allocation and quality of services and an inefficient referral system continue to favor some urban populations. Since these difficulties are part and parcel of broader underdevelopment, they will require time to overcome. One immediate objective is the implementation of a more efficient referral system in Addis Ababa. 57 The fact that most developing countries have inefficient referral systems indicates the magnitude of this task. 58
This study indicates that the use of traditional and transitional healers and lay practices is grossly underreported in Ethiopia. Without adequate information on disease prevalence and utilization of all health resources, it will be impossible to fully determine the health needs and health demands of the population. Self- care with modern and traditional medicine and use of indigenous healers must be expected to persist as alternative treatment options in the future owing to their cultural compatibility and their poor access to modern services in many areas. Our study suggests that the relatively low cure rates reported for modern medical services reinforce existing medical pluralism in both urban and rural communities. This total medical system, consisting of modern, transitional and traditional subsystems, is characterized less by complementarity of care than by lack of coordination and exploitive elements, often resulting in delay and discontinuity of treatment.
Whether and in what way these and other problems of the health services will be solved depends to a large degree on national priorities and decisions based on health policy as specified or implied in the Ten-Year Plan. According to Gish, much of the present state of affairs can be explained by the country's recent adoption of socialism which has not yet revealed the major beneficial effects of revised health policy, but he also recognizes the impact of recurrent famine and the war on the economy. 59 This study indicates that more broadly based socioeconomic development which results in elevating the standard of living and greater equity in access to medical services are additional prerequisites to improving health.
The writers are grateful to Hailu Meche and Mehari Wolde Ab of the Planning and Statistics Departments of the Ministry of Health for stimulating discussions and for making certain documents available. Abebe Engedasew and Befekadu Girma of the Addis Ababa City Council kindly gave permission for this study and provided constructive comments on the questionnaire. We are also indebted to the Geography Department of Addis Ababa University and the respective keftegna, kebele and peasant association chairmen for providing technical support, to several senior geography students for assistance with interviews and to the interviewed households for their cooperation.