There are very few documented large-scale successes in nutrition in Africa, and virtually no consideration of contracting for preventive services. This paper describes two successful large-scale community nutrition projects in Africa as examples of what can be done in prevention using the contracting approach in rural as well as urban areas. The two case-studies are the Secaline project in Madagascar, and the Community Nutrition Project in Senegal. The article explains what is meant by 'success' in the context of these two projects, how these results were achieved, and how certain bottlenecks were avoided. Both projects are very similar in the type of service they provide, and in combining private administration with public finance. The article illustrates that contracting out is a feasible option to be seriously considered for organizing certain prevention programmes on a large scale. There are strong indications from these projects of success in terms of reducing malnutrition, replicability and scale, and community involvement. When choosing that option, a government can tap available private local human resources through contracting out, rather than delivering those services by the public sector. However, as was done in both projects studied, consideration needs to be given to using a contract management unit for execution and monitoring, which costs 13-17% of the total project's budget. Rigorous assessments of the cost-effectiveness of contracted services are not available, but improved health outcomes, targeting of the poor, and basic cost data suggest that the programmes may well be relatively cost-effective. Although the contracting approach is not presented as the panacea to solve the malnutrition problem faced by Africa, it can certainly provide an alternative in many countries to increase coverage and quality of services.
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In the last decade there has been increased interest in the potential of home gardens to add to the food supply and income of rural households. A special issue of the Food and Nutrition Bulletin (vol. 7, no. 3, 1985) was devoted to this topic, and a later special issue (vol. 9. no. 2, 1987) called attention to the often overlooked possibilities of gardens for the urban poor. In general, it has been assumed that gardens that add to household food supplies and income also improve nutritional status. The following article specifically examines the effect of a "successful" home garden project in Senegal on the dietary adequacy of participating families. The project added significantly to the families' income. However, the diets were reasonably adequate before the project was introduced, and added money was not spent on food. Accepting this to be true, how should it be interpreted? To answer this question, information would be necessary on morbidity from infectious diseases, child growth, cognitive performance, and educational achievement. Improvement in family income may have had health benefits not looked for in this study-for example, reduced morbidity from infectious diseases associated with improvement in environmental sanitation and personal hygiene. This might also lead to better child growth and improved educational performance. The fact that expenditures on medicine and health care were not increased can have two interpretations. Either there was less need for such expenditure because of decreased illness, or, more likely, they were missed by the methodology. Hundreds of studies by anthropologists have documented the struggle of poor families to obtain money for medicine and medical care. Nevertheless, the paper points out that it cannot be assumed that successful home gardening programmes will have a direct effect on dietary adequacy in populations with other felt needs that are given a higher priority.
Présenté par François Gros RésuméPourquoi les résultats pour la santé en Afrique sont souvent décevants ? Parce-que nous n'avons considéré que la moitié de l'image en ce qui concerne l'allocation des ressources pour la santé. La plupart des projets financés par les gouvernements ont souvent abouti à des résultats décevants, certains indicateurs de santé avancent péniblement et d'autres stagnent. Pourquoi ? L'une des causes, selon l'auteur, serait la concentration des interventions sur le secteur public, sans tenir compte que la moitié des dépenses en santé en Afrique vont au secteur privé. Il est temps de considérer le système de santé dans sont entièreté, et pas que le secteur public.Dans cet article le secteur privé est défini comme étant toute provision de service de santé fournie par un prestataire non-étatique, qu'il soit du secteur privé formel (pharmacie, clinique, par exemple) ou qu'il soit du secteur privé informel (tradithérapeute, échoppe, par exemple).
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