Development assistance: Ruined hopes and great expectations in Africa

This paper highlights the difficulties and complexities of development assistance projects through an analysis of 2 Urban Functions in Rural Development projects conducted by the US Agency for International Development (AID) in Upper Volta and northern Cameroon in 1977-82. The general objectives of the Upper Volta project were to carry out urban function studies, develop a plan for strengthening the contributions of urban centers to rural development, develop a list of investment priorities for facilities and services, and increase the capacities of the Ministry in planning processes and methods. The 2-year project was hindered by a 1-year delay in initiating assistance due to difficulties in locating a contractor. In addition, the contractor and other team members felt there was little justification for studies of spatial organization in a country with so much evident need; rather, they focused on a small rural works program and establishment of effective local government, producing an inconsistency between team activities and the original project agreement. A request by the team to extend the project 1 year beyond its official completion date to compensate for early delays was rejected by USAID. Nonetheless, there was agreement that the project had a small positive impact in Upper Volta. Key lessons from Upper Volta were transferred to the Cameroon project. Although this project was judged to have achieved its objective of preparing a regional plan and of identifying programs for facilities, services, and small-scale enterprises, it was beset by problems of inexperience and technical underqualification of team members, poor communication, inconsistency of USAID guidelines, and methodological confusion. It is suggested that a central challenge for such programs is to create a body of qualified Americans who can work with their local counterparts in meeting the challenges of development. A measure of the success or failure of these projects should be the degree to which learning contributes to improved performance.     

Competence to consent to treatment as a psycholegal construct

The issue of whether civilly committed patients should be extended the right to accept or refuse treatment has generated much controversy and litigation during the past 15 years. In general, the current rule is that in nonemergency situations, individuals who are competent to give informed consent to treatment should be extended the right to refuse it. Obviously, the manner in which this rule is implemented partly depends on how competence to consent to treatment is defined and measured. Most researchers have implicitly assumed that an understanding of treatment information is the sole criterion of competence. It is argued that such a definition may be incomplete and is in need of reexamination. Following a review and analysis of the relevant legal and psychological literature, a comprehensive construct of competency to consent to treatment is proposed and future directions for research are discussed.     

Consumer-sponsored prepaid group practice: restructuring the health care system

The traditional separation of health care delivery and financing systems is breaking down as various new types of health care facilities are established and as payment continues to be a major concern. Group Health Cooperative of Puget Sound (GHC) was organized as a prepaid group practice system responsive to consumers. Costs, methods of payment and delivery of care are interrelated and are all influenced by consumer ownership. GHC has been refining its benefit programs since 1945. Strategies for controlling use and costs focus on improved provider management and on flexibility. This article explains how the structure of GHC benefits the consumer.