health and Human Rights ···

Jonathan Mann, MD, MPH (editor) and John F. Lauerman (Managing Editor)

Health and Human Rights is a New International Quarterly Journal published by The Francois-Xavier Bagnoud Center for Health and Human Rights and the Harvard School of Public Health Rights. The journal presents the experience of health and human rights workers who have collaborated to bring about positive change; communicate results of research and analysis in health and human rights; and provide a forum for further exploration of the complex relationships between health and human rights. In addition, Health and Human Rights will report on important developments in the UN system and in other intergovernmental, regional and non-governmental agencies. Health and Human Rights journal is distributed free to individuals in developing countries. Institutions and individuals in industrialized countries must subscribe at a modest rate.

For more information, contact: Health and Human Rights Journal Office
Harvard School of Public Health 677 Huntington Ave. Boston MA 02115, USA
tel (617) 432-4611 fax (617) 432-4314
e-mail contact:

··· "PARACELSUS " ···

The PARACELSUS list was created by AMR'TA, the Alchemical Medicine Research and Teaching Association, a non-profit organization. The primary focus of this list is the clinical practice of natural medicine, alternative therapies and complementary healthcare. The purpose of this list is to engender collaboration and communication between eclectic health care professionals around the world, and to promote networking between individuals with similar interests. While the orientation is intended to emphasize natural/alternative/ complementary/holistic therapeutics, it is not intended to exclude conventional approaches. Discussion of any topic relevant to clinical practice is encouraged, and is limited only by the energy and creativity of those participating.

To subscribe, send the following message: subscribe your-list-name by email to the Majordomo address: <

Please send a biographical note about yourself, your training, your practice, and your interests to: <>.

Subscription is limited to health care professionals. Students at medical schools of various orientations are also welcome. Refer questions or problems to: Mitchell Bebel Stargrove, N.D., L.Ac., <>.

For more information on AMR'TA, contact <

Epidemiologist position

Victoria Hospital Research Institute (VHRI), London, Ontario, Canada is looking for a MSc level epidemiologist. Victoria Hospital is a tertiary care teaching hospital affiliated with the University of Western Ontario. This position is a three year contract posting with the Critical Care Management and Evaluative Research Group. The successful candidate will work closely with a multi-disciplinary team of clinicians, managers and researchers in the Southwest Ontario Critical Care Research network to develop a registry of clinical activity across multiple institutions and to design and manage related research projects.

Specific tasks include: independent and collaborative design of diverse research projects; management and quality control of data; preparation of grants and publications to peer review agencies and presentations to small groups and at scientific conferences.

The successful candidate will have excellent written, verbal, design, analytic and organizational skills and must be able to manage numerous projects. Familiarity with and the ability to use the appropriate computer tools are essential (ex. SAS, BMDP, SPSS, presentation packages, word processors etc.). This position has the potential to grow with the abilities and needs of the successful applicant. Renumeration is competitive and dependent on qualifications and motivation. For more information and further contacts, please reply via e-mail to: Dr. Gordon Doig, VHRI,


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

PHNLINK is pleased to announce the broadcast of PARTNERS, a new list-serv, which will specifically address ISSUEs relating to health care reform. Please see attached for details on how to subscribe.

Partners for health: a network for health reform

A Joint Venture of the World Health Organization (WHO), the United Nations Development Programme (UNDP), and the World Bank.

··Why a New Network?··

Many countries are in the process of undertaking ambitious reforms to achieve better health. The design and implementation of health reform entails difficult analysis of policy options and managing complex institutional changes. People implementing change face a number of problems. They feel isolated, lacking interaction with colleagues to help them solve difficult problems. They have limited access to information about current approaches to the many aspects of health reform. Often, the required information is not available in time and in user-friendly form. Overall, there is a poor match between demand for and the supply of technical and financial resources for health. Achieving such a match is difficult, given the complexity of the reform process, the varied nature of requests and the often limited repertoire of available responses. In order to address these problems, it is proposed to establish a network among partners in health reform at the local and global level.

··The Scope of the Network··

The basic mission of the net work is to support people and institutions involved in implementing health reform. Specific objectives are:

- to improve access to information based on experiences of health reform, including comparative analysis of approaches to key ISSUEs;

- to support informed choice of approaches to health reform in countries;

- to develop, refine and promote utilization of tools and processes for health reform;

- to serve as a forum for advocating action for health reform in countries;

- to facilitate access by countries to technical and financial support, with emphasis on longer-term capacity building.

The network will address ISSUEs related to health development, health care, institutional and global change.

··Network Architecture··

The network will consist of members, a secretariat and an advisory group.


- Network members will be the owners of the network. They will be both users and providers of knowledge, technical and financial resources.

- Membership will be open to individuals acting in their personal capacity or on behalf of their institutions. The possibility of different types of membership with access to different types of information and support will be reviewed by the advisory group.

- Members must agree to adhere to the basic objectives of the network and observe the operating principles to be defined by the advisory group.

- Members must be accessible by E-mail or fax.

Secretariat Functions

- Facilitate access to the network by individuals and institutions, especially in developing countries.

- Facilitate exchange of information between members.

- Provide access to information already available and easily retrievable.

- Support the production of information not currently available, or available but not in user-friendly form.

- Act as an intermediary among network members to ensure that requests for technical support receive appropriate responses.

- Monitor events which have a critical impact on countries' capacity to implement health reforms.

- Challenge current practices and directions which affect health reform and development and advocate change accordingly.

- Ensure adherence to the operating principles defined by the advisory group.


- The secretariat will consist of a small core of technical and administrative support group to be established at WHO and of focal points (with their own administrative support) in the World Bank and UNDP. The secretariat, in carrying out its functions as described above, will draw on existing groups and networks, and, in some cases, create new working groups.

- Financial resources required for the secretariat and its activities will come initially from WHO, the World Bank and UNDP.

Advisory Group

There will be up to twelve advisory group members; with one representative for each of the core members (WHO, World Bank, UNDP). Other members will be elected by the network members from among themselves.

Advisory Group members will

- liaise with their own and other relevant organizations in the network to ensure appropriate institutional responses to needs and requests emerging from the network members;

- develop guidelines on membership, access to technical information and other operating principles of the network; and

- orient activities and review achievements of the network and the secretariat, including quality and timeliness of technical information and support.

Examples of How it Might Work

1) The Ministry of Health in Country X would like to know what the experience has been with decentralization in other regions. He/she sends off an electronic mail inquiry which is disseminated throughout the network. Responses are sent via E-mail or fax. The secretariat monitors the exchange, and if no responses are forthcoming, either provides information directly, or contacts members in specific countries to ask them to contribute their experience.

2) A consumer organization in a country is concerned about the unregulated growth of private medical facilities which are becoming exploitative. It requests the network for information about regulation of private sector medical institutions and consumer protection measures in different countries. Members respond with regulations from relevant countries.

3) A research organization, concerned about the imbalance of medical facilities between urban and rural areas and the concentration of medical manpower in the former to the detriment of the later, is attempting to work out alternative models for medical manpower development for delivery of health care services in remote areas. It solicits the network for various successful examples in different parts of the world. Members with relevant information respond.

4) Field trials of new malaria vaccines are successful enough to warrant discussion of "what next?". The network forms a subgroup of interested parties. This working group clarifies the ISSUEs and options, and proposes a strategy for a collective response.

Individuals and institutions located worldwide who are involved in health reform are invited to participate in the PARTNERS for Health Network. To subscribe to the Partners list-serv, please send a message to:

In the body of the text, type: subscribe partners e-mail address YourFirst-name YourLast-name
for example, John Smith would type: subscribe partners John Smith

The network does not wish to exclude those who are not yet electronically connected. Interested parties who would like to receive Network announcements via fax or mail should contact:

Dr. Roberta Ritson

Division of Intensified Cooperation with Countries (ICO)

World Health Organization
Avenue Appia
CH-1211 Geneva 27
Fax: 41-22-791-0746 Telex: 415 416


Electronic Newsletter on Population, Health and Nutrition Issues

Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Better Health for Africa
· Center for Health Economics
· Lecturer Position- London School of Hygiene and Tropical Medicine

Better Health for Africa

High rates of disease and premature mortality in Sub-Saharan Africa are costing the continent dearly. Poor health causes pain and suffering, reduces human energies and make millions of Africans less able to cope with life, let alone enjoy it. The economic consequences are immense. Poor health shackles human capital, reduces returns to learning, impedes entrepreneurial activities and growth of gross national product.

'Better Health in Africa'(BHA) presents African countries and their external partners with positive ideas on how to improve health. It argues that despite tight financial constraints, significant improvements in health are within reach in many countries as testified by experiences in countries as diverse as Benin, Botswana, Kenya, Mauritius and Zimbabwe. The report documents lessons learned and "best practices" in four major areas.

First, to achieve better health, African households and communities need the knowledge and resources to recognize and respond effectively to health problems. Formal and informal education play a major role, providing information and practical guidance on self-care cleanliness, food preparation and nutrition. The central position of women in household management and health must be emphasized. Intersectoral interventions to complement and sustain health improvements, such as the provision of safe water, along with community participation in the management of health services are crucial to an "enabling environment for health."

Second, BHA shows that much of the improvements in health can be achieved by reforming health care systems to use available human and financial resources more productively. For example, inefficiencies in the pharmaceuticals industry are so extensive that, in some countries consumers receive only $12 worth of drugs for each $100 spent on drugs by the public sector. Inequities prevail to the extent that poor households in many countries have no access to quality care at times of serious illness or injury.

Third, cost-effective packages of basic health services can go a long way to respond to the needs of households and reduce the burden of disease in Africa. A package of such services can be provided in a typical low income African country for as little as $13 per capita per year. This compares with the average per capita expenditures on health from all sources in SSA of $14, ranging from $10 or less per capita (in Niger and Zaire) to over $100 per capita (in Botswana and Gabon). The key to improving the use of resources is to reallocate funds to the most cost effective services.

Fourth, BHA envisions that Africans in low income areas can obtain basic health services with an additional $1.6 billion per year. Cost sharing can contribute to health equity and the sustainability of health services. Furthermore, it can stimulate the provision of quality services in rural and urban areas. User fees and health insurance are a reality in many countries and merit increasing roles as evident in the willingness and ability of African households to pay for quality services.

Larger commitments of domestic resources from government, NGOs and households can lead to more financial support from donors. A scenario in the report shows that Africa's low income countries would increase their total annual spending on health by $1 billion - a goal within reach through gradual increases in government financing and increasing participation by households. Donors might be expected to contribute over $600 million, reflecting a 50% increase in external assistance for health in Africa today; mostly to low-income countries that are implementing the actions necessary for better health.

Transition to better health will vary from country to country and no one formula would apply to all. However, it is important that no country should delay committing itself. the first step is to establish an action plan and yardstick to measure progress.

Initiatives in these areas have already commenced with participation of African health experts in the review of this study and discussions with health officials from Cameroon, Central African Republic, Congo, Cd'Ivoire, Gabon, Guinea, Kenya, Sierra Leone, Tanzania, Uganda, and Zambia; and a review by an Independent African Expert Panel on Health Improvement in Africa. The panel is chaired by Professor Ransome-Kuti, former Nigerian Minister of Health and former chairman of the WHO Executive Board and co-sponsored by the World Health Organization (WHO),the the United Nations Children's Fund (UNICEF), as well as bilateral donors and foundations supporting its work program. The Bank has asked the Panel to take the lead on BHA follow-up activities. The Panel is to meet in Paris in February 1995 to agree on its work program of activities for dissemination of the study, advocacy of health reform, and assistance to specific reform initiatives. (adapted from the joint foreword by the World Bank Regional Vice President for Africa, E.V.K. Jaycox, Mr. James P. Grant, Executive Director, UNICEF and Dr. G.L. Monekosso, Regional Director for Africa, WHO of 'Better Health in Africa: Experience and Lessons Learned', World Bank, 1994).

For a copy of the executive summary of BHA, which is available in English or French, please contact: Donna McGreevey, by email: or tel: (202)473-4087. Please specify language when placing your order.

Copies of the book is available at The World Bank Bookstore. Tel: (202) 473-1155, or fax: (202) 676-0581. Outside the US, contact your local World Bank distributor. For a list of distributors, please send a written request to:

The World Bank 1818 H St. N. W. Department T-8051 Washington, D.C. 20433

Centre for health economics

WHO Collaborating Centre for Health Economics

The Centre for Health Economics, Faculty of Economics, Chulalongkorn University, Bangkok, Thailand, is organizing two health economics training programs:

1. MSc in Health Economics : A one-year programme starting from June to May of each year. 1996/97 Program Last submission date is 30 November 1995

2. Six one-month short courses starting in August 1995- January 1996. Application must be made 6 months before the applied course begins.

The Director

Centre for Health Economics
Faculty of Economics
Chulalongkorn University
Bangkok 10330
Tel: 66-2-2186280-81
Fax: 66-2-2186279

Lecture position in health economics

The ODA-funded Health Economics and Financing Programme at the London School of Hygiene and Tropical Medicine, is about to advertise a post of lecturer/senior lecturer in health economics to join an existing group of around 8 health economists. Our main concern is health economics research in low- and middle-income countries. We seek someone interested in applied research, who has qualifications in health or development economics and relevant experience in the Third World.

For further information contact Dr. Anne Mills, Programme Head, tel UK 171 927 2354 fax 171 637 5391 email


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Enriching Lives
· Health Economics Position

Enriching lives

Executive Summary

The control of vitamin and mineral deficiencies is one of the most extraordinary development-related scientific advances of recent years. Probably no other technology available today offers as large an opportunity to improve lives and accelerate development at such low cost and in such a short time.

Dietary deficiencies of vitamins and minerals-life - sustaining nutrients needed only in small quantities (hence, "micronutrients") - cause learning disabilities, mental retardation, poor health, low work capacity, blindness, and premature death. The result is a devastating public health problem: about 1 billion people, almost all in developing countries, are suffering the effects of these dietary deficiencies, and another billion are at risk of falling prey to them.

To grasp the enormous implications at the country level, consider a country of 50 million people with the levels of micronutrient deficiencies that exist today in South Asia. Such a country would suffer the following losses each year because of these deficiencies:

· 20,000 deaths
· 11,000 children born cretins or blinded as preschoolers
· 1.3 million person-years of work lost due to lethargy or more severe disability
· 360,000 student-years wasted (3 percent of total student body).

In terms of losses by type of deficiency, more than 13 million people suffer night blindness or total blindness for the lack of vitamin A. In areas without adequate iodine in the diet, five to ten offspring of every 1,000 pregnant women are dead upon birth or soon thereafter due to iodine deficiency. Severe iron deficiency causes as many as one in five maternal deaths, as well as the death of about 30 percent of children who enter the hospital with it and do not get a blood transfusion (those who do get the transfusion are exposed to other risks).

The World Bank's World Development Report 1993 found micronutrient programs to be among the most cost-effective of all health interventions. Most micronutrient programs cost less than US$50 per disability-adjusted life-year (DALY) gained. Deficiencies of just vitamin A, iodine, and iron-the focus of this book-could waste as much as 5 percent of gross domestic product (GDP), but addressing them comprehensively and sustainably would cost less than 0.3 percent of GDP.

The 1990 Summit for Children endorsed three micronutrient goals for the end of the decade: the virtual elimination of iodine and vitamin A deficiencies and the reduction of iron deficiency anemia in women by one-third. The goals were reaffirmed in 1991 at the Ending Hidden Hunger conference and in 1992 at the International Conference on Nutrition. The goals are achievable only if political will, state-of-the-art technology, and private, public, and international resources are marshaled for the effort.

The Need for a Comprehensive Approach

The alleviation of poverty and the strengthening of national health care systems alone cannot solve the problem of micronutrient deficiencies. Because the micronutrient content of foods is a hidden property, consumers do not automatically demand micronutrient-rich foods with increased income. Thus, food and agriculture policies need to watch over not only the quantity but the nutritional quality of the food supply and promote the production, marketing, and consumption of micronutrient-rich foods. Likewise, safety net programs, including refugee feeding, must respond to the total nutritional needs of target groups and not just to their calorie and protein needs.

An overall improvement in health system management will go a long way toward improving micronutrient malnutrition as long as programs train and monitor medical personnel for the prevention and management of micronutrient deficiencies, reach groups not currently using the health care system, and, through teaching and persuasion, transform consumers into a constituency for healthful diet.

Three Types of Approaches

Even with the most nutritionally enlightened economic development plan, developing countries must still take direct aim at micronutrient malnutrition through consumer education, aggressive distribution of pharmaceutical supplements, and the fortification of common foodstuffs or water. Fortunately, all of these options are inexpensive and cost-effective. The particular mix of interventions chosen depends on country conditions. But the key constraints to achieving the summit goals are a lack of awareness and commitment of policymakers and consumers, a weak capacity to deliver supplements and education, and a lack of enforcement of industry compliance with fortification laws.

Social Mobilization

Policymakers must be motivated to take action against micronutrient malnutrition. They need persuasive information on the economic and social costs of micronutrient malnutrition and on the political salience and cost-effectiveness of micronutrient programs. Then, during implementation, good management information systems and public education programs designed into the overall initiative can make the public aware of the improvements resulting from the micronutrient programs and draw the connection to the responsible program managers and policymakers. That connection provides public support and reward for the initiative of the political leaders. Beyond the immediate political feedback they provide, programs to educate, persuade, and change the behavior of consumers are essential to the long-run elimination of micronutrient deficiencies. Subconscious consumer demand for micronutrients needs to be made conscious and directed to appropriate foods and pharmaceuticals. This demand will serve as a "pull" factor to bring the target groups to distribution points for supplements, to overcome resistance, and, if necessary, to induce consumers to pay a little more for a better (that is, a fortified, although unfamiliar) diet. Social marketing of micronutrients and micronutrient-rich foods is necessary in virtually all developing countries, even where health service delivery is good and the food industry is well developed.

Pharmaceutical Supplementation

Two key problems in pharmaceutical supplementation have been poor coverage of at-risk groups and inadequate supply management. To overcome the coverage problem, the delivery of supplements must break out of a single- clinic-based track and employ every possible avenue of convenience and opportunity, including school visits, workplace programs, and nutritional safety net programs. The goals of supply management are to procure effective supplements that look appealing, have helpful packaging and labeling, come in the right doses, and are affordable; to store and transport them for maximal quality and preservation; and to deliver them to well-selected distribution points in adequate numbers of doses at an appropriate frequency. Achieving these goals requires committed program leaders, motivated and well-trained workers, good monitoring and surveillance, and a demanding public. The private pharmaceuticals market May have an important role to play in developing new products and delivering supplements in a cost-effective manner at the community level.

Effective Regulation and Incentives for the Private Food Industry

The food industry responds to both positive and negative policy signals. Broad legislation, followed by technical regulations, should require micronutrient fortification of basic foodstuffs and support a fair and honest regulatory system that monitors compliance and punishes the noncompliant.

This legislation should be joined by financial and political inducements to industry. Some of the incentives used in effective fortification programs have been tax relief, import licenses, loans for equipment, subsidies on fortificants, and positive press coverage. A third component of any successful food control system is consumer awareness and pressure for industry compliance. Consumers can be mobilized through social marketing and consumer organizations to demand effective fortification. Without confidence in both the industry and the regulatory apparatus, enlightened consumers will not be willing to buy new products.

Developing Nutritional Awareness and Habits

Political sustainability comes from monitoring and communications as well as satisfaction of consumer demands. One of the greatest advantages of micro- nutrient programs is that, because results are unambiguously attributable to specific interventions, policymakers can take credit for improvements.

Operational sustainability depends upon good management, continual oversight, the retraining of personnel, and the supervision of delivery systems (particularly the health system and food industry).

Behavioral sustainability will come only after consumers form good nutrition habits, whether that means eating carrots, taking a daily iron pill, or buying a fortified food.

Economic sustainability is a function of national and household ability to pay. Micronutrients are so inexpensive that, regardless of the form, they should ultimately be affordable by the intended beneficiaries. From equity reasons or in the short term, some form of targeted subsidy May be necessary to reach the poorest and to form habits among the desired beneficiaries. In the long run, however, financial sustainability will depend upon consumers' willingness to pay for the nutrients. It is the government's responsibility to choose the most cost-effective means of delivering micronutrients to the population.

The Need for External Start-up Support

Micronutrient interventions are among the most cost-effective investments in the health sector. Because fortification of water and foods is also extremely cost-effective, nontraditional sector involvement is desirable as well. Donors have a key role to play in assisting with program design and financing. Addressing micronutrient deficiencies globally will require an estimated $1 billion per year-about US $1 per affected person. That figure is equivalent to the economic costs of endemic deficiencies of vitamin A, iodine, and iron in a single country of 50 million people. Most of these costs will ultimately be borne by consumers when purchasing food with higher nutritional quality.

In the short run, however, donors and governments May have to assume a major financial burden for project preparation, start-up costs, and recurrent costs in the early years. The economic and social payoffs from micronutrient programs reach as high as 84 times the program costs. Few other development programs offer such high social and economic payoffs.

Enriching Lives is now available at the World Bank Bookstore: (202) 473-3193. For a mail order copy, contact: The World Bank Bookstore 1818 H St. N. W. Department T-8051 Washington, D.C. 20433 Tel: (202)473-1155 or Fax: (202)676-0581.

For orders of 50 copies or more at a discounted price, please contact: Ms. Judy McGuire Tel: (202)473-3452 Fax: (202)522-3234 or (202)522-3235

Health economics position

Medical Research Council Laboratories in the Gambia, under their new Director Prof. K. McAdam, are expanding their areas of work. A post of health economics has just been advertised, to establish health economics in research projects in the Gambia, particularly on communicable and non-communicable diseases. Involvement with health policy ISSUEs in West Africa will be encouraged. The aim is to build up strength in health economics in the MRC lab. The post is for 3 years, with the opportunity to be linked to a home institution in the UK and to return there for a further 2 year period.

Further information from Ms. Mags Clappison, Medical Research Council, 20 Park Crescent, London W1N 4AL, tel 71 637 6005, fax 71 637 0361. Closing date 3 March. Those interested in an appointment linked to the London School of Hygiene and Tropical Medicine, please contact:

Anne Mills, Head, Health Economics and Financing Programme, LSHTM (


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Physician Behavioral Response to Price Control
· Training Materials in Health Systems Research
· Conference on Health Care Delivery in a Multicultural Context

Physician Behavioral Response to Price Control

The need to contain escalating health care costs is one of the major challenges facing health care systems today. It is often argued that price control is an effective tool for reducing both the level and the rate of growth in health spending. However, experience suggests that these savings May be partially offset by volume increases. These increases are initiated by providers, particularly physicians, who attempt to provide more health care goods and services in order to recapture lost revenues. This phenomenon is called the behavioral offset or volume response.

The extent of this behavioral change has major implications for health care finance in developing countries. However, due to data limitations, it is not always possible to analyze the impact of price controls on provider behavior in the developing world. Hence, this paper draws upon the experience of the United States in order to shed some light on financing ISSUEs in developing countries. More specifically, it examines the physician behavioral response to the fee reductions at the practice level using the data from the U.S. Medicare program for 1989 and 1990. At the time of this writing, this was the most recent data available at the practice level for the Medicare program. This period of time corresponds to the fee reductions mandated by the Omnibus Budget Reconciliation Act of 1989 (OBRA89) which, as a consequence, created losers and winners (non-losers). The results show that winners do not exhibit any behavioral change. By contrast, losers are expected to offset the fee reductions by about 40 percent. This means that, for every dollar cut in their fees, physicians will recoup 40 cents by increasing volume.

The presence of a volume response suggests that price control alone is not sufficient to cap rising health care costs. This indicates that additional or other tools must be considered if cost containment is to be attained.

(abstract from Human Resources Development and Operations Policy Working Paper no. 46 by Nguyen Xuan Nguyen)

Training Materials in Health Systems Research

Health systems research (HSR) aims to improve the health of a community by enhancing the health system, which is seen as an integral part of the overall socioeconomic development process. HSR seeks to provide community leaders, health workers, and managers at all levels with the information they need to make good decisions.

International Development Resource Center (IDRC), along with the World Health Organization (WHO), decided to support the preparation of a set of training materials in HSR aimed at specific target groups. The result is a five-volume set of publications.

- vol. 1: Promoting Health Systems Research as a Management Tool.

Based on an analysis of experience in developing countries over the last 10 years, it provides an overview of how HSR can lead to better decisions, as well as information on how to foster effective research programs at a country level.

- vol. 2: Designing and Conducting Health Systems Research Project. Part I: Proposal Development and Fieldwork covers the development of research proposals of a participatory nature and the implementation of a field study. Part II: Data Analysis and Report Writing deals with data analysis and the dissemination of results.

- vol. 3: Strategies for Involving Universities and Research Institutes in Health Systems Research. Reviews the strategies to assist universities and research institutes to integrate HSR concepts into health and social sciences degree programs.

- vol. 4 - Managing Health Systems Research (for managers of health systems research programs). Topics include the processing of research applications, funding and coordinating research projects, and utilizing research results.

- vol. 5: Training of Trainers for Health Systems Research (for trainers and facilitators) is a course outline in a modular format to assist those who organize and conduct training in HSR. It contains 15 modules on the basic concepts of HSR, educational methods and training strategies. The teaching methods outlined have general application for training health staff in a variety of topics.

Each volume costs Can $12.95 with the exception of vol. 2 which costs Can $19.95. All volumes are available free of charge to developing countries. The five volumes are published in Spanish and French (pending).

For more information, contact: IDRC Books PO Box 8500 Ottawa Ontario, Canada K1G 3H9 Tel.: (613) 236-6163; Fax: (613) 238-7230 Telex: 053-3753; Cable: RECENTRE OTTAWA Internet:

Health care delivery in a multicultural context fifth annual Conference

New York City
Monday, April 10, 1995
8:00 am - 5:00 pm
Sponsored by St. John's University (Psychology Department, Center for Psychological Services and Clinical Studies and Graduate School of Arts & Sciences), this conference is the fifth in a series devoted to a systematic exploration of social/psychological ISSUEs from a multicultural perspective.

For more information, contact:

Warren Bush
Dept. of Psychology
St. John's University
or request for a complete conference by email: A8G3SJU@SJUMUSIC.STJOHNS.EDU

In this ISSUE...

· The Economic Impact of AIDS
· What's New in the PHNFLASH Archive?
· Cultural Diversity, Public Policy and Survivorship Symposium

The Economic Impact of AIDS

The AIDS epidemic, through its effects on savings and productivity, poses a threat to economic growth in many countries that are already in distress. World Bank simulations indicate a slowing of growth of income per capita by an average 0.6 percentage point a year in the ten worst-affected countries in Sub-Saharan Africa. In Tanzania, where income per capita has already fallen 0.2 percent a year in recent years, the estimated slowdown ranges between 0.1 and 0.8 percentage point, depending on the assumptions used. In Malawi, which has had a recent growth rate of 0.9 percent a year, the simulated reduction ranges from 0.3 to 0.5 percentage point. These calculations include the effect of the epidemic on population growth, which will slow slightly in severely affected countries.

The heavy macroeconomic impact of AIDS comes partly from the high costs of treatment, which divert resources from productive investments. Tanzanian clinicians estimate that, on average, an HIV-infected adult suffers 17 episodes of HIV related illnesses prior to death and a child suffers 6.5 episodes. Depending on how much medical care a patient gets, in the typical developing country the total cost per adult death ranges from 8 to 400 percent of annual income per capita; the average is about 150 percent of annual income per capita.

Although AIDS remains much less common in the developing world than diseases such as malaria, it economic impact is greater for two reasons: it mainly affects adults in their most productive years, and the infections resulting from it lead to heavy demand for expensive health care. The fact that AIDS kills so many skilled adults adds to its economic impact. At a large hospital in Kinshasa, for example, more than 1 percent per year of the health personnel, including highly trained staff, become infected (through sexual rather than occupational contact). Among the (largely male) employees at a Kinshasa textile mill, managers had a higher infection rate than foremen, who in turn had a higher rate than workers. The cost of replacing skilled workers will be substantial. A study of Thailand estimates that through 2000 the cost of replacing long-haul truckers lost to AIDS will be $8 million, and another study, of Tanzania, projects the cost of replacing teachers at $40 million through 2010.

The death of an adult can tip vulnerable households into poverty. Even in Tanzania, where the government pays a large share of health costs, a World Bank study shows that affected rural households in 1991 spent $60-roughly the equivalent of annual rural income per capita-on treatment and funerals. The study also showed that the effects of losing an adult persist into the next generation as children are withdrawn from school to help at home. School attendance of young people ages 15-20 is reduced by half if the household has lost an adult female member in the previous year.

Because individuals with AIDS are typically more prone to pneumonia, diarrhea, and tuberculosis, the cost of medical care is high even though there is no effective treatment as yet for the disease. Research in nine developing and seven high income countries suggests that preventing a case of AIDS saves, on average, about twice GNP per capita in discounted lifetime costs of medical care; in some urban areas the saving May be as much as five times. Calculations for India show that given prevailing transmission patterns, each currently HIV-positive person infects one previously uninfected person every four years. At this rate, there will be six HIV-positive persons in the year 2000 for every one today. If the transmission rate could be slowed to one every five years, that number could be reduced to four infected persons in 2000 for every one today. The corresponding reduction in medical costs, after discounting at 3 percent a year amounts to $750 by 2000 for each currently HIV-infected person for a total saving of $750 million. (adapted from Investing in Health, World Development Report 1993).

Cultural Diversity, Public Policy and Survivorship

5th Biennial Symposium on Minorities, the Medically Underserved and Cancer
April 22-25, 1995
Crystal Gateway Marriott
Arlington, VA
Last Call for Abstracts, Deadline: March 3, 1995

The Final Deadline for submitting abstracts for consideration for oral or poster presentation is March 3, 1995. It is anticipated that 16 scientific or community abstracts and 16 student abstracts will be selected for oral presentation. In addition, a total of 30 to 40 abstracts will be chosen for poster presentation.

Topics: Major Cancer Sites Research Updates (Breast, Prostate, Lung, Colorectal, Gynecological, Liver, Thyroid & Skin Cancers), Health and Lifestyle Issues (Diet & Nutrition, Tobacco & Alcohol, Environment & Family History/Genetics), Public Policy, Survivorship, Model Intervention Programs, and Resources

Oral and Poster Presentations

Focus: Basic to applied research and demonstration projects including behavioral, clinical trials, and community interventions.

Continuing Education Opportunities

Cancer Education Resources Center. Concurrent with the program, educational exhibits and a daily schedule of program demonstrations and materials (e.g., films, automated data bases, etc.) will be scheduled throughout the symposium. For abstract and registration information contact:

Donette L. Walker 5th Biennial Symposium 1720 Dryden Street, Suite C Houston, Texas 77030

Tel. (713) 798-4617

Fax (713) 798-3990

Presented by: Baylor College of Medicine UT MD Anderson Cancer Center Howard University Hospital Susan G. Komen Breast Cancer Foundation American Cancer Society Kellogg Company


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Early Childhood Development

· Announcement: Health Care Alliance seek US Health Care Institutions' Partnership in Central and Eastern Europe

· Announcement: Postdoctoral Fellow Position - The Netherlands

· Special Notice to JSI subscribers

Early Childhood Development: The World Bank's Agenda Health and education projects are central to the World Bank's strategy of poverty alleviation.

The Bank is the largest single source of external funding for health and education in developing countries. And increasingly, Bank investment has been directed toward young children - the human capital of the future. By the end of fiscal year 1994, the Bank will have lent cumulatively over US$ 745 million for projects that integrate health, nutrition and early child care services.

The brochure entitled "Early Childhood Development: The World Bank's Agenda" is based on best practices paper on early child development (see "Investing in Young Children," a World Bank Discussion Paper no. 275, 1995 by Mary E. Young) provides a short review of new Bank initiatives, freestanding projects and other social sector projects on early childhood development.

For a copy of the brochure, send a request to Mr. Odell Shoffner by email: or tel: (202)473-7023.

Health Care Alliance/USAID Seek US Health Care Institutions for Partnership Projects in Central and Eastern Europe

Original posting from the NISHEALTH Clearinghouse (

The American International Health Alliance, Inc. (AIHA) and USAID announce the planned expansion of their hospital partnership program to include the Central and Eastern European (CEE) countries of Hungary, Latvia, Romania, and Slovakia, and a second hospital partnership in Croatia. AIHA is soliciting interest from qualified US hospitals and health care institutions willing to devote substantial in-kind resources, mainly in the form of human resources committed on a volunteer basis, to a 3-year partnership with their counterparts in one of the CEE countries.

These partnerships will be part of an ongoing health care development program financed through USAID and managed by AIHA that includes 25 existing partnerships in 10 of the New Independent States (NIS) ant the CEE countries of Albania, Croatia, and Estonia. AIHA partnerships have enabled American health care providers to work with their colleagues abroad to address significant mortality and morbidity ISSUEs, improve health care organization and introduce market-oriented solutions to health system delivery problems. The emphasis of the program is on professional exchanges, involving physicians, nurses, administrators and technicians. AIHA partnerships also collaborate with related ministries of health, local and regional health system administrations, and schools of health sciences to ensure that critical areas of health education and administration are adequately addressed at these higher institutional levels, and that the capacity to carry out other developmental assistance efforts is enhanced.

The new CEE partnerships will share certain goals, namely improving medical and technological knowledge, expanding the role of nursing, enhancing institutional management and financing skills, and training health policymakers to effect rational adaptations of health financing and delivery reforms. Each of these partnerships will develop community-based programs impacting the populations served by the CEE partner institutions. However, the focus of activities will vary with the specific need of each country.

Hospitals or health care institutions wishing to be considered should send a short statement (10 pages maximum) BY MARCH 15, 1995, detailing their interest and ability to enter into a collaborative relationship with a CEE partner hospital under the AIHA model (A formal grant application is not necessary). The statement should describe the institution's resources commitment to the partnership program, strengths of the institution that enhance its ability to address the needs of the CEE partner. Working with USAID and an outside advisory panel, AIHA will select the institution or group of institutions which best match the needs of each CEE partner, and offer the greatest potential for sustaining a partnership beyond the availability of AIHA funding.

Statements should be directed to:

Donn Rubin Program Director, Central & Eastern Europe American International Health Alliance, Inc. 1212 New York, Avenue, NW, Suite 750 Washington, DC 20005

For more detailed information contact Donn Rubin, or Christina Patterson, Program Analyst Tel: (202) 789-1136; Fax: (202) 789-1277.

Postdoctoral Fellow Position

Postdoctoral Fellow (Increasing carotenoid bioavailability),

Graduate School for Advanced Studies in Nutrition, Food Technology, Agrobiotechnology and Health Sciences (VLAG)

Professor A.G.J. Voragen of the Department of Food Science and Technology and Professor C.E. West of the Department of Human Nutrition of Wageningen Agricultural University have been awarded a grant by the Graduate School VLAG in order to appoint a Postdoctoral Fellow. The task of the Fellow will be to examine ways of increasing the bioavailability of carotenoids from plant sources.

Qualifications: Applicants should have a PhD degree (or expected before 30 September 1995). They should not be Dutch citizens or permanent residents of the Netherlands. Candidates should have strong background in food technology and/or chemistry and an interest in human nutrition. Basic knowledge and experience in a range of analytical techniques such as HPLC is essential.

Conditions: The position is for one year and cannot be extended. The fellowship must be taken up before 1 October 1995. The stipend is Dfl 2500 per month tax free and the Fellow must arrange health insurance either before taking up the position or immediately on arrival at Wageningen. The Fellow will work jointly in the Departments of Food Science and of Human Nutrition of Wageningen Agricultural University.

Applications should be sent before 15 March 1995 to:

Professor C.E. West Department of Human Nutrition Wageningen Agricultural University P.O. Box 8129, 6700 EV Wageningen, The Netherlands.

Applications should include a curriculum vitae, copies of the three most relevant publications an names of two or three referees. A decision will be made no later than 20 April 1995. For more information: fax (+31-8370-83342) or e-mail: clive.west@et3.voed.wau.nly

· JSI subscribers: To resubscribe PHNFLASH under your new e-mail address and unsubscribe PHNFLASH your old e-mail address, please send the following two messages (separately) to:

1) subscribe-PHNFLASH new-email-address first-name last-name e.g. subscribe-PHNFLASH Claudia Chesneau

2) unsubscribe-PHNFLASH old-email-address eg. unsubscribe-PHNFLASH


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...
· Bank's Activities in Copenhagen
· APLIC Conference Announcement on HIV/AIDS: Global Information Resources

Bank's Activities in Copenhagen

The Bank delegation to the World Summit for Social Development (WSSD), better known as the Social Summit includes: Mr. Sven Sandstrom, Managing Director (EXC), Mr. Armeane Choksi, Vice President of Human Resources Development and Operations Policy (HROVP) and staff from the departments of Education and Social Policy (ESP), Population, Health and Nutrition (PHN), Environment-Social Policy and Resettlement (ENVSP), regional departments and the Paris Office. In Copenhagen, the Bank will carry out activities in two different fora - the Summit itself and the NGO-Forum.

At the official Summit, Mr. Sandstrom will deliver the Bank speech on March 10, followed by a press conference. At a separate press conference (March 7), Mr. Choksi and Bank staff presented the two reports prepared for the Summit entitled "Advancing Social Development" and "Investing in People".

The NGO-Forum is an event organized by NGOs that will take place from March 3-12, in parallel to the official Summit. Over 3,000 NGO-delegations and more than 10,000 people are scheduled to participate in the NGO-Forum daily. Here, the Bank will host four panel discussions: Bank-NGO Collaboration (March 4), Investing in People (March 7), The World Bank and Participation (March 8) and The Bank and the Challenge of Development (March 9).

Staff will also participate in other events in connection with the Social Summit. Among others, Oey Meesook (ESP) will give a presentation on "The Bank's New Poverty Agenda" before a meeting organized by the Danish Association of Development Researchers; and Minh Chau Nguyen (ESP) will participate in a meeting organized by the Danish Association for International Cooperation on Tough Remedies, Silent Tragedies: Women as Economic Actors.

Copies of Investing in People (stock no. 13207, $6.95) and Advancing Social Development (stock no. 13208, free) are available at the World Bank Bookstore Tel: (202) 473-3193. For a mail order copy, contact: The World Bank Bookstore 1818 H St. N. W. Department T-8051 Washington, D.C. 20433 Tel: (202)473-1155 or Fax: (202)676-0581.

HIV/AIDS: Global Information Resources

28th Annual Association for Population/Family Planning Libraries and Information Centers (APLIC) Conference

April 4-6, 1995

Hyatt Regency Embarcadero, San Francisco, CA

The APLIC - International preliminary schedule for their annual conference (held in conjunction with the Population Association of America (PAA) meetings).

Peter Way, US Census Bureau, is the keynote speaker on Tuesday April 4, followed by a speaker from the San Francisco Planned Parenthood affiliate. Networking with colleagues, business meeting and a dinner complete the day.

Jeanne La Rocco and John Watson, Centers for Disease Control (CDC) AIDS Clearinghouse will speak about the clearinghouse resources, followed by a panel discussion on the resources of the VA Medical Center AIDS Information Center, the Center for AIDS Prevention Studies and the Multi-Cultural AIDS Resource Center of California.

Susan Pasquariella, UN POPIN Global Coordinator, will demo and discuss the POPIN gopher.

APLIC will have a table exhibit during the PAA Conference and will sponsor a Video Festival of new films on Thursday April 6.

For information or a registration form, please contact Conference Chair:

Debbie Bauer, Planned Parenthood of Minnesota
1200 Lagoon Avenue South
Minneapolis, MN 55408 USA
TEL: 612-823-6568
FAX: 612-825-3522


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Economic Reform and Investment in People: The Keys to Development
· International Conference on Health and Communication in the Americas, Toronto, Canada

Economic reform and investment in people:

Speech by Mr. Sven Sandstrom, Managing Director, The World Bank Group at the Social Summit, Copenhagen, Denmark, March 10, 1995

Introduction: Development and People

Development is all about people. By that criterion, the development effort of the last generation has been a remarkable success; there has been more progress for more people than at any time in history. Since 1960, average life expectancy in the developing countries has increased by about twenty years; adult literacy has risen from around 40 percent to near 70 percent; and the share of households with access to clean water has more than doubled. Average per capita incomes in the poor countries also have doubled. In some East Asian nations, they have quintupled. More and more developing countries have become integrated into the global economy and many have joined the ranks of "emerging markets." A billion workers have been added to the world's labor force. All this has enabled large numbers of people to lift themselves out of poverty. Real progress can be measured in that a child born today in the developing world is half as likely to die before the age of five as a child born just a generation ago, is twice as likely to learn to read, and can expect more than twice the standard of living. >> An Enormous Challenge And yet, an enormous challenge remains. Over the past thirty years, incomes in the countries with the richest 20 percent of the world's population grew nearly three times faster than in those countries with the poorest 20 percent. And that gap is widening. Nearly eight million children die every year from diseases linked to dirty water and air pollution. Fifty million children are mentally or physically impaired due to inadequate nutrition. One hundred and thirty million children - 80 percent of them girls - are denied the chance to go to school. As our upcoming World Development Report on labor will emphasize, 140 million people are unemployed. Almost a billion people are underemployed and do not earn enough to feed their families. And three billion more people will be added to global population within the next 40 years - creating an unprecedented demand for more education, health care, and jobs. Again, the real challenge facing us can be measured in that a child born today in one of the poorest countries is more likely to be malnourished than to go to primary school, and as likely to die before the age of five as enter secondary school. >> Social Development and the Bank We have learned a lot about how we can help to improve the quality of life for that child.

· About promoting open markets and growing economies to provide people with jobs and incomes - and governments with resources for social investment;

· and about education, health, nutrition, and family planning to underpin growth - and help as many people as possible to share in it. Both sound economic policies and investment in people are essential: for poverty reduction, employment growth, and social progress. The Copenhagen Declaration recognizes this, just as we all recognize that social investment is not only good for human well-being, it is good economics. Education, for example, is critical to build a modern, market-based economy and to raise living standards. Most of the rapidly growing East Asian nations have achieved universal primary education; average wages for their workers have risen two-and-a-half times in real terms over the last thirty years; and during that same period, the region has achieved the fastest rate of poverty reduction in history. In Sub-Saharan Africa, by contrast, almost a third of all children still do not go to primary school; workers' wages have been stagnant over the last three decades; and, in many parts of the region, poverty is increasing. The lesson is clear: if countries do not educate their children, they cannot compete in the global economy, they will not overcome poverty, and real development will remain unattainable. Education and other social investments reinforce each other. Early childhood programs enhance the effectiveness of primary and secondary education, which brings about improved health and increased incomes. These gains then boost productivity and, ultimately, lower the cost of providing basic social services. Girls with more education grow up to be women who have fewer and healthier babies, make more informed choices about caring for their families and environment, and become more skilled workers. That is why getting more girls into school is the most effective investment in the world today. It is also one of the best ways to transform the vicious circle of economic decline and poverty into a virtuous circle of growth and opportunity. Helping to create these virtuous circles is at the core of the World Bank's work. This is reflected in our support for agriculture, infrastructure, and policy reforms to help open up markets, strengthen economies, and create jobs. It is also reflected in our increasing emphasis on investment in people. Over the last three decades, the Bank has lent nearly $30 billion to 110 countries for education, health, population, and nutrition. Over the last decade, our support for human resource development has increased five-fold to an annual average of over $3 billion. At a time when official aid flows are not increasing, the Bank's ability to borrow on the capital markets and thus fund investment in people is becoming all the more important. The Bank today is the largest external financier of developing countries' investment in education, health, nutrition, and AIDS prevention. It is also a leading investor in early childhood development, family planning, water and sanitation, and environmental protection. And our country assistance plans call for more: about $15 billion for human resource development over the next 3 years - some 50% above the level of the last 3 years. This investment translates into programs that make tangible improvements in people's lives: more education for girls in Bangladesh and Yemen; better health for mothers and children in Bolivia and Thailand; AIDS prevention in Brazil and Kenya; and protection for the unemployed in Eastern Europe and the former Soviet Union, as economic reforms lay the basis for renewed growth and employment generation. >> Social Development and Policies Social investment, in itself, is important. But by itself, it is not enough. No country has managed to raise living standards over the long term without growth. Child mortality rates in the 1980s for example, fell almost twice as much in countries where average incomes grew by more than 1% a year than in countries where growth did not occur. Moreover, the right kind of economic policies bring about a pattern of growth that attacks income inequality and creates jobs for the poor:

· Macroeconomic stability is key. We have seen how high inflation in many Latin American countries in the late 1980s and early 90s, for instance, led to a worsening of income distribution and social disintegration.

· Sectoral policies are key. Strengthening basic infrastructure, and building strong local capital markets and well-functioning labor markets.

· Agriculture, in particular, is key. Policies that fail to benefit farmers will bypass most of the poor. That is why a country like Vietnam, following the path of its East Asian neighbors, is giving priority to agriculture as it embarks on reform - with the aim of halving poverty by the turn of the century.

· Openness to trade and private investment is also key. Expanding trade means more jobs and higher incomes. In countries where trade grew faster than average over the last twenty years, average wages grew at 3% a year in real terms. Where trade did not grow, wages stagnated. From Botswana, to Chile, to Indonesia, experience shows that countries which have successfully implemented growth-oriented policies over the last decade have also been able to expand access to health and education - and increase wages and employment. But experience also tells us that if the policy fundamentals are not in place, simply pouring more money into social services will not work. There is no substitute for using public resources more efficiently and effectively. One of the most common misallocations of public resources is to give excessive emphasis to higher education at the expense of primary schooling. This is inequitable - because students in higher education typically come from the highest income groups; and it is wasteful - because the subsidies displace private spending. As a result, in some African countries, the current generation of children is likely to receive less than half the years of schooling as do those in other countries of the region, even though per capita incomes and public spending on education are about the same. A similar story can be told for health: most poor people do not have access to hospitals; yet that is where 50-70 percent of public health expenditures in developing countries go. To give an example of what can be done by focusing resources on basic health services: China spends a full percentage point of GDP less on health than other countries at the same per capita income level, but life expectancy is ten years higher. We must be clear on this point: improving the impact of social investment means increasing the share of public spending that goes to the poor. It also means more participation by the poor in the design and implementation of social programs. In the early childhood development project in India, the Philippines basic health project, the Zambia social investment fund and a growing number of other programs, Bank-supported operations are emphasizing local participation and ownership. But we recognize that this is an area where we - and most other international agencies - still have a long way to go. So do many governments. Broadening participation is essential for social development and for good governance. The involvement of independent unions and local civic associations, for example, is often key in helping to address critical ISSUEs such as eliminating discrimination at work and eradicating exploitative forms of child labor. Governance ISSUEs are becoming increasingly important in Bank-supported programs: helping governments to strengthen civil institutions and focus public spending on priorities - away from military expenditures, for example, and toward health and education. This is the case in Uganda where, over the past two years, the government has cut the size of its military force in half and increased basic social services. >> Lessons Learned and Applied We have learned that making social programs work requires careful design, strong institutional capacity, patience and commitment by governments. We have also learned that to make those programs even more effective, the international assistance effort will have to change: the current mosaic of multiple, uncoordinated initiatives is simply not good enough. Social programs must be country-driven, not donor-driven. The Bank welcomes the Copenhagen Declaration's call for coordination of assistance efforts in line with specific country needs. We also welcome initiatives to reduce the debt burdens of low-income countries engaged in economic reform - and we have flexible instruments in place to support those efforts. Sound economic policies are the starting point for sustained social progress. But we have learned that during the process of economic reform - before higher growth leads to substantial poverty reduction - vulnerable groups left out or hurt by transition must be protected. Safety nets to protect the families of laid-off workers, combined with active programs to help the unemployed find jobs, are particularly important. The Bank has worked extensively in recent years on the provision of safety nets and other special measures. But we recognize that we must do more to help our borrowers protect social expenditures during the period of economic transition; and, beyond this, to focus social spending on the poor: that means primary education, basic health care, and the early needs of children. Economic transition must not be at their expense. Helping our borrowers to protect social expenditures and focus them on the poor has already become best practice in Bank-supported reform programs: as in Guatemala, Niger and Pakistan. There, social spending was not only increased, but also reallocated toward primary health and education. The challenge now is to make this approach standard practice. >> Resources and Priorities The Copenhagen Declaration sets out a framework of commitments for advancing social development on many fronts. Implementing those commitments will require substantial resources. The World Bank will do its part. IDA's role as the linchpin for concessional financing in the poorest countries is especially vital. Given the broad consensus now on what needs to be done to accelerate social development, the international community's vigorous support for IDA-11 is critical. National governments, of course, will continue to have the main responsibility for the well-being of their people. Again, experience suggests that they can best meet that responsibility by focusing on the main priorities:

· First, economic policies that promote labor-demanding growth - jobs for the poor;

· Second, high-return investments in people: primary education, basic health, and early childhood development;

· And third, increased efficiency and accountability in the use of public resources.

>> Conclusion: Social Development and the 21st Century Social development is at the heart of how countries prepare themselves for the 21st century and a world in which computer skills will be as important as basic literacy and numeracy; a world in which rich and poor nations will be linked increasingly through trade, capital, and information flows. This rapidly changing world offers tremendous opportunities for both developing and developed countries. A quarter of developed-country exports, for example - and some 15 million jobs - are now linked to trade with the developing nations. To consolidate these mutual gains, the developing nations need growing, competitive economies - and healthy, well-educated people. The World Bank has clearly demonstrated the priority it attaches to basic social investment. We have the experience and the capacity to help even more. Working with all our partners, we are ready to do it.

International conference on health and communication in the AMERICAS

March 27-28, 1995
Ryerson International,
Ryerson Polytechnic, University
Toronto, Canada

For a preliminary program schedule (update) or further information contact:

Ruth Nesbitt, Ryerson International, Ryerson Polytechnic Univ.
350 Victoria Street, Toronto, Ontario, Canada, M5B 2K3
Phone: (416) 979-5026
Fax (416) 979-5352
gopher site: Distributed Learning Project menu on gopher.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· A Sound Economy and Investments in People
· HIV/AIDS Surveillance Database

A Sound Economy and Investments in People: World Bank's Social Summit Strategy

Sound economic polices and investments in people are absolutely essential for economic and social progress, according to "Advancing Social Development," a World Bank report prepared for the World Summit on Social Development in Copenhagen, March 6-12.

Economic and social development are at the core of the Bank's mandate. Share of Bank lending in people has increased from 5 percent in the early 1980s to 15 percent 1994. Currently, the Bank is the world's largest financier of investments in people, providing:

- more than $2 billion a year for education,
- over $1 billion a year for health,
- about $200 million a year for population activities, and
- nearly $200 million a year for nutrition.

Bank lending will continue to shift toward investing in people, with commitments expected to increase over the next three years. The four priorities for action are:

- investing in basic education,
- investing in basic education,
- investing in girls' education,
- investing in cost-effective health services, and
- investing in early childhood development.

The report notes that there is no blueprint for development, but investing in human capital - education, health, nutrition, and family planning - is essential for sustaining economic growth, raising living standards, and enriching people's lives. However, investments in people will not be effective unless the overall economic policy framework is conducive and supportive.

The role of governments are critical to economic and social progress. Only the governments, states Mr. Choksi, Vice President of Human Resources Development and Operations Policy, "can create an environment that allows private enterprise to flourish and makes it possible for civic society to thrive. Such an environment requires sound economic policies."

Increasingly, countries are faced with hard choices concerning the restructuring of public spending. Governments today are not channeling enough resources to the basic social services. The Bank will continue to help governments implement policy reforms and assist with social safety nets to mitigate the transition costs. Two sets of policies are needed: first, policies to maintain macroeconomic stability and price incentives, and second, structural policies aimed at removing biases against agriculture, restructuring public expenditures, building effective financial systems and breaking down barriers to informal sector activities.

The report states that the Bank will continue to build on its two main roles - lender and advisor - and that it will continue to mobilize and invest substantial resources for development. It will also pay more attention to the needs of the poor, to the allocation of public expenditure and to the environmental and social impacts of projects.

To this end, the Bank will also strengthen strategic alliances with its partners in development in:

- mobilizing greater external resources in support of economic and social development and carrying out the social development agenda agreed to at the Social Summit.

- working with governments and other agencies to support institutional development and capacity-building, including encouraging greater local involvement in Bank-supported projects.

- working with other donors to encourage micro-enterprises and promote small-scale environmental initiatives.

- working in collaboration with UN agencies and other donors to improve baseline information on poverty and to develop sustainable poverty monitoring systems to help governments assess progress in reducing poverty.

(Source: Press Release on "A Sound Economy and Investments in People: World Bank's Social Summit Strategy," Paris, February 28, 1995)

For more information, contact Klas Bergman at (202)473-3798.

HIV/AIDS surveillance database

The database is the 17th major update to the HIV/AIDS Surveillance Database, December 1994 release, compiled and maintained at the International Programs Center, Population Division, U.S. Bureau of the Census. The current update incorporates all available epidemiological information for developing countries presented at the Tenth International Conference on AIDS - International Conference on STD, Yokohama, Japan, August 1994.

Other reports available:

· Recent HIV Seroprevalence Levels by Country, Dec. 1994, Research Note 15

- updated summary tables and maps showing seroprevalence estimates for high and low risk population groups by country and region.

· Trends and Patterns of HIV/AIDS Infection in Selected Developing Countries: Country Profiles, Research Note 16

- highlights the updated and/or recent developments and emerging trends in various countries.

For copies of the above, please contact:

Karen Stanecki De Lay, Chief Health Studies Branch International Programs Center Population Division U.S. Bureau of the Census Washington, DC 20233-8860 Tel: (301)457-1406 Fax: (301)457-3034


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Good News for Nutrition
· Announcement: New and Noteworthy in Nutrition and What it Means for the Bank
· Announcement on new PHNLINK services: WWW and QCARE
· What's New in the PHNFLASH Archive?

Good News for Nutrition

An initiative that eventually could lead to a monumental turnaround in the way donor agencies and other institutions help countries improve nutrition was launched at a November conference at the Rockefeller Foundation's facility in Bellagio. The starting point for the conference was the recognition that, first, few countries had people experienced in managing, designing, and evaluating large-scale nutrition operations (although many countries do have people with graduate degrees in biochemistry and other biomedical aspects of nutrition). Second, although sizable resources go into other aspects of nutrition research, the lack of work on and answers to simple practical field problems often limit the accomplishments of existing programs. In short, there was increasing uneasiness about the disconnect between existing research and training efforts and operations. What emerged was a consensus about the need to change substantially the emphasis in research and training - to focus attention on the identification and solution of operational problems. The conferees adopted a Bellagio Declaration that spells this out, established a steering committee to shepherd the initiative, and set in motion a process designed to lead to an entity with regional orientation that will foster and finance such an approach.

(extracted from New and Noteworthy in Nutrition, vol. 25)

New and Noteworthy is available for retrieval in the archive under filename nnnvol25. Please see instructions under section "What's New in the PHNFLASH Archive?"

New and Noteworthy in Nutrition - and What it Means for the Bank

April 3, 1995
4:30 - 6:30
The World Bank 701 18th Street, NW, Washington, DC
Room JB1-080

In honor of Alan Berg, architect of much of the Bank's broad-ranging nutrition work, there will be a lively, informal discussion of what is new and noteworthy in nutrition and the related challenges for the Bank. Following observations by PHN Director, David de Ferranti, a panel of international figures in the field of nutrition will respond to a series of provocative questions: Per Pinstrup-Andersen, Director General, International Food Policy Research Institute, Jayshree Balachander, Nutritionist, Africa Technical Department, World Bank, Marcia Griffiths, President, Manoff Group, Inc., James Levinson, Professor, Tufts University, and Richard Skolnik, Division Chief, South Asia Country Department II, World Bank. A reception will follow. Please RSVP to Vincent Prosser at (202)473-4744 by noon, April 3.

New PHNLINK Services

· World Wide Web (WWW) page

Human Resources Development and Operations Policy Vice Presidency is happy to announce the establishment of a WWW service on ISSUEs in population, health and nutrition, education and social policy, operations policy, procurement policy, media and press releases, and NGO liaison. The page May be accessed via

PHNLINK is pleased to announce the reopening of QCARE, led by Willy de Geyndt and assisted by a team of regional moderators. QCARE is an electronic discussion group on improving the quality of health care services in developing countries. It is a forum to discuss and share approaches to measuring, assuring and improving the quality of care and to stimulate exchanges on the use of quality improvement tools and actions.

To subscribe to this service, send the following message: subscribe QCARE First-name Last-name


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Implementing the Cairo Agenda: What's to be Done?
· Family Planning Training for Central Asia
· What's New in the PHNFLASH Archive?

Implementing the Cairo Agenda: What's to be Done?

Now recovered from the marathon 15-day Cairo conference, donor agencies, national governments, and NGOs have been organizing to implement its 20-year action plan. In a variety of actions, these groups have been rolling up their sleeves to determine how best to build on the consensus and momentum forged in September. In defining strategies and preparing implementation plans, they struggle with how to move from demographic targets to reproductive health goals, how to strengthen family planning and other reproductive health services and ensure their complementarity, and how to increase support to broader social sector goals, and especially women's education and empowerment.

Bank staff have been active participants in many of the meetings and brainstorming sessions taking place at international agencies. For instance, the Development Assistance Committee of the Organization for Economic Cooperation and Development (OECD/DAC) met in November to ponder ISSUEs of donor coordination and resource mobilization. Similarly, the Standing Committee of the World Health Organization's Special Program on Human Reproduction (WHO/HRP) wrestled with these ISSUEs at a December meeting. A draft statement on Who's approach to reproductive health provides a review of WHO actions in the field to date, and a strategic framework for future action.

Of interest is the division of labor between the many divisions within WHO that address ISSUEs of reproductive health. Also in December, UNFPA hosted an expert consultation on reproductive health and family planning to gather feedback on its plans for new directions. Following the Cairo mandate, UNFPA is planning to broaden its strategy and scope to include aspects of reproductive health beyond family planning, such as maternal care, management of reproductive tract infections (RTIs), etc. UNFPA's next steps will focus on helping governments to formulate integrated national plans and put them into action.

Bank staff had their own brainstorming session in December, in the form of a seminar entitled "Implementing the Reproductive Health Approach in Population/Family Planning Programs." The agenda included a mix of technical sessions, case studies of Bank projects, and discussion sessions. In some ways, the Bank's general focus on the health sector as a whole facilitates implementation of the reproductive-health approach. However, the technical challenges of expanding specific programs areas remain. Follow-up to this session will include a series of brown-bag lunches, seminars, and retreats to facilitate technical training and exchanges of experience. Population, Health and Nutrition Department is developing a reproductive health information packet summarizing relevant research in this area for use by senior management and task managers, as well as for dissemination to external audiences.

Family Planning Training for Central Asia

Family Health International (FHI), a nonprofit research and technical assistance organization dedicated to improving reproductive health, has been awarded a contract from the United Nations Population Fund (UNFPA) to conduct training in several Central Asian republics. FHI will receive $500,000 from the UNFPA for the first year of a multi-year program in the republics of Central Asia.

Family planning training will be given to obstetricians, gynecologists and medical paraprofessionals in Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. Topics will include contraceptive safety and technology, counseling and communications. This training will coincide with the provision of contraceptive supplies (condoms, injectables, oral contraceptives and IUDs) from the UNFPA to governments in the region. FHI works worldwide to improve the quality of family planning services and to prevent sexually transmitted diseases, including AIDS. Much of its work is done in developing countries.

For more information, please contact:

Matthew Tiedemann
Program Officer
Family Health International
P.O. Box 13950
Research Triangle Park, NC 27709 U.S.A. 919-544-7040


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE ...

· Cost-Effectiveness and Health Sector Reform
· Conference: First Interamerican Forum on Cooperative Health Care and Related Services, Sao Paulo, Brazil
· What's New in the PHNFLASH Archive?
· Announcement: Public Health Research Training Grants

Cost Effectiveness and Health Sector Reform

The World Bank's 1993 World Development Report (WDR): Investing in Health makes extensive use of the concept of the global burden of disease to measure the state of health of a population and, together with the related concept of cost-effectiveness, to judge which health care interventions deserve the highest priority for public action. These criteria are not always understood, in part because of uncertainty over their meaning and in part because they May appear to conflict with other criteria which are widely accepted in the health sector. By addressing the following six questions, the report seeks to clarify what the WDR has to say on the subject, and to illustrate how these ideas are relevant to health care reform:

· What does the WDR say about the burden of disease and cost effectiveness?
· How necessary is this approach?
· Is cost-effectiveness an objective measure?
· Is cost-effectiveness compatible with equity?
· Is cost-effectiveness compatible with other ethical rules?
· How can a reform be implemented to incorporate cost-effectiveness?

(The entire document is available for your retrieval under filename hrwp041. Please refer to Section on "What's New in the PHNFLASH Archive?" for retrieval instructions.)

First Interamerican Forum on Cooperative Health Care and Related Services

Sao Paulo, Brazil
June 12-14, 1995

The International Cooperative Alliance (ICA), together with Unimed do Brasil, a cooperative organization with over 72,000 physicians members serving 9 million Brazilians nationwide, is hosting the First Interamerican Forum on Cooperative Health Care and Related Services. The Forum will be held in Sao Paulo, Brazil, on June 12 to 14, 1995 and is expected to attract over 200 delegates.

The conference will focus on the Health Care sector and the potential contribution of cooperatives and similar organizations in managing this complex ISSUE. The aim of the Forum is to assess ISSUEs and opportunities, share knowledge and experiences in meeting the challenge.

For more information, please contact:

Unimed do Brasil
Alameda Santos, 1827 - 15o. andar
Sao Paulo - SP - 01419-909, BRAZIL
Facsimile: ++55 11 253.6633 extension 375
(Reposted from

Public Health Research Training Grants 1995-1996

In recognition of the importance of developing the public health research capacity of individuals and institutions in Latin America and the Caribbean, the Pan American Health Organization (PAHO/WHO) and the International Development Research Centre (IDRC) of Canada announce the 1995-96 Public Health Research Training Grants.

The initiative proposes to train leaders in public health research by offering them the opportunity to acquire advanced training in this field as well as the possibility to receive additional funding for the implementation of a research project. Given its focus on applied research and on the strengthening of research institutions as well as individuals, the initiative strives to positively impact the decision making process of countries in the region, thereby contributing towards the health of their populations.

Candidates should be residents of Latin America or the Caribbean with a Master's degree in any area related to public health research, and have a solid foundation in research and a demonstrated capacity for leadership. The candidate must be affiliated with a recognized research institution in his or her country of residence and have a research proposal endorsed by that institution.

The deadline for submission of applications is June 15, 1995.

For additional information (available in English and Spanish), please contact the PAHO/WHO Office in your country or:

Public Health Research Training Grants
Pan American Health Organization (PAHO/WHO)
525 23rd Street, N.W., HSP/HSR Room 627
Washington, DC 20037
Tel: (202) 861-3283
Fax: (202) 223-5871


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Egypt: Recent Changes in Population Growth, Their Causes and Consequences
· What's New in the PHNFLASH Archive?
· On the Internet: Population Index on-line
· Health Economist Vacancies - Liverpool School of Tropical Medicine

Egypt: Recent Changes in Population Growth, Their Causes and Consequences

This paper will examine the determinants and consequences of population growth in Egypt in the recent past and the near future. Since slowing the growth rate of population has long been an objective of Egyptian government policy, it also contains policy recommendations for minimizing growth. Egypt has one of the largest populations in the Middle East. It has increased by almost six times in the last century and three times since 1950. Even under the best case scenario, it will increase from about 58 million currently to 90 million in 2035. If a fast fertility decline is not achieved, it could easily reach 103 million by that time.

Data on migration are so unreliable and the prospects for migration to relieve population pressures are so uncertain that this paper concentrates on changes in mortality and fertility. Life expectancies have increased by about 20 years on average for Egyptian men and women since 1950. Since the late 1970s, infant and child mortality have fallen by 55 percent. These recent reductions have resulted from reductions in fertility, improvements in immunization, and general improvements in living standards. There remain, however, substantial socio-economic inequalities in mortality levels and recent economic stagnation have probably accentuated these.

Fertility rates have fallen erratically since the 1960s, but since the mid 1980s, this decline has accelerated dramatically. These declines have resulted from increases in the age of marriage and, more importantly, earlier reductions in the desired family size which have translated, after a lag, into increases in contraceptive use. Underlying these changes have been mortality reductions which reduce the number of children that parents think they need to have, improvements in education of parents and, recently, improvements in access to contraception, particularly IUDs, through both the public and private sectors. To continue this trend in fertility reduction, it will be necessary to improve the education of rural girls and to make further improvements in the family planning program. It will not be easy to expand education to girls in rural areas, especially in Upper Egypt, but it is necessary. There are three primary factors that are essential to improve the use and effectiveness of contraception: (i) counseling of women needs to be improved so that they know the proper use of methods and the alternative methods available when a method proves unsuitable; (ii) the range of methods available must be increased to include methods compatible with breastfeeding for women who object to IUDs and coital-related contraceptives; and (iii) males must be included more extensively in IEC efforts in family planning.

Historically, Egypt has had excellent access to donor support for its family planning program. In addition, since 1984, it has had a population policy that has been very supportive of the family planning program. USAID has played a particularly valuable role in recent years in expanding the role of the private sector in the provision of family planning services. The question that Egypt faces at this point is how to make the necessary changes in the program and how to make the transition to greater financial self-sufficiency.

(Abstract from Human Resources Operations and Development Policy Working Paper no. 49)

(The entire document is available for your retrieval under filename hrwp042. Please refer to the section "What's New in the PHNFLASH Archive?" for retrieval instructions.)

What's on the Internet?

Two volumes of the widely respected quarterly demographic bibliography Population Index are now available on the World Wide Web. The full contents of all 1993 and 1994 ISSUEs (Volumes 59 and 60) are available from our new Web site. Each ISSUE is indexed geographically and by author. A comprehensive author index to all 1993-1994 ISSUEs is also provided. Point your Web browser to the following URL:

Unrestricted access to these on-line volumes will be available at no charge through June 1995.

All records from 1986 onwards will eventually be available in the same format, accompanied by more sophisticated indexes and search capabilities, at reasonable individual and/or institutional rates. The editors hope you find our new service useful, and welcome your comments. Send mail to:

(reposted from

Health Economist Vacancies

The Liverpool School of Tropical Medicine is an international postgraduate centre of excellence in tropical medicine and public health, working collaboratively with Ministries, Universities, multilateral agencies and non-government organizations worldwide. The School is expanding its work in health services in developing countries and has support to develop a program of research and training in health economics in a friendly academic environment. Applications are invited for:

· Senior lecturer/lecturer in health economics to co-ordinate the disciplinary development; applicants should have a degree in economics, and a PhD or equivalent in published research, and have experience working in financing and economics in developing countries. This is a School contract for an initial period of 5 years on the lecturer scale (14,756 -30,533 pounds)

· Lecturer in economic evaluation to work with epidemiologists and clinicians setting up research activities related to HIV disease and malaria in developing countries in work programs supported over 5 years by the Overseas Development Administration. Economic evaluation experience required. Developing country experience not essential, but could be an advantage. This is a 3 year contract extendable annually to a maximum of 5 years (scale 14,756 - 25,735 pounds).

· Research Associate in health financing and management to be part of a 5 year research program in Health Sector Reform in developing countries. Experience of health systems (in developing countries or the UK) is essential. This is a 3 year contract extendable annually to a maximum of 5 years (scale 13,941 -20,953 pounds).

Further information is available from and applications including c.v. and the names of 3 referees should be sent to:

The Personnel Officer, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, U.K. Fax:0151-708-8733 Tel:0151-708-9393. Closing date: 7.4.95


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Incentives and Provider Payment Methods
· What's New in the PHNFLASH Archive?
· Francophone Africa Family Planning and Reproductive Health (FP/RH) Conference
· Seminar on "Setting Tomorrow's Agenda: New Directions for Health Policy in Developing Countries"
· Lecturer/Senior Lecturer in Public Health - London School of Hygiene and Tropical Medicine

Incentives and Provider Payment Methods

The mode of payment creates powerful incentives affecting provider behavior and the efficiency, equity and quality outcomes of health finance reforms. This paper examines provider incentives as well as administrative costs, and institutional conditions for successful implementation associated with provider payment alternatives. The paper focuses on payments by institutions (third parties) to providers. The alternatives considered are budget reforms, capitated payments (capitation), fee-for-service, and case-based reimbursement. The authors conclude that competition, whether through a regulated private sector or within a public system, has the potential to improve the performance of any payment method. All methods generate both adverse and beneficial incentives affecting the volume, quality and mix of services. Systems with mixed forms of provider payment can provide tradeoffs to offset the disadvantages of individual modes. The desirability of specific approach depends on the economic, social and institutional context. For example, low income countries should avoid complex payment systems requiring higher levels of institutional development.

(The entire document is available for your retrieval under filename hrwp043. Please refer to Section on "What's New in the PHNFLASH Archive?" for retrieval instructions.)

Francophone Africa Family Planning and Reproductive Health (FP/RH) Conference

At a March conference in Ouagadougou, Burkina Faso, multi-disciplinary reproductive health professionals from 10 francophone African countries drafted action plans to improve the quality of national family planning programs within their countries. Examples of proposed activities include new ways of providing FP/RH services outside health clinics and legislation that would improve the status of women, which in turn could lead to better reproductive health and greater use of family planning. Family Health International, the Program for International Training in Health, and A Johns Hopkins Program for International Education on Reproductive Health, supported the March 12-17 conference that was designed and driven by an Africa-based Technical Committee. This conference called "Increasing Access and Improving the Quality of FP/RH Services" was financially supported by the U.S. Agency for International Development. A total of 126 participants attended, including 54 delegates from Bn, Burkina Faso, Cameroon, Cd'Ivoire, Guinea, Madagascar, Mali, Niger, Senegal and Togo. Participants represented government and private organizations, religious groups, women's advocacy groups, and international donor agencies.

For more information, please contact:

Jill Gentry
Family Health International
P.O. Box 13950 Research Triangle Park, NC 27709
TEL: (919)544-7040
FAX: (919)544-7261

Setting Tomorrow's Agenda: New Directions for Health Policy in Developing Countries

Boston University - School of Public Health Seminar
Sept 15 - Oct 6, 1995

This three-week seminar in intended for decisionmakers, senior managers, and political leaders. It will address challenges facing the health sectors of countries pursuing development in a context of declining infant mortality, aging populations, and a growing burden of chronic diseases. The seminar will focus on:

· investment choices and methods of assessing and choosing appropriate technology.

· balancing the roles of the public and private sectors as countries seek to maximize the public good.

· emerging concerns, including accidents, violence, smoking, and gender ISSUEs.

The seminar will be held at an executive conference center in Boston.

Enrollment is limited to maximize the benefit for participants.

For more information, please contact:

Center for International Health
53 Bay State Road
Boston, Massachusetts 02215
Tel: (617) 353-4524
Fax: (617) 353-6330

Lecturer/Senior Lecturer in Public Health

Health Policy Unit (HPU), London School of Hygiene and Tropical Medicine

We are seeking a public health specialist with strong interests in applied research to initiate new areas of activity within the HPU. The Unit consists of a multi- disciplinary group of staff concerned with the development and evaluation of health policy in less developed countries. You should have qualifications in a health-related subject, and relevant experience in the third world.

Further information available from the Head of Unit, Dr. Anne Mills, email, tel 44 171 927 2354, fax 44 171 637 5391.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· The Micronutrient Initiative
· TDR Programme
· What's on the Net?

The micronutrient initiative (mi)

Micronutrient deficiencies are a major impediment to the health, nutritional status and development of many of the world's population. Given the significance of the problem, The Summit for Children (1990) and the International Conference on Nutrition (1992) have jointly endorsed the goals for their elimination or significant reduction of by the year 2000.

In 1992, the MI was established to provide the impetus to strengthen, expand and accelerate operational programs to achieve the goals of the World Summit for Children:
o virtual elimination of iodine deficiency disorders
o virtual elimination of vitamin A deficiency and its consequences including blindness
o reduction of iron deficiency anemia in women by one-third of the 1990 levels.

The MI is a secretariat within the International Development Research Centre (IDRC) and co-sponsored by Canadian International Development Agency, IDRC, United Nations Childrens' Fund, United Nations Development Programme and the World Bank. It works collaboratively with other institutions in its endeavours to control micronutrient malnutrition and mobilize resources. The primary focus is sustainable interventions, with fortification of commonly eaten foods with essential micronutrients. The MI program for 1994-1997 supports five critical areas:

· Advocacy and partnership.
· Development of sustainable interventions.
· Support for effective programmatic actions.
· Capacity Building
· Resolution of key operational ISSUEs

A complete report on the MI May be retrieved from the PHNFLASH archive under filename idrc001 (Please refer to the following section for instructions).

For more information on MI, please contact:

The Executive Director, The Micronutrient Initiative, c/o International Development Research Centre 250 Albert Street, Ottawa, On K1G 3H9 Canada. Tel: 1-613-236-6163 Ext 2118; Fax: 1-613-567-4349; Internet: TGUAY@IDRC.CA

TDR program

The UNDP / World Bank / WHO Special Programme for Research and Training in Tropical Diseases (known by the acronym TDR) is an international technical cooperation programme. Established in 1975, the Special Programme has two objectives:

- to develop new methods of prevention, diagnosis, treatment and control of the major tropical diseases;

- to strengthen the capability of developing endemic countries to undertake the research on their own.

TDR's research activities are targeted towards 6 disease groups: malaria, schistosomiasis, filariasis (including onchocerciasis), trypanosomiases (African sleeping sickness, Chagas disease), leishmaniases and leprosy.

For more information on TDR, please contact TDR Communications at: or refer to the WHO Web page

What's on the Net?

TDR-SCIENTISTS List is an unmoderated electronic list open to researchers working on tropical diseases. Originally conceived to be an alternative to the quarterly TDR NEWS, it can be used as an open forum to broadcast messages.

To subscribe, or unsubscribe, send a message to:
or contact the List-owner, K.R. Hata at:


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· The Beijing Conference on Women
· What's New in the PHNFLASH Archive?
· Announcement: Primary Health Care Management Advancement Program Plenary Session

The Beijing Conference on Women

The Fourth UN World Conference on Women will be held in Beijing, China, in September 1995. Convened by the United Nations General Assembly, the Conference provides governments from around the world with the chance to assess the progress made in reducing gender inequality, as well as the chance to reaffirm their commitment to the advancement of women. The main document for the Beijing Conference is the draft Platform for Action. This concentrates on a number of "critical areas of concern" identified as obstacles to the advancement of gender equality in the world. These include poverty, the lack of access to education and health services, violence against women, economic inequality, armed conflicts, and human rights. A parallel NGO Forum will also be held in Beijing to influence the Platform for Action and highlight women's vision for equality for the 21st century.

Bank's Involvement: The World Bank has actively participated in most of the regional and international preparatory meetings for the Conference. In Beijing, the Bank will present a background paper entitled Gender and Development: Equity and Efficiency, which makes the case that inequalities between men and women in the acquisition of human capital and in their access to employment opportunities constrain society to a lower level of welfare and economic growth. The paper also calls for national action to reduce inequalities between women and men and enhance development. In addition to the paper, the Bank will disseminate three documents in Beijing: (i) the Bank's gender policy paper entitled "Enhancing Women's Participation in Economic Development"; (ii) a brief guide to gender work in the Bank; and (iii) the report "A New Agenda for Women's Health and Nutrition".

(Source: Social Summit Newsletter vol.1 no. 3).

Please refer inquiries regarding the Bank's participation in the Beijing Conference to Paola Cesarini by email:

Primary Health Care Management Advancement Program (MAP) Plenary Session

George Washington University (GWU), Colonial Commons
2nd floor, Marvin Center
800 21st Street, NW, Washington, DC

This conference is cosponsored by the GWU Center for International Health, Aga Khan Foundation and USAID.

Plenary Session I: May 17 (9:00-12:30)

· Keynote address by Dr. John Bryant, Emeritus Professor of Community Health Sciences at the Aga Khan University, Karachi, Pakistan on "Developing A Management Culture for Health Care Services."

· General overview of the MAP modules

· Panel Discussion on experiences from the field: NGOs, government health services and training institutions in Asia, Africa and Latin America

Plenary Session II: May 19 (1:00-3:00)

· Summary of Workshop outcomes with presentations by participants on lessons learned, key opportunities and constraints for future lessons learned, key opportunities and constraints for future application and adaptation

· Panel discussion on "Follow-up and Future Directions" by representatives from PAHO, USAID and the World Bank

Orientation Workshop on the MAP modules (May 17-19): (i) assessing information needs; (ii) assessing community health needs and coverage (iii) planning and assessing health worker activities (iv) surveillance of morbidity and mortality (v) monitoring and evaluating programs (vi) assessing the quality of service (vii) assessing the quality of management (viii) cost analysis (ix) sustainability analysis. There is a charge for the workshop but the plenary sessions are free. For more information, please contact: Hammy Aklilu at (202)994-5682 or fax:(202)994-0900.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Cervical Cancer: Promising Approaches
· What's on the Net?

Cervical Cancer: Promising Approaches

For women in the developing world, cervical cancer is the leading killer of all cancers. Annually, there at least 350,000 new cases of cervical cancer, with 80 percent from developing countries. As the incidence of HIV infection increases and as developing country populations age during the coming decades, the number of cervical cancer cases is expected to increase.

Because cervical cancer generally develops slowly and has a readily detectable and treatable precursor condition (severe dysphasia/carcinoma in situ [CIS]), it can be prevented through screening and treating women at risk. In many Western countries, invasive cervical cancer incidence and mortality has been reduced by as much as 90 percent through screening programs based on routine cytological examination of Papanicolaou (Pap) smears and treatment of precancerous conditions. However, such screening services are not always feasible in developing countries because cytology treatment and services are largely unavailable and are often costly. The author offers a more limited, feasible, and cost-effective approach which includes:

· targeting older women (age 35 and older).

· screening all at-risk women relatively infrequently (for instance, every 10 years) or even once in a lifetime.

· treating only women with severe dysphasia, based on the recognition that most mild dysphasia does not progress to more severe disease.

· using relatively inexpensive outpatient treatment techniques to eradicate cervical lesions. In settings where even limited cytology screening programs (based on Pap smears) present formidable challenges, promising alternatives include visual inspection, aided visual inspection (VA), and human papillomavirus (HIV) screening.

Through the Special Grants Program, the Bank is currently funding research on feasible cervical cancer dysphasia treatment approaches for developing countries. The study includes an inventory of current treatment practices, an assessment of training requirements and service delivery logistics, and analysis of the cost-effectiveness of various approaches.

Screening programs will be most cost-effective in regions with the highest incidence of cervical cancer, in programs targeting especially high-risk groups (women over 35 who have never had a Pap smear), and where cervical screening services are integrated with programs that have ready access to sexually active women in their thirties (for instance, surgical sterilization programs, maternal-child health clinics, and perhaps STD clinics).

Policy makers need to be aware of the problem of cervical cancer in their countries and about how feasible, public health-oriented approaches to prevention can reduce incidence and mortality.

(based on HRO Dissemination Note no. 46, March 27, 1995) The complete document May be retrieved from the PHNFLASH archive under filename hrn027. Please refer to the next section for retrieval instructions.

What's on the Net?

The following are Internet resources on the United Nations Fourth World Conference on Women:

· BEIJING95-L: a moderated discussion and information exchange dedicated to the Beijing Conference.

To subscribe, send an email message to:

In the text, type: subscribe Beijing 95-l Your-email-address

· Women who are interested in the discussions on the BEIJING 95-L list are invited to subscribe to BEIJING 95-WOMEN (a women-only discussion list) by sending an email message to:


In the text, type: subscribe Beijing 95-women Your-email-address

· An NGO electronic forum will be offered by the Association for Progressive Communications (APC) to exchange information, coordinate actions and share strategies and ideas. APC will provide technical assistance to women's groups, offer training and help establish electronic "conferences" around the 1995 conference and other women-specific topics.

For more information contact: Sally Burch, APC Women's Program Coordinator, INTERCOM/ECUANEX, Casilla 17-12-566, Quito, Ecuador. Tel: 593-2-528716. Fax: 593-2-50573. Email:


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Nutrition and Early Child Development: Into the Year 2020
· Announcement: International Symposium on Schistosomiasis, Bahia, Brazil

Nutrition and early child development: into the year 2020

Today, approximately one in every five person in the developing world is living on diets that are insufficient for maintaining a healthy life and an estimated 184 million children of preschool age is suffering from moderate forms of protein-energy malnutrition (PEM) and weigh below accepted international weight standards. The effects of persistent PEM can be devastating as evident in a study by Pelletier et al. (1994). The study of 53 countries found that PEM, even in a mild to moderate form, contributes to 56 percent of all child deaths due to its potentiating effects on childhood infectious diseases.

The International Food Policy Research Institute (IFPRI), through its "2020 Vision for Food Agriculture and the Environment" study, projected that if current trends continue, the number of children with PEM will continue to increase and peak at about 200 million by the year 2000. Despite projected declines in fertility rates, the number of affected children is expected to remain at about 200 million through 2020. However, these projections do not consider possible breakthroughs in food production or disasters such as the uncontrolled spread of AIDS. The optimistic scenario is based on the "best five year historical trends between 1975-1990; and the pessimistic scenario is based on the "worst five year historical trends" over the same period.

The best-case ("optimistic") scenario projects that by 2020, there will be 100 million preschool children with PEM and the potentiating effects of malnutrition on infectious diseases will be responsible for about 56 million child deaths. The situation is most prevalent in South Asia. Over one-half of the world's underweight children (100 million) are in India, Pakistan, Bangladesh, Nepal, Sri-Lanka and Bhutan; followed by Sub-Saharan Africa (30 million), China (24 million) and Southeast Asia (20 million).

Optimistic regional projections, show that by 2020 virtually all regions in the world will experience a decrease in the number of underweight preschool children, with the notable exception of Sub-Saharan Africa. China and Southeast Asia (Indonesia, Thailand, the Philippines, Vietnam, Malaysia, Myanmar, Laos, and Kampuchea) will likely experience the most dramatic improvements.

The policy implications are clear. Explicit programs on nutrition and early childhood development would need to increase. Several programs and policies aimed at a systematic attack on PEM have been successfully implemented in Thailand, Indonesia, Zimbabwe, Tamil Nadu in India, Costa Rica, and Chile. Increases in incomes and reductions in poverty are important, although recent experience in some countries suggests that even where there is no rapid improvement in incomes, malnutrition can be reduced by explicit programs and policies that aim at improving household access to food and health services, and improving child care practices such as optimal breastfeeding and proper infant weaning practices.

(based on HRO Dissemination Note no. 47. You May retrieve the entire document from the PHNFLASH Archive under filename hrn028. Please see next section for retrieval instructions). For further references, please contact Marito Garcia at

V International symposium on schistosomiasis

BAHIA - BRAZIL - OCTOBER 10-13, 1995

This event is sponsored by the Oswaldo Cruz Foundation from the Brazilian Ministry of Health, and coordinated by the Centro de Pesquisas Goncalo Moniz (a WHO Collaborating Center in Schistosomiasis).

Colleagues of all Brazilian states are invited to share their experiences on the epidemiology and control of schistosomiasis, as well as in the clinical, therapeutic, immunology, biochemistry, molecular biology areas and some others.

Official languages: Portuguese and English. Simultaneous translation will be available.

Conference topics: Progress towards a vaccine against schistosomiasis; cytokines : role in immunoregulation and immunopathology; and the impact of Brazilian research on the knowledge of schistosomiasis.

Round table discussion topics include immunoregulation in human and experimental schistosomiasis; host factor of susceptibility and resistance; recent contributions to human and experimental pathology in schistosomiasis; advances in clinical research and in molecular biology of schistosomiasis; control of schistosomiasis and the role of WHO collaborating centers.

For more information, please contact:

Dr. Mitermayer Galvao dos Reis
Centro de Pesquisas Goncalo Moniz - FIOCRUZ
Rua Waldemar Falcao, 121, Brotas Salvador - Bahia - Brazil
Tel.:(071)359-4320 FAX:(071)359-4295
E-mail: 40.295-001 Salvador,Bahia - Brasil -


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Community-Managed Health Care Programs in Mali
· What's New on the Net?

Community-Managed Health Care Programs In Mali

Today, one of five Malian children will die before reaching the age of five, and their life expectancy is one of the lowest in the world. To compensate for the high infant mortality, the fertility rate in Mali (seven births per woman) is one of the highest in the world. However, there is recent evidence of fertility transition and decreased mortality rates, attributable to a new and innovative approach to providing primary health care.

In December 1990, the Government of Mali, building on the Bamako Initiative, adopted a new sectoral health and population policy and a district approach to the provision of primary health care (PHC). The objective was to improve the health status of Mali's population, particularly women and children, by increasing the coverage and quality of health services, integrating family planning in primary health care services, and providing access to safe drinking water.

The project is co-financed by five donors (FAC, EU, KFW, USAID and IDA) and is also fully supported by UNICEF under parallel financing. Total project funding amounts to approximately US$105 million (including UNICEF funds and a recent addition of US$15 million by USAID for AIDS/STD prevention and family planning). The joint approach to health care financing and the high level of coordination among donors is a unique experience in the region.

A distinctive component of the project is the Community Health Center, a primary health care facility fully managed and financed by the community with support from the district health team. The project establishes a clear repartition of responsibilities between central, regional and local administrative structures and introduces competition among the Districts by setting a set of eligibility criteria for funding the districts' health development plans. A key feature of the decentralized planning process has been the high level of participation by beneficiaries in mapping health facilities and their areas of coverage, defining operation and cost recovery rules, and setting up management mechanisms run by elected committees.

In the currently operating Community Health Centers, vaccination coverage (DTCP3) has increased from an average of 40 percent to approximately 80 percent, and in some centers, contraceptive use has increased from 1 percent to 6 percent among married women of reproductive age. In addition, between 40 to 70 percent of pregnant women have had a pre-natal consultation compared to a national average of 25 percent In addition, the average cost of a prescription now varies from 600 to 1200 FCFA, well below current national averages, and within the financial reach of the majority of the population. A longitudinal study will be conducted to study the impact of the project on morbidity and mortality.

(based on HRO Dissemination Note no. 49. The complete document is available for retrieval under the filename hrn029. Please see next section for retrieval instructions)

What's New on the Net?

The Consortium for International Earth Science Information Network (CIESIN) and the World Bank are pleased to announce experimental Internet access to two major World Bank data-sets:

- Social Indicators of Development, 1994 (, and
- Trends in Developing Economies, 1994 (

A positive response to this experiment from an active user community May result in providing similar (or enhanced) Internet access to additional World Bank data-sets.

These data-sets are also search-able using CIESIN's Gateway - a distributed search and retrieval tool enabling access to a large collection of information about human interactions in the environment. For more information on the Gateway, see .

"Social Indicators of Development" contains the Bank's most detailed data collection for assessing human welfare to provide a picture of the social effects of economic development. Data are presented for more than 170 economies, on a country-by-country basis. Indicators reported include: size, growth, and structure of population; determinants of population growth (including data on fertility and infant mortality); labor force; education and illiteracy; natural resources; income and poverty; expenditure on food, housing, fuel and power, transport and communication; and investment in medical care and education. Footnotes associated with the printed data are preserved in the hypertext version so that users will be fully aware of significant nuances associated with particular indicators and countries.

"Trends in Developing Economies" (TIDE) provides brief reports on most of the World Bank's borrowing countries. This compendium of individual country economic trends complements the World Bank's World Development Report. TIDE digests information from national sources and adds staff commentary to explain recent developments for the benefits of readers who are familiar with macroeconomics but not, perhaps, with every country under review.

For further information contact:

CIESIN User Services
2250 Pierce Road
University Center, MI 48710
United States of America
telephone: +517-797-2727
facsimile: +517-797-2622

PHNFLASH 73 June 7, 1995

Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE..

· International Migration: Implications for the World Bank
· What's New in the PHNFLASH Archive?
· Vacancy Announcement: Initiatives Staff Associate, JSI Research and Training Institute

International Migration: Implications for the World Bank

International migration is receiving increasing attention within the international community. The United Nations Population Division estimates that more than 100 million people are living outside their countries of birth or citizenship. They include 36 million people in Asia, the Middle East, and North Africa; over 23 million in Eastern and Western Europe; over 20 million in the United States and Canada; 10 million in Sub-Saharan Africa; 6 million in Latin America and the Caribbean; and 4 million in Oceania. These figures include refugees (who numbered 12-13 million in the mid-1980s) as well as temporary and permanent migrants.

The report reviews recent trends in international migration; its relation to other demographic factors; and the consequences of migration. The report goes further to explore the implications of international migration for the Bank.

Many developing country governments encourage international labor migration, more often implicitly than explicitly. By providing employment for both unskilled and skilled workers, emigration offers an outlet for domestic frustrations that might otherwise present serious political problems, and can produce large inflows of valuable hard currency remittances. The consequences of international migration for development (of development on migration) in countries of origin and destination remain hotly debated.

Although international migration is not seen as a high profile matter within the Bank, it is addressed in the Bank's economic and sector work, policy dialogue, project preparation and lending. Some examples include:

· Poverty Assessment in Jordan studied the implications of in-migration and emigration in relation to poverty alleviation, labor markets, macroeconomic conditions, housing and education strategies

· A labor market study of Malaysia examined the relationship of migration to changing sectoral and skills composition of the economy, technological shifts, and Malaysia's international competitiveness. The study also examined the likely effects of alternative labor importation strategies on the adoption of technology, incomes and foreign capital inflows.

· The Bank is financing Cd'Ivoire's participation in the Network on Migrations and Urbanization in West Africa, an eight country project coordinated by the Centre for Applied Research on Population and Development (CERPOD) in Mali.

· The return of refugees and externally displaced persons to their countries of origin - is a prominent contextual factor in Bank lending for reconstruction and rehabilitation in post-conflict situations such as in Cambodia, Honduras, Mozambique, the Occupied Territories and Viet Nam.

While the report does not recommend a major migration initiative for the Bank, it does suggest some possible actions that can enhance the internal and external flow of information, to increase awareness, and to develop a critical mass of internal experience and capacity.

(based on HRO Working Paper no. 54, May 1995).

The complete document May be retrieved from the PHNFLASH archive under filename hrwp045. Please refer to the next section for retrieval instructions.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Ending Hidden Hunger-An Achievable Goal for the Year 2000
· Announcement: International Course on Food and Nutrition, the Netherlands
· New Publications

Ending Hidden Hunger- An Achievable Goal for the Year 2000

The World Health Organization (WHO) estimates that about 2 billion people, most of whom are in developing countries are at risk for iron, iodine, and vitamin A deficiencies. Ending micronutrient malnutrition is the most achievable international health goals of the decade. According to the World Bank, "No other technology offers as large an opportunity to improve such a low cost and in such a short time."

Micronutrient Malnutrition and its Consequences:

Iodine deficiency is the greatest single cause of preventable brain damage and mental retardation in the world. WHO estimates that around 1.5 billion people or one third of the world's population live in iodine deficiency environments. Deficiencies in iodine that occur later in infancy and childhood have been shown to cause mental retardation, delayed motor development, growth failure and stunting, neuromuscular disorders and speech and hearing defects. Even mild iodine deficiency has been reported to reduce intelligence quotients by 10-15 points.

Vitamin A deficiency is one of the most preventable causes of blindness. WHO reported in 1994 that 3.1 million pre-school age children had eye damage due to a vitamin A deficiency and another 227.5 million are subclinically affected at severe or moderate level. Annually, an estimated 250,000 and 500,000 pre-school children go blind from this deficiency and about two-thirds of these children die within months of going blind.

Iron deficiency is the most common nutritional disorder in the world and affects over one billion people, particularly women of reproductive age and preschool children in tropical and sub-tropical zones. The effects of this deficiency have been anemia, reduced work capacity, diminished learning ability, increased susceptibility to infection and greater risk of death associated with pregnancy and childbirth. The overall anemia prevalence for women in developing countries is estimated at 42% equivalent to over 370 million women.

Some interventions to overcome the constraints of the deficiencies include:

· Dietary diversification: Encouraging the consumption of micronutrient-rich foods, such as: dark green leafy vegetables, mangoes other carotene rich fruits.

· Food Fortification: Addition to a food of one or more nutrients absent or present only in minimal amounts.

· Pharmaceutical supplementation: Massive dosing of nutrients by mouth or by injection.

To achieve sustainable elimination of micronutrient deficiencies, programs will need to integrate interventions with social communications and focus on these activities:

1. Raise consumer demand for micronutrients from natural food, fortified food or pharmaceutical supplements.

2. Improve the effectiveness and coverage of pharmaceutical delivery systems, including exploitation of new outreach mechanisms, better logistics and improved client counseling.

3. Maximize industry compliance with fortification mandates through incentives and properly enforced regulation.

The global control of micronutrient deficiencies by the end of this decade is a realizable goal considering the many challenges that lie ahead.

(Source: Micronutrient Initiative, International Development Research Center) The complete document May be retrieved from the PHNFLASH archive under filename idrc002. Please refer to the next section for retrieval instructions.

12th International course on food and nutrition program management

Wageningen/the Netherlands
October 22- December 2, 1995

This course aims at enhancing the participants' capacities to manage programs and projects directed at improving the food and nutrition situation of population groups in all socioeconomic situations. This course is a training activity of the Sector Nutrition and Food Technology of (IAC), responsible for the International Courses on Food Science and Nutrition.

To obtain an application and get more information, please contact:

International Agricultural Center

P.O. Box 88 6700 AB Wageningen the Netherlands
Lawickse Allee 11
Applications are due before August 1, 1995

New publications

The Instituto Mexicano de Investigacie Familia y Poblacion, has recently completed the publications of 72 books in Spanish on family life and sexuality education for children from ages 2 to 12 under the title Planeando tu Vida. In addition, seven books in Spanish focusing on self esteem, communication, family, and social group, hygiene and health, decision making, ecology, and sexuality. To obtain an order form or more information about any of these publications, contact:

The Instituto Mexicano de Investigacion de Familia y Poblacion
Malaga Norte #25, Col. Insurgentes Mixcoac, Mexico D.F. 03920
Phone: 5(25) 611 58 76 or Fax: 5 (25) 563 62 39

··· The Center for Disease Control and Prevention, Division of Reproductive Health has released the following reproductive health survey reports: Jamaica, 1993 Contraceptive Prevalence Survey; Czech Republic, and 1993 Reproductive Health Survey; Ecuador, 1994 Reproductive Health Survey. Single copies are available free of charge from:

The Behavioral Epidemiology and Demographic Research Branch Division of Reproductive Health, MS K-35, Center for Disease Control and Prevention, 4770 Buford Highway, NE, Atlanta, GA 30341-3724.

(Reposted from: American Public Health Association, Population, Family Planning, and Reproductive Health Newsletter)


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE...

· Bangladesh's Family Planning Program: A Model Fighting Against the Odds
· What's on the Net?
· Vacancy Announcement: Research Technician, Colorado State University

Bangladesh's Family Planning Program: ''A Model Fighting Against The Odds''

Although Bangladesh is a country that is faced with many challenges which range from natural disasters to illiteracy; the high rate of population growth is one that is being curbed. In 1995, the total fertility rate is down to less than 4 births per woman compared to 20 years ago when it was about 7. Also, contraceptive use by women under the age of 50 rose from 3% to 45%. Erik Palstra, Population Specialist for South Asia, warns "We must be careful about applauding the program now in such a way that we have no eye for what's going to happen. Most people are below the age of 16 and they have not yet entered the reproductive pool. The figures force us to continue to address the population challenge and not sit down and relax."

Bangladesh's Family Planning Program achieved the above results by building health and family welfare clinics all over the country; training over 35,000 female workers to take family planning advice directly to the people's doorsteps; and by using mass media campaigns which generated awareness about family planning. Bangladesh can attribute its successes to the strong political commitment from its government; the tailor-made program which provides a door step approach; a strong working collaboration with NGO's and coordinated assistance from donors. Although these are promising results, challenges are constantly impeding on the program.

One major challenge for the Family Planning Program has been the high rates of maternal mortality. It is estimated that over 28,000 Bangladesh mothers die during childbirth each year and over 375,000 become debilitated. According to a United Nations Development Program Report, 27% of all female deaths are related to pregnancy. These alarming figures have created concern about the strategic implementation of the pre- and neonatal services that are provided. Decreasing this figure is a major challenge that is being undertaken by the 4th Population and Health Project, a Consortium of 10 donors led by the World Bank.

A sector study in Bangladesh, "The Determinants of Reproductive Change", found that none of the socioeconomic factors traditionally associated were significant in explaining fertility decline. The country's overall economic portrait has neither improved nor worsened, and was not shown to have affected fertility rates. Despite recent improvements in women's autonomy and the trend towards delayed marriages, the social structure continues to be conservative, favoring males over females, restricting the opportunities of women, and relying on adult sons to take care of their aging parents. Children continue to play a critical social and economic role. In addition, child mortality is declining only gradually. What socioeconomic changes there have been are too recent to have had any significant effect on fertility reduction in Bangladesh.

Bangladesh's Family Planning Program is an investment in the future and a fundamental aspect of all human resource development programs. But the reality of the population growth is still evident. Palstra says, "Even under the most optimistic conditions of fertility decline the population will probably reach around 150 million by the year 2010. These expected population figures confirm that we should further and faster reduce fertility. It is already difficult to imagine a social economic scenario that can sustain the current population, let alone the expected substantial increases."

Overall, Bangladesh's program has shown encouraging results, but challenges like the stabilization of maternal mortality, the need to improve the quality of care, and reduce program costs are constant reminders of the tasks to be completed. Much more work is needed to fully implement a successful Family Planning Program which will further reduce population growth and decrease maternal mortality in Bangladesh.

News release

Conference on "Combating Emerging Infectious Diseases: Challenges for the Americas"
June 14-15, Pan American Health Organization
Washington, 15 June 1995

An international group of experts on new and emerging infectious diseases today concluded that early warning of, and rapid response to infectious disease threats is needed, and recommended better surveillance, improved communications, more research, and more resources for health systems in developing countries. The group, noted that an increasing number of new, emerging, and re-emerging infections and infectious diseases have been identified in both developed and developing nations and they threaten to increase in the near future. The conference, was designed to shape a regional strategy for the prevention and control of emerging infectious diseases which could pose serious threats to the peoples of the Americas. The complete document May be retrieved from the PHNFLASH archive:

Filename Title
Early Warning Against New Diseases Needed, Experts Say
To retrieve this document, send the following message:
get-PHNFLASH filename
e.g. get-PHNFLASH paho001
to: (World Bank staff May send message to: @list)

Note: Do not add period, quotes, or brackets around the filename and request one article per message. Filenames must be in lowercase letters. Only subscribers have access to the archive.

If you receive any error messages while attempting to retrieve articles, send a message to: (World Bank staff, send message to: PHNLINK via All-in-1).

If you are not a subscriber but wish to receive PHNFLASH, send the message:
subscribe-PHNFLASH email address Your-First-name Your-Last-name
e.g. subscribe-PHNFLASH Jane Doe
to: (World Bank staff May send message to: @list). If you received an error message, send a message to:

HEALTH-GIS is a "new" electronic discussion forum on Geographic Information Systems a section of the Division of Control of Tropical Diseases, World Health Organization, Geneva. Discussion is bilingual in French and English.

HEALTH-GIS is for anyone interested in the application of GIS for health. The objective is to promote exchange of information regarding projects, methodologies, partners in countries, availability of databases, maps, software, sources of finances, etc. You can SUBSCRIBE by sending the following message to: subscribe health-gis your-first-name your-last-name

For more information, please contact:


Division of Control of Tropical Diseases World Health Organization 20 Avenue Appia, 1211 Geneva 27, Switzerland

Tel: +41.22.791 3861/3898, fax: +41.22.791 48 69, email:
Job Announcement Environmental Health Advanced Systems Laboratory Colorado State University


Part-time, non-tenured position.

Expertise: In GIS, Remote Sensing Classification, computer programming. Experience/knowledge of spatial analysis, risk assessment, simulation modeling and/or epidemiology.

The candidate would be working on an assortment of funded projects in risk assessment and environmental health applications of spatial analysis + assistant teaching. Salary $25-$30K + incentives/benefits dependent on qualifications and experience.

Start date negotiable, preferably. before/on July 15, 1995. Guaranteed salary for 2 years with potential extension to 5 yrs+.

Contact J.Nuckols, ATTN: TECH POSITION, B120 Microbiology Bldg., Colorado State University, Fort Collins, Colorado 80523 ph (970)491-7295
Closing date 7/1/95.


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE:

· Swimming Against the Tide: Strategies for Improving Equity in Health
· Conference Announcement: USAID HIV/AIDS Prevention, Washington, D.C.
· Improving Health Care Management: A Workshop on PHC MAP
· Vacancy Announcement: Russian Speaking Program Associate

Swimming Against the Tide: Strategies for Improving Equity Health

The evidence shows that government spending for health in many developing countries benefits the well-to-do more than the poor. However, a combination of favorable political forces and sound public policies can shift the focus of government expenditures toward the poor. Doing this is an essential part of any effective poverty reduction program in developing countries.

The better-off gain disproportionately in part because most public spending goes toward curative, high-cost hospital care in urban areas, where income is usually above average and where the wealthy have better access to care. In addition, health care subsidies for the middle classes, in the form of tax relief and government transfers to social security-based health insurance, skew total public expenditure further toward the better-off. This inequity can be understood in the context of "public choice" theory: politicians and bureaucrats seek not to optimize economic efficiency, but instead to maximize their chances of getting re-elected or staying employed.

This paper suggests that to implement health policies that favor the poor, it is necessary to "swim against the tide." Costa Rica, Korea, Malaysia and Zimbabwe provide examples of success stories with lessons for other countries. High and sustained economic growth has set the stage for redistributive health spending. So have pro-poor political forces. In Zimbabwe, for example, these forces were represented in post-independence groups eager to redress earlier discrimination. In Korea, it was a modernizing authoritarian regime in search of greater legitimacy.

In political environments like these, pro-equity governments have reduced, eliminated or avoided health care subsidies that blatantly or covertly favored the better-off. Public spending has been targeted toward initiatives serving primarily the poor, such as rural health facilities and basic primary and preventive care. In middle-income countries like Costa Rica, Korea and, to a certain extent, Chile, increased public spending has universalized health insurance. In these circumstances, general tax revenues have come to subsidize insurance for the poor more than for the middle class.

The authors argue that donor involvement can help to implement policies and programs to improve equity in health. They also advocate expanded donor backing for applied research to measure existing inequalities and to analyze the political dynamics behind the distribution of public resources for health.

(Abstract from Human Resources Development & Operations Policy Working Paper No. 55)

The complete document May be retrieved from the PHNFLASH archive under filename hrwp046 Please refer to the next section for retrieval instructions.

3rd USAID HIV/AIDS Prevention Conference

August 7-9 1995
Renaissance Hotel, Washington, D.C.

"Evolving Responses to an Evolving Epidemic", the conference program is designed to underscore the lessons learned from USAID-funded projects around the world. Topics will include: Behavior change, interventions, policy, behavioral research, and ISSUEs on sexually transmitted diseases.

There is no cost to attend the conference, however hotel, meals, and other expenses are the responsibility of the individual participants.

For more information, please contact:

AIDSCAP (AIDS Control and Prevention Project)
2101 Wilson Boulevard, #700 Mail Stop 731 Arlington, Virginia 22201 USA
Tel: (703) 516-9779 Fax: (703) 516-4489

Improving Health Care Management

A Workshop on PHC MAP

Senior international health officials gathered in Washington D.C. from May 17-19 to learn about the Primary Health Care Management Advancement Program (PHC MAP) an innovative and cost-effective method for improving health management in developing countries. The workshop was hosted jointly by Aga Khan Foundation U.S.A., USAID and the George Washington University Center for International Health.

PHC MAP is a series of training modules that assist local health care management teams to collect, process and analyze management information. In the context of health reform, PHC MAP is a tool which supports the current trend toward localized decision-making, shifting responsibility away from central government to local managers and communities. Through MAP training, local health teams, community organizations and people learn to determine investment priorities and monitor and evaluate progress toward better health.

In his keynote address, Dr. John Bryant, Emeritus Professor of Community Health Sciences at Aga Khan University noted the importance of MAP management training in the promotion of sustainable health systems. The PHC MAP series has been applied in areas as diverse as urban squatter settlements in Bangladesh and inner city clinics in Washington D.C. Widespread dissemination of these materials and sharing of experiences are now available on the Internet.

To subscribe send an e-mail message to: LISTSERV@GWUVM.GWU.EDU For the message type: SUBSCRIBE INTERMAP

For further information contact: Anne LaFond, Program Officer Aga Khan Foundation Phone:(202) 293-2537 e-mail:


National Public Health and Hospital, Alexandria, VA

· Russian Speaking Program Associate with a specialization in health care and family planning·
Responsibilities: Monitoring the technical assistance of the family planning program in Russia.

· Implementing and analyzing program activities
· Drafting and translating project related correspondence
· Acting as the liaison within the region
· Providing on-site technical assistance in the field

Based in Alexandria, Virginia and May involve 30% regional travel in Russia. Salary: About 24K

Interested persons May e-mail or fax resumes to:

Fax: (703) 528-1477


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE:

· A Successful Approach to Participation: The World Bank's Relationship with South Africa
· International Health Training Program (PAHO)
· Research Training Grants Award-Sponsored by World Bank, UNDP, WHO
· 1995 World Health Report
· A Successful Approach to Participation: The World Bank's Relationship with South Africa

A Successful Approach to Participation: The World Bank's Relationship with South Africa

When the Bank began to re-establish formal relations with South Africa around 1990, its image in the country was very negative. Politicians, academics and even some business groups perceived the Bank as an inflexible, authoritarian sponsor of failed economic policies. By contrast, when the government headed by Nelson Mandela was inaugurated in 1994, the Bank was perceived as a flexible institution capable of effectively addressing the country's specific economic and social problems. The change had been so dramatic that Prof. Francis Wilson, a leading South African academic and authority on poverty, stated at a NGO conference in Washington, D.C. in 1994 that "The World Bank's experience in South Africa during the past three years should be considered a landmark in that institution's evolution."

This paper documents the approach that the Bank adopted in South Africa to change its image and lay the basis for a fruitful working relationship in a sensitive political context. Some of the characteristics of the approach were the inclusiveness of the Bank's approach, which sought to touch base with a wide circle of constituencies; the transparency of its objectives; the strong participation of South Africans in its work; and an adjustment of its internal procedures with a view to streamlining them and accentuating their client orientation.

(Abstract from Human Resources Development & Operations Policy Working Paper No. 57)

Training program in international health 1996

PAHO, Washington D.C.

The Pan American Health Organization (PAHO) is inviting interested health professionals of the countries of the Americas to apply to the 1996 Training Program in International Health. The Program's goal is to promote leadership in public health by enabling participants to develop a broader vision of international and regional health trends, and a more profound understanding of technical cooperation in this field.

The learning process is based on a work-study format and takes place primarily at PAHO headquarters in Washington, D.C., but entails visits to PAHO member countries to either observe or provide direct support to specific projects.

The Training Program in International Health begins in mid-January and ends in mid-December. Participants receive a stipend of US$1,900.00 per month to cover basic living costs. In addition, each resident is provided with a round-trip air ticket from his or her country of residence to Washington, D.C. and basic health insurance.

To qualify for the Program, candidates must:

- have a master's degree in Public Health or an equivalent graduate degree, including the social sciences as applied to health;

- have a minimum of two years experience in directing programs, projects or services; in education; or in health research;

- be thirty five years of age or less;

- be a resident of one of the PAHO member countries;

- be fluent in English with a working knowledge of Spanish.

To obtain an application and information packet, interested individuals should contact the PAHO/WHO Office in one of the member countries or direct their request to:

Training Program in International Health Human Resources Development Program Division of Health Systems and Services Development Pan American Health Organization 525 Twenty-Third Street, N.W. Washington D.C. 20037-2895 Telephone: (202) 861-3296 Fax: (202) 861-8486

The deadline for accepting applications is 15 September, 1995

Award for research training grants

Sponsored by: UNDP, World Bank, WHO
Program for Research and Training in Tropical Diseases (TDR)

TDR has two closely interrelated objectives: to support the research and development of tools for the control, prevention, and treatment of its six target diseases: malaria, leprosy, leishmaniasis, trypanosomiasis, and Chagas disease and to strengthen the capability of developing countries to create such tools themselves.

TDR invites applications for such grants from disease endemic country nationals whose research is related to one or more of the targeted diseases. Support is offered for acquiring research skills in one or more of these diseases or in a related discipline such as molecular and cell biology, immunology, parasitology, epidemiology, clinical pharmacology, synthetic chemistry, social sciences, health economics, health education, and communication.

Preference will be given to applicants:

· from the least developed countries, particularly those targeted for intensified TDR support for capacity building during the next 2-3 years, which include Benin, Burkina Faso, Cambodia, Guinea, Haiti, Laos, Mali, Nepal, Nicaragua, Niger, Sudan, Uganda, Viet Nam and Yemen;

· working in Ministries of Health and involved in planning, executing and evaluating disease control programs related to TDR target diseases;

· currently involved in, or with past experience of working with, a TDR-funded project;

· seeking support for training in epidemiology, social sciences, health education and communication, health economics or in the conduct of health intervention related research.

For more information, please contact:

Dr. J. A. Hashmi Special Program for Research and Training in Tropical Diseases (TDR) World Health Organization 1211 Geneva 27, Switzerland Telephone: (41-22) 791-3805 Fax: (41-22) 791-4854 Email:

Note: All applications must be received by 30 November, 1995

1995 World health report


A new annual publication designed to provide an accurate profile of world health in a useful, easily understood way is being released by the World Health Organization. World Health Report 1995: Bridging the Gaps (WHR 1995) provides an assessment of world health priorities and trends.

The report is aimed at non-medical professionals, including development planners, policy makers, international funding organizations, donor institutions, and the educated public. Written in a reader-friendly style, WHR 95 is about 110 pages long and includes a 12-page executive summary.

For further information, contact: Mr. M.A. Subramanian, WHO, Geneva Tel: (41-22) 791-2370


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE:

· Learning from Experience: India's Fourth Population Project
· What's on the Net?
· Call for Abstracts: "Virtual Elimination of Vitamin A Deficiency"
· Vacancy Announcement: Tulane University Center for International Development
· PHNFLASH Subscribers: Information Requested

Learning From Experience: India Fourth Population Project

During the past 25 years, the World Bank has been involved in many health projects in India, including child survival, maternal and child health, HIV/AIDS control, and numerous population projects. A recent project completion report looks at the outcomes and lessons learned from the Fourth Population Project. Approved in FY85, the $51 million credit from the International Development Association (IDA) supported the family welfare program in West Bengal.

According to the report, which provides a refreshingly honest review of both Bank and borrower performance, the "project's objectives were by and large achieved." These goals included increasing contraceptive prevalence, increasing the use of temporary methods among family planning clients, increasing the percent of births attended by trained personnel, and increasing antenatal and immunization coverage.

In looking at project experience, the report found the appointment of senior project coordinators to be a key element of success. One troubling aspect of the project -which included service delivery, IEC, and training activities - is an uncertainty over sustainability, given limited state finances.

The report recommends that future projects address policy ISSUEs at the federal level in addition to supporting family welfare programs at the state level. The Child Survival and Safe Motherhood project follows this approach, and similar efforts are underway in family planning and reproductive health.

(extracted from Population Network News No.11, Spring 1995)

What is New On the Net?

ProMED, the Program for Monitoring Emerging Diseases is co-sponsored by the World Health Organization and the Federation of American Scientists. A central goal of ProMED is to establish a direct partnership among scientists concerned with emerging infectious diseases in all parts of the world; building the appropriate networks to encourage communicating and sharing information is a key objective. In cooperation with Satel-Life/Health-Net, ProMED has inaugurated an E-mail conference system on the Internet, to encourage timely information sharing and discussion on emerging disease problems worldwide.

To subscribe to the ProMED electronic conference (which is moderated), send an E-mail message to:

In the text, type: subscribe promed

For further information on ProMED:

Dr. Stephen S. Morse, Chair, ProMED Rockefeller University 1230 York Avenue, Box 120 New York, NY 10021-6399 E-mail:

For questions on the ProMED electronic network:

Dr. Jack Woodall, ProMED List Moderator NYS Department of Health Albany, NY 12201 ·

Call for abstracts

"Virtual Elimination of Vitamin A Deficiency: Obstacles and Solutions for the Year 2000"

The International Vitamin A Consultative Group is calling for abstracts for their XVII Meeting in Guatemala from March 18-22, 1996 on "Virtual Elimination of Vitamin A Deficiency: Obstacles and Solutions for the Year 2000"

Abstracts will be selected from the following topics:

· Population assessment of vitamin A deficiency and marginal vitamin A deficiency
· Biologic significance of vitamin A deficiency and marginal vitamin A deficiency
· Appropriate interventions, especially food-based approaches and highlighting food fortification

To receive a copy of the abstract form or other information about the XVII IVACG meeting, please contact:

International Life Sciences Institute Research Foundation at: Tel:(202) 659-9024; Fax:(202) 659-3617 e-mail: Only abstracts received by July 22, 1995 will be considered.

Vacancy announcement

Tulane University
Center for International Health & Development


1. IEC Specialist for Population and MCH
2. Health Care Financing Specialist
3. Rural Integrated Services Development Specialist

Tulane University is recruiting qualified candidates to be nominated in its proposal for a USAID-funded contract to provide technical assistance to the Government of Niger through an integrated population and health services development project. Interested candidates are sought for the three long term technical assistance positions listed above. Those interested must be willing to serve in Niamey, Niger for a period of at least two years beginning in early 1996.

Qualifications: The candidates for all three positions must be fluent in French, previous African experience (more than 5 years desirable), and masters degrees or equivalents in a relevant public health discipline.

For more information contact:

Dr. Nancy Mock P.O. Box 13, 1440 Canal St., Suite 2200 New Orleans, LA 70112 Tel: 504-587-7318; Fax: 504-584-3653 email:


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE:

· Suicides in Estonia: A Public Health Problem
· What's on the Net?
· Award for Regional Linkage Grants
· Vacancy Announcement: Epidemiologist

Suicides in Estonia: a public health problem

A study commissioned by the Estonia-Swedish Suicidology Institute (a WHO collaborating center) under the Population and Human Resources Development WHO collaborating center) under the Population and Human Resources Development grant concluded that, Estonia, as well as other Baltic states, is experiencing very high suicide rates. In 1994, mortality from suicides was about 40.9 per 100,000 population each year, a rise from about 27.1 per 100,000 population in 1990, the highest rate ever recorded in Estonia. The average suicide rate for European Community countries is about 13 per 100,000 population. Suicide is a significant contributor to adult mortality, which is a high priority public health problem in Estonia.

The study breaks down the suicide rate into two parts: (1) a base rate that is relatively constant over time in a given geographic region and for a given ethnic and cultural background; and, (2) a variable rate that responds to socioeconomic changes.

Between 1985-1991 suicides declined by 29 percent due to Gorbachov's strict alcohol policies, the politically more liberal perestroika and Glasnost period, and the surge of optimism among Baltic nations with the prospect of independence. The decline was followed by a sharp rise of 42 percent to higher than pre 1985 levels during the socio-economic transition period beginning in 1991.

The decline of suicide rates between 1985-1990 May indicate that base rate is considerably lower than current overall rate, and that a significant potential exists for reduction of suicide deaths in the society. An integrated multi-sectoral and multi-disciplinary approach to curb the high suicide rates includes:

1. Improving the general health and socio-economic well-being of Estonians.

2. Educating the public on risk factors, strategies for prevention, crisis management, and rehabilitation.

3. Creating a comprehensive strategy for reduction of alcohol consumption.

(Please refer any comments/questions via email to: Toomas Palu at
The abstract of the paper May be retrieved from the PHNFLASH archive under filename oth0006 Please refer to the next section for retrieval instructions.

What is New on the Net?


The NISHEALTH Bulletin is an information source related to health care and technical assistance in the New Independent States of the former Soviet Union (NIS) and the countries of Central and Eastern Europe (CEE). The Bulletin includes a listing of articles, reports, and other information made available through the NISHEALTH Clearinghouse.

The NISHEALTH Clearinghouse is not operated on a listserv. To receive the bulletin, send a written request to:

Nismedinfo project

NISMEDINFO disseminates medical and health policy information and abstracts from medical journals as well as announcements of other Internet-accessible medical resources.

Note: Membership to NISMEDINFO is restricted to health professionals from the NIS/CEE.
For more information, please contact: Ms. Kimberly Brooks at

Award for regional linkage grants

Sponsored by: UNDP, World Bank, WHO Program for Research and Training in Tropical Diseases (TDR)

TDR invites junior researchers in Latin America, South-East Asia, the Pacific Region and Africa to apply for grants enabling them to acquire graduate (M.Sc. or Ph.D.) or post-doctoral training in field or laboratory research on malaria, schistosomiasis, lymphatic filariasis, onchocerciasis, Chagas disease, leishmaniasis or leprosy. Please apply directly to the person(s) named in each of the regional linkages. Grant recipients will receive training at two or more centers participating in each of the following regional TDR networks:

Latin American Research Training Consortium

Topics: molecular entomology, vector biology and control, molecular epidemiology, immunobiology and pathogenesis, molecular genetics of virulence, disease surveillance and prevention (including geographical information systems GIS)

For information contact:

· Dr Hoomen Momen, Department of Biochemistry and Molecular Biology, Oswaldo Cruz Institute, Rio de Janeiro, Brazil [fax: 55-21/590-3495; e-mail: momen@brlncc.bitnet]

· Dr Nancy Saravia, Fundacion CEDEIM, A.A. 5390, Cali, Colombia [fax: 57-23/672-989; e-mail cideim@ujccol.bitnet]

· Dr Ulises Lopez, Institute of Biophysics, Universidade Federal de Rio de Janeiro, Brazil [fax: 55-21/265-1903]

· Dr Daniel Colley, Division of Parasitic Diseases, Centers for Disease Prevention and Control (CDC), Atlanta, Georgia [fax: 1-404/488-7794; e-mail] South-East Asian Research Training Consortium

Topics: malaria - epidemiology, immunology, health economics, treatment, clinical studies, pathogenesis and parasite biology

For information contact:

· Department of Medical Research, 5 Ziwaka Road, Yangon, Myanmar Tel: 95-1/73085; Fax: 95-1/73085

· Centre for Health Economics, Faculty of Economics, Chulalongkorn University, Bangkok 10330, Thailand Tel: 662/2186281, Fax: 662/2186279; E-mail:

· Malaria Research Unit, Department of Parasitology, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8, Sri Lanka Tel: 1-699284: Fax: 1-699284 E-mail:

Philippine Research Training Consortium

Topics: biomedical research, public health, clinical and social sciences as related to malaria, schistosomiasis, lymphatic filariasis and leprosy

For information contact:

· Dr Wilfred Tiu, College of Public Health, University of the Philippines, Manila, P.O. Box EA-460 Ermita, Manila, Philippines [tel: 63-2/596-808; fax: 63-2/521-1394]
Nigerian Research Training network

For information contact:

· Dr O. Walker, Department of Pharmacology, University of Ibidan, Ibidan, Nigeria

· Professor P.O. Okonkwo, Department of Pharmacology, University of Nigeria, Enugu, Nigeria

· Professor L. Salako, National Institute for Medical Research, 6 Edmond Crescent, P.M.B. 2013, Lagos, Yaba, Oyo State, Nigeria


· The International Agency for Research on Cancer(IARC)

· Unit of Environmental Cancer Epidemiology ·

Position: Epidemiologist

Location: Lynon, France

The IARC conducts a broad range of studies in the fields of cancer cause and prevention. The Unit of Environmental Cancer Epidemiology conducts research on the carcinogenicity of environmental agents, with special emphasis on occupational exposure, tobacco and chemotherapy drugs. Most of the projects take the form of international, collaborative cohort or case-control studies, and in many projects biomarkers are applied.


Assist the Chief of the Unit in the design, implementation and analysis of projects, such as a multicentric case-control study of genetic susceptibility to lung cancer among non-smokers, a study of second cancer following chemotherapy for Hodgkin's disease, and cohort studies of asphalt, pulp and paper and mercury workers.

Qualifications required:

Master's degree or Ph.D in epidemiology, environmental health or a related discipline. Three to five years' experience in the field of data collection, management, analysis and interpretation of epidemiological data at either the national or international level. Excellent knowledge of English, with a good working knowledge of French.

Annual salary (net of tax): US$38,291 at single rate and US$40,997 with primary dependents.

Those interested should write, enclosing a brief resume to:

Personnel Office International Agency for Research on Cancer
150 cours Albert Thomas F-69372
Lyon cedex 08
Fax: +33 72 73 85 75


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE:

· Commitments to Reproductive Health and Rights
· Parasitology Course: McGill University, Canada
· 11th Meeting of the International Society for STDs Research: New Orleans, Louisiana

Commitments to Reproductive Health and Rights

The following is a summary of the key facts about women's reproductive health and the conclusions and recommendations from the Conference on Population and Development in Cairo. This information card is produced by the World Bank, UNFPA, WHO and it will be distributed at the U.N. Conference on Women, to be held in Beijing in early September.


· 500,000 women die every year, one every minute, from pregnancy-related causes-99% of them in developing countries;

· 120 million women say they do not want to be pregnant but are not using family planning;

· 20 million unsafe abortions occur every year resulting in tens of thousands of deaths and millions of disabilities;

· more than 15 million girls aged 15 to 19 give birth every year;

· over 300 million new cases of sexually transmitted diseases (STDs) occur every year, affecting 1 of every 20 adolescents;

· by the year 2000, up to 40 million people could be HIV-infected;

Reproductive health for all by the year 2015

Reproductive health, including family planning and sexual health, through the primary health care system, should include:

· quality family planning, including a full range of contraceptives;

· maternal care, including prenatal, delivery and post-partum care, as well as essential obstetric care;

· prevention and treatment of reproductive tract infections, including STDs, prevention of HIV/AIDS, and availability of affordable condoms;

· access to quality services for the management of complications from unsafe abortion; in circumstances where abortion is not against the law, such abortion should be safe; and post-abortion family planning counseling and services;

· information, education, and counseling on human sexuality;

· and referral for these and other conditions, such as breast cancer, cancers of the reproductive system, and infertility.

Rights and responsibilities

Reproductive rights should be a fundamental basis of all programs and policies. Reproductive rights include:

· the right to freely decide the number and spacing of children, and to have the information and means to do so;

· the right to attain the highest standard of sexual and reproductive health;

· and the right to make decisions concerning reproduction free of coercion, discrimination or violence.


· Eliminate discrimination against girls and women.
· End all harmful practices, including female genital mutilation.
· Ensure quality care for victims of sexual abuse or violence.
· Provide adolescents with appropriate sexual and reproductive health information and services.
· Develop innovative sexual and reproductive health programs to reach men.


· Promote reproductive health and rights throughout national policies and programs.

· Give reproductive health high priority in national agendas and budgets. Launch education programs to increase gender sensitivity, eliminate violence against women and children, and raise awareness of sexual and reproductive health and reproductive rights.

· Empower women from a young age to exercise their rights, especially through education.

· Enable pregnant adolescents to continue their schooling.

· Improve the quality of services, including better training and interpersonal skills, availability of reliable supplies and equipment, monitoring and supervision, and expanded reproductive choices.

· Stress sensitivity to gender ISSUEs and the needs and perspectives of adolescents in the training of health care provider.

· Integrate services to maximize use of resources and improve access. Support research to improve sexual and reproductive health.


· Involve all levels of society in making reproductive health and rights for all a reality.

· Mobilize partnerships between government and civil society, including non-governmental organizations and the private sector.


In September of 1994, governments reached consensus and committed themselves to a program of action which places reproductive health and rights at the center of the population and development agenda. Implementation is the right and responsibility of each country, responsive to its national priorities, needs and cultural context. · This is also in the PHNFLASH archive under conf001

Advanced laboratory parasitology course

McGill University

The McGill University Center for Tropical Diseases, The London School of Hygiene and Tropical Medicine and Laboratories De Sant will sponsor a Parasitology course from August 21-25, 1995 at McGill University, Canada.

The course will consist of a combination of lectures and hands-on laboratory sessions to provide relevant clinical and technical information in the rapidly evolving field of Parasitology. Topics will include:

· Assessing the value of laboratory diagnostic tests and commercial kits

· Opportunistic parasites in AIDS patients

· New development for malaria detection

· The many faces of malaria

Course tuition: 600 Canadian Dollars Deadline: August 1, 1995

For more information contact:

Evelyne Kokoskin
McGill University Center for Tropical Diseases
Tel:(514) 934-8049
Fax:(514) 933-9385

11th meeting of the international society for sexually transmitted disease research

New Orleans, Louisiana August 27-30, 1995

ISSTDR's 11th annual meeting provides an opportunity for education and discussion of the latest research results relevant to all aspects of STDs. The meeting will look into the current and future state of STDs through state- of-the-art plenary sessions, which provide broad and timely summaries of recent advances in particular areas, and special symposia on recent research advances.

For registration information, please contact:
Gail Brophy (201) 947-5545; Fax:(201) 947-8406


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE:

· United Nations Conferences Find Consensus Elusive
· Material Safety Database on CD-ROM
· New Publications: Salt Iodization Manual
· United Nations Conferences Find Consensus Elusive

United Nations Conferences Find Consensus Elusive

The 1994 International Conference on Population and Development, popularly referred to as the Cairo Conference, was highly publicized for its heated debates over abortion. Acrimony and disagreement have also marred more recent U.N. conferences and their preparatory committees. The lack of agreement over some May seem to indicate troubling times for International relations, but differences in viewpoint must be expected when key social ISSUEs such as resource allocation and women's status are at ISSUE. By exposing and debating the range of opinions, the conferences have served to highlight the importance of these ISSUEs and the alternative approaches to dealing with them.

At the World Summit on Social Development that took place in Copenhagen in March, compromise and consensus were difficult to achieve. Given the broad array of items on the agenda and the distance between government delegations on traditionally divisive ISSUEs such as resource mobilization, the eventual adoption of a final declaration can be seen as a step forward in building global commitment to decreasing poverty. The final declaration includes a commitment on increasing aid for developing countries, and especially for social sectors. It also urges governments to promote full employment, gender equality, and access to education and health care services.

For three weeks in March and April, the U.N. Commission on the Status of Women served as the preparatory committee for the Fourth World Conference on Women. The Conference itself will be held in Beijing, China, next September. The PrepCom negotiated a Platform for Action to be adopted in Beijing, but failed to resolve many ISSUEs of concern to women's advocates. Despite the decision on the part of conference organizers to extend the conference an extra two days to continue discussions, large sections of the document remain in brackets and will be the subject of further negotiation in Beijing. Much of the controversial text appears in sections relating to women's health. As might be expected, phrases such as "reproductive health" and "sexuality" are bracketed. Also subject to further discussion, however, are more mundane phrases like "maternal health" and "emergency obstetrics."

Women's health is not the only area of disagreement. In fact, the PrepCom ignited in debate over the meaning of a word crucial to discussing women's role in society, "gender." A delegate from Sudan was quoted in the Washington Post as saying "We discovered that gender means something other than just men and women. It covers a whole range of meanings, including homosexuality, lesbianism, bisexuality, whatever you want." According to U.N. documents, "gender relations are the social, economic, and political relationships that determine gender identity. Gender relations shape women's access to resources and their work opportunities." Debate on the ISSUE was closed through a procedural ruling.

Additional friction was created at PrepCom by the announcement by Chinese officials that the NGO Forum to take place at the same time as the official conference will be moved to a site about 20 miles outside of Beijing. NGO leaders decried the move as limiting their access to the official conference and also raised concerns over the process by which NGOs are being accredited. It has been reported that as many as 500 NGOs have been denied accreditation by the U.N.

· Material Safety Data Sheets (MSDS) Database on CD-ROM
· Hazardous Materials Information System

A comprehensive two CD-ROM set containing fully indexed (MSDS) for over 162,000 products/chemicals. Updated quarterly. Complete with Search and Retrieve software.

·· Most Recent Edition - $98.75 US
·· Annual Subscription (4 quarterly sets) - $325.00 US

Each MSDS record contains 238 data fields within the following categories:

Standard PMS (Product Control) Identification Data; General Information; Physical/Chemical Characteristics; Fire and Explosion Hazard Data; Reactivity Data; Health Hazard Data; Precautions for Safe Handling and Use; Control Measures; Transportation Data; Disposal Data; Label Data; Ingredient Data

The MSDS CD-ROM is provided by SOLUTIONS Software Corporation and Distributed as an essential reference database for Environment, Health and Safety. The MSDS Database on CD-ROM is the largest and most comprehensive compilation available in the world.

For more information, please contact:

SOLUTIONS Software Corporation
1795 Turtle Hill Road
Enterprise, Florida 32725 USA
Tel: (407) 321-7912
Fax: (407) 323-4898

New Publications: Monitoring Universal Salt Iodization Programs

The Program Against Micronutrient Malnutrition has prepared a Salt Iodization Manual in response to a strong need in the field to establish a permanent iodized salt monitoring system. The goal of the manual is to integrate and institutionalize salt monitoring and quality assurance into the daily activity of salt producers with periodic monitoring by the government.

For more information or to obtain a copy of the manual, please contact:

International Health,
Rollins School of Public Health
Emory University
1518 Clifton Road NE, 7th Floor Atlanta, GA 30322
Tel: (404)727-5724; Fax: (404)727-4590 E-mail:
· There is no cost for the manual.

PHNFLASH 82 August 9, 1995

Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE:

· Madagascar: Increasing Food Security and Nutrition
· Grant Awards: Tropical Disease Research-Malaria
· Call for Proposals: 2nd Canadian Conference on International Health.
· Madagascar: Increasing Food Security and Nutrition

Madagascar: Increasing Food Security and Nutrition

Poverty has been increasing steadily in Madagascar since the early 1960s. In 1993, an estimated 54% of the population was living below the poverty line. The quality of basic education and health services has declined sharply. Madagascar is one of the few countries in the developing world where the younger generation is likely to have a worse educational attainment than that of its parents.

The infant mortality rate is 107 and 75 per 1000 live births respectively in the rural and urban areas. Between 45% to 49% of children are malnourished when measured by height for age or weight for age. And over 60% of the households obtain their water from easily polluted sources such as lakes, rivers and ponds while 12.5% obtain water from public taps.

The Madagascar Food Security and Nutrition (SECALINE ) Project, operational since mid-1993, is designed to address poverty, food insecurity and malnutrition in areas with a particularly high incidence of poverty.

The objectives of the project are to reduce food insecurity and malnutrition by empowering communities to help themselves. It combines a mixture of three interlinked approaches to achieving these objectives including: support for income generating activities; nutrition programs; and institutional development to increase national awareness and capacity to combat poverty, food insecurity and malnutrition.

In the first full year of operation, the project's social fund has helped create 213,000 person-days of temporary employment, financed 114 contracts with micro and small enterprises, and supported sustainable income-generating activities by 10 NGOs.

Malnutrition in target communities has fallen from 19% to 12% The iodine deficiency disorders component completed its phase of distributing iodized capsules and is now providing equipment and support to the private sector to iodize salt. An Information, Education and Communication (IEC) campaign has been launched to promote improved nutritional habits and the importance of using iodized salt.

This project's success can be attributed to: the involvement of beneficiaries at all stages; active collaboration with NGOs; and close collaboration with other donors such as Unicef, the International Labour Office ( ILO ), the World Food Programme (WFP).

In an effort to help take this success nation-wide, the Bank is assisting the government in developing two related projects, Social Fund II and Nutrition II. Again, the emphasis will be on the involvement of all stakeholders from design through implementation, which has been key to the success of this initiative and offers a concrete example to learn from in Sub-Saharan Africa.

(source: FINDINGS newsletter on the African Region no. 45)

· The complete document May be retrieved from the PHNFLASH archive under filename find001. Please refer to the next section for retrieval instructions.

Grant announcement

Tropical Disease Research Task Force on the Environment

The UNDP/World Bank/WHO Special Program for Research and Training in Tropical Diseases and the environment invites applications for grant proposals on PARASITIC DISEASES AND CHANGING LAND USE: Malaria risk in agroforestry. The Task Force is focusing its research on malaria and its link with land use changes. The following are five scientific questions considered for funding by the Task Force:

1. what is the relationship between land use changes and risk of malaria (or other tropical diseases)?

2. how can these risks be changed through land use decisions?

3. how best can land and water management interventions be implemented so as to reduce risks to health?

4. how can the health benefits and costs be quantified in economic terms so that the health effects of development are routinely considered in project appraisal?

5. how can the design of development projects be improved through understanding of the associated health benefits and costs of interventions?

Application forms are available from:

Dr. Melba Gomes
Task Force on Tropical Diseases & the Environment
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases (TDR)
World Health Organization CH-1211 Geneva 27, SWITZERLAND
Tel: 41-22-791-3813 Fax: 41-22-791- 4854 Email:
·· Deadline: September 15, 1995

Call for proposals

2nd Canadian Conference on International Health

November 12 - 15, 1995 Ottawa, Ontario, CANADA

The International Health community is invited to submit paper and workshopsymposium proposals for the Canadian Conference on International Health (CCHI), which will be held November 12-15, 1995 at the Radisson Hotel in Ottawa.

The conference theme is "Health Reform Around the Globe: Towards Equity and Sustainability?

The 1995 CCIH conference will accept paper and workshopsymposium proposals from the broad field of international health and development including social, economic, preventive, clinical and biomedical ISSUEs.

The deadline for submitting applications (proposals and funding requests) is August 15, 1995. To obtain an application package or for further information, please contact:

Deborah Shnay, Conference Coordinator
Canadian Society for International Health
170 Laurier Avenue West, Suite 902 Ottawa, Ontario, K1P 5V5 CANADA
Tel: (613) 230-2654 ext.307 Fax: (613) 230-8401
email: World Wide Web


Electronic Newsletter on Population, Health and Nutrition Issues
Population, Health and Nutrition (PHN) Department, World Bank

In this ISSUE ...

· Do Women Workers Gain or Lose During Economic Growth or Adjustment?
· Course: Modern Approaches to the Epidemiology and Control of Infectious Diseases, University of Oxford
· New Publication: Improving Feeding Practices During Childhood in Africa
· Do Women Workers Gain or Lose During Economic Growth or Adjustment?

Do Women Workers Gain or Lose During Economic Growth or Adjustment?

Do women workers in developing countries share the benefits of growth, or do they lose (more than men) during adjustment? The answers to these questions are unclear. First, macroeconomic changes affect different sectors (industries, occupations) or groups of workers (younger versus older women) differently. Second, the more generic problem of how to conceptualize and measure women's unpaid work is aggravated by a lack of reliable labor market data in developing countries.

This note which is based on a report entitled "Growth Adjustment and the Labor Market: Effects on Women Workers," summarizes the results of an analysis of changes in women's wages and employment over time in six countries in Africa, Asia and Latin America during the 1980s. Contrary to conventional wisdom, the study found that the average annual increase in female to male wages in all six countries was about one percent. The author identifies two main reasons for the increase in women's' relative wages. First, more women are successively employed in higher paying sectors, particularly in manufacturing. Second, the gender wage gap within sectors have declined.

(Source: HRO Dissemination Note No. 50) The complete document May be retrieved from the PHNFLASH archive under filename hrn031. Please refer to the next section for retrieval instructions.

New publication:

"Improving Feeding Practices During Childhood Illness and Convalescence"

This paper reviews available literature on feeding practices during childhood illness and convalescence in Africa. The document summarizes information on the design, results, and costs of programs to improve child feeding practices in eight African countries, and it provides recommendations for future educational efforts to improve child feeding during childhood illness and convalescence on the continent. It is a useful tool for funding agencies, program mangers and policy makers in Africa.

To obtain a copy of this document please contact:

The SARA Project Academy for Educational Development
1255 23rd Street, N.W. Washington, D.C. 20037
Tel: (202) 884-8822
Fax: (202) 844-8701

PHNFLASH 84 August 23, 1995

Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE ...

· Women's Determination Results in Smaller Families Worldwide
· New Publications: Hunger 1995: Causes of Hunger
· ENVIRO-HEALTH: Government Hotline on Environmental Health
· Women's Determination Results in Smaller Families Worldwide ·

Women's Determination Results in Smaller Families Worldwide

A new international report, "Hopes and Realities: Closing the Gap Between Women's Aspirations and Their Reproductive Experiences", produced by the Alan Guttmacher Institute (New York), examines aspects of childbearing shared by women in developed and developing countries and finds that women spend half to three-quarters of their childbearing years trying to avoid pregnancy.

The report found that women in most countries want smaller families now than in the past, reflecting the changes in modern life and economic (and their wish to improve their children's education). Their determination to control their own childbearing, in spite of substantial barriers, has led to a dramatic reduction in family size in many, if not most, developing countries.

Yet, despite widespread contraceptive use, approximately one in six women of reproductive age throughout the world-nearly 230 million-lack the means to achieve their childbearing goals. They lack access to effective reversible contraception and voluntary sterilization. While the gap between the number of children women want and actually have has narrowed, it remains sizable. More than one in four of the 190 million pregnancies to women worldwide each year end in abortion, and many women say their last birth was unwanted or mistimed.

Women's ability to have the number of children they want, when they want them, is central to the quality of their lives and the well being of their families. The ability to achieve this goal, in turn, has important consequences for the social and economic well-being of the communities and nations in which they live, and ultimately, for the future of the world. Yet, poverty, marriage at a young age, early childbearing, low educational achievement, and profound inequalities between women and men severely limit women's ability to contribute to, and to take advantage of, social and economic progress.

The following are additional key findings from the report:

· Average family size has dropped from 6 to 3 children in the last 20-30 years in many Asian and Latin American countries (The only exception is the Sub-Saharan Africa;

· women typically want 2-4 children and are moving towards that goal;

· 40% or more of sexually active women use effective contraception in many countries;

· women worldwide still have difficulties having the number of children they want, when they want them-40-60% of recent births were poorly timed, or unwanted;

· 30-67% of women in many developing countries have their first child before age 20-in Cameroon and Nigeria at least 10% have a baby before age 15;

· girls with little schooling are at least twice as likely to have a child before age 20, as their better educated peers;

· more women now receive secondary schooling-in some countries, women in their early 20s are 3 to 4 times as likely to have done so as those in their early 40s- but often educational levels are still quite low;

· men in most countries May have substantial influence on the number of children women bear, yet they rarely assume responsibility for contraception; and,

· 20-60% of women in their 30s and 40s have seen at least one of their children die, largely because of substandard health conditions.

The report addresses the challenges that face women throughout the world simply because they are women and suggests the following steps for countries to take:

· provide greater access to a broad range of reproductive health services including modern and effective contraceptive methods, voluntary sterilization, and safe abortion;

· eliminate discrimination and violence directed at girls and women; encourage greater involvement of men in contraceptive use and childbearing responsibilities; and,

· Provide better educational opportunities for girls and greater equity in the labor force.

If you would like more information regarding this report, please call:

The Alan Guttmacher Institute
Ms. Susan Tew
(212) 248-1111

New publication

Hunger 1995: Causes of Hunger Fifth Annual Report on the State of World Hunger

"Hunger 1995: Causes of Hunger" probes the reasons behind the most profound moral and spiritual contradiction of our age- the persistence of hunger in a world of plenty. The report analyzes powerlessness; violence and militarism; population, consumption, and environmental degradation; racial, ethnic, gender, and age bias. Hunger 1995: Causes of Hunger suggests short and long term responses to reduce World Hunger.

For more information, please contact:

The Bread for the World Institute
1100 Wayne Avenue, Suite 1000 Silver Spring, Maryland 20910 USA
Tel: (310) 608-2400
Fax: (301) 608-2401

Enviro-health · · government hotline on environmental health ·

Enviro-Health is a clearinghouse on environmental health effects, it is a free information source and referral service sponsored by the National Institute of Environmental Health and Sciences (NIEHS). NIEHS, is a clearinghouse that provides environmental health information to the general public. The Enviro-Health hotline responds to a broad range of questions regarding the human health effects of electromagnetic fields, pesticides, indoor air quality, multiple chemical exposures, radon, industrial emissions, drinking water, and other health related topics.

Calls and requests to Enviro-Health are received by technical information specialists who provide information over the telephone, via fax, and through the mail. Enviro-Health can be reached through a toll-free telephone number (1-800-NIEHS-94), by e-mail ( or by fax (919-361-9408).


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE ...

· Sri Lanka's Poverty Alleviation Project: A review of the food supplement Thriposha
· New Publication: Nutrition in the Nineties: Policy Issues
· 7th Asian Congress of Nutrition: Beijing, China
· HIV Dipstick Test Reviewed

Sri Lanka's Poverty Alleviation Project: A review of the food supplement Thriposha

Sri Lanka, is a country whose achievements in human development are far superior than similarly developed countries. The Sri Lankan government has made a commitment to provide free basic health services which has led to exceptional levels of social indicators: literacy rate of 88%, population growth rate of 1.4%, contraceptive prevalence rate of 60.6%, and an infant mortality rate 19 per 1000 live births, but despite these promising figures, malnutrition rates are still high.

Possible reasons for this paradox could be that even though mothers have basic education (with a female literacy rate of 83%) they do not necessarily have the adequate knowledge on the fundamental health and feeding practices. For example, some mothers continue to breast feed a child up to 12 months without introducing solid foods. This can be attributed to the cultural belief that a child is unable to eat solids without their teeth, and that the child must be fed its first mouthful of solid food at an auspicious ceremonious time. In addition, mothers who are poor are unable to feed their children adequately.

The most serious health problem is malnutrition; with over 35% of children who are between 3-60 months being underweight. This is 15 times higher than the level expected in a well nourished population. The Janasaviya Trust Fund (JTF), a non-profit quasi governmental agency was established in 1991 to channel resources for poverty. One of the main components of the JTF Poverty Alleviation Project is to curb the malnutrition rates which cover 1.4 million of the current Sri Lankan population. The project has achieved promising results. There has been a 15% reduction in serious malnutrition in the under five age group. According to the Mid-term review for Sri Lanka's Poverty Alleviation Project, the decrease in malnutrition has had nothing to do with the food supplement Thriposha.

The word Thriposha means triple nutrient as it provides energy, protein, and micro-nutrients, as a pre-cooked cereal based food which was distributed through maternal child clinics and within the school system. Since 1973, the Thriposha Programme has been an important part of Sri Lanka's nutrition program. Three main objectives of the Thriposha program were to: serve groups of the population who are nutritionally vulnerable with a suitable food supplement (free of charge); progressively increase the local food input into the food mix in order to ensure that Thriposha will ultimately be replaced by an entirely indigenous nutritive supplement; and introduce Thriposha to the local markets as a low-cost high protein food.

To date, these objectives are far from being reached. The findings in Sri Lanka were not encouraging: some of the children who were on Thriposha were kept underweight to be eligible for the supplement. Men in the Sri Lankan household insisted on eating Thriposha, as a result only a little of the supplement reached the target groups (mothers and children). When Thriposha was given to children under five, the mother often reduced the child's regular amount of food resulting in no increase in nutrient intake. Also, studies have found that the reliance on the food supplement have reinforced a dependency attitude on the part of the recipient; and all the ingredients of Thriposha are imported which limited sustainability. These disturbing facts have led The World Bank and the Janasaviya Trust Fund to re-examine the current Thriposha program and its effectiveness.

Some suggestions have been made by the Poverty Alleviation Project to replace Thriposha with a local product. For example, Project funds would be loaned to a local group of women who will utilize locally available grains and pulses to produce an inexpensive weaning food. Officials hope that this product will reinforce basic nutrition education, as well as being an income-generating activity for community women. Although Thriposha will continue to be distributed in Sri Lanka, the Poverty Alleviation Project recommended discontinuation of its use.

According to Dr. David Pyle, from John Snow, Inc. who participated in the recent midterm evaluation of the project, "Once Sri Lankan communities understand there is a nutrition problem and can identify the causes of their children being underweight, they will then be willing and able to change behavior and improve nutritional status of their preschool children on a sustained basis."

New publication: nutrition in the nineties: policy ISSUEs ·

By: Margaret Biswas and Mamdouh Gabr

This book presents a discussion of major policy ISSUEs with regard to nutrition which have been evolving during the last decade. The major ISSUEs for the nineties includes education in general, nutrition and health education in particular, developing countries, with an emphasis on research to establish an ideal diet in different cultures and ecological environments in all countries.

To obtain a copy of the book please contact: Oxford University Press Walton Street, Oxford OX2 6DP UK Fax: 0144 865 56646

7th Asian Congress of Nutrition
October 7-11, 1995
Beijing, China

The 7th Asian Congress is being organized by the Chinese Nutrition Society, Food and Agriculture Organization of the United Nations, The World Health Organization, UNICEF, and the National Natural Science Foundation of China. The scientific program will consist of plenary lectures, symposia, free communications, and posters covering a wide range of topics in nutrition. Plenary lectures will be on the following: A forum on the current food and nutrition situation in Asian Countries; A Global View of Food Supply; Access to Food and Nutrition Adequacy; Trace elements in health and disease; and Antioxidants in Food and Chronic Degenerative Diseases.

For more information, please contact:

Mr. Ma Shi-liang
Chinese Academy of Preventive Medicine
27 Nan Wei Road Beijing 100050 China
Tel: 86 1 3022960
Fax: 86 1 3170892

High marks for HIV-dipstick test

The HIV dipstick, developed by Program for Appropriate Technology in Health (PATH) is a low-cost, easily performed test for HIV-1 and -2, it does not require sophisticated equipment and can be performed in laboratories with limited facilities. It was designed for use in low-volume testing facilities and as a backup to conventional methodologies. Over one million tests have already been sold and distributed by the manufacturers worldwide.

The four licensees of the HIV-dipstick test have recently had their test kits successfully evaluated by World Health Organization's Global Programme on AIDS. The kits produced by manufacturers in Argentina, Indonesia, and Thailand, all tested at an initial sensitivity of 100% and a final specificity of 98.8% or higher. The fourth kit from the licensee in India tested at 100% sensitivity and 93% specificity.

The HIV dipstick was developed with funding from the International Research Development Centre in Canada and The Rockefeller Foundation. Technology transfer and advancement is partially supported under the Technologies for Child Health (Health-Tech) project.

For more information, please contact:

Kharin Kirkpatrick
Program for Appropriate Technology in Health (PATH)
4 Nickerson Street Seattle, WA 98109
Tel:(206) 285-3500
Fax:(206) 285-6619


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

A Special ISSUE on the Women's Conference in Beijing:

· The Gender Issue: World Bank Urges Governments to Invest in Women
· New Bank Publications

The gender ISSUE is key to development: world bank urges governments to Invest in Women

The World Bank is sharply increasing its investments in women, as the gender ISSUE is becoming increasingly important across the entire spectrum of Bank activities. The Bank is urging governments to invest more in women in order to reduce gender inequality and promote economic development.

Gender inequality hampers growth and governments can no longer afford not to invest in women, according to a new Bank report entitled "Toward Gender Equality: The Role of Public Policy."

A series of measures and actions by the Bank over the last two decades has resulted in a new policy for the Bank to promote gender equality as a matter of social justice and to enhance women's participation in economic development. A steadily increasing number of Bank projects now address gender concerns.

"Investing in women is key to development and to the Bank's efforts to reduce poverty in the world," says Ms. Minh Chau Nguyen, Manager of Gender Analysis & Policy," and it is an increasingly important part of the Bank's lending program."

"As the world community gathers in Beijing, the Bank stands ready to play its part in reducing gender inequality and promoting greater investments in women," says Mr. Armeane M. Choksi, Vice President for Human Capital Development and Operations Policy. "Development is about investing in people to enable them to build a better future. This cannot be done if half the people are left behind."

Some facts about World Bank activities on gender:

· more than a third of the Bank's lending portfolio now address gender concerns, compared to less than 10 percent a decade ago, and this figure is expected to increase steadily in the years to come;

· over $5 billion of the Bank's annual lending is devoted to improving women's status in education, population, health, nutrition, and agriculture.

· a new $200 million micro-level credit program (CGAP) has been launched, of which the majority of the beneficiaries will be women among the very poor;

· over $5 million in special grant funds to the World Health Organization (WHO) and various non-governmental organizations (NGOs) support reproductive health research, population and women's health, and adolescent health;

· internally, the Bank has committed itself to an ambitious recruitment program to increase the number of women among all levels of its professional staff.

Bank studies point to considerable progress in the past decades in promoting gender equality in developing countries:

· 85 girls for every 100 boys are now enrolled in primary school, compared to 65 girls for every 100 boys in 1960.

· the average six-year old girl now goes to school for 8.4 years, compared to 7.3 years in 1980.

· since the 1950s, the female labor force has grown at twice the rate of the male labor force - today, 30 percent of women over 15 years of age in the developing world are in the formal labor force.

But, many inequalities between women and men persist:

· 77 million girls of primary school age are not in school compared to 52 million boys.
· boys receive more education than girls.
· women's wages are only 60 to 70 percent of men's wages.
· women spend more time on paid and unpaid work than men do.
· women are less likely to be in positions of responsibility.
· 500,000 women die annually from pregnancy and childbirth.
· young women are more vulnerable than young men to HIV infections.

The challenge to reduce the gender gap continues. Successful efforts will require participation from women, government commitment and collaboration with the other international agencies, communities and NGOs.

New Publications

Two new reports have been prepared specifically for the Conference:

"Toward Gender Equality: The Role of Public Policy," which analyzes problems and outlines four areas where public policy can contribute directly or indirectly to reducing gender inequalities. "The vicious circle of discrimination in the household and the feedback to and from the market must be broken by public policy," says Kei Kawabata, one of the authors of the report.

"Advancing Gender Equality: From Concept to Action" argues that gains from investing in women are compelling. The booklet reviews a series of Bank-supported projects that are advancing gender equality.

The two booklets are available at The World Bank Bookstore, tel: (202)473-3193.

For a mail order copy, please contact:

The World Bank Bookstore 1818 H St. N. W.
Department T-8051 Washington, D.C. 20433
Tel: (202)473-1155 or Fax: (202)676-0581.


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

Special Issue no. 2 on the Fourth World Conference on Women

· Gender and the World Bank

Gender and the world bank

Why Gender Matters

In spite of the considerable progress achieved in the last twenty years, significant gender inequalities persist in all regions of the world. The empirical evidence clearly shows that such inequalities result in lower quality of life for society and hinder economic efficiency and growth. Furthermore, it demonstrates that investing in women is not only an act of social justice, but also an efficient and effective development strategy.

· Data from around the world show that overall private returns to investments in education are the same, or marginally higher, for women than for men

· More importantly, social returns, or total benefits to society, to investments in women's human capital are significantly greater than for similar investments in men. For example, there is a strong correlation between women's education and the health of future generations and between women's education and reductions in fertility and infant mortality rates.

· Investing in women has a significant impact on their productivity. Simulation studies on Kenya show that, if women have the same level of education and agricultural inputs as do men, farm-specific yields could increase by 7 to 22 percent.

· Facilitating women's access to financial services is an effective strategy for poverty reduction. Recent studies of the three credit programs on Bangladesh show that credit provided to women has not only made economic and financial sense in terms of repayment rates, it has also increased families welfare and enabled them to grow out of absolute poverty within five years.

· Finally, increasing women's education and land security promotes environmental sustainability. Educated women ease population pressures by having fewer children, while women's ownership of land is correlated with higher investment in land conservation.

World Bank Policies on Gender

Addressing gender ISSUEs is essential for the Bank's poverty reduction mandate. The Bank's policy aims at assisting its borrowing countries in four areas:

· Designing policies and programs that are gender-sensitive to ensure that development efforts benefit women and men in an equitable manner

· Addressing national legal and regulatory frameworks to ensure equal opportunities for women and men, as well as the actual implementation of necessary changes

· Strengthening the institutional capacity to implement policies and programs that advance women's status, including the databases to generate gender-specific information

· Mobilizing financing for the policy and program changes needed to promote gender equality in client countries

Some examples of Bank action on Gender

· India's Country Assistance Strategy discusses women's ISSUEs with respect to family planning, maternal health, nutrition and education. It focuses on deepening the dialogue with the Government on policy, administrative and legal reforms designed to increase the role of women in the development process. It provides emphasis to strengthening gender analysis and ensuring an increase in women-in-development components and activities in upcoming projects, notably in agricultural and forestry, and population and nutrition.

· Morocco Poverty Assessment focuses on male-female differences in social indicators, health, education, public expenditure, rural-urban employment and wages and proposes gender-sensitive recommendations such as hiring female teachers, and providing child care and meals to mothers.

· Economic and sector work in Cambodia includes recommendations that support the needs of female farmers, and promote girls' enrollment in schools and maternal and child health programs aimed at improving vitamin and mineral deficiencies in pregnant.

(For more information on Bank's participation, please contact Klas Bergman at (202)473-3798)


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE ...

· World Bank Grant Program Funds Innovative NGO Activities
· WHO Task Force on Health Economics and Publications

World bank grant program funds innovative NGO activities

The World Bank annually supports dozens of indigenous NGOs in developing countries through the Population NGOs Special Grant Program (SGP). Recognizing the key innovative role of NGOs and the need to build the capacity of grass roots organizations, the Population NGOs SGP funds NGOs under two broad themes: improving family planning and reproductive health services, and strengthening the linkages between enhancing women's status and social development, and fertility decline. In FY95, the program provided $850,000 in support of NGO activities, much of which was channeled through "umbrella" organizations.

The following report is from the German World Population Foundation (GWPF), one of the agencies that identifies and monitors the activities of the local NGOs under this program.

Following a visit to East Africa in February 1995, Dr. Hans Peter Voigt of the GWPF reports that there is an immense demand for small grants among that are very active in population and reproductive health, but are in need of financial support to build their institutional capacity. This demand for grants is not met by large donors or by the very small funding sources available locally. Dr. Voigt met with representatives of governmental and NGOs, including those from small self-help and women's groups in Ethiopia, Kenya and Tanzania. The following are some examples of the NGOs receiving support from the GWPF:

· Alongside the Tanzanian Kibiti-Dar-Songea highway, 23 women's health groups have taken root at truck stops. In two offices, donated by the community, they offer information and services on STDs and AIDS. These groups provide a valuable service, but suffer from financial instability. If given start up funds, they would undertake income-generating activities to ensure their sustainability. Under a GWPF grant, each women's group will be provided seed funds of $500. A larger NGO, the African Medical and Research Foundation (AMREF), will provide local coordination and supervision.

· In Kenya, the Single Mothers Association (SMA) supplies family planning services for single mothers. Founded as an NGO by 40 employed women, SMA has built up its own information center, including outreach and education activities. It has received a small grant to educate and train other mothers on how to initiate and run income-generating activities. The training activities will not only focus on management skills and handicrafts, but will also provide information about STDs and family planning.

· The Youth Counseling and Education Program is a very experienced and active NGO in adolescent family planning information and education in Ethiopia. A small grant will allow them to strengthen youth centers in Addis Ababa. At the centers, teens can learn skills, relax in a safe environment, and benefit from youth-oriented information programs with an emphasis on family planning, reproductive health, and the rights of youth.

· In Ghana, the NGO Youth Population Information and Communication Program is an active player in the field of adolescent reproductive health and rights. A small grant has been given for a program targeted at reintegrating adolescent prostitutes in Kumasi into society. In addition, young peer counselors will be trained in reproductive health ISSUEs to work with street children.

Who task force on health economics and publications

The WHO Task Force on Health Economics has the prime objective to enhance the Organization's capacity to provide support to countries, especially those in greatest need, by using health economics for the implementation of health reform policies.

The Task Force is chaired by WHO's Assistant Director-General, Dr F.S. Antezana, co-chaired by Dr M. Jancloes, Director of the Division of Intensified Cooperation with Countries (ICO) and Dr G. Carrin (ICO) is the Task Force's Secretary. Members of the Task Force are drawn from a number of WHO technical programmes at headquarters in Geneva and represent the broad range of WHO's specialist expertise in this field.

The Secretariat of the Task Force on Health Economics can be reached as follows :

WHO - 1211 Geneva 27 - Switzerland,
tel. + 41 22 791 2780 or + 41 22 791 2184
fax. + 41 22 791 4153

E-mail : or

Publications of the Task Force on Health Economics that are currently available by e-mail include :
- A bibliography of WHO literature (WHO/TFHE/93.1)

English version:
French version:
- A guide to selected WHO literature (WHO/TFHE/94.1)

English version:
French version:

- Une demarche participative de reduction des couts hospitaliers, Hospices cantonaux vaudois (Suisse). (WHO/TFHE/95.1):

- Environment, health and sustainable development: the role of economic instruments and policies (WHO/TFHE/95.2):


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE ...

· Key Indicators for Family Planning
· Announcement: Overseas Research Grant
· Announcement: Asia-Pacific Conference on Tobacco or Health, Chiang Mai, Thailand

Key indicators for family planning

According to a review of Staff Appraisal Reports, over one-third of Bank population projects do not include specific indicators. Consistent use of indicators could not only facilitate periodic monitoring of short-term changes in program performance, but also long-term impact on beneficiaries.

According to Bulatao, author of a forthcoming World Bank Technical paper "Key indicators for family planning projects," to be useful, indicators should be: (i) precise, program-specific and sensitive (ii) unidirectionally linked to program success (iii) easy to measure reliably (iv) summary in capturing multiple dimensions simultaneously (v) balanced as a set, fairly reflecting different aspects of a program.

The report proposes the following 10 key indicators:

· family planning approval- a survey-based measure collected for men and women to indicate general acceptability of contraception

· female secondary enrollment ratio - strongest socioeconomic influence on demand for contraception

· management information score - strategic measure of the organizational's institutional capital.

· couple-years of protection (CYP) provided per worker - measure of program efficiency

· proximity of services - the proportion of married women of reproductive age with services within their rural village or urban neighborhood or no more than 1 km away.

· dropout ratio - a measure of contraceptive method discontinuation; sensitive to quality of services that clients receive.

· contraceptive prevalence rate, the proportion of couples in union using contraception

· total fertility rate

· infant mortality rate

· proportion of high-risk births among all births; an alternative to the maternal mortality rate, which is difficult to measure because of its rarity

Most of these indicators can be obtained from periodic household surveys. A survey matching the standards set by the Demographic and Health Surveys (DHS), is recommended near the start of a project, and a follow-up survey at the end, and possibly another at midterm to assess progress. The reference cited above also provides menus of alternative indicators for those who wish to choose their own.

(based on the Human Capital Development and Operations Policy Dissemination Notes no. 57, September 25 1995)

Overseas research grant

INTERFAITH HUNGER APPEAL (IHA) announces two grants for qualified faculty for overseas research projects. Grantees will work in conjunction with staff of IHA's partner agencies-Catholic Relief Services (CRS), Church World Service (CWS), Lutheran World Relief (LWR), and The American Jewish Joint Distribution Committee (JDC)-to develop research goals and a program prospectus. Grantees will travel to selected sites of relief and development projects, meet with project participants, recipients, overseas NGO staff and members of the local community. The program envisions at least 2 distinct written outcomes: first, the grantee will prepare a document for the IHA partner agencies, which will advance the understanding on the ISSUE, identify related areas that will require further study and help NGOs better evaluate their projects. Second, the Grantee will prepare a pedagogical essay or "case-study" for publication in IHA's quarterly, TeachNet. It is also hoped that Grantees will participate in seminars and debriefings, and present their results in a university, both in the U.S. and overseas.

Grants will underwrite grantee expenses on-site, including lodging and board, airfare, and other incidental expenses. The Grants also carry an honorarium. It is expected that the home institutions of Grantees will contribute sabbatical or release time. Two grants will be awarded in the current cycle, one from each of the two categories below:

Grant Category One:: Health Care Projects
Deadline for Application: October 10, 1995

A. Zimbabwe. In 1993, JDC, in cooperation with local partners, opened a clinic at the Bindura Provincial Hospital to provide comprehensive eye care services and train Zimbabwean medical professionals in up-to-date opthalmological practices. The project also serves outlying areas with a Mobile Eye Unit. At the end of 1995, the Zimbabwean Ministry of Health will take on full responsibility for the project's future. Key questions include: what have we learned? How can we assure its continued success?

B. Czech Republic. In April 1991, JDC introduced the Training Institute/Model Community Living Arrangements Project in Prague with a grant form USAID. Its purpose is to offer training in Western theory, methodologies and services for persons with disabilities to professionals and care givers who serve them. After December 1995, the project will be handed over to and managed by Czech professionals. Some key questions are: what have we accomplished? How can we ensure the continued success of the project?

Prospective applicants should submit a letter of interest to IHA identifying the project of interest, along with a current CV. Please call us at 212/870-2035 for a more detailed project descriptions and intial Terms of Reference.

Fourth Asia-pacific conference on tobacco or health

Theme: Strengthening National Policies in Tobacco Control November 22-24, 1995 Chiang Mai, Thailand

For more information, please contact the Secretariat:

Dr. Chanpen Choprapawon
Secretary-General Fourth Asia-Pacific Conference on Tobacco or Health
Thailand Health Research Institute
National Health Foundation
1168 Soi Phaholyothin 22, Phaholyothin Road Ladyao, Jatujak, Bangkok 10900 Thailand
Tel: (66-2)939-2239/2261/2143/2207 Fax: (66-2)939-2122


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE...

· Bank's 'Green' Lending Continues to Climb
· Postdoctoral Research Positions - Queensland Institute of Medical Research, Australia

Bank's 'green' lending continues to climb

This article taken from the World Bank News, October 2, 1995 coincides with the Third Annual World Bank Conference on Environmentally Sustainable Development that is co-sponsored by the Bank and the National Academy of Sciences.

The World Bank is now the world's leading financier of environmental projects in the developing world, with $10 billion in its environmental portfolio for 137 projects in 62 countries. More importantly, the Bank is "greening" its general operations, which average $20 billion annually, according to the Bank's 1995 environment annual report.

"Mainstreaming the Environment: The World Bank and the Environment Since the Rio Earth Summit" describes how some $5.6 billion of the $10 billion in loans has been invested since the 1992 Earth Summit in Rio and how the Bank will be incorporating environmental concerns in an estimated $200 billion of its lending over the next 10 to 15 years.

"When co-financing is included, averaging 60 percent of a Bank- financed project, some $500 billion in projects will receive environmental scrutiny and supervision, making such investments a massive force for environmental progress in developing countries," says Ismail Serageldin, the Bank's vice president for environmentally sustainable development.

"This global shift signals a growing demand for 'greener' projects and illustrates how developing countries have overcome the old 'development-versus-environment' argument," says Andrew Steer, director of the Bank's environment department. "We are committed to strengthening the partnership between economic development and environmental sustainability."

The report describes substantial progress in the way the World Bank assists client countries in addressing environmental concerns, but it also notes that the agenda is unfinished. The challenges that are expected for the next three to five years are:

o Implementing the portfolio of environmental projects. Ensuring that projects continue to perform well and that lessons from innovative approaches are learned and disseminated. The majority of projects in the current portfolio of $10 billion are new.

o Moving beyond project-specific environmental assessment. Environmental assessment techniques need to be broadened to the sectoral and regional levels.

o Improving the monitoring of impacts on the ground. Information on environmental trends remains weak. The Bank will need to strengthen efforts to identify and reinforce indicators of progress.

o Addressing the social dimensions of environmental management, ensuring that stakeholders are involved in the design and implementation of projects. Cultural ISSUEs, social costs and benefits must be taken into account.

o Developing and applying global overlays. Global environmental goals must be integrated into national strategies and action plans for sustainable development. "The report says, No, we haven't arrived yet, although there's been very good progress to date," Steer comments. "If we are successfully greening the entire portfolio of the Bank," concludes Serageldin, "or moving in that direction, then, indeed, the likely impact of the Bank, in terms of environmental development, can be much larger than just the environment portfolio itself."

Postdoctoral research positions

The Queensland Institute of Medical Research, Australia

Three vacancies exist from January 1996 for suitably qualified postdoctoral researchers in the areas of malaria immunology, molecular biology and cell biology to work on projects within the Malaria Laboratories of The Queensland Institute of Medical Research.

Projects currently include

I. an investigation of the cellular immunity of P. falciparum and P. vivax, particularly the role of cryptic epitopes in potential vaccine candidates

II. development of murine models to study the nature of immunity to malaria.

III. Phase I and Phase II testing of malaria vaccine candidates. This work includes studies on the human T and B cell response to vaccine candidates, development of in-vitro correlates of protection and investigation of human immune responses to experimental infections in humans

IV. Investigation of the selection pressures required to maintain the high polymorphism in many malaria antigens found in field isolates

V. Molecular epidemiology of malaria: measurement of transmission rates, genetic recombination and association of parasite types with disease, especially in relatively low endemic regions.

VI. Investigation of the function of defined malaria antigens, particularly proteins in the rhoptry organelles of merozoites. Work will involve subcellular localisation of antigens and attempts to modify the expression of these antigens through the use of anti-sense DNA and or transfection experiments.

Applicants for the immunology position should have a background in molecular and cellular aspects of immunity. Experience in protein chemistry, the use of anti-sense DNA or transfection systems would be an advantage. For the cellular biology position, general experience in subcellular localisation at the light and electron microscopy level would be an advantage, and experience with using confocal microscopy would be particularly valuable. Some experience in protein chemistry, metabolic labelling of proteins immunoprecipitation and western blotting would also be advantageous. For all three positions, prior experience working with malaria of other parasites is not required, but would be useful.

For more information contact Prof Allan Saul ( or Prof Michael Good ( Phone 07 3362 0400, FAX 07 3362 0104. Formal applications (enclosing a C.V. and names and addresses of three referees) should be addressed to: The Secretary, The Queensland Institute of Medical Research, P.O. Royal Brisbane Hospital, Qld 4029, Australia, by the 30th October 1995.


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE...

· UN System to Collaborate on New Global Program to Fight HIV/AIDS
· What's New on the Net?
· Call for Papers on Data Archiving, Johns Hopkins University

Un system to collaborate on new global program to fight HIV/AIDS

Beginning in January 1996, the Joint United Nations Program on AIDS (UNAIDS) will take responsibility for coordinating the global response to the HIV/AIDS epidemic.

Dr. Peter Piot, Executive Director of UNAIDS, highlighted the true extent of the HIV/AIDS epidemic at the first meeting of the Program Coordinating Board (PCB), which was held in Geneva on July 13 and 14, 1995. To date, 15 million people have been infected with HIV/AIDS. Each day, 6,000 additional people are infected. Current transmission patterns show that adolescents must be a priority in prevention programs, as according to WHO, 70 percent of new HIV infections globally are in young women aged 15 to 25. Since HIV/AIDS generally affects young adults, their children also pay a price. By the year 2000, there will be an estimated 5 million orphans worldwide whose parents died of AIDS-related causes.

UNAIDS will play a crucial role in responding to the HIV/AIDS crisis. However, the sponsors of UNAIDS see the agency not as a central control agency, but as an advocate and a source of technical knowledge. In this regard it is a catalyst, building political commitment to address the pandemic, serving as the primary source of policy, technical and strategic guidance on responding to AIDS, and building national capability to respond to HIV/AIDS. It will address the problem from a multisectoral perspective, focusing on ISSUEs of human rights and social development, as well as the prevention and treatment of the disease itself.

The World Bank is one of six cosponsors of UNAIDS, providing support through its Special Grant Program. The other sponsors of the program are UNDP, UNESCO, UNFPA, UNICEF, and WHO.

UNAIDS will be housed at WHO in Geneva, but report to a Program Coordinating Board made up of regional representatives elected for one to three years. The Executive Director of UNAIDS is expected to have considerable independence in managing the program. The World Bank, together with the other five cosponsors, has permanent membership on the board, but no vote. Five NGOs will also have membership, but no vote. The program's total annual budget is still under discussion, but is expected to be around $60 million.

(Population Network News, no. 12, Summer 1995)

For Bank involvement, contact Ms. Debrework Zewdie at For information on the UNAIDS newsletter, please refer to section on "What's New on the Net?"

What's New on the Net?

UNAIDS newsletter is available electronically.

To subscribe, send an e-mail message to:

In the body text of the message, type: subscribe UNAIDS-newsletter
or via WWW at

For more information on the newsletter, contact Monika Gehner at

Call for papers ''data archiving in an electronic age''

Deadline for submission of abstract/paper is OCTOBER 15, 1995

The Johns Hopkins Population Center and the Center on the Demography of Aging have been asked to organize a thematic session entitled "Data Archiving in the Electronic Age" for the PAA Meeting scheduled to be held in New Orleans, on May 9-11, 1996. We are currently soliciting papers and presentations from knowledgeable demographers, public health researchers, or information experts in the field of data archiving. We would like to present a seminar that will give new approaches based on research and experience. Is there someone working in the field of electronic data archiving who you would recommend we contact for submission of a paper on this theme? Would you, yourself, be interested in submitting a paper? Please complete the Response Form, below, and e-mail or mail to either: or

1996 PAA Session on "Data Archiving" c/o Penny Welbourne The Hopkins Center on the Demography of Aging Johns Hopkins University School of Public Health 615 N. Wolfe Street Baltimore, MD 21205 We thank you in advance for your assistance in this matter.


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· In Health and Education: Public or Private?
· Request for Information, South East Asia HIV/AIDS Project

In health and education: public or private?

According to a new World Bank study entitled "Private and Public Initiatives, Working Together for Health and Education," widely held biases, either for or against public or private sector-oriented strategies, are incorrect. Furthermore, there is no single ideal balance of public and private service provision in a diverse and changing world. "Equity, quality and efficiency are not always better or worse when government is dominant, or when the private sector has the larger role. Reality is more subtle." Instead, the report proposes examining initiatives that have worked and adjusting to meet the specifics of each new or changing situation. The best examples are a public-private mix in which both sides complement each other, playing different roles.

The study found that the private sector are more cost-effective in delivering social services. Critics, however, have argued that private providers May reduce quality by reducing inputs (for example, keeping teachers' and doctors' salaries low). Proponents of the public sector, on the other hand, have cited equity as the reason for strong government controls. But, inequality in access and quality May often be aggravated by government policies, In Indonesia, for example, the rich receive almost three times as much public health care as the poor. The report suggests that governments have a critical role in setting appropriate policies. According to author, van der Gaag, governments still have an important role to play, "but they do not necessarily have to supply the services themselves. They must be there to ensure equity and quality and to provide financing for the poor so that everyone has access to education and health."

Today's governments must strive to achieve the most productive balance of the private and public sector in the delivery of health and education services. The report provides examples of projects to help governments attain the public/private mix that is best for the particular circumstances in each individual country. Some of the case studies highlighted include Pakistan's Primary Education Program; Bolivia's Social Investment Fund; AIDS program in Brazil and Burkina Faso; and India's Urban Slums Family Project. The Bank is giving priority to helping countries respond to the challenges and opportunities before them. Bank lending for education, health, nutrition, population and other aspects of human capital development has increased sharply in recent years.

The Bank is currently the world's largest financier of social services, supplying $2 billion a year for education, $1 billion for health and $200 million for population activities. Over the next three years, new commitments are expected to reach a record $15 billion. The booklet is available at the World Bank Bookstore; Tel: (202) 473-3193. For a mail order copy, Tel: (202)473-1155 or Fax: (202)676-0581. or write to: The World Bank Bookstore 1818 H St. N. W., Dept. T-0851 Washington, D.C. 20433

South east Asia HIV/AIDS project: request for information

The World Health Organization and the World Bank are currently establishing a regional HIV/AIDS Project in Bangkok. The aim of the project is to help strengthen the responses to HIV/AIDS in eight countries of the region in particular, namely: Cambodia, Laos, Malaysia, Myanmar, Thailand, Philippines, Vietnam and China (Yunan Province).

One of the initial activities to be undertaken by the project is to establish information support services in the region, including an electronic mail network. It is proposed that members of the proposed network could share information through a moderated mailing list and text file archiving facility based in Bangkok. Two of the additional resources planned for on-going development include an inventory of HIV/AIDS information resource centers throughout the region and an inventory of HIV/AIDS-related information resources accessible through e-mail (and gopher/World-wide web) - both of which would be updated on a regular basis and made available to mailing list subscribers.

We are currently developing the final proposals for these regional support services and would appreciate your feedback (however brief) in three main areas:

1. Will the services outlined above be useful to you in your work and that of your organization?

2. What other services would be of particular value in meeting your HIV/AIDS-related information requirements in the region?

3. Are you aware of existing services of this kind within the region?

Please reply to: Dr. Tim France, SEA HIV/AIDS Project via e-mail

Please include your organizational affiliation (if any) - as responses will be used as the basis of a mailing list for future announcements about the services described.


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· Contraceptive Implants: Friend or Foe?
· CDC's Emerging Infectious Disease Slides
· Vacancy: Assistant Professor/Cancer Epidemiologist

Contraceptive implants: friend or foe?

On July 18, 1995 numerous experts in the area of contraceptive implants came to the Bank to brief staff on the state of the art in contraceptive implant technology and practice. Dr. Giuseppe Benagiano, Director of the UNDP/UNFPA/WHO/World Bank Special Program of Research, Development, and Research Training in Human Reproduction (HRP) provided insights into the history of implant technology, which dates back to the late 1960s. Dr. Soledad Diaz (ICMER), who has supervised multiple clinical trials of contraceptive implants in Chile, explained the mechanisms of action, benefits and drawbacks of the different types of implants that are available or under development.

Norplant is the only contraceptive implant now on the market, and is currently used by more than 3 million women worldwide. The largest number of Norplant users is in Indonesia, followed by the United States. Once the six progestin-releasing rods are surgically placed in the upper arm, Norplant is effective for five years, although it May be surgically removed at any time.

Joanne Spicehandler of USAID provided the group with a review of the lessons learned in the introduction of Norplant into program settings. Issues of training, counseling, quality control, and monitoring of patients must be carefully planned out in the early stages of method introduction to avoid complications.

Many people know Norplant more for the controversy that has surrounded its development and introduction than for its contraceptive benefits. Much of the concern over this method has centered on two ISSUEs. First, women must have timely access to removal of the implants when they want them removed. Second, critics worry about the potential for coercion in the use of a method that requires the participation of a medical provider to initiate and end use.

Judy Norsigian of the Boston Women's Health Coalition shared the perspectives of many women's groups in developing countries on Norplant. Protests on the part of women's groups have led to meetings between the developers of contraceptive implants and NGO representatives. Nevertheless, continued discussion will be required to ensure that concerns are adequately addressed.

(Population Network News, no. 12, Summer 1995)

Cdc's emerging infectious disease slides

A slide set and information packet have been developed to accompany "Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States," the strategic plan developed in 1994 by the Centers for Disease Control and Prevention and its partners. The packet contains technical notes to accompany 40 slides, which define the problem of emerging infectious diseases, provide information about these challenges, and propose solutions. Also included are lists of references and suggested readings that give additional information on today's and tomorrow's emerging infectious diseases. It can be used in workshops, lectures, and courses, and might be of particular interest to health-care providers, public health professionals, and others interested in public health ISSUEs, especially those related to infectious diseases.

The slide set information packet is now available on the Internet. The slides and technical notes can be viewed on-line and can be downloaded individually or in sets. The slides are available in the "gif" file format. The slide set can be found on CDC's World-Wide Web (WWW) at:

or you can connect to CDC's WWW page at: and select Publications.

The slide set can also be found through anonymous File Transfer Protocol (FTP) at: in the pub/infectious diseases/emergplan/slides directory.

Assistant professor/cancer epidemiologist vacancy

University of Minnesota The Division of Epidemiology, School of Public Health, University of Minnesota, seeks a full-time tenure-track Assistant Professor for teaching and research in its Cancer Epidemiology program.

Specific requirements:

1) PhD in Epidemiology or a related discipline, or

2) MD with master's degree in Epidemiology, or

3) MD with PhD in Epidemiology,

4) demonstrated research interest in cancer, and

5) at least 2 years of post-doctoral teaching and research experience. Primary criteria are a relevant publication record in peer-reviewed journals, demonstrated ability through grant awards for significant research, demonstrated skills in research management and data analysis, and evidence through student evaluations of successful teaching.

Primary responsibilities: design/analysis/management of case-control, cohort, and intervention studies; development of data collection and analysis techniques; and assisting in the further development of a biological and behavioral cancer research program. Primary teaching duties include teaching in Cancer Epidemiology and Topics in Cancer and Nutrition/Topics in Cancer Biology, as well as advising master's, doctoral, and post-doctoral students.

The position is available on or about March 1, 1996. Interested applicants should submit a curriculum vitae, publications list, and list of at least 3 references by December 1, 1995, to:

Dr. Thomas A. Sellers c/o Kathy Ramel Division of Epidemiology School of Public Health University of Minnesota 1300 S. 2nd Street, #300 Minneapolis, MN 55454-1015

PLEASE REFERENCE JOB #SPH 127 NOTE: We also have NIH-funded post-doctoral fellowships in Cancer Epidemiology. These fellowships are available only to individuals who are U.S. citizens or permanent residents of the U.S. If you or someone you know are interested in these positions and would like further information, please contact: Lawrence H. Kushi, Sc.D. Division of Epidemiology University of Minnesota School of Public Health 1300 S. 2nd St., Suite 300 Minneapolis, MN 55454-1015 email: telephone: 612-626-8578 FAX: 612-624-0315


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· Technology Developments for Nutrition Education
· "On the Net" Updates: CDC's Morbidity and Mortality Weekly Report
· Onchocerciasis Conference - Brasilia, Brazil
· Vacancies: Tulane University/Niger

Technology developments for nutrition education

Today, enhanced communications are fast becoming an important aspect of project work in the developed and developing world. A report entitled "New Developments in Technology for Nutrition Education" highlights the opportunities that new technologies provide for nutrition educators and explores the expanded uses of computer-mediated nutrition education programs.

The report discusses at length, the different computer-mediated communications (stand-alone and linkage applications) that have emerged as a viable means of gathering and disseminating information. Stand-alone applications which are computer programs and multimedia applications are more commonly used in nutrition education. Linkage-applications such as e-mail, Internet and World Wide Web are just emerging and are often limited to on-line databases, electronic bulletin boards, fax and teleconferencing.

The author emphasizes that use of technology alone is necessary but not sufficient for a successful nutrition education or communication program. Design and selection of appropriate technology for the purpose of the program are also critical. Moreover, institutions, governments and international agencies need to provide the financial support and commitment to fund workshops and other training opportunities and the equipment needed for implementation in programs.

This report is available under the filename omni1001. Please see next section for retrieval instructions.

For additional information, contact: Dr. Kathy Kolasa: or The Manoff Group:

''On the net'' updates

The of the Morbidity and Mortality Weekly Report is now available in Adobe Acrobat format on the Internet.

Article of interest:

· Progress Toward Poliomyelitis Eradication - South East Asia (October 27, 1995/Vol. 44/No. 42 edition)

To access the MMWR via the MMWR web page: Go to: "Publications, Products, and Subscription Services," then "Morbidity and Mortality Weekly Report (MMWR)" to find the MMWR.

-OR- Via anonymous FTP: in directory pub/Publications/mmwr/wk/mm4442.pdf
- OR - via e-mail from the Majordomo list server. Send the following e-mail message: get mmwr mmwr.archive.951027 to:

A searchable index is now available for ISSUEs of MMWR dating from 1993 to the present. Via the World Wide Web, access:

If you have other problems or questions, send an e-mail to:

Fifth inter-american conference on onchocerciasis

Brasilia, Brazil

November 7-10, 1995

"Traditional Cultures and Onchocerciasis Control" This is an action-oriented conference aiming to define operational ways to eliminate the most severe clinical manifestations of the disease by the year 2007, as well as to interrupt transmission in selected endemic foci in the Americas.


· Ministry of Health, National Health Foundation (FNS) - Brazil
· Pan American Health Organization (PAHO/WHO)
· Onchocerciasis Elimination Program for the Americas (OEPA)

For more information, contact:

HCP/HCT PAHO/WHO 525 23rd St. NW. Washington, DC 20037 Tel: (202)861-3381 Fax: (202)862-8483 or OEPA 4a. Ave Sur Prolongacion #23 Antigua, Guatemala


Tulane University Center for International Health & Development Location: Niger, West Africa Positions:

1. IEC Specialist for Population and MCH
2. Health Care Financing Specialist
3. Rural Integrated Services Development Specialist

Tulane University is recruiting qualified candidates to be nominated in its proposal for a USAID-funded contract to provide technical assistance to the Government of Niger through an integrated population and health services development project. Interested candidates are sought for the three long term technical assistance positions listed above. Those interested must be willing to serve in Niamey, Niger for a period of at least two years beginning in early 1996.

Qualifications: The candidates for all three positions must have fluent French, previous African experience (more than 5 years desirable), and master degrees or equivalent in a relevant public health discipline.

For more information, please contact:

Dr. Nancy Mock P.O. Box 13, 1440 Canal St., Suite 2200 New Orleans, LA 70112 Tel: 504-587-7318; Fax: 504-584-3653 email:


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· The Economic Value of Contraception
· "On the Net" Updates: Spanish Health List
· Senior MCH/FP specialist position - Middle East

The economic value of contraception

Contraception is a medical success story. It permits couples of reproductive age to choose whether and when they wish to have children. For women who should not become pregnant because of medical problems, contraception saves lives and prevents morbidity. Reversible methods (such as oral contraceptives and condoms) regulate fertility while preserving the capacity to bear children, and in the latter, protect against sexually transmitted diseases. Sterilization (vasectomy for men or tubal ligation for women) provides the surest protection from unintended pregnancy. The available methods provide individuals with a considerable range of options, allowing them to choose the method that best suits their needs for ease and safety of use, reversibility, and efficacy in avoiding unintended pregnancy and sexually transmitted diseases.

A new study by James Trussell et al. examines the costs associated with these contraceptive choices. For 15 different methods, they analyze the direct costs of obtaining and using the method, the medical costs or savings of resulting side effects, and the direct cost of unintended pregnancy. While their cost data and conclusions are specific to the United States, their model could be used for other countries for which such costs can be estimated.

The outcome measure calculated for each method is the number of pregnancies avoided, defined as the difference between the number of pregnancies expected to occur if no method was used and the number expected to occur with that method. The estimated "failure rate," i.e., the probability of becoming pregnant in one year, is estimated to be 85 percent when no contraceptive is used and ranges from 0.04 percent for vasectomy to 30 percent using the sponge. These rates May vary in other socioeconomic settings.

Method use costs include the costs of office visits, procedures, drugs, and devices. Side effect costs are based on the frequencies of both adverse and beneficial side effects for each method, estimated from the literature. For example, the higher incidence of urinary tract infections among diaphragm users raises the cost of that method, while the lower incidence of cervical cancer associated with barrier methods lowers their cost. The cost of method failure was taken into account by applying the annual failure rate for each method to the cost of a typical unintended pregnancy outcome (the weighted average of costs of ectopic pregnancy, induced abortion, spontaneous abortion, or term delivery). Nonmedical costs, such as travel costs and reduced productivity while hospitalized or recovering from delivery, were not considered.

Taking into account the costs of using the method, side effects and unintended pregnancies, the study found that, after one year of use, oral and injectable contraceptives, along with IUDs, had the lowest total cost. At five years, the copper-T IUD, vasectomy, and implant were the most cost effective. All methods were more cost-effective than no contraception. The high medical costs following method failure make less effective methods more costly in the longer run.

The advantage of this approach is that it allows decomposition of the total costs to reveal the sources of the differences over time. For example, in a highly effective method such as tubal ligation, 5-year method costs (the initial procedure) reflect 96 percent of total costs. For a much less effective method such as the male condom, 5-year total costs are similar, but the costs of unintended pregnancies reflect 85 percent of the total.

The authors conclude that:

· Regardless of the method, contraception is highly cost-effective;
· Method failure is costly because unintended pregnancy is costly;
· Methods that are most cost-effective in the long run May appear less so in the short run: upfront acquisition costs are inaccurate predictors of the total cost of competing contraceptive methods over time.

(Human Capital Development and Operations Policy Note no. 59, October 10, 1995)

Based on James Trussell et al. "The economic value of contraception: A comparison of 15 methods", American Journal of Public Health, Vol.85, No.4: 494-503

''On the net'' updates

A new Public Health mailing list in SPANISH: "lista-spublica" will be a forum for discussions and a bulletin board on topics related to the Public Health field (epidemiology, health education, preventive medicine, etc.). It is a semi-automated mailing list located in the Department of Preventive Medicine of the University of Santiago de Compostela (Spain).

To subscribe, please send an e-mail to:

Bahi Takkouche: or Agustin Montes:

For more information, please contact:

Bahi Takkouche
Department of Preventive Medicine
University of Santiago de Compostela
Fax: 34-81-572282
(original posting in Epidemio-L list)


Senior Maternal and Child Health/Family Planning (MCH/FP) Specialist wanted for full-time, long term, Overseas Position to:

· oversee major, national 3-year development project in the Middle East, involving development of clinical and managerial protocols for MCH and reproductive health and FP services.

· supervise technical specialists in the reorganization and development of community level service delivery systems, including systems redesign, facilities renovation, curricula development and training, the introduction of Total Quality Management (TQM) and Continuing Quality Improvement (CQI) methods.

· train local hire understudy to take over incumbent's position after three years of preparation.


· MD plus public health (MPH or DrPH) professional credentials; ten years experience in MCH/FP work; experience in urban postpartum care; and familiarity with clinical procedures involved in postpartum care

· Demonstrated technical skills in design; implementation and evaluation of community level service delivery systems

· Experience in cross cultural settings, particularly the Middle East

· Knowledge of USAID project management policies, rules and regulations.

· Arabic language fluency preferred, but not required.

Excellent salary and benefits package available, commensurate with experience.

Current resumes and further inquiries should be directed to:

Kim Heath, Vice President/Chief Operating Officer E. Petrich and Associates, Inc. E-mail: Fax in USA: 805-541-2762

(original posting in Partners list)


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank

In this ISSUE ...

· The Ecoregional Factor
· ONCHOSIM simulation software
· Intern Position in PVO/NIS - Washington, DC

The ecoregional factor: new perspectives on malnutrition and POVERTY?

It has long been recognized that the natural environment and resource base of an economy are key determinants of an economy's wealth. Economies heavily dependent on agriculture with a poor resource base, leading to and/or coupled with low agricultural productivity, are more likely to be poor and more likely to exhibit a high incidence of malnutrition. The natural environment is also responsible for permeating conditions which enhance or mitigate the spread of disease, worsening the health and consequent nutrition outcomes of the resident population.

A recent study entitled "Overcoming Malnutrition: Is There an Ecoregional Dimension?" by Garcia et. al (1994) sheds a new perspective on the interaction of the natural environment with overall economic conditions in determining poverty and malnutrition outcomes. The study explores the relationship between ecoregions and incidence of malnutrition. An ecoregion is a geographic variation of the Consultative Group on International Agricultural Research's (CGIAR) nine-zone agroecological classification of land.

The study based on data from 93 countries concludes that: (1) the highest incidence of malnutrition are in the semiarid tropics, a zone with the smallest increases in land and labor productivity; (2) the incidence of malnutrition at the agroecological zone level is generally lower in the cool tropics and sub tropics zones than in the warmer zones. Exploitation of these linkages has the potential to improve both targeting and interventions against malnutrition endemic. (summarized from the Human Capital Development and Operations Policy Dissemination Notes no. 55, August 28, 1995) The complete document May be retrieved under the filename hrn032. See next section for retrieval instructions.

Onchosim simulation software

ONCHOSIM is a computer simulation program for use in determining the transmission and control of onchocerciasis. Developed jointly by the Onchocerciasis Control Programme in West Africa (OCP) and the Erasmus University of Rotterdam, onchosim has been applied successfully as a tool for strategic planning and operational decision making in the OCP since 1987 (see Parasitology Today, vol8, pp 99-103).

Recently, TDR has funded the transformation of ONCHOSIM from a specialized computer program, designed for use in the OCP only, to a more friendly package which can be used elsewhere by persons and institutions with interest in the epidemiology and control of onchocerciasis or other helminth diseases.

A first release of ONCHOSIM is now available free of charge for institutions in developing countries. The costs of the package for institutions in other countries is US $150 (incl. manual and shipment).

To obtain an order form, please contact: A.P. Plaisier Centre for Decision Sciences in Tropical Disease Control Department of Public Health, Faculty of Medicine, Erasmus University Rotterdam P.O. Box 1738, 3000 DR Rotterdam, The Netherlands Tel. (+31) 10-408-7714 Fax. (+31) 10-436-6831 E-mail

Intern position for PVO/NIS project available

The Private Voluntary Organizations Initiative for the New Independent States (PVO/NIS) Project of World Learning Inc. seeks an intern for our Washington, DC office.

The PVO/NIS Project, with funding from the US Agency for International Development (USAID), administers grants to implement humanitarian and development activities that encourage the growth of the non- governmental organizations (NGOs) and voluntarism in the former Soviet Union. The project works closely with American private voluntary organizations working in partnerships with NIS NGOs in all sectors. With the first phase of the project, the solicitation and award of grants, now complete, the project has now moved into its second and third phases, which combine on-going monitoring of projects, training, and drawing on lessons learned to inform future NIS programming.

Job Description: Provide administrative support to the PVO/NIS Project based in Washington, DC and reports to the Program Associate.

Salary and Hours: $5/hour for 10-12 hours per week (not to exceed 20 hours per week).

Requirements: Organized and detail-oriented; strong written and oral communication skills; familiarity with office procedures; proficiency in Windows and Word 6.0 (preferred) or WordPerfect 5.1; ability to work with a variety of people and under deadlines; enthusiastic and willing to learn. Interest in NGOs, foreign assistance, international development; knowledge of Russian, Ukrainian, and/or other NIS language; additional computer skills (Excel, databases, e-mail) are a plus.

For further information or to apply, contact:

Kathy Kalinowski, Program Associate PVO/NIS Project, World Learning Inc., 1015 15th Street, NW, Suite 911, Washington, DC 20005. TEL: 202-408-5420. FAX: 202-898-1920. E-MAIL: <>

(original posting in NISHealth list)


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE...

· FY95 Population and Reproductive Health Lending Up
· "On the Net Updates: Population Reference Bureau's Web Site
· Vacancies: Health Researcher & Statistician

Fy95 population and reproductive health lending up

Preliminary estimates show that in the fiscal year ending June 30, 1995, the World Bank approved more than $450 million in lending commitments to finance population and reproductive health activities. The twenty-four projects that include family planning, safe motherhood, and other population and reproductive health interventions were funded in twenty-two countries. In 1994, only 16 projects related to population and reproductive health were financed. Although the 1995 figures are still subject to verification, these estimates indicate that fiscal years 1994 and 1995 witnessed almost $900 million in lending commitments for family planning, safe motherhood, AIDS prevention and related activities.

Activities range from comprehensive approaches to meeting women's health needs in the Philippines, to AIDS prevention and treatment in Kenya, to micronutrient supplementation for pregnant women in China. In Pakistan, a large project will support the population ministry as part of a coordinated Social Action Program. The Chad Population and AIDS Control project will emphasize the importance of communication strategies for the success of programs addressing these areas. In Croatia, better training and equipment will be provided to improve the identification and treatment of high-risk pregnancies. In a number of countries, including Zambia, Uganda, and Turkey, a basic package of health services will be implemented. As outlined in the 1993 World Development Report, family planning and reproductive health activities make up an important part of the core package of cost-effective interventions. These projects are characteristic of an increasing trend in World Bank lending to finance integrated projects that focus on the health system as a whole, rather than vertical population programs.

On a regional basis, Africa was the largest recipient of Bank loans for population and reproductive health activities. The nine projects in African countries together account for over thirty percent of the lending. East Asia and the Pacific, and South Asia also had five and three projects respectively. These two regions absorbed almost fifty percent of the lending.

Twenty-two of the projects financing population and reproductive health activities fall within the population, health and nutrition (PHN) sector. In all, twenty-six PHN projects were approved in FY95, providing $1.16 billion in financing. Two of the population and reproductive health-related projects are classified in the social sector, and include population and reproductive health activities as part of broader social development projects.

The definition employed has been broadened to include population and reproductive health activities, and consistent with the package of essential services contained in the Bank's recent publication "A New Agenda for Women's Health and Nutrition."

For more information, contact (Population Network News, no. 12, Summer 1995) -

''On the net'' updates

The Population Reference Bureau is pleased to announce its home page on the World Wide Web at:

This Web site offers a number of on-line resources, including Population Today (probe's newsmonthly), a guide to on-line population-related information resources (under "Media Guide"), and a soon-to-be-launched queriable 1995 World Population Data Sheet. The Web site is designed for the low-end user, particularly in developing countries, so it is not loaded with large graphics files.

Please send comments and/or suggestions for links to other useful population-related Web sites to:

Population Reference Bureau 1875 Connecticut Ave., NW Suite 520 Washington, DC 20009-5728 USA Tel. 202-483-1100 Fax 202-328-3937 E-mail:


The University of Massachusetts Medical Center's (UMMC) Occupational Health Program is seeking:

A) Senior Level Health Services/Outcomes Researcher

An experienced researcher to join our expanding Health Services Research faculty, focusing on ongoing studies of quality and outcome in the care of work-related conditions. Responsibilities include study design; coordinating pilot tests of questionnaires and data collection methods; directing research assistants and statisticians in data collection; verification and analysis in collaboration with pricipal investigators; and provide occasional technical and statistical support to other UMMC investigators.

Requirements: PhD or equivalent, with an extensive background in design, implementation, management and analysis related to clinical studies of multiple outcomes, preferably in the areas of rehabilitation or musculo-skeletal disorders. Additional experience in health services research, including the use of administrative databases and a variety of health status measures, statistical methods for longitudinal analysis is desirable.

B) Statistician

A full-time masters-level statistician for several studies of long term outcome in work-related musculo-skeletal disorders, and other investigations in the areas of health services and outcomes research, focusing on a variety of populations. Working closely with the principal investigator and statistical consultants, the statistician will be responsible for implementing procedures for data collection and analysis; maintaining and verifying study databases; establishing routines for data entry by research assistants; supervising day-to-day related activities of research assistants and others; and performing analysis as requested.

Requirements: experience in collection and analysis of clinical, questionnaire-based data. Considerable familiarity with various programs for data entry, data analysis and database maintenance; a good working knowledge of SAS and Epi-Inf and familiarity with a variety of data entry and database software. Three to five years of post-graduate experience preferred.

For further information, please contact:

Dr. Glenn Pransky, Associate Director Occupational Health Program, Department of Family and Community Medicine, University of Massachusetts Medical Center, 55 Lake Avenue North, Worcester, MA 01655-0309

Tel: (508) 856-4159 email:


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· Reorienting India's Family Welfare Program
· Call for Papers: International Association of Health Policy Conference, Montreal, Canada
· Vacancies

Reorienting India's family welfare program

In a participatory process, representatives of the federal and state governments in India worked with World Bank staff to review the progress made by the Family Welfare Program (FWP) and make recommendations on how to move towards a client-centered "reproductive and child health approach."

The result of this joint analysis, "India's Family Welfare Program: Toward a Reproductive and Child Health Approach," points out that India today faces a very different demographic and health situation than it did when the national family planning program was launched in 1951. In the intervening period, mortality fell by nearly two-thirds, fertility declined by about two-fifths, and life expectancy at birth almost doubled. India's population has more than doubled since 1961. Mortality and fertility declines ran roughly in parallel for many years, so that the population growth rate remained above 2 percent per year until 1991. By 1992, India had achieved 60 percent of its goal of replacement fertility, with fertility having declined from about 6 to 3.4 births per woman.

According to the authors of the study, the FWP, now in its fifth decade, has made an important contribution toward improving the health of mothers and children, and providing family planning services. The contraceptive prevalence rate now stands at slightly over 40 percent of eligible couples. For the past decade, the program has gradually shifted away from a predominant focus on family planning to a broader effort to improve maternal and child health. The main emphasis of the report is to move still further in reorienting the FWP towards a reproductive and child health approach. It focuses on the specifics of how the FWP can carry out the commitment given at the Cairo population conference to implement a client-centered approach that responds more effectively to the reproductive health and family planning needs of women and men in India.

Building on the reproductive health approach and the recommendations of the 1993 World Development Report, the team outlined a core set of essential services and estimated the costs associated with implementing them. Included in the recommended package are family planning; abortion safety; safe motherhood; prevention and management of reproductive tract infections and STIs; child survival; health; sexuality and gender information, education and counseling and ensuring adequate referral systems.

The report makes recommendations on five key ISSUEs, each of which May include lessons for other countries as well:

- moving away from numerical, method-specific contraceptive targets and incentives to a client-centered system of performance goals and measures

- expanding the use of male methods and reversible methods of contraception, and broadening the overall choice.

- improving the breadth, availability and quality of services, and involving communities in managing the public sector program.

- strengthening the role of the private sector in the FWP

- mobilizing adequate funding for the current program. and the expansion implicit in adopting the reproductive health approach.

The collaborative effort that infused the preparation of this report holds promise for future project activities. The Bank and Indian representatives are currently discussing a reproductive and child health project to be prepared in the coming year.

(extracted from Population Network News, no. 12, Summer 1995)

Conference announcement and call for papers

International Association of Health Policy (IAHP)

Ninth Congress
Universite de Montreal Montreal, Canada
June 13-16, 1996
Theme: Beyond Medical Care: Policies for Health
Two main ISSUEs of the conference:

· Organization and financing of medical and hospital services. What should be the relative proportions of private and public funding, the market and the State? Should this system have different/new regulation mechanisms, for example, leading to a decentralization of health initiatives/activities and of decision making? How should medical practice be developed to incorporate better the results of scientific research? How should we balance, in the most rational way, investments in primary health care, specialized care and public health?

· Policies to improve the population's health, given the understanding that medical services are just one among many factors which influence health. Expressions like "healthy public policies", "healthy cities", "health promotion", and "prevention" reflect these new concerns. How can public policies contribute to improving health? How can civil society be mobilized for health? How do international relations impinge on the development of health and social policies? What is this new paradigm, this new perspective, that we talk about more and more?

List of proposed topics: Social Environment and Health; Resources for Health Care; Delivery of Health Care; and Health and Globalization

Authors wishing to submit an abstract must do so according to the specifications mentioned in the "Call for abstracts and Registration circular". To obtain this document and information about the conference, please contact:

Secretariat of the 9th Conference International Association of Health Policy Bureau de consultation et d'organisation de congres Universite de Montreal C.P. 6128, Succ. Centre-ville Montreal, Qc Canada H3C 3J7 Phone: (514) 343-6492 Fax: (514) 343-6544 E-Mail:

Deadline for abstracts: December 22, 1995 Deadline for preregistration: March 31, 1996


Agriteam Canada Consulting Ltd., a company committed to international development, is presently expanding its professional resource pool of health specialists interested in being considered for short- and long-term consultancies on overseas projects. At this time we are particularly interested in:

- health economists with experience in Asia
- GIS specialists with experience in health projects in developing countries
- epidemiologists with experience in Asia

Language capabilities in Bengali and experience in Bangladesh would be a definite asset.

Please forward your CV by e-mail or by fax (403) 253-5140 to the attention of Shelley Uytterhagen. We also invite CVs from specialists in other health areas, but we ask that these be submitted on disc and hard copy by mail to:

Agriteam Canada Consulting Ltd., Suite 890 - 10201 Southport Road SW, Calgary Alberta T2W 4X9

Agriteam Canada has implemented projects in Asia, Africa, Latin America, the Caribbean, and Eastern Europe. Our approach is team-oriented, participatory, practical and focused on sustainable benefits.

(original posting in CANCHID list)


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

Note to Subscribers: The World Bank's network and mail server was down last Wednesday. As a result, some of you May not have received PHNFLASH Issue 98. This ISSUE for retrieval under filename "00116". For retrieval instructions, please refer to section on "What's New in the PHNFLASH Archive?"

In this ISSUE ...

· HIV/AIDS: World Bank Calls for Proactive Global Response
· Vacancies: UNAIDS

HIV/AIDS: world bank calls for proactive global response

Washington, December 1, 1995, World AIDS Day - No population is harder hit and more exposed to the consequences of HIV/AIDS than people in developing countries, making HIV prevention a top priority in the World Banks human development programs. Indeed, the World Bank is the single largest source of external funding for HIV/AIDS prevention and control in the developing world.

"HIV/AIDS is a developmental priority which, if not tackled aggressively in its early stages, results in devastating consequences, as we've already seen in Africa," said David de Ferranti, Director of the Human Development Department.

"The center of gravity of the infection is shifting from Africa to Asia. Both large and small countries in Asia have the opportunity to take effective action now and avoid facing a crisis in the near future," noted Dr. Richard Feachem, Senior World Bank Health Advisor. The Bank is currently supporting six HIV/AIDS projects in Asia, and expects this number to increase.

Dr. Feachem added, "the best time to spend a dollar on HIV control is when you've got no HIV in your country; the cost-effectiveness of control declines markedly as prevalence rises; countries as yet little affected should be investing heavily."

On World AIDS Day 1995, the World Bank took stock of its efforts to fight the pandemic in developing countries and articulated its strategy for the future. By 1996, the Bank will have invested approximately $700 million in HIV/AIDS/STD prevention and control in over 60 health projects. To date, 49 percent of World Bank HIV/AIDS funding has been allocated to projects in Sub-Saharan Africa, followed by Latin America and the Caribbean (24 percent), and Asia (23 percent). On a smaller scale, the Bank is also supporting interventions in Eastern and Central Europe (3 percent), and the Middle East and North Africa (1 percent). 65 percent of all World Bank financing for HIV/AIDS is provided through the International Development Association (IDA), the Banks soft loan window that extends interest-free loans to countries with per capita incomes below $865.

Research in Tanzania has shown that low-cost investments in the treatment of sexually transmitted disease (STD) are not only highly effective in controlling STDs, but also decrease HIV transmission rates by over 40 percent. These results confirm that STD treatment must be a central part of all HIV control programs.

"It's a win-win investment. It reduces the suffering and long-term consequences of STDs in women and men and simultaneously has a large impact on HIV transmission the best news we've had for quite awhile," says Debrework Zewdie, World Bank AIDS Coordinator.

In the projects it supports, the Bank is increasingly working through non-governmental organizations (NGOs) to reach vulnerable populations not normally accessible to government programs, and through community-based organizations (CBOs) created by people at high risk of infection. For example, under a successful Bank-supported project in Brazil, the federal government has contracted with NGOs and CBOs to deliver services and information to prostitutes, street children, and drug users. The World Bank is one of six co-sponsors of the newly-formed UNAIDS, which, on January 1, 1996 will replace the World Health Organizations Global Programme on AIDS.

Vacancies: joint united nations programme on HIV/AIDS (unaids)

OUNAIDS was established in order to provide a coordinated and coherent response by the United Nations System to the HIV/AIDS pandemic. It involves six UN agencies: United Nations Children's Fund (UNICEF); United Nations Development Programme (UNDP); United Nations Educational, Scientific and Cultural Organization (UNESCO); United Nations Population Fund (UNFPA); World Bank; and World Health Organization (WHO). UNAIDS is dedicated to preventing the transmission of HIV, reducing the suffering caused by HIV and AIDS, and countering the impact of the pandemic on individuals, communities and societies.

Recruitment has now begun for senior technical experts, based in Geneva, Switzerland, to develop, advocate and implement "international best practice". International best practice comprises the principles, policies, strategies and activities that, according to collective international experience, are known to be the most effective in responding to HIV/AIDS. Accordingly, we are currently looking for senior (e.g. up to ten years professional experience) technical experts in the following areas; all will be P4/P5 UN structure grades:

Community Mobilization Adviser JP/P/95/28 ·
Social Scientist JP/P/95/32 ·
Clinical and Nursing Care Adviser JP/P/95/39 ··

Salary and other conditions of employment are internationally competitive. Specific vacancy announcements provided on request. Applications with detailed curricula vitae should be sent to:

Personnel Officer - UNAIDS - 20 avenue Appia - CH 1211 Geneva 27 - Switzerland
or Fax (+41 22) 791 4880 internet:


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...
· Impact of Structural Adjustment Programs on Health
· What's New on the Net: WHO TB list
· TDR's Call for Proposal
· Health Finance Positions Available

Impact of Structural Adjustment Programs on Health

Message to subscribers:

We have reached the 100 mark - A perfect ending to 1995! This is the last ISSUE of PHNFLASH for 1995. PHNFLASH will resume again Jan 5,

1996. We would like to wish everyone a warm and safe Happy Holiday season. Thank you for your patronage and we look forward to serving
you in the coming year.


Impact of Adjustment Programs on Health

Are Donor-Supported Structural Adjustment Programs Responsible for Reductions in Public Spending on Health? The answer is "No," based on a background study by Yazbeck, Tan and Tanzi (1995) for the World Bank's World Development Report 1993: Investing in Health. Using new data on government spending during the 1980s, the study shows that health spending was more sensitive to overall economic conditions than to the fact that a country had received donor-supported structural adjustment loans. Indeed, in countries that received such loans, the economy rebounded faster, and public expenditures on health recovered more quickly and to higher levels than they did in countries not receiving adjustment loans; Mauritius and the Philippines are examples of two recipient countries that experienced particularly rapid recovery in public expenditures on health.

The Context and Issues

In the 1970s publicly-financed health and other social services expanded rapidly everywhere. Unfortunately, economic conditions deteriorated in the 1980s, and many developing countries adopted new policies to boost economic growth and correct short-run macroeconomic imbalances, and these new policies have often involved reductions in large public sector deficits. Some countries received structural adjustment loans from the World Bank and the International Monetary Fund to facilitate the change in policies.

How have the cutbacks in public spending affected people's health, especially the health of those on small incomes? Because the anticipated adverse effects are mediated partly through reductions in public spending on social services, the sectoral distribution of cuts in overall public spending is a major ISSUE. The ISSUE has attracted much debate, but little consensus has emerged thus far.

One reason for the inconclusive debate is that most studies in the past have relied on data from the International Monetary Fund's Government Finance Statistics, which refer only to central government accounts. The paper by Yazbeck, Tan and Tanzi advances the debate by analyzing more comprehensive data on consolidated government spending at the national and sub-national levels. Using such data is important because spending on health by sub-national governments is substantial in some countries. The data come from World Bank country reports, and are available for twenty countries for single years between 1980 and 1990.

What the Data for Twenty Countries Show

Using the same criteria as the World Bank's 1992 report on Adjustment Lending and Mobilization of Private and Public Resources for Growth, the sample countries were grouped intensive adjustment countries and non-intensive adjustment countries. Intensive adjustment countries" were those that received at least two structural adjustment loans or three sectoral adjustment operations, all effective by June 1990 and with the first operation effective by June 1986. Data were available for Bolivia, Brazil, Chile, Cost Rica, Kenya, Republic of Korea, Mauritius, Mexico, Philippines, Tunisia, Turkey and Uruguay. "Non-intensive adjustment lending" countries were those had not received adjustment loans by June 1990. Data were available for Burkina Faso, Dominican Republic, Egypt, El Salvador, Guatemala, Liberia, Malaysia, and Papua New Guinea.

Whether or not countries received adjustment loans, public spending on health as a share of GDP follows a similar cyclical pattern (see figure), declining between 1980 and 1985/86, and rising by 1990. The decline is sharper, however, in the non-recipient group, and the recovery flatter and slower. A similar pattern emerges when using data on per capita public spending on health. Simple regression analysis also shows that being a recipient of adjustment lending has no effect on trends in public spending on health.

Implications for Future Work

The available evidence fails to confirm a popular perception that donor-supported adjustment loans have had detrimental effects on health through reductions in public spending on health. The data pertain to an admittedly small sample, and are somewhat dated. Lack of detail in the data also prevented analysis of the effect of adjustment lending on the distribution of spending within the health sector. Additional work on the subject is sorely needed to inform the continuing and often polemical discussion of the relation between adjustment lending and health expenditure. Later generations of adjustment programs have much more explicitly sought to protect health expenditure, especially those elements (such as essential drugs and supplies) thought to be vulnerable to budget cuts and yet are critical for effective health services. A new analysis using more recent data for an expanded sample could document not just the effect of adjustment loans in safeguarding public spending as a whole, but also their effectiveness in shifting the spending toward more cost-effective patterns.

( HCO Dissemination Note no. 61 November 6, 1995. Based on report by Jee-Peng Tan et. al (1995) "Public Spending on Health in the 1980's: The Impact of Adjustment Lending Programs.")

What's new on the net?

TB Control and Private Health Care Providers: Global Brainstorming for a Global Emergency

TB (tuberculosis) has been declared a global emergency, by the World Health Organization (WHO). This is not only due to the magnitude and trend of suffering and death inflicted by TB, but also due to the availability of a cost-effective strategy to combat TB. The cost-effective strategy promoted by the WHO's Global Tuberculosis Programme has been labeled DOTS. This strategy has been shown to yield cure of infectious (sputum-positive) TB more consistently and at lower cost per cure than any other strategies so far attempted. An important spin-off from this strategy is that widespread misuse of drugs is actively discouraged, delaying (and hopefully averting) the disaster of widespread multiple-drug resistance (MDR). MDR TB is known to be a killer not only in developing countries, but also in advanced industrialized countries such as the USA. MDR TB is also much more expensive to treat, in terms of drugs, intensity of health worker involvement and infrastructure required, than TB which is sensitive to the relatively inexpensive anti-microbials recommended for DOTS.

TB control depends on treatment of persons with disease. Cure of infectious persons is the most cost-effective form of prevention. Since persons with TB disease (eg., respiratory symptoms) often seek treatment for their own good, it is not certain which providers of health care they will favor. In many countries, more than half of symptomatic individuals are believed to approach a private provider of treatment in the first instance. The private provider has little or no incentive to turn away patients (sources of revenue) even it is well known that the public sector offers free TB treatment. Moreover, the principles of DOTS are applicable by private sector providers only if they make imaginative adjustments to their normal practices.

The problem faced by TB control campaigns in countries with a high incidence of TB disease and a thriving private health care sector May be summarized as follows: How can the behavior of relatively powerful (informed) professionals be aligned with the public interest?

Several options come to mind for immediate implementation: improve the quality and attractiveness of public sector services, inform the public about TB and DOTS, educate (and exhort) private sector providers. However, these remedies are likely to solve only part of the problem. The behavior of private providers of health care has been studied in many parts of the globe and found to be consistently and heavily influenced by self-interest.

TB control has attracted widespread and increasing attention. This has been partly matched by investments in TB control, from financiers such as the World Bank, overseas development aid and non-governmental foundations. TB is an emergency. We cannot but proceed. The role of the private sector in TB control remains one problematic area. Advances in understanding and interventions in this area are especially important.

If you have been familiar with TB control, OR influencing the behavior of private health care providers or both, your wisdom and input could prove valuable. Do something great: fight TB.

If you would like to participate in a global brainstorming session on the topic of "TB control and private health care providers" over the coming months, subscribe to this discussion group.

To subscribe:

Create an Internet message addressed to:

The message body should contain only one line (not on the subject line)
subscribe tb-priv-l

To participate in the discussion, send contributions to:


Pass the word around: forward this to a few people who might be interested. Let us come up with good ideas, which could prove suitable for evaluation and, eventually, widespread use.


Joel Almeida, Internet:
TRS, Global TB Programme, voice: +41 22 791 2655
WHO, fax: +41 22 791 4199
211 Geneva 27, Switzerland.

Tdr's call for research proposals

Improving the Home Management of Malaria in Africa

Rapid identification of danger signs and prompt, appropriate action can avert most deaths from malaria. For this reason, TDR is interested in funding the following types of intervention studies aimed at improving the recognition and management of malaria:

- studies to examine the extent to which improvements can be achieved in the maternal recognition and subsequent management of life

- threatening symptoms (e.g. generalised convulsions, anemia) in children;

- studies to explore the extent to which improved packaging (and package inserts with better written instructions) for anti-malarials can improve compliance with multi-dose anti-malarials;

- studies to improve the home treatment of malaria using shop-bought drugs through education of families and shopkeepers in the community;

- studies to improve compliance with verbal advice given to patients (or caretakers) on the use of anti-malarials at the time of consultation (1) at first-level outpatient facilities; (2) at shops and by drug vendors; and (3) by private practitioners, including traditional healers;

- studies to compare different drug formulations for pediatric malaria in terms of (1) their efficacy in treating of mild and severe malaria at the periphery; (2) their impact on correct dosing by families and health workers; and (3) their cost-effectiveness in improving patient acceptance and compliance with treatment.

- studies to examine the impact of improved private-sector diagnosis and treatment for malaria on reducing case-load and case-fatality at hospital facilities.

Persons interested in carrying out any of the above studies should send their CV and a letter of intent, specifying their topic of interest and describing their area of study, to:

Dr Patricia Hudelson/Dr Melba Gomes
TDR, WHO, 1211 Geneva 27, Switzerland
(tel: (+41) 22-791-3813; fax: (+41) 22-791-4854).

Letters of intent should reach TDR no later than 31 December 1995. Selected researchers will be provided with assistance in the development of their research proposals.

Health finance positions available

The Futures Group International (TFGI) operates large international technical assistance programs in reproductive health policy, social marketing and planning in developing countries throughout the globe. For these programs, we seek to fill the following two positions:

Senior Health Finance Specialist

At least 3 years experience in domestic or developing country health care finance. Candidates should have relevant experience in reproductive health finance, developing country health finance and resource allocation including experience with managed care, cost recovery and fee structuring. Candidates should have superior communication skills and the ability to lead and mentor less senior staff. A Ph.D., MD or equivalent training and experience is necessary. Candidates must be willing to travel to implement reproductive health finance programs. Written and verbal ability in a second language is important.

The successful candidate will lead and participate in country team efforts within the scope of TFGI's ongoing international reproductive health policy and social marketing projects. Opportunities also exist to work within and help expand the company's domestic health portfolio. The successful candidate will be encouraged to participate in developing this aspect of TFGI's work.

Health Finance Analyst

The successful candidate will assist project managers and health finance staff with their ongoing projects. The successful candidate must have at least two years of international experience, with at least a master's degree in a development or health/population field where the emphasis has been on financing, sustainability or economics. Good quantitative skills including facility with spreadsheets and statistical software packages are necessary. The candidate must be willing to do extensive international travel. Ability to speak a second language such as Arabic, French, Portuguese, Russian, or Spanish is a must.

For more information, please contact:

1050 17th Street, NW., #1000
Washington, DC 20036
fax (202) 775-96 98/9694.
Attention: Human Resources/Health Finance.


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· HIV/AIDS in Sub-Saharan Africa
· Consultative Meeting on Education-Health Linkages in Africa
· WHO/TDR Call for Research Proposal
· What's New on the Net?

HIV/AIDS in Sub-Saharan Africa

AIDS is exerting a dramatic impact in Sub-Saharan Africa by reducing life expectancy and productivity, disrupting social systems, and increasing poverty. AIDS is believed to be the leading cause of death between the ages of fifteen to thirty-nine in Botswana, Malawi, Uganda, Zambia, and Zimbabwe. An estimated 8.5 million people in Sub-Saharan Africa are currently infected with HIV. HIV/AIDS is also projected to further slow the already unfavorable per capita income growth of many countries in this region through its effects on savings and productivity. In the ten Sub-Saharan countries with the most advanced HIV/AIDS epidemics, estimates indicate that per capita income growth will be slowed by an average of 0.3 percentage points a year between now and 2025.

Studies have documented an increased risk of HIV infection among individuals already infected with another sexually transmitted disease. Such data are particularly significant in Sub-Saharan Africa where rates of untreated STDs are high. Work supported by the Bank has focused on learning more about the prevalence of STDs in certain population groups. Rapid assessment studies have estimated the prevalence of STDs in conjunction with the risk behaviors responsible for their high transmission in pregnant women, military recruits, truck drivers, and commercial sex workers.

These studies have been completed in Burkina Faso, Lesotho, Mali, Niger, Senegal, and Uganda, and are under way in Chad, Madagascar, and Zimbabwe. Other studies are being planned for Benin, The Gambia, and Togo. Rapid assessments provide the data that AIDS program managers need to monitor populations' vulnerability to HIV and STDs and disease prevalence trends, adjust patient treatment guidelines, and learn more about common risk behaviors. For example, although truck drivers in Niger report frequent changes in sexual partners and nearly all have heard of condoms, only about 14 percent use condoms regularly.

The results of such research have served to highlight the vulnerability to HIV that women of reproductive age face in Sub-Saharan Africa. Among some population groups, over 40 percent of pregnant women have at least one STD. The presence of such high STD rates indicates both a biological vulnerability to HIV infection and a lack of access to basic health care services and information. The World Bank has responded to this still evolving health and development crisis by supporting health and social development projects, sector work, and regional initiatives. Between 1987 and 1996, the Bank will have supported 43 projects in 27 Sub-Saharan African nations, with IDA funding for all but three of these projects.

(reprinted from "The World Bank and HIV/AIDS")

Consultative Meeting on Education-Health Linkages in Africa

U.S. Agency for International Development
Washington, DC
January 17-18, 1996.

The purpose is to convene education, health, population, and nutrition experts to address the links between education and health/population/nutrition sectors in development programs in Africa; and to assess prospects and models for better achieving education and health objectives through programmatic collaboration.

For more information, contact:

Jim Williams
1111 19th Street, Suite 300
Rosslyn, VA 22209
Tel.: 703-235-4970

Who/TDR call for operational research proposal on implementing bednet Interventions

Insecticide-impregnated bednets (IIBN) have emerged in recent years as one of the most promising malaria control interventions for prevention of morbidity and mortality, particularly among children in Africa. Results of large-scale trials evaluating the efficacy of IIBNs in reducing morbidity and mortality in well-defined epidemiological settings in Africa will become available towards the end of this year and in the first few months of 1996. On the basis of the results of these studies, WHO will develop a set of recommendations and guidelines related to the potential role of IIBNs in malaria control strategies in Africa.

UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Disease (TDR) and the International Development Research Centre of Canada (IDRC) have developed a joint initiative to encourage and support operational research on the most efficient means of promoting, implementing and sustaining IIBN interventions in different settings. Proposals should describe the objectives of the research and how they will be evaluated, the type of implementation and promotion that is proposed or under way in terms of both financing and delivery.

Persons interested should submit proposals to:

Dr J. Cattani, WHO/TDR, 1211 Geneva 27, Switzerland
(Telephone: (+41) 22-791-3737; Fax: (+41) 22-791-4854)
by 28 February 1996. Application forms are available at the above address. Proposals will be reviewed in March 1996 by the Task Force on Insecticide-impregnated Bednets.

What's new on the net?

International Development Research Centre of Canada (IDRC) Micronutrient Initiative's MN-NET web site provides updated information and resources on micronutrient malnutrition.


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· HIV/AIDS in Asia
· Public Health Research Training Grant
· Vacancy Announcements

HIV/AIDS in Asia

The center of gravity of the AIDS epidemic is shifting from Africa to Asia, and barring an unexpected breakthrough in medical research, by the year 2000, most new HIV cases will occur in Asia. WHO estimates that about 3.5 million people have been infected with HIV, and cumulative infections in the region are expected to quadruple to more than 10 million by the year 2000. Currently there are two primary foci of HIV/AIDS in Asia: (a) India; and (b) Cambodia, Myanmar and Thailand. It is anticipated that the greatest epidemics of HIV/AIDS will occur in the world's most populous developing countries: China, India, and Indonesia.

These epidemics, still in their early stages, May dwarf the epidemics from which Sub-Saharan Africa has suffered for the past decade. Across Asia the epidemic has become well established where high risk behavior related to intravenous drug use and commercial sex is prevalent. At present, parts of Cambodia, India, Myanmar, and Thailand are particularly affected. In places, the rate of increase in HIV prevalence outstrips what Africa has experienced. Political commitment is an essential prerequisite for an effective response. In the currently less affected Asian states, the degree of seriousness with which the authorities view the ISSUE varies enormously.

The World Bank's attention to HIV in Asia began early. In 1988, an offer was made to the government of Thailand to assist with its program to combat HIV. Laudably, the Thai government decided to finance its own program. This first step by the Bank was followed by the first HIV project in Asia, in India in 1992 (see below). In response to the rapidly growing crisis, the Bank is expanding its funding for HIV/AIDS prevention in Asia. Beyond the sheer magnitude of the anticipated HIV/AIDS epidemic, the Bank upholds another compelling reason for investing in HIV/AIDS control in Asia: the fact that the problem is not yet too large or uncontrollable. Investments in HIV/AIDS control prior to the presence of high rates of HIV in the general population are much more likely to be cost-effective than investments in HIV control when the epidemic is mature. Both large and small countries in Asia have the opportunity to take effective action now, and consequently avoid facing a severe situation in the near future. The World Bank is currently supporting six HIV/AIDS projects in Asia, and expects this number to increase.

India: National AIDS Control Project

India's National AIDS Control Project is one of the Bank's earliest free-standing HIV/AIDS projects. This 1992 project initiated a start-up investment to create sustainable capacity to cope with the evolving needs posed by HIV/AIDS in India. Notably, this project called for launching a comprehensive, and multisectoral approach. The project has established the administrative and technical basis for program management. Special programs have been developed to target youth, including a pop music program that emphasizes means of HIV/AID prevention and films. Rural youth have been targeted through 700 Nehru Yuvak Kendrachapters, which exist across the country. The project has also made extensive use of folk music, festivals, awareness campaigns, and elephant parades to highlight the risk and prevention of HIV/AIDS.

Southeast Asia: Regional Policy Development on HIV/AIDS

Apart from its role as a source of financing, the Bank is also engaged in policy discussions and provides support for studies and research. A regional project based in Bangkok is addressing policy ISSUEs affecting the surrounding countries. The new UNAIDS program will assume responsibility for its activities. Economic Development Institute has undertaken a series of policy seminars and Bank supported research is being undertaken in Cambodia on intravenous needle use, in China on the transport industries, and in Thailand on the cost-effectiveness of AIDS treatment.

HIV has spotlighted the mobility of Asian society. People in Irian Jaya, Indonesia have become infected through contacts with Thai fishermen; Uzbeki women now work in the sex market of Karachi, Pakistan; and Vietnamese women May be found working as commercial sex workers throughout Cambodia. The situation is complex, with much human misery and exploitation, particularly of young women drawn into the sex establishments. Only non-governmental organizations (NGOs) and community-based organizations (CBOs) can grapple effectively with high risk behaviors and social intimidation. Partnerships between governments, NGOs and CBOs are crucial to success, but recognition of this is not widespread.

Some bright spots are appearing on the HIV map of Asia. In Thailand, condom use has soared, STD rates are much reduced, and the HIV prevalence rate among new army draftees is starting to decline in some parts of the country. These changes demonstrate what is achievable. Social marketing of condoms in Vietnam and Cambodia is showing signs of success if the numbers purchased are used as an indicator.

(reprinted from "The World Bank and HIV/AIDS")

Public Health Research Training Grant

This initiative is jointly funded and administered by the Pan American Health Organization (PAHO/WHO) and the International Development Research Centre (IDRC) of Canada.

The program is divided into two phases. During the first phase, Fellows will spend 9-12 months at leading teaching/research institutions outside their native countries. The format will be similar to that of a post-doctorate with a marked emphasis on practice. During the second phase, Fellows will implement the research project with the support of the home institution. Funding for the second phase is subject to approval of the research protocol by the Review Committee.

The exact amount of the award will depend on the specific needs of each case, taking into account prevailing norms and regulations of PAHO/WHO. In any case, the award is not to exceed US$25,000. In the event that the Grant does not cover all anticipated costs, the candidate will be asked to demonstrate the availability of funds for the remainder.

NOTE: Deadline for receipt of applications is May 15, 1996.

For further information or to request an application, please contact the

PAHO/WHO Office in your country or:

Public Health Research Training Grants
Pan American Health Organization (PAHO/WHO)
525 23rd Street, N.W., Room 701
Washington, DC 20037
Tel: (202) 861-3283 / Fax: (202) 223-5871

For information regarding other PAHO/WHO Fellowships, internet users can browse the PAHO/WHO WWW site at:
(original reposting from

Vacancy Announcements


AIHA is a non-profit group which supports health care assistance projects in the New Independent States (NIS) of former Soviet Union and in the countries of Central and Eastern Europe (CEE), under grants from USAID.

AIHA is currently seeking qualified candidates for the following positions:

1) PROCUREMENT OFFICER: Manages procurements of goods and services in a timely fashion; reviews/revises procurement policies to ensure compliance with all relevant U.S. government standards; maintains proper documentation in procurement files; develops and maintains a computerized property management system. Requires 3 or more years of procurement experience for a federally-funded not-for-profit organization; familiarity with Federal procurement rules including OMB A-110, A-122, Handbook 13 and the FAR; experience preparing RFP s and cost/price analyses consistent with Federal rules.

2) PROGRAM ANALYST: Manages portfolio of partnerships, including logistics support, monitoring work-plan progress, projecting and analyzing expenses and ensuring adherence to AIHA/USAID policies. Maintains documentation and data; manages special projects, including clinical task forces. Acts as liaison with AIHA Regional Offices. Requires B.A./B.S., preferably with concentration in Russian/Eastern European Studies, Health Policy and Planning, International Relations, International Business, or Economics; graduate work desirable. Knowledge of spreadsheet and word processing software as well as foreign language skills (Russian/E.European) are advantageous, but not required.

3) EDITORIAL ASSISTANT: Assist in editing and writing of bilingual international health magazine and other print and electronic publications. Some administrative duties involved. Requires B.A./B.S. in Journalism/Communications and two years of experience in related work. Russian language, desktop publishing and Web skills preferred.

4) INFORMATION ANALYST: Assist in the development of information resources; primarily on developing pages on the Web. Participate in the collection of information and the preparation of corporate publications. Requires extensive experience with the Internet and specifically with Web page design; general proficiency with computers (word processing and database programs); and strong writing skills. Russian language skills helpful, but not required

Please respond (with cover letter indicating position applying for) to:

Human Resources
P.O. Box 28056
Washington, D.C. 20038-28056
(original posting from


Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· HIV/AIDS in Latin America and the Caribbean
· Vacancy Announcement

HIV/AIDS in Latin America and the Caribbean

Estimates of total HIV infection in Latin America and the Caribbean indicate that 1.2 to 2.0 million people had been infected by 1995, with more than 300,000 new HIV infections occurring every year. However the lack of seroprevalence studies makes reliable estimates difficult. To date, Latin America has recorded 126,000 cumulative AIDS cases and 59,162 deaths. The numbers for the Caribbean are 8,065 recorded cases and 4,778 deaths. New infection is particularly evident among the most socially and economically marginalized populations in the region. Epidemiological data suggest that young people (particularly females) aged fifteen to twenty five are the most vulnerable to infection. It is this group that tends to be highly mobile or involved in tourism or commercial sex industries but are typically the least accessible to government or international HIV/AIDS programs.

The World Bank has responded to the threat in the region by sponsoring a regional initiative on HIV/AIDS in Latin American and Caribbean (1996-98). The initiative is designed to mobilize and unify national and international efforts against HIV and STDs by, raising the awareness of government administrators in the region, assisting in the development of a new generation of STD/AIDS control programs that would follow the first generation of programs implemented in Brazil and Honduras, and assisting in the development of regional approaches to STD/AIDS control. The total cost of this project is estimated to be US$6.6 million, of which the World Bank will provide approximately US$1.0 million. The initiative will enable countries in the Region to share the results of studies in different countries, to build on the best practices of each others' programs, and to develop strategies for controlling AIDS and STDs across borders.

In addition to the regional initiative, the Bank has financed projects or project components in Brazil, Haiti and Honduras.

Brazil: The total number of cases in Brazil far outstrips the rest of the region. At the end of 1994, there were 50,000 known AIDS cases and an estimated 400,000 people with HIV. The Brazilian government is taking bold action against AIDS and is working with NGOs, health care providers, researchers, and other Brazilian and foreign experts, including the World Bank. The US$160 million comprehensive and innovative project in AIDS and STD control is the largest to date. A positive impact is already evident one year later, especially among some high risk populations.

· Brazil's federal government is taking a first stride in contracting with non-governmental organizations (NGOs) and community-based organizations CBOs) to reach prostitutes, street children, and drug users. The project has financed the activities of more than 120 NGOs in providing outreach education and other services. Close to 400 grants of around US$100,000 each have been awarded to NGOs under this scheme. The federal government is also undertaking a major revamping of the national laboratory system to upgrade capacity and establish centers of excellence for monitoring and referral for STDs. Concomitantly, the Ministry of Health (MOH)'s HIV and STD program is a leader in implementing its new decentralization policy, whereby state and municipal governments are responsible for operating health care and other programs that deliver HIV, STD, and AIDS services and information. Prompted by the Bank's proposal and encouragement, the Brazil's MOH convinced the Ministry of Finance to lower the cost of condoms by eliminating tariffs and promoted the elimination of federal and state taxes on condom sales. Combined with social marketing and widespread condom distribution, the elimination of taxes has dramatically increased availability and affordability.

· Honduras: In 1991 HIV prevalence and AIDS incidence in Honduras were among the highest in the region. This threat is compounded by the widespread presence of untreated STDs. The World Bank has worked with the government of Honduras, the Pan-American Health Organization and the Global Programme on AIDS on a Medium-term AIDS Control Program for 1993-95. The program targets a full range of control, prevention, and treatment activities required to curb the spread of HIV infection and AIDS.

· Haiti: The Bank-sponsored AIDS Control Program, initially slated to start in 1990, was delayed until 1995 due to political unrest. This AIDS project component is funded by IDA and aims to integrate with the government's national AIDS control program and national tuberculosis control program in both health and social programs because of the close epidemiological relationship of these diseases.
(adapted from World Bank's Work in HIV/AIDS)

Vacancy Announcement

Washington-based International Management consulting organization seeks a Senior Market Research Director. Candidates must have broad-based knowledge of qualitative and quantitative marketing research techniques used to develop, test and evaluate advertising campaigns and new product introductions for consumer products and health-related services throughout Asia, Africa, the Middle East and Latin America. The Senior Market Research Director will be responsible for: designing and coordinating over 60 research studies annually; training and managing local research firms and project staff; and ensuring that standards of research excellence are met. Studies include product positioning and advertising protesting, baseline and tracking surveys, retail audits, mystery shopper studies, pricing studies, project evaluations, innovative lifestyle and geographic information system (GIS) studies, and cross-national studies of special interest. The Director must be able to translate research findings into programmatic recommendations for communications and marketing plans in a variety of country and program settings. Excellent oral and written communications, organizational and interpersonal skills are required. The candidate must be willing to travel internationally to monitor field activities. An advanced degree is preferred. Knowledge of USAID systems is useful. A second language is a plus. EOE. To apply, send resume and salary history to:

The Futures Group International
c/o Lourdes Loch-Martinez
1050 17th St., N.W., Suite 1000
Washington, D.C. 20036
Fax: (202) 775-9694
No phone calls please.


The World Bank
Human Development Department (HDD)

In this ISSUE ...

· Improving Reproductive Health
· Announcement: Award for writing

Improving Reproductive Health: The Role of the World Bank

The Reproductive Health Approach

The Programme of Action of the 1994 International Conference on Population and Development (ICPD) represents a major departure from conventional thinking on population and development. The international community has gone beyond concern about mere numbers of people and demographic targets, and explicitly places human beings at the center of all population and development activities. Investments in people, in their health and education, are seen as the key to sustained economic growth and sustainable development.

The Programme of Action calls for family planning to be integrated into the broader context of reproductive health. The World Bank supports and is seeking to implement ICPD's recommendations for a reproductive health approach. This booklet describes how the Bank is implementing this approach in its population, health, and nutrition work. Reproductive health is not merely the absence of disease or infirmity. It is a state of physical, mental, and social well-being in all matters related to the reproductive system and to its functions and processes. Reproductive health therefore implies that women and men can have a safe sex life, and are able to reproduce if, when, and as often as they wish to do so. This in turn implies the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of regulating childbearing. It also requires health services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.

The objectives of the Bank's investments in reproductive health include:

· providing access and choice in family planning;

· caring for women before, during, and after pregnancy;

· preventing and controlling sexually transmitted diseases (including Human Immunodeficiency Virus [HIV], which leads to AIDS);

· preventing and treating cervical cancer;

· promoting the health of adolescents;

· supporting positive health practices.

These objectives are pursued through a range of comprehensive activities in Bank-supported projects in population, health, nutrition, and education, though specific components of projects are always determined in consultation with government officials and beneficiaries to take account of specific country needs.

Reasons for Investing in Reproductive Health

The problems are widespread and serious:

· Illness and death from unwanted pregnancies. Birth rates are still very high in much of the world, and frequent pregnancies are correlated with poor health and poverty. One in five births is unwanted, in part because safe and effective methods of fertility regulation are not available. The majority of the 40-60 million abortions performed per year are unsafe. Between 60,000 and 200,000 deaths from unsafe abortions occur annually, most in developing countries.

· Illness and death from complications of pregnancies. One-third of the 200 million women who become pregnant each year experience complications that require treatment from a trained provider, and one in ten requires hospitalization. But most women in developing countries lack access to basic prenatal and delivery care. As a result, countless millions suffer from preventable or treatable conditions, 15 million develop long-term disabilities, and an estimated half a million die. The infants they are carrying May also be damaged by many of these pregnancy-related complications.

· Illness and death from Sexually Transmitted Diseases (STDs). STDs are a major cause of serious illness and death. They usually affect people in the 15-44 age group, the most economically productive years. In some countries, congenital syphilis is one of the principal causes of illnesses and deaths of newborns. The presence of STDs - especially those associated with genital ulceration - speeds the rate of transmission of HIV, substantially increasing both the susceptibility to HIV and AIDS, and the infectiousness of an HIV- infected individual. Some 20 million people are infected with HIV worldwide, and more than one-half live in Sub-Saharan Africa.

· Illness and death from preventable cancers. Cervical cancer, which is preventable at low cost if detected early, is among the most common cancers in the developing world, causing 183,000 deaths a year. As the incidence of HIV infection increases (women with HIV-induced immune suppression are at high risk of developing cervical cancer), and as developing country populations age during the coming decades, the number of cervical cancer cases can be expected to increase. Breast cancer, which is more difficult and costly to treat, causes 158,000 deaths every year.

· Traditional practices harmful to health. Two million young girls are subjected to circumcision and other forms of genital mutilation every year. These practices can lead to death, acute pain, recurrent urinary tract infections, mental trauma, painful intercourse, and complications during childbirth. Discrimination in the way girls are treated can damage their reproductive health. For example, inadequate feeding during childhood May stunt growth, bringing higher risks of complications during childbirth. Early marriage and adolescent pregnancy are serious problems because of the greater health risks of pregnancy for adolescents than for women in their 20s and 30s, as well as the adverse effects on education and employment opportunities.

The Solutions are Cost-Effective and Feasible:

· Value for money. As background work for the 1993 World Development Report, the Bank, in collaboration with the World Health Organization (WHO), carried out a comprehensive analysis of the disease burden - the amount of premature death and disability attributable to specific diseases and injuries. In combination with information on cost-effectiveness of health interventions, these estimates help set priorities for the health sector and guide governments in redirection of public spending. The 1993 Bank report assesses the cost-effectiveness of a wide range of health interventions and identified a minimum package of essential health services. Reproductive health interventions-including family planning services, prenatal and delivery care, and case management of STDs-are a fundamental part of this minimum package. Clustering services can further increase their cost-effectiveness. For example, providing STD management and prenatal care services, or postpartum family planning and infant care, at the same place and time often promotes positive interactions in health benefits and reduces service delivery costs and women's time and travel costs.

· Cost-effective interventions. Quality family planning services can eliminate the health risks of unwanted pregnancies. Extending prenatal, delivery, and postpartum care to the underserved would substantially reduce the burden of complications and death associated with child-bearing. Because STDs increase the ease with which HIV is transmitted, controlling STDs is one of the most important interventions for containing the spread of AIDS. Prenatal screening and treatment for syphilis and iron supplementation have been recommended for the minimum package, because of the health benefits for mother and child and the low cost of treatment. In developing countries with the financial resources and political will to go beyond the minimum clinical package, a more comprehensive set of services could include appropriate screening and treatment for cervical cancer.

· Benefits to the society. Reproductive health is fundamental to improving human welfare, reducing poverty, and promoting economic growth. Investments in reproductive health have multiple payoffs for families, communities, and the national economy. In particular, reproductive health has a significant effect on the health and productivity of the next generation, in addition to its benefits for the current generation. In contributing to sustainable development through improving equity, quality of life, and economic potential, investing in reproductive health confers widespread benefits to the society as a whole.

Policy and Program Design

From the experience and expertise in reproductive health and human development that the Bank has built up over the years, certain imperatives have emerged in its policy dialogue with member countries. First, convincing governments to build organizational and service delivery capacity to extend reproductive health information and services is critical. Second, reproductive health policies and strategies need to be integrated with social policies that address a range of poverty reduction and human development objectives, including education of girls and empowerment of women. Third, interventions should respond to individual needs and aspirations rather than being driven by top-down demographic targets. Finally, a policy or program needs to address each country's specific situation.

Integrated approaches to reproductive health are more likely to succeed when adequate account is taken of the specific needs of a country, its cultural values, and its financial and institutional constraints. In most cases, an incremental approach will be needed that works toward provision of the essential package on the basis of existing capacity and with initial emphasis on closing the most serious gaps in the reproductive health needs of its population.

(reprinted from Tinker, A., T. Merrick, and A. Adeyi. Improving Reproductive Health: The Role of the World Bank, 1995)

Announcement: Award for writing

Award for Excellence - Women and HIV/AIDS

Family Health International/AIDS Control and Prevention Project (AIDSCAP) and the United Nations AIDS Programme (UNAIDS) announce an international award for excellence in writing on women and HIV/AIDS. The award, as one of several actions launched at the Fourth UN World Conference on Women in Beijing to highlight women and HIV/AIDS, will recognize the journalist who writes the most compelling article about women's ISSUEs related to the epidemic.

Deadline: Submissions must be received by April 15, 1996.

Selection Process: All articles will be judged by an international panel of renowned journalists. The winner will be notified by June 1, 1996.

Criteria: Articles published in a newspaper, magazine or popular journal between April 15, 1995 and April, 15, 1996 are eligible for consideration.

They should be between 750 and 2500 words. The article will be judged based on the following criteria:

· promotes readers' understanding of women's risk to HIV/AIDS;

· promotes readers' understanding of the societal changes needed to

· empower women to protect themselves from infection (and to remove obstacles to them doing so);

· encourages political awareness, commitment and action to respond to the specific needs of women;

· is balanced, accurate, and clear.

Award will include transportation to the Eleventh International Conference on AIDS in Vancouver, Canada (July 7-12, 1996) hotel, per diem, conference registration fee, and a gift in recognition of the journalist's achievement to be presented by the sponsors during the conference.

How to apply: Interested journalists should submit only one article; those published in other languages should be accompanied by a typed, double-spaced English translation. The materials should be sent along with the journalist's name, address, telephone and fax numbers to:

AIDSCAP Women's Initiative/UNAIDS Journalist's Award
Family Health International/AIDSCAP
2101 Wilson Boulevard, Suite 700
Arlington, VA 22201
Tel: (703)516-9779
Fax: (703)516-9781

If you work for a publication, please include a letter from your editor-in-chief stating that you can attend the Vancouver conference to accept the award.


Electronic Newsletter on Population, Health, and Nutrition

The World Bank
Human Development Department (HDD)

In this ISSUE ...

· World TB Day
· Forum on Health Sector Reform

World tb day - March 24

World TB Day, falling on March 24 every year, serves to remind us that the tuberculosis (TB) epidemic is still out of control in many parts of the world, more than forty years after the cure was discovered. In 1996, for the first time, a global campaign is underway to mark World TB Day and to draw international attention to the TB epidemic.

March 24 commemorates the day in 1882 when Dr Robert Koch officially informed the scientific community that he had discovered the TB bacillus. At the time of Dr Koch's announcement in Berlin, TB was raging through Europe and the Americas, and was widely feared. How bad was the epidemic? It killed one out of every seven people in these regions. The medical community heard Dr Koch's presentation with stunned admiration. The doctors knew that his discovery would carry them to a new level of understanding, which would help them in later years to diagnose, cure, and perhaps even eliminate this fearsome killer.

Instead, a century of neglect has followed. Rather than using Koch's discovery and the effective drugs that were later developed to eradicate this disease from the planet, TB has sent at least 200 million people to their graves since 1882.

In many ways, the tuberculosis epidemic is worse now than ever before. TB is still the world's single greatest infectious killer of youth and adults, taking nearly 3 million lives each year. Now, the creation of multidrug-resistant strains of TB is beginning to return the epidemic to the pre-antibiotic era. And HIV is helping the disease to spread faster in some communities than ever imagined possible.

In 1982, on the one-hundredth anniversary of Dr Koch's presentation, the International Union Against Tuberculosis and Lung Disease (IUATLD) proposed that March 24 be proclaimed an official World TB Day. However, except for the activities of a handful of organizations, very little has otherwise been done to highlight the occasion since then.

In 1995, with renewed zeal for collaborative public outreach in the fight to control TB, WHO joined with the IUATLD and a wide variety of other concerned organizations to multiply the awareness and impact of this important day. All groups embraced a plan to commemorate World TB Day worldwide, hoping to make a real difference to the millions of people now suffering and dying from TB.

World TB Day is not a celebration, as there is no victory to applaud as of yet. One of the greatest killers of humans throughout history is alive and well, in spite of our scientific breakthroughs. World TB Day is a time to demand that the effective tools and medicines discovered long ago be put to proper use. It is time to bid TB goodbye.

For information about the global TB epidemic, or for advice on running public relations events to mark World TB Day, please contact:

Courtenay Singer,WHO Communications Officer
e-mail: SingerR@WHO.CH or FightTB@WHO.CH

WHO's 1995 annual TB report can also be found on the web at:

Forum on health sector reform

Update February 1996

The Forum is a small group of experienced senior technical people with a common interest in health policy and health sector reform who meet regularly. Members are drawn from bilateral and international agencies, regional development banks, ministries of health and selected resource institutions. Their backgrounds cover public health and medicine, health economics, social sciences, public administration, and politics.

The group is small and has a relatively stable membership in keeping with its chosen emphasis on informality and continuity. WHO provides the secretariat for the Forum. A current list of members is available.

The aims of the Forum are to:

· share information about the scope and nature of current and planned activities related to supporting health sector reform;

· discuss relevant country experiences as well as different agencies' approaches to supporting the reform process in countries;

· identify priority ISSUEs in health sector reform;

· invite experts to present a range of perspectives on key ISSUEs in health sector reform;

· commission and review discussion papers on priority topics;

· produce and publish a discussion paper series for dissemination.

Members meet twice per year at rotating venues. The first meeting took place in Geneva in December 1993. Subsequent meetings were held in Brussels, Stockholm and Geneva. The next meeting is scheduled for July 1996 in London.

The following titles have been published to date in the Forum's Discussion Paper series:

No. 1: Cassels, A. Health Sector Reform: Key Issues in Less Developed Countries
No. 2: Creese, A and Kutzin, J. Lessons from Cost Recovery in Health
No. 3: Cassels, A. Aid Instruments and Health Systems Development: An Analysis of Current Practice
No. 4: Saltman, R. Applying Planned Market Logic to Developing Countries' Health Systems: An Initial Exploration
No. 5: Paul, S. Capacity Building for Health Sector Reform
No. 6: Kalumba, K. Towards an Equity-oriented Policy of Decentralization in Health Systems under Conditions of Turbulence (coming soon)

Other topics currently under discussion are:

· tracking context, process and outcomes of health sector reform, and
· public sector reform: downsizing, restructuring, improving performance.

New ISSUEs for further exploration identified at the last meeting are human resources policy, and developments in private financing and service provision.

The discussion papers are available free of charge to those in developing countries, although a charge May be levied for multiple copies. Institutions in developed countries will be charged 12 Swiss francs per paper; pay orders May be placed directly with Distribution and Sales, World Health Organization, Geneva, fax: (+41 22) 791 4857.

For further information write to:

Dr Katja Janovsky, Secretary
Forum on Health Sector Reform
National Health Systems & Policies Unit
Division of Strengthening of Health Services
World Health Organization
CH-1211 Geneva 27, Switzerland
Tel: (+41 22) 791 2568
Fax: (+41 22) 791 0746


Electronic Newsletter on Population, Health and Nutrition Issues

Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· Home-Grown Initiatives Bring Better Services to India's Slums
· What's New on the Net?
· Vacancy Announcements

Home-grown initiatives bring better services to mothers and children in India's slums

With one in three of its urban citizens living in abject poverty, India is seeking newer and better ways to target women and children, who account for more than two-thirds of the urban poor. India's centrally controlled Family Welfare Program has made real gains over the past forty years, programs recommended by the World Bank-supported Urban Slums Family Project, which invite local people to define local problems and use private individuals and organizations to provide needed services, promise even better results.

While India's population has more than doubled over the past fifty years, its urban population has nearly quadrupled. Over 200 million people now live in 3,600 Indian cities, one in three of them in abject poverty. This means that 70 million Indians live in unhygienic tenement houses, illegal squatter colonies, or even on pavements with no shelter at all. Every year another 15 million swell their ranks, and nearly 68 percent of these slum-dwellers are women or children. Under its centrally controlled Family Welfare Program, India reduced the rate of infant deaths from 135 per thousand (in the early 1970s) to roughly 80 per thousand (in 1989) and the rate of fertility from almost 6 (in the 1960s) to 3.9 (in 1988). Yet- as Bank-supported family planning efforts in Bombay and Madras have shown- programs devised by communities and carried out in cooperation with private medical practitioners (both allopathic and traditional) and local medical associations can be even more effective.

The five-year, Bank-supported Urban Slums Family Welfare Project therefore proposes to enlist private organizations and medical practitioners to train (and supply with an essential medicine kit) some 21,000 urban health workers and local leaders. When each municipality was asked to assess its own needs for this project, moreover, Calcutta stipulated that three-quarters of its trainees be local women.

The Urban Slums Family Welfare Project will also promote community involvement by supporting supplementary health support schemes run by neighborhood committees (often in partnership with private voluntary organizations) in nutrition, sanitation, and health. To raise the quality of family welfare services and make them more widely available, the project has made a concerted effort to secure the involvement of those private voluntary organizations with established ties in India's slum communities. It will also pay fees and offer free supplies and training to private medical practitioners working in slums.

Finally, to increase demand, the government has initiated a program to educate the populations of Bangalore, Calcutta, Delhi, and Hyderabad about the benefits and availability of family welfare services newly improved under the Urban Slums project.

(Reprinted from Jacques Van Der Gaag, Private and Public Initiatives: Working Together for Health and Education, World Bank, Washington, DC. 1995. This publication is available at our Web site, (select health, then Public and Private Initiatives, Part 1 and 2).

What's new on the net?


Want a copy of the latest OMNI publication without waiting for the mail to come? Need information about the micronutrient situation in Zambia or Sri Lanka? Just pay a visit to the OMNI Home Page at via the Internet to get all the latest information on global micronutrient activities. OMNI is utilizing the vast frontier of the Internet to disseminate information and resources relating to micronutrients and nutrition with the establishment of its World Wide Web Site.

OMNI's web page provides information on a range of micronutrient ISSUEs and OMNI activities in English, French and Spanish. Information is being updated and added continually. Resources include: OMNI publications, such as the OMNI Update series, OMNI Briefs, Micronutrient Fact Sheets and Manuals; information about OMNI Research; descriptions of country projects; how to request OMNI services; information about OMNI partners and personnel; and descriptions of other related organizations. For OMNI, the Web offers another channel for disseminating information.

To visit OMNI's site set your browser to: For more information about OMNI contact:

OPPORTUNITIES FOR MICRONUTRIENT INTERVENTIONS (OMNI) is funded by the Office of Health and Nutrition of the U.S. Agency for International Development (USAID) in Washington, D.C. and managed by John Snow, Inc. OMNI's mission is accomplished by developing integrated, comprehensive programs and strategies to reduce and eliminate major micronutrient deficiencies throughout the developing world. Participating countries are based on their micronutrient malnutrition problems, commitment by local officials (public and private) to micronutrient activities, and their capacity to achieve and sustain a demonstrable impact.

OMNI is located at 1616 North Fort Myer Dr, Suite 1100, Arlington, Virginia 22209 USA
Tel: 703 528-7474
Fax: 703 528-7480


Vacancies: Pan American Health Organization/World Health Organization

Vacancy Notice: 96/PAHO/02
Post Title: Healthy Lifestyles and Mental Health Program Coordinator
Level: P.5
Post Number: .3367
Closing Date: 15 March 1996
Duty Station: Washington, D.C.
Tenure: Two years, first year probationary period
Division/Program/Office: Health Promotion and Protection (HPP)

Basic Salary: $53,611 at single rate, $57,806 staff member with primary dependent (per annum net of taxes) Post Adjustment: $15,869 at single rate, $17,111 staff member with primary dependent (per annum net of taxes)

Minimum Requirements:

Education: M.D. degree with post graduate studies in a social/behavioral science, or a Ph.D. degree in one of the behavioral/social sciences and specialized training to the master's degree level in public health.

Experience: At the national level: Ten years of experience in the field of health promotion, particularly in the planning, implementation, evaluation, and research of health promotion activities in specific settings (communities, municipalities, schools, work place, etc.) Teaching and research backgrounds are an asset.

At the International level: Three years of experience in international technical cooperation programs in health promotion in general, and in the application of behavioral/social knowledge and techniques in public health.

Languages: Very good knowledge of English or Spanish with a working knowledge of the other.

Vacancy Notice: 95/PAHO/42

Post Title: Advisor on Healthy Aging
Level: P.4
Post Number: 4.5352
Closing Date: 15 March 1996
Duty Station: Washington, D.C.
Tenure: Two years, first year probationary period
Division/Program/Office: Health Promotion and Protection (HPP/HPF)
Basic Salary: $45,413 at single rate, $48,824 staff member with primary dependent (per annum net of taxes)
Post Adjustment: $13,442 at single rate, $14,452 staff member with primary dependent (per annum net of taxes)

Minimum Requirements:

Education: M.D. or Ph.D. degree in one of the social or behavioral sciences with training in epidemiology of aging and gerontology or extensive work experience in epidemiology of aging and gerontology. Postgraduate studies in public health would be an asset.

Experience: Seven years in national programs. Two years of international experience.
Language: Very good knowledge of English or Spanish with a working knowledge of the other.
Vacancy Notice: 96/PAHO/03
Post Title: Project Manger for PROMESSES Central Supply for Essential Drugs and Medical Material Project
Level: P.4, Post Number: .6062
Closing Date: 22 March 1996
Duty Station: Port-au-Prince, Haiti
Tenure: Two Years, First year Probationary Period
Division/Program/Office: Health Systems and Services Development (HSP/HSE)
Basic Salary: $45,413 at single rate, $48,824 with primary dependents (per annum net of taxes)
Post Adjustment: $12,761 at single rate, $13,719 with primary dependents (per annum net of taxes)
Hardship/Mobility: $10,148 at single rate, $13,530 with primary dependents (per annum net of taxes)

Minimum Requirements:

Education: A postgraduate degree to a least the master's level in two of the following fields of study: management, business administration, marketing, finance, economics, pharmacy, or a field related to the organization and management of large supply acquisition and distribution projects.


At the national level: seven years of experience in general management in the private sector including teaching/training at the managerial level. At the International level: two years of experience in developing countries preferable at the training/teaching and project level. Experience in project management and knowledge of internal markets would be an asset.

Languages: Very good knowledge of French with a working knowledge of English. Knowledge of other languages would be an asset.

For more information regarding any of the above positions, including information on skill requirements and duties for specific positions, contact:

Pan American Health Organization/World Health Organization
525 Twenty-Third Street, N.W.
Washington, D.C. 20037 USA
Tel: (202) 861-3376; Fax: (202) 861-3379


Electronic Newsletter on Population, Health and Nutrition Issues

Human Development Department (HDD), World Bank
Please address subscription and archive request to:

In this ISSUE ...

· For Those Who Will Be Six in the Year 2000
· What's New on the Net?
· Economist Position, CDC

For those who will be six in the year 2000

The children who will enter primary school in the year 2000 are now preparing for the future. Yet every year, more than 11 million of them die from preventable diseases, and 130 million, most of them girls, do not attend primary school.

What happens to children in the very first few years of their lives-how health care, nutrition and mental stimuli affect their mental, emotional and physical growth-is critical in determining how the rest of their lives will be played out.

"Children whose earliest years are blighted by hunger or disease, or whose minds are not stimulated by appropriate interaction with adults, pay for these early deficits throughout their lives," said Armeane Choksi, World Bank vice president of Human Capital Development. Four out of five of the world's children live in developing countries, where only 1 percent of mothers get any help in rearing infants beyond what is provided by immediate family and friends. Only 1 percent of eligible Sub-Saharan children are enrolled in pre-school programs, and few developing countries have achieved pre-school coverage of even 25 to 30 percent. "Yet none of this need happen," Choksi maintains.

Thirty years of research have shown that early childhood programs can do much to prevent malnutrition, stunted cognitive development and insufficient preparation for school. Such programs can improve primary and even secondary school performance, increase children's prospects for higher productivity and future income, and reduce the likelihood that they will become burdens on public health and social service budgets. A new report released by the World Bank, Early Child Development: Investing in the Future, makes a very strong case for child development programs and provides an overview of the many programs around the world that are targeting children from birth to age eight.

Examples include programs to educate parents in Israel, Turkey and Mexico; training projects for caregivers in Trinidad and Tobago, Kenya and the former East Bloc; programs that deliver services to children in India, Guyana and the Philippines; projects to reform formal education systems in Chile, El Salvador and Venezuela; and those using the media as an education tool in Bolivia, Nigeria and the Philippines. The report also makes very convincing economic arguments, should anyone still have doubts about the benefits of such programs. Some of the programs described in the report are still too new to have established a track record, but many others have been tested and proven effective. "Since the 1980s, the World Bank has opened a new front in its fight against poverty by tripling its lending for health, education, nutrition, reproductive health and other aspects of human capital development," Choksi said. "The Bank's social service lending now averages more than $3 billion a year-substantially more than goes to economic reform programs-making the Bank the largest supporter of social programs in the world."

The social and economic benefits of pre-school programs are obvious: a review of 71 reports and seven long-term studies in the United States showed that programs had positive effects on IQ, abilities and achievement, and that they had the potential to confer important long-term benefits for youngsters living in poverty. Benefits firmly linked to integrated interventions in early childhood included improved nutrition and health; higher intelligence; higher school enrollment; lower repetitions; and fewer dropouts.

Investing in young children increases a country's overall standard of living in many ways. Such investments help build human resources; generate higher economic returns and reduce social costs; achieve greater social equity; increase the efficacy of other investments; and help mothers as well as children. The report discusses various approaches to early childhood development and program design options. It lists children's needs at different stages of development, provides an example of a child development chart, and lists indicators for assessing the success of programs, based on potential benefits. It also gives advice on working with non-governmental organizations and other agencies. A separate section contains valuable information for those involved in determining costs and evaluating cost-sharing arrangements for programs.

The scope and content of child development policy in individual countries will vary with the needs and resources of each country, but certain program goals are recognized as universal: giving economically disadvantaged children the same chance to develop as their more fortunate peers, and addressing children's total needs by providing an integrated package of services in health care, nutrition and psycho-social stimulation.

"Where there is enough political will to do so," the report says, "the potential gains are great." The World Bank, in collaboration with the Asian Development Bank, in 1995 published a companion report to Early Childhood Development (stock no. 13547), titled Improving Early Childhood Development: An Integrated Program for the Philippines (stock no. 13350). It was produced to help in the preparation of a national investment plan for early childhood development and was the first time that either development bank had done a country study to look at the ISSUE in an integrated way, across health, nutrition and early education.

For price and ordering information, call Distribution at (202) 473-1155, fax (202) 522-2627 or e-mail: Early Childhood Development is coming soon to our Website (, then select health)

What's new on the net?

"Leprosy" is an experimental discussion list for scientists, programme managers, agencies and individuals involved and interested in the elimination of leprosy as a public health problem. This was setup by the Action programme for the Elimination of Leprosy (LEP), World Health Organization, Geneva.

The objective is to keep the scientific community, national programme managers and all interested parties informed about the developments /progress towards leprosy elimination. In addition, we hope that the subscribers can raise questions, suggest topics for discussion and assist in providing answers to specific queries received from individuals within or outside the discussion list.

To subscribe, send a message to with one line text in the body: subscribe leprosy

After subscription, posting of messages to the list can be sent to:

The administrator of the Leprosy discussion list can be contacted at:

Currently, the list is not moderated. The list is coordinated by:

Dr V. Pannikar LEP/WHO Geneva Fax: +41.22. 791 4850 E-mail:

For more details on the Action Programme for the Elimination of Leprosy, please visit our Web page: homepage

Economist position

Position: Economist, GS-0110-13 Centers for Disease Control and Prevention (CDC) National Center for HIV, STD and TB Prevention (Proposed), Division of HIV/AIDS Prevention, Program Evaluation Branch Atlanta, Georgia

Duties: Recommends priorities for economic evaluations and policy assessments of HIV prevention activities. Identifies methodologies and designs for cost-analysis, cost-benefits, cost-effectiveness, cost-utility studies and mathematical models. Collaborates with program managers and operatives, scientists, public health experts and officials, and others in the design and implementation of economic evaluations and policy assessments, preparation and dissemination of findings and the application and translation of findings to prevent activities. Maintains expertise in the state of the art regarding economic evaluation analyses. Provides advice and consultation in regard to cost-analysis, cost-benefit, cost-effectiveness, and cost-utility. Provides leadership and technical assistance for the development of research and evaluation projects, study methodology and cost effective interventions. Conducts in-depth analyses of data. Serves as primary resource on economic evaluation ISSUEs and ensures the integrity of assessment findings. Represents the Program Evaluation Branch at meetings. Prepares reports and manuscripts for publication.

Qualification: Applicants must meet the basic requirements outlined in Office of Personnel and Management Qualification Standards Handbook. A. Degree: Economics which included at least 21 semester hours in economics and 3 semester hours in statistics, accounting, or calculus or B. combination of education and experience - courses equivalent to a major in economics, plus appropriate experience or additional education. In addition, applicants must have 1 year of specialized experience equivalent to the next lower grade in the Federal Service.


· ability to apply economic evaluation and policy assessment research methods and analytical techniques.

· ability to design and conduct economic evaluations (cost-benefit, cost-effectiveness and cost-utility analyses) and policy assessments in applied research settings

· ability to prepare and publish manuscripts in peer-reviewed, scientific journals

· ability to collaborate effectively with members of a multi-disciplinary project teams

Application forms must be obtained from and returned to:

Centers for Disease Control and Prevention 4770 Buford Highway, N.E., Atlanta, Georgia 30341-3724 Human Resources Management Office, Operations Branch, ATTN: Central Staffing Activity, Mailstop K-16

NOTE: Application form must show announcement number, position, title and grade(s) for which you are applying.

Refer inquiries to: Deborah Rugg (email: or Bob Moran Tel: (404)639-0952 Fax: (404)639-0929


Electronic Newsletter on Population, Health, and Nutrition
The World Bank
Human Development Department (HDD)

In this ISSUE ...

· Colombia's Education Voucher System
· Seminar Announcement
· Vacancy Announcements

Does Colombia's education voucher system work?

Colombia's cities are surrounded by poor, densely-packed neighborhoods that lack even the most essential services. Few have a sufficient number of public secondary schools, and schools run by church groups or other private voluntary organizations have sprung up to fill the gap. To increase the educational opportunities open to its poorest children, Colombia's government has initiated a Bank-supported, short-term incentive program that grants individual student vouchers usable in private schools.

Although Colombia can now boast nearly universal primary education among its urban labor force, less than half of its children go on to acquire secondary schooling. This is in part the legacy of the country's meager investment in education among the lowest per capita in Latin America in the 1970s and no more than 7.5 percent of GDP throughout the 1980s. Not surprisingly given this investment history, most public schools are now operating on two and even three shifts, and 40 percent of the country's secondary schools are privately owned and run.

In 1991, recognizing that the private sector would have to be part of the solution if the country was to solve its secondary education deficit, the government began granting vouchers (paid for jointly by the central and municipal governments) to poor students to attend private schools. The school voucher program is designed to create 546,000 new school places from 1991 to 1994 and to raise secondary school enrollment from 46 to 70 percent. To upgrade the quality of schools, the national government has also established incentives to commercial lenders (akin to guarantees offered for lending to small businesses) to encourage lending to finance improvements in private schools. Under the secondary school voucher program, municipalities determine the number of vouchers they need and can afford to cosponsor. They also choose private schools to participate. Qualifying schools must have adequate health and educational facilities and be licensed by the Secretary of Education to grant the baccalaureate degree. Private schools will be deemed to provide an adequate quality of education when their students scores on national exams are at least equal to those achieved by students in public schools.

In all the voucher program is designed to reach 45 percent of Colombia's school-age population. As of now, only 87 schools have been chosen to participate, each in a municipality of at least 10,000 with at least three secondary schools. To receive vouchers, students must be fifteen or younger, come from the lowest two economic strata, and have graduated from elementary school. Distribution of the vouchers was weighted to the beginning of the program: 72,000 were distributed in 1992 and 25,000 were given out each year from 1993 to 1995. In 1993 the average voucher cost the government US$143.

Problems encountered so far include municipalities that have shirked their cofinancing responsibilities, thereby putting the future of the program in jeopardy. The problem of substitution where vouchers merely allow students to shift schools rather than increasing overall enrollment could be reduced or even eliminated by better targeting, such as granting vouchers specifically to 5th-graders identified as about to drop out. Vouchers ideally should be targeted to students too poor to attend school without them.

To determine whether or not vouchers increase overall school enrollment and influence the poorest people's education decisions, Colombia is studying two sample populations-one that received vouchers and one that did not. Affects on achievement will be determined by comparing grade-point averages, test scores, attendance records, juvenile delinquency rates, rates of transition to tertiary education, and rates of employment after leaving school. When the results of these studies are in, education policymakers from around the world should be able to draw valuable lessons from the Colombian experience.

(reprinted from Jacques Van Der Gaag (1995) "Private and Public Initiatives: Working Together for Health and Education, The World Bank, Washington, DC)

Seminar series on technology

Information for Action

This seminar series, organized by the APHA International Clearinghouse, focuses on information sharing and support for community development. It highlights the applications of computer networking and multi-media technologies for community action among organizations (particularly NGOs) involved in population, health and nutrition programs. The series is co-sponsored by USAID's Office of Health and Nutrition, World Bank Human Development Department and the Benton Foundation.

April 3, 1996 12.30 - 2.00 p.m.
American Public Health Association
Conference Room A
1015 15th St. NW, Suite 300
Washington, DC
(metro: McPherson Square or Farragut North)
Suzanne Kindervatter
InterAction, Commission on the Advancement of Women (CAW)
Mobilizing beyond Beijing: how women's NGOs are holding governments accountable

InterAction is a coalition of 160 US NGOs working in international development, disaster relief, refugee assistance, public policy and global education. The Commission on the Advancement of Women promotes gender equity in development policy and practice.

For more information contact:

Virginia Yee, APHA Clearinghouse
Telephone 202-789-5686
Fax 202-789-5661
E-mail: or

Vacancy Announcements


Economic Analysis Program Manager

USAID-funded micronutrient project seeks individual skilled in economic analysis to monitor and backstop country and global economic analysis programs. Must have Masters Degree in Public Health, Nutrition, or Economics; at least two years work experience; experience with statistical packages. Spanish proficiency desired.

OMNI is a five-year project funded by the Office of Health and Nutrition of the U.S. Agency for International Development (USAID) to control and prevent micronutrient deficiencies in developing countries. The economic analysis program manager (EAPM) will work under the supervision of the Project Director and Deputy Project Director and with OMNI Technical Advisors and Program Managers. Specifically the EAPM will assist the OMNI advisor for micronutrient analyses to develop, monitor, and backstop country and global economic analysis programs. Additionally the EAPM will backstop other global activities (25% time) working directly with the Project Director. Specific responsibilities and duties include, but are not limited to, the following:

· Serve as key member of the OMNI staff to assist in developing and updating strategies, annual work-plans, activities, budgets, and task orders related to economic analyses and other global activities.

· Coordinate training, capacity building, data collection and analysis and the activities of the country teams working on economic analysis.

· Coordinate consultancies including assisting in recruiting consultants and developing scopes of work; drafting travel concurrence cables and coordinating travel; coordinate technical review, editing, approval and distribution of reports; and organize debriefings and consultancy evaluations.

· Organize and implement workshops and meetings of country teams in Washington

· Track budgets for country activities and monitor use of resources.

· Contribute to country or regional sections of quarterly and annual reports and other reports as requested.

· Travel to countries to establish field offices, train in-country administrative staff, support country planning, data collection, analysis and dissemination activities.

· Maintain regular communications with in-country program staff and host-country subcontractors and subprojects and coordinate feedback and responses.

· Procure equipment and supplies for field activities. Track financial status of activities and in-country offices including processing field accounts and wire transfers.

· Perform other duties as specified by OMNI Project Management.


1. Masters degree in Economics, Finance, Public Health, Nutrition, Public Administration, International Development or related field, and at least two years experience working in the field of international economics, finance, nutrition, health or development, or a Bachelor's degree and at least three years experience in international nutrition, economics, finance, health or development.

2. Ability to work independently and manage various projects on a daily basis with minimal supervision.

3. Ability to work effectively and harmoniously with project staff, subcontractors, consultants, USAID/Washington and Mission staff, other USAID contractors, and representatives of international donor agencies.

4. Strong organizational and communication skills.

5. Proficiency in Spanish is desired but not required. Computer literacy with experience in word processing, spreadsheet, and database software required. Excellent written and verbal English.

6. Developing country experience highly desirable.

Please send your resume to Project Administrator, OMNI Project, John Snow Inc., 1616 N. Fort Myer Drive, 11th Floor, Arlington, VA 22209 or by FAX to 703-528-7480.


Electronic Newsletter on Population, Health, and Nutrition

The World Bank
Human Development Department (HDD)
subscription and archive:

In this ISSUE ...

· Investing in Our Children First
· What's New on the Net: WHO/Global Tuberculosis Programme
· Vacancy Announcement: IFPRI

Investing in our children first

Developing countries can learn from successful programs like the U.S. Head Start Program. By providing children with appropriate health care, nutrition, education, and stimulation in their early years, developing countries can save millions of dollars and help break the cycle of poverty according to a new Bank report entitled, "Early Child Development: Investing in the Future". "No matter the country and cultural setting of such programs, they share a single goal: improving very young children's development and therefore, their prospects for the future," says Mr. Armeane Choksi, World Bank Vice President for Human Capital Development.

The report was prepared by Mary EMing Young, Senior Public Health Specialist for the Human Development Department, was prepared for the upcoming conference "Children First: A Global Forum" that will be held in Atlanta on April 9-12 at the Carter Center. "Children First: A Global Forum" is organized by the Task Force for Future Child Survival and Development and cosponsored by the Annie E. Casey Foundation, the Joseph B. Whitehead Foundation, Centers for Disease Control and Prevention, the Robert Wood Johnson Foundation, UNICEF, World Health Organization, World Bank, the Rockfeller Foundation, UNDP and UNFPA. This forum builds on the World Summit for Children and will address child development ISSUEs including physical, mental, economic, environmental and educational factors necessary for children to achieve their full potential.

Preceding this conference, the World Bank will be hosting a conference on "Early Child Development: Investing in the Future" on April 8-9. Discussions will focus of the conference is on the economics of early child development programs. The goals of this conference is to increase public awareness and policy dialogue concerning the need of young children worldwide; encourage the implementation and expansion of integrated early childhood programs in developing countries, and contribute to the ongoing research and evaluation of early childhood programs. Participants will exchange ideas with leading experts in the field while examining the importance of investing in human capital formation through early childhood programs.

The agenda for the conference was previously archived under filename conf005. It is also available at our Website: (select conf005)

Abstracts for the conference are archived. See next section "What's New in the PHNFLASH archive"

The publication "Early Child Development: Investing in the Future" is available at (select Early Child Development: Investing in the Future)

For more information about Early Childhood Care and Development moderated by The Consultative Group on Early Childhood Care and Development, check the website:

What's new on the net: who global tuberculosis programme

Tuberculosis and the Private Sector: WHO strategy formulation workshop The Global Tuberculosis Programme (GTB/WHO) recognizes that an adequate strategy to deal with the private sector is a necessary part of TB control. As part of ongoing efforts to refine GTB's strategies in this sphere, a global workshop is proposed to be held later in 1996 (tentatively 19th and 20th August). Participation by invitation.

Those interested in coming to this workshop are advised to join and participate actively in the email discussion group on this subject (to join, send the message "subscribe TB-PRIV-L" to "").

Vacancy: post doctoral fellow, IFPRI (Research Program on Urbanization)

The International Food Policy Research institute (IFPRI) is recruiting a Post Doctoral Fellow for its Food Consumption and Nutrition Division (FCND) as part of a multi-country research program analyzing the impacts of urbanization on food, agriculture and nutrition in developing countries. The research aims at generating information that enables the improved design of policies and programs to reduce poverty, food insecurity and malnutrition in urban areas of the developing world. It is anticipated that the Fellow will:

a) contribute to preparation of literature reviews, proposals, and collection and analysis of data (including report-writing);

b) publish research results in leading refereed journals and other fora; and

c) assist in outreach and administrative responsibilities related to the multi-country project.


(Required): Recently or nearly completed Ph.D. in Nutrition or International Nutrition with a basic background in epidemiology. Exceptionally strong analytical skills especially as related to modeling and sampling ISSUEs. Experience in the conduct of fieldwork and analysis of nutrition and socioeconomic data. Experience in working with economists or other social scientists. Strong interests in food security and nutrition ISSUEs confronting urban areas. Fluency in written and spoken English is essential.

(Preferred): Minor in Agricultural Economics, Economics, or Statistics.

Fluency in Spanish or French.

IFPRI offers a stimulating, collegial research environment, competitive salary with excellent benefits and allowances for this two-year, renewable position based on funding and performance. Salary is commensurate with experience and competitive with other international organizations. Please send a detailed letter of interest, curriculum vitae, publications list, a recent relevant publication (non-returnable), and at least three references (names, phone and fax numbers) to: Ms. Jodie Nachison, Head, Human Resources, IFPRI, PD14/FCND/R, 1200 17th Street, NW, Washington, DC 20036, USA. Phone: 202-862-5600; Fax 220-467-4439; e-mail:

Closing date: April 15, 1996. Resumes will be accepted until qualified candidates are identified.

IFPRI encourages applications from female and developing country professionals.

IFPRI is one of the international agricultural research institutes organized under the umbrella of the Consultative Group on International Agricultural Research (CGIAR). The mandate of IFPRI is to identify and analyze alternative national and international strategies and policies for meeting world food needs in ways that conserve the natural resource base, with particular emphasis on low income countries and on the poorer groups in those countries.


Electronic Newsletter on Population, Health, and Nutrition
The World Bank
Human Development Department (HDD)

In this ISSUE ...

· World Bank Supports Safe Motherhood NGO in Uganda
· Vacancies - Global TB Programme, WHO, Geneva
· Peter Berman Book Signing - Washington, DC

World bank supports safe motherhood NGO in Uganda

In 1989, representatives from more than ten women's groups in Uganda pledged to improve the health of mothers in their country. With funds from the Uganda First Health Project, which is financed in part by a loan by the International Development Agency (IDA), they organized a national Safe Motherhood Conference. The aim of the conference was to share information on the causes and dimensions of maternal mortality, and generate ideas and political commitment toward the goal of addressing this problem.

The women's groups then formed a new NGO The Safe Motherhood Initiative for Uganda that received further funding under the First Health Project, as well as from other donors, to develop specific safe motherhood interventions. The NGO focuses on addressing the underlying causes of poor maternal health, specifically lack of knowledge about the risks of pregnancy and childbirth, poor health practices in the community, and the low social and economic status of women. The Initiative's strategy is to educate and mobilize women and their families to prevent maternal health complications from developing and to act quickly when they arise.

The strategy adopted in Uganda also builds on ideas developed and disseminated under the Inter-Agency Safe Motherhood Initiative, comprised of the World Bank, UNICEF, and WHO, among others. This initiative has been supported by the World Bank s Safe Motherhood Special Grant Program to develop safe motherhood strategies, conduct operations research, and design training and advocacy materials to be used around the world. The Safe Motherhood Initiative for Uganda was able to benefit from this investment in strategy and materials development through its contacts with Family Care International, a U.S.-based NGO that provided technical assistance in the design of a pilot safe motherhood project for Uganda.

The pilot project began implementation in September 1990 in eight of Uganda's 34 districts. Project activities included:

· seminars with community representatives to raise awareness about maternal mortality and morbidity;

· survey on women's use of health services and the social, cultural and economic obstacles to use; the establishment of a pregnancy monitoring system to identify pregnant women in the project areas, educate them about good health practices during and after pregnancy, and maintain records on the progress and outcome of their pregnancies; and

· support for local initiatives such as maternity waiting homes and other self-help projects to improve women s health and economic well-being.

After the initial two-year pilot phase, the Initiative expanded its operations to additional districts, as well as new activities aimed specifically at mobilizing men and adolescents. The Safe Motherhood Initiative for Uganda is recognized nationally and internationally as one of the leading NGOs in Uganda working on reproductive health. It serves as a model for other countries; indeed, some of its activities have already been replicated in Nigeria.

(reprinted from Population Network News, volume 13, December 1995)

Vacancies - global TB programme, who, Geneva

The Global TB Programme of the World Health Organisation, in Geneva, Switzerland, is currently searching for public relations specialists to draw attention to the worsening tuberculosis epidemic. Action-oriented individuals are needed who can be contracted for the following advocacy, public relations and writing responsibilities:

PUBLIC RELATIONS SPECIALIST Responsible for promoting World TB Day activities, publicising major reports and conducting other media relations activities. Must have a proven track record of successfully developing and managing extensive, multifaceted publicity campaigns.

Salary: $50,000-$90,000, tax-exempt.

WRITER/PUBLICATIONS SPECIALIST Responsible for researching, writing reports and newsletters on the global TB epidemic. Must be exceptionally talented in writing for both popular and technical health publications, and possess extensive experience managing all facets of the publications process. Salary: $50,000-$90,000, tax-exempt.

ADVOCACY CONSULTANTS Short-term advocacy and public relations consultants are needed who are based in Asia, Africa and Latin America. Must have substantial experience promoting public health ISSUEs and success in influencing public policy decisions.

HEALTH PROMOTIONS FELLOW An opportunity for an exceptionally bright and ambitious health communications graduate student to gain hands-on experience promoting TB control policies in developing countries. Must have five years experience living in a developing country, and posses exceptional verbal and written persuasion skills. Ten-month fellowship with a $20,000 stipend, tax-exempt.

PUBLIC RELATIONS AIDE Short-term contracts are available for qualified graduate students and entry-level individuals to assist in publicising the TB epidemic. Must have previous public relations work or internship experience, and posses excellent verbal and written communications skills. Three month contracts with a $3,000 stipend, tax-exempt.

Interested candidates should send a resume, covering letter and three writing samples (not returned) to: Kraig Klaudt, Global TB Programme, World Health Organisation, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Fax: 41-22-791-4199.

Book signing by Peter Berman - Washington, DC

Dr. Peter Berman, Project Director of USAID's Data for Decision-Making project (DDM), will be in Washington next week to sign his book, "Health Sector Reform in Developing Countries: Making Health Development Sustainable".

The book, funded through the DDM project and published by Harvard University Press, includes papers presented at a joint USAID-DDM conference in Durham, New Hampshire in 1993. The papers written by a distinguished group of international health professionals draw on many sources, including several USAID-supported health activities, to give a comprehensive review of major international health sector reform ISSUEs.

The work reflects on experience with health reform in countries with vastly differing social and economic conditions, including Chile, China, Kenya, Mexico, Sweden, and the Russian Federation. Dr. Berman, who edited the book, is a health economist at the Harvard University School of Public Health. In addition to his work with the DDM project, Dr. Berman has advised USAID field projects on health care financing and reform ISSUEs for many years. He also served overseas with the Ford Foundation in India and with UNICEF in Indonesia. The book-signing will take place on Thursday April 11, at Sidney Kramer Books (1825 I Street N.W., near the Farragut West Metro) from 5:30 -7:00 pm. Wine and cheese will be served.


Electronic Newsletter on Population, Health, and Nutrition

The World Bank
Human Development Department (HDD)

In this ISSUE ...

· Protecting the Poor During Adjustment
· Public Health Physician - Medicins San Frontieres, Cambodia
· Infectious Disease Control Course - LSHTM, UK

Protecting the poor during adjustment

Protecting the poor, especially during transition or adjustment is critical for alleviating poverty and sustaining the reform process. The Human Capital Development Working paper entitled "Protecting the Poor During Adjustment and Transition" by Subbarao et. al reviews the safety net programs implemented in selected countries. In particular, two questions are addressed: "How have countries implemented the programs in practice?" and "What are the lessons learned?". The paper briefly discusses the conceptual ISSUEs underlying the choice between various safety instruments. It goes further to review country experience with five kinds of programs: (i) food subsidies and related interventions, (ii) food for works and other public works programs, (iii) credit-based self-employment programs, (iv) social funds and related interventions, and (v) child allowances. More representative than comprehensive, the selection of programs and countries is based on the availability of rigorous evaluations, the importance of the program, and the ISSUE under consideration.

In choosing between the instruments and their duration and coverage, governments face key ISSUEs, including how much to spend and how to finance programs; how to target assistance to the poor, within politically feasible limits; how to select the most appropriate delivery mechanism; and how to avoid adverse effects on incentives for labor supply and private savings and transfers.

The reviewed program and country experience offers a few key lessons. First, it is essential to institute safety nets as an integral part of the overall package of economic reforms, instead of as "add ons" after the program begins. Second, the instruments should build on, and complement, existing arrangements, both formal and informal. Third, the outreach of programs and benefits must be held in check, and the targeting must be effective in order to avoid (i) adverse effects on incentives to work, and (ii) crowding out private transfers.

In general, social assistance transfers are best financed from the general revenues. However, excessive funding for transfers would either (i) crowd out other developmental expenditures, or (ii) require heavy taxation that could kill incentives and distort results. Therefore, spending levels on poverty-targeted programs have to be low and consistent with the government's overall target for fiscal balance.

The complete report is available for your retrieval under filename hrwp049 (84925 bytes). (See next section for retrieval instructions)

Medicines San frontiers/doctors without borders

Medicines Sans Frontiers (MSF)/Doctors Without Borders is urgently looking for a Public Health Physician for schistosomiasis control program in Cambodia.

Terms of Reference:

Job Title: Schistosomiasis control program physician

Accountable to the project coordinators of Kratie and Stung Treng Provinces and to collaborate closely with the MSF doctor in Sambo

· Job dimension: To work within the country policy of MSF H/B/CH and the rules and protocols of the Ministry of Health (MoH).

· Location: Kratie Province

· Starting date of mission: ASAP

· Minimum Duration of mission: 1 year


· Training: Physician with a strong public health background or an MPH.

· Field experience: MSF field experience is expected, field experience in a research or epidemic control program is an advantage.

· Language: French and English. The language spoken in the hospital and at the MoH is French, therefore a good knowledge of either French or English and a working knowledge of the other is essential.

· Specifications: The incumbent will be expected to work and plan independently and be flexible in the carrying out of the schistosomiasis control program.

For a complete job description and more information, please contact:

Kathleen Dennis
355 Adelaide Street West, 5 B, Toronto, Ontario M5W 1S2
Tel: (416) 586-9820, Ext. 21 ; Fax: (416) 586-9821
(Original posting in


Announcing a New MSC course: control of infectious diseases

Countries with problems of endemic disease, international agencies and rapidly changing health scenarios demand individuals with training in intervention skills. This new course will bridge the disciplines of epidemiology, laboratory sciences and public health & policy, and will train or retrain students who wish to work directly on the implementation of disease control. The course is suitable for the staff of health ministries, regional or local health departments, national or international disease control agencies, international aid organizations, and research institutes.

Students May concentrate on geographical regions, including Europe, or on individual countries. They May also develop specific expertise in the control of particular infectious diseases. Students will have the opportunity of studying an intervention programme with up to two months spent in a suitable location overseas or in the UK.

Full details and application form from Deputy Registrar, LSHTM, Keppel Street, London WC1E 7HT. Tel: +44 171 927 2239. Fax:+44 171 323 0638.


Electronic newsletter and archiving service on human development ISSUEs

World Bank
Human Development Department (HDD)

In this ISSUE...

Priorities and strategies for education: a world bank review
vacancy announcements

Priorities and strategies for education: a world bank review

The following is a foreword by Mr. Armeane Choksi, Vice President of Human Capital Development taken from "Priorities and Strategies for Education: A

World Bank Review," World Bank, Washington, D.C., 1995

Education produces knowledge, skills, values, and attitudes. It is essential for civic order and citizenship and for sustained economic growth and the reduction of poverty. Education is also about culture; it is the main instrument for disseminating the accomplishments of human civilization. These multiple purposes make education a key area of public policy in all countries. Its importance is recognized in several international conventions and in many national constitutions. In 1990 it was the subject of a landmark international meeting: the World Conference on Education for All, held in Jomtien, Thailand, under the joint sponsorship of the United Nations Development Programme (UNDP), the United Nations Educational, Scientific, and Cultural Organization (UNESCO), the United Nations Children's Fund (UNICEF), and the World Bank.

The civic purpose of education - the sharing of values throughout society - is becoming more salient in light of the widespread political liberalization of the past decade. This trend, which is most notable in Eastern Europe and Central Asia, also includes the consolidation of civilian democratic rule in Latin America, the introduction of multi-party systems in Africa, and the devolution of political power to subnational levels of government in many regions of the world. Research and experience have also led to a deeper understanding of how education contributes to economic growth, the reduction of poverty, and the good governance essential for implementing sound economic and social policies. In line with these changing circumstances and perceptions, the World Bank's financing of education has grown rapidly in the past fifteen years, and the Bank is now the single largest source of external finance for education in low- and middle-income countries. Projects to support primary and lower-secondary education - basic education - have become increasingly prominent in Bank lending for the sector. This emphasis is in harmony with the recommendations of the World Conference on Education for All.

The expansion of World Bank lending for education has been accompanied by a series of studies on education policy in developing countries: Education in Sub-Saharan Africa (1988), Primary Education (1990), Vocational and Technical Education and Training (1991), and Higher Education (1994). In addition, recent World Development Reports - Poverty (1990), The Challenge of Development (1991), Investing in Health (1993), and Workers in all Integrating World (1995) - have highlighted the importance of education for development.

To order a copy of the report electronically, check out the publications Homepage at:

The World Bank Bookstore
For a mail order copy, contact: The World Bank Bookstore
1818 H St., N.W., Department T-8051
Washington, D.C. 20433
Tel: (202)473-1155 or Fax: (202)522-2627

Vacancy announcements

Global TB Programme, World Health Organization (WHO), Geneva, Switzerland
- Public Health Specialist (Medical Officer or Scientist)

Closing date: May 31, 1996

WHO is currently recruiting a public health specialist (medical officer or scientist) for its Global Tuberculosis Programme (GTB), based in WHO Headquarters in Geneva. The GTB mission is to lead, strengthen and support the international community to eliminate TB as a global public health problem, especially in poor and disadvantaged communities. The selected applicant will work in the National Programme Support Unit (NPS), which has the following three objectives: (i) establish effective National Tuberculosis Programmes; (ii) Expand the knowledge base on TB control; (iii) establish globally accepted norms for TB control.


- degree in medicine or other health sciences and postgraduate degree in public health

- minimum five years experience in disease control programmes, preferably in several countries, experience in team leadership and negotiation for infrastructure and policy change at national or international level

- excellent writing and public speaking skills, as well as diplomacy and proven ability to work in an international environment. Specifically, the ability to articulate compelling reasons for the Programme approach and the rationale behind its strategy

- Good technical competence in establishing and managing TB programmes is an asset, as well as the ability to assess strengths and weaknesses of existing TB control activities.

The incumbent will be working as technical backstop from Headquarters to TB control activities organized by WHO's Regional Offices, in particular the African Region. He/she will provide direct technical assistance to high priority countries, assist NPS to develop programme policy and technical guidelines and monitor the trend of the global TB epidemic.

Net annual salary: US$ 90 000 to 100 000, depending on qualifications.

Interested candidates should send a resume and covering letter to:

Dr Sergio Spinaci, Chief, National Programme Support, Global TB Programme, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland;

Fax: +41 22 791 4199 or e-mail:
The Micronutrient Initiative (MI)- Senior Programme Officer, Food Technology Specialist
Closing date: June 14, 1996.

The MI is an international secretariat housed within IDRC (International Development Research Centre) whose mission is to facilitate the achievement of global goals related to the elimination of micronutrient deficiencies. The MI is governed by a Steering Committee comprised of representatives of its sponsoring institutions which include IDRC, CIDA, the World Bank, UNICEF and the UNDP. The MI is currently seeking for a food technology specialist for the Ottawa office.

Working within the framework of the MI's strategy and program priorities, the incumbent will identify opportunities for MI support in food fortification and technology development and transfer; promote public-private partnerships; assess and develop proposals; manage and evaluate projects; and provide specialized advice and professional guidance to external contacts working to advance efforts to fortify commonly eaten foods (eg., flour, fats and oils) with micronutrients.


- Graduate degree in food sciences or food technology or field related to the food industry. An equivalent combination of education and experience will be considered;

- Minimum 10 years working experience in progressively responsible positions in the private or public sectors, program development and administration;

- Demonstrate ability to work and communicate with food industry leaders, government representatives, development assistance managers, and researchers in industrialized or developing countries;

- Demonstrate high level of familiarity with international ISSUEs pertaining to sustainable development coupled with working experience in developing countries, and proven ability to operate with tact and sensitivity to socio-cultural differences;

- Able to undertake travel assignments.

Experience in a developing country, and bilingualism are definite assets.

TERM: Two year contract

Qualified candidates should forward their CV and covering letter to:

Competitions, Office for Human Resources, IDRC, PO Box 8500, Ottawa, Ontario, Canada K1G 3H9
fax: (613)238-7230

Salary commensurate with experience.

United Nations Administrative Committee on Coordination (ACC)/Sub Committee on Nutrition (SCN), Geneva, Switzerland - Technical Secretary
Closing Date: May 24, 1996

Responsible for tasks assigned by the SCN to the Secretariat in the implementation of the mandate given by the ACC, notably:

- to prepare, organize and service meetings of the ACC SCN, its Advisory Group on Nutrition, as well as symposia, working parties, seminars, or other meetings convened by or under the auspices of the SCN. The work involves preparation of technical and non-technical documentation for discussion, participation in the work of the meeting, and drafting of reports and conclusions of the meetings.

- prepare work programs for the SCN for consideration by the SCN and other ACC subsidiary bodies requiring submission of a biennial budget for endorsement by the SCN, as well as a program of work to be carried out within the context of the SCN's mandate.

- to manage agreed programs of work of the SCN involving:

· collection, analysis and publication as appropriate of data and information on aspects of international nutrition, in close collaboration with participating UN agencies and other collaborating institutions

· compilation and interpretation of information in relation to implications for policies and programs affecting nutrition

· selection and recruitment of consultants and experts to assist in carrying out the tasks

· arranging for production, publication and distribution of SCN reports, bulletins, and other publications

· ensure provision of funds for program activities from participating UN agencies, bilateral or other governmental or non-governmental agencies

- to ensure follow-up action on decisions and recommendations made at meetings of the SCN, and other UN fora, keeping members currently informed

- to bring attention of the SCN, individual members, or the AGN, as appropriate, matters deemed to require attention of the bodies concerned, together with recommendations or suggestions suitable for action

- to represent ACC/SCN, together with its chairman where appropriate, at meetings of other international, governmental, or non-governmental bodies as well as bilateral agencies and the scientific community, thus inter alia contributing to advocacy of the cause of nutrition

- responsible for work of the Secretariat including technical contents of reports and publications. Involves supervision of staff, issuance of all documentation, maintenance of financial control over the income and expenditures, including report to donors, communications with all participating and collaborating bodies, and the physical accommodation of the Secretariat

- to perform such other duties as required, notably as requested by the Chairman, SCN


- University degree in nutrition, health, social science or closely related field, including aspects of agriculture, with appropriate postgraduate training; either undergraduate or postgraduate qualification should include a concentration in nutrition

- 10 years experience, including field experience in nutrition, nutritional policy and programs and related subjects

- experience in quantitative analysis (e.g. epidemiology, policy analysis) in relation to nutritional status and its determinants, desirable

- full working knowledge of English, working knowledge of other official UN languages desirable

- ability and initiative to supervise a UN interagency activity including strong drafting ability as well as ability to work harmoniously with officials from UN member countries and with other international governmental and non-governmental organizations familiarity with current problems in international nutrition, in particular those of developing world

Terms: Two years, with possibility of extension

Submit CV format of any one of the UN organizations, supplemented with any details deemed important, including a covering letter to: Chairman, ACC/SCN, c/o World Health Organization, 20 Avenue Appia, CH 1211 Geneva 27 Switzerland; fax: 41 22 798 88 91, tel: 41 22 791 04 56, e-mail:


Electronic newsletter and archiving service on human development ISSUEs

World Bank
Human Development Department (HDD)

In this ISSUE...

· Social Indicators of Development
· XVII International Vitamin A Consultative Group (IVAGC) Meeting
· Health Care Alliance Seek Partnership in Bosnia-Herzegovina

Social indicators of development

The world's poor are concentrated in 65 low-income countries, mainly in Sub-Saharan Africa and South Asia, with a population of 3.2 billion and a per capita income of $390 a year. Most live in rural areas; lack adequate access to safe water and other basic services; nearly 40% of their children are malnourished and over 40 percent of their children are malnourished; and over 40 percent of primary school-aged children are not enrolled in school. These statistics are disheartening, yet over the past 20 years, significant progress has been made in improving social conditions in these countries, especially for women and children, who make up the majority of the world's disadvantaged.

· Fertility rates are declining in low-income countries, from 5.6 births per woman in the early 1970s to 3.3 in 1994. This decline has not been evenly spread. Over this period, fertility declined by nearly 40 percent in South Asia, but only by slightly more than 10 percent in Sub-Saharan Africa.

· Declining fertility has been accompanied by significant increases in access to education, especially for girls. In South Asia, primary school enrollment rates increased dramatically from 50 percent of all school-age girls in 1970 to 87 percent in 1993. In Sub-Saharan Africa, enrollment rates increased by 50 percent. In low-income countries as a whole, enrollment of girls increased by about 20 percent, while total primary enrollment increased by over 40 percent.

· Preventive health care has improved. For example, childhood immunization against measles in low-income countries has risen from 50 percent of children in 1985 to 86 percent in 1992, with South Asia showing the most dramatic increase. Access to health care in South Asia rose from 54 percent of the population in 1980 to 96 percent by the end of the decade, and access to safe water increased from 50 percent of the population to 70 percent over the same period.

· As a result of these improvements, children born in low-income countries in 1994 can expect to live, on average, 63 years, compared with 54 years for those born 20 years ago.

Improving living standards and reducing poverty nevertheless continue to pose challenge to governments and the development community. Around 1.3 billion people (1993 estimate) in the developing world live on less than one dollar a day. Because this figure conceals large regional differences, poverty will remain a persistent problem requiring concerted efforts.

Thirty-nine percent of the world's poor live in South Asia, while only 17 percent live in Sub-Saharan Africa. But nearly 40 percent of Sub-Saharan Africa's population is below the poverty line, and the region has seen a gradual erosion of living standards over the past two decades. Real per capita income declined, reflecting weak economic growth and a rapidly rising population. A few countries have experienced increases in infant mortality, decreases in life expectancy, and slight increases in child malnutrition. Others have experienced some deterioration in the provision of social services: fewer people today than in the 1970s have access to safe drinking water, and primary school enrollment rates have fallen or leveled off by contrast, East Asia - with the exception of China - has reduced the share of its population living in poverty, from about 23 percent in 1987 to 13.7 percent in 1993. Annual GNP per capita growth rates accelerated from 4.3 percent in 1970-75 to 7.2 percent in 1989-94; over the same period, population growth rates declined from 2.3 percent to 1.4 percent. In countries such as Indonesia, the proportion of people living below the poverty line declined from 45 percent in the early 1980s to 17 percent a decade later. Per capita income rose from $230 in 1975 to $880 in 1994; infant mortality was more than halved; and access to basic services, such as safe drinking water and education increased. Much of the progress in this region reflects a policy of fostering broad based economic growth, coupled with the expansion of basic services and major investments in human capital.

(Patel, Sulekha, "Social Indicators of Development," in Finance and Development, volume 33, number 2, June 1996)

The article is based on information available in Social Indicators of Development (SID) 1996. SID provides social and economic indicators for 191 countries and is ISSUEd in diskette and in print. To order, contact: World Bank at by e-mail, fax: (202)676-0581 or tel: (202)473-1155

The ''scientific'' and ''programmatic'' come together to fight vitamin a deficiency at the xvii ivacg meeting in Guatemala

"Virtual Elimination of Vitamin A Deficiency: Obstacles and Solutions for the Year 2000" was the theme of the XVII International Vitamin A Consultative Group (IVACG) Meeting, held March 18-22 in Guatemala City, Guatemala. Representatives from 66 countries were among the 484 policymakers, programmers, and scientists in health, nutrition, agriculture, and development who attended the meeting.

USAID which supports a variety of programs through the OMNI Project to combat vitamin A deficiency, sponsored 60 participants to attend the five-day meeting. Among the USAID/OMNI-sponsored group were representatives from India, Bangladesh, Sri Lanka, Indonesia, Thailand, Ghana, Tanzania, Malawi, South Africa, Ecuador, Bolivia, El Salvador, Nicaragua, Brazil, and Egypt. For these participants, the meeting provided an opportunity to share project experiences from their countries, to strengthen working relationships, to make valuable contacts, and to gather useful information all in one place in order to develop and implement policy and to strengthen national programs.

New data on the prevalence of vitamin A deficiency showed that progress is being made. More countries recognize the existence of vitamin A deficiency as a public health problem than at the time of the last IVACG meeting in 1994. In addition, the World Health Organization documented a shift in the severity of vitamin A deficiency being reported at the country level. Several countries have moved from the severe vitamin A deficiency category to the subclinical category.

As a result the IVACG Meeting being in Guatemala, where sugar fortification has been implemented successfully, this year's meeting had a greater emphasis on fortification than ever before. Fifty of the participants visited a nearby vitamin A premix factory and sugar mill.

The Guatemalans shared their more than 20 years of experience in fortification including problems they have encountered over the years. These include the lack of quality assurance and problems with the high humidity and its effect on the vitamin A fortificant. OMNI introduced its newly published three-volume Manual for Sugar Fortification with Vitamin A, which was received with great interest by meeting attendees which will result in those responsible for vitamin A fortification of sugar in other countries having the most recent technical information at hand.

For the OMNI program managers attending the meeting IVACG offered a rare opportunity to work with all of their country groups face-to-face in one location. They were also able to bring people together from different countries facing similar ISSUEs to share what has worked or not worked in micronutrient interventions. The participant from Nicaragua, for example, met the participants from Bolivia and discussed Bolivia's recent sugar fortification experience.

For OMNI Project Director Dr. Ian Darnton-Hill, one of the most exciting things to come out of this year's meeting was the results of a study on home gardens presented by Martin Bloem of Helen Keller International (HKI). "We already know that the income generated from home gardens generally goes to women who spend more on food and who, as they become more empowered, generally have fewer but better nourished children. But Martin's presentation, based on work done in Bangladesh, showed for the first time that home gardens actually had a biological impact on both mothers' diarrhea and on maternal night blindness," said Dr. Darnton-Hill. "While there tends to be a feeling of tension at these meetings between the pure scientists and the increasing number of programmatic people attending, Bloem's study was the best example of the scientific and the programmatic coming together."

The XVII IVACG Meeting was co-hosted by the International Vitamin A Consultative Group and a local organizing committee coordinated by the Institute of Nutrition of Central America and Panama (INCAP), and funded by USAID. IVACG is administered by the OMNI Partner, International Life Sciences Institute (ILSI). The International Vitamin A Consultative Group was established in 1975 to guide international activities aimed at reducing vitamin A deficiency in the world.

For more information, contact:

OMNI 1616 North Fort Myer Dr, Suite 1100, Arlington, Virginia 22209 USA Tel: 703 528-7474 Fax: 703 528-7480 E-mail: WWW:

Health Care Alliance/USAID

Seek US Health Care Institutions for Partnership Project in Bosnia-Herzegovina

WASHINGTON, DC - The American International Health Alliance, Inc. (AIHA) and the USAID announce the planned expansion of their health care partnership program with a new partnership in Tuzla, Bosnia-Herzegovina. AIHA is soliciting expressions of interest from qualified US hospitals and health care institutions willing to devote substantial in-kind resources, mainly in the form of human resources committed on a volunteer basis, to a two-year partnership with counterparts in Bosnia.

The new health care partnership will be part of an ongoing health care development program financed through USAID and managed by AIHA which includes forty partnerships in nine countries of Central and Eastern Europe (CEE) and ten republics of the former Soviet Union. AIHA partnerships have enabled American health care providers to work with their colleagues abroad to address significant mortality and morbidity ISSUEs, improve health care organizations and introduce market-oriented solutions to health system delivery problems. The emphasis of the program is on professional exchanges involving physicians, nurses, administrators and technicians. AIHA partnerships also collaborate with related ministries of health, local and regional health systems administrations, and schools of health sciences to ensure that critical areas of health education and administration are adequately addressed at these higher institutional levels, and that the capacity to carry out other developmental assistance efforts is enhanced.

The new partnership in Bosnia is intended to further USAID's objective of promoting ethnic reconciliation and strengthening the on-going peace process. USAID and AIHA believe that the partnership will reinforce the credibility of the new Muslim-Croat Federation - a cornerstone of the Dayton agreement - by providing tangible evidence that the Federation can serve local needs.

The Bosnia partnership will share certain goals with existing CEE partnerships, namely improving medical and technological knowledge, expanding the role of nursing, and enhancing institutional management and financing skills to develop in the Bosnian institution a capacity to sustain itself financially. Moreover, the partnership will develop community-based programs impacting the populations served by the Bosnian partner institutions by, for example, improving the delivery of primary care and strengthening linkages between hospital and primary care practitioners.

According to USAID, the success of the Federation ultimately will depend on "the political will of local communities of Croats and Bosnians to devise the institutional means to begin their own recovery." At a later stage of the partnership, AIHA anticipates that the community-based programs will develop an active multi-sector community participation that would encourage local leaders to work together to determine local priorities and implement community-based intervention strategies.

AIHA and USAID expect that the CEE partner will be located in Tuzla, a city in north-eastern Bosnia where the U.S. military presence is centered. The hospital component of the partnership May target critical medical/surgical procedures, emergency medicine, or rehabilitation at Tuzla's teaching hospital in addition to management training and development. The focus of the partnership's community outreach component will depend upon the priorities of the Bosnian partners.

AIHA/USAID is not the principal funding source for partnership activities, but rather supplements the voluntary and in-kind contributions of the partners and their respective communities in the US and abroad. Existing AIHA partnerships have leveraged nearly three dollars of voluntary support for every US government dollar expended. AIHA/USAID funds will mainly support travel and other costs essential in establishing and realizing the full potential of a partnership program, including communication and interaction with other partnerships. AIHA staff in Washington, DC and in Europe will provide logistical support and assist in monitoring the progress of the partnership.

Interested US partners must have the willingness and capacity to meet the specific health care delivery needs described above, and must satisfy the following criteria:

· Be institution-based - e.g., a hospital or group of hospitals; health care planning consortium sponsoring a healthy communities project; other institutions engaged in the implementation and/or the evaluation of a healthy communities project. If a group of institutions is involved, a lead institution must be designated;

· Be supported by the institution's senior leadership and Board and clearly identify an overall partnership coordinator;

· Make substantial voluntary commitment to the partnership through significant contribution of resources, including human resources;

· Actively involve the local community served by the US partners, including any significant emigre community that May be present;

· Share information openly and participate fully in AIHA's efforts to exchange information with other US/CEE and US/NIS partnerships through the AIHA Partnership Clearinghouse and dissemination conferences and seminars;

Adhere to AIHA's rigorous objective-setting and results-oriented approach, including:

(a) Enter into a formal Memorandum of Understanding (MOU) and work within the overall coordination and guidance of AIHA and its designated program coordinator;

(b) Develop demonstration-type interventions with significant training components and capacity for replication;

(c) Establish mechanisms (such as training programs and conferences) for the diffusion of partnership successes; and

(d) Participate in regular program evaluations to assess partnership progress and achievements.

Hospitals or health care institutions wishing to be considered for participation in the new Bosnia partnership should send a short statement (10 pages maximum) by JUNE 15, 1996 detailing their interest and ability to enter into a collaborative relationship with a Bosnian partner under the AIHA model. The statement should describe the institution's commitment to the partnership program, the human and material resources it will devote to a partnership, and specific strengths of the institution that enhance its ability to address the needs of the Bosnian partner. Working with USAID and an outside advisory panel, AIHA will select the institution or group of institutions which best match the needs of the Bosnian partner, best fulfill the criteria listed above, and offer the greatest potential for sustaining a partnership beyond the availability of AIHA funding.

Statements should be directed to :

Mr. Donn Rubin Program Director, Central & Eastern Europe American International Health Alliance, Inc. 1212 New York Avenue, NW, Suite 750 Washington, DC 20005
For additional information contact Mr. Rubin, or Elizabeth Schroth,
Program Analyst. Tel: (202) 789-1136; Fax: (202) 789-1277.


Electronic newsletter and archiving service on human development ISSUEs
World Bank
Human Development Department (HDD) e-mail:

In this ISSUE ...

· Capacity, Capital and Calories: 9th Annual Martin Forman Memorial Lecture
· New Publication: Global Burden of Disease and Injury Series
· Vacancy Announcements

Capacity, Capital and Calories: 9th Annual Martin Forman Memorial Lecture

Due to the overwhelming response, we are including an abstract of the Ninth Annual Martin Forman Lecture.

Abstract of "Capacity, Capital and Calories," the Ninth Annual Martin J. Forman Lecture, delivered by Beryl Levinger, Ph.D., on June 10, 1996 in conjunction with the annual meeting of the National Council for International Health.

This lecture offers a conceptual model for human capacity development and then explores the role of nutrition within that framework. The concept of "participation opportunity" is essential to the model and is defined as "any productive interaction that enables individuals to contribute to the development of their nations, communities, and families." Participation opportunities span the course of a person's life cycle and include the chance to go to school, secure gainful employment, influence civic affairs, raise a healthy family and protect the environment. Human capacity development occurs when available participation opportunities are accessed. The process of accessing existing participation opportunities creates a mutually reinforcing cycle wherein new participation opportunities are created for oneself and others.

This model of human capacity development is concerned with activities that transcend what has been the traditional focus of human capital or human resource development: the individual as labor force participant. In contrast, human capacity development is concerned with a broader range of roles and behaviors. In particular, it is rooted in the very qualities that make homo sapiens human: creativity, love, learning, and social interaction. This is reflected in the model's emphasis on flexibility, collaborativeness, adaptability, and problem-solving skills in the context of four core domains: family living, livelihood, civil society and environment. Individuals are, thus, valued in terms of the many roles they play over the course of their lives: comunity member, learner, earner, consumer, parent, partner, environmental steward and citizen. The underlying assumption of the model is that in each of these roles, individuals make choices that have a direct and profound bearing on the quality of life that they, their families, and their fellow citizens will enjoy.

In the context of such a model with its emphasis on participation and the factors that predispose individuals to participate, the importance of nutrition as a development discipline grows significantly. There is a persuasive body of evidence, summarized in the lecture, to suggest that, throughout the lifespan, an individual's participation behaviors are profoundly influenced by current and prior nutritional status. Adaptations to malnutrition generally involve an increase in resting and inactivity. Such a response is both an individual and societal problem since those who fail to avail themselves of existing participation opportunities also fail to create new ones for others.

The lecture concludes with a series of recommendations addressed to the international development community in general and the international nutrition community more particularly. Included among these are the following: 1) the need to move beyond nutritional status changes and also consider behavioral outcomes associated with nutrition interventions; 2) the need to link demand for participation opportunities to nutritional status in project planning, implementation and evaluation; and, 3) the need to rethink institutional capacity development in accordance with the paradigm presented.

For the entire text of this message please check the listing in the archives (conf007).

Global burden of disease and injury series

"Global Burden of Disease and Injury Series," edited by Christopher J.L.

Murray and Alan D. Lopez.

The series is published by the Harvard School of Public Health on behalf of the World Bank and the World Health Organization and distributed through Harvard University Press.

It describes a new approach to assessing the state of the world's health, an approach that has generated global health data unprecedented in their completeness, comparability and objectivity. To compile these data, over 100 researchers collaborated on the five-year Global Burden of Disease Study (GBD). This series presents the GBDs updated fifth round of results.

The Global Burden of Disease (Volume I) provides an overview of the methods and results of the GBD Study, presenting a portrait of the world's health that is exceptional for its breadth, its level of detail, and its technical rigor. While it minutely examines causes of death, the GBD is unique among studies of health status in its inclusion of non-fatal health outcomes. The resulting statistical tables and in-depth conclusions provide illuminating information of interest to anyone concerned with the health of populations.

Global Health Statistics (Volume II) provides useful epidemiological statistics for 240 important sequelae included in the GBD. In this volume, an encyclopedic set of tables presents internally consistent and objectively determined estimates for widely used, standard epidemiological measures: mortality, incidence, prevalence, duration, average age of onset, and projections of deaths. These data are disaggregated in ten age-sex groups and eight regions. Formatted for readers of English, French or Spanish, this volume's succinctly presented data set is intended for broad use. It should stand as an unparalleled desktop reference for anyone interested in the patterns of disease within populations.

To order contact Harvard University Press: Tel: 617-495-2480
Fax: 617-495-8924 , Web order form:
For more information:

Vacancy announcements

Needed: Technical Consultants for Evaluation in Russia and Ukraine The Institutional Partnerships Project (IPP), under a three-year cooperative agreement between the International Research and Exchanges Board (IREX) and US Agency for International Development (USAID), funds and fosters partnerships between US educational institutions, professional associations, and trade organizations and counterparts in the Russian Federation and Ukraine. The project's goal is to assist the newly independent states (NIS) to grow stronger as institutions, build their capacity to provide professional-level training, and improve their member services.

IPP is currently recruiting short-term technical consultants to act as outside evaluators for the project's 16 Russian-American and six Ukrainian-American partnerships. The focus of these evaluations will be to assess the technical merit and appropriateness of the work being done by the partners. IPP cannot support international travel for evaluators and is only seeking candidates currently based in Russia or Ukraine or those who can support their own travel. Assignments will vary from one to six weeks and will take place this fall.

Preferred Qualifications:

· Technical expertise in one of these areas: Agriculture; Health; Environment; Engineering; Energy; Democratization; Local Government; Human Rights; Housing; Disabilities; Infrastructure; NGO Development; and Economic Restructuring;

· Background in professional and/or continuing education and training;

· At least 1 year of work experience in the NIS;

· Advanced knowledge of English and Russian and/or Ukrainian;

· Prior experience evaluating international technical assistance programs; and

· Excellent analytical writing skills

Please fax or e-mail resume to 202-628-9818 or to JWARNER@IREX.ORG. Resumes received by July 25, 1996 will receive preference.

Positions Available (2) at the American International Health Alliance (AIHA), Washington, DC

AIHA is a non-profit group which supports health care assistance in the NIS and CEE under grants from USAID.

Please respond BY JULY 15, 1996 to:

Human Resources
PO Box 28056
Washington, DC 20038-8056


AIHA is currently seeking an Information Analyst to assist in projects working with health care professionals/medical librarians in the former Soviet Union and Central and Eastern Europe. The Information Analyst will assist in the development of educational programs, provide both onsite and on-line training, and be responsible for developing on-line resources.

The position requires: Master's degree in Library Sciences, familiarity with the Internet, and previous experience in health and medical resources. Russian/Eastern European studies background and reading knowledge of Russian is preferred. Salary: $26,500.

Manages portfolio of partnerships, including logistics support, monitoring work-plan progress, projecting and analyzing expenses and ensuring adherence in AIHA/USAID policies. Maintains documentation and data; oversees special projects, including clinical task forces. Acts as liaison with AIHA Regional Offices.

Requires B.A./B.S., preferably with concentration in Eastern European Studies, Health Policy, Management and Planning, International Relations, International Business, or Economics; graduate work desirable. Knowledge of spreadsheet and word processing software as well as foreign language skills (E. European) are advantageous, but not required.

Salary: $21,500-$27,500.


Electronic newsletter and archiving service on human development ISSUEs
World Bank
Human Development Department (HDD) e-mail:

In this ISSUE...

· India's Family Welfare Program: Direction in Development Report by Anthony Measham and Richard A. Heaver

· Program for Adolescent Mothers in Jamaica - Family Health International

· Vacancy Announcements

India's Family Welfare Program: Directions in Development Report

The World Bank's Direction in Development Report - 'India's Family Welfare Program: Moving to a Reproductive and Child Health Approach' focuses on how the Family Welfare Program (FWP) can carry out the commitment (given at the Cairo population conference) to implement a client-centered approach that responds more effectively to the reproductive health and family planning needs of women and men in India. The report, written in collaboration with the Ministry of Health and Family Welfare, aims to identify specific constraints that stand in the way of reorienting the FWP toward a reproductive health approach and to delineate feasible actions which can be taken to overcome them.

The 1994 Cairo International Conference on Population and Development formalized a growing international consensus that improving reproductive health, including family planning, is essential to human welfare and development. This brings to light the crucial distinctions between the overall goals of a population policy and those of a reproductive health program.

The Indian Family Welfare Program, now in its fifth decade, has made important contributions to improving the health of mothers and children and providing family planning services. During the past decade its focus has gradually shifted away from family planning and toward a general effort to improve maternal and child health. However, problems of access to services and the quality of services continue to plague the program. These ISSUEs have to be addressed if the program is to become more client-centered.

Some key ISSUEs which need to be resolved are :

1. Moving away from numerical, method specific contraceptive targets and incentives to a client-centered approach. It has been recognized that contraceptive targets imbue the FWP with a demographic planning emphasis that is antithetical to the reproductive health approach. It is suggested that the government develop a broad system of performance goals and measures which focus on a range of reproductive services.

2. Expanding the use of male and reversible contraceptive methods and broadening the choice of contraceptives. Male contraceptive methods account for only 6 percent of current contraceptive use. There is an urgent need to promote the use of condoms as a contraceptive method and as a means for preventing the spread of the HIV/AIDS epidemic. Although female sterilization still accounts for 75% of modern contraception methods there is still a high unmet need for reversible methods. Therefore increasing contraceptive choice for individuals deserves a high priority.

3. Improving the breadth, access and quality of services; and involving communities (women's groups, those representing the poor, scheduled castes, scheduled tribes) in the operations of the FWP is critical. Although community involvement has been growing over time, the potential for playing a larger role is enormous, and the benefits of such involvement are likely to be considerable.

4. Strengthening the role of the private sector The private sector accounts for three-quarters of all health expenditures in India and emphasizes curative rather than preventive care. Social marketing, private medical practitioners and private voluntary organizations (PVOs) are three components of the private sector. The report recommends assessing the current system for marketing of contraceptives and additional health and nutrition products, supporting and promoting the involvement of private practitioners in reproductive and child health care by providing training and overhauling the operational systems of PVOs thus allowing them to be strengthened and more focused on reproductive concerns.

5. Adequate funding for the current program and expansion of the reproductive health approach. The FWP is substantially underfunded particularly in the areas of facilities, staffing and transport. The public sector will need to increase its budget in these areas and have a central role to play in financing the reproductive and child health package of services. Additional discussions on financing can be found in the report on health finance (World Bank 1995e) and the India Country Economic Memorandum.

To order a copy of the report electronically, check out the Publications Homepage at:

For a mail order copy contact:

The World Bank Bookstore
1818 H St., N.W., Department T-8051
Washington, D.C. 20433
Tel: (202)473-1155 or Fax: (202)522-2627

Case Study on Adolescent Program in Jamaica

The Women's Studies Project (WSP) at Family Health International

(FHI) has published a case study on the Program for Adolescent Mothers in Jamaica. Administered by the Women's Center of Jamaica Foundation, the island-wide program provides assistance to pregnant teenage girls by 1) helping teens continue their education during pregnancy and return to the regular school system as soon as possible and 2) educating teens about family planning so that they May delay a second pregnancy.

The case study is part of a series of profiles of women-centered health programs published by the WSP. The Jamaica case study includes a history of the Program, information about Program administration and funding, interviews with current and former participants, and interviews with community members. Former participants discuss the long-term effects of the Program, noting it offered a friendly, non-judgmental environment at a stressful time in their lives. The Program also helped them improve relationships with their parents, accept the responsibilities of motherhood, become family planning users, gain self-esteem, and demand more in their relationships with men.

The case study was written by Barbara Barnett, Elizabeth Eggleston and Karen Hardee of the WSP staff and Jean Jackson of the Fertility Management Unit (FMU) of the University of the West Indies. A limited number of copies are available. The publication is free and can be obtained by contacting Ms. Debbie Crumpler, Publications Coordinator, Family Health International. Fax: 919-544-7261. The text of the case study also is available on FHI's web site:

Vacancy announcements search for high caliber research scientist

Recruitment Notice
Global Tuberculosis Programme
World Health Organization
Geneva, Switzerland

The Mission of the Global Tuberculosis Programme (GTB) of the World Health Organization is to relieve the considerable burden of death and suffering caused by tuberculosis. GTB's role is to lead and support the international community, to eliminate TB as a global public heath problem, especially in low-income countries. The Tuberculosis Research and Surveillance unit (TRS) of GTB, has committed itself to promoting the research necessary to achieve this mission.

The objectives of TRS are:

i. to gather information to describe the status of the TB epidemic and the impact of attempts to control it;

ii. to promote the research necessary to disseminate the WHO recommended strategy to TB control; and,

iii. to promote research aimed at improving this strategy.

We are, therefore, looking for professionals with diverse skills to apply their initiative and enthusiasm to this task. In particular we are seeking an experienced scientist who has a background in biomedical research or in infectious diseases, particularly in anti-infective agents and/or diagnostic tools. The preferred candidate will either have worked for at least five years in the pharmaceutical or biomedical industry or have had, in the course of his/her work, close dealings with these industries. Successful candidates will be expected to develop strong working relationships with leading biomedical research institutions and research funding institutions worldwide, keep abreast of developments, facilitate consideration of products and approaches with particular attention to their relevance to developing country settings, challenge established wisdom and convention to encourage innovative approaches to research, its strategy and development of effective public/private partnerships. Leadership, initiative, and proven management skills are essential. Specific experience in the field of tuberculosis or mycobacterial infections will be an advantage. We envisage the successful candidate will have a Ph.D. or equivalent, or a medical degree, with extensive experience in a biomedical research area and a good publication record with proven project management experience. Excellent written and oral presentation skills in English are essential.

Applications from women are encouraged. Remuneration: Salary plus Post Adjustment (subject to fluctuations)

US$85 000 - 115 000.

The successful candidate will be based in Geneva and will have substantial opportunity for international travel. A detailed curriculum vitae with an accompanying letter quoting references and explaining why the candidate believes they would be the best person for the position should be sent to the address below by August 1, 1996.


Head, Professional Candidates

World Health Organization
20, Avenue Appia
CH-1211 Geneva 27
WHO Facsimile No. +41-22-791-07-46

Head of institutional partnerships project office in Moscow opens in July

International Research & Exchanges Board (IREX) announces an opening in mid-July of the Moscow Representative position for the USAID/IREX Institutional Partnerships Project.

The Institutional Partnerships Project (IPP), under a three-year cooperative agreement between IREX and USAID, helps educational institutions, professional associations, and trade organizations in the Russian Federation and Ukraine build capacity to provide professional-level training, as well as improve their member services. By strengthening the institutional bases of civil society and their lasting links to American counterparts, USAID and IREX hope to make a substantial contribution to the development of democratic norms and free market economies in the two countries.

The head of the IPP Moscow office supervises a team of three Russian nationals. They jointly monitor and support 16 of the project's 22 partnerships. The value of the grants to the US-Russian partnerships is approximately $25 million. The position is one of major substance and importance to IREX and to USAID.

The Moscow Representative reports to the Project Director in Washington, but works and coordinates closely with the main Moscow office of IREX. Projects are scattered across the 11 time zones, from Magadan and Yakutsk to Pskov and St. Petersburg, so that a good deal of oversight travel is necessary. Key components of the position include: close collaboration with the Russian and US partners to help them communicate well and cohere in common purpose; and management of the professional relationship with the USAID Mission in Moscow.

Excellent Russian speaking and writing skills are indispensable to success in this position. Experience in exchanges and training management, particularly with respect to non-government organizations, is highly desirable. Promising candidates will have at least two years of living and working experience in Russia. Administrative ability and patience are essential. Broad general knowledge and adaptability are desirable, given the range of areas in which the partnerships work, from agribusiness to urban housing, and from medical training to aquaculture. IREX is an Equal Opportunity Employer.

Candidates are encouraged to make their interest known to IREX as soon as possible by mail to IREX/IPP, 1616 H St., NW, Washington, DC 20006, or by facsimile at (202) 628-9818.


Electronic newsletter and archiving service on human development ISSUEs

World Bank
Human Development Department (HDD)

In this ISSUE...

· Improving Women's Health in India
· What's New on the Web: Abstracts from XI International AIDS Conference
· Award Program for NGOs
· Report on Ottawa International Conference on Food Fortification


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Improving women's health in India

India has made considerable progress in indicators such as life expectancy, infant mortality, and literacy. However, improvements in women's health, particularly in the north, have lagged behind gains in other areas. Its maternal mortality rates in rural areas are among the world's highest. Infectious diseases, malnutrition, and maternal and perinatal causes account for most of the disease burden. Females experience more episodes of illness than males and are less likely to receive medical treatment before the illness is well advanced. Because the nutritional status of women and girls is compromised by unequal access to food, by heavy work demands, and by special nutritional needs (such as for iron), females are particularly susceptible to illness, particularly anemia. Women, especially poor women, are often trapped in a cycle of ill health exacerbated by childbearing and hard physical labor.

In India, women's health and nutritional status is inextricably bound by social, cultural, and economic factors. This has consequences not only for the women themselves but also for the well-being of their children (particularly females), the functioning of households, and the distribution of resources. The report examines the status of women's health status, analyzes the factors affecting women's well-being, and identifies workable strategies for improving the health and nutritional status of India's girls and women.

The report concludes that focused efforts to improve the health and overall status of females will provide substantial benefits in terms of human welfare, poverty alleviation, and economic growth.

To order a copy of the report electronically, check the Publications Homepage at:

For a mail order copy contact:

The World Bank Bookstore
1818 H St., N.W., Department T-8051
Washington, D.C. 20433
Tel: (202)473-1155 or Fax: (202)522-2627

What's New on the Web...

Abstracts for the Vancouver AIDS Conference can be found on the Web! All abstracts and the on-site newspaper (html version) from the XI International Conference on AIDS held recently in Vancouver, Canada, July 7-12, 1996 are available on the Web. The address is:

Sixth International Conference on System Science on Health

The Sixth International Conference on System Sciences in Health Care (SSHC '96) will be held in Barcelona, Spain from the 16-20 September 1996. The overall theme of the Conference is the international comparison of health care systems at different stages of development. The objective is to review the results of reforms to date, to apply the lessons learned from this experience to health systems still debating the broad direction in which they should move, and to provide a forum for methodological debate and the comparison of international health systems.

Major topics will include:

- Health Systems reforms to coverage and financing

- Challenges face by Central and Eastern European countries

- Health Systems reforms related to delivery and management

- The role of international agencies and consultancy in developed and developing health systems

- The role and scope for state intervention in an increasingly global pharmaceutical market

For further information please contact:

c/o Numancia, 98 (Pl. les Corts)
08029 BARCELONA (Spain)
Tel. +34.3 419 27 85
Fax +34.3.419 27 85

Award program for NGOs

The Micronutrient Initiative (MI) has the pleasure of announcing a new award program to support Non-Governmental Organizations (NGOs) to contribute to the virtual elimination of Vitamin A deficiency by the year 2000. This award program implemented by PATH Canada, is part of the Global Vitamin A Initiative of the Micronutrient Initiative housed at the International Development Research Center (IDRC). The Global Vitamin A initiative, a wider program of support for vitamin A interventions, has been made possible by a grant from the Canadian International Development Agency (CIDA). Local, national, regional, international and Canadian NGOs are invited to apply for the award. Grants will be awarded up to a maximum of $100,000 Canadian, for an implementation period of no more than 24 months. The closing date for submission of proposals is September 30, 1996.

Interested persons can obtain the Guidelines for Proposal Submissions from PATH Canada (see below). The "Expression of Interest" form, contained in the Guidelines package, should be submitted by August 15, 1996. All correspondence should be addressed to:

Sian FitzGerald
Project Manager, Global Vitamin A Initiative
PATH Canada
902-170 Laurier Avenue, West
Ottawa, Entire, K1P 5V5, Canada

Ottawa international conference on food fortification

A report on the Ottawa International Conference on Food Fortification in now available for the OMNI project. The Forum, organized by The Micronutrient Initiative (MI), Program Against Micronutrient Malnutrition (PAMM), and The Keystone Center aimed to: create awareness among all stakeholders of the global problem of micronutrient malnutrition; garner trust and develop creative solutions amenable to all stakeholders, public and private; and to discuss and disseminate food fortification strategies which have the potential to provide nutrient-rich foods affordably and sustainable to populations in need.

At the Forum it was decided that national discussions should address: research necessary to determine a country-specific, overall strategy; target populations; technology and information transfer; consumer awareness and education; regulations, enforcement and monitoring programs; and economic, pricing and cost ISSUEs.

A copy of this report can be obtained by contacting the OMNI project at omni

1616 North Fort Myer Dr, Suite 1100,
Arlington, Virginia 22209
·Tel: 703 528-7474 ·Fax: 703 528-7480
E-mail: omni


Electronic newsletter and archiving service on human development ISSUE’s

World Bank Human Development Department (HDD) e-mail:

Preventing and Mitigating AIDS in Sub-Saharan Africa

"Preventing and Mitigating AIDS in Sub-Saharan Africa", produced by the National Research Council examines the need for research and data in the social and behavioral sciences to improve and extend existing programs and devise more effective strategies for preventing HIV transmission and mitigating the impact of AIDS in the region.

Sub-Saharan African is geographically, demographically, socially and culturally a heterogeneous region. Thus, it is difficult to generalize about the AIDS epidemic in the region. Other than Cd'Ivoire in West Africa, the most afflicted countries are geographically concentrated in East and Southern Africa: from Uganda and Kenya southward to Rwanda, Burundi, Tanzania, Malawi, Zambia, Zimbabwe and Botswana.

There is a need for immediate action to combat the spread of AIDS as in many parts of the region the epidemic has not yet peaked, and because the cost-effectiveness of prevention efforts declines rapidly as the epidemic spreads the timing of interventions is crucial. The report offers recommendations in five critical areas:

1. Basic surveillance systems for monitoring the prevalence and incidence of STDs and HIV must be strengthened and expanded.

2. Gathering information on sexual behaviors is needed to help project the future course of the epidemic, to develop more effective prevention strategies, and to provide baseline data for evaluating the effectiveness of alternative preventive strategies.

3. Conducting more evaluation research on primary prevention strategies in order to correlate process and outcome indicators with reduction in HIV incidence or prevalence. To date, few rigorous evaluations of intervention programs in sub-Saharan Africa have been conducted and as a result, few strategies can demonstrate their effectiveness. It is only with more rigorous designs that more definitive information on intervention effectiveness can be obtained.

4. Focusing on the needs of the people with AIDS. Simple, cost-effective solutions to daily living problems faced by persons with AIDS May make larger, more expensive interventions unwarranted.

5. The need for building an indigenous capacity for AIDS-related research in Africa. There is a role for international organizations in assisting local research efforts through funding, technical assistance and training.

For further information on the book, "Preventing and Mitigating AIDS in Sub-Saharan Africa: Research and Data Priorities for the Social and Behavioral Sciences", please visit the National Academy Press' Web site at: http:\ Select 'new publications'.

For a mail order copy of the publication, please contact

National Academy Press
2101 Constitution Avenue, NW
Box 285
Washington DC 20055
Tel: 800-624-6242 (toll-free)
Fax: 202-334-2451

Request for proposals

The American Association for the Advancement of Science (AAAS) International Directorate's Program on Population and Sustainable Development (PSD) is pleased to announce a request for proposals for the International Research Cooperation Project (IRCP) Human Population, Biodiversity and Protected Areas.

The objective of the grant is to stimulate new research or enhance existing research on the topic of population and biodiversity. A total of four (one each from Africa, Asia, Latin America and Europe/North America) research grants of US$10,000-$15,000 each year, for a period of two years, will be awarded beginning in Fall, 1996.

Individual scientists or teams of scientists (preferably from the social and natural sciences) who have experience in scientific research on human population and the environment are eligible to apply. Proposals from individual scientists from the country in which the research is being undertaken, and/or those which include in-country scientists as "principal investigators" will be viewed most favorably. Proposals which involve collaboration of scientists and/or institutions on a cross-regional basis are welcome.

Deadline for receipt of proposals is no later than September 16, 1996.

Applications should be sent or faxed to Victoria Dompka, PSD Director, AAAS, Room 710, 1200 New York Avenue, NW, Washington, DC 20005, USA, Fax USA+ 202-289-4958.

CONTACT: For more information contact Victoria Dompka, PSD Director at phone USA +202-326-6658, fax USA+ 202-289-4958, email "" or Amy Matza, PSD Project Assistant at phone USA +202-326-6652, email "".


1. SOCIAL SCIENTIST, UN/WHO Level P5, International Centre for Diarrhoeal Research, Bangladesh

The International Centre for Diarrhoeal Disease Research, Bangladesh, is a leading international research centre for population studies, reproductive and sexual health, and child survival. The successful applicant is expected to have experience in qualitative methodologies and of conducting in-depth research, preferably in developing countries. She/he will be Head of the Social and Behavioural Sciences Programme at the Centre.

Requirements: a postgraduate research degree in medical anthropology and/or sociology and experience in public health, but candidates with experience in related social sciences, health education or communications are encouraged to apply. Successful applicants will probably have had 5-10 years as a principal investigator in community based health research, including intervention studies, and have a good list of international publications. Fluency in English is essential and experience in South Asia would be an advantage. Evidence of an ability to develop research proposals and obtain funding will be required.

The appointment is initially for three years. Candidates wishing to discuss the post are encouraged to send a full CV to Professor Patrick Vaughan, Director of Community Health Division (Fax 880-2-886050) and to include telephone, fax and email contact numbers. Full applications should be sent with a covering letter and a detailed curriculum vitae, together with the names, addresses and contact numbers (telephone, fax and email) of three referees to the: Division Director, Administration and Personnel, ICDDR,B, GPO Box 128, Dhaka-1000, Bangladesh (Fax # 880-2-883116).

2. SOUTH ASIA PROGRAM DIRECTOR, Micronutrient Initiative, New Delhi

The Micronutrient Initiative (MI) is an international secretariat housed within the International Development Research Centre (IDRC). Its sponsoring institutions include IDRC, the Canadian International Development Agency (CIDA), The World Bank, UNICEF, and UNDP. This is a three-year assignment. Located in New Delhi, the successful candidate will work mainly with policy planners in Bangladesh, India, Nepal and Pakistan to develop national strategies to achieve sustainable elimination of micronutrient deficiencies.

Requirements: a university degree in nutrition, health or food sciences; agriculture, or social science, with appropriate postgraduate training (either undergraduate or postgraduate qualification should include a concentration in nutrition and/or food science); ten years of relevant professional experience including field experience in nutrition policy and program planning and implementation; extensive experience in international development work, particularly in program design and management; strong leadership and entrepreneurial skills as well as be highly motivated and committed to people-centred development.

Experience in fund-raising and external public relations valuable. Experience desirable in food processing and fortification, social marketing, public health, and participatory development. Fluency in English. Working knowledge of Hindi, Urdu or Bengali would be an asset.

Qualified candidates should forward their curriculum vitae, quoting reference PO851 to:

Office for Human Resources
PO Box 8500
Ottawa, Ontario
Canada K1G 3H9 fax: (613)238-7230


The address for the Micronutrient Initiative Award Program is c/o:

Sian FitzGerald
Project Manager, Global Vitamin A Initiative
PATH Canada
902-170 Laurier Avenue, West
Ottawa, Ontario, K1P 5V5, Canada email:


Electronic newsletter and archiving service on human development ISSUEs

World Bank
Human Development Department (HDD) e-mail:

In this ISSUE...

· World Bank's Partnership with Non-governmental Organizations
· What's New in the HDDFLASH Archive?
· Forthcoming Publication by PAHO
· USAID - Concept Papers for Funding
· Health Care Alliance/USAID: Partnership Project in Albania
· International Internship Opportunity
· Proceedings of a Workshop on Iron Intervention

Message to HDDFLASH readers

Kindly note that effective immediately HDDFLASH will be ISSUEd on the first of each month. The next ISSUE will be out on October 1, 1996.

World Bank's Partnership with Non-governmental Organizations

The publication "The World Bank's Partnership with Non-governmental Organizations" outlines the mechanisms by which the World Bank and Non-governmental organizations (NGOs) work in partnership.

As the complexities of development become more apparent, it has been easier to recognize ways in which NGOs can supplement public sector efforts. This has led to a greater focus on partnerships between governments, donors, and civil society. Increasingly, the World Bank is recognizing the important role that NGOs, both local and international, play in meeting the challenges of development. Because of their close contact with the poor, NGOs are well suited to help them identify their most pressing concerns and needs.

The NGO-World Bank Committee

Established in 1982 to address ways in which the Bank could increase the involvement of NGOs in Bank-financed projects, the NGO-World Bank Committee has provided the arena for policy discussions among senior Bank managers and NGO leaders from around the world. In recent years, the committee has focused upon structural adjustment and participation. The Committee remains unique because of its geographical representatives and its continuity.

Working Together in Bank-Financed Projects

Operational collaboration between the World Bank and NGOs has greatly intensified over the last decade and increasing numbers of Bank financed projects include provisions for NGOs. Although NGOs can play specific roles at various stages of the project cycle, experience has shown that collaboration is most successful when NGOs are involved from the beginning of the project cycle.

Issues in Bank-NGO Collaboration

· Channeling Financial Resources to NGO
The World Bank does not fund NGOs directly. The most common way for an NGO to receive project funds is by working as a paid consultant or contractor to the borrower. Bank-financed projects are sometimes designed to include mechanisms for channeling funds to NGOs - the most significant are the Bank-financed social funds. In addition, a very limited number of internal Bank-operated grant programs - are the exception to these general rules.

· Capacity Building
The World Bank and other donors recognize that the NGO community faces significant institutional, legal, financial, or political barriers. Strengthening the capacity of NGOs to contribute to the development process is an important ISSUE for many international NGOs and official aid agencies, including the World Bank.

· Cooperation in Research and Analysis
The Bank carries out a broad range of research and analysis, known as economic and sector work (ESW), which is a key element of its assistance to borrowers. The purpose of this work is to provide a thorough understanding of borrowers' development problems and opportunities, and advice on how to tackle them. In recent years, NGOs have become active contributors to much of the Banks ESW, particularly in the environmental, social, and poverty-related spheres.

Policy Dialogue

The rapidly expanding cooperation between the World Bank and NGOs in operational work is paralleled by increased dialogue on policy ISSUEs, the Bank has come to recognize the value of exchanges of information, opinion, and experiences with NGOs on development ISSUEs.

Poverty, hunger, the environment have been important themes in the Bank's interactions with NGOs and over the years several conferences which have dealt with these themes have been held. Participatory development, a process in which stakeholders influence and share control over development initiatives and over the decisions and resources that affect them, has been a subject of increasing exchange in recent years and the World Bank has begun a process of mainstreaming participatory approaches in all of its development activities. NGOs which have skills and experience in rural and urban community development are especially sought after as potential partners, because of the Bank's focus.

To order a copy of the report electronically, check the Publications Home-page at:

For a mail order copy contact:

The World Bank Bookstore
1818 H St., N.W., Department T-8051
Washington, D.C. 20433
Tel: (202)473-1155 or Fax: (202)522-2627

What's new in the HDDFLASH archive?

These documents, the last ISSUE of 'Mothers and Children' (Volume 14, No.3) are published by the Clearinghouse which is supported by USAID, Office of Health and Nutrition. They are available for retrieval from the archive.

Filename Title
Family Food Security: A Vietnamese Approach (7,647 bytes - 8/96) Change Attitudes, Change Society Radio Programs for Rural Kenya (4,641 bytes- 8/96) Wan Smolbag: A Community Theater (8,051 bytes - 8/96) mce14s Women in Community Radio (2,803 bytes - 8/96) Breastfeeding: a community responsibility (5,761 bytes - 8/96)

mcs14p Seguridad alimentaria de la familia Metodo vietnamita (8227 bytes-8/96) mcs14q Cambio De actitudes, cambio de sociedad (5178 bytes - 8/96) mcs14r Wan Smolbag: un grupo de treatro comunitario (10,592 bytes-8/96) mcs14t Lactancia natural: una responsabilidad comunitaria (6,883-8/96)

mcf14p Securite alimentaire de la famille: Un exemple vietnamien (8997 bytes-8/96) mcf14q Nouveaux comportements et changement social - Programmes radiophoniques au Kenya (5,672 bytes - 8/96) mcf14r Wan Smolbag: un theatre communautaire (10,736 bytes - 8/96) mcf14s Femmes et radio communautaire (3305 bytes - 8/96) mcf14t Allaitement maternel: une responsabilite de la collectivite (7188 bytes - 8/96)

Note to Subscribers:

Some of experienced problems retrieving the file aids001 entitled "Women and HIV/AIDS' (aids001) from the archive. These problems have now been solved and the article is now available for your retrieval. We apologize for any inconvenience.

To retrieve these documents, send an e-mail message to:
(Bank staff: sending an All-in-1 message will need to add the extension @internet).
In the body of the message, type: get HDDFLASH filename e.g. get HDDFLASH mcf14p

NOTE: Do not add periods, quotes, or brackets around the filename. Request only one article per message. Filenames must be in lower-case letters. Only subscribers have access to the archive. If you are not a subscriber, but would like to receive HDDFLASH and access to the archive, please send the following message: subscribe HDDFLASH Your-First-name Your-Last-name e.g. subscribe HDDFLASH Jane Doe

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Forthcoming Publication from PAHO: Biodiversity, Biotechnology and Sustainable Development in Health and Agriculture

The Pan American Health Organization (PAHO) is pleased to announce its forthcoming publication, "Biodiversity, Biotechnology, and Sustainable Development in Health and Agriculture: Emerging Connections." This publication, available in September 1996, explores the connections among biodiversity, biotechnology, and sustainable development by examining the drug discovery process and agricultural improvements for better nutrition.

The first section discusses different bioprospecting ventures- including the now famous agreement between Merck & Company and Costa Rica's National Institute for Biodiversity (INBio)-and suggests policy options for potential host countries. Subsequent sections explore such ISSUEs as costs, scientific and resource requirements, and economic prospects of different drug development models; the legal ramifications of intellectual property rights, fair compensation for indigenous knowledge, and various contractual arrangements; and how to assess biodiversity's economic value. A final section discusses whether biodiversity-"green gold"-will, in fact, become Latin America and the Caribbean's new competitive advantage.

The pre-publication price is $36.00, and discounted at $27.00 for purchases from developing countries, plus $6.00 for shipping and handling within the U.S./$7.00 outside the U.S. For more information, or to order, call (202) 293-8129, fax (202) 338-0869, or email to

USAID Concept Papers for Funding

The POLICY Project, funded by the U.S. Agency for International Development (USAID), invites submission of concept papers for funding consideration under its global policy research program. The Project expects to make several awards ranging from $50,000 to $250,000 for studies beginning in 1997. Concept papers should describe proposed research pertaining to one of the following priority research themes:

1. family planning and reproductive health financing;

2. benefits of family planning and other reproductive health programs for the development of human capital;

3. the impact of family planning on preventing abortion;

4. the impact of policy changes on program outcomes; and

5. the influence of policies on young adult reproductive health.

Authors of the most promising concept papers will be asked to submit detailed proposals for funding consideration through a competitive awards process. Collaboration with developing country researchers is strongly recommended.

Deadline: October 4, 1996.

Before submitting a concept paper, please request a copy of the guidelines for submission and a description of the priority research themes. from: Director, POLICY Project, The Futures Group International, 1050 17th Street, NW, Suite 1000, Washington, DC 20036. Phone:202.775.9680; FAX: 202.775.9694; Email:

These guidelines are also contained on the TFGI homepage:

Health Care Alliance/USAID Seek US Health Care Institutions for Partnership Project in Albania

The American International Health Alliance, Inc. (AIHA) in collaboration with the United States Agency for International Development (USAID) soliciting expressions of interest from qualified US hospitals and health care institutions willing to devote substantial in-kind resources, mainly in the form of human resources committed on a volunteer basis, to a two-year partnership with counterparts in Albania.

This health care partnership is part of an ongoing health care development program financed through USAID and managed by AIHA which includes forty partnerships in nine countries of Central and Eastern Europe (CEE) and eleven republics of the former Soviet Union.

AIHA/USAID is not the principal funding source for partnership activities, but rather supplements the voluntary and in-kind contributions of the partners and their respective communities in the US and abroad. Existing AIHA partnerships have leveraged nearly three dollars of voluntary support for every US government dollar expended. AIHA/USAID funds will mainly support travel and other costs essential in establishing and realizing the full potential of a partnership program, including communication and interaction with other partnerships. AIHA staff in Washington, DC and in Europe will provide logistical support and assist in monitoring the progress of the partnership.

Interested US partners must have the willingness and capacity to meet the specific health care delivery needs described above, and must satisfy the following criteria:

· Be institution-based - e.g., a hospital, group of hospitals.

· Be supported by the institution's senior leadership and Board and clearly identify an overall partnership coordinator.

· Make a substantial voluntary commitment to the partnership through a significant contribution of resources, including human resources.

· Have experience implementing successful "healthy communities" or other community outreach projects.

· Actively involve the local community served by the US partners

· Share information openly and participate fully in AIHA's efforts to exchange information with other US/CEE and US/NIS partnerships through the AIHA Partnership Clearinghouse and dissemination conferences and seminars.

· Adhere to AIHA's rigorous objective-setting and results-oriented approach. Hospitals or health care institutions wishing to be considered for participation in the Albania partnership should send a short statement (10 pages maximum) by September 15, 1996 detailing their interest and ability to enter into a collaborative relationship with Albanian partners under the AIHA model.

Statements should be directed to :

Mr. Donn Rubin
Program Director, Central & Eastern Europe
American International Health Alliance, Inc.
1212 New York Avenue, NW, Suite 750
Washington, DC 20005

For additional information contact Ms. Eun-Joo Chang, Coordinator of CEE Hospital Programs, or Elizabeth Schroth, Program Analyst.
Telephone: (202) 789-1136; Facsimile: (202) 789-1277.

International Internship Opportunity - Fall 1996

The American International Health Alliance (AIHA) is a non-profit organization which supports health care assistance projects in the Newly Independent States and the countries of Central and Eastern Europe. This internship provides an opportunity for prospective interns to gain invaluable experience in a professional working environment and to explore a variety of international and health care ISSUEs.

Job Title: Administrative/Programmatic Intern
Salary: Paid
Hours: 20-24 hours/week

Duties & Responsibilities: Intern will provide comprehensive support to staff members in the daily maintenance of the office; including monitoring of international/national phone calls, conference preparation, and implementation of new software database. Intern will also assist with any special projects which May be assigned.

Please mail or fax resumes to:

American International Health Alliance
1212 New York Avenue, NW, Suite 750
Washington, DC 20005
Fax: (202) 789-0519

Proceedings of a workshop on iron interventions for child SURVIVAL

Efforts to reduce and control iron deficiency anemia in infants and young children were addressed in a May 17-18, 1995 workshop in London, organized by USAID/OMNI and The London Institute for Child Health. The proceedings of this workshop on "Iron Interventions for Child Survival" are now available through OMNI.

The proceedings:

· describe local and national pilot programs that have addressed iron deficiency in children under five years of age;

· present research findings that stress the importance of tailoring efforts to improve iron status to individual countries;

· examine the challenges programs have faced and how they were overcome;

· review key research questions that must be addressed to increase the effectiveness of iron interventions;

· provide information that could guide and prioritize program agendas for the future.

To receive a copy of the Iron Proceedings, please contact OMNI via email: WWW:
OMNI: 1616 North Fort Myer Dr, Suite 1100, Arlington, Virginia 22209 USA
Tel: 703 528-7474 - Fax: 703 528-7480

PHNFLASH 104 February 9, 1996

Electronic Newsletter on Population, Health and Nutrition Issues
Human Development Department (HDD), World Bank e-mail:
Please address subscription and archive request to:

Improving Health in Rural Panama

Despite substantial economic gains made during the 1970s and early 1980s, almost a quarter of Panama's population today still live in conditions of poverty. In the ten poorest districts- which account for about 15 percent of the country's total population- the average household earns less than US$850 a year; life expectancy at birth is ten years below the national average; and the infant mortality rate is three to four times the national average. In these same districts, a shocking 40 to 70 percent of children aged six to nine suffer from moderate to severe growth retardation caused by chronic malnutrition, and a third of all households have no access to clean water and basic sanitation. Despite Panama's sophisticated and costly public health system, 30 percent of the population do not have access to a health facility that could provide even a minimum package of primary care.

Past social sector development efforts have relied heavily on the central administration and the public sector, which does not have the logistical support systems needed to deliver social services. With the assistance of the World Bank, therefore, the Panamanian government has now initiated a Rural Health Project to seek out beneficiary and community organizations better situated than the government to deliver basic health and nutrition services and to construct water and sanitation infrastructure. Once facilities have been constructed, ownership of water and sanitation infrastructure will be transferred to the beneficiary communities, who will then be fully responsible for their operation and maintenance.

The project will also support the training and equipping of about 1,500 community health workers (CHWs), a new category of personnel whose efficacy has been amply demonstrated in other small-scale programs. Community health workers will be trained and equipped to provide a limited range of primary health care services including caring for newborn babies, vaccinating children, monitoring children's nutrition and growth, and distributing complementary food packages and micronutrient supplements.

CHWs will be trained by the Ministry of Health or by non-governmental organizations or other private sector agents with appropriate experience. As local health workers, they will be remunerated by the community they serve rather than by the Ministry of Health. It is expected that greater community involvement and more reliance on voluntary and other private organizations will help Panama bring the most essential services even to isolated rural citizens.

(reprinted from Jacques Van Der Gaag (1995) "Private and Public Initiatives: Working Together for Health and Education, The World Bank, Washington, DC)

What's New on the Net?

Announcing SEA-AIDS UNAIDS South East Asia HIV/AIDS Project, Bangkok - 24 January 1996
SEA-AIDS is an electronic-mail discussion and information service aimed at connecting the people building and shaping the response to HIV and AIDS in the South East Asia region. It aims to bring together a broad range of people including:

- people living with HIV or AIDS

- those working in government ministries, non-governmental and community-based organizations, and other national or international organizations

- representatives of the business sector

- academic researchers.

We are pleased to invite you to subscribe to the following services:

SEA-AIDSLink - a simple and direct way to share experiences and information using an electronic mail network - all you have to do is send your electronic mail messages to the SEA-AIDS computer and they will be distributed to all colleagues throughout the region who have also joined the group.

SEA-AIDSFiles - you can also get information and materials on HIV/AIDS South East Asia by using simple e-mail commands.

SEA-AIDSFlash - as a member of the group you will automatically receive this bi-weekly news digest on HIV and AIDS from the region, which includes information about new documents, news items and forthcoming conferences or training in the region. The first ISSUE of AIDSFlash, to be distributed on 1 February 1996, will include a description of the South East Asia HIV/AIDS Project and its planned activities.

Step-by-step instructions are provided at every stage, to make the SEA-AIDS services easy to use.

For a FREE subscription to SEA-AIDS, send an e-mail message to: with the following in the text body of the message: subscribe sea-aids

For further information about sea-aids services, send an e-mail message to the same address with the following in the text body of the message: info sea-aids

SEA-AIDS information support services are provided free of charge by:
The South East Asia HIV/AIDS Project of the Joint United Nations
Programme on HIV/AIDS
3rd Floor (B Block), UNESCAP Building Rajadamnern Nok Avenue
Bangkok-10200, Thailand.
For further assistance:
TEL: (662) 288-2179 FAX: (662) 288-1092

Call for research proposal

"Gender, Health and Technology" is the topic of the fifth IDRC/TDR award on gender and tropical diseases sponsored by by Canada's International Development Research Centre (IDRC) and the WHO Special Programme for Research and Training in Tropical Diseases (TDR). Participants must submit their entries before the deadline of 30 April 1996.

The award is worth C$5000. Ideally, papers should focus on one or more of TDR's target diseases (malaria, schistosomiasis, lymphatic filariasis, onchocerciasis, African trypanosomiasis, Chagas disease, leishmaniasis and leprosy). Issues linked to interrelationships among gender, technology and health are equally relevant to other diseases, and a broader health focus (with the exceptions of AIDS and reproductive health) is also acceptable. Papers on reproductive health and AIDS technologies will not be accepted for consideration, unless they are clearly related to tropical diseases. An example is the lack of attention devoted to health implications of possible interactions between tropical disease and contraceptive technologies.

Papers May include case studies and/or original research based on qualitative or quantitative data, with a gender-based analysis of the findings. Submissions from social scientists, biomedical scientists, health workers and service users are invited. Papers by women from developing countries and papers based on research conducted with the participation of women are particularly welcome.

The papers - in English, French or Spanish - May be based on either secondary sources or original research, and will provide a basis for future research that could be supported by the IDRC and TDR. They must be original, i.e. not have been published elsewhere; they should offer a critical review of current knowledge on the chosen topic; and they should focus on practical disease control ISSUEs. Previous winners of an IDRC/TDR award are not eligible for the award.

Manuscripts should not exceed 30 typewritten, double-spaced (A4) pages (including tables, figures and references) and should begin with a short summary in English. Submission and request for information should be addressed to:

Dr Carol Vlassoff , Manager
Gender and Tropical Diseases Task Force
1211 Geneva 27, Switzerland


Electronic newsletter and archiving service on human development issues

World Bank
Human Development Department (HDD)

* Secretary Shalala on International Health
* What's New in the HDDFLASH Archive?
* World AIDS Day, December 1, 1996
* Publications from OMNI (Opportunities for Micronutrient Interventions)
* Training course: Quantitative Methods for the Evaluation of Tropical
Disease Control
* 16th International Congress of Nutrition
* Book Project - Visions of the Future of Africa

Secretary Shalala on International Health

"Now more than ever, the organizations involved in international health and health related areas have to work more closely together. The problems are more complex. The resources are thinner...," noted U.S. Secretary of Health and Human Services, Donna Shalala in her opening remarks to Bank staff. Secretary Shalala addressed Bank staff on the priorities in international health and the role of U.S. and the Bank in addressing these challenges at the launch of the Human Development Network on September 16, 1996.

She stressed the importance of international collaboration on major health issues, "...that it can never be done by one institution alone or by one nation alone but requires a kind of cross cutting within organizations, as you are embarked on now in the World Bank, as well as across organizations."

There were only two occasions -- small pox eradication and the child survival -- where the Bank and the major economic powers have successfully organized themselves. As a result of available technology being used in concert—oral rehydration therapy, growth monitoring, immunizations -- five million children's lives are saved each year. Polio has been eliminated from this hemisphere, with substantial progress from other regions of the world.

"The Bretton-Woods institutions, the multilateral health and related organizations, such as WHO, UNICEF, UNHCR, the private and volunteer organizations, have to achieve greater coordination to focus their efforts." She credits the Bank on its contributions to health, which includes the 1993 World Development Report: Investing in Health as " a very important blueprint, and countries like the U.S. take that report seriously as we lay out our initiatives," and the policy report on women's health initiatives.

She emphasized the role the Bank can play in health investments, that is "... to use [Bank] resources as an economic incentive. in addition to loans which are already being provided to get some nations of the world to invest in the high priority cost-effective interventions that were described in Investing in Health." She added that countries often overlook investments in preventive care and health infrastructure, "... they're caught up in their own bureaucracies, and, in part, because their focus is on acute care and on dealing with diseases as opposed to the investments in fundamental prevention. We must do whatever we can to stimulate them, either with matching funds or with other economic stimuli, to help them understand that the prevention infrastructure: clean water, clean air, and investments in anti-smoking campaigns, have more to do with long-term health costs, and is needed." She cited the U.S. experience which has focused most of its health dollars on chronic care and curative care and very little on prevention.

On global surveillance of emerging and re-emerging infectious disease, she cites the work of Center for Disease Control (CDC), the World Health Organization (WHO) and The Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS should be seen within the context of sexually-transmitted diseases and the broader health issues worldwide if it is to get the focus or the kind of energy we had on international vaccination campaigns, or the child survival campaigns."

Secretary Shalala concluded with an assurance that the U.S. is committed to working alongside these efforts. "We must mainstream the health issues with the other kinds of economic development investments ... the best way to do that is with actual economic incentives, so that our overlying strategies to make sure that every nation in the world has the kind of public health infrastructure it needs is encouraged while the countries themselves make very specific investments that are culturally-specific and leadership-specific.

All of us know that the diseases don't have a clue about country, gender, religion or race. They are however a threat to all of us."

What's New In The Hddflash Archive?

Articles from two issues of 'Network' produced by Family Health International are available for your retrieval.Family Health International, Vol. 16 No. 3

Filename Title

fhi1631 Barrier Methods Require Consistent Use (42496 bytes)
fhi1632 Dual Method Approach and Consistent Use (23552 bytes)
fhi1633 Methods Work Better When Couples Talk (36352 bytes)
fhi1634 Microbicide Research To Prevent STDs (29184 bytes)
fhi1635 Spermicide Research and HIV Prevention (33280 bytes)
fhi1636 Developing New Diaphragms and Similar Devices (30208 bytes)
fhi1637 STD Protection After Intercourse (41472 bytes)
fhi1638 The Dual Goals of Reproductive Health (33792 bytes)

Family Health International, Vol, 16 No. 4
Filename Title
fhi1641 Oral Contraceptives (OCs) are Very Effective (28160 bytes)
fhi1642 OCs Relationship to Cancer (27136 bytes)
fhi1643 How to Use Oral Contraceptives (13312 bytes)
fhi1644 Better Communication Improves OC Use (40448 bytes)
fhi1645 OCs and Emergency Contraception (29184 bytes)
fhi1646 Contraceptive Update (29184 bytes)

To retrieve these documents, send an e-mail message to:
(Bank staff: sending an All-in-1 message will need to add the extension @internet). In the body of the message, type: get hddflash filename e.g. get hddflash fhi1641
NOTE: Do not add period, quotes, or brackets around the filename. Request only one article per message. Filenames must be in lower-case letters. Only subscribers have access to the archive.

If you are not a subscriber, but would like to receive HDDFLASH and access to the archive, please send the following message: subscribe hddflash YourFirstName YourLastName e.g. subscribe hddflash Jane Doe to:

If you received an error message, contact us at:

World Aids Day - December 1, 1996

The American Association for World Health (AAWH), the U.S. sponsor of World AIDS Day is pleased to announce the 1996 theme, "One World, One Hope". The theme was designated by the Joint United Nations Program on HIV/AIDS (UNAIDS) to "emphasize the need for people everywhere to put aside their differences and to work together to face the challenge of slowing down the epidemic and alleviating its impact. At the same time it reflects a universal aspiration to find the means to prevent and cure HIV/AIDS".

World AIDS Day, observed annually on December 1, is the launching of HIV/AIDS awareness activities and programs planned throughout the year. World AIDS Day activities range in diversity from action days in schools, distribution of condoms and prevention literature, testimonies by people living with HIV/AIDS, candlelight memorial vigils, to the release of songs of inspiration and works of art by various artists.

As in years past, the American Association for World Health will produce an action kit to help groups and communities coordinate efforts in observance of World AIDS Day. To get on the mailing list to receive a kit, please contact: AAWH, (202)466-5883; fax (202)466-5896, E-mail:

Omni Micronutrient Publications Available

OMNI has a limited number of older publications on global micronutrient activities available on a first come first serve basis. Many of these documents were developed through the VITAL project. Although some are several years old, we feel that they still can provide important information to
organizations, governments, projects and individuals involved in the elimination of micronutrient malnutrition globally. Every week we will make different documents available.

  1. Micronutrients: Increasing Survival, Learning, And Economic Productivity

This is a brief report on the USAID micronutrient program, published in 1993 and available only in English.

2. World Declaration And Plan Of Action For Nutrition

This document represents the culmination of the 1992 International Conference on Nutrition (ICN). The World Declaration reflects the pledge of member countries, non-governmental organizations, and the international community to eliminate or reduce substantially -- within this decade -- starvation, widespread undernutrition, and micronutrient malnutrition which constrain progress in human and societal development around the world.

The Plan of Action for Nutrition provides a framework to go about achieving these objectives, drawing on the recommendations for policies, programs, and activities which emerged from an intensive pre-conference consultative process.

The source of this document was the ICN, Food and Agriculture Organization of the United Nations/World Health Organization Joint Secretariat for the Conference, 1992.

3. The Carotenoid Content Of Foods With Special Reference To Developing Countries

This publication brings together data on many different foods, excluding data compiled by the Nutrient Composition Laboratory of the United States Department of Agriculture on foods consumed in the United States. It was reviewed at both the XV International Congress of Nutrition in Australia (1993) and the Food-Linked Agro-Industrial

Research (FLAIR) Programme of the Commission of the European Communities held in Portugal (1993).

The report is produced by VITAL and available only in English.

4. West African Conference On Vitamin A Deficiency

This report is a summary of a conference held in Accra, Ghana, in 1993 and jointly funded by USAID, Micronutrient Initiative, IRDC, UNICEF, and ODA. The main objectives of the conference were (1) to identify feasible program options for the prevention and control of vitamin A deficiency in the West African subregion and (2) to discuss the key policy issues for catalyzing the implementation of country plans of action for micronutrient deficiency control. The conference also identified the research, training, and institutional requirements for achieving vitamin A deficiency control policies and programs, and provided a forum for promoting intergovernmental, program, and institutional linkages for micronutrient deficiency control in the subregion.

5. Omni Brief: Bioavailability & Bioconversion Of Carotenoids

This is a summary of a 1995 workshop on Bioavailablity and Bioconversion of Carotenoids organized jointly by the Micronutrient Initiative and USAID/OMNI project to address the question: Can foods rich in provitamin A carotenoids provide adequate vitamin A for human needs?

In addition, the participants: 1. Identified key research questions that must be addressed for food-based vitamin A strategies to be more effective:

2. Established their priority, 3. Suggested experimental approaches; and

4. Provided program guidance that could have the greatest relevance to populations most at-risk of clinical and subclinical vitamin A deficiency--women, infants and children in developing.

6. Vital Nutrients

This document provides a brief overview of recent studies on the effects of micronutrients, current knowledge on how and why micronutrient deficiencies occur, who is particularly at risk, interventions that work, and how professionals engaged in a broad range of programs can play a key role in preventing and controlling micronutrient deficiencies.

7. United Nations Scn News: Focus On Micronutrients

This 65-page publication, published by the Administrative Committee on Coordination (ACC) - Subcommittee on Nutrition (SCN) of the United Nations, is a periodic review of developments in international nutrition which is normally published twice a year. This particular issue (number 9), produced in 1993, focuses on micronutrient deficiencies and programs and is available only in English.

8. Frontiers Of Nutrition And Food Security In Asia, Africa, And Latin America

This publication explores innovative programs in Asia, Africa, and Latin American on demonstrates how healthful behaviors such as immunization, prenatal care, and wholesome diets can significantly raise levels of nutrition and health.

Drawn from a colloquium sponsored by the Smithsonian Institution in association with the International Life Sciences Institute (ILSI) North America and the World Food Prize, this volume was published in 1992 and is available only in English.

OMNI is located at 1616 North Fort Myer Dr, Suite 1100, Arlington, Virginia
22209 USA - Tel: 703 528-7474 - Fax: 703 528-7480

Quantitative Methods For The Evaluation Of Tropical Disease Control

This training course is organized by the Netherlands Institute for Health Sciences (NIHES) and the Department of Public Health, Erasmus University Rotterdam, The Netherlands.


Decision making on how money can be spent most effectively for the control of tropical diseases should be supported by a systematic comparison of the available control options. Mathematical, quantitative models are developed to organize the available evidence in a coherent framework and permit estimation of short and long term effects.


* The public health burden of disease in different parts of the world and ways to reduce it
* Different types of quantitative models for the evaluation of tropical disease control and their application
* Different measures of duration and quality of life and how to use each one appropriately
* Interpretation of the information generated by mathematical models, including an understanding of their limitations
* Ways in which interventions can affect disease transmission and disease occurrence both on the short term and on the long term
* Measuring the costs incurred by the individual and the community as a consequence of disease
* Modeling approaches for specific diseases such as Leprosy, Schistosomiasis and Sexually Transmitted Diseases
* Students will learn to work with the user-friendly software ONCHOSIM, a computer simulation program for the transmission and control of onchocerciasis (river-blindness).


Prof. Dik Habbema, Drs. Willem-Jan Meerding, Drs. Bram Meima, Dr. Gerrit van Oortmarssen, Dr. Anton Plaisier, Dr. Kitty van der Ploeg, Dr. Johan Velema (course co-ordinator), Drs. Carina van Vliet and Dr. Sake de Vlas, who are all staff members of the Center for
Decision Sciences in Tropical Disease Control, Dept. of Public Health, Erasmus University Rotterdam. In addition, guest lecturers from other institutions will contribute to the course.


Contact: Ms. Gerda Bathoorn, Admissions Co-ordinator, the Netherlands
Institute for Health Sciences, Room Ee 2185, Erasmus University Medical School, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
Phone: + 31 10 408 82 88, Fax: + 31 10 436 59 33
Dr. Johan P. Velema dept. Public Health
Erasmus University Rotterdam
Tel: +31-10-4087714
Fax: +31-10-4366831

16th International Congress of Nutrition

The 16th International Congress of Nutrition will be held in Montreal, Quebec, Canada, July 27 to August 1, 1997. "From Nutrition Science to nutrition practice for better global health"

The program will cover the major areas of nutrition: nutritional epidemiology, food security; micronutrient malnutrition; nutrition issues important to women's and children's health; models and state-of-the-art methods for nutrition research; foods for health: bioactive factors, genetically modified and functional foods; nutrition in treatment of diabetes, AIDS, obesity,osteoporosis, cancer, hypersensitivity, and mental disorders; and nutrition education.

In addition to plenary lectures and traditional there-specific symposia, the program will feature debate sessions on controversies in nutrition. Workshops will be organized in one of four formats: Poster Workshops, Media Demonstrations, Reports of Nutrition Program and Working Group Sessions.

The Registration Bulletin and Call for Abstracts of the 16th International Congress of Nutrition will be available in October 1996 by:

1. direct request sent to the Congress Organization
Congress Secretariat
16th International Congress of Nutrition
National Research Council Canada
Montreal Road, Building M-19
Ottawa, Ontario
Telephone: (1 613) 993-7271
Fax: (1 613) 993-7250

2. by accessing INTERNET (information is thus readily available and by completing the Reply Form you are ensured of receiving a copy of the Registration Bulletin and Call for Abstracts by mail).


Receipt of abstracts

January 15, 1997

Advance Registration

April 15, 1997

Hotel Accommodation

June 6, 1997

Visions of the Future of Africa - Book Project

Young, dynamic, and talented Africans who are 40 years of age or under are invited to contribute papers to a proposed book tentatively entitled "Visions of the Future of Africa". Each contribution should be from the personal perspective of the author. Although contributing authors can examine additional issues which they deem to be important for the future of Africa, each author should at the least explore the following questions in their essay:

What do you think about the future? What are your visions, hopes, fears, ambitions, and goals for the future? What are your perceptions about the trends that will shape the world, your region, nation, and societies?

Which of these trends would you like to encourage and which ones would you like to discourage? How do you see the future of the world, the African continent, your nation, and your community? What type of an Africa would you like to live in? How can your vision of the future be attained? What role do you see yourself playing not only in your country but in the world of the future?

Authors should have in mind a time frame of about 30 years into the future. That is, the year 2026 should be the focus. Authors should limit their contributions to 4000 words. Although the deadline for submission of manuscripts is 30 December 1996, sending a paper early will allow more time for its consideration. Authors whose articles are selected for inclusion in the book will be paid an honorarium of US$500.

Please distribute this information to anyone you feel might be interested or should participate in this book project. If you would like to nominate someone or yourself to contribute an article to be considered for inclusion in the book, please provide the following information (Name, Profession & Job Title, Nationality, Sex, Address, Telephone #, Fax #, and Email) on each of your nominees. We will need this information as soon as possible so that we can send you and other nominees the book proposal and guidelines for contribution.

Direct inquiries to Olugbenga Adesida and Arunma Oteh.
Contact address: B.P. 46 Guichet, Annexe BAD,
Abidjan, Cote d'Ivoire; Tel: (+225) 44 80 81 / 44 70 02;
Fax: (+225) 22 26 64 / 44 70 02; Email:

Redesigning Government's Role in Health: Lessons for Indonesia from Neighboring Countries

Since 1973, the Government of Indonesia has expanded its role in health, with favorable results initially. IMR (per 1000 live births) fell from over 100 in 1970 to roughly 86 by 1980, with recent surveys showing IMR of 57 for 1990s. Despite these gains and extensive government involvement, perform

ance in Indonesia's health sector has been disappointing and lagging behind its neighbors. What can Indonesia learn from its neighbors? The report "Redesigning Government's Role in Health: Lessons for Indonesia from Neighboring Countries," by S. Lieberman, Division Chief (EA3PH), attempts to address these issues. The study provides a comprehensive historical review of the health system and policies pursued in Indonesia and its neighboring countries (Malaysia, the Philippines and Thailand).

Chronically low levels of health spending provides only a limited, proximate explanation of the poor performance. Acknowledging the differences in income and spending, the study concludes that Indonesian planners can learn from some of the initiatives of its neighbors. Among the recommendations were:

* decentralization of major health responsibilities to the provinces;

* strengthening the capacity of MOH in technical support, program review, policy analysis and advocacy;

* better coordination between public and private sector.

* rethinking and reinvigorating community-based activities

* increasing public funding

A limited number of copies of the report are available. To request a copy, please contact Tracee Graham-Williams at (202)458-2531 fax:(202)522-3394 and by e-mail:

Short Courses in Health Economics

The CENTRE FOR HEALTH ECONOMICS, Chulalongkorn University, Bangkok, Thailand is offering a number of short courses in Health Economics.

- Organization Management And Decision Making In The Health Sector (December 2 - 27, 1996)

Analysis and decision making in health care organizations in the private and public sectors. Attention will be given to the assessment of strengths and weaknesses of modeling in relation to particular types of decisions.

- Health Economics Research Methods (December 30, 1996 to January 24, 1997)

Principles of health economics research, including the roles of questions, hypotheses and theories in the research process, with critical review of research design and methodologies. This will lead to the ability to prepare a research proposal, including strategies for data management, analysis and communication of results.

Fees and other estimated expenses for a four-week course in year 1996-97 are approximately 51,250 Baht (US$2,050). Please request application materials and other information from :

Director of Short Courses in Health Economics
Centre for Health Economics, Faculty of Economics
Chulalongkorn University
Bangkok 10330, Thailand
Tel: (662)218-6281 Fax: (662)218-6279
Email: or

Opportunities for Micro Nutrient Interventions (OMNI): Report Of The Xvii Ivacg Meeting

Virtual Elimination of Vitamin A Deficiency: Obstacles and Solutions for the Year 2000", the report of the XVII IVACG Meeting, (held in Guatemala, March 1996) is now available from the International Vitamin A Consultative Group (IVACG). It contains the XVII IVACG Meeting program, meeting summary and recommendations, abstracts of presentations, and participant lists.

The five-day meeting program included 130 presentations related to the obstacles and solutions to implementing programs to eliminate vitamin A deficiency as a public health problem as well as other topics related to vitamin A deficiency.

To order your copy, send a message to:

IVACG Secretariat,
ILSI Research Foundation
1126 Sixteenth Street, NW
Washington, D.C. 20036, USA
tel (202) 659-9024; fax (202) 659-3617

Opportunities For Micronutrient Interventions (OMNI) is located at

1616 North Fort Myer Dr, Suite 1100, Arlington, Virginia
22209 USA - Tel: 703 528-7474 - Fax: 703 528-7480