Int J Health Serv
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The National Action Plan for Primary Health Care, a planning document of the Sierra Leonean Ministry of Health for the restructuring of the country's rural health services, is analyzed in its social, economic, and historical context. It appears to be an attempt of the national government to gain control over the highly devolved health care delivery system, but the state has neither the political will nor the power to achieve this goal. The utility of the document is therefore in doubt, which raises two important questions: Whose interests does this plan serve, and at whose cost?
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The World Health Organization estimates that almost half a million women in developing countries die in pregnancy and childbirth every year. Unsafe induced abortion is responsible for perhaps one-quarter of these deaths. ⋯ United States international policy on funding abortion-related activities in maternal health and family planning programs is especially restrictive. A new policy approach is clearly needed if unacceptably high rates of maternal morbidity and mortality in many countries are to be reduced.
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Comparative Study
Do nutrition programs make a difference? The case of Brazil.
Four Brazilian food and nutrition programs operating during some part of 1974-86 are evaluated for their effectiveness in curing or preventing infant and child malnutrition, including low birth weight when pregnant women were beneficiaries. Two programs distributed free food to identified clients: traditional commercial foods in one case and specially formulated supplements in the other. The other two programs subsidized four or more basic foodstuffs: one experiment quantitatively restricted a subsidy to identified families, and the other was unrestricted and open to all families patronizing certain shops. ⋯ Donation programs including medical and educational components proved more effective than pure subsidies, showing that while poverty may be the chief cause of malnutrition, the problem should be seen as poor health rather than simply low food consumption. Evaluation also shows that programs were inefficient in transferring benefits, and that clients were deterred from participating by the costs of obtaining the food and its poor quality and small volume. Longer participation improved results, but more frequent participation in a given interval did not necessarily do so.
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This article uses the current controversies in the British debate about health to illustrate the need to theorize, and therefore critically evaluate, the links between medicine and health policies, including health care policies. The medical model of health is deeply embedded in institutional practices in many countries, and while this model has attracted deserved criticism in recent years, an alternative social model, or one that incorporates indispensable aspects of the medical model, has attracted much less attention and requires sustained development. Comparative study of patterns of inequality in health, and especially of the correlation between material deprivation and premature mortality, necessarily reveals causal determinants of both health and ill-health in populations and invites ambitious programs to develop a social model.