Provision Of Basic Health Care Research Articles

Basic Health Care Provision Fund Project Implementation

Introduction: Knowledge and skills in quantitative/numerical disciplines are some of the essential skills necessary for sustainable and successful administration and management in financing health care. It is not clear whether the personnel across relevant establishments in the health sector of Nigeria have the requisite capacity to implement and manage a performance-based financing project. This survey assessed the availability of certain technical skills among selected mid-level managers in charge of the implementation of the Basic Health Care Provision Fund Project (BHCPFP). Materials and Methods: Data were collected with the aid of a self-administered questionnaire developed from a review of the project document. A total population of mid-level managers from all the respective ministries was studied across the six states in Southwest Nigeria. Data collection was conducted between February and June 2019. Data analysis was done using SPSS version 22. Frequency tables were generated and charts were constructed. Results: A total of 234 eligible participants were studied. Those who had formal training in quantitative/numerical-based skills such as accounting-related courses were about one-third, 77 (32.8%) and those who had acquired formal training in insurance-related disciplines were 91 (38.7%). A little above one-third, 66 (28.2%) had a form of on-the-job health insurance training. Conclusions: This study showed that mid-level managers had poor quantitative-related skills necessary for administrative and technical roles for implementation of BHCPFP. Mid-level managers should be trained and re-trained on those administrative and technical skills for better implementation of BHCPFP.

Universal Health Coverage

Universal Health Coverage has attracted global attention as an ideal vehicle that will drive health care services to the individuals, families, and communities globally. Good health systems are capable of serving the needs of entire populations, including the availability of infrastructure, human resources, health technologies, and medicines. This study seeks to identify the barriers and challenges which have hindered the provision of basic health care to communities and suggest ways of addressing some of them. Literature search reviewed 40 materials which were more relevant. Results revealed that there have been disparities in the provision of healthcare. Challenges in service provision include; lack of political commitment, weak health system resulting from limited financial allocation and poor leadership, lack of adequate number of skilled human resources, equipment and supplies and poor infrastructures. For UHC to be successful, an effective and well-functioning Primary Health Care (PHC) system is essential. Thus health systems can be strengthened through financial allocation; training of skilled and well-motivated healthcare workers. Also provision of right equipment and supplies, equity in resource distribution, improvement of infrastructures to meet the needs of the people is fundamental.

Ensuring gender and social equity in health: an analysis of Nigeria's Social Health Insurance Scheme and Basic Health Care Provision Fund

BackgroundIt is expected that a well-functioning, pre-paid health financing system that aims to move a country towards universal health coverage (UHC) will be equitable and gender-balanced. However, this feature is not automatic; much depends on the policy environment, including legal frameworks, implementation design, and management of the health financing scheme. To move towards UHC, Nigeria is implementing two key reforms: the Basic Health Care Provision Fund (BHCPF) and Social Health Insurance Scheme (SHIS). The BHCPF was created under the 2014 National Health Act to provide a basic package of health care to all Nigerians. Here, I report on a review of policy and legal frameworks at the policy formulation stage of the reforms, with a focus on gender and equity. MethodsI used findings from Abia state gender and equity analysis conducted to identify gender-related and equity-related barriers and opportunities in the design and implementation of the BHCPF and SHIS. I undertook project monitoring of the early-stage policy formulation phase of the reforms across functional areas of governance, revenue generation, risk pooling, enrolment strategies, and health benefit package. FindingsInitial assessment results showed several service delivery barriers to gender parity in staff (men in leadership and women in service delivery positions), low level of male engagement, lack of youth-friendly health services, unavailability of gender-based violence services, and low level of knowledge and understanding of gender and equity issues among key state-level implementing institutions. But early intervention results showed that progress has been made in the inclusion of men and women in the governance of the scheme, the establishment of an equity fund to subsidise those who are too poor to pay and progressive financial contributions into the scheme based on the ability to pay, and a central pooling of risk. Furthermore, a sustainable effort towards bridging the knowledge gap of key health-care professionals and policymakers in gender and equity issues in health has been instituted by national government implementing agencies with the mainstreaming of gender issues in the BHCPF manual and followed through with trainings of community representatives and health service providers. InterpretationUHC is hinged on gender and social equity in access to health-care services. Efforts to achieve this must begin at the policy formulation stage and carry through to policy implementation. However, UHC does involve political trade-offs and the degree to which implementation practice will conform to policy directions already set out is yet to be seen. FundingUSAID through Health Policy Plus (HP+) implemented by Palladium.

The role of National Health Act in Nigeria Health System strenghening

The National health act took a long period of 2004 -2014 before coming to existence, it serves as a legal backing for the regulation, development, and management of our health system. It also sets a standard for delivering health care to all citizens. The NHAct is a way of saying good bye to the era of poor access to health care, stock-out syndrome of essential drugs and vaccines, skewed health manpower distribution, mushroom health facilities, hospitals turned to “mere consulting clinics”, unregulated and unethical health researches, assault on health workers, total paralyzing strikes that leave the nation no option than unnecessary death of the citizens. The 2014 NHAct, therefore sets out a legal framework for the provision of health services which is a strong potential to transforming health care provision in Nigeria through the Basic Health Care Provision Fund (BHCPF) by extending primary health care to all Nigerians. As such, the NHAct can be used as a tool to strengthen the health system which is synonymous to the country as the roadmap to Universal Health Coverage (UHC). It is therefore recommended that all health workforce, health Ministries, Departments and Agencies (MDAs) and the three tiers of government work together harmoniously, so that our health system can be strengthened.Keywords: National Health Act, Basic Health care fund, Legal framework, Health System Strengthening.

Assessment of a free maternal and child health program and the prospects for program re-activation and scale-up using a new health fund in Nigeria.

A Free Maternal and Child Health program (FMCHP) was implemented in 12 states in Nigeria by the National Health Insurance Scheme (NHIS), between 2009 and 2015, using funds from the debt relief gains. It was called the Millennium Development Goals (MDGs) NHIS-MDG FMCHP. The program ended with the termination of the MDG in 2015. With the creation of the Basic Health Care Provision Fund (BHCPF) in Nigeria, this study sought to examine the past implementation experiences of the NHIS-MCH project with a view to identifying the enabling and constraining factors to program implementation, and the opportunities for adaptation and program scale-up in Nigeria using the BHCPF. The study was undertaken in the Federal Capital Territory, Abuja, and involved review of relevant documents and in-depth interviews with 21 key informants. The program was assessed in themes from the conceptual framework. Interviews were transcribed and analyzed using thematic analysis. The program enrolled about 1.5 million pregnant women and children during the period of implementation in the country. The respondents perceived the program as pro-poor, efficient, and effective, and led to marked improvement in the functionality of the facilities, availability of services and reduced out-of-pocket expenditure, which led to increased demand and utilization of MCH services. There was inadequate stakeholder consultation, alleged corrupt practices, challenges with registration, issues with counterpart funding and public financing management issues identified. Most respondents supported the idea of using the new fund (BHCPF) to revitalize/scale-up the Free MCH program. This study highlights the key lessons and implementation challenges identified by the respondents. The NHIS-MDG FMCHP had positive impact on the target population though it was not sustained following the conclusion of the MDG program. The findings will inform policy decisions about the appropriateness of sustaining the program and the feasibility of extending healthcare coverage using the proposed BHCPF. The new fund (BHCPF) can be used to reactivate and scale-up the Free MCH program, but the current level of funding will not assure universal health coverage for the target beneficiaries as realized from the costing aspect of this study.

Examining the Financial Feasibility of Using a New Special Health Fund to Provide Universal Coverage for a Basic Maternal and Child Health Benefit Package in Nigeria.

Background: A special health fund was established in Nigeria in 2014 and is known as the Basic Health Care Provision Fund (BHCPF). The fund is equivalent to at least 1% of the Consolidated Revenue of the Federation. The BHCPF will provide additional revenue to fund primary healthcare services and help Nigeria to achieve universal health coverage (UHC). This fund is to be matched with counterpart funds from states and local government areas (LGAs), and is expected to provide at least a basic benefit health package that will cover maternal and child health (MCH) services for pregnant women and under-five children.Objective: To determine the financial feasibility of using the BHCPF to provide a minimum benefit package to cover all pregnant women and under-five children in Nigeria.Methods: The study focused on three states in Nigeria: Imo, Kaduna, and Niger. The feasibility analysis was performed using 3 scenarios but the main analysis was Scenario 1, which was based on the funding of drugs and consumables only. All the costs and revenues were in 2015 levels. The standard costs of a minimum benefit package for the different states were multiplied by the number of target beneficiaries to determine the amount required for the year. Financial feasibility is determined by the excess or otherwise of revenue over costs.Findings: It was found that in the best case funding scenario of using 95% of the CRF with 25% counterpart funding from states and LGAs, the entire available funds were not adequate to cover the benefit package for all the pregnant women and under-five children in the three states. The funds were also inadequate to cover the target beneficiaries that live below the poverty line in two of the states.Conclusion: The BHCPF is a good step toward providing essential MCH services, but the current level of funding will not assure UHC for all the target beneficiaries. However, the available funds should be used immediately to target priority mothers and children such as vulnerable groups, whilst sourcing for additional funds to ensure universal coverage of MCH services.

Accountability mechanisms for implementing a health financing option: the case of the basic health care provision fund (BHCPF) in Nigeria

BackgroundThe Nigerian National Health Act proposes a radical shift in health financing in Nigeria through the establishment of a fund – Basic Healthcare Provision Fund, (BHCPF). This Fund is intended to improve the functioning of primary health care in Nigeria. Key stakeholders at national, sub-national and local levels have raised concerns over the management of the BHCPF with respect to the roles of various stakeholders in ensuring accountability for its use, and the readiness of the implementers to manage this fund and achieve its objectives. This study explores the governance and accountability readiness of the different layers of implementation of the Fund; and it contributes to the generation of policy implementation guidelines around governance and accountability for the Fund.MethodsNational, state and LGA level respondents were interviewed using a semi structured tool. Respondents were purposively selected to reflect the different layers of implementation of primary health care and the levels of accountability. Different accountability layers and key stakeholders expected to implement the BHCPF are the Federal government (Federal Ministry of Health, NPHCDA, NHIS, Federal Ministry of Finance); the State government (State Ministry of Health, SPHCB, State Ministry of Finance, Ministry of Local Government); the Local government (Local Government Health Authorities); Health facilities (Health workers, Health facility committees (HFC) and External actors (Development partners and donors, CSOs, Community members).ResultsIn general, the strategies for accountability encompass planning mechanisms, strong and transparent monitoring and supervision systems, and systematic reporting at different levels of the healthcare system. Non-state actors, particularly communities, must be empowered and engaged as instruments for ensuring external accountability at lower levels of implementation. New accountability strategies such as result-based or performance-based financing could be very valuable.ConclusionThe key challenges to accountability identified should be addressed and these included trust, transparency and corruption in the health system, political interference at higher levels of government, poor data management, lack of political commitment from the State in relation to release of funds for health activities, poor motivation, mentorship, monitoring and supervision, weak financial management and accountability systems and weak capacity to implement suggested accountability mechanisms due to political interference with accountability structures.

Health-Care Access during the Ebola Virus Epidemic in Liberia.

The Ebola virus disease (EVD) epidemic, which began in West Africa in December 2013, claimed more than 11,000 lives, with more than 4,800 of these deaths occurring in Liberia. The epidemic had an additional effect of paralyzing the health-care systems in affected countries, which led to even greater mortality and morbidity. Little is known about the impact that the epidemic had on the provision of basic health care. During the period from March to May 2015, we undertook a nationwide, community-based survey to learn more about health-care access during the EVD epidemic in Liberia. A cluster sampling strategy was used to administer a structured in-person survey to heads of households located within the catchment areas surrounding all 21 government hospitals in Liberia. A total of 543 heads of household from all 15 counties in Liberia participated in the study; more than half (67%) of urban respondents and 46% of rural respondents stated that it was very difficult or impossible to access health care during the epidemic. In urban areas, only 20-30% of patients seeking care during the epidemic received care, and in rural areas, only 70-80% of those seeking care were able to access it. Patients requiring prenatal and obstetric care and emergency services had the most difficulty accessing care. The results of this survey support the observation that basic health care was extremely difficult to access during the EVD epidemic in Liberia. Our results underscore the critical need to support essential health-care services during humanitarian crises to minimize preventable morbidity and mortality.

Report on Health Provision to Nomads: Improving Medical Staffing at Haima Hospital, Jiddat-Il-Harasiis, Oman

Introduction In January 2012 the authors visited Haima Hospital in the Jiddat-il-Harasiis, Al Wusta province, Sultanate of Oman (Figure 1). It is the most remote secondary health care service in the country--nearly five hundred miles from the capital, Muscat, and five hundred miles from Salalah in the south (Figure 2). The visit was part of a larger research initiative to document contemporary life among the Harasiis pastoral camel- and goat-herding nomads and those Harasiis families newly settled in the government-built 'tribal centre' at Haima. This initiative followed on from the original United Nations Development Programme (UNDP) project to extend government services to pastoral nomads in the interior deserts of Oman without forcing them to settle. The UNDP project helped support the development of weekly boarding schools, mobile primary health care and expanded immunization initiatives as well as the establishment of social affairs offices, veterinary support and other government initiatives (Chatty 1996: 92). The Harasiis are a mobile herding tribe of approximately five thousand people spread out over a traditional territory, which they have occupied for several centuries, of about forty-two thousand square miles, an area about the size of Scotland, along the edge of the Empty Quarter (Rub' al-Khali). For several decades, the government of the Sultanate has tried to extend meaningful health services to this largely mobile if not entirely nomadic population. Over the years several hospitals have been built on this site; and mobile services have been initiated and just as suddenly stopped. Difficulties in maintaining a consistent level of use have meant that it has been very hard to retain staff and the services offered at these institutions have generally shrunk to the bare minimum, making the hospitals at times no more than primary health care units. This report attempts to examine the difficulties of providing secondary health care services to a widely dispersed population and makes a number of suggestions for enhancing and improving health care delivery to remote and widely dispersed populations in general. Background Basic health care provision for pastoral peoples in the Middle East has been difficult to provide due to their remoteness and mobility. These marginal mobile or recently settled populations have had limited access to government health care provision. In addition, the populations of the Middle East have experienced particularly rapid socio-economic change over the past forty years, due largely to the discovery and exploitation of oil and the consolidation of the nation state. The basic social, political and cultural rights of the pastoral populations of the peninsula have largely been ignored, in part due to their remoteness and inaccessibility, but also due to the very fact of their mobility. Government services, based upon Western models, are designed for fixed, permanently domiciled populations. The organization of pastoral societies, with their mobile and constantly shifting households, does not fit into existing paradigms of Western-inspired development. A shortage in the resources and funds of government ministries has restricted public health services and the establishment of mobile clinics. Furthermore, pastoral societies' communal, traditional pattern of land use has not been understood by states in the region. This has resulted in serious societal upheaval, loss of control over vital grazing lands and often coercive pressure to settle and farm or enter the unskilled labour market. In the arena of health care, these marginal, mobile and remote populations have largely been excluded or have excluded themselves from government initiatives. Those that have settled have had only limited provision within or nearby their rural villages. In addition, the providers are largely focused on curative aspects rather than health promotion and disease prevention. [FIGURE 1 OMITTED] [FIGURE 2 OMITTED] Many of the Harasiis have moved into social housing provided by the government in the tribal centre at Haima. …

An interview with Médecins Sans Frontières

Since 1971 Medecins Sans Frontieres (MSF) has been providing emergency medical assistance to populations in crisis. In 2011 MSF has projects in more than 60 countries, and is one of the most widely known independent humanitarian non-governmental organizations (NGOs). While the core remit of the organisation is to provide emergency aid, MSF's work also encompasses provision of basic health care in places where this is insufficient or nonexistent, training of local medical personnel, bearing witness to and raising awareness of populations in danger Material aid is delivered concomitant to medical aid, and when necessary MSF teams are able to repair or develop medical and sanitation facilities. While there is information available online, we considered that an interview with MSF would be of interest, in particular to GP trainees and GPs who are considering taking time out to work overseas. Two specific themes thought to be important to discuss were what opportunities exist for GP trainees to contribute towards MSF's work, together with accountability and sustainability aspects of MSF's projects. On 12 March 2010, Nell Gray, Field HR Officer at MSF UK was interviewed by Dr Luisa Pettigrew and Dr Ha-Neul Seo. > Ha-Neul Seo (HS): Firstly, we would be grateful for an overview of the application process for UK GP trainees and GPs within 5 years of qualification (First5). More specifically, are there any waivers to your essential criteria, and are there any additional assets that you would look for in a doctor specialising in general practice? > > Nell Gray (NG): UK GP trainees would apply using the standardised process for all applicants, after FY2 plus at least 1 year of clinical work (MSF website). > > There are no waivers to the essential criteria. UK GP training forms a good basis for an application as much MSF work is based in primary care. …

Regional disparities in child mortality within China 1996-2004: epidemiological profile and health care coverage.

China was one of the 68 "countdown" countries prioritized to attain Millennium Development Goals (MDG 4). The aim of this study was to analyze data on child survival and health care coverage of proven cost-effective interventions in China, with a focus on national disparities. National maternal and child mortality surveillance data were used to estimate child mortality. Coverage for proven interventions was analyzed based on data from the National Health Services Survey, National Nutrition and Health Survey, and National Immunization Survey. Consultations and qualitative field observations by experts were used to complement the Survey data. Analysis of the data revealed a significant reduction in the overall under-5 (U5) child mortality rate in China from 1996 to 2007, but also great regional disparities, with the risk of child mortality in rural areas II-IV being two- to sixfold higher than that in urban areas. Rural areas II-IV also accounted for approximately 80% of the mortality burden. More than 60% of child mortality occurred during the neonatal period, with 70% of this occurring during the first week of life. The leading causes of neonatal mortality were asphyxia at birth and premature birth; during the post-neonatal period, these were diarrhea and pneumonia, especially in less developed rural areas. Utilization of health care services in terms of both quantity and quality was positively correlated with the region's development level. A large proportion of children were affected by inadequate feeding, and the lack of safe water and essential sanitary facilities are vital indirect factors contributing to the increase in child mortality. The simulation analysis revealed that increasing access to and the quality of the most effective interventions combined with relatively low costs in the context of a comprehensive approach has the potential to reduce U5 deaths by 34%. China is on track to meet MDG 4; however, great disparities in health care do exist within the country. It is therefore necessary to specifically target rural areas II-IV. Many causes of child mortality can be prevented or averted through the provision of basic health care. However, the leading predisposing factor contributing to child mortality in China is the insufficient coverage and poor quality of maternal and child health care services. Based on these data, we recommend that the government put more effort to ensure the health of the Chinese people, particularly in terms of providing the most vulnerable populations, i.e., children from the poorest areas and households, with access to good quality essential health care services.

Solidarity in practices of provision: distributing access to genetic technologies in health care in Germany, the Netherlands and the United Kingdom

Solidarity is widely described as one of the leading principles for the public provision of health care in Western Europe and is therefore prominently discussed in debates on the introduction of genetic technologies in national health care provision arrangements. However, solidarity is often defined in an essentialist and quantitative way, which does very little to show the complexities of and changes in health care allocation. In this paper we therefore propose to analyze solidarity as a value that is reproduced in practices of providing health care. This means that we analyzed how three particular genetic technologies are incorporated in basic health care provision in Germany, the Netherlands and the United Kingdom and how individuals or groups at risk get access to them. On the basis of a characterization of the distributive mechanisms in these three countries, we argue for a discussion on genetics and solidarity that pays attention to the complexity and specificity of practices in the analysis and politics of solidarity.

Wealth, health, and democracy in East Asia and Latin America

Why do some societies fare well, and others poorly, at reducing the risk of early death? Wealth, Health, and Democracy in East Asia and Latin America finds that the public provision of basic health care and other inexpensive social services has reduced mortality rapidly even in tough economic circumstances, and that political democracy has contributed to the provision and utilization of such social services, in a wider range of ways than is sometimes recognized. These conclusions are based on case studies of Argentina, Brazil, Chile, Costa Rica, Indonesia, South Korea, Taiwan, and Thailand, as well as on cross-national comparisons involving these cases and others.

Vascular Surgical Education in a Medium-Income Country

Medium income country such as South Africa face a dilemma on the need to offer high quality vascular surgical care in a resource constrained environment, where the vast majority of population has inadequate access to even the most basic health care provision. At the same time with rapid development in technology there is also the need to provide high technological treatment to a small population that can afford high cost therapy. This apparent dichotomy in health care provides a challenge and the solution is for all role players in the health care provision to find a solution which will suite the population at large.

Are global guidelines desirable, feasible and necessary?

Clinical Guidelines are primarily developed in the affluent West. This Viewpoint article discusses whether these guidelines are really useful and relevant to resource-poor, developing countries, and whether attempts to adhere to such guidelines obscure more fundamental issues such as the provision of basic health care. The authors argue that if guidelines are adapted to local resources and needs, and employ a 'cascade' approach they can work.

Basic health care provision and under-5 mortality: A Cross-National study of developing Countries

Summary In two cross-sections of developing countries, under-5 mortality is found to be associated strongly with maternal and infant health program effort and with the share of births attended by trained personnel, but never with any indicator of health care spending. From the standpoint of reducing under-5 mortality, then, the main challenge in many developing countries may be less to raise overall public health spending, or even the share of public health spending devoted to basic services, than to assure that a very small absolute amount of revenue is spent effectively to raise access to, or improve the quality of, maternal and infant health care.

Managed Care and the Safety Net: More Pain for the Uninsured?

The introduction of managed care has dramatically changed the US health care market. However, most of the literature has focused on analyzing the performance of managed care relative to other types of health insurance, while research focusing on its impact on the uninsured has been minimal. This paper contributes to fill this gap and analyses the impact of managed care on access to care and quality of care for the uninsured. We expand Frank and Salkever's (1991) model to analyze hospitals' decision to provide charity care, and use a probit model to test the results empirically. We find that managed care has negatively affected both aspects of the uninsured's health, by increasing the probability of closure of the safety net hospitals and the services most used by the uninsured, and by negatively affecting the quality of government hospitals. Therefore, the impact of managed care goes beyond its effect on its enrollees and on efficiency. In fact, by increasing price competition and reducing hospital revenues, managed care penetration has affected the overall health care market. These results have important policy implications. With the introduction of managed care, the health gap between socioeconomic groups will widen and more public subsidies will be needed in order to guarantee the provision of basic health care to the growing uninsured population. The results also bring a new perspective on managed care. Its impact on American health should be analyzed beyond its efficiency implications and more research should be done into its effects on the overall health care market.

Women's Reproductive Health & Population Policy: Tanzania

Population policies have rarely been linked to economic policy, although the promoters of economic liberalisation also support the embrace of population policy as important to the economic wellbeing of African states. Using a case study from Tanzania, I argue that population policies with a limited focus on fertility reduction may continue to be successful in the context of post-adjustment African health care systems, but policies that aim for the larger goals of improving women's reproductive health will be severely limited. Tanzania's donors and lenders promoted Neo-Malthusian types of population policies aimed primarily at reducing childbearing as a partial solution to the country's economic crisis. However, in the mid-1990s, the international discourse on population shifted toward a new dependent variable of ‘women's reproductive’ health. The notion of reproductive health reunites population and development issues in the context of basic health care provision. Improvements in the reproductive health of Tanzanian women will require more than simply the effective provision of contraceptives. This article argues that the challenges of improving reproductive health are unlikely to be met without a revitalisation of public health care provision in African countries.

Operation Lifeline Sudan

The provision of aid in war zones can be fraught with political difficulties and may itself foster inequalities, as it is rare to be allowed access to civilians on both...

Ruptured uterus in Ethiopia

Unbooked emergencies account for over 80% of hospital maternal deaths in sub-Saharan Africa—disproportion and ruptured uterus being the commonest complications. We did a prospective study of patients admitted to Attat (a rural hospital serving a population of 0·5 million) with ruptured uterus over 52 months between 1991 and 1995. Follow up since the first and last patients were studied ranges from 5 years 9 months to 17 months. There were 245 patients. 95·9% of patients and 91·6% of husbands could neither read nor write. 34% had no live children and a further 58% had only one live child. Two patients were primigravidae; 50·6% were gravida 4 or less. 18 had a previous lower segment caesarean section and 6 had a previous ruptured uterus. 54% had no antenatal care. The attendant for most of the labour before the rupture was suspected or diagnosed was an untrained relative in 96·3%. Mean duration of labour was 29·24 h. The time taken to reach Attat was a mean of 6·82 h. Fetal heart was present on admission in six patients—one of these babies died in the neonatal period and five were healthy. Rupture was incomplete in 5 patients and complete in 240. In eight patients the bladder was also ruptured. Of the 18 patients who had a previous lower segment caesarean section, there were five incomplete ruptures of the lower segment scars and nine complete ruptures of that scar. In two patients, the lower segment scar remained intact but the uterus ruptured posteriorly; a further two patients had rupture of the anterior uterine wall and one of these also involved the lower uterine segment. 238 patients had the uterus repaired, six had a hysterectomy, and one was too ill for either—necrotic tissue was removed from the uterus and bladder (which was repaired) and subsequently the remains of the uterus was passed vaginally as a slough. There were 239 stillbirths and one neonatal death. There were 13 maternal deaths (5·3%). Comparing the 13 mothers who died, with the others, the statistically significant factors were duration of labour (p<0·001), low haemoglobin (p<0·05), time since the pains stopped (p<0·05), and the time to reach hospital (p<0·05). In the follow up so far, the outcome of those who accepted antenatal care and residence in the maternity waiting area in the latter months of pregnancy was 84 healthy babies. 54 mothers subsequently had healthy babies by caesarean section; two had two healthy babies by caesarean section; 26 had healthy babies by the vaginal route, and two had two subsequent healthy babies by the vaginal route. Patients who delivered vaginally did so because this was what they wished or they came to the delivery ward progressing well in labour—they were all counselled about hospital care and residing in the MWA in any delivery subsequent to the rupture. With good antepartum and intrapartum care, patients with a history of ruptured uterus might achieve results similar to labour after caesarean section where the risks are outweighed by the higher maternal mortality and morbidity in caesarean than vaginal delivery. As 63 patients had tubal ligation at their request, either at the surgery for rupture or subsequently, there are 27 capable of becoming pregnant, that we have, as yet, not followed up. Interventions to prevent/treat ruptured uterus and its consequences should aim at improving education for all especially women, access to care programmes involving all health care workers, and access to a hospital with appropriate facilities for any required surgical operation. For women who have no, or only a few living children, and who desire more, repair is culturally acceptable and, from our follow-up so far, safe. Attempts should be made to change policies which have deleterious effects on the poor. The per-capita gross national product for Ethiopia is £67 per annum. Imposing or increasing user fees for basic health care provision may benefit middle income countries but is one reason why maternal mortality is not falling in the poorer countries of Africa—a caesarean section costs the equivalent of 9 months’ average wage in Nigeria and attendance at University College Hospital, Ibadan, has fallen by two-thirds since 1990. The World Bank calculates the cost of the most basic of primary care packages at about 12 US$ per head per year, while most countries in sub-Saharan Africa spend 2 to 3$ per head per year on health care.