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there is a related issue in the functioning of the two national hospitals in Ouagadougou and Bobo-Dioulasso. The establishment of self-financing (excepting salaries) for the hospitals in 1991 (para. 2.19) has had the untoward effect of weakening the health pyramid, in particular its tertiary level. National hospital data indicate that, probably for financial reasons, there has been a shift within hospitals toward less costly primary and secondary care (for malaria, infectious respiratory diseases, diarrhea, hemias, etc.) and away from complicated, expensive procedures which few people can afford. As a result, the occupation rates for the national hospitals have declined from 96% and 90% in 1986 to 45% and 53% in 1991, for Bobo-Dioulasso and Ouagadougou, respectively. Furthermore, 20% of income from the national hospitals has been used to increase hospital personnel salaries.

2.27 Poor Eguipment and Lack of Maintenance. Budgetary constraints have caused many of the nation's health facilities to become non-fonctional because of a lack of equipment, and a long list of equipment and vehicles awaiting repair. Regarding maintenance, there is also a serious lack of institutional capacity. There is only one team for hospital equipment maintenance, located in the Ouagadougou hospital; this team is poorly eąuipped, overloaded with work, and cannot maintain other health fkcilities.

2. Issues with regard to Nutrition and Control of Certain Endemic Diseases

2.28 Nutrition. An assessment of the extent and severity of micronutrient deficiency in the country is incomplete, although studies which have been undertaken suggest that deficiencies are severe particularly in the outlying northern and eastern provinces (Annex 2.3). With regard to iodine and vitamin A deficiencies, however, a number of provinces have never been surveyed. Hence, there is the need for rap id surveys to better define areas suspected of suffering from severe deficiencies. Existing donor programs to provide supplementation in iodine and vitamin A (identified in the World Bank's World Development Report, 1993, as one of the most cost-effective health interventions to reduce child mortality) remain patchy at best. Food fortification, likely to be morę sustainable and cost-effective than supplementation, has not yet been introduced in Burkina Faso. Nutrition activities, including nutrition education, child growth monitoring and promotion, and micronutrient supplementation are given Iow priority by health workers.

2.29 Sustaining Endemic Disease Control. It is imperative that the gains achieved fiuough the successful elimination of onchocerciasis be maintained (paras. 2.6-2.7). The prevention of recurrence of onchocerciasis as a public health problem requires: 0) both active and passive epidemiological surveillance to detect any instances of recrudescence; and (ii) immediate treatment of any new cases, especially within the migrant population. Given the technical constraints of active epidemiological surveillance of the disease, it is infeasible for the peripheral health centers to assume responsibility for it. Nevertheless, their role is important in the detection of new cases (passive surveillance), in case containment, and in sensitization of the population, sińce many people remain unnecessarily worried about the return of non-infective flies following the cessation of larvicide spraying.

2.30 The control of trypanosomiasis depends on: (i) both active and passive epidemiological surveillance to detect and treat new cases in high risk areas, and (ii) informing populations on ways to control the vector. While increasing awareness among populations can be undertaken by trained CSPS health workers, diagnosis of the disease reąuires skilled technicians, specific medical eąuipment, and active campaigns of detection followed by treatment of cases once a year in high risk areas.