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Different Exclusion Patterns, Different Challenges

Table of Contents Introduction Obstacles to progress: context or policy? Context Matters The Many Faces of Exclusion from Care Different Exclusion Patterns, Different Challenges

The policy challenges differ between countries that are close to universal access (where exclusion is limited) and those where exclusion is pervasive. The countries where exclusion is limited to a small and marginalized part of the population are usually on track, or at least show slow progress in terms of reduction of child mortality. These are countries with well-extended health systems, although not always with an optimal range of technical interventions. Examples of countries in this group include Brazil, Colombia and the Dominican Republic. Here, the challenge is one of targeting to give the mothers and children currently excluded the possibility of claiming their entitlements: tackling the roots of social exclusion, removing the barriers to the uptake of health benefits, responding appropriately to their needs, and offering them financial protection from the consequences of illness and obtaining care.

Most of the countries that stagnated or went into reversal, and many of those that showed slow progress in terms of child mortality reduction, show patterns of massive exclusion or queuing. Such countries include Bangladesh, Chad and Ethiopia. They typically have weak, low-density and fragile health systems; they also suffer from poverty, and sometimes HIV/AIDS and complex emergencies, additional constraints to health systems development. In this group the main challenge is to build and roll out primary health care as the vehicle for maternal, newborn and child health care.

The momentum created by the primary health care movement of the early 1980s focused attention on issues of equity and access, and resulted in the extension of basic health services to the rural poor. Maternal and child health programmes were integral to this extended coverage: antenatal clinics were intended to provide the first contact that would continue through childbirth and postnatal care for the mother and with clinics for children.

In the early 1990s, the view gained ground that primary health care had to be decentralized and organized in "integrated health districts". Countries that had been doing so for quite some time saw their earlier choices reinforced, and others, such as Cambodia and Niger, moved to adopt district policies. Many development agencies put districts at the core of their health development strategies, particularly for the countries that combined the poorest health status with the weakest health systems.

Are districts the right strategy for moving towards universal coverage?

Organizing the delivery of primary health care through health districts promised a fast-track response to the rising demand for health care. Apart from the frustration caused by the diminishing returns of the vertical approaches of the 1970s and 1980s, there were three good reasons for this.

The first was that the "health centre" - the heir of the dispensaries, but now the centrepiece of the whole system, and the equivalent of the family doctor or general practitioner - was the most viable alternative to village health workers, vertical programmes and commercial health care. It was also the only one that responded to the demand for care by the population. National decision-makers were alert to this argument, which was based on the experiences of a number of small and medium-scale field projects: Pahou in Benin, Danfa in Ghana, Machakos in Kenya, Pikine in Senegal, and Kasongo and Kinshasa in Zaire. These projects had shown that health centres were a feasible ( ⁴⁰ , ⁴¹ ), affordable ( ⁴² - ⁴⁴ ) and efficient ( ⁴⁵ - ⁴⁷ ) option for delivering care, and a realistic alternative to vertical disease control programmes.

Second, hospitals providing referral-level care were part and parcel of the district model. Although the referral system remained the weak point, it became possible to take on the maternal health agenda because of the hospital’s ability to deal with obstetric complications. Moreover, the inclusion of hospitals brought a vital part of the public health infrastructure and personnel back on the scene. This was a relief for the administrative elite and the middle class, who had never considered the grassroots primary health care of the 1980s as something to aspire to for themselves.

Third, the health district fitted well with the movement towards decentralization, to which most countries were at least theoretically committed. Health districts seemed both manageable and sufficiently decentralized to be flexible and affordable ( ⁴⁰ , ⁴⁸ ).

A strategy without resources

By the mid-1990s many countries were creating district systems, setting up drug procurement agencies and defining a minimum package of services. However, as in the years after Alma-Ata, money did not follow, particularly in sub-Saharan Africa, and results were slow to come. In the bleak economic environment, financing remained a real barrier to progress. With a decrease in gross domestic product per capita in real terms between 1990 and 2002, total health expenditure in many African countries stagnated or decreased, and public health expenditure remained below US$ 10 per person. External assistance did not make up for this, as per capita flows also stagnated up to 1999 ( ⁴⁹ ).

The real extent of the failure to increase financing of the health sector during the 1980s and 1990s appears in the detailed breakdown of what financing there was: in Cameroon, for example, recurrent public expenditure declined from US$ 5 per inhabitant in 1990 to US$ 3.5 in 1996. Of this, US$ 2.1 went on salaries and US$ 1.12 on other recurrent expenditures. The districts were left with a mere US$ 0.28 per person per year for non-salary recurrent expenditures.

There has been little flexibility to improve working conditions in the public sector, especially in terms of salaries and incentives, because of civil service regulations and structural adjustment policies. As a result many health workers have moved to the private sector. Data from Ghana, Zambia and Zimbabwe show that losses of health workers from the public health sector continued or accelerated during the 1990s ( ⁵⁰ ). The stringent budgetary measures under structural adjustment programmes also imposed ceilings on recruitment. Even in countries with unemployed health professionals such as Zambia, governments often were not able to enrol more staff ( ⁵⁰ ).

Absenteeism was another major issue that affected the already scarce human resources. In Burkina Faso, for example, absenteeism of health district doctors in seven rural districts in 1997 varied between 30% and more than 80% ( ⁵¹ ). Vacancy rates for doctors in Ghana increased from 43% in 1998 to 47% in 2002. Over the same period vacancy rates for registered nurses rose from 26% to 57% ( ⁵² ). Much of the absenteeism was related to inadequate working conditions, insufficient salaries and declining staff morale. In a number of countries, however, the HIV/AIDS epidemics aggravated what was becoming an acute human resource crisis. Data are scarce but suggest that besides contributing to absenteeism, HIV/AIDS may cost Africa’s health systems one fifth of their employees over the next few years ( ⁵³ ). The absence of adequate measures to protect health workers against HIV/AIDS and the stress of caring for HIV/AIDS patients are additional factors motivating them to migrate.

The real wages of public servants continued their decline in the 1990s: in six years they dropped by 21% from their 1990 level in Togo, 34% in Burkina Faso, 35% in Guinea-Bissau, and 41% in Niger. Absenteeism continued - 35% for district doctors in 1997 in Burkina Faso - as did "seminaritis": in 1995 in Mali, regional health staff spent 34% of their total working time in workshops and supervision missions supported by international agencies; this figure rose to 48% for chief medical officers. Predatory behaviour ( ⁵⁴ - ⁵⁷ ) and moonlighting ( ⁵⁸ , ⁵⁹ ) became the norm, contributing to the shortage of health workers in the public sector ( ⁵⁰ ).

The shortages of health personnel are the most visible aspect of the human resources crisis in sub-Saharan Africa. The figures are stark: in Zimbabwe, of the 1200 physicians trained during the 1990s, only 360 were still practising in the country in 2001 ( ⁶⁰ ). Ghana’s loss of 328 nurses in 1999 was the equivalent of its annual output ( ⁵⁰ ). More than half of the health professionals in Zimbabwe, Ghana and South Africa are thinking of migrating to other countries ( ⁶¹ ). At the same time, 35 000 South African nurses are not employed in the health sector and two thirds of the health workforce in Swaziland is working in the private sector ( ⁶² , ⁶³ ).

Have districts failed the test?

The environment in which district health systems had to be set up has been decidedly unfavourable. Some countries, such as Mali, managed to expand health centre networks and services for mothers and children ( ⁶⁴ ). Overall expansion, however, has been slow. In 2000, for example, only 13 of Niger’s hospitals had appropriate facilities to perform a caesarean section ( ⁶⁵ ). This was also the case for only 17 of the 53 district hospitals in Burkina Faso, nearly 10 years after districts had been established; moreover, only five of those 17 hospitals had the three doctors required to ensure continuity throughout the year ( ⁶⁶ ).

The slowness of rolling out health districts has been disappointing: it takes time to transform an administrative district into a functional health system (see Box 2.5). Nevertheless, where districts have reached the critical point of becoming stable and viable structures, they have shown credible and visible results, sometimes in very adverse circumstances, as in Guinea and the Democratic Republic of the Congo.

On balance, the experience of the last decade suggests that health districts still stand as a rational way for governments to roll out primary health care through networks of health centres, family practices or equivalent decentralized structures, backed up by referral hospitals. There are no real alternatives to serve as a vehicle for a continuum of integrated care for mothers, newborns and children. The challenge now is to scale up implementation in an adverse environment where exclusion is further fuelled by the rampant commercialization of the health sector, including within public and not-for-profit facilities. The second challenge is to tailor health care delivery strategies to the specific situation and exclusion patterns of each country. At the same time, it is no longer possible to experiment with district projects without looking at the wider context of cross-cutting, system-wide constraints. Without a real commitment to strengthening district health services, talking about the priority status of mothers and children is likely to remain mere lip service.

Part of the task ahead is political. Maternal, newborn and child health cannot be reduced to a set of programmes to be delivered to a target population. Rather, mothers and children must be in a position to claim a set of entitlements as their right. This implies an adjustment of macro-level health policies and resource mobilization, at country level and internationally. Three issues cry out for attention: the funding of the health sector, the human resource crisis, and the accountability of health systems and providers to their clients.

But the task ahead is also one of refocusing programme content. For too long attention has been directed towards the development of technologies, rather than towards embedding these in viable organizational strategies that organize and ensure a continuum of care. Given the complexity of expanding district health care systems, the temptation is to go back to vertical programmes built around disease control technologies. In the past this has led to a considerable amount of fragmentation, at the expense of ensuring the continuity of care from pregnancy throughout childhood. Much of the challenge, in fact, is to accommodate both programmatic and systemic concerns: an organizational rather than a technical problem. The next chapters relocate the technical strategies available for improving the health of mothers, newborns and children within health systems that are scaling up and facing an increasingly vocal demand for care.

Footnotes

⁴⁰ Pangu KA. La santé pour tous d’ici l’an 2000: c’est possible; expérience de planification et d’implantation des centres de santé dans la zone de Kasongo au Zaïre [Health for all by the year 2000: it can be achieved; experience of planning and setting up health centres in the area of Kasongo in Zaire]. Brussels, Université Libre de Bruxelles, Faculté de Médecine, Ecole de Santé Publique, 1988.

⁴¹ Equipe du Projet Kasongo, Darras C, Van Lerberghe W, Mercenier P. Le Projet Kasongo: une expérience d’organisation d’un système de soins de santé primaires [The Kasongo Project: experience of organizing a system of primary health care]. Annales de la Société Belge de Médecine Tropicale, 1981, 61(Suppl.):1-54.

⁴² Knippenberg R, Soucat A, Oyegbite K, Sene M, Bround D, Pangu K et al. Sustainability of primary health care including expanded program of immunizations in Bamako Initiative programs in West Africa: an assessment of 5 years’ field experience in Benin and Guinea. International Journal of Health Planning and Management, 1997, 12(Suppl. 1):S9-S28.

⁴³ Jancloes M, Seck B, Van de Velden L, Ndiaye B. Financing urban primary health services. Balancing community and government financial responsibilities, Pikine, Senegal, 1975–81. Tropical Doctor, 1985, 15:98–104.

⁴⁴ Pangu KA, Van Lerberghe W. Self-financing and self-management of basic health services. World Health Forum, 1990, 11:451-454.

⁴⁵ Van Lerberghe W, Pangu K. Comprehensive can be effective: the influence of coverage with a health centre network on the hospitalisation patterns in the rural area of Kasongo, Zaire. Social Science and Medicine, 1988, 26:949-955.

⁴⁶ Van den Broek N, Van Lerberghe W, Pangu K. Caesarean sections for maternal indications in Kasongo (Zaire). International Journal of Gynecology and Obstetrics, 1989, 28:337–342.

⁴⁷ Van Lerberghe W, Pangu KA, Van den Broek N. Obstetrical interventions and health centre coverage: a spatial analysis of routine data for evaluation. Health Policy and Planning, 1988, 3:308-314.

⁴⁸ Better health in Africa. Washington, DC, World Bank, 1994.

⁴⁹ Organisation for Economic Co-operation and Development. International Development Statistics on line (http://www.oecd.org/dataoecd/50/17/5037721.htm, accessed 15 December 2004).

⁵⁰ The health sector human resources crisis in Africa: an issue paper. Washington, DC, United States Agency for International Development, Bureau for Africa, Office of Sustainable Development, SARA Project, 2003.

⁵¹ Bodart C, Servais G, Mohamed YL, Schmidt-Ehry B. The influence of health sector reform and external assistance in Burkina Faso. Health Policy and Planning, 2001, 16:74-86.

⁵² Dovlo D. The brain drain and retention of health professionals in Africa. A case study. Paper presented at: Regional Training Conference on Improving Tertiary Education in Sub-Saharan Africa: the things that work! Accra, 23-25 September 2003.

⁵³ Tawfik L, Kinoti SN. The impact of HIV/AIDS on the health sector in sub-Saharan Africa: the issue of human resources. Washington, DC, United States Agency for International Development, Bureau for Africa, Office of Sustainable Development, SARA Project, 2001.

⁵⁴ Lambert D. Study of unofficial health service charges in Angola in two health centers supported by MSF. MSF Medical News, 1996, 5:24-26.

⁵⁵ Meesen B. Corruption dans les services de santé: le cas de Cazenga [Corruption within the health services: the case of Cazenga]. Brussels, Médecins Sans Frontières, 1997 (Repères: 1–20).

⁵⁶ Parker D, Newbrander W. Tackling wastage and inefficiency in the health sector. World Health Forum, 1994, 15:107–113.

⁵⁷ Asiimwe D, McPake B, Mwesigye F, Ofoumbi M, Ortenblad L, Streefland P, Turinde A. The private-sector activities of public-sector health workers in Uganda. In: Bennett S, McPake B, Mills A, eds. Private health providers in developing countries: serving the public interest? London, Zed Press, 1997.

⁵⁸ Roenen C, Ferrinho P, Van Dormael M, Conceicao MC, Van Lerberghe W. How African doctors make ends meet: an exploration. Tropical Medicine and International Health, 1997, 2:127-135.

⁵⁹ Macq J, Van Lerberghe W. Managing health services in developing countries: moonlighting to serve the public? In: Ferrinho P, Van Lerberghe W. Providing health care under adverse conditions: health personnel performance & individual coping strategies. Antwerp, ITG Press, 2000 (Studies in Health Services Organisation and Policy, 16:177-186).

⁶⁰ Lowell G, Findlay A. Migration of highly skilled persons from developing countries: impact and policy responses. Geneva, International Labour Office, 2001.

⁶¹ Awases M, Nyoni J, Gbary A, Chatora R. Migration of health professionals in six countries: a synthesis report. Brazzaville, World Health Organization Regional Office for Africa, 2003.

⁶² The international mobility of health professionals: an evaluation and analysis based on the case of South Africa. Paris, Organisation for Economic Co-operation and Development, 2004 (Trends in International Migration Part III SOPEMI 2003).

⁶³ World Health Organization/Ministry of Health and Social Welfare of the Government of Swaziland. A situation analysis of the health workforce in Swaziland. Geneva, World Health Organization, 2004.

⁶⁴ Maiga Z, Nafo TF, El Abassi A. La réforme du secteur santé au Mali, 1989-1996 [Reform of the health sector in Mali, 1989-1996]. Antwerp, ITG Press, 1999 (Studies in Health Services Organisation & Policy, 12).

⁶⁵ Bossyns P, Abache R, Abdoulaye MS, Van Lerberghe W. Unaffordable or cost-effective? Introducing an emergency referral system in rural Niger (submitted).

⁶⁶ Bodart C, Servais G, Mohamed YL, Schmidt-Ehry B. The influence of health sector reform and external assistance in Burkina Faso. Health Policy and Planning, 2001, 16:74-86.

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