This briefing paper has been prepared based on the basis of field level experiences. It highlights the emerging decentralized leadership in the WASH sector in light of the Master Plan and ODF movement in Nepal. The Master Plan has introduced innovative institutional arrangement of inclusive WASH Coordination Committees to lead ODF movement. These committees leadership of such committees hashave come up with several innovations in planning, financing, implementation and monitoring, and promoting inclusive and participatory governance process in sanitation development. Nepal's sanitation campaign has visibly scaled up ODF status despite some shortcomings. Mobilization of local resources is possible through local leadership, sustainability requires equal emphasis on behavioural and facility aspects and advocacy for health benefits of the improved sanitation are the prime drivers for changes. Similarly, cross-learning are vital for innovations in the sector and integration of sanitation with other development sector activities enhances synergy. The post-ODF intervention is leading the sanitation sector towards livelihood promotion and social wellbeing aspect too.
Investments for basic rural sanitation programs should not only focus on the construction of new installations, but also on the necessity of implementing proper management models that guarantee the operational and financial sustainability of the investments. The integrated rural sanitation system (SISAR) is based on the idea of creating a confederation of local user groups which come together on a regional basis, and through an adequate institutional setup, are responsible for managing SISAR and assuring the adequate provision of water supply and in some cases, wastewater services. Financial sustainability is achieved by the implementation of tariffs for water consumption and provision of wastewater services generating revenue which is redistributed among all systems in order to cover all operational, maintenance and administration costs. Important stakeholders in the model include, besides the users, local and state government and international financing institutions responsible for financing the investments in the construction of rural water supply and wastewater systems. This document focuses on the experience and results achieved by SISAR in the Brazilian state of Ceará. In 2001 eight SISARs began providing improved water supply services in 66 settlements. Today, more than 560 settlements (more than 330,000 inhabitants) are supplied by SISARs.
1. Look as shit as an asset, the beginning of a whole sanitation value chain 2. Emphasize the role of the private sector in sanitation, in particular small scale private enterprises 3. Pay attention to the economics of investing in sanitation 4. Increase the efficiency of the sanitation value chain 5. Look at advantages of small scale decentralized versus large scale centralized waste water treatment (WWT) plants 6. Considering sanitation as a multi-governance challenge 7. Consider the economics of different technological options for sanitation 8. Incorporating informality in the sanitation sector 9. Tap alternative sources of finance for sanitation 10. Be aware of the politics of sanitation
(See the article by Aaby et al, on pages 245–52.) There is now clear evidence that the simplistic conventional model of immunization is invalid [1]. We can no longer assume that a vaccine acts independently of other vaccines, or that it influences only infections caused by the target disease. Strong evidence from randomized trials suggests that bacillus Calmette-Guérin vaccine (BCG) reduces mortality from infections other than tuberculosis and that measles vaccine reduces mortality from infections other than measles [1–4]. However, there is worrying evidence that whole-cell diphtheria-tetanus-pertussis vaccine (DTP) may increase mortality from infections other than diphtheria, tetanus, or pertussis in high-mortality areas [1, 3–8]. These nonspecific effects of BCG, measles vaccine, and DTP are generally stronger in girls, appear to be maximal in the first 6 months after immunization, and are largely determined by the most recent vaccine administered [1]. Randomized trials show that measles vaccine has strong nonspecific effects. Providing it is not given after vitamin A or followed by DTP, measles vaccine reduces mortality from diseases other than measles by 45% (95% confidence interval [CI], 14%–65%) when given at 4.5 months of age [9], and by 47% (95% CI, 23%–63%) when given to girls at 9 to 10 months of age [1]. In this issue of the Journal, Aaby et al present further evidence, from Guinea-Bissau, that BCG has potent nonspecific effects on mortality [4]. Low-birth-weight neonates were randomized to receive BCG at birth or via the routine immunization program at an older age (median, 7.7 weeks). The biological effects of BCG are shown by the outcome during the first 4 weeks after randomization, before children in either group had been given DTP and when few children in the control group had received BCG. In this period, BCG reduced mortality by 45% (95% CI, 11%–66%); there were fewer deaths from sepsis and acute respiratory infection, and no deaths from tuberculosis (which is a rare cause of death at this age). This spectacular reduction in mortality is consistent with the results of 6 controlled trials performed in 45,662 children in the United States and the United Kingdom in the 1940s and 1950s, in which BCG reduced mortality from causes other than tuberculosis by 25% (95% CI, 6%–41%) [1, 2]. Although BCG reduced mortality in the first 4 weeks of life in the trial in Guinea-Bissau, investigators observed no difference in mortality after that age [4]. This is not surprising, because by 2 months of age 58% of the controls had received BCG and over 60% of children in both groups had received DTP. Consequently, BCG did not significantly reduce mortality in the first 12 months of life, the observed reduction being 17% (95% CI, −8% to 37%). This was the primary endpoint of the trial, which was underpowered because infant mortality was 101 deaths per 1000 live births, rather than 250 deaths per 1000 live births as predicted when the trial was designed. A lower-than-expected mortality often occurs when trial participants in a high-mortality area are offered free treatment, as in this study. This illustrates how difficult it is to do randomized trials in high-mortality areas, where we most need to obtain information about how to lower mortality. A worrying finding in this trial was that children who had received DTP by 2 months of age had an increased mortality between 2 and 6 months of age: Mortality was increased 4.3-fold (95% CI, 1.5–12.2-fold) in the BCG-at-birth group and 1.7-fold (95% CI, .7–4.0-fold) in the control group [4]. DTP was observed to have similar effects in a randomized trial of revaccination with BCG at 19 months of age in Guinea-Bissau [3]. In that trial, 60% of the participants had not received their last dose of DTP (DTP4) at the time of enrollment, and many of these children were given DTP4 after entering the study. Children who received BCG had a lower mortality than controls if they had received DTP4 before enrollment (hazard ratio, .36; 95% CI, .13–.99) but a higher mortality if they had not received DTP4 before enrollment (hazard ratio, 1.78; 95% CI, 1.04–3.04); the difference was highly significant (P = .006). Mortality was 0.36 deaths per 100 person-years if DTP4 had been given before BCG revaccination, 1.02 deaths per 100 person-years in controls who were not revaccinated with BCG (mortality was not affected by DTP4 status at enrollment), and 1.83 deaths per 100 person-years if DTP4 had not been given before BCG revaccination [3, 10]. These 2 studies suggest that BCG lowers mortality if it is given alone or after DTP, but that mortality may be increased if DTP is given after BCG as recommended in the schedule for the Expanded Program on Immunization (EPI) [3, 4]. The administration of DTP after BCG was not randomized in these studies, so the observed increase in mortality with DTP may have been caused by bias. However, this seems unlikely. In the trial of BCG in low-birth-weight babies [4], the infants who had received DTP by 2 months of age (and had increased mortality) were larger babies who would be expected to have a lower mortality in the absence of a nonspecific effect of DTP. In the trial of BCG revaccination at 19 months of age [3], mortality in the control group (no additional BCG) was not influenced by DTP4 status at the time of randomization, suggesting that this was not an independent risk factor. Even in unimmunized communities, diphtheria, tetanus, and pertussis cause far fewer deaths than pneumonia, sepsis, and diarrhea [11]; despite reducing mortality from diphtheria, tetanus, and pertussis, DTP will, therefore, increase total mortality if it causes even a small increase in mortality from pneumonia, sepsis, and diarrhea in high-mortality areas [12]. When DTP was first introduced into Guinea-Bissau, despite the absence of herd immunity, mortality was 5.1 deaths per 100 person-years among children who did not receive DTP but 11.3 deaths per 100 person-years among children who did receive DTP (risk ratio, 2.03; 95% CI, 1.17–3.52) [7]. I know of no other study of the introduction of DTP in a high-mortality area with sufficient power to test the effect on total mortality. No randomized trial has demonstrated that it is safe to give DTP to young infants in high-mortality areas, and there is now worrying evidence that DTP may increase mortality under these circumstances—especially when it is given after BCG as recommended in the EPI schedule [1, 3–8]. In 2002, 2003, and 2004, the WHO Global Advisory Committee on Vaccine Safety (GACVS) concluded that the evidence did not support an increased risk of mortality after DTP immunization [13]. However, the onus of proof is surely the reverse of this—we need clear evidence that a vaccine is safe when it is given routinely to all infants in high-mortality areas. In addition, the Committee based its conclusion on observational studies, all of which had one or more serious methodological problems [1, 5, 14–16]. First, any observational study (with nonrandom allocation of vaccines) may induce a spurious association between vaccination and survival [16]. Second, vaccination was often withheld in sick children, which causes selection bias in favor of DTP [5]. Third, many of the studies classified dead children as unvaccinated if there was no evidence they had been immunized; as some of these children will have been vaccinated, this causes survival bias in favor of DTP [1, 5, 14–16]. Fourth, most of the studies did not test the effect of the most recent vaccine received by each child over time: the first dose of DTP has different effects when given before, with, or after BCG [4, 5]; the last dose of DTP has different effects given before, with, or after measles vaccine [5, 6]; and the effects differ by sex [1]. Fifth, many children were given BCG at the same time as DTP, rather than at birth (6 weeks before DTP) as specified in the EPI schedule [5]. In 2008, GACVS finally endorsed the view that evidence for the safety of DTP is “unlikely to be obtained from observational studies” [17]. Given the very large number of lives at stake, it is disappointing that it took the Committee so long to decide that observational studies are unlikely to provide adequate evidence that it is safe to give DTP to infants who have been vaccinated with BCG at birth, and even more disappointing that international agencies have not funded randomized trials to test the effect of DTP on all-cause mortality in children in high-mortality areas [5, 18]. We could obtain this information while still immunizing against diphtheria, tetanus, and pertussis if we randomized children to receive the primary series of DTP at different ages, or to receive a booster dose of DTP at different ages [18, 19]. The current EPI schedule is BCG-polio at birth; DTP-polio at 6, 10, and 14 weeks; and measles vaccine at 9 months–but tuberculosis, polio, diphtheria, tetanus, pertussis, and measles are not the main causes of death in children, even in unimmunized communities [11]. The main reason that the EPI program has been beneficial may not be because it protects against these infections, but because the nonspecific effects of BCG and measles vaccines reduce the very large number of deaths from pneumonia, sepsis, and diarrhea. It is exciting that we may be able to save several million more lives each year just by making better use of the current EPI vaccines in an improved schedule—we urgently need randomized trials of the effects of the EPI vaccines on total mortality to help us design the optimal schedule [5, 18].
Failure is the norm for urban sanitation infrastructure in Ghana: of the rather substantial number of wastewater and faecal sludge treatment plants, with about 70 mostly decentralized systems throughout the country, less than 10 are operating effectively. This research presents an overview of the related sanitation situation in Ghana, and compares the few successful facilities with their failed counterparts in order to decipher the factors that enable the former to prevail. The research reveals important differences in the operation and maintenance (O&M) strategies, financing schemes and incentive structures in the successful versus unsuccessful facilities, which are probably not unique to Ghana. Based on the findings, we suggest a set of guiding questions for incorporation into the existing planning, funding or general decision-making framework in order to avoid commonly observed traps, which not only undermine progress in the delivery of sanitation services but also harshly affect environmental and public health.
Honoratha Mushi, K. Mullei, J. Macha, Francis Wafula · 7 authors
Health worker training is a key component of the integrated management of childhood illness (IMCI). However, training coverage remains low in many countries. We conducted in-depth case studies in two East African countries to examine the factors underlying low training coverage 10 years after IMCI had been adopted as policy. A document review and in-depth semi-structured interviews with stakeholders at facility, district, regional/provincial and national levels in two districts in Kenya (Homa Bay and Malindi) and Tanzania (Bunda and Tarime) were carried out in 2007-08. Bunda and Malindi achieved higher levels of training coverage (44% and 25%) compared with Tarime and Homa Bay (5% and 13%). Key factors allowing the first two districts to perform better were: strong district leadership and personal commitment to IMCI, which facilitated access to external funding and encouraged local-level policy adaptation; sensitization and training of district health managers; and lower staff turnover. However, IMCI training coverage remained well below target levels across all sites. The main barrier to expanding coverage was the cost of training due to its duration, the number of facilitators and its residential nature. Mechanisms for financing IMCI also restricted district capacity to raise funds. In Tanzania, districts could not spend more than 10% of their budgets on training. In Kenya, limited financial decentralization meant that district managers had to rely on donors for financial support. Critically, the low priority given to IMCI at national and international levels also limited the expansion of training. Levels of domestic and donor support for IMCI have diminished over time in favour of vertical programmes, partly due to the difficulty in monitoring and measuring the impact of an integrated intervention like IMCI. Alternative, lower cost methods of IMCI training need to be promoted, and greater advocacy for IMCI is needed both nationally and internationally.
El primer objetivo de esta tesis es la identificación y análisis de aspectos clave para la gobernanza de los servicios de agua rural en países que adolecen de bajos niveles de cobertura, altos índices de pobreza, se encuentran en procesos de descentralización, reciben un importante apoyo de donantes internacionales. Esta situación es común para muchos países de África Sub-sahariana. Por ello, se eligió Tanzania como objeto de estudio. El segundo objetivo de esta tesis ha sido el ensayo de nuevas herramientas y mecanismos institucionales para la mejora de la eficiencia, equidad y sostenibilidad en la provisión de agua en las zonas rurales, con especial énfasis en el nivel de gobierno descentralizado. Para ello, se desarrollaron experiencias piloto así como procesos de investigación-acción. En el capítulo 1 se estudia el papel desempeñado por los diferentes actores internacionales en la financiación del sector del agua en los países en desarrollo durante la década 1995-2004. En el capítulo 2 se analizan los indicadores existentes para el seguimiento del sector del agua a nivel internacional, específicamente los utilizados para valorar el cumplimiento de los Objetivos del Milenio, así como el Índice de Pobreza Hídrica (Water Poverty Index). Se detallan algunos limitantes en cuanto al alcance y metodología de cálculo de estos indicadores, y se proponen las características básicas que los indicadores deben tener para apoyar la toma de decisiones a nivel gubernamental. En el capítulo 3 se presenta una metodología para el desarrollo de indicadores más completos de acceso al agua, basándose en el Mapeo de Puntos de Agua (Water Point Mapping-WPM). La metodología propuesta, denominada Mapeo Mejorado de Puntos de Agua, incluye la medición de parámetros básicos de calidad del agua y estacionalidad de los servicios. La factibilidad y pertinencia de la adopción de esta metodología a nivel nacional se desarrolló satisfactoriamente a modo de experiencia piloto en dos distritos de Tanzania, con una población rural aproximada de 840.000 personas (capítulo 4). En el capítulo 5 se analiza la sostenibilidad de los servicios de agua rural en relación al tipo de tecnología utilizada para el abastecimiento. El análisis se basa en los datos de 6814 puntos de agua, sobre una población equivalente al 15% de la población rural de Tanzania. El capítulo 6 se analiza el proceso de toma de decisiones, desde el nivel central al nivel comunitario, para la asignación de recursos en el sector del agua rural. Los resultados en los 4 distritos estudiados muestran que menos de la mitad de los proyectos asignados se destinan a zonas con baja cobertura de servicios. Las incoherencias entre el diseño y la implementación de los planes nacionales, y la influencia de los poderes políticos locales son los mayores obstáculos para una equitativa distribución de los recursos. El capítulo 7 detalla el caso de investigación-acción ejecutado a nivel de gobierno local entre 2006 y 2009 con el gobierno del distrito de Same, Tanzania. La mejora de la equidad y la sostenibilidad se fomentaron mediante el desarrollo de herramientas de planificación basadas en el WPM y de mecanismos institucionales para el apoyo a largo plazo a los sistemas de agua rurales. En el capítulo 8 se detallan las conclusiones generales y líneas de investigación futuras. La resolución de los desafíos principales encontrados implican la adopción de paradigmas diferentes: i) la aceptación del agua rural como un servicio responsabilidad del gobierno y no de las comunidades; ii) las actuaciones deben decidirse en función de las necesidades de las comunidades, y no de su capacidad de demanda, iii) el establecimiento de sistemas de información internos que partan desde el nivel local y estén adaptados a las capacidades de actualización disponibles, iv) el desarrollo de mecanismos para la orientación y el seguimiento cercano de los procesos de toma de decisión a nivel local The first objective of this thesis is the identification and analysis of key issues in the governance of rural water services in countries that suffer from a lack of rural water access, high levels of poverty, are under decentralization processes and receive significant donor support. This is a common situation for many Sub-Saharan countries. To address the relevant aspects, Tanzania was taken as a case study and was analyzed in depth. The second objective was to test tools and propose institutional arrangements at that can improve efficiency, equity and sustainability in the provision of water for the rural areas, with special focus at the local government level. This was made through pilot experiences and an action research case study. In Chapter 1 we analyse the role played by the international actors in the financing of the water sector of developing countries, in the period 1995-2004. In Chapter 2 we study existing indicators for international monitoring, specifically the ones used by the Joint Monitoring Programme for the monitoring of the MDGs, as well as the Water Poverty Index (WPI). Some drawbacks are found the indicators’ scope and methodology, which prevents them from being used as policy drivers at national level. The chapter concludes by proposing the main characteristics that those indicators must entail to be useful for governmental decision making. In Chapter 3, a methodology to define water access indicators, based on GIS-based Water Point Mapping (WPM) is proposed. The methodology, named Enhanced Water Point Mapping (EWPM), includes the measurement of basic parameters of quality of water and seasonality of the service. The feasibility and relevance of adopting this methodology at national level was tested with success in two districts in Tanzania, covering a rural population of approximately 840,000 people, as described in Chapter 4. In chapter 5, we analyze the sustainability of systems over time, and the relation between sustainability and technology; this chapter is based on the study of 6814 water points, covering 15% of the rural population in the country. Chapter 6 analyses the aspects affecting financial resource allocation for rural water in Tanzania at all levels, from central government to village level. Results in four districts studied showed that less than half of allocated projects go to underserved areas. Incoherencies between the design and the implementation of the plans and political influences at local level are highlighted as major obstacles to the effective, equitable allocation of resources. In chapter 7, we describe an action research process that was carried out at local government level, together with Same District Council, between 2006 and 2009. The improvement of equity and sustainability was supported through the development of EWPM based planning tools and new institutional arrangements for the long-term support of community managed water supplies. In Chapter 8 the overall conclusions and future research lines are presented. We propose some new paradigms in the sector: i) rural water supply must be considered as a service, with government and not communities as main duty bearers; ii) the adoption of a needs-based approach to projects planning at community level, instead of the current demand driven, iii) the establishment of bottom-up internal information systems adapted to available updating capacities and iv) the development of mechanisms for the guidance and close monitoring of local government decision-making.
Abstract In recent decades, many changes have occurred in the approach to financing and operating water services in developing countries. The demand‐responsive approach is now adopted in many countries in a context of donor‐supported decentralization processes, which gives more responsibility to end users. However, the government's responsibility at different levels is enforced by the international recognition of the human right to water. This paper examines specific actions that build the role of local government authorities in this scenario. A collaboration between an international NGO and a rural district in Tanzania from 2006 to 2009 is used as an action research case study that is representative of local capacity‐building needs in decentralized contexts and rural areas. Three main challenges were detected: i) lack of reliable information; ii) poor allocation of resources in terms of equity; and iii) lack of long‐term community management support from the district. Two mechanisms were established: i) water point mapping as a tool for information and planning; and ii) a District Water and Sanitation Unit Support (DWUS) for community management. The results show how the framework provided by the goal of human right to water helps to define useful strategies for equity‐oriented planning and post‐project support at the local level.
Jennifer Bryce, César G. Victora, Jean‐Pierre Habicht, Robert E. Black · 5 authors
OBJECTIVE: To summarize the expectations held by World Health Organization programme personnel about how the introduction of the Integrated Management of Childhood Illness (IMCI) strategy would lead to improvements in child health and nutrition, to compare these expectations with what was learned from the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE-IMCI), and to discuss the implications of these findings for child survival policies and programmes. DESIGN: The MCE-IMCI study designs were based on an impact model developed in 1999-2000 to define how IMCI would be implemented at country level and below, and the outcomes and impact it would have on child health and survival. MCE-IMCI studies included: feasibility assessments documenting IMCI implementation in 12 countries (1999-2001); in-depth studies using compatible designs in Bangladesh, Brazil, Peru, Tanzania and Uganda; and cross-site analyses addressing the effectiveness of specific subsets of IMCI activities. RESULTS: The IMCI strategy was successfully introduced in the great majority of countries with moderate to high levels of child mortality in the period from 1996 to 2001. Seven years of country-based evaluation, however, indicates that some of the basic expectations underlying the development of IMCI were not met. Four of the five countries (the exception is Tanzania) had difficulties in expanding the strategy at national level while maintaining adequate intervention quality. Technical guidelines on delivering interventions at family and community levels were slow to appear, and in their absence countries stalled in their efforts to increase population coverage with essential interventions related to care-seeking, nutrition, and correct care of the sick child at home. The full weight of health system limitations on IMCI implementation was not appreciated at the outset, and only now is it clear that solutions to larger problems in political commitment, human resources, financing, integrated or at least coordinated programme management, and effective decentralization are essential underpinnings of successful efforts to reduce child mortality. CONCLUSIONS: This analysis highlights the need for a shift if child survival efforts are to be successful. Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches. The focus on process within child health programmes must change to include greater accountability for intervention coverage at population level. Global strategies that expect countries to make massive adaptations must be complemented by country-level implementation guidelines that begin with local epidemiology and rely on tools developed for specific epidemiological profiles.
Each year, up to three million deaths due to malaria and close to five billion episodes of clinical illness possibly meriting antimalarial therapy occur throughout the world, with Africa having more than 90% of this burden. Almost 3% of disability adjusted life years are due to malaria mortality globally, 10% in Africa. New information is presented in this supplement on malaria-related perinatal mortality, occurrence of human immunodeficiency virus in pregnancy, undernutrition, and neurologic, cognitive, and developmental sequelae. The entomologic determinants of transmission and uses of modeling for program planning and disease prediction and prevention are discussed. New data are presented from the Democratic Republic of the Congo, Tanzania, Ethiopia, and Zimbabwe on the increasing urban malaria problem and on epidemic malaria. Between 6% and 28% of the malaria burden may occur in cities, which comprise less than 2% of the African surface. Macroeconomic projections show that the costs are far greater than the costs of individual cases, with a substantial deleterious impact of malaria on schooling of patients, external investments into endemic countries, and tourism. Poor populations are at greatest risk; 58% of the cases occur in the poorest 20% of the world's population and these patients receive the worst care and have catastrophic economic consequences from their illness. This social vulnerability requires better understanding for improving deployment, access, quality, and use of effective interventions. Studies from Ghana and elsewhere indicate that for every patient with febrile illness assumed to be malaria seen in health facilities, 4-5 episodes occur in the community. Effective actions for malaria control mandate rational public policies; market forces, which often drive sales and use of drugs and other interventions, are unlikely to guarantee their use. Artemisinin-based combination therapy (ACT) for malaria is rapidly gaining acceptance as an effective approach for countering the spread and intensity of Plasmodium falciparum resistance to chloroquine, sulfadoxine/pyrimethamine, and other antimalarial drugs. Although costly, ACT ($1.20-2.50 per adult treatment) becomes more cost-effective as resistance to alternative drugs increases; early use of ACT may delay development of resistance to these drugs and prevent the medical toll associated with use of ineffective drugs. The burden of malaria in one district in Tanzania has not decreased since the primary health care approach replaced the vertical malaria control efforts of the 1960s. Despite decentralization, this situation resulted, in part, from weak district management capacity, poor coordination, inadequate monitoring, and lack of training of key staff. Experience in the Solomon Islands showed that spraying with DDT, use of insecticide-treated bed nets (ITNs), and health education were all associated with disease reduction. The use of nets permitted a reduction in DDT spraying, but could not replace it without an increased malaria incidence. Baseline data and reliable monitoring of key outcome indicators are needed to measure whether the ambitious goals for the control of malaria and other diseases has occurred. Such systems are being used for evidence-based decision making in Tanzania and several other countries. Baseline cluster sampling surveys in several countries across Africa indicate that only 53% of the children with febrile illness in malarious areas are being treated; chloroquine (CQ) is used 84% of the time, even where the drug may be ineffective. Insecticide-treated bed nets were used only 2% of the time by children less than five years of age. Progress in malaria vaccine research has been substantial over the past five years; 35 candidate malaria vaccines are in development, many of which are in clinical trials. Development of new vaccines and drugs has been the result of increased investments and formation of public-private partnerships. Before malaria vaccine becomes deployed, consideration must be given to disease burden, cost-effectiveness, financing, delivery systems, and approval by regulatory agencies. Key to evaluation of vaccine effectiveness will be collection and prompt analysis of epidemiologic information. Training of persons in every aspect of malaria research and control is essential for programs to succeed. The Multilateral Initiative on Malaria (MIM) is actively promoting research capacity strengthening and has established networks of institutions and scientists throughout the African continent, most of whom are now linked by modern information-sharing networks. Evidence over the past century is that successful control malaria programs have been linked to strong research activities. To ensure effective coordination and cooperation between the growing number of research and control coalitions forming in support of malaria activities, an umbrella group is needed. With continued support for scientists and control workers globally, particularly in low-income malarious countries, the long-deferred dream of malaria elimination can become a reality.
Summary This article analyses the structure and organization of RDRS, one of the largest rural development NGOs in Bangladesh. RDRS's Comprehensive Project works with 120,000 households, through small groups of about 15, motivating and educating people on joint savings and investment, agricultural and off-farm income generation, primary health and family planning, literacy, social awareness, and women's development. Groups have access to credit provided by RDRS or banks. No free inputs are given. The Comprehensive Project's Community Health Unit runs 55 antenatal centres and a leprosy treatment service. The Rural Works Project plants 250,000 trees per year, and supervises construction of schools, markets and small bridges and culverts in isolated rural communities. RDRS has almost 1,700 staff. Field implementation is decentralized to area-based units, within a common policy, activity, financial and personnel framework. Six sectoral advisory units are responsible for innovation, quality control and coordination across the whole programme. Résumé Les ONG: le cas du Service rural de Rangpur Dinajpur Le présent article contient une analyse de la structure et de l'organisation du RDRS, l'une des plus importantes ONG (Organisation non gouvernementale) rurales du Bangladesh. Le Comprehensive Project du RDRS intervient auprès d'environ 120 000 ménages sous forme de petits groupes d'environ 15 personnes; le RDRS a pour rôle de motiver et d'éduquer les participants quant aux économies et investissements conjoints dans le ménage; la génération de revenus fermiers et outre-fermiers; les soins de santé primaires et le planisme familial; les campagnes d'alphabétisation; les programmes de sensibilisation sociale; et le développement des femmes dans la population. Les groupes ont accès au crédit fourni par le RDRS ou par les banques. Aucune contribution n'est gratuite. Le groupe des Soins de santé communautaires du Comprehensive Project organise 55 centres de consultation prénatale, ainsi qu'un centre pour le traitement des lépreux. Le service des prestations rurales plante environ 250 000 arbres par an et contrôle la construction des écoles, des marchés et des petits ponts et caniveaux dans les communautés rurales isolées. Le personnel du RDRS compte presque 1700 effectifs. Les antennes exécutives rurales sont décentralisées en unités à base géographique, or elles restent liées par une organisation de gestion commune des politiques, des activités, du financement, et du personnel. Six groupes de conseil sectoral se chargent des programmes d'innovation, de contrôle de la qualité et de coordination du programme au niveau de l'ensemble. Resumen Organizaciones no gubernamentales: el caso del Servicio Rural en Rangpur Dinajpar El artículo analiza la estructura y organización del RDRS, uno de los proyectos de desarrollo rural más grandes de las Organizaciones no gubernamentales en Bangladesh. Este proyecto exhaustivo comprende 120.000 familias, en grupos de quince familias, motivando y educando a la población en áreas como: ahorro colectivo e inversiones, producción de ganancias fuera de la granja, salud y planificación familiar, alfabetización, conciencia social y el desarrollo de la mujer. Los grupos tienen acceso a créditos provistos por RDRS o instituciones bancarias. No se otorga dinero gratis. La Unidad del Proyecto de Salud Comunitaria maneja 55 centros pre-natales y un servicio para el tratamiento de la lepra. El Proyecto de Trabajos Rurales planta 250.000 árboles por año, y supervisa la construcción de escuelas, mercados, puentes y alcantarillas en comunidades rurales aisladas. RDRS tiene un personal de casi 1700 empleados. La implementación de base se descentraliza en forma de unidades en cada área, que sin embargo siguen una línea común en cuanto a a criterios, actividades y estructuras financieras y de personal. Hay seis unidades consultivas responsables por las innovaciones, control de calidad y coordinación de la totalidad del programa.