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Background: For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter. Beyond obvious problems of cost and access this study shows to what extent the behaviour of the health worker in its interaction with the patient can be a barrier of its own.Methods: Information was triangulated from three sources in two rural districts in Niger: first; 46 semi-structured interviews with health centre nurses; second; 42 focus group discussions with an average of 12 participants - patients; relatives of patients and others; third; 231 semi-structured interviews with referred patients.Results: Passive patients without 'voice' reinforce authoritarian attitudes of health centre staff. The latter appear reluctant to refer because they see little added value in referral and fear loss of power and prestige. As a result staff communicates poorly and show little eagerness to convince reluctant patients and families to accept referral proposals.Conclusions: Diminishing referral costs and distance barriers is not enough to correct failing referral systems. There is also a need for investment in district hospitals to make referrals visibly worthwhile and for professional upgrading of the human resources at the first contact level; so as to allow for more effective referral patterns

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West Africa has probably the highest levels of maternal mortality in the world. A new method has been developed by the Institute of Tropical Medicine of Antwerp (Belgium) that gives an estimate of the Uncovered Obstetrical Need. This technique tested in different Western African countries has been now evaluated also in an urban medical district in Niamey, capital of Niger, for the year 1999. The uncovered obstetrical need has been estimated at 15 major Obstetrical Interventions for this period; this means that 15 pregnant women didn't undergo a major surgical intervention necessary to save their life and that they probably died because of this non-intervention. We met quite a lot of problems with this new method: (i) the first problem is related to the difficulty to obtain correct demographic information: it is very difficult to estimate population growth in urban african areas, present population and number of attended births. (ii) The second difficulty came from sociocultural habits: primipare women in Niger go back to their family to deliver (and the place where their family lives is not necessarily the same as the place where they stay with their husband); it is quite possible that a number of primipare women needing a major surgical intervention didn't undergo this intervention because they delivered in their home village (and perhaps died there). (iii) At last, the estimation of a reference rate (calculated at 0.9% for Niger) implies that all women needing a major obstetrical intervention in Niamey, and having a theoretical easy access to medical infrastructures (first line as second line hospitals) present themselves when having a major obstetrical problem. This is probably "wishful thinking". The interest of this new method lies in the fact that it is a cheap technique and easy to put into practice ... provided that one disposes of medical infrastructures that collect correctly all necessary medical information.

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OBJECTIVE: To show that low-cost attitudinal, structural and procedural changes aimed at improving responsiveness to patients have the potential to increase uptake of family planning (FP) even among populations considered reluctant to do so by health personnel. METHODS: Intervention study with before-after comparison of contraceptive acceptance, couple-years of protection (CYP) and an 'index of contraceptive uptake' (IUC) in rural health centres in Niger. The intervention consists of a package of instructions to actively propose family planning, integrated within curative and under-fives consultations, coupled with measures to increase the health centres' responsiveness to their clients. RESULTS: Implementation of the intervention package was followed by marked increases in family planning uptake. CONCLUSION: Health services in Niger present an untapped potential for improving family planning through low-cost supply-side measures.

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Good access to health facilities providing good first-level health care remains problematic in many developing countries. It is a hindrance to effective and efficient functioning of the hospital, as outpatient departments become overcrowded with patients from areas without health centres. In many cases the quality of care delivered to these patients is poor because within the district health system the hospital is not the best place for the supply of comprehensive, integrated and continuous care. Eventually, high hospital involvement in first-level care can jeopardize the delivery of adequate referral care for those patients who desperately need the hospital's technology and expertise. This paper provides an account of the way this problem was investigated and managed by the district health management team in the Murewa district in north-east Zimbabwe. The design of a comprehensive 'master plan' or 'coverage plan' is presented as well as the problems and difficulties encountered. The Murewa experience highlights the relevance of a coverage plan for rational and coherent health infrastructure planning at district level. The approach followed by the Murewa team illustrates the use of action research as an integral part of the management of district health systems.

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