Cover Page The handle http://hdl.handle.net/1887/18587 holds various files of this Leiden University dissertation. Author: Leenstra, Melle Title: Beyond the façade : instrumentalisation of the Zambian health sector Issue Date: 2012-03-14 Annexes Annex I Analysis of the National Health Strategic Plan 1995-1999 In this annex we present and analyse a specific policy document that captured the spirit and intent of the health reforms at their conceptual maturity, the National Health Strategic Plan 1995-1999. This plan, which was first drafted in 1994 and of which a revised third edition was published in July 1996, covered the main aspects of the implementation of reforms conceived over the previous years, as the MMD came to power. The Foreword to the plan, presented in Box I.1 was written by a remarkable character who figures prominently in this dissertation, Dr. Katele Kalumba, the deputy minister and later Minister of Health, who was credited as being one of the theoretical and political architects of the reforms. He began the Foreword by looking back at the history of Zambia’s health sector in colonial times.1 Kalumba reflected on the tur- bulence that ambitious reform plans face and the imperfect nature of government action anywhere. As we will see later, with this presentation, Kalumba not only looked back at the past of his colonial ‘predecessor’, but also to the future of his own reforms failing to bypass the ‘pitfalls of the past’ that he was determined to avoid. From here, Kalumba proceeded to describe what is required for this process of im- plementing and fostering a shared vision for reform. He stressed the need to increase choice by creating a plural health policy environment, decreasing central government bureaucracy, and creating partnerships with private actors in the health sector. Kalumba saw this as an appropriate reaction against ‘a stifling background of socialist tradition ... which assumes a classless society’. He thus felt that there was a need to ‘negotiate the health order’, sketching a harmonious image of dialogue, shared values, and win-win situations as elements of this process. To guide the partners in this process Kalumba stressed the need to ‘formulate a futurist vision of health’ so as to overcome the pitfalls caused by ‘the practice of disjointed incrementalism in health planning’. Furthermore, the reform process was to be based in influence instead of control, interactive learning processes, and greater respect for individual and local autonomy. This foreword is exceptional in the tradition of usually bland planning documents. It demonstrated the intellectual, theoretical, and ideological inclinations of this specific political actor. The discourse used by Kalumba was influenced by his own empirical assessment of previous reform efforts,2 but also based on the ideology of the new MMD government that had started out as a democratic movement, before entrenching itself as 1 This came from Kalumba’s dissertation: Kalumba, ‘The practice’. 2 It was also influenced by the social science tradition in which he fitted, drawing heavily on names such as Bourdieu, Foucault, and Giddens in his dissertation. This influence is apparent in his use of terms such as ‘adaptive response repertoire’, ‘corporatist interventions’, ‘symbiotic interactions’, and ‘a multiplicity of nodes of power’ in this foreword. As is common in such scientific traditions, to an extent the use of such terms in this eloquent prologue may have served to ‘intimidate people with difficult words’. That this indeed happened is suggested by the fact that the next national health strategic plan (1998-2000) contained roughly the same foreword, albeit summarised and simplified. Recollections by Zambians and expatriates alike also attest to Kalumba’s theoretical prowess. 310 a ruling party. Finally, this discourse and its operational translation resonated with the international donor community, as it tied with the contemporary neo-liberal discourse on the role of the state, which was seen ideally to be more a facilitator and a regulator than a provider of goods and services that could be produced by the market. Box I.1 Statement by the Deputy Minister of Health3 “To achieve anything, there must be a shared vision, a preferred future that is not simply stumbled into but deliberately chosen. This must be a morally preferred vision chosen not only because it seeks to make things better for us today but rather because it forces us to take tough decisions now in the service of our collective responsibility to ensure the positive interests of our future generations. We are determined to avoid the pitfalls of the past. Witness the observation of Dr Haslam, then Director of Medical Services between 1933-1946 as he introduced his Ten-Year Health Services Devel- opment Plan (1945-1955): Sitting down at the age of fifty-seven, to write the memorandum on development of health services in Northern Rhodesia, I am reminded of Captain Hook in Peter Pan saying: “Something moves me to make my dying speech, for it seems certain that I shall never carry out the plans, dearly as I should like to do so.” Like others who have done a great deal of planning, I have been at times, somewhat cast down when many hours of work and thought have served no more useful purpose than swelling the bulk of a file called Health Department; Future Development. Like others too, I have smiled sadly when turning the yellowing pages of an ancient file recording the plans of a predecessor which, after a full, carefull and hopefull period of gestation either failed of delivery and died in utero or succumbed soon after birth to the east wind of financial stringency. (Dr. J.F.C. Haslam, Director of Medical Services, HDS 1945) Haslam’s Plan suffered the same fate that many attempts at reform in the health sector have suffered many years after colonial rule. Recent political, social and economic changes in Zambia as in most African countries have em- phasized the growing awareness of the turbulent environment within which such health reforms have to be developed and implemented. Further, the turbulence involved in these changes has re-affirmed our understanding that government intervention anywhere is self-evidently partial, incoherent, and provi- sional in nature.” The plan articulated the vision that drove the health reforms. Since it was launched in 1991, this vision or mission statement has featured in many health policy documents in Zambia, even to this day. This vision, which many health workers still refer to when reflecting on their work is the following: ‘The Government is committed to providing Zambians with equity of access to cost-effective, quality health care as close to the family as possible’. In addition to this vision, health reform documents such as this one consistently stress three principles: Leadership, accountability, and partnership (com- monly abbreviated to LAP). Finally, to justify the health reforms, a metaphor was used that came back in numerous speeches and policy documents4 in the gestation and early implementation period of the health reforms: 3 While this foreword was signed on 17 July 1996 by Kalumba as minister, erroneously his title in the caption was not changed after he had been promoted from deputy minister to minister several weeks earlier. 4 See for instance, Kalumba, Towards; World Bank, Staff (EKN files, ISN 442); and Martínez, J. & T. Martineau, Human resources and health sector reforms (Liverpool, 1996). 311 The health system in Zambia has been likened to a Cadillac which was maintained by a relatively wealthy family for years. The family’s economic situation has changed, and it can no longer afford to maintain this expensive vehicle without seeking assistance from cousins and relatives who could help fuel, repair and maintain the vehicle. The design and construction of an affordable and effective health care system, and defining the strategy for transforming the existing system into the more affordable one, is the purpose of this Strategic Health Plan.5 This metaphor clearly explains not only the aims of the health reforms but also the zeitgeist of the period and the context in which they were formulated. It reflects the rationale behind ‘structural adjustment programmes’ of slimming down public bureau- cracy to focus on core tasks in line with what a country can afford. The provenance of this metaphor is unclear. In a staff appraisal report, the World Bank attributes the metaphor to a speech to Parliament by Michael Sata as Minister of Health in 1994.6 Katele Kalumba, on the other hand, attributes the metaphor to a World Bank support mission in 1992 that advised the Ministry of Health on the reforms’ process. The bank had felt that the ministry had no clear vision of the health sector after reform: In other words, what the Zambian car would look like. Instead, the ministry had been making plans for individual reformed components: In other words, designing individual car parts.7 What is striking here is to see is how the World Bank pushes the metaphor and with it the health reform as a product of Zambian ‘ownership’, whereas, according to Kalumba’s detailed description, it was the bank itself that launched this metaphor that took such a central place in the creational mythology of the health reforms. On the one hand, this highlights the ambiguity in the origins and ownership of policies and programmes in donor-dependant countries; on the other hand, it shows a measure of mutual adaptation between donors and recipient government in the language used in policy-making. Now let us go further in describing what these health reforms entailed. A starting point in the health reforms was the assertion that resources needed to be redistributed from a focus on expensive care in central hospitals to more cost-effective primary health care at the level of health centres and district hospitals.