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Improving Equity in the Provision of Primary Health Care: Lessons from Decentralized Planning and Management in Namibia Ruth Bell,1 Taathi Ithindi,2 & Anne Low3

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Improving Equity in the Provision of Primary Health Care: Lessons from Decentralized Planning and Management in Namibia Ruth Bell,1 Taathi Ithindi,2 & Anne Low3 Improving equity in the provision of primary health care: lessons from decentralized planning and management in Namibia Ruth Bell,1 Taathi Ithindi,2 & Anne Low3 Abstract This paper draws lessons from a review of primary health care services in Windhoek, the capital of Namibia, undertaken by a regional health management team. The review was carried out because of perceived increases in workload and inadequate staffing levels, arising from the rapid expansion of the city associated with inward migration. A survey of the utilization of government clinics was used to develop a more equitable allocation of primary health care services between localities. The survey revealed disparities between patterns of utilization of the services and the allocation of staff: the poorer localities were relatively underprovided. Decisions made centrally on resource allocation had reinforced the inequities. On the basis of the results of the review, the regional health management team redistributed nursing and medical staff and argued for a shift in the allocation of capital expenditure towards the poorer communities. The review demonstrates the potential for regional and provincial health management teams to make effective assessments of the needs of their populations and to promote the equitable delivery of primary health care services. In order to achieve this they need not only to become effective managers, but also to develop population-based planning skills and the confidence and authority to influence the allocation of resources between and within their regions and provinces. Keywords Primary health care/utilization; Health services accessibility; Health care rationing; Health manpower/utilization; Personnel staffing and scheduling; Ambulatory care facilities/utilization; Social justice; Health care surveys; Namibia (source: MeSH, NLM). Mots cle´s Programme soins courants/utilisation; Accessibilite´ service sante´ ; Gestion ressources sante´; Personnel sante´/utilisation; Affectation personnel et organisation temps travail; Services soins ambulatoires/utilisation; Justice sociale; Enqueˆte syste`me de sante´; Namibie (source: MeSH, INSERM). Palabras clave Atencio´ n primaria de salud/utilizacio´ n; Accesibilidad a los servicios de salud; Asignacio´ n de recursos para la atencio´n de salud; Recursos humanos en salud/utilizacio´ n; Admisio´ n y programacio´ n de personal; Instituciones de atencio´ n ambulatoria/ utilizacio´ n; Justicia social; Encuestas de atencio´ n de la salud; Namibia (fuente: DeCS, BIREME). Bulletin of the World Health Organization 2002;80:675-681. Voir page 680 le re´sume´ en franc¸ais. En la pa´ gina 680 figura un resumen en espan˜ ol. Introduction Background Health sector reform in developing countries, including the Health sector reform in Namibia decentralization of management and the provision of primary When Namibia gained its independence in 1990 it inherited a health care, is expected to produce changes in the pattern of state health system typical of colonial Africa: centrally planned, health service delivery and improvements in the equity of largely based on hospitals and in urban areas, and fragmented on provision (1–4). In particular, first-level services may require ethnic lines (5–7). Subsequently, the Ministry of Health and strengthening in order to improve local access to basic Social Services adopted the primary health care approach (8). primary health care. This requires that local health manage- Thirteen regional health management teams were created in ment teams develop the skills to assess the adequacy of 1994 to decentralize responsibility for the planning and provision and to identify and implement ways of improving management of local primary health care services from four services. directorates, which were being phased out in 1997–98 when the This paper describes how the Khomas Regional work described in this paper was being carried out. The role of Health Management Team undertook a review of primary regional health management teams was to support and supervise health care services in urban Windhoek, Namibia, in order district health management teams in their role of operationaliz- to obtain evidence that would underpin local planning ing the primary health care strategy at the local level. There were decisions. The review led to changes in resource allocation between one and three districts per region. During the and enabled the team to influence central planning transitional period, assistance with finance and training was decisions. provided from programmes funded by donors. This help 1 Senior Registrar in Public Health Medicine, Northern Region, Newcastle-upon-Tyne, England, on secondment to the Ministry of Health and Social Services, Windhoek, Namibia. Current position: Lecturer in Public Health Medicine, Department of Epidemiology and Public Health, School of Health Sciences, Medical School, University of Newcastle, Newcastle-upon-Tyne NE2 4HH, England (email: [email protected]). Correspondence should be addressed to this author at the last-mentioned address. 2 Regional Medical Officer, Khomas Region, Ministry of Health and Social Services, Windhoek, Namibia. 3 Technical Adviser to the South Directorate, Ministry of Health and Social Services, Windhoek, Namibia. Current position: Consultant in Public Health Medicine, Sunderland Primary Care Trust, Sunderland, England. Ref. No. 01-1337 Bulletin of the World Health Organization 2002, 80 (8) 675 Policy and Practice included the provision of technical advisers who were involved undertake the assessment and treatment of acute illness; in the development of management and planning capacity in the however, they do not request investigations, treat certain regional and district health management teams. chronic diseases, or refer patients to hospital. Nurses working At the time of this work, key decision-making on in clinics without doctors are expected to refer appropriate resource allocation had not been decentralized to regional patients to the doctors at Katutura Health Centre. health management teams. The directorates retained respon- Katutura State Hospital, which is managed separately by sibility for setting official staff establishments for all primary the Ministry of Health and Social Services, is a national referral health care facilities, while decisions on capital developments, hospital, but also takes referrals from the primary health care such as the extension of clinics and the construction of new facilities in Windhoek and provides an accident and emergency facilities, were taken centrally by planners in the Ministry of service. The hospital provides a 24-hour assessment service, Health and Social Services. staffed by nurses, for self-referred patients not requiring emergency treatment. Windhoek: population and primary We focused on the clinics sited in Katutura and health care services Khomasdal. The Robert Mugabe Clinic in Windhoek town Before Namibia attained independence from South Africa in centre was excluded because it is situated some distance from 1990, Windhoek was racially segregated: the areas of Katutura the other clinics and has a relatively affluent catchment area. At and Khomasdal were designated for the Black and Coloured the time of the survey it was undergoing renovations and the populations, respectively, while the rest of the urban area was staff were providing limited services at an alternative site in the designated for the White population. In 1995, urban Windhoek town centre. had an estimated population of 181 000 and an annual population growth rate of about 5.4%, resulting mainly from Review of primary health care services migration from rural areas (9). The urban area expanded to Purpose and objective accommodate the migrant population, largely in informal The review was intended to address the problems of an settlements of shacks spreading outwards from Katutura. Such increasing workload, inadequate staffing levels, and the need to communities suffer high levels of poverty and ill-health (10). In improve access to services provided by the study clinics within 1995 a survey revealed wide geographical variations in the the rapidly growing informal settlements, as identified by the levels of poverty in the urban area of Windhoek (Table 1) (9). regional health management team. The specific objectives For the purposes of primary health care management, were as follows: to assess the equity of primary health care urban Windhoek is covered by a region and a district, both of provision and identify any relatively underprovided localities; which have the same boundaries. The overall planning and and to make recommendations for a more equitable allocation management of primary health care services are undertaken by of primary health care resources. the regional health management team, while district staff are It was anticipated that in conducting the review the responsible for delivering services in the clinics. regional health management team would improve its capacity There are seven clinics in the urban area. At the time of for evidence-based planning. The review was undertaken the review, four were staffed by nurses only and three had between July and December 1997 and was overseen by an doctors on site (Table 2). The nurses provide preventive intersectoral steering committee comprising representatives of services, mainly immunization and family planning, and the Khomas Regional Health Management Team, Katutura Table 1. Population characteristics of urban Windhoeka Area of Windhoek Katutura: Katutura:
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