Health in Africa Public Disclosure Authorized Dlecember14, 1993 Humanresources and Poverty Division Africatechnical Department

ReportNo. 12577-AFR

BetterHealth in Africa Public Disclosure Authorized Dlecember14, 1993 HumanResources and Poverty Division AfricaTechnical Department

FOR OFFICIALUSE ONLY Public Disclosure Authorized Public Disclosure Authorized

M4ICROGRAPHICS

EPeportNo: 12577 AFR Type: SEC Public Disclosure Authorized ~~4~i~i~mein IiAft*rd ditstributioioandi ma Y b,e used by ehpnt '~yhe~erfomance*fthir offiial. duties. 4ts-tonterits rhay not otherwise FOR OFFICIAL USE ONLY

BETTERHEALTH IN AFRICA

The World Bank AfricaTechnical Department HumanResources and PovertyDivision Washington,D.C. December1993

Thisdoment has a resricteddistribuon and maybe usedby recipientsonly in the performace of tbeir officia duties. Its contentsmay nototwise be disclosedwitout WorldBank authozation. content

FOREWORD ...... x

ACKN UOWLEDGEME1N4S ...... xH CHAPTER1:NTRODUCTION ANDOVERVIEW ...... I TheChallenge...... I TheObstacles ...... 2 PathwaystoAction...... 4 RoleofGovernment ...... S Underpinninpof a Cost-EffectiveApproah...... CostingBasic Health Senices ...... 12 ResourceMobilizadon ...... 13 A CaitoAction ...... 14

CHAPTER2: HEALTHAND DEVELOPMENTSTRATEGY ...... 16 Introduction...... 16 PARTI: CHALLENGESAN! PERFORMANCE...... 16 HealthIndicators ...... 17 CausesofDeathadnlness ...... 18 Persistentand NewHealthThbreas ...... 20 Combatft gDNeoplcPressureaidSTDs ...... 23 PARTU: HEALTHAND DEVELOPM3ENT ...... 26 EconomicCossofIness ...... 26 CreatinganEnabfingEnvironmentforHeakh ...... 29 Incoe and Wealth...... 29 EnviromnenServices ...... 31 FoodandNutrition ...... 33 FemaleEducatin...... 34 Cultue ...... 36 Householdsat tCenter ...... 36 PARTI: COPLETING THEAGENDA ...... 37

CHAirER 3: IPROVING HEALTHCARE SYSTEMS ...... 42 aoduction ...... 42 Past Pedonne ...... 43 MuIt-TiredSyems ...... 44 PerfomuneofCenMr Hospltal ...... 45 Reod of PiwmayHealth Car Stratgies ...... 47 SelectivePrmaryHealthCaue...... 47 VigaeHedth Workers ...... SO wha is Missing?...... S1 Underpi~mipgsofaCost-EffectiveApproawh...... 53 HealthC'entr CanMakeTheDlffer ...... 566...... FiatRermr Hospital ...... 57

i How Central HospitalsPit In ...... 59 CommunityEffectiveness and Multi-SectoralInputs . 60 Conclusion 62

CHAPTER4: PHARMACEUTICALSAND ESSENTIAL DRUGS. .63 Introduction.63 Perfom.nce .64 Constraihtsand Opportunities.65 A Demand-SidePerspective. 65 A Supply-SidePerspective .67 Assessment.69 QuantifyingInefficiency and Waste .69 What is Missing? . 71 OvercomingObstacles .72 Role of NationalGovermnents .73 Conclusion.76

CHAPTER5: MAJNAGINGHUMAN RESOURCES . .77 Introduction .77 Under-Utilizadonand Under-Supply. 77 Ca,;ses and Consequences... 80 Whatis Missing?.82 Opportunitiesat the Primary Care Level.83 The-Faciliating Role of Govermnent.85 Conclusion.87

CHAPTER6: INFRASTRUCTUREAND EQUIPMENT .89

Intoduction .89 Performance.89 The Decline of Health Infrastructureand Equipment.92 Whatis Missing?.94 Steps to Greater Efficiency .94 The SpecialProblem of Tertiary Care Facilities 96 AssessingTechnology Choice .96 Conclusion.98

CHAPTER7: MANAGEMENTCAPACITY AND INSTITTONAL REFORM.99

Introduction .99 InitiaingReform .102 OptimizingPerfomance of ExistingInstitutions ...... 103 DevelopingPolicy and Planning Skills .104 Encourinsg Istitutional Pluralismand Inter-SectoralCooperation .106 PromotingDecentralization .108 Encouragingand Sehening Comunity Organizations .110 ManagfngHealth Servicesat the District Level .111

ii CommunityParticipation ...... 114 Monitoringand EvaluatingDistrict Level Services ...... 115 DevelopingResearch Capacities ...... 117 Conclusion...... 119

CHAPTER 8: COSTING AND PAYINGFOR THE BASICPACKAGE ...... 120

Introduction ...... 120 A BuildingBlock Approach ...... 120 Low IncomeAfrica ...... 121 HigherIncome Country ...... 124 Who ShouldPay for What ...... 126 Affordability...... 128 FinancingGap ...... 130 Conchlsion...... 131

CHAPTER9: OPTIONSFOR RESOURCEMOBILIZATION ...... 132 Introduction ...... 132 Part I: ExpenditureLevels and Trends ...... 133 GovernmentExpenditures ...... 133 ExplainingShortfals ...... 135 Combatft Inefficienciesand Inequity...... 137 PrivateE enditures...... 138 Interional Aid...... 140 Par R: ResourceMobilizaion ...... 143 User Feesand Cost Recovery ...... 143 User Fees in Hospitals...... 144 Cost-Sharingin HealthCenters and Dipensaries...... 147 Fee Structr and Provisionsfor the Poor ...... 149 HealthInsurance ...... 151 EncouragingRisk Sharing...... 152 Roleof Goverranentin Insurance ...... 153 Conclusion:Resolving Crises ...... 15S

CHAPTER10: TIMETABLEFOR CHANGE ...... 159 Introduction...... 159 ActionAgenda ...... 160 Dynamicsof Change ...... 166 Linkswith the InernationalCommunit ...... 167

STATISTICALAPPENDIX ...... 171

BIBUOGRAPHICALNOTES ...... 193

MAPS ...... 219 GeographicVariatons in Under-FiveMortality Rate, Sub-Sahrn, 1991 (IBRD 25405) Estimaten HV Infections,Sub-Sahan Africa, 1990 (IBRD25406)

iii Table

cha,ewo2 TableI. Key Hedathbdikctor,S.S anfica and Otdh Counries, 1991 ...... 17 TableH. Distributinof Cas of DeathWihin Age Groupsin bSaharan Africa,190 .. . 19 TableM. Chid Moity by SelectedSocio-Ecoomic Ch...... 20 Table IV. The Rankand She of Mbal , AEDS,and Ote Diseam in th Totl Burdenof Dlaeaseand uju hnAflans inl990 ...... 22 TableV. EconcmicBurdenoflness, ThreCo aun ...... 27

Chaptr 3 Table. Singe Purposeltervention: A Revlewoffuie i Afica...... esnAfic . 48 TableH. R.eewofVHW andCHWProgams ...... 51

Chaptr 4 Tabe I. Expendiur on ican Seected Afican Countries,M-1980s...... 66 TsbleH. Pr CapitaHouseholdEFxniauresaon Medidnes,GOhna(1987188) ...... 67 TableM. AverageDug Coss per Treatnt Episodeby Level of Cae, SelectedAfticn Contries, 198388 ...... 68

Vhlmpt 5

Tablel. HelthlumanRcmsrceRados,1985-1990 ...... 79

chaper 6 Table1. The Gowth of Hedth Centersin SelectedAfrican Countries and the Chalenge Ahead ...... 90 TableH. Acom to Hedth Cae Fadcties and the Need for locatin Paning in Selected AfiicanCouties, Late 1980 ...... 91 Tableim. HealthCme iupmrNot in Service in Nigeria,1987 ...... 93

Chappr8 TableI. Annud ndicaive Per Capita Costs for a Ditict-Based Hath Car Systre put Apiw ...... 122 TableU. Anual hdikcte Per CapitaCosts for a Dsit-Bsed HealthCar Systm Oup Aw b ...... 12S TableM. WhoPays For Wbh In Th BasicPackage: A Combined arventdonad Target Approach ...... 127 TablIV. Groupingof Slectd Africn Countris by Rdave Levelof Expendit n Health, 1990 ...... 128

lv TableV. RoughE stim of AdditionalRevenue Effort for Healthby Govermenatand Donors in Low IncomeAfrica ...... 130

Chaptw 9 TableI. Groupingsof SelectedAfrican Counties by RekliveLevel of CentralGovernent Expditues on Health,Population Weighted Averages, 1980s ...... 134 TableII. Per CapitaHousehold Expenditus on Healthin SelectedAfrican Countries ...... 139 Tablem. Exrnal Assistancefor the HealthSector, Selected African Countries, 1990 ...... 141 TableIV. Revemnefrom User Chargesas a Percentof Recrrent GovernmentExpdres on Health ...... 144 TableV. Percentageof PopulationCovered by Health Insurance In Selected African Countries ...... 152

Chapter 10

TableI. ActionAgenda and Timetablefor Change ...... 162, 163

V Text Boes

ampt.rl

Box 1. The EnablingEnvironment for Hdth ...... 3 Box 2. Publicand PrivateExpendtu Prioritieson Health...... 7 Box3. Mdmiing CommunityEffectiveness ...... 9

haptw 2

Box1. Violence agastWomen asaHealthlssu ...... 21 Box2. Heth BenefitsofFamilyPlanning ...... 24 Box 3. TheEnvironmenaDimension of UrbanHealth: TheCue ofAccac ...... 32 Box4. Nutition and Household eath...... d ...... 33

Chapr 3

Box 1. ThreeGood Reasoh WhyPrmary Care ShouldNot be Povided i Hospits...... 44 Box2. Cost-EffectiveHealth Care Interventions ...... 54 Box 3. ComparativeAdvantages of HealthCeme ...... 55 Box4. PrototypicalHealth Cener ...... 56 Box5. PrototypicalFirst Refal Hospit ...... 58 Box6. AIDSand HealthCar Reformin Africa ...... 60 Box7. Ensing Supportfrom Public HealthSevcs Sev...... 61

Chaptr 4

Box 1. ImprovingPrmacutical MarketsTrough GovenmentAction ...... 74 Box2. Evaluationof Drg Needsin AfiicaNeed Not be Difficult ...... 75

Chapter 5 Box 1. PlanningHuman Rsources for Healthin Tanzania...... 82 Box 2. Demonsated Leadenhipat the DistrictLevel in Ghana ...... 84 Box 3. Ste nigHumanResources Planning and iement in Lesotho's Ministry of Hedth ...... 5 Box 4. Cooperationbetween Traditonal Healers and Modern Health Care Providers...... 86 Box 5. DevelopingHuman Resourcesfor Health Ladership and Reseach in Africa ...... 87

Chapter6

Box 1. SuccessfidMantenan in ZambianMine Hospitals ...... 95 Box 2. Acquiring New Technologies ...... 98

vi Chapter 7

Box 1. Information,Education, ad Communicationand the Health Bdavior of ndlvidualandHouseholds ...... 101 Box 2. DiagnosingHelth System Performancein Guinea, Benin and Togo 104 Bo- 3. Roles and ResponsibilidesUnder DecentralWiionof Ministries of Helth. 109 Box4. Trainingand Developmentof Heath Disrict Tems in Ghana ...... 112 Box 5. Accountabilityand Tranacy in the Use of Conmmnitytesources .114 Box6. Monitoringthe Provisionof HealthCare Servicesat the DistrictLevel in Guinea .... 116 Box7. A HealthResearchUnit Makes a Diffrence in Ghana .118

Chapter 9

Box 1. MacroeconomicChange, Struural Adjustmen,and Health.136 Box2. ThreeStories of CostRecovery in Hospitalsand OtherPacilities: Ghana, Senegal and Malawi .145 Box 3. Use of HealthCenters by the Poor in Cameroonafter IntroducingCost recovery and Quality Improvemens .148 Box4. CommunityLevel Insurance Plans: Lessons from Zaire 154 Box5. Public-PrivateCollaboraion. 157

Chapter 10 Box 1. InternationalInitiatives and SustainableOutcomes .168

vii Cbapter2 Figu r. PopulationGrowth in Africa,19902025 ...... 25 Figure2. Poal AIDS Treatmet Cost as Pecent of Total and GoveramentHealth Ependture.. 28 Figue 3. Per CapitaIncome and Under-FiveMortality in Eigt Sub-SaharanAfrican Counties, 1990 30 Figure4. ServicesContributngtoH o usehDhdoealth.. 31 Figure5. Under-FiveMortalty and Levelof FenaleEducatdon, Sdeed Countres, 1985-90 . 35

Chapter3 Figure1. PerfomrmnofEP UnderDlfferentConditions.49 Par A: EP ThroughCampign and/orMobile Stategies Pa B: EK ThroughStrmg Network or HealthCente

haptr 4 Figure 1. Inefficienciesad Wastein the Supplyof Dngs .70

Chapter 5 Figure 1. Under-Utilizatonand Under-Supplyof Healthad HumanResourc .78

Chapte 7 Figur 1. Dimenionsof Capaity Buildingfor Health.102

vii' Stiil App_ad

APPENDIX TABLES ...... 173

Table 1. Healthand DevelopmeAtIndicaos Table2. Poulation Projectons(Stada edium)

Table 3. PopulationProjections (Rapid Fertilit Decline) Table4. Morality TableS. Incomeand Poverty Table6. Education Table7. TheHealth and Statusof Women Table 8. Food and Nutrition Table9. Accessto Water,Sauiton and Heah Car Serces Table 10. Immunizatin Table 11. Heath Care Penmel Table12. Heath Care Facildes Table 13. Heah Exnditus

TECHIJCALNOCES ...... 186

lx Foreword

Africa's' high levels of mortalityand morbiditycost the continentdearly. Poor health increasessuffering, reduces humanenergies, and makes millionsof Africans less able to cope with and enjoy life. Poor health shackleshuman capital, reducesthe returns to leaning, and impedesentrepreneurial activities. Africansocieties must - amd can- increasethe ability of individualsand householdsto improve their health.

Better Health in Aica sets forth a vision of health improvementthat presents African countries and their external partners opportunitiesto rethink current health strategies. The report's underlyingmessage is that great improvementsare witn reach in many African countriesidespite tight financialconstraints. This study complements World DevelopmentReport 1993. Investing in Health, by offering a regional, operationallyoriented perspective on how health gains can be realized. It also draws upon important initiativesfrom other organizations. The World Health Organization, through its Three-Phase Scenario for Health Developmentand its support to district health systemsand other programs,has long been at the center. UNICEF, through the 1990 WorldSummit for Childrenand its follow-upin NationalPlans of Action, has given new impetusto actions to bolster health.

BetterHealh in Africadiscusses action and "bestpractices" by Africancountries and their external partners and documentsexperiences in three major areas.

First, the report emphasizes the importance of strengtheningthe capacity of African households and communitiesto recognize and respond to health problems. Vitally importantto this endeavorare the promotionof developmentstrategies that focus on the poor, support for more education of girls and women, the strengtheningof communitymonitoring and supervisionof health services, and providinginformation on health conditionsand services to the public. Action at the communitylevel is a key means of balancing responsibilitiesfor better health among the public sector, non- governmentalorganizations, communities, and households.

Second, the report strongly supports the endeavorsof African governmentsto reform health care systems. Strategicemphasis is placed on makilg basic packages of health services availableto all people throughhealth centers and first referral hospitals. Criticallyimportant to this endeavorare improvingthe managementof health care inputs, such as pharmaceuticals,health care personnel,infr ture, and equipment,along with institutionaland policy reforms. New partnershipsbetween public agencies and nongovermental health care providers will be required, as will continuousattention to strengtening capacities throughout the sector, from Ministries of Health to non- governmentalproviders of health services. Ministriesof Health can facilitatereform by givng more anention to policy formulationand public health activities,encouraging the health work of private voluntary organizations,and creatig an enabling environment more conduciveto the provisionand financingof health services by the private sector.

1. in fthisreport Africa refers to Sub-alar Afdcaand the two tems areused synomously.

x Third, the report underscores the need for more efficient allocation and managementof public financial resources for health so as to increase their impact on critical health indicatorslike life expectancyand child mortality. Equally important is the reallocationof public resourcesfrom less productiveactivities to the health sector. Action is also required to increasepublic and privatefunding of healthactivities. Greater commitmentfrom domesticsources can be expectedto be accompaniedby increases in financial support from donors. About $1.6 billion per year would be needed in incrementalresources to ensure a basic packageof health services in the rural and peri- urban areas of low income Africa. Beyond an increase of nearly $1 billion from governents, the possible donor share of somewhatover $600 million would represent a 50 percent increase in levels of extenal assistancefor health in Africa. Donors may wish to concentratetheir support on low incomeAfrican countries with active reform program.

Verbal pledgesto improvehealth must now be followedby concreteaction. The length and nature of the transitionto better health will undoubtedlyvary from country to country, but no country can delay committingitself more vigorouslyto the task.

The first step shouldbe the creation,at the nationallevel, of an agendafor better health. Action planning and the establishmentof signpoststo measure progress would follow. At the internationallevel, a ConsultativeGroup of Africansand donors could be formedto set prioritiesand ensure coordinatedinternational support for healthtraining and operationallyoriented research initiatives. A ministerialconsultation could help to launch the Consultative Group, determine an initial action agenda, and establish monitoring and evaluation benchmarks. Such a consultation could bring African Ministers of Health and senior personnel from Ministries of Finance and Planning together with senior staff from donors and other internationalagencies.

Better Heafth in Africa was written by World Bank staff, in close cooperation with many individualsand institutionsoutside the World Bank. Africans have been associatedwith its designand preparationsince the outset. The RegionalDirector of the WHO RegionalOffice for Africa, ProfessorG.L. Monekosso,and his staff participated in ways too numerous to mention. Staff from UNICEF assisted in the conception, preparation, and review of the study. An IndependentAfrican Expert Panel on Health Improvementin Africa reviewedthe report and made suggestionsfor improvement. The panel, co-sponsored by the African DevelopmentBank, WHO, UNICEF, and the SwedishInternational Development Agency, was chairedby the former Nigerian Federal Minister of Health and former Chairmanof the WHO ExecutiveBoard, Professor 0. Ransome-Kuti.

xi Tbisreport was wrte by R. Pau Shawand A. EdwardElmendorf. The study toamfor Bear HeakhIn 4fiw wasmanaged by A. EdwardElmendorf and Jean-Louis Lamboray,under the genral direcdonof hbratZ. Husainand PierreLandell-Mills. Jeai-LouisLamboray and ReilkoNiimi contributed to the conceptualdesign of the study, the preparion of initil draft of Chapters2, 3 and 7, and coordinateda reviewof npus of exeral panes. Zia Yusufconbuted to the designof the cosdagand finann frameworkused in Chpter 8. My Vu and Ali Sy preparedthe saiical appendix,and JamesShafer had principalresponsibility for processingte text. TheRegional Director of WHOfor Africaprovided invaluable advice and moral support in the task. His African AdvisoryCommittee on Health Development (AACHD),ad the WHO/AFRO'Health for All' teamprovided technical inputs and cIII,IIIat _ vadou stages. WHO Hadquarters also providedimorta suport. SeveralUNICEF staff members,at Headqarters and in the field, made substi contibu , at the design,in wridng,and finalreview stages. A largenumber of extnal and intenal consultations,with Afican health leaders, donors to health improvementin Africa, and nn-govnmental orgMiatons aidinghealth in Afnca, conwtrud to the final product. Preparationof the studywas also aidedby a seriesof papers,as wellas the conbutions andcommeats of manypeople inside and outsidethe Wod ank Theyare shownin the bibliography. WHO/ICOcontbue to the financingand plg of the shldy. FINNDA financedthe workshopsheld in Africa, and the SwedishInternational Development Agencyfinanced the Africanexpert reiew panel. The governmentsof Belgium, Finiland,Japan, and the Netherlandscontrbuted consultantsupport. Supportwas also receivedfrom the Cer for Health and Developmentat The GeorgeWashington University,and the Interational OrgnizationFeilows Progrm of the UnitedNations Asociation/NationalCapid Area.

xii CHAPTER 1: INTRODUCTIONAND OVERVIEW

The Chllenge

Good health is basic to human welfare and a fimdamental objective of social and economic development. Yet, most counties in Africa lag far behind the - -rmance of other developing countries in achievinghealth improvements.I Life expecVincyis , vears less, and infant mortalit 55 percent higher in Sub-SaharanAfrica than in o* - low uome coutries. Matrnal mortality, at 700 womenper 100,000live births in 1988, is aist double that of other low and middle incomecounties and more tdan 40 timesgreater than in high incomecounties.

The potential economic benefits of improved health m Africa are such that the productivity of workers in some countries could increase by up to 15 percent through reduced morbidity. Pressures on households to borrow and dis-save at times of sickness could be significanty reduced. A reduction in the horrendous toil of maternal morbidityand mortality could considerablyraise women's welfare and their contributionto development. And, with the control of disease and reducedrisks of illness, new socioeconomicopportnies can be expected, such as the opening up of agriculture in lands previously inaccessibledue to disease; greater rers on mvestmentsto educaton through longer life-expetancy; and greater command of reproducdve outcomes through reduced infant mortality, thus paving the way for demographic and ecomic transition.

At ceter of the ehaflenge to achieve better health are African hoeholds and communities. At this level, key health decisionsare made on a daily basis. Householdsaffect health tumgh the food they produce or buy, their source and treatent of drnking water, self- care practices, use of traditionalhealers, puchases from private pharmacists,and as clients of privately and publicly provided health services. Woman play particularly important roles as manags of health at the householdlevel. There is convincingevidence that householdsand communitiesare willing to expend substantialout-of-pocket sums for quality health services, Idkating considerablescope for mobilizingprivate resources, even within poor communities.

The challenge facing African societies is to increase the ability of individuals and households to reduce suffenng, morbidity and mortality at a faster rate than in the past. SuccessfWlhealth systems in Africa focus on household capacity for health and conceive of health services as support to households(see Box 1). It is only at the level of householdsand communitiesthat the information,time, and resource of householdmembers can be combined

1. TMetems AMicaand Su9 an Aficsam usedsynotmousy in Xs suy. 2 effectivelywith the purchaseand use of healthgoods, such as phannaceuticals,and basic services,such as clean water. Nationaland local govenmmentshave a key role to play in cratig an enablingenvironment for health, throughgreater commitmentto providepublic servicessuch as safe drnkng waterand sanitation,public health activities such as massmedia campaignsfor AIIDSprevention, and assistance to thoseleast able to affordhealth care. To this end, the capacityof nationalsystems of healthcare mustbe improvedso as to performmore efficienty,equitably, and sustinably. And, betteruse mustbe made of donorfunds to build nationalcapacities and sustainablehealth outcomes.

Thisstudy argues that the healthstatus of Africanscan be significandyimproved despite binding financial constraints. This will require using public resources for health more efficiently,gmng greaterpriority to primarycare, rescturing healthcare deliverysystems, gning management,mobilizing private reurces, improvingefficiency in the hospital system, and targetingfunds to cost-effective"packages" of health services. Some African countriesare alreadytakdng important strides in these directions,and successfulexperiences featureprominently in this report.

A priority is to improveconditions in low-incomeAfrica, where a large majorityof peopleare poor and underservedin rural and pen-urbanareas. The high levelof unnecessary sufferng and the wasteof humanlives and potential underscore the urgencyof the task. What followsis an overviewof major themes,approaches and findingsdeveloped throughout this report. The Obstacles

The successof householdsand communitiesin preventingdisease and suffenngis often influencedby conditionsoutside their direct control. Part of the problemstems from thefailure of governmentsto createan appropriateenabling enviroment for health. Despite tments to the principlesof primaryhealth care (PHC),for example,most governments have been slow to faciLitatecommunity-oriented and intrsectoralapproaches to planningand operatingsystems of healthcare. (see Box 1)

Equallyproblematic is the lopsidedway that privateand publicsystems of healthcare have evolved. In manyAfrican countries 45 percentof the populationdoes not have regular accessto modernhealth care. Moreover,a large shareof publicfunds for healthas much as 80 percent- goesto urban hospital-basedcurative care. Private-for-profitproviders tend to be concentratedin urban areas,serving middle and upper incomeclients who are most able to pay for services. Privatevoluntary organizations such as missionsare helpingto fill gaps, but theyseldom represent more than about 5 to 10percent of expenditureson health. For mral householdsand communities,especially remote ones, qualitycare is a rarity and reaching hospitalsoften imposesimmense time and travelcosts. Incidentsof peopledying en route to healthcare facilitiesare commonin Africa. Inefficienciesin systemsof healthcare are rampant,with the reswltthat householdsget too little qualitycare for the scarce resourcesthey have. Current systemstend to be multi- dered, oftenwith five or six levelsranging from village health post, to dispenury,health center, 3

Box 1. TheEnabling Environment for Health

Personal Health Care Services

Anlviduals,\ PhysicalEnvirnmernt, 4 louseb olds,and Public Health PopulationGrowth and Communis are Activiftes Strcture, Culture,and te key actos Politics 9hha

Natinal Income,Education, Water,Santion, FoodSecurty andNutrition

Betterhealth in Africahinges on the abilityof housholdsand communities to obtainquality healthservice at lesscost andto use themmore effectvely. Thisrequires:

* a strong poical commitmentto improvinghealth, as reflected in preferentil govermen spemig; - an intersectoralperspectve in plannig and operatingsystems of health care, includingprovisions for safe drking water, saniation, and health education; * an arpriate organonal frameworkand managerialprocess; * an equitabledistribution of healthresources; * communuiyinvolvement at all levels.

mal hospital or district hospital, regional hospital, and national hospital. Poorly trained personnel and inadequatesupplies within several of the bottom tiers - a problem of spreading resourcestoo thinly - prompts residentsat the communitylevel to by-pass lower levelsto seek basic care from intermediate-levelfacilities and hospitals. In doing so, first referral care is often obtained at a higher cost than it should be, while personneland facilitiesmost appropriatefor hospital-basedcare are mis-usedfor simpler forms of care - care that should be providedat the communitylevel.

Management and operational problems undermine the supply of key health inputs. Ceral levels of health planning- ministriesof health - tend to be inappropriatelystaffed with inadequatelytrained health professionalsand managers,and personnelat all levels(for example, ral disicts) tend to be underpaid and de-motivated. Publicly owned and operated infhsructur and eqiment ten to be poorly managed and are visibly in decline in many countries. Stock-outsof drugs and suppliesare frequent,especially in publiclyrun health centers and health posts. There is evidenceto suggest that inefficienciesand waste in the procurement, 4

storage, prescription,and use of drugs - a major cost componentin private and public health expendituresare such that consumersin some countries are effectivelyusing only $12 worth of quality drugs, on average, for each $100 spent by the public sector (see Chapter 4, Figure 1).

Broader societal conditionssuch as political instability, macro-economicshocks linked with the international economy, and national disasters are also part of the environment for health, affecting health outcomes in a major way. When political and economic problems precipitate ethnic conflictor civil war, entire systemsof health care are disruptedor overrun by refugees and displaced families. Today, there are between 10 and 15 million such people. Wben poor econonic performance and fiscal mismanagement (combined with mounting indebtedness)mandate budgetary reforms, govermmentshave too often reduced the priority for health, while leavingother expendituresintact, such as military outlays. Between 1975-89, for example, governmenthealth expenditures(as a share of total govermmentexpenditures) fell in 13 of the 22 countries for which time series data are available. And when national disasters such as prolonged drought weaken farm productivityand food security, malnutritionseverely threatens the health of the population, as observed in Southern Africa between 1991-92.

Rapid population growth and poverty are confoundingmatters. Combined with poor economicperformance, rapid populationgrowth has contributedto negligible, if not negative, rates of growth in GNP per capita in more than half of African countries over the past two decades. Women and childrenare particularlyvulnerable; rapid populationgrowth has resulted in huge increases in those most vulnerableto parasiticand infectiousdiseases, such as infants, toddlers and women of childbearing ages. Contraceptiverates are only about 11 percent, meaning that the positive health effects of family planning on reducing infant and maternal mortality - through improvedtiming and spacing of births - have been barely captured. Such problems are particularlyconcentrated among the poorest people, numberingabout 185 million in 1990.

Weaknesses in social services other than health pose further problems. The level of female education is known to be critical to long term health improvement,yet participationof girls in schools in Africa lags well behind the rest of the world, with 58 percent female enrollment in primary school in Africa against 92 percent for all low incomecountries. Pathways to Action

Admitting that some obstacles are more stubborn than others, this study targets coains most amenableto change from a nationalperspective. It recommendsa restuctuning of systemsof health care to the effect that:

* Governmentswould attach priority to creating an enabling environment for health through financingand provision of public health goods and services which benefit society at large, as well as subsidizingaccess to health care amongthe poorest segmentsof the population. 5 * Systemsof health care would be deenualied, featuringmanagement of health centers and a first referral hospital, at the districtlevel, as well as strong communityparticipation in the demination and managementof health services. Greater autonomyat the district level would also be expectedto contribute to organizationalunits that are more manageable,and to help to compemate for weaklesses in public and non-governmentalcapacity at the national level.

* Emphasis would be placed on basic services, provided in a cost-effectivemaner, featuring essential drugs and supportng communityservices, such as nutritonal education and home visits. These would meet the needs of the most vulnerable groups - the newbom, children under 5, and women of reproductive age - as well as major diseases - perinatal, infecuousand parasitic. This would ain to accommodateup to 98 percent of problems that can be treated clinically. Such services would be stndardized featuring internationallyrecognized essential drugs and norms for monitoringand evaluatingquality of care.

* Cost-sharing would be practiced on a wide scale at the communitylevel, but not withoutthe simultaneousimprovement in the qualityof services. Assurancesof qualitywould therefore build confidencein the system and contributeto a sustainablecost-sharing strategy.

* Beyondfirst referral hospitals,central, national,and teachinghospitls wouldcontinue to offer terdary level care and focus on training, with the caveatthat patients seekingcare would proceed through an orderly referral system- now streamlinedand more efficientgiven district fnbctions. Cost recovery would be implemented more extensively in such hospitals and government budget funding would be phased down. Patients by-passing the referral system would be charged up to 100 percent of cost.

* Ministries of Health would step up their leadership role in creating an enabling environment through financing, monitoring, and supervisorysupport of health activities right down to the communitylevel, planing of natdol health systemswith greater autonomyat the distict level, promotion of cost-effectivepackages of health care, and creating condtons favorable to non-governmentalfinancing and provisionof such care. The need to conentrate himitedpublic sector capacity on these issues, and the prevailing tendency of private-for-profit health services to concentrate in larger urban areas, means tbat private voluntay providers of health care and communty autonomy in the fina g and mamagingof health services ment maximumencouragement. Role of Goverment

The role of the public sector in bnnging about change is pivotal. Government's first priority should be to pursue its comparativeadvantage in providing goods and servces that construe health benefits to society at large. Broadly speaking, this pertains to ensuring the financing and provision of public goods known to have immense impacts on health and social well-being, such as safe drinling water, sanitation, roads, communicationssystems. These require resourcemobilization and economiesof scale that are almost alwaysbeyond the capacity of individualsalone. 6 In the healthsector govermment's comparative advantage lies in financingand ensuring provisionof public health activitiessuch as epidemiologicaldata collection,health system plamning,health education,regulation, licensing, and preventionof communicablediseases. Many of these activideshave strongredistributive effects because, in the absenceof adequate govemmentspending, the poor tend to be least able to solve the problemstargeted by the spending. WithoutNational Demographic and HealthSurveys, for example,it wouldnot be knownthat 70 to 75 percentof deathsin the youngestage groupsare causedby problemsat or near birth, or by infectiousand parasiticdiseases. This infornationis crucialto seting bealth targetsand indicatingwhat actions are appropnate. Thatgovernments should be attachinghigh priorityto providingpublic health goods and otherpublic goods and servicesis depictedin the figurein Box2. Thisprovides an analytical perspectiveon publicsector versus private sector priorities, and a frameworkof analysisfor this report.

Aside from public healthactivities, governments in many Africancountries are also involvedin financingand, often, providingpersonal health care services. They have great interestin assuringuse of cost-effecdveservices. Cost-effectiveness is all the more important becausegovernments face a heavyburden in assistinga large and growingnumber of poor familieswith a fractionof the resourcesavailable to moredeveloped countries. Such assistance also benefitssociety at large whenit includesmaternal and child healthcare, familyplanning, infantnutrition, immunizadon, and treatment of communicablediseases. Thisplaces a premium on identifyingcost-effective health services, tailored to the needsof the mostvulnerable groups and the major diseasesthey encounter. This concernis depictedin Box 2 as a large circle, intendedto represemgovernment's concern with "cost effectivepackages of basic health services"(defined below).

Thisreport does not assumethat governmentshould be the mainprovider of healthcare, however. Ideally,government's role shouldbe one of leadership,promoting cost-effective approachesin the provisionof care, and persuadingnon-governmental partners to makethem available.Government's share in healthexpendiur variesfrom as high as 60 percentor more in somecountries (Burundi) to as low as 5 percentin others(Zaire). Finally, owes priority is accordedin the figurein Box2 to spendingpublic fundson acute care, in-patientand out-patientservices at hospitals,and hospital"hotel" services since thesedeliver few benefitsat a morecollective, societal level. Consequently,user fees andcost recoveryat publichospitals are justifiedas this wouldfree up a sizablechunk of Ministryof Health budgetscurrently going to subsidizeinterventions based on curativecare at central hospitals,for reallocationto preventiveand prnmary care. The figurein Box2 a'so suggeststhat the reverse applies to private spendig priorities. Individualsare most willingto pay for emergencyand curativecare at hospitals. In sum, prioritis for actionby Africangoverments revolve around the following: * Establishingprograms of publichealth services, and financingthem before supportng otherhealth semrves. 7

Box 2. Publicand PrivateExpenditure Priorties on Health

LowPriority - ' PrivateExpenditure HighPriority

PrivateParticipation In Financingthe Basic

PubWc ; <>OtherHospital Hean Sonices wfth ~~~andAmbulatory AetivKbu POSMvE{e.g.. n" t s9- Care

HighPriority 4 Public Expenditure <- LowPriority The war on diseasein Africacannot be won by individually-orientedhealth care servicesalone, but must involveinterventions to controlthe transmissionof diseaseand disease vectors in thephysical environments where they thrive. Theseinterventions, such as health education and nfornautionand the eradiationof malariafrom swamp areas, are usuallysupported and sometimesundertaken by governments,because collective action is requiredto make investmentsbeyond the capacityof individualsalone. Theyare calledpublic goods because they tendto benefitthe communityas a whole,and no individualcan be excludedfrom their benefits. It is equallyimportant to fiance and. wherenecessary, provide other public health service, such as epidemiological data collection and analysis, health system planming,provision of beal infotmationto healthcare providers and consumers, health education, regulation, licensing, andprevention of communicablediseases. As depicted in thefigure above, expenditures on publichealth activities and otherpublic goods should be a highpriority of goverments. Indeed, without commitment to publichealth improvements, as wellas an enablingenvironment for betterhealth, high levels of percapita income cannot ensure good health. Governmentsalso have a criticalrole to playin supporingactivities that sometimesbenefit individuals directly (thusqualifying them more as privategoods) but also construe large benefis to societyat large. Theseinclude fmnily planning,matenal and child bealth,infant nutrition, immunization, and treahnentof communicablediseases. In the endeavorto assistthe poorest households, government support for cost-effective packages of basichealth care will almost certainlyinclude such services . In the figureabove, this is conveyedby the largecircle, suggesting that governments have a stronginterest in idetifyingand partlyfinancing cost effectivepackages of healthcare. Finally,the lowest public pririty, andconversely, the highest private priority, is to allocatefunds to acutecare. inpatientand outpacient services, laboratory services and hospitl hotel' services.In the ftgureabove, this is captured in the secdon*other hospital and ambulatory care'. Animplication is thatcharging fees and fullcost recovery are most feasibleat centralhospitals because such tertiary-level services benefit individuals, and people are mostwilling to pay for them.

* Detrmnng packages of personal health services which, if adequately used by providers and consumersof health cae, are the most cost-effective.

* Providing incentives to non-governmentalbodies, especially pnvate voluary organizations,to makethese basic packagesof care availableto the largestpossible share of the population.

* Subsidizingthose componewtsof the package with positive externalities. 8 * Subsidizingaccess to the package of services by the poor and, in the absence of non- govermnentalwillingness to provide them on acceptableterms, directly providing these services.

* Providing informationto the public that will stimulatedemand for the basic package of health services, empower citizens to choose wisely among providers, and assist householdsto make sound use of the package of health services.

* Reduchg direct government engagemen in provision of health care where non- governmentalproviders show potential for an increasing role, and realocating public financial support for health care from tertiary care to primary and preventive services with greater direct impacton health outcomes for the majority. Underpinnin of a Cost-EffectiveApproach

Households and communitiescan get the best possible health per dollar spent in three mutually reinforcing ways. The first element involvesa flexible, cost-effectve package of essential health care services right down to the communitylevel. Much can be learned from an assessmentof successfiulexperiences and factors undern-ning health inputs at the community level (see Chapter 3). The secondelement pinpoints improved management of essential inputs to health care - pharmaceuticals(Chapter 4), personnel(Chapter 5) and infrstructure (Chapter 6). This is informed by an analysis of managementpractices currently at odds with efficient ealth care delivery. The third element involves decentralizationof health care delivery, featuring a leaner and more effectiveMinistry of Health, institutionalpluralism with strong non- governmentalrepresentation, and managementof district-basednetworks of communityhealth centers and first referral hospitals (see Chapter 7).

The communityfigures prominenty in the search for a cost-effectiveapproach to better health in Africa because it is at this level of population aggregation that health care can be effectively complementedby collective action to provide critical public services (for example, hand pumps for safe drinkingwater, pit latrinesfor sanitationin rural areas). This is immensely important in Africa because so many people live in areas separatedfrom urban-basedutilities which have yet to extend to pen-urban and rumralareas.

The Package Concept: The cost-effectivepackage envisaged in this study is concerned with providing the best health services at the lowest cost in countries facing binding fnancial constaints. First, it emphasizes basic health care inputs relevant to the demographic and epidemiologicalprofile of most African countries. People at greatst risk tend to be members of vulnerable groups, includingnewborns, infants, toddlers, and women of reproductiveage. High risk groups tend to be afflicteddisproportionately by infectiousand parasitic diseases.

Services in the package include prenatal, labor, and delivery care, management of obstetic complications,post-partum care, well-babyservices, and family planng, general outpadent care for such afflitions as diarrhoea and skin diseases, and the maagement of chronic illnesses. Methods employed include vaccinations, oral rehydration fterapy, chloroquine, preventingirn deficiewy, and treatingurinary and gynecologicalinfections. Stocks of esseal 9 drugs in the package are cognizantof the priority diseases n Africa such as malaria, diarrhoea, diabetes, respiratory infections, measles, asthma, polio, and sexually transmitted diseases, includingAIDS. Combined,these componentsspeak to importanthealth targets in low-income Africa. They are compatiblewith internationallyaccepted goals of 80 percent coveragefor ante- natal care, and 80 percent coverage for immunization(see Chapter 3).

Second, the essentialpackage emphasizesa broad range of information,communication and educationservices that enhancethe impactof any contactbetween a health care provider and a patient seekinghelp. For example,a woman brings her child to a health center for treatment of chronic diarrhoea, and leaves not only with a cure but preventive information on better nutrition and health advantagesof family planningmethods. As another example, the package includesdissemination of self-carepractices for the infirm and elderlyat home, as well as AIDS patients. These supporting services help maximize community effectivenessby increasing channelsof communicationbetween providers of servicesand householdpreferences, demands, and use of services.

Third, the package includesprovisions for additionalinputs - beyond basic individual health care services for those communites that can afford them. These are treated as incrementalintersectoral interventions insofar as they involveadditional costs and mobilization of resources at the communityand local governmentlevel to pay for them (Chapter 9). They include safe driking water and sanitation. Box 3. MaximizingComunity Effectiveness The effectivenessof the essential health care inputs, supporting services, Maximizing = A: BasicPackage of and intersectoral interventionsdescribed Community HealthCare Inputs above dependslargely on the degree to Effectiveness + which they come together - private as B: SupportingSerces well as public health activities - at the tersectoral+C: level of the community. It is their l:rventions proximity and responsiveness to households and the community that counts. This is one reason why A: Essenial = (EPI,Ante andpost-natal care, effectiveness is conceived in terms of HealthCe tamnt ofmatenal morbidity, "maximizing community effectiveness" in Inputs fmily planning,out-patient care, Box 3. Well-functioning communitybased health centers, for example, can provide a mix of preventive and curative B: Suppting = (Information,education and care that can meet up to 90 percent of Services communicationto improve; health care needs. + screening& diapostic accuracy + providercompli. a + patientcompliance) Maximizing community effectiveness also makes sense from a facility-based perspective. When cost- C: Iersectoral = (Safedridnking water effective packages of health care are Interventions + sanitation) offered in well-functioning community health centers, overall hospital admission 10 rates havebeen rduced by up to 50 percent,whereas admissions for illnessessuch as measles, tetanusand diarrhoeahave been reduced by up to 80 percent(see Chapter 3). The rationalefor promotingeffective basic care at the communitylevel, is not only to minimizecosts, but also to (i) provideindividual care at the closestpossible level of contact(public health centers or private clinics),(ii) get the referralsystem working well throughcontact with a first referral hospitalat the district-level,and (iii) reservepersonnel and equipmentat the tertiarylevel for fintions that are less commonor more costly, suchas "high-tech"care. Gettingthe first two tiers in workng order could accommodateup to 98 percentof the healthproblems likely to arise, thusreducing lopsided funding of centrallevel hospitals. Better Managent: Betterhealth in Africa involveshundreds of millionsof people living in hundredsof thousandsof communities,countless private practitionersand private voluntay organizatons,public heah systems, Ministriesof Health and cadres of related instdons, billionsof dollars,and the contributionsof dozensof donors. Yet managementof health car systemsin most countriesof Africa is generallyextremely poor, being overly cetnalized, with resticted or limitedauthority delegated to districtand locallevels. Deficienciesin managementstart with the inadequateformulation of nationalpolicies, and extendto weakplanning, monitoring and evaluationof specificinputs to betterhealth care - pharmaccuticals,personnel, infrastructure, and equipment.As one example,national drug policiesthat abideby essentialdrug lists are a rarity in mostcountries, though governments tend to be heavilyinvolved in drug imports. As anotherexample, expenditure statistics and survey data on healthpersonnel, infastruce, and equipmentare mostlydeficient, so muchso that fiDnng of these itemscannot be adequatelyassessed in more than half of Afncancounties becauseof tbe absenceof data on non-govemmentalexpenditures. Nor is policyformulation and planninggenerally in the handsof professionalmanagers whoare trainedin the principlesand procedures of policyanalysis and health care management. In one country,for example,almost all of the top managementpositions in the Ministryof Healthare heldnot by professionalmanagers, but by physicianswithout significant management taining. Suchpractice squanders human resources and reducesefficiency by usingphysicians in task for whichthey have neither the inclinationnor the trainmg. Wherepossible this studybuilds on "bestpractices" including incentive structures for aptimal performanceof line management,and managementinformation systems (MIS) that monitorand evaluatehealth inputs, health system outputs, and healthoutcomes. These issues are taken up specificallyin the context of managingpharmaceuticals, personnel and infrastrctue in ChaptersFour through Six. Alsoaddressed are prioritiesfor governmentaction in determiningthe kindsof managementstucres neededto assure greatercomplementarity betweenpublic expendius on publichealth activities and health care. InstittIonal Reform and Decentralizationof Health Care Delivery: The institutional weaknessesand system-wideproblems that afflict public managementand goverment admnistratos consitute a major obstacleto better health in Africa. For this reason, the organizationand mt of the healthsector occupies a specialplace in this report; it has a cical bearingon cost-effectiveness.In somecases, sy3stemc problems have been exacerbated 11 by verticalprograms, such as immunizationcampaigns, with staff, goals,and budgetsthat are almost independentof existinghealth care systems. Undertakenso as to by-passor avoid addressingsystemic issues, they have often had the unintendedeffect of fragmentg health sector activities. Many such initiativeshave been donor driven. Aware of such problems, African governmentsand donorshave long been callingfor more concertedefforts to build permanentinstitutions and integratedhealth systems - in other words, nationalcapacity building, Despite reforms in the 1980s, however,Africa's public administrationsconinue to remainweak (Worid Bank: 1989). Amongthe principalcauses are:

* Inadequatetransparency and accountabilityin the use of publicfimds

* Weakand underfunded local govermments, with uncleardelineations of authorityand responsibilityfor mobilizingresources * Proliferationof undisciplinedcivil servantsin highlycentralized public bureaucracies and publicenterprises

* Staffwho have litfle in-depth understading of eitherthe institutionsthey are supposed to manageor of the broadercontext in whichthey are expectedto function.

* Difficultiesfaced by managersin motivatingand disciplining their staff owingto the socialand politicalcontext in whichthey operate. For the most part, these systemic shortcomingsneed to be addressedas part of comprehensivepublic sector reform programs, since it is difficultif not impossibleto attempt to reform one ministryon its own. Recognizingthe drawbacksof relying too heavilyon centralizedpublic bureaucracies, several African governments have considered various degrees of decentralizationto the localand community level in the managementand delivery of services includinghealth, educationand public utilities. Successis particularlyapparent when the planning and delivery of cost-effectivehealth services are combined with communty participationand public support,at the districtlevel. From the perspectiveof ministies of health,the districtcan be seenas an effectiveunit of d ization. The districthas alsooften servedas an effectiveadministrative unit for communitiesto exert influence"upward", thereby to be heardby higher-levelgovernment providers of healthservices, as wellas poliymakers. This appearsto be payingoff, particularlywhen communities are givena greatervoice in determiningwhat is to be providedand whatis affordable.While there is no simplemodel of how to organizea nationalhealth care system,organizational principles are reviewedin Chapter7, basedon evidencefrom African countries with relatively strong health systems. This providesa perspectiveon therelationship between health planners and policymakers at the cen (ministriesof health),decentralization of healthfunctions to the districtlevel, and communit managementof healthcenters within districts. 12 CostingBasic Health Services

Costinga basic packageof health servicesmight best be left to individualcountries where detailed informationon incomes, prices, and priorities is most readily available. Yet a major concern of this study has been to assess the financialunderpinnings of a cost-effectivepackage of health care, especiallyrlevant to low-incomeAfrican countries. There is also great demand for indicative costs based on real experiences, especiallywhen some countries in Africa have participatedin those experiencesand others wish to learn about them. Accordingly,a detailed costing framework, presented in Chapter 8 of this study, demonstratesthe underlyingprocess by which inputs to a cost-effectiveapproach have been decided upon, and costs assigned. Includedin the "package"are basic health care goods and servicesthat speak to the demographic and epidemiologicalprofiles of the majority of people in low income countries. The costing frameworkis also used to illustratehow costs would likely change (upwards)for countries with higher levels of income.

This study estimatesthat a basic packageof health care services,plus incremental,multi- sectoral services can be provided for approximately$13 per capita, per year in low income countries. This has been disaggregatedinto costs for health care and facilities ($7.74 per capita), intersectoral interventionsincluding safe drinking water and sanitation ($3.98), and institutionalsupport ($1.50 per capita). No pretense is made, however, that a universally applicablecost or a singlerecipe for an essentialpackage of health care servicescan be derived. One reason is simply that final costs (and services) will be highly conditionalon differences between countries in wage and price levels, technologies in use, per capita incomes and aspirations. Another reason is that socioeconomicchange brings with it modified demographic sures, epidemiologicalconditions, and changingsocietal priorities. Thus, a parallel costing exercise for a relatively "high-income"country in Africa, also presented in Chapter 8, suggests that costs would be about 20 to 25 percent higher, at about $16 per capita, per year.

Establishingan indicativefigure of $13 per capitafor a basic package of services in low- income Africa is vahiable as a means of promping reflection on what people are getting now for the amount they pay; how resources might be reallocatedto usher in a more cost-effective approach; and additionalresource requiments to assure that the poorest countries and poorest groups withincountries could afford such a package. Accordingly,Chapter 8 goes on to assess financingof the package in three groups of African counties, classifiedaccording to levels of gross national product and per capita expenditureson health. Assuming the public sector - governments and donors - were willing to increase their resource commitments in ways suggestedin Chapter 8, an additional$1.6 billion per year would be mobilizedfor better health in low-incomeAfrica. Governmentswould contribute almost one billion dollars. Assumingthat all low-income African countries had suitable health reform programs, the donor share, comprisingabout $650 millionper year, would be about 50 percent more than the amount now provided from external sources in assistancefor health improvementin Africa. 13 Resource Mobilization

All countries face financialproblems when it comesto mobilizingresources for health, includingrelatively rich, developedcountries such as the United States where nmawayhealth expenditumsare eating 14 percent of GNP. This study has been guided by realitiesand needs in Africa, to argue for action along five dimensions(Chapter 9). First, many African countries lag behind other less developedcountries in their expenditureson health as a share of GNP. Equally, if not more important, is that many governmentsare lagging in their commitmentsof public expenditureson health as a sbare of their total governmentexpenditures. Action needs to be taken to restore commitmentsto health in contextswhere they have diminishedor to raise such commitments in recognition of the immense importance of health for sustainable development. Ultimately, of course, well-allocatedreal per capita health expenditurescount as much or more than the health share of the public budget or of GNP. Monitoringperformance in this respect promises to pay dividends for African governmentsand their partners in health improvement.

Second, governmentshave control over how governmentexpenditures are allocated,and can have an immense impacton the "enablingenvironment" for health by spendingpublic funds on public health goods and services. This study shows that large shares, and sometimes the majority, of public funds for health are not being used to financeor provide public health goods and services. Action can be taken progressivelyto match symboliccommitments to preventive and primary care with reallocationof public funds away from relatively cost-ineffectiveand expensive, urban-based curative care, particularlythose services concentratedin teriay and central hospitals.

Tird, governmentscan progressivelyimplement user fees and cost recovery to help ensure financial sustainablity of publicly financed or provided health care. This study shows there is considerable scope for expandinguser fees. Though revenuesgenerated at the outset may be modest, improvementin cost recovery is an essential part of any health finance reform program because (i) retentionof fees at the point of collectioncan be an incenfiveto hospital and clinic managersto enhanceboth revenuecollections and service quality, (ii) purely on equity grounds, patients from higher incomehouseholds (many of whom will have health insurance), should be required to pay for the health care they receive, and (iii) research has revealed that even middle and low-income households are prepared to pay for most curative services, especially if service quality is good.

Fourth, governmentscan create conditionsfor the expansionof both public and private insurance programs, generating increased revenues for the health sector in general and stmulating expansionof privateproviders of healthcare. This studyshows there is considerable promise for expandinginsurance. A requisite is to introduceuser fees so that possible private providers are not in competitionwith free health care. A possible approach for government action is to mandatecompulsory insurance for salariedworkers, encourageexpansion of private or employer-providedinsurance programs, and provide technicaland other support to stinmlate provider-based insuranceprograms at the communitylevel. 14 Fifth, governmentscan progressivelypromote public-private collaboration as a means of increasing efficiency and fostering development of private-for-profit and private voluntaty organizations. Subsidizingmissions, for example, has paid handsomelyin Africa as a means of providing for indigentsand of servingareas where public and private-for-profitfacilities are scarce. It also makes sensein viewof the co-subsidieswhich come fom abroad, paying salaries of mission staff, providing essential drugs, building and maintaining facilities. Fostering community control and ownership of health facilities and financing mechanisms- such as prepaid community-basedinsurance - has worked well to mobilize revenues in rural areas.

Finally, governmentscan reap far greatersustainable benefits through the use of available external fundingthan they have in the past. This studyargues that donor initiativesand lending, while valuable on a number of criteria, have had problems achieving sustainableeffects, and have often been criticizedfor fragmentinghealth systemsrather than buildingnational capacities. A Call to Action

Who stands to benefitand who will be motivatedto take action in keepingwith the major themes of this report? Obviously,African householdsand communitiesstand to benefit in their quest to alleviate pain, suffering, and disease, through greater access to, and use of, quality health care. Public health officials are likely to be supportive because the cost-effective approachesemphasized here provide a frameworkfor organzing their work more efficiently, equitably, and sustainably. Policy analysts associated with professional health associations, universities and think tanks can benefit in their endeavorsto devise strategiesfor better health in Africa. Core agencies, such as Ministriesof Planning, Finance, and Centrl Banks, stand to benefit given their interest in restructuringhealth care systems, as well as increasingefficiency and equity, in ways that countries can afford without compromisingprogress to better health. And the donor communitycan be countedon to play a supportingrole given the promise that domestic health expenditureswill be used far more cost-effectivelythan in the past.

Hard decisionson health are needed now, to convert the vision set forth in this study and other reports into implementableaction plans. Governmentshave a responsibility,as well as the mandate, to take action that will reduce unnecessary suffering, increase human resource potential, and contributeto a major foundationof sustainabledevelopment. This study urgently recommendsaction along five distinct dimensions:

* Comprehensivehealth policies need to be adopted with explicit operational goals, prescriptionsfor the role of govermmentin public health activitiesand other public services such as safe drinkingwater and sanitation,and statementson how the enabling environmentaffecting householddecision-making and preferenceswill be strengthened.

* Cost-effectiveapproaches to basic health services need to be implemented,featuring basic health care and drugs in well-functioninghealth centers and first referral hospitals, with particular attention to the most vulnerablegroups in low-incomeAfrica.

* Managementcapacity and institutionalreforms need to be acceleratedso as to improve the performance of health care systems and strengthen research support - including the 15 managementof pharmaceuticals,personnel, infrascture, and equipment- and to build more effectivepartnerships for health with pnvate and prvate voluntary providers.

* Government commitments to health expenditures need to be increased, with simultaneous action to reallocate public expenditures so as to increase efficiency, and to stimulateexpansion of pnvate sector fmancingof health.

* Govermets need to develop national strategiesto direct external assistance, rather than mold national strategiesaround availabledonor funding. Where governmentshave sound plans for health reform, cost-effectiveinterventions, and a clear commitmentto implementation, a doubling of current levels of donor financingfor health improvementin low-incomeAfrica might reasonably be proposed. This would result, overall, in an increase of about 50 percent in external assistancefor health in Africa.

Other counties are achievingbetter health at low levels of per capita income, why not countries in Africa? The child mortality rate in China, for example, is one-half the level in Zimbabwe, and one-quarter the level in Senegaland Cote d'Ivoire. It achievedthis feat with a per capita incomethat is only 50 percent that of Senegaland C6te d'Ivoire. Though cultural and political differences are involved, many of the lessons learnd are generalizable and tnsferrable. Moreover, Africans hemlves have been experimentingwith new approaches, the results of which constitutebuilding blocks for future action. This study incorporatesthose lessons with the vision that the dream of "Healthfor All by the Year 2000" will be delayed, but that its worthy goals remain attainable. CHAPTER 2: HEALTH AND DEVELOPMENT STRATEGY

Introduction

High levels of mortality and morbidity throughout most of Africa are costig the contnent dearly in the quality of life and the capacity of its human resources. Poor health increasessuffering, reduces people's alertness, and the abflityto cope with and enjoy life. From a societal perspective, poor health sbackles human capital, reduces returns to leamning,and undermines socioeconomicenvironments conducive to entreprenerial activities.

This chapter describes the epideniological, demographicand socioeconomicconditions affectng health in Africa. It identifiesimportant links betweenhealth and development,making the argumentthat far better health outcomesare possibleeven at low levels of income. This can be partally achievedby improvingknowledge and use of factors that have immenseimpacts on health such as safe drinking water, sound food preparation and nutritionalpractices, education - especially of girls, sanitation, and family planning. Goverments have an importantrole to play in targeting public expendies to such ends because they contribute to the enabling environmentfor better health, includingprevention of communicablediseases. Without such an enviroment, individualhealth care will yield far lower returns than are otherwisepossible. PART I: CHALLENGESAND PERFORMANCE

Africa is host to a number of major disease vectors, the tramnsmissionof which is aided by a warm, tropical climate and variable rainy seasons. As but one example, the mean number of infectivemalra bites per person in forest or savannahareas can be ten times the number in the Sahel or more mountainousareas. In agriculturalcommunities, the worst times of year tend to be the wet seasons when food shortages,high food prices, and demandfor agriculturalwork combine with high exposure to infection,especially diarrhoea, malaria, and guinea worm.

Slow economicgrowth, combinedwith rapid popuLationgrowth, has held back per capita inomes, u ining the ability of householdsto pay for better health and the capacity of governments to fill gaps. Rapid population growth has multiplied the membership of demographic groups most vulnerable to parasitic and infectious diseases, outstripping the capacityof governmess to meet basic needs. Moreover, persistentlyhigh ferttlity regimes, and lmited use of modern family planning metods, have undermined the positive effects that improved timing and spacing of births might otherwisehave on infant, childhood and matemnal mortality. 17

Progress in underlyingsocioeconomic deteminants of health - especiallythe education and emancipationof women - has also been slow. Only 68 percent of 6 to 11 year-olds are emolled in primary school, and the percentageof femaleenrollments tends to be about half those of males. Illiteracyis correlatedwith poor nutritionalpractices and inappropriatesantation, and inhibits informationand communicationabout better health practices.

Political instabilitiesarising from coups d'etat and civil wars have also underminedthe effectivenessof health administrationsin dealingwith millionsof refugeesand displacedpersons beyond the reach of formal health care systems. Upwards of 60 million Afncans have been adversely affected by civil conflict and related faminebetween 1980 and 1990. Ten to fifteen million refugees and displaced persons are currently beyond the reach of formal health care systems. In countries such as Angola, Mozambique,Ethiopia, Somalia, and Uganda, health facilities have been extensively damaged or destroyed. It is under such conditions that householdsstruggle to improvetheir health and that systemsof health care are expectedto make a difference.

Health Indicators

In the past quarter century, Africa's struggle to overcomedisease has produced a mixed record of success. On the positive side, the mortalityrate for childrenunder the age of five has been cut in half and life expectancyincreased by more than a decade between 1956-90. At the beginning of the period, only one in seven Africans were suppliedwith safe drining water, whereas twenty-five years later about 40 percent of the African population was obtaning drinking water from a safe source. By the end of the 1980s, aroundhalf of all Africans were able to reach a modern health care facility within one hour (UNICEF 1992b).

Despite these achievements, however, life expectancy in Africa is only 51 years, compared with 62 years for all low incomecountries, and 77 years for high incomecountries. Africa's infant mortality rate is almost 50 percent higher than in all low income countries, and at least 10 times higher than in high incomecountries. Maternal mortality in Africa is twice as high as in aU low income countries and six tmes higher than in middle income TableL. Key Health Indicators, Sub-Saharan countries (Table 1). Africa and Other Counties, 1991

Within the continent, mortality Cou GF differentialsbetween countries are no less tigh Midkle Low S aa striking. Mortalityof childrenunder five Income income Income a years of age ranges from more than 200 deaths per 1,000 live births in countries Lif Expctay 77 68 62 51 like Mali, Angolaand Mozambiqew,to at Bith (Years) less than 100 in counties like Botswana wm morwity 8 38 71 104 and Zimbabwe(see mapat end of report (per1,00 live titled, "GeographicVaations in Under- births) Five MortalityRate, Sub-SaharanAfrica, MatemalMorwayit - 107 308 686 1991"). Maternal deathsper 100,000live (prt), birlts have been estimatedto range from Souce: Wod Bank1993e. 18

83 in Zimbabweto over 2,000 in Mali. Adult mortality- the risk of dying betweenages 15-60 - has been estimated to range from 18 percent in Northern Sudan to as high as 58 percent in Sierra Leone (Feachemand others 1991). In many countries, more than 30 percent of females and 40 percent of males of worldng age will die before the age of sixty.

Mortality also varies widely within countries, revealing inequalities in health status betweenurban and rural residenceas well as socioeconomicgroups. In Zimbabwe,for example, childhoodmortality of urban residentsis 45 percent less than levels in rural areas, and up to 20 percent less amongurban dwellersin the Sudan, Togo and Uganda. Childrenof married women with secondary education are 25-50 percent less likely to die before age five than are children of womenhaving no education. Differentialsbetween higher income/residentialareas and lower income/residentialareas have given rise to the so-called "10 to 20" nrIe of thumb, meaningthat in most sewttngs,life expectancyof the richest 10 to 20 percent of the populationis somewhere in the order of 10 to 20 years higher than that of the poorest 10 to 20 perce (Gwatkin1991).

Cultural makes such as ethnicity also rank as powerful correlates of infant and childhood mortality differentials, even after controlling for educadon and occupation. In Cameroonbetween 1968-78,for example, the mortality of children less than two years of age ranged from 116 per 1,000 live births among one ethnic group, to 251 for another. In Kenya, child death rates ranged from 74 for one etnic group to 194 to anodter, while in Ghana, they ranged from 74 to 158 and in Senegal, from 261 to 452 (Akoto and Tabutin 1991). Ethnic differentials may be pardally attributable to different attitudes concerning illness, minutional practices, access to and use of modern health services, and attachments to modern versus traditionalhealers. They are also due to schismsbetween ethnic groups that manifest in unequal access to socio-economicopportunities.

At all levels of statisdcal aggregation, therefore, huge gaps are apparent in key health indicators. Yet, the prevailing dffferencesbetween countries in Africa, between people living in rl versus urban areas, and between groups of people classifiedby socio-economicstatus, are also indicativeof the 'art of the possible'. A challenge facing all partners in better health in Africa is to identify ways both within and outside the health sector of closing gaps between those realizing better health outcomes and those excluded from them.

Causes of Death and Illness

Major causes of deathand illnessvary by age group, yet certain healthproblems condmie to threaten all members of society (see Table 11). Perinatal, infectiousand parasiticcauses are responsiblefor 75 percent of infant deaths in Africa. Infectious diseases and parasitic causes are futher responsiblefor 71 percent of the deathsof 1-4 year olds, and 62 percent of the deaths of children aged 5-14 years. Childhoodhealth in Africa is threatenedparticularly by diarrhoea, acute respiratory infections, malara, and measles (see Table IMI). The incidence of diease among children can be profiled as follows (Feachemand Jamison 1991):

o The typical African child under five yeas old has five episodes of diarrhoea per year, a 10 percent risk of suffering from diarrhoea on any given day, and a 14 percent risk of dying from a severe episode. Diarroea accountsfor 25 percent of all illnessin childhoodand for 15 19

TableH. Distributonof Causesof DeathWithin Age Groupsin Sub-SaharanAfrica, 1985 Proponionof totaldeath wPhinthe age ategory Tol Deaths Cie of Death < 1 J4 5-14 1444 4564 65+ (OO:'s) Percent

Perintal 30.0 0.0 0.0 0.0 0.0 0.0 627 9.3 Infctions and paidc 45.0 71.0 62.0 53.0 28.0 19.0 3,403 47.2 Cancers 0.1 0.3 1.0 3.0 14.0 9.0 42 3.4 Crcuoy Sys. 1.0 2.0 6.0 12.0 34.0 41.0 909 12.6 Matemal 0.0 0.0 0.0 4.0 0.2 0.0 48 0.7 Injury 1.0 3.0 6.0 12.0 5.0 2.0 294 4.1 Other 23.0 24.0 24.0 16.0 18.0 28.0 1.635 22.7

Total 100 100 100 100 100 100 7.203 100.0

Note: a. Ages are in Yeas. Source:Feachem and Jamison1991. percent of admissions to health facilities. WHO estimates that 37 percent of all cases of dirrhoea in the world occur in Sub-SaharanAfrica where only 50 percent of chlldren benefit from oral rehydrationtherapy, comparedwith 70 percent of children in Asia and North Africa (WHO 1990).

- The typical child appears to have approximatelyten episodes of acute respiratory infections(ARI) per year and a 25 percent chanceof suffering from ARI on any particular day. It is estmated that ARI is responsiblefor 25 to 66 percent of childhoodillness and for about 17 to 41 percent of visits and admissionsof children to a health facility.

* Vaccine-preventablediseases are associatedwith 20 percent of child mortality.

In 1985, before the effect of AIDS mortality was being felt on adult mortality, about half of all deaths of adults 14-44 was also due to infectiousand parasitic diseases. However, the World Health Organizationnow estimatesthat one in forty Afican adults is infected with the human immunodeficiencyvirus (HIV), whichcauses AIDS. In many hard-hitAfrican countries, AIDS is the major cause of adult deaths in this age group (see below). Among older adults, cancer and circulatorysystem diseases prevail among those 45-64 years of age, and 65 years and older. Injuries appear to be surprsingly unimportant,though the accuracy of these estimates is doubtful. A large proportion of deaths in all age groups (16-28 percent) are lumped under "other causes' in Table II, reflectingthe weaknessof the data.

Maternal mortality in Africa is unparalleled due to a number of factors, including hemorrhage,infections, obstructedlabor, anaemia,hypertensive disorders of pregnancy,unsafe abortions, and sometimes violence (see Box 1). Problems are exacerbated by infrequent gynecologicalcheck-up and care, tardiness in teatment when infectionoccurs, and higher risks of sexually tranitted diseases due to multiple sexualpartners. In Angola, rates of matemal mortality ranged from 570 per 100,000 live births nationallyto more than 1,600 in areas like Kuando Hubango and Huamb in the early 1990s. 20

TableI. ChildMorbidily by SelectedSocio-Econonuc Characterstics

iax Residence Education Secondary Proportionof Male Female Urban Rural None Prina,y or More alldren witk (%) (%) (%) (%) (%) (%) (%)

(Proportonof ChildrenAffected) Diarrheat Chana 40.8 41.9 44.0 40.3 39.6 43.7 29.3 Senegal 55.2 52.0 48.2 56.7 55.4 51.9 31.9 Zimbabwe 39.5 33.5 29.0 38.9 37.2 34.7 39A

Fevei2 Ghana 37.4 35.4 33.1 37.6 34.5 38.5 31.6 Senegal3 61.9 60.1 46.6 68.9 64.8 48.1 33.3 Zhmbabwe 7.1 7.0 5.7 7.5 8.0 6.8 6.9

Respiratory Pmbems' Ghana5 20.8 20.4 18.6 21.4 18.9 21.9 21.5 Senegal na na na na na na na Zimbabwe7 51.5 47.6 47.0 50A 48.6 49.8 49.6

Notes: 1. Cldren less than 2 years old with diarrhea in the 2 weeks precedingthe survey. 2. Childrenless than S yearsold withfever in the 4 weekspreceding the survey. 3. Data referto malarladuring the lastcold season,0-6 monthspreceding the survey.4. Seenote 3. 5. Severecough or dikult breafig. 6. Damanot available. 7. Rapid or difult breathing. Soarce: 1986-89National Demographic and Health Surveys.

Abortion-relateddeaths are thoughtto be a major cause of maternal mortlity in Africa. Though comprehensivedata on abortionin Africa are lacking,recent data from a studyin Kenya estimated there were approximately75,000 abortions in the country in 1990. Extrapolatingto Sub-SabaranAfrica suggeststhere could be up to 1.5 millionabortions each year in the region. Studies in Ethiopiaand Nigeria further indicatethat almost 50% of materal deaths reslt from complicationsdue to abortion (Rogo 1991).

Africa also has the highest adolescentpregnancy rate in the world. Betweenthe ages of 15 and 19 years, 18 percent of all African girls become pregnant each year, compared to 8 percent in lAn America, and 3 percent in Europe. A survey of 1S to 24 year olds in Uganda revealedthat 7 percent had an abortion (Ageyiand Epema 1992). Early entry into reproductive life increases risk of health problems such as anaemia, malnutition, and sexually transmitted diseases (Wasserheit 1989).

Persistent and New Health Threats

Malaria continues to be Africa's largest and most persistent disease problem. Pregnant women, feuses, and young children are particularly susceptibleto malarial infection and its conseqwences.WHO estimatesthe global number of malaria cases per year at 110 million, with ualy 80 percent of cass occurring in Sub-SaharanAfrica and only 1000 cases in North Africa. 21

Bax 1. Violenceagainst Womenas a HealthfIsue

Violenceagaist womenis a sigpihcantcause of femalemorbidity and morality, leadig to psychologicaltma and depression,njuries, sexualy transmited diseases, unwanted pregnancies, suicide and murder. Violenceagainst women includes childhood sexual abuse, physical and sexualassault, and certaincultur-bound practices, such as femalegenital mutlation, that are harmfulto women. A studyin Kenyafound that 42 percentof womenwere ubeaten regularly' (Raikes 1990). Womenare oftenbeaten or otherwiseabused if theydo notcomply with men's sexual and childbeaing demands. Where spousal consent is requird beforecontaeptives can be obtained,women can be at increasedrisk of violence. In Kenya, womenhave been kmownto forge their parmer'ssignature rather than open themselvesto violenceor abandonment.When family planning clinics in Ethiopiaremoved their requirement for spousalconsent, clinic use rose 26 percentin just a few months(Cook and Maine 1987).

A review of more than 400 studieson the subject suggeststhat malaria is responsiblefor about 40 percent of fever cases, and accountsfor 20 to 50 percent of all admissionsin Afrcan health services per year (althoughonly 8 to 25 percent of peons with malaria visit health services) (Brhkman and Brnian 1991).

Malaria also appears to be worseningin much of Africa, due to resistanceof malaria parasitesto chloroqumeand other drugs. The incidenceof malaria indicatesannual growth rates of 7 percent for Zambia, 10 percent for Togo, and 21 percent for Rwanda. Data for Burkina Faso show a downward trend of 15 percent during the years from 1973 to 1981, but an 11 percent increase per year since then. And hospital data reported for Zambia indicate that mortalityfrom malaria is rising 5 percent per year among children, almost 10 percent for adults (Brinkmanand Brinknan 1991).

The incidence of tuberculosis is rising in Africa due in part to the interactionbetween TB and AIDS, and in part to the breakdownof surveillanceand managementof cases. By some estimates, approximately171 million TB carriers are in Africa, and 10 percent of all deaths occur in children under 5 years of age (WHO 1991b).

AIIDS,Acquired Immunodeficiency Syndrome, is the most dramaticnew threat to health in Africa. More than 8 million Africanadults are estmated to be infected with the AIDS virus, HIV. Of those infected, over 1.5 million Africans are estimated to have progressedto AIDS, although only 210,000 adult and pediatric AIDS cases have been officially reported to WHO.

Geographicalvariations in the prevalenceof HIV are wide among countries (see map at end of report titled, "EstimatedHIV Infections, Sub-SaharanAfrica, 1990"). Approximately one half to two-rds of the HIV infectionshave occurred in East and Central Africa - an area accouning for only one-sixth of the total populationof Africa. The number of HIV infections in men and women is close to equal. Young girls and commercialsex workers are particularly vulnerable. Also, in contrast to malaria and many other causes of excess adult mortality in Africa, AIDS does not spare the elite.

High levels of otber sexually transmitted diseases, such as chancroid, syphilis and gonorrh, and the high rates at which new unprotectedsexal encountersoccur, appear to be 22

TableIV. ne Rank and Share of Maklria,AIDS, and OtherDiseases in the TotalBurden of Diseaseand Injuryin Africansin 1990 Share Share Females (%) Males (%) Malaria 11% Injuries 13% Respiratoryinfections 11% Respiratoryinfections 11% Diarrhealdiseases 10% Malaria 11% Childhoodcluster' 9% Dianteal diseases 10% HIV/AIDS 6% Childhoodcluster' 10% Pernatal 6% Perinatal 9% Maternal 6% HIVtAIDS 6% Injuries 6% Tuberculosis 5% Tuberculosis 4% OtherSTDs 2% OtherSTDs 3% OtherCauses 23% OtherCauses 28% 100% 100%

Note: 1. Pertussis, polio, diphtheria,measles, and tetanus. Source:World Bank 1993e. importantfactors in HIV transmission. Thus prevalencerates of STDs, other than AIDS, are good indicatorsof the potential spread of HIV in countries where HIV infectionrates are still low.

Recent data suggest that the pandemichas continuedto spread, particularly in Southern and Western Africa. Over 600,000 people are estimated to be infected in Zimbabwe, alone. In the major urban areas of Botswana,HIV prevalence has exceeded 18% among adults. In West Africa prevalence among pregnant women m Abidjan is reported to have nsen from 3.0 percent in 1986 to 14.8 percent in 1992. Sentinel surveillancefrom Nigeria shows that the epidemichas spread throughoutthe country. In 9 of the 11 states in which sentinelsurveillance has been instituted among people attendingSTD clinics, prevalence is reported to range from less than one percent to 22%.

The fact that African countriesface such a formidablearray of healthproblems highlights the need for a comprehensiveapproach which can address a wide range of illnsses. Such an approach must aim at reducingthe transmissionof diseasevectors throughappropriately targeted public fwizdsand public health activities. This is not being done to the extent qired in most counties. Much of the excess morbidityand mortality in Africa could be brought under control with technically simple interventions. Tranmission of diarrhoea (the leading cause of death among children) in principle could be dramaticallyreduced if fecal contaminationof drnkig 23 water, food, and the living environmentwere halted. The communicabledisea of childhood including measles, polio, whooping cough ard diphtheria could be controlled by timely vaccinations. The presence of helminthscould be reducedthrough mass chemotherapy. Other parasitic diseases could be containedtbrough measuresto halt the breeding of the vectors that transmit the parasites among their principal hosts or reduce human contact with the vectors. Schistosomiasiscould be controlled if human wastes were kept out of ponds, lakes and rivers.

There is also growing recognitionthat many chronic diseases among adults are not the inevitable consequence of aging but are the result of lifestyles and behaviors that can be changed. All the biologicalmechanisms are not fully understoodand for many chronic diseases such as cancer and coronary heart disease, multiplerisk factors inteact in complexways. Still, informingthe public that reducingdietary fat and salt, avoidingobesity, exercising,sleeping and eating regularly, using alcohol moderately, and avoidingtobacco, has, in some countries, had a major effect on lifestyles and in declinesof some of the leading causes of death (Mosley and Cowley 1991).

A comprehensive approach must also emphasize basic services and essential drugs commensuratewith the epidemiologicalprofile and illnesses incurred. The death rate due to acute lower respiratory infectionsfor examplecould be slashed through the use of inexpensive antibiotics. Yet, more than half of Africans live without regular access to essential drugs. People at greatest risk include:

* Members of particularly vulnerable demographic groups, including the newborn, imfantsand toddlers, and other clients of maternal and child health programs

= High risk groups afflicteddisproportionately by infectiousand parasitic agents

* Poverty groups, relativelydeprived in education, income and nutrition.

That HIV is becomingso widespreadin many Africancounties further suggeststhe need for a comprehensiveapproach, away from short-termcrisis interventionto combatan epidemic, towards long-term health system development with strong STD detection, treatment, and counseling, as well as informationand communicationprograms.

Combatg Demgraphic Prssres and STDs

Africa is a contnent of exceptionallyhigh fertility and very low contraceptiveuse. In 1992 the total fertility rate - or children ever-born to women of reproductive ages - was approximately6.5 children comparedwith about 3.6 children for all less developedcountries. Conruaceptiveprevalence rates were only 11 percent on average in 1990, compared with approximately51 percent for all less developedcountries and 71 percent for more developed counties.

Rapid populationgrowth also exacerbatescritical gaps in basic healthservices, especially when economies are growing slowly or per capita incomesare in decline. Combined, rapid populationgrowth and poor economicperformance are responsiblefor negativeaverage anmal 24 growth rates of GNP per capita for almost Box2 Healh Bents of FandlyPlanning one-half of all African countries between 1965-90.This is one reason why the ratio of Te mostwidely confirmed health benefits peopleserved per doctorin Africaincreased of familyplanning derive from more efficient birh at only half the rate of otherlow and middle spacing.This can be achievedthrough modern income countries over the past 25 years. mehodsof familyplanning, helping women to improvetheir heathinm the processas well as to inrea chans t childrenwill survive. To A consequenceof low contraceptive illustrate, infant mortalityrazes are 69 percent use is that couples are deprived of health higheramong women in Ugandahaving a childless benefits associated with family planning. thantwo yearsafter a previousbirth, than among Birth spacingand the integrationof family those who wait two to three years. lbe same planningservices with maternaland childhood surveyshows that child deaths before five years of health care leads to reduced infant, ageare 27 permt higheramong women who had childhood,niftnalaW mortality (wetheir firstbirth before age 20, tha thoseaged 20 to childhoods and maternalmortality (see Box 29. Inadequatebirth spacing also places women at 2). risk of deaththemselves.

The AIDS epidemic provides an Thatwomen want such services, yet do not additional reason for including family have sufficientaccess to them, is apparentfrom pilannng and STD servicesas part of cos- nationalDemographic and Health Surveys in nine Sub-SaharanAffican countries, which reveal unmet effectivepackages of health care. Various need for such servicesraning from 22 to 40 estimatessuggest that womenwith sexually percentof marriedwomen. Closing these gaps will tansmitted diseases (STDs) are 10 to 50 clearlyenhance the criticalrole womenhave to imesSmore iely to contrat the AIDSvius play as agentsof changefor ber health. than those witout STDs. According to a Fortunately,awarens regaring the recentWorld Bank/WHO study of womenat hazadsof rapidpopuaton grwth has rien greatly a prenatal clinic of Malago Hospital, amongAfrcan policymaers. Many Aican Kampala,Uganda, syphilisand gonorrhoea countrieshave developed, or are in the processof were prevalentamong 11 percen, chlamydia developing,national population policies, and most T among 5 percent, and trichomonas Africangovemnment leaders are signatoriesof vaginalis among 37 percent. Health care seminaldeclations by parlm riansin support faciities should be orgae to prevent, of slowingrpid populationgrwth. TheReport of facilites shudbnognzd t oetseuUprevnst,e fth SouthCommission, writte by leadersfrom diagnose, and treat sexually trananitd Nigeria,Ivory Coast, Mozambique, Zimbabwe, and diseases at any contact betweenclient and Senega took a particularlystong stand on provider, whether the consltation is population. Chairedby Julius K. Nyerere of motivatedby an episodeof childillness or for Tanzania,the Commissionconcluded that not only other reasons do high rates of popation growth reduce the resourcesavailable per capita,making it difficultin somecountries to maintainsubsistence levds, but Persistenceof high fertilityrates also alsolimit the abilityto raiseproductivity. meansthat growthof particularlyvulnerable demographicgroups is likely to outstripthe capacityof privateand publichealth care providers. Rapidpopulation growth produces an age stucture that is heavilyweighted towards infants, toddlers,and womenof reproductiveages. Between1990-95, approximately 75 millionnewborns will join Africa'spopulation, 14 million each year. As notedpreviously, this has epidemiologicalimplications. It is preciselythese groups that are most susceptibleto the major killers in Africa - penatal problemsand infbetiousand parasiticdiseases. 25 World Bank projections indicate that Figure 1. PopuladonGrowth in Africa, 19904025 at present trends, the number of Africanswill grow from 502 million in 1992 to 634 million by the end of the decade, and to over 1.2 1400 billion by 2025. Under this scenario, in less g 1200 2 than 10 years, another 130 million people 1000 933 wiU be placing demands on a health care , 800 626634 system that is already unable to fulfill the ¢ 600 502 502 demands on it today; and, in a little more i 400 than a generation, policymakerswill be 200 confronted by health demands from a 0 populationmuch more than twice the current 1992 2000 2025 size. Year

Yet a different scenario can also be | RapidFortility Decline 0 StandardFertility envisioned. Africa's population could grow Decline far more slowly, to the extent there would be pproximately 8 million fewer people than Source:Statistical Appendix. under current fertility rates, by the end of this decade; and 270 million fewer by 2025 (see Figure 1). By 2025 Africa's population growth rate would fall from its current level of 3.0 percent per year to 1.3 percent per year (see Figure 1). To accomplishrapid fertility decline, family plannig would have to becomean integral part of health care delivery, to the extent that contraceptiveprevalence rates rise from about 11 percent, on average, throughoutAfrica today, to about 45 percent by the end of the decade and to 75 percent by 2025 (McNamara 1992). More than half of this increase could be achievedsimply by accommodatingunmet needs of 20 to 40 percent of sexually active women who currently want to limit their ferdtlity,but do not have access to family planning.

Implications of current and prospective demographictrends for better health in Africa therefore are:

* Planning for better health in Africa will be hazardously incomplete unless family planning services are fully integrated with maternal and child health, including appropriate informationcampaigns on STDs, and outreach to the community. As a sign of progress in this area, govermmentsof seventeenSub-Saharan Africa countriescurrently have official population policies, nine having been adopted since 1990 (African Population AdvisoryCommittee 1993b).

* The importance of raising contraceptiverates sharply throughout Africa cannot be overstated, especially over the next 10 years when reduced fertility will have a major impact on "populationmomentum" and the age distribution. Some countries, such as Botswama,Kenya, Mauritius, and Zimbabwe,are moving aggressively in this area. At the very least, this will help provide "breathingspace" for governmentscurrently unable to meet gaps in demand for basic health services. 26 * Even withprogressive family planning,population momentm in most countries is such that cost-effectivepackages of basic and health services will be urgently required for rapidly growing numbers of people.

Proposals in this report - detailed in Chapters 3 and 9- discuss the resources necessary to help achieve these goals. PART II: HEALTH AND DEVELOPMENT

Economic Costs of Illness

The effects of poor health go far beyond physicalpain and suffering, to the extent that learning is compromised, returs to human capital diminish, and environments for entepeneurial and productive activities are constrained. And, in view of the demonstrated inmportanceof humancapital to economicdevelopment, it comesas little surprisethat no country has atained a high level of economicdevelopment with a populationcrippled by high infant and matrnal mortality, pervasive illness of its workforce, and low life expectancy.

Evidence showing that poor health imposes immense economic costs on individuals, householdsand society at large is strong worldwide. A selectionof findingsmakes a compelling case that better health can contibute positivelyto economicoutcomes in Africa:

e Householdsurveys in eight developingcountries show that the economiceffects of adult ilness are substantal; three of the four studycountries with the highest incidenceof adult illness are in Africa - te d'Ivoire, Gbana and Mauritania. In M6ted'Ivoire, 24 percent of the adult labor force experiencedsome illnesslinjuryduring the monthpnor to the survey, and 15 percent became inactive due to their illness/injury. Those inactiveexperienced a loss of five full days of work, on average, and costs to treat their illness/injuryamnounted to about 11 percent of their normal monthly eangs. Bearing in mind the adjstments made by others and the cost of treatment, the economiccosts of illnessequalled almost 15 percent of per capitaGDP. The loss of income from illness is similar in Ghana and Mauritania. Given the slow or even negative rates of growth of per capita GDP in many Sub-SaharanAfrican counties during the last decade, the loss of 15 percent of GDP on a per capitabasis takes on immensesignificance (see Table V).

* Studies of malaria in Rwanda, Burkina Faso, Chad, and the Congo suggest that the direct and indirect cost of an average case of malaria in Sub-SaharanAfrica is equivalent to about 12 days output, on average. Accordingly,the anmualeconomic burden of malaria has been esdmatedto be $800 million in 1987, and is projectedto rise to $1.7 billion by 1995. The economiccost of malaria representedabout 0.6 percent of GDP in 1987,and is projectedto rise to 1 percent of GDP by 1995 (Shepard and others 1991). By c, o iparison, the latter figure exceeds average governmentexpenditures on health in several Sub-SabaranAfrican counties during the mid-1980s.

* In Nigeria, Guineaworm has had multipleadverse consequences on health, agriculture, school atendance, and the overall quality of life of affectedcommunites. In 1987 2.5 million Nigerians were infected, with temporary inapacitation for periods of 1 to 3 months. A 27 cost/benefit study of rice production TableV. EconomicBurden of Illness, Three revealedthat, apart from finance, Guinea Couties worm is the leading constraint to rice production;that approximately 12 percent LaborForce Cated'hoire G&hna Mawvoma. of person days in rice production are lost Aged20to 59 Years (1987) (198889) (1988) due to Guineaworm; and that days lost Workersxperiencin translates into more than $50 million llness/Iury(%) 24.A 44A 18.4 worthof rice production. The benefitsof WorkrsInactive due to implementing a worm control program "'" (%ury) 14.8 26.4 17.2 wereestimated to exceedcosts after only AverageWork Days Lst to four years(UNICEF 1987). UlnjuredWorkers 8.6 4.8 9.4 Shamof Norml Monrly Diseases such as onchocerciasis EarinsUsed to Tret and malariaare location specificand have lUness-njury(%) 10.9 6.7 17.6 been shownto discouragesettlement on Cossto nessInjury . .'. anddevelopment of fertileland. By some AveragedAcrs AU Workers accounts,trypanosomiasis has rendered up AverageIncome Loss per to one-thirdof Africaunsuitable for cattle LaborForce Member (%) 6.4 6.4 6.5 raising in the past, and has aggravated nomeLossas Perent of protein deficiencyproblems (KamarCk and percapitaGDP (%) * 15.3 13.5 16.1 World Bank 1976; Wells and Klees 1980). Onchocerciasishas beenshown to Note: * Incomeloss as a percentof percapita GDP is higherthan contribute to the depopulation of river incomeloss per laborforce memberbecause, in te fomer valleys in Nigeria (Bradley 1976) and in measure,e level of per capitaGDP isreduced by pooling wohvorkersandnon-workers. Ghana (Hunter 1966). Malaria and trypanosomiasisare acknowledgedfactors inhibiting migration and resettlementto new lands in Uganda.

* Even though it is far from the most prevalent disease in Africa, AIDS will have immense economic consequencesbecause it is fatal and primarily affects adults in their most productive years. Mortality from AIDS will lower the incomes and well-being of affected households- leading to higher levelsof malnutritionamong children, lower schoolenrollments, lower consumptionlevels for survivorsand higher morbidityfor the rest of the household(Over et al, 1989). Household savingsand productiveassets are likely to be liquidatedto pay for medical care and funerals. AIDS mortalitymay have particularlyharsh impacts on women, as in many societiesthey are not entitledto inherit the propertyof their deceasedhusbands. Thus, the AIDS epidemic will create new pockets of poverty and leave large numbers of surviving family members, such as orphans and the elderly, with no means of support.

AIDS wiU also have a broad impacton African economies. Householdsand the health sector will be faced with potentiallyhuge treatmentcosts prior to AIDS deaths. Figure 2 shows the potential cost of AIDS treatmentif all persons infected in selected countries had sought and received health care. The cost of tatn existing AIDS cases in Rwanda, for example, is potentially the equivalent of 60 percent of the public health budget. In severely affected countries, the work force is likely to become younger, less experienced, and less tained. In Tanzaniaand Uganda, AIDS has already increasedabsenteeism and lowered the productivityof the work force by killing some of the most skilled labor. Most models of macroeconomic 28 imact suggest that adut deaths from AIDS will cause per capita economicgrowti to be lower than it would have been in the absenceof the disease. (Ainswordhand Over 1992, World Bank 1991i, African PopulationAdvisory Committee 1993c).

* Dissavingand borrowingoften take place at the onset of illness, to finance medicalcare and maintain consumption. West African households suffering from onchocerciasis, for example, used assets like bridewealthto financemedical care (Evans 1989). In CMted'Ivoire, averagemedical expenditures by householdsat the time of illnessexceeded full-time employment earnings - at the local minimumwage - lost during illness (Corbett 1988). Sale of livestock and land has also been frequentlycited as a coping responseto consumptionshortages (Over and others 1991); in fact, in coastalKenya, ill-healthwas the reason for selling land in 24 percent of land transactions(Chambers 1982).

* In addition to the direct costs of obtainingtreatment and the indirect costs of foregone earnings from days of work lost, the costs of 'coping mechanisms"adopted by the family, community and employer can also be substantial. To illustrate, among 250 Sudanese tenant families that became il due to malaria and schistosomiasis,(El Takir and others 1986) unaffected family members took time from other activitiesto preform the work functionof the ill to maintain production. Other studies of malaria also found that decreaseddays worked by the affected individual were at least parially compensatedfor by other members of agricultural households(Conly 1975; Castro and Moakte 1988). And in urban areas, employerswho suffer from high absenteeismdue to employeehealth problemsmust sacrifice specializationand thus deprive their enterprise of many of the benefits of mass production (Over and others 1991).

FIgwre2. PotentraAIDS Treatment Cost as Percentof Totaland GovernmentHealth Expenditure

70 (Various years 1 987-1 989)

_ 60 2. "-I m6......

20 . o.. _......

w *------|---...... --= ------...... Io0 .,......

_ Zmbabwe KAya Mao Tar mbd Rwanda Counties AieTota Heath Etupeatr AIDS/Gavmni Heath Exwme

Somre. Ainsworff and Over IM9. 29 The relationshipbetween poor health and economicactivity is biguous. By extension,improved health can be expectedto havea positiveimpact on theeconomic well-being of familiesby loweringcosts of treatmentfor dsease, reducingdemands on familymembers to care for the ill or for their survivors (for example, orphans), and reducing labor turnover and the loss of key sklls and experienceto employers.

Creating an EnablingEnvironment for Health

Soundgovernance is essentialto creatingan enablingenvironment for better health. Governance,as it affectsthe rroundingof householdsand communities, has manydimensions that go well beyondstrictly political issues. The extentof the involvementof beneficiaresin the designand managementof healthpolicies and programs,decentalization, and autonomous local managementof health services, reflects governmentattitudes towards appropriate goverance in bealth. The designand definitionof publicexpendiue programsfor healthis anotheraspect. Enormousbenefits could, for example, be gainedby reducingexcessive military expenditureso as to expandpublic health activitiesand other social services. One study observedthat whenthe shareof healthservices in twentydeveloping countries fell, on average, by nearlyone quarter,from 5.5 to 4.2 percentof cental governmentexpendiues between1973 and 1986,defense expenditures climbed, on average,from 12.7percent to 15.2 percent- an increaseof one-fifthin a publicexpenditure category that was alreadythe sigle highest. This sectionconsiders, in fuirtherdetail, the followingaspects of theenabfing environment for health: incomeand wealth; water supply and sanitation; food and nutrition;female education; roles and statusof women;culumre; and the roles of households.

Income and Wealh.

A cursoryinspection of the worldhealth picture suggests that the singlemost important factor determiningsurvival is icome. Sub-SaharanAfrica, with an averageper capitaincome of $340, has an averagelife expectancyof 51 years, whileNorth Americawift a per capita incomeof about$20,000 has a life expectancyof 75 years on average. Indeed,the higher a country'saverage income per capita,the morelikely its people are to live longand healthy lives. Yet a cental messageof this study is that even whin existinglevels of per capita income,health in Africacan be dramaticallyimproved by appropriatehealth and development strategies. Householdactivites and publicfunds can be directd moreeffectively to createan enablingenvironment for health. As a public health activity,for example,households and communitiescan be educatedabout the immenseimportance of health determinantsthat lie outsidethe formalhealth sector.

That incomeis not the sole determiningfactor in health status is apparentfrom an analysisof cross-counryvariations in life expectancythat simulously assessesthe impact of incomeas wellas other influences.Only one-bhalf of the total gain in life expectancyover a 30 year periodfrom 1940to 1970could be accountedfor in terms of changesin per capita income,adult literacyand calorieintake (Peston 1980 and 1983). Equallyimportant is to realizethat wealthdoes not necessailybring health. Oneof the bestperformers - world-wide - is China,which has reducedits malechildhood mortlity rate to 40 with a per capitaincome of only $370. This is less thanin Thailandwhich has a per capitaincome of $1,400,as well 30 FNm 3 Per Capita Income & Under 5 Mortality in 8 Sub-Saharan African Countries 1990 2600 240 ' 220 MaIwi t200 Nigeria i1 Eao '.GCate dalvore

La 140i b ra.66 !120-

60-

40 kreeo e - China Zitmbbwe 20 wfthOhfne:rm.38 w&=t hWo*a: rg.66 160 200 260 300 360 400 460 600 60a 800 650 700 760 800 Per Capita Income ($)

as in Saudi Arabia with a per capita income of $7,000.

Figure 3 further shows that the childhood morality rate of males under 5 years old in Zimbabweis approximatelyone-half that in CMted'Ivoire, even thoughZimbabwe's per capita income is lower. And in Kenya, with a per capita income one-halfthat of CMted'Ivoire, the childhood mortality rate is again lower, at 112 per thousand, compared with 144 for C6te d'Ivoire.

To explore why a few poor developingcountries and regions have managed to achieve such remarkablegains in health, the US based RockefellerFoundation convened an international conference in Bellagio, Italy in 1985 on the theme "Good Health at Low Cost" . Selectedfor in-depthanalyses were China, Sri Lnka, Costa Rica, and the state of Kerala in India. Although Kerala was among the poorest states in India with a per capita income of $160 in 1982, it had already achieved a life expectancyof 69 years. The conferenceconcluded that good health in poor countries can be achieved if there is a political commitment to equity, translated into policies and programs that assure wide accessto basic health services,education, and food. The four countzycase studies indicatedthat to guarantee access to health care, governmentsmust work to overcome the socialand economicbarriers that can exist betweendisadvantaged groups in the population and medical services. A common characteristicin these countries was that their approach to a specificdisease problem, such as diarrhoea, was multifacetedinvolving social and environmentalinterventions as well as the introductionof medicaltechnologies through a well-managedand accessiblehealth system. 31 Fge 4

SERVICESCCONTRIBUTING TO HOUSEHOLDHRALTH

SAFEWATER POODSECtIRnFYHTH FAMLY

Figure 4 places this commitmentin perspectiveas it relates to the simultaneoususe of other inputs known to impact on health at the householdand communitylevel. The kinds of benefits involved can be illustrated with regard to environmentalservices (water supply and saniton), food security and nutrition,education, and culture.

EnvironmentalServices

Safe water is an essental pillar of sustainablehealth for rural and urban populationsin rich and poor countries alike. Yet large shares of the populationare deprived of safe drinking water in many African countries, particularly in rural areas. In Ethiopia, Mali, and Uganda, for example, less than 25 percentof the populationhave accessto safe drinkingwater, and most live in urban areas. Poor sanitationand disposalof fecal matter complicatematters, particularly in nrual areas and peri-urbanslums where seepage can contaminateponds, strams, and rivers (see Box 3).

A review (Esrey and others 1991) of findings from 144 studies revealed that improved water supply and sanitation often reduces child diarrhoeal mortality by 50 percent, and somedmesas much as 80 percen, dependingon the type of interventionand on the presenceof risk factors such as poor feeding practices and maternal illiteracy. Improvementsin the rural water supply in Africa have resulted in a remarkablereduction in the nunber of cases of Guinea worm. In Nigeria for example, there were 640,000 cases reportedin 1989,declining to 282,000 in 1991 as a result of a combinationof improved water supplyltreatmentand education.

It is also evident that improvedexcreta disposal has a major impact on health, as does improved personal, domestic, and food hygiene. According to one study, improvementsin excret disposal reduced diarrhoeamorbidity by 22 percent as comparedwith improvemen in water quality (16 percent) and water availability(25 percent) or both together (37 percent). Studes in Lesotho recorded a 36 percent reduction in diarrhoea related to improved excreta 32

Box 3. TheEnvironental Dimensionof UrbanHealth: The Caseof Accra

TheAccra MetropolitanArea (AMA)has an estimated1990 populadon of 1.6 millionthat is expectedto grow to more tha 4 millionby the year 2020. Accra is chamcterizedby overcrowding,inadequate municipal services, and substndard housing. Amost half of the urban popubdon have incomes below the World Bank's absolute poverty threshold. In this environment,cholera cases are increasingsteadily: 113 cases reportedbetween July and Sptember 1990 rose to 354 in Novemberand 239 in the first two weeks of December,mostly in low-incomeresidential areas. Almost half of the 36 signfant diseases tiat are reported in Accra (malaria, measles, enteric fever, food poisoning, tuberculosis,diarrhea, leprosy, polio, guinea womn, typhus and cholera) can be linked to the following problems: a. Overcrowdingin economicallydepressed neighborhoods - for example, with averageoccupancy rates of 4.4 personsper roomin the low-incomeresidential area of James Town- facilitatesthe sprWadof communicabledisease and puts enormouspressure on sharedresources sucb as kitchens,bathrooms and laundries. Poor drainageforces sullage, or waste water discharge, to flow throughholes in householdwalls onto the ground outside and gives rise to stagnant poos for mosquitosand moist soils in which hookwormova readily develop. Data fom 1988 showmalaria to be the single most widespreaddisease, with 92,046 reportedcases in the AMA, or over 40% of diseases report at outpadent facilities. b. Wher excreta disposal systems are poorly developed- especially in slums, squatter setdementsand peri-urbanareas withoutconvenient access to public facilities- defecationin public space, beaches and watercourses is common. c. In slum areas where water is ftequently purchased and/or water supply is iregular, daily per capita consumptionis about60 liters, or less dan half of middle incomeneighborhoods. White water qualityis generallygood at the source, its risk of contaminationduring transport, and low likelihoodof beingboiled for sterilization,raises the incidenceof water-bornediseases. d. Until recently,illegal garbagedumps have chokedthe roadside,drains and open spacesaround households, and provided breeding grounds for nsects and rodents. Incineratng refuse has resulted in air pollutionand acute respiratorydiseases within the conmuity. e. Poor hygienicfood preparationand handlingin Accra lead to higher prevalenceof coimukicable diseases, as noted in: (i) a 36% prevalenceof diarrheaamong childen in householdswhere their handswere not washedprior to eating; (u) swarmsof disease-spreadingfies aroundstreet side foodvendots and small restunts hop bars); and (m) the absence of enforceablelegisladon on food qualit and hygiene. f. Accra's high temperanuresand considerablerainfall also favordisease vectors, of whichthe most problmatic are malaria-rnsmitting mosquitos, houseflies, cockroaches, bed bugs, and lice; rodents are also prevalent. Unforouately, toxic pesticidescan also have negativehealth consequences. These environmentahealth problemsarise from a combinaionof inadequa inratuce and services, lack of setdementsplanning, and culual pracdtes. The resultdg economiccost 70% of nadonal expenditureon heal problemsin Gham has been attributedto environmentallyreated diseases- taking accountof lost labor, and the cost of resoucs (doctors,nurses, teWnians, adminis_ttion,equipment, and drugs). disposal (Daniels and others 1990). The study concludedthat interventionsto viproveexcreta dips would produce larger impactsthan improvementsin water quality, particularlyin highly contaminatedenvironments where the prevalenceof diarrhoea is high.

Fecal-oraldisease transmission, on the other hand, becomesmore importantas population densities increase. A study (Bradleyand others 1992)comparing infection with helminthsin an urban slum in Lagos and a nral area showedthat 95 percent of schoolchildren in the study area were infected, as compared with 52 percent in the rural area. Differences were due to the population density, low levels of hygiene, poor drainage and absence of exereta disposal facilities. Other sanitationinterventions such as solid waste management,sllage disposal, and drainage are importa in urban areas and all have importantimpacts on health (Box 3). 33 Food and Nutrion

Malnutritionunderlies more than one-third of infantand child mortalityin manyAfrican countries(McGuire and Austin1986) and 20 to 80 percentof matermalmortality. In Tanznia in the late 1980s, half of all children under five years were malnourished. Protein-energy malnutritionnutntional anaemia, vitamin A deficiency,and iodine deficiencydisorders have beenidentified as the mostserious problems in Africa. Inadequatequality and quanity of food intake(including breastmilk) causes growth failure, decreased immunity, learning disabilities, poor reproductiveoutcome, and reducedwork productivity. Breastfeeding also reducesthe risk of infection. (see Box4).

Accordingto FAO estimates,the averageper capitadietary energy supply had increased worldwidefrom 2000 in 1983to 2600calories per dayby 1985,but currendyonly 2100 calories are availableper personper day in Sub-SabaranAfrica. Tboughincreases in incomesof the poor may lead to increasesin calorie consumptionover and above the generalpopulation, improvedincome alone cannot be expectedto raise calorieintake. Nutritionpolicy can make a difference,however, by offeringnutrition education parallel to income-generatingactivities so as to influencepurchasing and feedingpractices, providing women with fmctional literacy classesusing nutitional themes,and targetingfood subsidies.

Box 4. Nutriton and HouseholdHealth

Nutitonal deficienciesreprest an exremelysenous health problem in Africa. Stuntmg,which reflects chronic, longsmding undernutnron, is movewidly prevalent that wasting, which refects acute mntritionalcrisis. A series of demographicand householdssurveys in the 1980s revealed more than 25 percent of children from tee to thirty-six months old to be stunted, compared to only 2 percent in a rerece population. Undenwitlonamong Children Age 3 to 36 MonthsIn Seectd AfricanCounris. 1986-1991

Burundi 148 Uganda 44 Ngeria 138 Togo 31 Ghana 30 Zimbabwe 30 Mali 124 Senegal 23 Cameroon 23 . ~ ~~~~~~~~ I --- - 0 6 10 15 20 25 30 35 40 45 S0 Percent Seim: adaptedfrom US Agencyfor Inntional Deveopment1991, FPure 2, p.S.

Poor feedingpractices are at the heart of child nutition issues, reflectingonce again the iportanc of householdbehavior for health improvement. WHO recommendsthat all infants be breasdte exclusively until they are 4 to 6 months old, but in Nigeria, for e=amWle,only one percent of such infant are exctusively breastfed. In conta, in Uganda, exclusive breastfeding in this period is 70 percent, despitethe fact that older ifnts and young childrenae widely undernourished. Similarly,WHO recommendsthat, by the age of 6 months, all infanu shouldreceive solid foodsin additionto breast milk. Yet, only 45 percent of infan fiom 6 tO 9 months old in Mali, and 57 percent in Ghana, receive breast milk and solid foods. 34

Nutritionalrehabilitation is best doni as part of a basic package of health services - as elaborated in Chapter 3. In Tanzania, for example, the Iringa Nutrition Program and child survival and development programs in other regions have succeeded in teducing severe mlnutrition from a pre-program level of about 6 percent to a post-programlevel of 2 percent. In Botswana,supplementary feeding programs achieved83 percent coverage as compared with 6 to 10 percent in other countries, largely because of wide primary health care coverage.

Along with increasinghousehold food security, nutrition social marketing can also be used as a key public policy interventionthat can help to generateconsumer demand for nutritious foods, healthy child growth, and complementaryhealth and nutriton services. Such policy for example can emphasize the mmnunologicaland nutritonal benefits of breastmiLkin African countries, where UNICEF reports the proportion of infants0 to 3 months exclusivelybreastfed to vary from about 2 percent to 89 percent. A breastfed baby is only one-twentiethas likely to die from diarrhoeal diseases and one-quarteras likely to die from pneumoniaas a baby who is bottle-fed (UNICEF 1992a).

Female Education

The education of females is so important to health imp-ovement that it merits special atention in any reformulationof health policiesthat aim to imp- we health outcomesrather than solely the delivery of health care services. More educated women marry and start having children later, make better use of health services, and make better use of informationthat will improve personal hygiene and the health of their children. Household surveys in Ghana, Nigeria, and Sudan show that the single most importantinfluence on child survival is the level of a mother's education (see Figure 5). Data for thirteen African countries between 1975 and 1985 show that a 10 percent increase in female literacy rates reduced child mortality by 10 percent, whereas changes in male literacy had little influence(World Bank 1993e). The effect of a mother having attained secondary level education may contribute to lowering the infant mortaliy in a given family by as much as 50 percent. Finally, having an educatedadult female population can significantlyincrease the effectivenessof governmentexpenditures on health; withoutan educatedfemale population, the impactof governmentexpenditures on health appears to fall dramatically (Bhargava1992; Stombergand Stomberg 1992).

Female participation in primary and secondary schools has improved significantly in Africa over the past 30 years, but has a long way to go to deliver the kinds of health benefits reviewed above. At the primary level, femaleparticipation rose from 24 percent in 1960 to 69 percent in 1990. At the secondary level it increased from 1 percent in 1960 to 16 percent in 1990. (Over the same period, male participation rose in primary education from 46 to 83 percent and in secondaryeducation from 4 to 32 percent.) These level compare poorly with the rest of the world. In 1985, for example, female primary enrollmentin Africa was 58 percent, compared with 92 percent for the low incomeeconomies as a whole. Furthermore, the chances for girls to pursue higher levels of schooling worsen as they progress from grade to grade. Seventy-sixpercent of girls start school, comparedwith 86 percentof boys, but only 36 percent of the girls finish primary school, comparedto 44 percent of the boys. Of the girls who finish primary school, only 41 percent condtne to secondaryschool, and - of this group - only 18 percent finish seondary school. These low levels of atainment are further reflected in the median literacy rates among African countries, which were only 30 percent for females in 1990, 35

Figure S. Under-FiveMortalty and Levelof FemaleEducation, SelectedCounries, 1985-90

250

§100 I i - ii _ _

Senegal Uganda Ghana Togo Sudan Kenya County

| * None ll* PrimaryComplete O Secondary& Plus]

Source:Compiled from Demographic and HealthSurvey data. as against 52 percent for males. (Hartnett and Heneveld 1993)

Special Roles and Status of Women

Women occupy a special place in efforts to improvehealth because they participate in, and often manage, many activities that impact on the health and well-beingof their families. For example, women perform an estimated 60 to 80 percent of all agricultural labor in Sub- Saharan Africa, thus placing them in an importantposition to contribute to food security and nutrition. Women are also largely responsiblefor fetching water and fuelwood, thus placing them in an importantposition to assure safe drinkingwater and adequatecooking and preparation of food. In Kenya, for example, 89 percent of mral women over age 14, but only 5 percent of the men, report fetching water and fuelwoodas one of their normal tasks (Cleaver and Schreiber 1992).

Research on the determinantsof infant mortality further shows that, "... the mother is the most important health worker for her children." (Schultz 1989). This conclusionnot only reflects the strong correlation between female literacy and lower infant mortality, but agrees with studies of governmentexpenditures on health showing that their effects are likely to be greater when they interface with an educated female population (Bhargava and Yu 1992; Stombergand Stomberg 1992).

Time availabilityis one of the most importantconstraints affecting the ability of women to produce health. Surveys in Central African Republic, Cote d'Ivoire, Sudan, Tanzania, and Zambia show that rural womenin Africa work more than ten hours a day, even withoutcounting child care and health care responsibilities(Leslie 1987). Policymakersneed to bear in mind that the supply of health care services, or even pharmaceuticals,may not lead to use if it does not respond to women's sense of priorities and imposesunacceptable time costs for travel or time away from work. 36 Culture

Africans have a long tradition of placing a high value on health care since good health is sen as the basis for developmentand societalgrowth. Traditionalnotions of disease and their origins are well establishedand can determinewhen, where, how, or even if, treatmentwill be sought. African traditional societies categorize diseases and illnesses as man-made and/or "spi y" induced. For instance, smallpoxamong somecommunities in BurkinaFaso, Niger, and Chad was considered of naural origin and not of sacred or supernaural sources. As a result, people practiced a combinationof vaccinationsand isolationof the sick. In contrast, in the Groun and Yoruba regions of Beninand Nigeria, respectively,smallpox was consideredto be the manifestationof a supernaturalpower, Segbata-a punishmentinflicted by the goddess on those who had mcured her anger. Instead of being isolated, the sick person was talen from one place of worship to another in an effort to appeasethe goddess and, being in constant contact with the worshippersof Segbata,spread the diseaseunnecessarily to a greater numberof people. Yaws is not considereda disease in some parts of Cameroon, and goiter, which is an indication of a malfunctioningthyroid gland, is not regarded as an illness in many traditional Nigerian communities.

So important are culture and ethnicity to health outcomes, that even if strucral constraints are removed in the health sector, desired results are unlikely to be achievedunless the cultures of communities,of health policymakersand plamners,and of providers of bealth cae are taken into consideration. Indeed, increasedattention by policymakersto these issues increases the chances of success in implemen policy. If this is done, providers will be less likely to display an ambivalencetoward the use of traditional medicine;and users will be less likely to vacillate betweenmodern and traditionalmedicine (Amadi 1992).

Householdsat the Center

Slowing the tamission of disease, and curing illnesses,will require a wide range of services, as shown above, includingsafer drinkdngwater and sanitation, increasing levels of educaton, improved food security and nutrition, family planning, and health care. The effectiveness of these services in interrupting the spread of disease and curing sick people depends critically on efforts by the individualand the household.

For drinking water to be safe and beneficial,households must be able to disdnguishsafe from non-potable water, filter water when necessary, and ensure that their members rely exclusivelyon these supplies for consumption. For example, a social marketing strategy was used in the Idere project in Nigeria to integrateprimary care and use of nylon filters for drinkg water, to prevent amsmissionof Guinea worm. Addressig malnutritionrequires appropriate storage, preparationand sharing of food. The managementof individualfood suppliesand use of food resourcescan only be undertaen at the householdlevel, occasionallywith community support.

Self-care for illness can be promoted by ensuring that householdshave sound health informationavailable and, in schools, suitablehealth education. The importanceof self-care is indicated by a study in a Nigerian town which revealed that over 80 percent of the illness episodes over a twelve month period had been managed by the household (Brieger, 37 Ramnakr l, and Adeniyi1986). Finally,without the active involvementof householdsin identifyingsymptoms of illess, providinginformation on the historyof the illnessto healthcare providers,and complyingwith treatmentplans, even the best individualhealth care will have no impacton illness. Increing levelsof educationwill contributeto the understandig of scientificrationale for care.

Engaginghouseholds and communitiesin health, and respondingto the health-related demandsof the public,must thereforebe centralto the concemsof Africangovernments for healthimprovement. How householdcooperation affects the outcomeof an intervention,and what can be done to ensureit, are importantquestions to be addressedin formulatinghealth policiesand programs. Importantimplications for healthin Africaare:

* Householdsand communitiesmust be recognizedas beingat the heart of the health system, not merely as recipientsof medicalinterventions but as participantsin the design, fundingand managementof a widerange of interventionscutting across many sectors.

X Provisionof soundhealth information, in formsthat are readilycomprehensible by and acceptableto households,is a cental responsibilityof Africangovernments.

* The impactof improvedhealth cae serviceson healthoutcomes of householdsand communitieswill either be greatlyfacilitated or constrained,depending on conditionsin the socio-economicand culturalenabling environment. PART EmfiCOMPLETING THE AGENDA AUacross Africa, health policymakers, planners, and researchershave been hampered by the lack of accurate,reliable, and timelydata on householdsand communities.As a result it is extremelydifficult to profilethe healthstatus, needs, behaviors and preferencesof different demographicgroups within counties, let alonethe epidemiologicalcharacteristics of different socio-economicgroups. ILackingsuch information,health problems tend to be "invisible"or "movingtargets" from a plming perspective.Moreover, household behaviors including self- diagnosis,self-treatment, willingns and abilityto pay for help from traditionalhealers and modem practitioners,remain poorly undestood. The entire process of monitoringand evaluatingprogress is underminedas a result. Systemsfor the registation of births and deaths are very weak across Africa, thus deprivingplanners of a timelytally of birthsand deaths, by characteristicand by geographicarea (AfricanPopulation Advisory Committee, 1993a). Only relatively small island nations have vital registraon systemsthat have been classifiedas "complete"(meaning more than 90 percent complete).These include Cape Verde, Mauritius, Reunion, Sao Tome and Principe, St. Helena, and the Seychelles.Several other African countries have vital registratonsystems but esmates of completenessof death registrationare only 10 to 25 percent. These includeBotswana, Djbouti, Guinea-Bissau,Kenya, Rwanda, Sierra Leone, and Togo. Since1984, Demographic and Health Surveys(DHS) have been undertakenin many countries,with 18 sub-Saharan countrieshaving conducted a DHSby 1992. In additionto completeinformation on fertilityand 38 contraceptiveuse, thesesurveys are an invaluablesource data on thehealth status of womenand children. By 1990,most countries of sub-SaharanAfrica had conductedpopulation censuses, thoughmajor bottleneckscontinue to underminetimely processing and disseminationof data. Growingmunbers of countries,however, including Burkina Faso, Niger,Tanzania, and Uganda, amongothers, are makinggood use of microcomputertechnology to produceresults in record time. Knowledge-basedaction for healthhas been furtherundermined by failuresto analyze data that has been collected,and to use the resultinginformation effectively (Lucas 1992). In some cases, healthinformation has been suppressed,whereas in others, epidemiologicaland other informationhas been ignored in drawing up priorities for action. Suppression of informationon the AIDSepidemic during the early 1980's is a casein point.

A first step, therefore, in completng the agendafor better health in Africa is to support essentialdata collection,analysis and researchon prevailingpatterns of morbidityand mortality, with special attentionto variationsin diseaseand illness by gender, and among socio-economic and culural groups. Data are particularlyscant on variationsin health status between ethnic groups in most countries, as well as the extent to which these variations are attributableto ethnicaly distinct culturalpractices, residentialpatterns, or variablesof a morepolitical nature. Given the concern with governance issues in Afica, its diverse ethnic background and the challenge of promoting equity in multi-ethnicsocieties, the demandfor such data is likely to grow in the fure. Actionfor better health in Africa is likely to be stalledif the commitmentof health plamersand policymakers to principles,declarations, and initiatives for pimary andpreventive healthcare remainsmore symbolicthan real. Most of the problemsdescribed in this chapter have been the subjectof nationaland internationalconferences, replete with calls for action. In 1978,the AlmaAta Declarationfocused attention on primaryhealth care, stressingthe moral imperativeof reducing gross inequalitiesin health status amonggroups of people, while acknowledgingthis couldnot be achievedwithout efforts to providecritical public health goods andservices, such as safedrinkng water, basic sanitation, maternal and child health care, family planningservices, beter nutrition,education, and so on. The Declarationgoes on to emphasize that theseaims can only be achievedthrough cooperation of the healthsector with othersectors andprograms, including public works, education, communications, and community development. In 1980the AfricanCharter for HealthDevelopment was signed,to implementthe call for Healthfor All in the AlmaAta Declaration. In 1985 in Lusaka,the Africanministers of health ratified the AfricanHealth DevelopmentScenario in Three Phasesdeveloped by the African RegionalOffice of WHO, AFRO. In 1987 at Addis Ababa, this approachwas unanimouslyratified by AfricanHeads of Statemeeting at the Organizationof AfricanUnity. By 1990these themes received further endorsement by manyAfrican govemments at the World Summitfor Children,sponsored by UNICEF. At this summitmeeting, governments agreed to drawup NationalPlans of Action(NPAs) covering, among other concerns, primary health care, familyplaming, environmentalsanitation, nutrition, and basic education(UNICEF 1990b and 1991). Prior to 1990, this study was able to fid comprehensive,operationay-relevant health policy statement by only seventeengoverments. Of these, only five focusedon problemsin the enablingenvironment for healthand outlinedproams to correctthem - Botswana,Mali, 39 Nigeria,Swaziland, and Tanzania. Followingthe WorldSummit for Children,NPA processes are underwayin many countries. WHO reports, as of mid-1993,that twenty-nineAfrican countrieshave adoptedbasic health policies (Monekosso 1993).

Perhaps most obvious is that health planners and policymakersshould promote intersectoralcollaboration for better health. At the nationallevel this means engagingand coordinatingthe healthrelated activities of principalagencies of govermnent,including public works(water supply and sanitation),comnerce (for drugsand other pricingissues), education (especiallyin supportof educationof girls and women),and so on. The role of the Ministry of Healthin this endeavormay be largelyone of advocacy,with policy coordination managed by a core agencysuch as financeor planning,or even the primeministry. Currentlyit is a rarity in Africafor suchcoordinating agencies to be effectivein thistask.

* A second step, therefore, in completingthe agendafor better health in Africa is for al governmentstoformulate comprehensivehealth policies, includingexplicit goals, targets, and statemnentson how the enabling environmentfor health will be strengthened,including specific arrangementsfor monitoringand evaluatingprogress. In particular, such policies should be operational relevant, and fully informed of the cooperationneeded between the health sector and other sectors and programs. Finally, suchpolicies should integrateinternational initiatives, such as the SPA process, the BamakoInitiative (Chapter9), and the 7hree-PhaseScenario, and adapt them to local circumstances.

Of the manyfactors that can makean immensedifference to healthoutcomes - outside of individualbehavior and economicgrowth - perhaps none is more importantthan a commitmentto providepublic goods and public health services known to haveimmense impacts on health. Such goodsand servicesare thosewhich people are unlikelyto be motivatedto provideon an individualbasis, such as vectorcontrol, but whichstand to benefitthe community at large. Thuscollective action is requiredby localor nationalgovernments to raisemoney and ensure that suchgoods are provided. Moreover,national and localgovemments are oftenthe only institutionsthat are officiallymandated to providesuch services. Publicgoods also have redistributive effects because they construe benefits beyond single individuals - to the wider community for example - and no one can be excluded from benefittingfrom them. Commitmentsto publichealth improvements are in keepingwith cost- effectivedevelopment strategies because (i) the publicsector almost always has a comparative advantagein mobilizingresources and capturingscale economies in providingsuch goodsand services,and (ii) such effortspromote equity through the redistributiveeffects of unrestricted accessto publicgoods, irrespective of incomelevel. A challengeto healthplanners and policymakersis to assesscurrent use of publicfunds to determineif they are being used cost-effectivelyand equitablyto create an enabling environmentfor healthand to financepublic health services. Thoughdata on the allocationof public expendiwurestend to be limited,of poor quality,and irregular,available assessments suggestthat inadequatetargeting of publicbealth expenditures is commonthroughout Africa. Whilethis subjectwill be taen up morefiuly in chapter9, expendiurepatterns in Ugandatell the story. In 1990 and 1991,63 percentof governmenthealth expenditures went to curative care, 20 percenton adminitaton andtraining overhead, 6 percenton preventivecare, and only 11 percenton other communitservices. Wellover half of Uganda'spublic spending on health 40 was devotedto curative care of the ten major killers and causes of morbidityin Uganda, despite the fact that most of this spending could have been avoidedthrough other public action. That is, it would have been far more cost-effectiveto allocate public fuids to interventionsaiming to control the underlyingcauses perpetuatingUganda's major killers - Malaria, ARI, Trauma, TB, Anemias, AIDS, Malnutrition,Meningitis, Diarrhoea, Tetanus- than to use the money to address symptoms.

* A thirdstep, therefore, in the agendaforbetter health in Africais to allocatesufficient publihcfndsto public healthand communityhealth activities, so as to gain greatercontrol over the underlyingcauses of preventablediseases and, subsequently,to reducecurative spending on symptoms.

Governmentsare also charged with promotingequity through assistance to low income householdsand the poor. This is importantbecause failure to includedisadvantaged groups in health care can result in negative extemalities that will affect the community at large. For example, if the poor cannot afford to pay for immunizations,and if immunizationsare not subsidizedor required by law, then the control of communicablediseases may be undermined, threatening the community at large. Assistance to low income households is a particularly important policy issue in Africa given the prevalence of poverty, as well as a variety of economic and political conditionsmalkng for unstable incomes. Tie challenge facing health planners and policymakersis to subsidize, provide, or facilitate such assistance in as cost- effective a manner as possible, with a fraction of the resources available to more developed countries.

In addition, governmentsshould play a cental role in providinga wide variety of health informationto consumersand providers of health care, and in promotinghealth education at all levels. Health education includes, for example, the health benefits of family planning, informationon sexuallytransmitted diseases, the role of food preparationin better nutrition, and the role of sanitationand safe drinkingwater in preventingparasitic and infectiousdiseases. All indicationsare that educationand communicationprograms on such themes - through radio for example - are most cost-effective, yet remain inacessible to a large share of the African population. * Therefore,a fourh step in the agendafor betterhealth in Africa is for govenments to provide leadershipin deternmningcost-effective approaches to health care, to sdtmulatethe adoptionof such approachesby public, private voluntary, and pnvate providers of healthcare, and to assurethat such approachesreach the poor.

As a consequenceof economic crisis in the late 1970's and throughout much of the 1980's, many African countrieschanged their economicpolicies. They adoptedmacroeconomic reforms intended to achieve price stability and sustainable internal and external monetary balance, and made institutionalreforms to promote the efficient use of resources and faster economicgrowth. These changes typically involvedchanges in public spending, the opening of the economy to competiton, liberalizationof prices, measures to improve the efficiency of public expendiures, and the developmentof sounder financialsystems and other institutions needed in a well-functioningmarket economy. 41 In supportof thesereforms, the World Bank and the IntenationalMonetary Fund have extendedadjustment lending. The purposeof this lendingis to cushionan economyduring the transitionalphase to its new growthpath. Adjustmentlending is thereforeessentially an investmentin a moreproductive future, and it has beencentral to the reformsin Sub-Sahaan Africa. However,adjustment lend is also a subjectof controversy,prompted by questions aboutits impac on thepoor andwhether cuts in publicspending have jeopardized food security, educationand health.

As thesequestions are takenup morefully in Chapter9, it is notedhere that adjustment lendinghas often contained"conditionalides" designed to protect investmentsin key social services, Moreover,as part of endeavorsto promotehuman resource development and protect the poor during adjustmentprograms, some governmentshave actively redirectedpublic expendituresaway from less productiveto more productivesectors of their economy. In Lesotho,for example,adjustment lending and austerityin somesectors has beenaccompanied by increasesin publicexpenditures on healthand education,both as a share of grossdomestic product,and in real, per capitaterms. Healthand welfarereceived about 6 percentof total governent expendius in 1982/83,rising to about10 percentin the early 1990's. Over the same period, education'sshare inreased from about 15 to 20 percent. To achievethese impressivecommitments, public expenditureson less productivesectors, namely military spending, have declined- as a share of total governmentexpenditures - from about 24 percent in 1982/83to about 10-12percent during the early 1990's. Theseare particularlyrevealing trends,because even if totalgovernment revenues and expenditure levels fall, government retains completecontrol over how those expenditres are apportionedamong competing social and economicsectors.

e Therefore, a fifth step in the agendafor better health in Africa is for governmentsto restnrture their health systems as part of the adjustmentprocess, rather than in reactionto it. Restructuringshould ain to weed out inefficienciesand inequities,and to foster the adoption of cost-effectivehealth services which maximizethe well-being of households and communities. With such changes in place, the extent to which current resources can most efficientlyfinance and/orprovide health services can be betterdetermined, and shortfalsdefined. CHAPTER 3: IMPROVINGHEALTH CARE SYSTEMS

Introduction

Effectiveuse of health goods and servicesby households- as part of the responseto the shock of illness - is what determineshealth. Yet, the success of households in prevendng disease and sufferng is heavily ifluenced by health care systems, and the extent to which they are operatingefficienty, equitably,and susainably. To expand coverage,systems of health care must provide preventive and curative care in greaterproximity to where the majorityof Africans live and work. To improve efficiency, they must provide services more cost-effectively. To promote equity, public resourcesfor health must constre greater redistributivebenefits for the poor. And, to ensure sustainableimpacts on health, investmentsin individualhealth care must be complementedwith multi-sectoralstrategies emphasizing safe dridnkingwater, sanitation,and other critical inputs.

Governmentsare concerned with improvingcost-effectiveness because unconstrained markets can allocate health resources inefficientlyand inequitably. Furthermore, governments may be the largest supplierof personalhealth services. In Nigeria, for example,the government health sector accounts for about 80 percent of health facilities and 70 percent of hospital bed capacity. On equity grounds, goverments play an importantrole in subsidizinghealth care for the poor, and wish to do so at least cost. This is particularly importantin peri-urbanand rural areas given that private-for-profitproviders tend to be concentrated in urban areas, serving relatively well-to-doclients. And, by lending support to more effectiveand inexpensiveforms of health care, governmentscan provide signals to the private sector about preferred methods and proven approaches.

This chapter describessystems of health care as they are performing now, and identifies approachesto resolving lagging performance. This provides a perspectiveon what is missing and ses the stage for a major concern of this report - underpinningsof a cost-effective approach to health care, particularlyapplicable to low-incomecountries. Experiencein several African cnWies suggeststhat householdutilities are expandedand cost-effectivenessprevails when prevenive and curative services are offered in the context of well-functioninghealth centers and first referal hospitals.

Specificson pharmaceuticals,personnel, infrascm, and administrativeenvironments that affect the quaity and qualityof public md privatehealth services are taken up in chapters 4 to7. 43 Past Performance

That systemsof health care in Africa have helped householdsin their endeavor to reduce morbidityand mortlity is not in question. The issue, rather, is that a great deal more remains to be done to expand household access to and use of basic services, inrease efficiency, and reduce inequities. Consider the following:

* During the period of colonial mle, health programs in Africa stressed the control of endemic diseases, especially those transmitted by insect vectors or by fecal contamination. Health care services were developedprincipally for the benefit of Europeanadministrators and setters, or were the by-productof missionaryactivities. A few elite Africanswere invitedfrom time to time to use the modem facilitiesestablished for outsiders. The French authoritiesmade serious efforts to deal with vector-bornediseases through the use of control programsorganized on a para-militarybasis. The British placed greater stress on controllingfecal contamination. Health education, immunization,screening of populations for latent diseases, and nutrition activities played only a small part in colonial health policies and programs. As a result, the health care systems inherted by African counties at independencewere equipped to provide modem, individualhealth care services to only a small fration of the population.

* Across Sub-SaharanAfrica, UNICEF data suggestthat for every ten people who can access health services in urban areas, only two or three have that possibility in rural areas (Africa's Children, Africa's Future 1992). When access is defined as being no more than an hour distant from a health facility by the local means of transportation,only 11 percent of the rural populationin Sierra Leone have such access, 15 percent in Somalia,25 percent in Rwanda, and 30 percent in Liberia and Madagascar. Some countries on the other hand have made a concerted effort to expand access by emphasizingprimary health care and out-reach in mral areas. Access is 99 percentamong mrualareas in Mauritius, 85 percent in Botswana,73 percent in Tanzania, and 70 percent in the Congo (Global Coalitionfor Africa 1993).

* In Togo and Ugandaonly one in five married womencan obtain familyplanning advice at health centers or pharmacieswithin walking distance. In Angolaonly 27 percent of pregnant women have contact with health services,and only 16 percent are attendedby a doctor, trained midwife, or tained traditionalbirth attendant. Conversely,close to 50 percent of mral women and 85 percent of urban women can obtain such services from health centers in Zimbabwe.

* Within countries, access to services tends to be highly unequal across administrative disticts and between rural and urban areas. Among23 states in Nigeria the prevalenceof health faciliffesranges from one per 200 people in Lagos State to one per 129,000in Benie State, and 75 percent of the country's public and private health facilitiesare concentratedin urban areas, serving only 30 percent of the population(World Bank 1991c). In Angolathe supplyof hospital beds ranges from 3.9 per 10,000people in the provinceof Malage,to 41.6 per 10,000 in Lunda Norte. In Kenya there is one doctor on average per 500 people in Nairobi, compated with one per 160,000people in Turkanadistrict. Peri-urban areas are also often underserved, especially squatter-typesettlements which also lack basic water and sanitation services. 44 Hospitalsoften utdlizehalf or more of Box 1. ThreeGood Reasons Why Pimary total nationalexpenditurs for the healthsector, CareShould Not be Providedin Hospitals and commonlyaccount for 50 to 80 percentof governmentrecurrent health sector expendiues * Providingprimary care at hospitals - for salaries,equipment, maintenance. In the is uneomomical because rcatmentcost per mid-1980s,the share of hospitalsin total public iness is muchmore expensive than at a health recurrent health expenditureswas 74 percent i centeror dispensary.By some estimates it can Lesotho, 70 percent in Somalia, 66 percent in belo to 25 timesas much. Burundi, versus about 49 percent in Botswana * Provisionof primay care at a and 54 percent in Zimbabwe(Barnum and Kutzin hospitaldistorts its functons,with many of the 1991). Hospitals also use a large proportion of apparentshortcomings of hospitals linked to the most highly aiined health personnel. In congested out-patient departments, and Kenya 60 percent of the total number of overworkedlaboratories performing hundreds physiciansand 80 percentof the nursingofficers of so-calledroutine tests. are assignedto hospitals.(Bloom, Segall, and * The pressureof primarycare on Thube 1986). The dominanceof hospitalsin the hospitalfacilities also distorts health program health system, the use of more expensive inputs developmentat the communitylevel, because in outpatientservices, and morereliable supplies it fixes attenton on the distessed hospital, creatingthe impressionthat fuftherextension of drugsoften means that hospitalscompete with, and developmentis required,when the real rather than complement,prmary care services needis for manymore effectively functioning (see Box 1). heathcentes.

Inpatientspending in hospitalstends to be on conditionsthat are preventable.These include malaria, tuberculosis, abortion, digestive ailments,ill-defined fevers, respiratory infections, and skin infections.Among the ten leading causesof admissionto hospitalsin Malawiand Nigeria,for example,parasitic and infectious diseasesranked first in the mid-1980s.On a conservativeesdmate, a third or moreof hospital expenditurescould be avoidedif other healthsector strategies that are more cost-effective- suchas vectorcontrol, environenl health,and sanitation- weresuccessful in reducingthe incidenceof infectiousand parasiticdiseases. Theseare examplesof the potentalgains from more cost-effective allocations of public sectorhealth expenditures and better resource managemen. In thepoorly performing countries, healthproblems continue to be connectedto the same infectiousand parasiticdiseases that for centurieshave dominated health problems in Africa,let aloneother worldregions such as Asia. Emphasison healthprograms that give childrena healthystart in life, that addressneeds of womenof childbearingages, and that seek to expandaccess to qualitycare m mrralareas and to residentsof peri-urbanslums must be a top priority.

Multi-TieredSystems Performanceproblems in the past can be partiallytraced to structuralproblems in the way health systemsare organized. In many Africancounties, prevailingstructures mirror existng adm ative hierarchies. Villagehealth posts, dispensaries,health centers, and provincial,regional, and nationalhospitals attempt to provide primarycare servicesto the suronding vilage, county,district, or province,while also servingas referralfaciLities for 45 patients from lower to higher levels. This structre can be viewed as a pyramid, its logic being to concentratethe supply of servicesin places where they are in demandand most cost-effective. This means that the base, or the broadest part of the pyramid, such as a village health post, is where the most frequently occurring health problems are supposed to be treated least expensively. At the top of the pyramid, such as a national hospital, the rarest and most expensive conditionsare supposedto be treated.

Structuringhealth servicesalong adninistrative lines and in tenns of the hierarchy above has not worked as intended,however. Public resourceshave not been allocated to allow least- cost health services to address the majonty of health needs, and household members tend to ignore administrativelevels when seeking the best possible care (Mwabu 1989). Nor have private providers or private voluntary organizationsfilled gaps. For profit reasons, private clinics and hospitalstend to concentratein urban areas, serving more well-to-doclients. Private voluntary organizations,such as mission hospitalsand clinics, tend to be effectivewhere they are located but represent only 5 to 10 percent of health expendituresin most countries (see Chapter 8).

Quality of care has been underminedin rural and pen-urban areas as a result, often visible in shortagesof qualifiedhealth workers, lack of essentialsupplies, unreliableinformation, and limited nmmbersof functioninghealth facilities. In some cases, primary health facilities are over-staffed and under-utilized; in some rural health centers in Tanzania for example, twenty health workers are available to treat three patientsdaily that have been referred by dispensaries, whereas other communitiesremain deprived of basic health services(World Bank 1989g). Even as public providers face budget crises, it is not uncommonfor expensive brand-namedrugs to be suppliedto a limitednumber of health facilitieswhen genericdrugs could be procuredat one- quarter to one-half the cost (see Chapter 4) A lack of standards in facilities and procedures complicatesmatters. As a result of laissez-fairebuilding standards, basic health facilities in Sahelian countries, for example, range anywhere from 46 to 1734 in in floor space, thus contributingto uneven infrastructureacross communities(Abeille 1991).

Clients often bypass poorly functioninghealth facilitiesand intermediatereferral levels to seek quality care at full-fledgedhospitals (Bocar Dem 1989). Over-qualified staff and expensiveinfstructure are thereforeused in ways that placehospitals in direct competitionwith primary care facilities whose mandateis to provide such care at far lower cost. Most hospitals in Sub-SaharanAfrica are now providing primary care services such as vaccination, growth monitoring,and ante-natalcare services (Van Lerberghe, Van Balen, and Kegels 1989). While the technical quality of the primary care provided by the hospitalsmay be quite good, it comes at a high cost. It should not be necessaryfor a pregnantwoman to travel for hours to seek prenatal care, nor to trek with her child for a vaccinationby harried and over-burdeneddoctors. In addition to longer travel and waiting times at hospitals, clients are deprived of personal attention and follow-upthat can be provided by a local health center.

Performance of Central Hospitals

Central or tertiary level hospitalsare at the top of the referfal pyramid in most African countries. Often, but not exclusively, they are associated with a medical school, and offer 46 clinical services highly differentiatedby function, technical capacity, and skills, includingfor examplecardiology and specializedimaging units. Dependingon the populationto be covered, the number of beds ranges from 300 to more than 1,500.

The greater case mix complexityand more intensive input use of higher level hospitals commonlytranslates into much higher operatingcosts per unit than at lower levelsof the referral hierarchy. However, the extent to which resourcesare concentratedin central level hospitals often goes beyond that which might be justified in order to fulfill their tertiary functions (Barnumand Kutzin 1991). In Zambia, for instance, the three large central hospitalsused 30 percent of Ministry of Health resources and an estimated 45 percent of total MOH hospital resources in the 1980s, leaving the remaining55 percent to cover 39 lower level hospitals. In Kenya the Kenyatta National Hospital used almost 20 percent of recurrent MOH hospital expendituresin 1986-87, while provincial hospitalsused another 24 percent. In Zimbabwe45 percent of MOH recurrent hospital expenditurewas for four central hospitals.

As routinely applied, services in upper level hospitalsare less cost effective in reducing mortality or morbiditythan alternativeuses of health sector resourcesdescribed above. Ghana provides an example of an epidemiologicalenvironment typical of many low income and high mortality African countries. The leading causes of morbidity are upper respiratory illmss, diarrhoea, and parasitic diseases and accidents. The leading causes of mortality are vaccine- preventable diseases, respiratory diseases, malnutrition, diarrhoea, and accidents. With the exceptionof accidents, hospitalsin general, let alone central hospitals, do not play a dominant role in reducing lost years of life from these causes (Barmumand Kutzin 1991). Rather, by eating up large shares of public resources,central hospitalscompete for resources from district level hospitals, underminingservice qualityand impedingthe functionof districthospitals as the institutionof choice for first referral.

Central and teachingho: pitals also tend to be located in cities and metropolitanareas. Even when they are intended to provide a tertiary referral service for a broad populationbase, they actually serve a disproportionatelyurban clientelefor primary and first-referralcare. And because the urban populationsgenerally have higher incomesthan those living in ural areas, the location of most central and teachinghospitals has implicationsfor incomeand geographical equity in access to health services. Surveys of patients at NiameyNational Hospitalin Niger, for example, showedthat inpatientshad a median incomethat was comparableor slightlyhigher than other urban residents, who in turn, had higher incomesthan rural residents. Outpatients also had a higher median income than inpatients(Weaver and others 1990).

Concentrationof resourcesat the central level, with benefitsdisproportionately going to higher incomehouseholds, is at odds with the priority objectiveof providingequitable and cost- effective basic health care, because even minimal preventive and curative services are not available to the majority of the population. Basic health coverage in urban areas is also underminedbecause overcrowdedoutpatient departments in large tertiary-carehospitals cannot develop the patient-providerrelationship essential for primary care. This does not mean that central hospitals should be ignored. They have a special role to play in treating cases that require specialized or high-tech medical procedures, where systems of health care already respond to social needs and financial possibilities, and are affordable to the country. The 47 challenge is to get the referral system working right so as to free up central hospitals and to allocate public fimancialresources more efficiendy. Record of PrimaryHealth Care Strategies

Generating political consensus on primary health care (PHC) is one matter, implementationis another. The 1978 Alma Ata Declarationput communityparticipation at the center of PHC. However, ensuing attempts to implementPHC spotlighted "selective PHC strategies" and Village Health Workers, and tended to ignore the wider socio-economicand cultural issues which impinge on the health of men and women. In most countries, neither strategyconvinced policy-makers to shift resourcesaway from central hospitalstowards primary care. Rather, selective programs were developed with the support of donors and the promulgationof ambitious internationalgoals.

Selective Prmary Health Care

in the past, selectivePHC strategieshave focussedon specifichealth problems, such as imunization, tuberculosis,and AIDS control and family planning. By narrowingthe range of activities involved, as well as assuring funds to reach specific health targets, these strategies were able to harness all possiblemeans - includingmobile teams - to provide qualitycare and to stimulate use of the specific interventionsthrough social mobilization. Coined vertical programs, these initiatives have appeared to perform well, particularly in the eradication of smallpox. They also appear to be cost-effectivewhen "crisis managementhhas been necessary to ward off epidemics or deal with emergencies.

However, there are limitationsin being selective. As African countries coMpliedwith donor initiativesto launchthese technocraticstrategies, vertical administrative entities developed parallel to existinghealth systems,bypassing instead of contributingto nationalcapacity building both within health care systems and in community development. With little coordination betweenvertical programs in the same country or region, and with little iration with the rest of the health care system, the impactof selectiveinterventions has been disappointing(see Table I). Reviews of programs in Burkina Faso, Mali, Niger, and Centrl African Republic have uncovered a plethora of problems, such as:

* Districthealth teams have had up to ten coordinators,each supervisinghealth personnel and reporting to discrete program hierarchies linked to the centrl level, when one or two supervisorscould monitor the same programsjust as well.

* Parallel distribution systemsexist in some countries for sending AIDS screening kits and EPI vaccines to the ultimate user. As an extreme case, Zaire's national family planning program was artificially divided and executed by two agencies (the Comite National des Naissances Desirables and the Projet des Services de Naissances D6sirables), at the cost of competitionthat did little to increase contaceptive prevalencerates in the country.

* As selective PHC strategiesattract a disproportionateamount of resourcesfrom both donors and governments,other causes of moralit and morbidity, such as sexually-transmied 48

Table L Single PurposeInterventions: A Review of Studiesin Africa Su*y design Imervenion Conclusion Longitdinalwith Meastesvaccination Reductionin measlesdeaths partly wiped out by controlgroup (Kasongo,Zaire: KasongoProject Team delayedexcess mortality from other causes in 1981) vaccinatedgroup; Before/after Ora rehydration Impacton underfive mortality lower than expected (Severalstudies: Black,R. 1984) fromreduction of diarhoeadeaths; Timeseries Communitybased nutrition Underfive mortality gains reversed due to malaria; aringa,Tanzania: JNSP 1988) Before/after Malariacontrol and measles vaccination Reductionin underfve mortalityauributed to (Saradidi,Kenya: Kasejeand others measlesvaccination, not nmlaria control; 1989) Before/after Measlesvaccinaton Impacton underfive mortality wiped out by malria; (Mvumi,Tanzania: Matamora 1989)

Source:Knippenberg, Ofbsu-Amaah, and Parker1991.

diseases have been largely ignored. Exceptionsinclude Zimbabwe, Senegal, and Zambia. A strikingeffect is to find up to 15 percent of womensuffering from untreatedsyphilis in the same areas where vertical progrms have been active, thus creatinga particularlyreceptive terrain for HIV. Althoughvertical programs may seem to address selected health issues more efficiently, the health care system has been fragmentedas a result.

* Routine bealth services can be disupted and national capacity undermined when vertical programs tain or support health specialists, luring them temporarily or permanently away from national health systems.

On a more positive note, selective PHC programs have enjoyed positive and robust reslts in situatons where health ceners and under five clinics offer integratedchild care. High levels of immunizationhave been sustined and significant reductions in infant and child mortalityrates achievedby integratingmaternal and child health care services in health facilities in Guinea and Benin.

The expenence with selective PHC strategies leads to a striking finding, perhaps best illustratedwith respect to cldld care and immunization.A child born after a mobileteam comes to its communityto vaccinateagainst immunizablediseases might wait another six months to be immunized, or may die from another disease in the meantime, instead of being taken by its mother to a health facility offering vaccinations. Hence nation-widesocial mobilizationefforts in Togo, Senegal, Ivory Coast and the Congo (UNICEF) increasedcoverage only temporarily where EPI was not integted into the daily responsibilitesof functioninghealth center networks (See Figure 1, Part A). In contrast, high levels of immumzationcoverage have been susuined, ad significantreductions in infantand child mortality achievedwhen matern and child health services have been integted in health facilites in Zimbabwe(Cornia, Jolly, and Stewart 1987), Botsw a and Cape Verde (UNICEF 1990a).In Benin strategiesof simultaneouslyimproving health service and immuniion coverage have led to a steady and sustained increase in Expanded Prgmme of Immunization(EPI) coverage (see Figure 1, Part B). Flgure 1: Performance of EPI Under Different Condiltons

PartA: EPI THROUGH CAMPAIGNAND/OR MOBILE STRATEGIES 100

90- 80- 70-

840 30- 20- 10-

1986 1987 198 1989 1990 Year

1BurkinaFaso C ote d'lvoire -- w- Mauritania - Togo

PartB: EPI THROUGHSTRONG NETWORK OF HEALTHCENTERS 100, 90-

70-eo- .60- ~50- 840- 30 Benin: OrganizedInfra- 20 stucture aroundEPI

O 19i6 1967 1$*199 99 Year -i- 3o0aa - CapeVerde -*- Rwanda to- Zmbabwe -m- Blenin 50 Unfortunately,the resourceswasted in fundixgselective PHC programsstand out sharply when comparedwith the lack of resourcesfor strengtheningthe health system as a whole. The challenge facing health planners and policymakersis to channel resources for specific health interventions in such a way as to strengthen rather dtan fragment health systems and to contribute to capacity buildingfor sustainablehealth outcomes.

VilDageHealth Workers

Another approach to PHC features networks of village or communityhealth workers (VHW or CHW). These have been modelledon the success of Chinese barefoot doctors and local-level initiativesin countries such as Niger, which helped to expand access to health care and combat inequalities. VHWprograms aimed to correct the mismatchbetween the care sought by householdsand services that health care systemswere providingby extendingmodem health care beyond hospitals and health centers. CHW programs were principally intended to be catalysts for communitydevelopment and a more holistic approach to health.

CHW programs have performedrelatively well when their role as liaisonsbetween the communityand the health care systemis clear, and whenthey receive supportfrom the system, particularly from reliable and viable health centers. This has been the case in Lesotho, where over 4,000 trained village health workers are supported by local developmentcouncils, in Zimbabwewhere over 6,000 CHWs receive stipendsas general developmentworkers from the Ministry of Communityand CooperativeDevelopment; and in Zaire, where CHWs are citizens selected by their respective communities to liaise with the health establishment whenever necessary - they are not necessarilyremunerated fiancially (Reyndersand others 1992). The contribution of VHW or CHW workers to community involvement in the planning and mnanagementof health services has also been documentedin Saradidi and Tenwek (Kenya), Mvumi (Tanzania), North Kivu (Zaire), and in northwestern Somalia (Lamboray and others 1991;Leneman 1986, p. 4; Vaughn,Mills, and Smith1984). Workingas part of the health care system,they have also filled gaps by servicinghouseholds and comuwnitiesthat would otherwise lack access to care for geographicor fmancialreasons.

Conversely, VHW and CHW programs have not worked well when links to the bealth system and communitieshave been weak or poorly established. In Burkina Faso, Gambia, Ghana, Niger, and Tanzania, CHWs were trained on a massive scale to be the principal vehicle for PHC implementationin the 1980s. With limited training, and nebulous links to the formal systemof health care, these CHWs were forced to rely on supportand supervisionby a cadre of specialized coordinators, often organized by NGOs and extnally-funded projects. The contribution of CHW to efficient, equitable, and sustainable health care in Africa has been blunted by lack of constnt support and supervision (Sauerbornand others 1989; Walt 1988; Walt, Perera, and Heggenhougen1989).

Table 2 smmarizes fmdings of a number of studies on the perfonnance of VHW and CHW programs, revealingthat their performancehas been mixed, somedmespoor. When they work in isolationrather thamas an extnsion of the health system, CHW throughoutAfrica have been bypassed as householdsgo to consult the first level of formal health care. Their presence may even delay necessary access to professional care rather than deterring unnecssary 51

Table1I. Rewews of VillageHealthWorker (Vw9 and CommwuityHealth Worker (CHW7 Programs COWy Metho Fmings Africa Reviewof 1000 publications Problemsin all aspects of the functioningof VHWs (Ofosu-Amaah1983) (tasks, selection,recruitment, training, remuneration, and most seriouslyin their support); West African Desk Review Same obsevations; Countries (Varkevisse1983) Senegaland West Case Studies Sameobservations; questionedrelevance and African Countries (Senghor1983) sustainability; Tanzania Multiplicityof methodswas used to gather Belowa certain level of support, the quality of informationon the acceptability,quality, community-basedhealth servicesis very and cost of the CHW program questionable; (Heggengougenand others 1987) Niger Systemsanalysis combined questionnaires Trainingof over 13.000 VHWprovided additional from VHWs, mothers, supervisors,and accessto PHC in 45 percent of the villagesof communityrepresentatives; structured Niger, but low quality of care was linkedto weak observationsof service deliveryand support support: activities;and focus group discussionswith villagers(PRICOR 1989} BurkinaFaso Representativehousehold survey on MCH Presenceof villagehealh posts did not increase utilizadonwas carried out udilizationof MCH care; (Nougtara1989) Gambia Mortality surveysto assessthe impactof a No impactof TBAs on matern.l morality; TBA program on maternal mortality (Lamb and others 1984) Ghana Studyof communityclinic attendants Problemsrelated to the selection,traiing, abuse of (VHWs)in nine out of the ten regionsof fmctions, lack of remuneration,shortage of drugs, the country (Ofosu-Amaah1990) and supervision; the program generallyfailed to achieveits objectives;

Source: Knippenberg,Ofosu-Amaah, and Parker 1991. consultations. The high attrition rates, exacerbatedby dwindling donor support for vertical CHW programs, call for a reexaminationof their role withineach country's national health care system before more resourcesare used in this direction. What is Mising?

The reality in many African counties is that systems of health care are not providing cost-effectivehealth services to householdsin ways that can make the greatest impact on major causes of illness and death. Health care tends to be multi-tiered, with fewest resources and poorest qualitycare availableat villagehealth posts, dispensaries,and heaIthcenters - precisely where the majority of Africans live. Poorly trained personnel and insufficientsupplies among several of the bottom tiers - a problemof spreadingresources too thinly - prompts residents at the community level to by-pass lower levels to seek primary care from intermediate-level facilities and hospitals. As a result, personnel and facilitiesmost appropriatefor curative care 52 ted to be mis-used to provide prmary and first referral care at higher cost. For households, this means low confidencein the health system, and barely marginal improvementsin health at the communitylevel. For governments,it means that a large share of public expenditureson health are wasted. And for private providers it means dealing with a vast number of unmet needs with little effective guidance,assistance, or competitionfrom the public sector.

Chronic shortages of drugs within health facilities as well as uninformed use by householdsare major bottlenecksto improvinghealth care in Africa. As documentedin Chapter 4, shortagesof appropriatedrugs tend to plague public sector health facilities. Prevailingdrug selection, procurement, distribution, and utlization practices have also underminedaccess to priority drugs. For example, in Nigeria, ineffectualand even dangerousdrugs abound and are unwittinglyprocured. Brandedrather than less expensivegeneric dmgs are procured, and some local goverments pay up to six times intemationalprices as drugs are often purchased locally in small quantities instead of in bulk through open internationaltender. Furthermore, many drugs are damaged after purchase by faulty storage practices or disappear due to inadeqate stock control procedures(World Bank 1991c).

Problems in the mainenance of equipment, logistical support, and supervision further contributeto inefficienciesbecause public sectorhealth workerscan neitherimplement what they are trained to do, nor can they exercise control over the situation(see Chapters5 and 6). Also lacking are proceduresor managementinformation systems to monitor and evaluate the quality of health care, and to assure that providers are accountableto clients. The same applies to naional standards and yardsticks needed to permit comparison of problems and progress in resolving them across communities,districts, and countries (Smith and Bryant 1988; Pangu 1988). Thus, it is difficult for anyone to know whether a particular health system is having a discernible impact on the major health problems in African countries, especially in poor nual and urban areas.

That the first referral hospitalis a vital elementof a well-functioninghealth care system seems obvious. Yet, policymakersbehaved as if distrct hospitals did not exist or were irrelevant in the aftermath of Alma Ata. Small, frst-refrral hospitals are only now being dused off, after hospitals in general fell into disrepute with PHC-consciousdonor agencies during the late 1970s. The Tanzanian Essential Drugs Programme, for example, provided donor-fundeddrug kits to dispensariesin the mral areas, but not to hospitals. PHC policies have done less to divert public resourcesaway from major urban and teachinghospitals than they have to weaken the resource base of peripheral district and rural hospitals. Small referral hospitals need to be strengthenedand organizedto complementprimary health facilitiesat costs lower than that of central and national hospitals.

Finally, if unprovements in health care are to have sustainable impacts on health outcomes, they must be complementedby multi-sectoralinputs such as safe drinking water, sanitation, and health education. Far too often such inputs are treated as being outside the traditional purview of ministries of health, the responsibilityof other agencies. It is at the household and community level where oppormities present themselves to merge these complementaryapproaches. Africansare organizedinto hundredsof thousandsof communies, often tight-knitwith commonbonds of kinship, language,and traditionalhomeland. It is at this 53 levelof populationaggregation that collectiveaction can mobilizeresources and capturescale- economiesin the provisionof criticalservices. Underpiings of a Cost-EffectiveApproach

Reactingto the problemsabove, a case can be made that a well-functioninghealth facility,together with the supportof a first referralhospital, could provide a mix of healthcare servicesresponsive to up to 98 percentof localhealth care needs. Basedon experiencein a mmber of Africancountries, the most fundamentalelement of suchan approachis a flexible, cost-effectivepackage of basicservices that can be deliveredright down to the communitylevel. Threecomponents of sucha packageare reviewedhere. The first is a basicset of bealthcare inputs. The secondis a batteryof supportingservices which aim to insurethat householdsmake mosteffective use of such inputs. The thirdcomponent comprises multi-sectoral inputs to better health,as discussedin Chapter2.

The basic servicesemphasized in this report, and particularlythe evidencesupporting their cost-effectiveness,pertains largely to countriesthat have as yet to pass throughwhat is coming to be labelledthe health trastion. This means a shift in the demographicand epidemiologicalmake-up of a countryfrom a pre-transitionenvironment dominated by high fertility,high mortality,infecdous disease, and malnutritionto a low mortality,low fertility environmentwith a diseaseprofile that increasinglyemphasizes non-communicable conditions of adultsand the elderly. It is also rue, however,that somepopulation groups within individual Afifcancountries, particulary among the elite, haveentered or passedthe health transition, and that the ideaof a basic servicepackage can applyto all countriesand populations.As will be demonstratedin Chapter8, boththe contentand the cost of a basicpackage will vary according to a country'sepidemiological profile, socialpriorities, and incomelevels.

A numberof publichealth interventions have been documentedto be particularlycost- effective,and include health and nutritional education aimed at personalbehavior change; control of environmentalhazards; ztion; and screeningand referral, for example,of selected infectiousdiseases and high risk pregnancies. A review of disease control priorities in developingcountries includes among the most cost-effectiveinterventions the following; breastfeedingpromotion, DPT plus polio immunization;measles immunization;smoking prevention;pneumococcal vaccine; antbiotic treatment of acuterespiratory infection in children; and supportingtheapy, includingvitamin A (see Box2).

Health facilities featuring cost-effectiveservices may be publicly operted, private-for- profit, or privatevoluntay organiztons, suchas missionfacilities. When they functionwell, they respondto local healthand economicconditions by "bundling"services into basic care packages.Moreover, this study emphasizes the delivery of theseservices in contextswhere they can be applied correctly - namely in well-functioninghealth centers - thus providing another rationalefor cost-effectivenessto be sustined if not increased. Basicpackages of carecan be flexibleinsofar as specificactivities may change over time to adaptto fte evolvingepidemiology, as wellas changingresource availability. For example, oral rehydrationtherapy (ORT) has been slronglypmoted in wellfuctionig healthceters, 54

Box 2. Cost-EffeciveHealth Interveniions

The cost-effectivenessof manyof the healthinterventions recommended in this studyhas been substantiatedin the WorldBa's 1993World Development Report, Investing in Health.Given a common currencyfor measuringcost, and a unit for measuringhealth effects, the 1993World Development Report comparesthe costs reqired for differentinterventions to achieveone additionalyear of healthylife. Outcomesare expressedin termsof disability-adjustedlife years(DALY's). The ratioof costand effect,or the unitcost of a DALY,is calledthe cost-effectivenessof the intervention.The lower the unit costto gain one DALY,the greaterthe valuefor moneyoffered by the intervention. Onlya smallshare of the thousandsof knownmedical procedures has beenassessed using the cost- effectivenesscriteria described above, but the approximatelyfifty studied would be able to deal with more than half the world'sdisease burden. Just implementingthe twentymost cost-effective interventions could eliminatemore than 40 percentof thetotal burden and fully three-quarters of the healthloss amongcildren. Severalpublic health activities stand out as beingparticularly cost-effective: the cost of gainingone DALYcan be remarkablylow - sometimesless than$25 and oftenbetween $50 and $150. Activitiesin thiscategory include immunitions; school based health services; information and selected services for family planing; programsto reducetobacco and alcoholconsunption; regulatory action, information, and limited publicinvestments to improvehousehold environment; and AIDS prevention. Thoughthe cost-effectivenessof clinicalservices will vary ftom countryto country,depending on localhealth needs and the levelof income,five groups of interventionsare highlycost-effective and address verylarge disease burdens. These include services to ensure pregnancy-related care (prenatal,childbirth, and postpartum);family planning services; control of sexuallytransmitted diseases; tuberculosis control; control of STD's; and care for the commonserious illnesses of children- difrheal disease,acute respiratory infection,measles, malaria, and acutemalnutrition. These interventions form the core of the packageof heath care servicesrecommended in this study.

Srce: WorldBank. 1993e.

as a low-costtechnology to managecases of diarrhoea. As the incidenceof diarrhoeadecreases, however - more people learn to use ORT at home or clean drinking water becomes more accessible - health workers would spend less time on treatmentand more on prevention. As coveragerates for munizationincrease- throughsustained understanding and demandby the population- vaccinationwould continue to be importantthough its place in the health worker's daily caseload would be reduced.

To combat frequently occurring illnesses and health conditions, such as malaria, hypertension, diarrhoea, diabetes, respiratory infections, measles, asthma, polio, STDs and malnutrition, a basic package of health care inputs also includes a regular supply of essential drugs. As far as householdsare concered, the availabilityof sound medicines is one of the most important and immediatelyvisible symbolsof qualitycare.

Making drugs, contraceptivesand vaccinesmore availableto the communityis only one dimensionof better healtn, however. Tee inputs need supporing serices to insure that people are diagnosedcorrectdy, that providersprescribe or apply the service correctly, and tt clients using the service do so corectly. While these underpinningsof cost-effectivenessmay sound obvious, problems of diagnosis, prescription,and use are sufficientlyprevalent in Africa that 55 effectivenessof potentially good solutions can Box3. ComparatveAdvanages of Heath be reduced by up to 50 percent (see Box 3). Centers

BringiD,gthese services together in well- Most health problems, ranging from fUnctioning health facilities can benefit common ilnessto measles,malnutrition, tuberculosis, householdsin a numberof importantways: the tecnology and competce availabteto well functioninghealth centers. And in 80 to 90 perent of * Comprehensivecare. This means that preventive work and for most curative cases, the the health care provider not only examinesthe health center can outperform hospitals in terms of continuity,comprehensiveness, integration, and cost symptoms,but also endeavorsto considerthe of care. underlyingcauses or the broadersocial context. For example, a battered child receives more The small scale of the health center also than a pain ckilleror a cast for a broken leg - favorsintegration of variousprogram.Maor gins thana P~~~~~~~U1 in~~~vaccination coverage or familyplanning can be his family situation is of concemnto the health made when the health center staff consults a sick care provider as well. Not only are vitamin child's growth monitoring chart and vaccination suffering record, Conversely,at a hospital, out-patientcare is supplements provided for the child a service separae from vaccination, growth from micro-nutrientdeficiencies - the health monitoring,or family planing. care provider takes stock of what the child is being fed. Over-prescriptionis also less common in healthcenters than hospitals. In Ghana, for example, a study found that the average cost of drugs per CContinuty of care. The health care person,per episodewas $.20 at hospitalsversus $.07 provider interacts with household members as at health centers, with the lowercosts explainedby long as necessary to have an impact on health lesssophisticated prescrion and better mangement status. A tuberculosispatient, for example,will of drug stocks (Hogerzeil1986). not only receive a prescription, but is asked to The health center's comparativeadvantage discss her work and family sitation so that an lies in its accessibility and potential for can be communicaton with the community. Its scale of appropriate treatment program operawonspermits urses to becomeacquainted with scheduled. If she stops treatmentprematurely, the households and their social environment.thus the health service will try to reestablishcontact preventingdrop-out and greater ease of reestablihing by visiting the home or contacting other contat if thepaent sps treament The small-scale center cannot guarantee greater members of the household. Continuityof cam ofinterpersonl the health communicaton and empaty towards also impliesthat comunmityhealth workers and clients, but it makes it possible. health care providers channel support to households who are not using the essential packageof careat opporametimes. For example,children less thanone yearold are idenfied duringhome visits, as has been practicedin well-functioninghealth facilities in Danfa,Ghana (Ofosu-Amaahand others), Zaire (Niimi 1991), Pahou, Benin(Alihonou and others 1988), and Nigeria(Ransome-Kuti 1990).

v Integratedcare. By movingfrom project-basedto program-basedapproaches, the healthcare providerperforms several tasks simultaneously,cognizant of the household'stime constraintsand culturalbackground. The provider may link preventiveand curative care so that a pregnantwoman who is feverishfrom malaria will have an antenatalconsultation before going home. Her children's immunizationrecords will be checkedat the same time, so that a vaccinationcan be givenif necessary. In Kenyaintegrated care resultedin increaseduse of underfive clinics,less consultations,a more balanceduse of healthstaff, a reductionin unmet 56 demand(such as womenwith an illnessneeding BOX4. PrototypicalHeakh Center antenatalcare or vice versa), and a striking ira in immunizationrates (Dissevelt 1976). Dembgr4picProfile of Commwo Served. TotalPopulation = 10,000 Health Centers Can Make The Difference Cd < I year(4% of thepop.) 400 Women15 to 49year (20%of fthpop.) 2,000 Chfldren< 15 years (50%of the pop.) 5,000 As a conceptthe healthcenter bas been aroundat least since the 1960s(Fendall 1963; PACKAGEOF CAREANDSERICESPROVIDED: King 1966; Roemer 1972). Duing fte 1970s * Pre.eliveycare, deliv,y care and potadelivey and 1980s, health ceners with conmunity cae outrch began to appear in Africa, launched * BrestfeediBgIEC with donor assistancein Danfa (Gbana), Pahou * Microutien Supplemt (iodie for pregnant (Benin), Maclakos (Kenya), Pikne (Senegal), - Spemetary Feedn (eprna ctatig wom) Kasongo(Zaire), Kinshaa, andLagos. As part Well-labySwvls of an evolutionaryprocess to make hlealth * E ed Programof Imnwzation MP *Micronuiet Swplemnts (in iodine, and centersmore effective, planns havedeveloped VininA) methodsto tackleproblems of accessibility(Van * Nutt Redabilitaon(children aged 0-5) Lerberghe, Pangu and Vandenbroek 1988), Su* em' PFeedinProgm (children aged 0- 2) acceptability, intensity and complianceof use, &hi UN quality of care (KasongoProject Team 1982), * Anti-helmint am (childrenaged 5-14) reCUent costs (Pangu and ofters 1988),and . Viin A + iodine,as requied CurativeCare (especiWlychildren 0-5) community ownership (Jacobson 1989; Kaseje . BasicTrauma and others1989; Matamora 1989). *maw * Diarfhoea In several African counties the health * Otherlocal neon Limite CbronicCare center (sometimes known as health post or * TReatt dispensary)is a recognizedphysical entity at the ST%sand AIDS hub of community life and is thefirst level of - testn. ratmet d MEC contact with the fornal health care system. * high'-risA p groups) (poion ofcondom an MC for Communityparticipation, and especiallythe FamilynPanag participationof women, in decidingthe location * Familypang Ec and operationof bealth centers is critical to . Prvision of contraceptives their success. By servingcommunities of 5,000 smAffPROFILE to 15,000 people, health centers are in a * doctr on viing basis fowmDit Heal positionto justify a criticalmass of personnel Managene_Team *I regtred muse; 2 assistam nurses/midwives,I and services, thus providing a strong comm service(FP/Nuton) assistant;I clerk underpinningof cost-effectivehealth care. This is one reason why selective PHC and VHW RASTRUCTUREPROFILE *I building(approxinmtely 125ni,includes stion experienceswere most successful in thecontext facirities);I housin unitfor staff of well-functioningheath cents. Health * 2 bicycles,I rfrgator and oter medicaland centershave also gainedattention because they officeequpnt have performed more effectively, and at less Ate: IEC Includesoigong dialogueduig cost, thanhospitals in providingprimay health ow taton ando h viits to vils andgroups care (see Box4). servedby dteheat ceter. Sowe: Adaptedfrm WorldBank 1993a. 57 An essentialprecondition for well-functioninghealth centers is that the communitiesthey serve be well-defined. For example, when a given health center is serving 10,000 people, the staff can estimate that about 400 children are likely to be born per year. To meet objectivesof universal immunization,the planningof EPI activitiescan therefore be based on roughly 35 new children a month. When district-basedhealth systemsare in place, health centers can obtain informationuseful for patientmanagement. Though largely ignored for such purposesin national health systems, household files can be used by health center nurses to contact individual households, to profile the communityto be served, even in urban areas where geographical boundariesare more fluid, and to provide measuresof health impactand promotionwithin the district.

Nutrition services targeted towards severely malnourishedchildren, as well as feeding programs for pre-schoolchildren, pregnantwomen, and lactatingmothers can also be organized effectivelyat the health center and communitylevel. Informationavailable to this study suggest nutritional services of this kind can be providedfor about $1.32 per capita (Yusuf 1993a).

IHealthcenters are also in a position to generate their own informationon commnity coverageand utilization. Whencombined with in-houseassessments of staffworkload and costs, a balance can be established to assure reliability, accuracy, and affordability of services (Imboden 1980, Dc Sweemer1982, Jagdish 1985, King 1984). For example, a low-costhealth mna gement informaton system (MIS) in Zaire has been developed to trigger timely managementdecisions and actions by health centers and communities(Beza and others 1986). In Guinea and Benin, the entire MIS was revampedand simplifiedso that health center staff could use it for integratingand managingtheir own services. Forms, fles, and registerswere redesigned to first serve supervisors and local monitoring needs (including feedback to communities),and secondlyfor reportingpurposes to provincialand nationallevel (Knippenberg and others 1990). Although registeringthe information(such as on patients, children, drugs, and receipts) and performing periodic analysis are time-consuming,most health center staff considerthis an importantresponsibility, and do not suggesta reductionof the quantityof forms and files (MSP Benin 1990, MSPAS Guinea 1990).

Any attempt to generalize characteristicsof well-functioninghealth centers must, of course, be wary of differentconditions, resources, and needs betweenand withincountries. At the same time, however, it is helpful to visualizewhat may be involved, especially in view of the renewed attention to criteria of well-functioninghealth centers in Afnca. A prototypical health center is therefore depicted in Box 4, in terms of demographics of the community serviced, package of care and services provided, staff profile, and inftructure.

Firs Referral Hospital

Well-functioninghealth centers require back-up for more complicatedhealth problems, typically by a district hospital. Working together, these two tiers have demonstaed their capacityto provide comprehensiveand effectivecare to the communitiesthey serve (WHO 1992; Hamel and Janssen 1988; Van Ltrberghe, Van Balen, and Kegels 1989; Barnum and Kutzin 1992; Mills 1990; Van Lerberghe and Lafort 1991). In Kasongo (Zaire), for example, the health center network that providescomprehensive primary care clearly reduces hospitalization rates. Hospital admission rates of nil Box 5. PrototypicalFirst Referral Hospital dwellers were 50 percent lower in areas with health centers than in areas without. Treatnent Dmogntphk Proj1eof Camauo to be Served: for illnesses, targeted in the past by selective programs, such as measles, tetanus, and Children< I year (4% of thepop.) 6,000 diarrhoea, dropped by 86 percent when health Women15 to 49 (20%of thepop.) 30,000 centers were in place providing, for example, Children < 15 years (50%of thepop.) 75,000 vaccination, ORT, chloroquine, as well as PACKAGEOF CAREAND SERVICESOFFERED: geneal outpatient care for amoebiasis, skin In-pat Cae diseases, and accidents. Conversely, patients * Obstetricsand Gynecology who really needed hospitalization,for example, a Pediats * Medicine:Infectious Diseases for cesarn section, benefittd from easier * Medicine:limited Surgery access to hospitl care within finctioning out-patientCare networks (Van Lerberghe and Pangu 1988). * Emergcies * Referredpatients Otherservices First referral hospitls also provide a * Basiclaboray package of services. Audging from the * Bloodbank performance of a number of rual hospitals in STAFFPROFELE: central Africa, three to four physicians, and * 3 medical doctors; 10 registered nurses; 25 sometimes a surgeon, are providing the assistantnurseslmidwives; 3 medical technicians following services at an affordable cost and * 2 managementstaff (incl.acmutant) with reasonable technical quality: * 15 supportstaff (inc. driver); 2 clerks INFRASRUCTUREPROFILE Outpatient Care: Doctors treat * I building(approximatey 4,000m 2l/140beds) health * 3 vehicles(including 2 ambulances) emergenciesad patients referred from * Cold storagefacilities cents. A nurse may provide the package of * Medicalequipent care similar to the health center, but it would * Otherequipmen (including beds, furiture, etc.) carry a high consultationfee so as to discourage Soure: Adaptedfrm WorldBank 1993a. patents from bypassing the first line facility.

Inlpatit Care: Wards for pediatrics, medicine, surgery and orthopedics,gynecology, and obstetrics are provided.

Laboratory Services: These services includeblood microscopy,direct examinationof cerebro-spinalfluid, urine and faeces tests, vaginal smears, HIV serology, and blood grouping. The hospital produces its own intravenous fluids, has a blood bank, and performs blood transfusions. Also importantis the qualitycontrol of microscopyat the health center, primarily for the detection of tuberculosis.

Radiography and fluoroscopy of extremities,skull, chest, stomach, and bowel.

There is of course great variation in district size, infrastructure, and personnel, both within and between countries. Basedon the medianof two surve.,s f 89 and 40 hospitals, and average figures from officialsources, a typical mral district hospitalserves 110,000to 160,000 ihabitants, with 140 beds, 3 physicians,and 10 peripheralunits in its district. It conduc-tsabout 1000 deliveies and hospitalizes4,000 to 5,000 patients per year on average. This varies from 59 as little as 30 to 40 beds in Mozambique,for example,and catchmentareas of tens of ousands, as in Lesotho, to hundreds of thousands,as in Ethiopiaor Tanzania(Van Lerberghe, Van Balen, and Kegels 1989; Hamel and Janssen 1988). More importantthan the number of beds or staff size is that the first referral hospital functionsat full capacity and is neither under-used (bypassed) or over-crowded(in competitionwith health centers). A prototypical firt referral hospitalis depictedin Box 5, againwith the caveatthat its communityprofile, services,staffing, and infrastructureare at best indicative.

How Central Hospitals Fit In

Buildingon the premise that a well-functioninghealth center and first referral hospital can serve up to 98 percent of preventiveand curative health care needs, central level hospitals could be expected to provide technical back-up and support by training health personnel for service in district-basedfacilities and to perform rarer interventions,such as cataract operations, that can be afforded by the country. One might also be developedand formally recognizedas a 'center of excellence', as in Mozambique.

The challenge is to enlist central hospitals as partners of more efficient and equitable health care in Africa, instead as competitorswhose consumptionof resourcesjeopardizes the adequate provision of basic packages of care to the majority of the population. Recognizing that central hospitals have a certain elitism in national systems of health care - created historically more from social than medical need and in response to technical pressure - their actual conitnbutionto the health needs of society merits reexaminationso that their links with the rest of the system can be better articulated. Instead of treating them as special cases, qualifyingfor disproportionateshares of resources, the outputs of central hospitalsneed to be quantified and analyzed so as to better determine whether the people requiring specialized procedures are actuallybenefitting, and the costs at which these benefits are provided. Despite the general dearth of such studies, central hospitaladministators will easily recognizethat most of their staff time and space are being used for primary and first-referraltype of health care.

Second, governmentsneed to considerways of enforcingthe referral system. One option is to recover costs of those who willfully by-pass the referral system - assumingthat a well- functioning health center and furst referral hospital are in place. One-hundredpercent cost recovery would not be unreasonableat central hospitals.

Third, governmentsneed to consider ways of charging user fees at cental hospitals, or assessingprivatization as an alternative,so as to divert public resourcesto health interventions that are most cost-effective. Prospects and methodsof cost recovery are taken up in Chapter 9, and it will suffice to say here that cost recovery at central hospitals has appeal because (i) people are generally willing to pay for care at hospitals, given that acute problems are usually involved, (ii) the demand for such care tends to be price inelastic, meaning that higher prices do not deflatedemand, (iii) clients of tertiary level hospitalstend to be from middle- and upper- incomeechelons of society, (iv) and hospitalsare more likely to have the admiistrative capacity to assess and collect fees. Change will not be easy becausethose who suffer short-termlosses as a result of cost-recoverytend to be better organized and have easier contact with decision makers than the vast majorityof the people who can be expectedto benefit from these actions. 60

Box 6. AIDSand HealthCare Refonn in Afnca

The burdenof AIDSunderscores the imponanceof reformingAfrican health care systems. Despitethe bIcurablecharacter of the disease,AIDS padents have begun to overwhelmhospitals in a numberof Africancapital cities, includingBujumbura, Harare, Kampala, Kigali, Kinshasa, and Lusaka. These padents displace others who can be cured, thusfurther reducing the effectivenessof the healthcare system. Thedevelopment and introductionof guidelinesfor treatmentand careof AIDSpatients for useby healthcare personnel are critical.WHO's Global Program on AIDShas doneimportant work on this subjectto helpdeveloping countries.

An appropriatepublic policy response by Africangovermnents to the publicoutcry to combatHIV infection startswith prevention. The toppriority is to useavailable public financial and humanresources for carefullytargeted publiceducation and condompromotion campaigns, and for the detectionand treatmentof othersexually transmitted diseases. For thoseaffected by the opportunisticinfections assoacated with AIDS, the firstpoint of contactin a well- funedoninghealth care system will be wit healthcenters for drugs,counseling, and relief of suffering.As the afflicted developfull-blown AIDS they may needreferral to a hospital. In the finalstages they tendto becomebed-ridden at home,best servedat thecommunity level by familymembers and outreach from health centers. Makingthe health care systemfimction as it shouldcan be expectedto reducewhat would otherwise become an unbearableburden of AIDS padentson Africanhosptals.

A possible first step would be to freeze existing budget levels for tertiary care, instead of inCreasng them with populationgrowth and inflation.

CommunityEffectiveness and Multi-Sectoral inputs

That well-functioninghealth centers combinedwith first referral hospitalsand redefined cental hospitalscan help transformhealth outcomesin Africa is beyonddoubt. Yet this report is also concerned with susainable improvementsin health with the implicationthat health care per se can only master part of the task. Equallyimportant is to determinehow complementary, multi-sectoralinputs can be put into place at the communitylevel as well. It is with this in mind that the idea of cost-effectivenessused in this report contains a provision for maximizing communityeffectiveness, achieved when a cost-effectivepackage of basic healthcare, supporting serces, and multi-sectorl inputs works together simultaneouslyto improvehealth.

It is at the local or communitylevel where women and children fetch drinking water; where human wastes need to be controlled to prevent contamination and disease; where nutritionaldeficiencies can best be seen and corrected; and where familiesmake decisionsabout the mmnberof children they want. Moreover, it is at the communitylevel where resources for many non-healthinterventions can best be planned, monitored,and evaluated,especially in rural areas where national or regional systemsof tapped water and sewagedisposal are not in place.

Becausethe support services and complementaryinputs usually require collectiveaction beyond the capacity of individualsor households,a certain level of populationaggregation is required to provide them. Singlecommunities, or collectivitiesof communitiescan perform this fumction. Collective action to provide mechanicallyoperated hand pumps is an example. Tweny communitiesin Kwara State, Nigeria, installedhandpumps to provide clean drinking water with the result that Guinea worm infections decreased by 81 percent (Edungbola and others 1988). Iaformation assembled in Chapter 8 suggests that a borehole and handpump serving up to 250 people in a village with about 20 liters each day can be provided for about 61

Box 7. EnsuringSupportfrom Public Health Services

Many of the servicesin the basic health servicespackage oudined in this chapter, such as immunizaon,nutrition programs, and masschemothepy againsthelmhint, are somelimesconsidered to be publichealth interventions becmse the benefits extend beyond the immediatrecipient. They are included in thebasic pakage herebecause they are usuallyprovided with the support of thesucture of healthcentes, first referralhospitals and distict healthmangement teams which provides individual health care also. In this study,therefore, public health services are conceivedsomewhat more narrowly. Key publichealth activities falling outside the basic packageof healthservices discussed in this chapter,which merit increasing attention in manyAfrican countries include:

* Diseasesurvne, epidmologicaland healh programanalysis, and policy formulation. A soundunderstandig of the diseaseprofile affectng households and communitiesis cntral to provisionof beadthinformation and choiceof cost-effectiveinterventions for inclusionin the basicpackage of health services. Yet, manyAfrican Ministres of Healthhave allocated few resourcesto theseessential actvites. As they reducetheir role in nmanmt of healthcare facilites, andgive greaterattention to steeringthe totalhealth care system,including private providers, and endeavor to take intoaccount the likelyhousehold responseto publicactions, African Ministries of Healthwil needto developincreasing sophistcated analytic capacity. Sometimesthey will be able to drawupon university facilities and otheroutsiders for policyand programanalysis, but formulaon of policiesis a publicfucution which cannot be delegatedto others.

* Provisionof healh iofomationto tle public. A wide rangeof healthinformation wLi help indivikdalsand householdsto take greaterresponsibility for their ownhealth, but it mustbe providedin a mnnmerand by sourcesthat makesit acceptableand credible. Healthinfotmation has sometimesbeen distortedor withheldby Africanand other govenments. Theissue is of such importancethat publicaccess to health informationis assertd as a humanright by somewriters (Lucas 1992). Topicsthat mightbe covd under informationprograms encompass: disease levels and outbreaks;the quality,price and availabilityof individualhealth care serces; environmentalhealth threats such as indoorair polluton; substanceabuse, including smoking and alcohol; and traffic safety, imcluding the growingburden of vehicle alcidentson Africanroads. * Healthkgislation and regulation.Many Afican counties havebasic healtd legislation that has not been updatedsince iodepdene. Bunndi, to cite an exampleto the contray, has adopteda public healthcode coveringthe promotionand protectionof healthand the exerciseof the medicalprofessions. Someother coies, icluding Angola,Botswana, Burkna Paso,Central Afncan Republic and Senegal, haveadopted laws or regulationstouching on key healthvariables (WHOIAFRO, 1990. documaet AFRO, ICPHILEIOO1,April 1990). Pharmacuticalsis a particularlyimportant area for action,given the technical comlexity of the issues(see Chapter 4).

$2.60 per capita per year (inclding amordzation)in low-incomecounties of Africa.

Anotherfeasible and affordabletechnology is the pit latrine. Improperdisposal of human faecal materidalcan lead to poRutionof ground water and springs, not to mention contamination of food supplies. A study in Uganda, for example, foundthat 30 to 40 people in a neighborhood were required to use the same latrine. Yet, as illustrated in Chapter 8, a ventilated and improved pit latrine (VIP), made of local building materials for a family or householdcluster of ten can be provided for about $1.40 per capita per year in low-incomecountries of Africa. 62 At the heart of the matter is collaborationand partnershipbetween providers of health care on the one hand and communitysupport of multi-sectoralinputs on the other. If national and local governmentsare already providing multi-sectoralinputs through public works and other support, then communityaction on this front becomes less critical. In most countries, however, national and local governmentsare havinga hard time maintaining,let alone extending public goods and services into more remote areas. Communityaction must therefore be at the apex of strategies for better health. Governmentscan help facilitatethis process, as argued in Chapter 7, by encouragingand empoweringcommunities to take a greater role in determining their own health outcomes. Conclusion

Far greater headwayis likely to be made in resolvingAfrica's health crisis if systems of health care feature cost-effectivepackages of basic services, well-functioninghealth centers and first referral hospitalsat the district level, and communityparticipation. Emphasison basic and essential health care services is precisely what is needed given the demograpthic and epidemiologicalprofile of African societies. Developmentof well-functioninghealth centers and first referral hospitalsis compatiblewiffi the goals of promotingequity by extendingservices to underservedhouseholds in rural and pen-urban commumities.By improvingefficiency of health care services at the first level of contactand gettingthe referral system workingwell, prospects of bringing skyrocketinghospital costs down improve. A distinctlycommunity focus helps to overcomeweaknesses in capacityat the national level and offersthe opportunityof detennining a locally relevant health care package, enhancingaccountability between providers and clients of health care, and mobilizingresources for multi-sectoralinputs to health. Finally, support from public health services can play a critical role in building more effective channels of communicationsbetween health providers and consumers as regards, for example, health legislationand regulation affetng facilities and health care services, and provision of bealth informationto the public (See box 7). CHAPTER 4: PHARMACEUTICALS AND ESSENTIAL DRUGS

Introduction

Medicinesoffer a simple,cost-effective answer to manyhealth problems in Africa, providedthey are available, accessible, affordable, and properly used. From the household's perspective, the availabilityof medicinesis one of the most importantand immediatelyvisible symbolsof quality care. Expenditureson medicineswere about48 percentof householdexpenditures on health m Senegalbetween 1981-89and 55 percent in Ghanain 1987-88. Inadequateor unreliablesupplies of drugs motivate clients to abandonone provider for another, and contributeto failure of the referral system.

From the perspective of health care providers, a regular supply of drugs is a fundamental componentof a well-functioninghealth system. In public and private health facilities,phanraceutical expenditu typically comprise 20 to 30 percent of total recurrentcosts, secondonly to personnelcosts (World Bank 1992d) When resources are insufficientto maintain stocks of drugs, the effectivenessof recommendedtreatmes and public confidenceis undermined. Studieshave found that when drugs are out of stock in Nigeria, for example, utilizationrates for health facilities can fall by 50 to 75 percent (World Bank 1989b).

Governmentsseek to improve the performanceof pharmaceuticalmarkets because drugs are a vital componentof cost-effectiveapproaches to health care. More than 90 percent of pharmaceuticals in Africa are imported,and both public and privateproviders are concernedwith prowrimgquality drugs at low cost. Governmes also have an important role to play in correcting imperfections and informationalasymmetries, which characterize markets for drugs. In pharmaceuticalmarkets, the consumer seldom chooses a particular drug, but rather relies on the competenceof the prescriber or seller. Consumersmay be entirelyunable to assessthe effects or relative merits of particulardrugs, even after using them. When drugs are inappropriatelyprescribed or mis-used,personal injury can result.

For the above reasons, govermnentshave a multi-facetedrole to play, related to disseminating informationon the proper use of drugs; institutingand maintainingquality controls; establishingessential drug lists; formulating national drug policies; ensuring appropriate roles for the public and private sectors; and coordinatingdonor assistancein financingand procuring drugs.

This chapter begins by documentingproblems that are underminingthe potentialcontribution of phannaceuticalsto better healthin Africa. Inefficienciesand wastein the managementof pharmaceuticals are highlighted. This sets the stage for a review of more efficient, equitable and sustainabledrug practices m the context of well-functioninghealth ceers and first referral hospitals. Such practices are particularlyrelevant to low-incomeAfrica and the cost-effectiveapproach to health care featured in this report (Chapter 3). Broad guidelinesfor govermnentaction in support of more comprehensive,national drug policies are then reviewed. 64 Performance

Between1986-87, the World Health Organizationconducted a survey in 104 developingcountries on the availability of essential drugs (WHO 1988d). In 17 countries comprising about 200 million people, including Nigeria, about 70 percent had no regular access to essential drugs. In another 14 countries, again conmprisingabout 200 million people, 40 to 70 percent had no regular access. And in nine countries with a combinedpopulation of 50 millionpeople, 10 to 30 percentbad no regular access. Combinedwith other sources, these estimatessuggest that up to 60 percent of the populationof Sub- Saharan Africa has no regular access to essentialdrugs.

Shortagesof appropriatedrugs plaguepublic sector health facilitiesin many countries, especially at lower levels in the referral system. Drug stock-outshave been widely documentedin pen-urban and rural areas due to management,logistical, and financialproblems. In Angola, drug stock-outshave been frequent, even in major hospitals. In seven provinces for which data are available, only 48 percent of the communitieshad regular health staff visits ("controlo sanitario' visits), to resupply local health facilitieswith drugs and other supplies. In Tanzania,under-financing of drugs by the Minisbtryof Health led to under-provisionof medicines in hospitalsand reliance on foreign aid to provide drugs for mral primary care.

Private-for-profitfacilities tend to have fewer problemswith drug shortages,but clients also tend to be upper-incomehouseholds in urban areas. The small numbers of trained pharmacistsworking in Africa generally prefer to open city retail pharmacies,conducting a trade largely in western specialty drugs. Western drug firms or their representativesoperate in similar fashion, as does the wholesale trade, providing supplies largely to private pharmaciesin cities. In Niger, for example, 46 percent of private drug sales in 1986 were in Niamey, the capital city, and another 35 percent were concenrated in capital citiesof other admiistrative depar . Only 20 percentof privatesector drug supplieswere distributedamong 85 percent of the remaiig populadton,located predominantlyin rural areas (World Bank 1986).

The organized private sector also tends to thrive on the sale of high-cost, high-profit drugs in cities, benefitng from the widespreadbelief that its products are superiorand thus worth a higher price. In Sierra Leone, for example,the mark-upon private sector sales of chloroquineranged from 400 to 800 percent in 1983. Iregular private drug suppliersare generallymore accessibleto peri-urban and mral householdsthroughout Africa - in the form of private clinics, drug shops, and travellingpeddlers - but the qualityof servicesprovided is often poor. Moreover,drugs sold at these outletsare frequentlystolen from the public sector or importedfrom neighboringcountries without quality control (Whyte 1990). Such non-systemproviders of care cannot be ignored. Markets,for example, were estinated to represent 35 percent of the supplyof antimalarialdrugs in Togo in 1989.

When medicinesreach their point of destination,they are often inappropriatelyadministered and used, because of inadequateknowledge among professionalsas well as consumers. In Mali, a survey fouwndthat the averageprescription contained ten drugs, sometimesincluding duplication of the same drug under different names. In many cases, it is likely that one or two drugs would have sufficed (Foster 1990). In the treatm of a large sampleof cases of diarrhoeain Nigeria, it was found that expenditures were some thirtytimes higher than they need have been, largelybecause of the use of specialtyantibiotics which were not required (senaklumheand Oviawe1988). And despite the fact that injectionsare needed only in a minority of treatments, a study in Ghana found that 96 percent of visits were treated with at least one injection. There was an average of 3.9 items per prescription(Dabis and others 1980). This did not, of course mean that each item was availableor efffectivelyused. 65 Drugs are all too readilyconceived as the answer to almostevery health problem in Africa, thus enouragig consumersto use them ineffectively.Even essentialdrugs are often mis-usedbecause himited undestand_ng and information leads to poor compliance with prescribed tegimens (Poster 1990). Moreover, a commonmisconepion among consuners (as well as prescribers),is that "generic"or low- coStdrugs suppliedthrough public services are inferior to those sold in the privatesector. This is rarely the case, but the misconceptioncan often lead to illogical and wasteful drug choices. In Kenya, for exaple, it was found that somepatients traded in their free genericdrugs at pharmaciesto buy identical specialty drugs which they believed were better (Ministryof Health, Kenya 1984).

Many countrieshave launchedEssental DrugsPrograms (EDPs)aimed at improvingavailability, affordability, and proper use. To help facilitatethis, the World Health Organizationhas prepared and occasionallyupdates a model list of about250 essentialdrugs that can effectivelytreat, at reasonablecost, a large majorityof ailments frequentlyexperienced in Africa and other world regions.

Yet, EssentialDrug Programsare not the fill answer to phannaceuticalproblems. In Angola an EDP was launched in 1987, supportedby the Swedish InternationalDevelopment Agency (SIDA), in cooperationwith UNICEF. An evaluationof Angola'sEDP by SIDA and the Ministryof Health in 1990 reveals problems commonto a number of African countries:

- The EDP is a vertical program with very little coordinationwith other programs.

* The EDP does not have a serious traimingprogram for health care providers.

* The information and feedback system on EDP performance is complicatedand is of little practical use, partially because the responsibilitiesand tasks of the NationalPharmaceutical Directorate and the National Directorate of Public Health have been poorly coordinated.

3 The country does not have a well-definedpharmaceutical policy, althougha NationalDrug Commissionexists.

In Ethiopia an essentialdrug list was adoptee in 1986. Two years later, however,a completeselection of essential drugs was found in only 7 percent of the country's health centers. A much more basic list of ten drugs was present in only 38 percentof the centers (Hodes and Kloos 1988). Co taints and Opportunities

The performanceof pharmaceuticalmarkets is shapedby the interactionof a varietyof demand and supply factors. Some present greater obstaclesto resolving shortages of drugs than others, and require coordinated action on several fronts to overcome them. In most African countries, private expendituresdominate pharmaceutical nmrkets, as in BurkinaFaso, CMted'lvoire, Ethiopia,Kenya, Niger and the Sudan (see Table 1). A clear indicationthat private expenditures,consumer preferences, and ability to pay are important determining factors in the availability and distributionof medicines is apparent from Table 1. In six of nine countriesfor which data are available, private expenditureson drugs exceedpublic expendituresby a considerablemargin. Supplyfactors, on the other hand, take on special significancebecause more than 90 percentof pharmaceuticalsin Africa are imported.

A Demand-Side Perspecve

From a demand-sideperspective, the importantfactors are incomes,prices, diseasepatterns and educationallevels: 66 * ncome Changesin total drug importsclosely follow changes in per capitaGNP. As a 'rule-of- thumb', a 10 percent increasein GNP per capita results in an 11-13 percent increase in per capita drug imports (Dunlop and Over 1988;Vogel and Stephens1989; Gertler and Van der Gaag 1990). In Ethiopia where average per capita GNP was about $130 in 1987, phanraceutical expendituresfrom all sources were about $.95 per capita during the mid-1980s. In Sudan and Kenya, with per capita GNP of about $330 in 1987, pharmaceuticalexpenditures were about $2.30 to $2.40 per capita. And in CMe d'lvoire with a per capita GNP of about $740, expenditureson drugs were about $8.60 per capita in the mid- 1980s.

Income takes on even greater significancewhen its effects are assessed across income groups within counties. Survey data on Ghana show that per capita householdexpenditures on medicinesare several tims more in the highest incomequintile than the lowestquintile (see Table 11). Each quintile contins 20 percent of households,the first being the lowest incomegroup, the fifth being the highest income group. These orders of magnitude suggest that effective demand for drugs is likely to be relatively weak among the poorest groups in peri-urban and rural areas. As such groups tend to rely disproportionatelyon public health facilities, they will be most sensitive to disruptionsin the supply of medicinesin governmentfacilities.

Just as an increase in income tends to raise consumptionof phannaceuticalsby more than a proportionateamount, a decline in per capita income- attributableto slow economicgrowth combined with rapid populationgrowth - can have the opposite effect. Per capita incomesand real purchasing power of African householdsgenerally declined during the 1980s, with the implication that falling incomes are at least partially responsiblefor shortfallsin drugs. Amongseven countriesfor whichtime- trend data are availablefor at least four years, a drop in the share of pharmaceuticalsin the recurrent

Table1. Expenditureson Pharmaceuticalsin SelectedAfrican Countries,Mid-I 980s Esiated % Estimated shareof Estimated Esimated Estimatedtotal per capita GDP publicpharma- privatepharma- pharma- pharma- comprsedby ceuical ceutical ceutical ceutical pharma- expenditures expenditures expenditures expen- ceutical CowY Year milion USS milion US$ millionUS$ dauresUS$ expeniures Burkina Faso 1981 5.5 10.1 15.6 2.19 1.38 C6te d'lvoire 1985 2.7 81.5 84.2 8.63 0.57 Ehhhopia 1986 8.7 33.8 42.5 0.95 0.86 Kenya 1986 16.0 34.0 50.0 2.36 0.84 Mozamnbique 1985 5.6 1.3 6.9 0.50 0.21 Niger 1989 5.9 18.3 24.2 3.20 1.03 Sudan 1988 5.5 49.5 55.0 2.31 0.49 Tanzania 1987 19.9 10.7 30.7 1.32 1.00 Zimbabwe 1988 15.1 6.5 21.5 2.42 0.38

WeightedAveage - - - 2.10 0.76

Source: World Bank 1992d. TWP No. 4. 67 costs of health facilitiesis apparent in Botswana,Kenya, Ethiopia and C6te d'Ivoire. Making the best use of avaiable resources for drugs, while simultaneouslyproviding for the poor, therefore takes on immenseimportance.

* Prices: Available evidence suggests that the price elasticity of demand for medicines is relativelyinelastic, meaningthat the demandholds up in the face of price increases(World Bank 1992d). In Cameroona pre-test/post-testexperiment showed that use of publichealth facilitiesby poor households acually grew when price increases were accompaniedby quality improvementsin health services, includingmore reliable suppliesof essentialdrugs. There is also evidenceto show, however, that the price elasticityof demand is likely to be greater for the poor than for more affluentgroups, as in C6te d'Ivoire (Bitran-Dicowsky1991; Gertler and van der Gaag 1990; Mwabu 1984). Again, this suggests the need for administrativelyfeasible approaches to provide the poor with accessto essentialdrugs so that dthy will not be adverselyaffected (see Chapter 7 also).

* Disease Patters and Drug Treatmt Costs:Changing patterns of diseaseand mortalityimpact on the kinds of drugs demandedand, sometimes,costs of particular kinds of drugs as well. Mortality and morbidityin Sub-SaharanAfrica are dominatedby peri-natal,infectious and parasitichealdh problems with the implicationthat a rather standardpackage of essentialdrugs shouldbe able to accommodatea sizablemajority of healthproblems in Africa. The World Health Organizationhas quantifieddrug needs on the basis of availablemorbidity data and informationon past consumptionin several Africancountries, to evaluate the cost of treatments using basic drugs. Results, summarizedin Table HI, show that treatment using 30 to 40 drugs in a well-equippedhealth center costs about $31, on average, per treatnent episode. Treatment of more complex illnesses - and comensurate drug regimes - is estinated to cost about $.50 at a hospitaloutpatient department. WHO concludedthat the range of costs is surprisinglylow when comparedwith existingexpenditure levels, thoughthese cost estimates assume a degree of efficiency in all aspects of the drug supply system that is rare in most countries (WHO 1988c).

* Education:Education is an importantdeterminant of self-medicationand treatment, with more educated consumersusing over-the-countermedications more appropriatelyand seeking care earlier in an illness episode (Dean 1981; Haynes and others 1976). This is consistentwith the role of education as an efficiencyparameter in householdconsumption of health care in general. In view of high levels of illiteracy in Africa, especially among females, this suggests that information, education, and communicationprograms could make a potentally immensecontribution to more efficientdrug use.

A Supply-Side Perspective

From a supply-side perspective, it is Table 11. Per CapitaHousehold Expenditures on commonly argued that shortages of drugs can be Medicines, Ghana (1987/88) attributed to limited prospects for domestic Household Expenditures productionon the one hand,as well as obstaclesto iom eQlluint) importation on the other. It is argued that local production could lead to savings of scarce foreign 1 1.45 exchange,produce drugs at less cost (assuminglocal 2 2.21 labor is cheaper), and eliminateproblems of paying 3 3.32 for out-of-date drugs. However, this position is 4 4.24 questionable. Though independentstudies on costs of local productionare difficultto obtain, especially Average 3.93 by type of drug, expert opinion suggests that internationalsources typically realize full economies Source: World Bank, LivingStandard Measurenme Surveys. 68 of scale at higher quality standards than would be Table IZI. Average Drug Costs possiblein most Africancountries in the foreseeable per Treatmw Episodeby Leve of Care, future(World Bank 1992d). SelectedAfrican Countnies, 1983-88

Where there is no current local Hospital pharmaceutical production and manufacturing Health Outpatient tradition, the extremely competitive world market Country/lstitution Year Center Department for generic drugs makes it highly doubtful that production should now be instituted. Very simnple Kea pruraryCare 1984 .20 products - where the transport costs of inported KenyaHospital OPD 1985 .50 items are disproportionately high, as in some Sudan 1985 .32 .59 intravenous fluids - may constitute an exception. Burundi 1986 .37 Where there is already a nucleus of local Gambia 1987 .35 .50 production, a phased approach is likely to show Guinea-Bissau 1987 .31 most promise, starting with packaging and tableting Uganda 1988 .29 .29 of widely used items such as aspirin and Average: .31 .47 chloroquine. Intermediate phases involve increasingly complex production processes until Source: WHO 1988c. ultimately, local industry is researching and producing pharmaceuticals (World Bank 1985c). This pattern has evolved in countries such as Ethiopia, Sudan, Kenya, Ghana, and Zimbabwe, and by 1992 local companies were producing a growing share of total domestic consumption. In Kenya, for example, the first of two essential drug kits, comprising 22-23 drugs for rural health facilities was imported; but the second, which containing 12 items, has been largely produced locally (Tropen 1989). Ethiopia produced a similar share of its essential drugs. Of the total demand for pharnacticals, about 30 percent is now met by domestic production using imported raw materials. Thus, while prospects are slim that economically competitive, large-scale domestic production can be relied upon to meet shortfalls in essential drugs, many countries should be able to expand production in key areas over the next decade or so.

Given Africa's reliance on phanmaceutical imports, the availability of foreign exchange constitutes another important supply-side constraint. Because supplies of foreign exchange are contingent on export earnings and terms of trade, which did not perform well during the 1980s in nany countries, it is not surprising to find that external resources have helped to sustain pharmaceutical imports throughout the region. Major multilateral and bilateral donors include DANIDA, SIDA, ODA, USAID, the World Bank, and the Drug Action Program of WHO. Total known assistance is over US$160 million per year in current programs, though the actual amount may be higher.

Still, the level of international assistance for drugs is small when compared to the size of the market, which has been estimated to lie somewhere between $850 million and $1.5 billion for Sub- Sabaran Africa in 1989 (World Bank 1992d). Moreover, foreign exchange can also be squandered if the private sector imports expensive specialty drugs that are no better than generics or have no value for health. Assuming that the willingness of donors to provide support cannot always be foreseen, the availability of foreign currency resources, as well as their use for public and private sector drug imports, needs to be evaluated critically. 69 Assesment

Becausepharmaceutical markets in Africa are heavilyinfluenced by private expenditures,income levels and prices, it wouldbe temptinglysimple to attributedrug shortagesin low-incomeAfrica to a lack of fimding, particularly in periods of economicdecline. And, because pharmaceuticalmarkets will continue to rely heavily op inports, it is temptingto seek remediesin donations,loans and reallocation of public expendituretowards more drugs, especiallyin view of uncertainies over future capita income growth, trade balances, debt servicing, foreign exchange,and the short-termeffects of macro-economic adjustment. Yet, studiespublished as far back as 1984/1985claimed that full coverageof essentialdrugs for primary health care couldbe achievedfor less dhn US$ I per personper year (KasongoProject Team 1984; Steenstrup 1984; Jancloes and others 1985). These impressionsare confirmedby tle evidence marshalledby WHO in Table III.

World comnmodityprices have risen since 1985,but the $1 per capitafigure still remainsgenerally valid because internationalcompetition on the genericdrugs market has intensiftedand drug prices have gone down rather than up. And $1 per capita is clearly below average per capita expendituresof about $2.10 computedfor the nine countriesin Table 1. This suggests that demand and supplyconstraint, as importantas they may be, are not the nain issue in drug shortagesin Africa. Quantifying Inefficiency and Waste

The loomingproblem in Africandrug marketsis iunefficiencyand waste. In Nigeria, for example, technicalreviews of public healthfacilities revealed that ineffectualand even dangerousdrugs have been frequentlyprocured; branded rather than less expensive genericdrugs tend to be purchased; drugs are often purchased locally in small quantities instead of in bulk through open internationaltender, thus underming cost-effectiveprocurement; many drugs are damaged after purchase by faulty storage practices or disappear due to inadequatestock control procedures; and becauseof inadequatediagnostic capabilities, health staff prescribe an excessive mber of drugs in an attempt to treat a number of possible diseasessimultaneously (World Bank 1991c).

Inefficienciesand waste appear to be sufficientlywidespread in many African countries that patientsof public sector health facilitiesmay be effectivelyusing only $12 worth of qualitydrugs for each $100 of tax money spent. Six factors are largely responsible.

First, selectionof drugs tends not to be based on cost-effectivenesscriteria. Prices for different drugs for the same conditioncommonly vary by as much as five to ten times and, exceptionally,by as much as 130 to 150 times. Comparisonsof drugs used in African countries in the 1980s, for example, reveal that more expensivedrugs for urinary ract infection,arthritis and inflammationcost six, eight and twelve tmes, respectively,more than their low cost alternatives(Upanda and others 1983). Drawingon an assessment of drug practices in Africa during the 1980s by WHO, the absence of cost-effective selection can be estimatedto be responsiblefor a loss of about ten percent, on average (WHO 1988c). As illustrated in Figure 1, this is equivalentto reducing $100 in the public budget allocationfor drugs to $90.

Second, quanificationof needed drugs over a given period (usual!ya year), is frequentlyabsent as a basis for ordering drugs. Once drug needs kave been quantifiedon the basis of morbiditypatterns, large quantities can be bought, with substantL vingsin cost. In Gabon, for example, in 1986"87a systemto calculateessental drugs requireme d have reduceddrug expendituresby up te45 percen (Soeters and Bannenberg 1988). On average, failure to order on this basis can result in a loss of 13 70

Inefficiencies& waste in the supply of drugs From budget allocation to consumer Budget Allocation Health tor drugs C0I QIQ ) 1* * O. ..*Q ite4S * * * *..Consumer idb

40.. m m m m

$20~~~$1 20 . 31 3 i3 5 $ 15 20

buaing Infantbtlonal nrr prwtmc "nefficlentfQuaftlo PPptb Non. probbnms distribution compiance by patiants O Remaining Value Cumuaive LosSeS

Sourte: Foster1990.

percentof every$100 spent. In Figure1, $76 nowremains of the original$100 for drugs. Third,proment is rarelybased on competidvebidding for generic drugs. Directimports tend to be arrangedfrom "high-pricedsources". Astutebuying on the worldmarket has sometimesreduced the averagecost of drugsimported to Africancountries by up to 40 perce (Margao and Segall1983; Hogerzeiland Moore 1987;Yudkin 1980). In a Nigerianstate a WHOstudy found that by funther shiftingfrom brand name to genericdrugs, costs could be reducedby another25 percent(World Bank 1989b).Comm importsof tetcine in Ethiopiawere narly ree timesthe pricepaid by a drug purchasingagency. On average,losses from inefficient procrem havebeen estied to amountto about27 percentof every $100spent. In Figure1 the balanceis now $49. Fourth, poor storageand inventorymanagement, expiration of drugs before use, theft and pilferagecontribute to fther losses.In somecountries, 15-25 percent of drugsremain in the systemuntil they are life-expiredand thus useless(WHO 1986; MSH 1984). In Cameroona studyrevealed that 35 percentof the medicineswere lost from centralmedical stores due to poor storageconditions and expirationresulting from poor inventorycontrol (Van der Geest 1982). Theft and cornrptionof pharmacuticalspose specialproblems because drugs can be easil, disposedof dtough privatesale. In Ugandaa thirdof all drugsare thoughtto be lostto theftand corruption. In Cameroon,30 to 40 perun may be "wihdiawnfor privateuse" by staff. In Guineain 1984 an estimated70 percentof the government'sdrugs disppeed (Foster1988). In Tanzaniathe rate of pilferageis estimatedat about 71 30 prcent for drugs outside the eenti drugs progrm (World Bank 1989g). On average, losses poor storage and distributionhave been emated to amount to about 19 percent of every $100 spent. In Figure I the balance is now $30.

Fifth, irrational drug prescription,as in poly-phamnacy,contributes further to inefficiencies. In the Kivu Region of Zaire, a study found that a typical prescription filled by a private phannacy f.- tratment of bronchitis in young children encompassedfive to six drugs includingan antibiotic, cough syrup, a tranquilizer,vitamins, aspirin, and, if fever was present, antimalarials,for an averagecost equal to approximatelyone month's per capita income(World Bank 1989h). Studies in 1992 of health care facilities in Nigeria and Tanzaniafound, on average, 3.8 and 2.2 drugs, respectively,per prescription (WHO 1993). On average, losses from irrationaldrug prescriptionbave been estimatedto accou for about 15 percent of every $100 spent. In Figure 1 the balance is now $15.

Sixth, problems of patientcompliance reduce the proportionof public drug expendiures that are used effectively, often the result of communicationfailures between health workers and patients. In Zimbabwe researchers concluded that self-medicationwith chloroquine for malaria prophylaxis was common, but that it was often wrongly used, and that if the useful life of this low-costdrug was to be prolonged and injury avoided, better public informationwas needed (Stein an-dothes 1988). Even essential drugs are often poorly used because inadequateinformation leads to poor compliancewith prescribed regimens (Foster 1990). On average, losses from inadequate patient compliance are responsiblefor another 3 percent of every $100 spent. The remainingamount in Figure I is only $12. Whatis Missing?

The reality in many African countries is that the present performanceof pharmaceuticalmarkets is at odds with efficient, equitable and sustainablesystems of health care. Symboliccommitments to primary healthcare are weakenedbecause reliablesupplies of medicinesare not availableto the majority of African householdsin peri-urbanand rural areas. This contributesto a lack of public confidenceand prompts residents at the communitylevel to seek medicinesfrom traders, and from intermediate-level facilitiesand hospitals,thus underminingthe referral system.

Cost-effectivecare is compromisedbecause recurringhealth conditionsin Africa are not treated by relatively simple regiments of essential drugs. Recurring illnesses associated with malaria, hypertension, diarrhoea, diabetes, respiratory infections,measles, asthma, polio, sexually transmitted diseases, and maldnutritioncan be effectivelycombatted by a relativelysmall number of "essential"drugs selected from the many thowusandsmarketed worldwide. They can be procured in bulk at low cost to the conumer with confidencethat the nedicines purchased are well-suitedto the health problems of the majority of the population.

Inefficienciesand waste in procurement,storage, prescription,and use prevail to the extent that far more is being spent than is necessary. Issues in prescriptionand use are particularly importan. These problems erroneouslyreinforce the impressionthat the answer to drug shortagesin Africa is more money, when greater headway is likely to be achievedby more effectiveuse of existing resources. To do so, improvedmanagement is requiredof all links in the chain, begiming with selection,procuremen, storage, prescription, and use of drugs, right down to the communitylevel.

Finally, because regular suppliesof medicinesare such a vitally importantcomponent of cost- efe healft serices, ways must be found to sustai revenues for drug supplies, par ary among public health provides, and to insure that foreign exchangereserves are availablefor maports. 72 OvercomingObstacles

Some, though not all, of the problems documentedare being resolved in the context of well- finctioning health centers, togetier with the support of a first referral hospital. Most important,the cost of drugs tends to be low in such contexts. This means that prices need not be high in relation to the abilit and willingnessof people to pay, even the poor.

In a well-functioninghealth center, the annual per capita cost of essential drugs has been estimated to range from $. 10 to $.25 (Yusuf 1993a). When dmg needs at the districthospital level are akded, costs are about $1 per person per year. This is enoughfor a "package"of genericessential drugs, sufficientto treat 85 percent of illnesses- as determinedby priority diseasesin the coveragearea such as malaria, diarrhoea, diabetes, respiratory infections, measles, pertussis, asthma, polio, sexually transmitteddiseases, malnutrition,hypertension, etc.. lProvisionsfor expandeddiagnosis and treatment of sexualy transmitteddiseases, made so importantby the AIDS epidemic,could reasonablybe expected to raise the $1 figure to about $1.Wsper person (see Chapter 8). This amount is less than per capita expenditureson drugs in six of the nine Africancountries in Table 1. It is also withinreach of the lowest income quintiles,as reported for Ghana in Table 2.

Distnbution of essential drugs within the context of well-functioninghealth centers and first referral hospitals can also extend essentialdrugs into rural areas where private pharmaciestend not to be profitable,especially in places of low populationdensity. To improveon distribution,many countries, such as Kenya, Tanzania,Uganda, Sierra Leone, and Zambia, favorpre-packaged, standardized drug kits which are assembled by the wholesaler and bypass the managerial problems of more centralized governmentdistribution systems. The contentsof the kits are tailoredto the average patternof use. This reduces cost, waste, and theft, as compared with systems where each drug is ordered and handled separately. This approach can thereforebe effectiveas a means of assuring that drugs actually reach the lowest levels of the health care system. Some care is needed to make sure that pre-packageddrug kits take into accountdifferential patterns of morbidityby location,and that the kit systemdoes not generate its own fonrs of waste.

Problemsof selecting,quantifying, ordering, and prescribingdrugs can be reducedby establishing needs at differentlevels of the referral system. For example, only 20 to 40 itemsare needed for primary care at bealth centers (Brudon-Jakobowicz1987). Quantificationof requirementsis easier at this level because the demographic and epidemiologicalprofile of conmmunitiesserved can be more readily determined, and actual practice of health centers versus district hospitalscan be assessed. The limited range of products needed also increases the likelihoodof sound prescription practices when used in tandem with standard treatm protocols,as in Zaire, Benin, and Guinea.

In well-functioninghealth centers, one-on-oneprovision of informationto consumershas been shown to improve compliancewith recommendeddrug therapies. As part of this process, prescribersat healft centers can be held accountableby a regularlyserved communityclientele who have recourse and provide feedback on the effectivenessof drugs, undesirableside-effects and so on. This process is reinforcedbecause personallinks tend to be establishedbetween providers and clientsat the conmnunity level.

Finally, in response to declining public resources for financing pharmaceuticalsand other recrrent costs, growing numbersof commuities have adoptedcost recoveryand self-fnacing schemes in local health centers and ditpensaries. Many such schemes have evolved under what has come to be known as the Bamako Initiative. In Benin, for example, the ever-diminishingpublic funds for drug 73 supplies led to an experimentalscheme under which patients would pay for the essential drugs they received. The price was set at three times the actual cost of the medicationsused; 85 percent of local operatingcosts, excludingsalaries, were covered by user fees, and helped to expand outreachof health services to communities. Over a three year period, receipts progressively increased as the public increasinglyaccepted the systemand the genericproducts whichit supplied. Eighty-fivepercent of local operatingcosts for the health service, excludingsalaries, were by that time covered by drug income,and the proceeds helped expand outreachof health services to additionalcommunities in the area.

A popular form of community financing is the so-called "drug revolving fund". The main features include(i) an initial stock donated by the community,government or other donor, (ii) sale of drugs to communitymembers, (iii) pricing for full recovery of drug supply costs, and (iv) use of sales revenue to replace stock and financeother operatingand distributioncosts. Drug revolving fund. can be operated on a public, private-voluntary,or private-for-profitbasis. In Africa such funds have been introduced in Benin, Cameroon, the Central African Republic, Chad, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leona, Sudan, Tanzania, and Zaire. Far from depriving the population of drugs, a successful revolvingfund actualy leads to etended coverage and better compliancewith treatment. Lessons learned in the design and implenentationof cost recoveryand revolvingdrug schemes include:

o Sharp price incrass should be avoided, especially in areas where the population is not accustomedto paying for servicesor drugs in the public sector (Blakneyand others 1989). Gradual price increasesover time, accompaniedby service improvements,are more acceptableto the population,which then have the time to observe and appreciate improved service delivery. A phased approach in the poorest areas mightwell require decliningsubsidies over a period of years insteadof an immediateswitch to full-cost recovery. In Nigeria, for example, states participatingin a nationally-sponsoredessential drugs program are being given five years to put full cost recovery into effect.

v A few experimentswith revolvingdrug funds, for example in Senegal, Niger and Mali, have run into problems because patient contributionsreceived have been insufficientto maintain momentum (Cross and others 1986; World Bank 1992d). These problems reflect failure to establish an effective scheme for the collectionof paymentsor to provide realisticallyfor the indigent,or they may result from an overambitious,national approach introducedwithout experimentation on a smaller, pilot scale.

* Cost recovery programsbased directly on the amount of drugs sold may create incentivesfor over-prescriptionand inappropriateuse of drugs. Standardtreatment protocols, external supervision, and payment by illness episode can help reduce incentivesfor excessiveprescriptions (McPake and others 1992). Role of National Governments

Improving the impact of medicineson health in Africa requires a facilitatingenvironment in which public officials, suppliers and distributorsof drugs, and providers of health care act together to promote widespreadavailability, accessibility and effectiveuse of drugs. Governmentshave an especially importantleadership role to play in institutingand maiaiing qualitycontrols, disseminatinginformation on the proper use of drugs to both prescribersand consumers,and monitoringdrug reform (see Box 1). Governmentsshould also take the lead by establishinga nationaldrug policy, overseeingthe planning, programmingand budgetingof nationalcapacity in the pharmaceuticalsarea, identifyingsuitably trained personnel to implementfinancial managementand drug informationsystems. Establishinga national drugs policy, based on the essentialdrugs concept, is an importantfirst step. 74

Ba 1. ImProvingPharmaceuWcal Markets Through Governm Action

&stUtimg and maintainingquaity controlsis a widelyneglected public role in drugs. Life-expiredand poor- quality phanabeutkas representa waste of resourcesas well as a threat to health. Some countriesare recipientsof majos flowsof false or spuriousdrugs. In the Adamaouaprovince of Cameroon,for example, it is reported that most mait drugs sold have been smuggledinto the countryfrom Nigena; manyare fakes. Qualitycontrol can be undertaken joiny by counties, involvingthe exchangeof informationon suspectsources or productsand the establishmentof joint qualt control centers. A precedentfor this type of collaborationis a regionalquality control laboratoryfor countries of southern Afica. situatedin Zimbabwe(Huff-Roussell 1990).

lnonnasion on the properuse ofdrugs,for both prescribersand consumers,is a publc goodmeriting far more atteion from Africangovernments than in the past. Initiativesto address poor use of drugs includepromoting better oteing to medicalstudents and otherson drugs. For example,a modelproblem-solving course in prescribinghas been developedand tested in Europe,and is beingimplemented and evaluatedin 15 otheruniversities, including two in Nigeria Nad Tanzania(De Vries 1992). Publicationscan be issued on the proper use of widely prescribeddrugs. Successful approaches include a pocket-sizednational formulary, reconmendedtreatbent schemes for common conditions,and regular drug informationbulletins such as the Zimbabweand CameroonDrugs Bulletins. Model texts, either for physiciansor for field workers, are readily available, from WHO, Health Action International,and the Inernational Socity of Drug Buletios. ufmnaiioncan be promotedthrough TV and other media, and govermnentscan take steps to counter mtisleadinginformation. Internationalstandards for ethical advertisinghave been establishedby both the pbiamaticasb industryand by WHO.

Governmentsalso have a critical roleto play in monitoringdrug reforms. Monitoringof reformscan be guided by:

* Pans for drug reform, detailing anticipatedimprovements in efficiency,mobilization of the private sector, esblishment of improvedtraining and drug informationfor medicalpersonnel, and provisionof drug informationto the public.

* The proportionof drugs on an agreed nationalessential drug list whichare accessible,without unreasonable constraintsimposed by distance, irregulardistribution, or financialbarriers, to not less than 80 percentof the population.

* The efficiencywith which resourcesare used in procurement,to determine(i) whetherexpensive specialty drugs are being importedin cases wherea high-qualitygeneric drug is muchcheaper, and if so, why; and (ii) the price paid for a standard mixed drug sampleas comparedwith that paid elsewhere.

* Efficiencyof prescribing. Sampledrug utfilizationstudies can be carriedout using well-establishedmethods, as in Zlmbebwe (van der Geest and Hardon 1988; Dukes 1993, and Nhachi and others 1991)) The African 'Drug Utlization ResearchGroup' sponsoredby WHO providesguidance in this area.

* Assessmentsof the abilityand willingnessof consumersto pay for drugs, analyzedfor varioussocio-economic groups.

Nationaldrg policies also ned a firm legal basisand structure for their execution. Existing laws and regulationstend to be concernedlargely with quality control or new drug approval. A snall but efficient drug authority, with a degree of autonomy and close links to govemmental and non- governme bodies involvedwith drugs, is likely to result in a more coordinatedand consistent multi- sectoraleffort. Much can be accomplishedthrough information, persuasion and incentivesfor all parties, coupled with a modicumof effective control to counter abuses. Least effective is to base policies on prohibition and repression. Unhealthypractices in the drug field are most effectivelycountered by offaring acceptablealternatives. The case of drug pedders in Kenya is typical. They largely lost their disreutable trade in malaria remedies once village health workers were adequately suplied with m_tlaaras (Mbum and others 1987; Whyte 1990). 75 Ongoing estimates of drug needs a B 2 E of DrugNees in Arca required to assure that the vast majority of the NeedN population has access to cost-effectivemedicines. Purchasingtoo much,or importingthe wrongdrugs, In Bobo-Dioulasso(Burina Paso)officials is obviouslywasteful, but inadequate purchasing will usedhe WHOprescitve methodto evaluatedrugs result in shortages which in turn can lead to need,based on mofbidy figures at threedispensaries, emergencybuying on the private market at inflated examinedover a 6-12month period. It wa assumed prices. Need estimatesare best madeby a joint thatstadrdd schemesof treatment would be used. Resultswere expressed per 1,000 inhabitants peryear. groupof healthprofessionals and resourcemangers Resultsproved to be reproducible.The method is so convenedby a drug authority(see Box 2). The simplethat after brief training it couldeasily be used estimatescan be published,as there is no needfor bytraied nurses. It resultedin imporntcorrecdons secrecy,and conmnentby bothproviders and users of preconceivedideas about what wasneeded. For at national,regional, and communitylevel can be example,the need for injectble produ provedto constructive. Guidanceon prices and sourcesof havebeen overestimtd (MaDcin and others1987). good quality drugs is available from regularly updated drug price lists issued by the WHO Essential Drugs Programme, UNICEF, ManagementSciences for Health (MSH), and the Interational Dispensary Association - a non-profit wholesale procurement organization for drugs and medica equipmentintended for non-ommercial health care projects.

Encouragingdevelopment of theprivate non-commercial sector, including the religiousmissions and such humanitarianbodies as Medecinssans Frontieresand te Red Cross Pharmaciesin Ethiopia is another means of expanding coverage of essential drugs. Various religious missions in Africa are increasinglyconsidering entering into collaborationwith one another to establishtheir own organizations for purchasing, warehousingand distributingdrugs, primarily to mission hospitals. In Zaire, concrete proposals were made in the early 1980s, and were widelyendorsed in church circles, to establisha no- profit, pharmaceuticalspurchasing group (World Bank 1989h,Annex m, p.2). These are often efficient operations, reflectingboth idealismand pragmatism. In several instancesthey have been guided into the essentialdrugs approachand use of generics in order to make betteruse of their resources(Hogerzeil and Lanberts 1984; Hogerzeiland Moore 1987).

Goverrnents can also foster developmnentof the private commercialand non-commerciatsectors by authorizinghealth servicesand hospitalsto make their drug purchasesfrom privatefirms where terms are more atractive, and supplies more consistentthan in central medical stores. The private sector has the same access to the world generic market as does the public sector, but is often capableof obtaDng better prices through its internationalconmnercial contacts and profit-maing incentives. The expansion of social marketingof essentialpharmaceutical products, such as contraceptives,can furdherstmuate developmentof the private commercialsector.

Where there is no viablenon-governmental alternative, African governmuents will need to continue to correct the principal defects of public sector pharmaceuticalentities, while providing incenives for private sector bodies to compete effectivelywith them. The ultimate balance between the public and privatesectors camot be predicted,and will probablyvary from countryto country. In some, the private sector may well develop to the point where it entirely supplantspublic mechanisms. Clearly, however, a public systemnfor purchase and distributionof dmgs should not simply be replacedby an unregulted private monopolyor cartel. In some cases, efforts may be justified to increase the efficiencyof public sector pharmactical entities as part of a program to prepare parastatal bodies for sale to the private sector. 76 Finally, assumingthat the willingnessof donors to provide support cannot alwaysbe foreseen, governmentsneed to criticallyevaluate the availabilityof foreigncurrency resources,as well as their use of public and private sector drug imports. In the absenceof an open trade and exchangeregime, a first step could be to considerclear inter-ministerialagreements on reservationof guaranteedforeign exchange for drug purchases, a practice followed by Zimbabwe. A commitmentto concentrateuse of foreign exchangeon drugs used at health centers and district hospitalsmay help. A small but finmagreement is far preferableto more substantialpromises that cannot be met. Long-termagreements can sometimes be negotiatedwith donors. This is far more likely to be attained, however, once donors are satisfiedthat coverage is increasing at the periphery and waste is being reduced. This subject is revisited in the financingand costing of basic health services in Chapters 8 and 9. Conclusion

Drugs are a central part of the challengeof better health in Africa. Africansare willingto, and do, make substantial out-of-pocketexpenditures for drugs. Yet, drug markets in Africa contain imperfectionsdriven by informationalasymmetries, the separationof financiersfrom decision-makersat the consumptionlevel, and by wasteand other problemsthat plague public interventionsin drug markets. At the same time, African countries have great potential for increasingcoverage and reducing the cost of drugs used by the population. Actions to reduce waste are tequired at all stages of the chain, from drug selection and purchasingthrough domesticdistribution policies and practices, to prescriptionand use of drugs by patients. Locally based drug revolving fimds have been successful in a number of African countries, and have the marked advarnageof communitycontrol. Monitoringof drug reform, and periodic assessmentof progress and results, are essential.

There is promising evidence that essential drugs can be provided for around $1.60 per capita anully for clients of well-funcioninghealth centers and district hospitalsand ihatcommunity-managed drug revolvingfunds can help assure sustainabilityof supplies(see also Chapter 8). Indeed, widespread coveragewith affordable,essential drugs is a criticalconmponent of the cost-effectivepackages of health care services discussed in Chapter 3.

While essentialdrugs lists are an importantcomponent of a comprehensivepackage of reforms that govemments, the private sector, and donors can promote, clear assignment of public policy responsibilityto a nationaldrug authority is needed. Consensus-buildingamong the many actors, from suppliersthrough prescribersand users, should be its style. Operationalresponsibilities for wholesale drug purchaseand distributionneed to be increasinglyassigned to the non-governmentalsector. To help facilitatethis process, governmentsare encouragedto be leaders of activitiesthat increaseefficiency in the operationof drug markets by fosteringdevelopment of the private commercialand non-commercial sectors; reinvigoratingpublic sector distributioncapacity and efficiency; and promotingcost-effective means of supplyingessential drugs on a sustainableand affordablebasis to the poorest groups in society. CHAPTER 5: MANAGING HUMAN RESOURCES

Introduction

Health systems canmot perform efficiently without well trained, motivated, and appropriately compensated personnel. Indeed, the quantity and quality of health services provided by doctors, pharmacists, nurses, public health specialists, health administrators,and related workers are criticallydependent on such conditions. They can makeor break otherwise cost-effectiveapproaches to health care.

Personnelconstitute the largest single item in Ministryof Health budgets. On average, more than 60 percent of public funds for health go to wages and salaries at the central level, to Ministry of Health managedhospitals and health centers, for administratorsat the provincialand district level, and so on. As most of these personnelhave been tained at public expense, and many of the services are expectedto benefit society widely, sound personnelmanagement is a priority for public action. The current situadonis extraordinarilyunsatisfactory, however. This chapter begis by docwnentingutilization and supply problemsthat plague health personnel in Africa today. Causes and consequences of these phenomena are then assessed. How improvements might be made, including complementary govermmentroles and supporing activities, are taken up in the balance of the chapter. Under-Utilizationand Under-Supply

Problemsfacing personnelmanagement in the health sector can be summarizedin terms of the under-utilizationof already tained staff on the one hand, and the under-supply of sufficientlytrained personnelon the other. When trainedpersonnel are utilized in ways that do not make full use of their skills, productivity falls. This is a pervasive problem throughout Africa, at all levels of the health camesystem. To illustrate:

* High level admimstrativepositions in ministriesof health tend to be filled by medical doctorsrather than by health professionalstrained in management,panning and budgetingskldls. In Ghana, for example, officials have insistedthat almost all of the top managementpositions in the Ministry of Health be held by physicians(World Bank 1989c). In Niger in 1984, 19 out of 52 doctors employed by the Ministry of Health acted also as full-time or part-time administrators(World Bank 1986). The effect of such practicesis to reduce efficiencyby using many of the reladvely few physicians in the country in roles for which they have neither the inclination nor the training, and to undermineperformance in administation and nagement in the process. 78 In Uganda in 1990, doctors in Ministry of Health hospitals saw far fewer patients per day than doctors in private voluntary hospitals saw (1.3 versus 6.7 per day) Under-utilization was such that Uganda was reported to be able to reduce health personnelby 30 percent without affectig the quantity or quality of services (Republic of Uganda, Ministry of Health 1991). Similarly, low productivitylevels have been reported among publc sector health personnel in Mali (World Bank 1991g, p. 7). Low productivityis frequentlyassociated with lack of supplies and equipment, or absence from duty in public facilities, due to the need for supplemental income.

* Were Rwanda's 500 midwivesfrilly utilized - meaning each would attend around 300 births per year in urban areas and about 200 in rural areas - about 36 percent of al} deliveries could be assistedby a midwife. In fact, only 18 percent of all deliveriesare attendedby trained personnel, implying that the equivalentof around half of Rwanda's midwives are being underutilized (see Figure 1).

Under-utilizationof health care personnel is also reflected in attrition of experienced personnel. This is particularlydamaging to the public sector when public funds are used to train

Fue 1. Under-Utilizationand Under-Supplyof HealthHunan Resources

Share of DeliveriesAssisted by Trained Personnel,Rwanda (1985)

18%18

Source-LWorld Bank. 79 personnel who then move out of the health sector, if not the country. Whle not all personnel who leave the civil service leave the health sector, many do. In Zimbabweit was projectedthat between 1991 and 1995, 1500 registered nurss would leave the public service, an annual attrition rate of 7.1 percent. In Uganda. as many as 40 percent of the nurses and 50 percent of the medicalassistants left the publicservice in 1986. Anothergroup with high attrition is female health workers who leave employmentto marry and raise children (Vaughan1991).

The emigration of large mumbersof health personnel has been lamented throughout Africa. Emigrationaffects mainlyhighly trained staff such as physicians,nurses, pharmacists, and senior laboratory technicians. Factors motivating emigration include better salaries and amenities,improved workingconditions, and politicaland social problemsin the home country. In Nigeria, based on 1988 exchangerates, losseshave been estimatedat about $30,000 for each emigrantNigerian physician(Ojo 1990). Furthermore,since emigrationis usually concentrated among the more senior personnel, it also tends to undermine future medical training and the developmentof research and institutionalcapacity.

The second major human resource problem in Africa is under-supplyof trained staff. Table 1 shows that thMpopulation to doctor ratio in Africa is five times that of all developing countries. In 1970 there were 19,000 persons per physician, and 3,000 persons per nurse in Africa. According to the latest availabledata, the ratios have improvd to 9,000 persons per physician and 2,000 persons per nurse. Despite major efforts to close gaps over the past generation,the supply of trainedpersonnel remains woefully inadequate, however. Africa-wide, the supply of trained personnel is so weak that less than 40 percent of African mothers had assisnce from a doctor, nurse, or midwife in childbirth over the period 1988 to 1992.

There ar also great variations in health personnel per capita among African counties. In the late 1980s the munber of people per doctor was 3,000 in Gabon but 29,000 in Ethiopia. In Botswanathere was one nurse/midwifefor each 500 people, but only one for each 20,000 people in Rwanda. Despite the improvementsin the 1960sand 1970s, the supply situationhas deterioratedin recent years, compoundedby rapid populationgrowth. Between1980 and 1986 Africa was the only region of the world where the number of doctors for each 10,000 people fell.

Table1. HealthHuman Resources Ratios, 1985-1990 All Developing Industrial Sub-Saiaa Africa Couries Couries World Popuation per doctor 9,000 1,500 350 900 Populationper nurse 2,000 1,700 180 570 Nurses per doctor 5 0.8 2 1.5

Source:Sudsa Appendix. Notes:Doctors include medical school graduates; nurses are regiered nursesand registeredmidwives only. Includesmidwive. 80 In view of the above, it is ironic that many Africancountries are beginningto experience the paradox of unemployedhealth care staf. As the number of health personnel completing education and training has risen, the demand for new staff in the public sector has fallen. In Tanzania 1,500 doctors and other health school graduates used to be absorbed into public employmentservice annually. This is no longerthe case. Mozambiquealso guaranteedpublic sector employmentto grduates of health institutionsin the past, but has had to scale back the mmber of trainees in recent years.

Countries such as Benin, Madagascar,Mali, and Zaire can now absorb only a fraction of the health school graduates in public employment. In Mali in 1987, the public service recruitedonly 4 out of 60 new physicians,one out of 35 pharmacygraduates and 19 out of 85 nurses. Projectionsmade in the late 1980sshowed that at prevailingrates of absorption in the public sector, Madagascarcould have a cumulativesurplus of 2,600 to 3,200 physiciansover ten years (World Bank 1987c, Annex 5, p. 1). Causes and Consequences

Under-utilization and under-supply of health personnel can be partially traced to compensationproblems, especially in the public sector. Wages and salaries tend to be so low that morale and motivationto perform designatedtasks are affected adversely. A study of 15 African countries showed that, from 1975 to 1985 the index of real basic civil service salaries for the lowest grades fell from 100 to an average of 53, and, for the highest grades, to an average of 41 (ILO 1989, Table 4.1, p. 84). In Tanzania, salaries declined, between 1981 and 1987, by 56 percent for the lowest grade workers, and 75 percent for those in the highest levels (World Bank 1989g). In Madagascarentry level salaries in 1988 were only 20 to 25 percent of 1975 levels - insufficientto support even a small family near subsistence. Professionally ined personmelin the publicservice find themselvesforced to work - informallyor officially- in private practice, or seek other inome-eaming opportnities.

Poor managerialcontrols, weak supervision, and unsatisfactorytraining are also to blame. Poor managerial controls are reflected in numerous categories of health personnel whose fuwctionsoverlap or are ill-defmed. A 1991 study in Uganda found 57 different categories of persomel in the health sector, 50 of which were clinically oriented (Republic of Uganda, Ministry of Health 1991, pp. 4-6). While Mozambiquehas reduced the number of categories somewhat, in the late 1980s there were still around 20, creating inefficienciesin curriculum developmentand health system staffing (World Bank 1990c,p. 53). The persistenceof large numbers of categories makes effective personnel management difficult, and the continuous addition of new categories, often under the impetus of donor-fundedprojects, compoundsthe problem.

Large numbers of low level and often excess functionariesfurther reflect the problem of managerial controls, and add to the expendiure burden in African Ministries of Health. In Ghana prior to restnctuing in 1987, there were 38,000 employeesin the Ministry of Health. Twenty-twothousand were non-technical,especially lower level staff, consming 53 percent of the recurrent budget. It was estimaed that the non-technicalstaff could be reduced by 8,000, thus saving 19 percent of the budget. In 1991 Uganda's Ministry of Health found that arnd 81 4,000 of its 18,000 employeeswere so-called "ghost workers", meaningpersons on the payroll who were not on the job. It concludedthat up to ten percent of total personnelexpenditures may have been lost through poor managementcontrols (Republic of Uganda, Ministry of Health 1991, pp. 134-135).

Weak supervisionreinforces the under-utilizationof public sectorhealth personnel. Clear and specificjob descriptions,performance criteria and appropriateformats for supervision are frequently missing. Practical training to acquire supervisory skills is lacking. In addition, budgetary restrictions in many countries have all but eliminatedtransportation, two-way radio and telephonecontact among ministry of health officials responsible for sepervisingsubordinates in distant places. To mention but a few indicativeexamples of weak supervision:

* In Niger, nurses are supposed to visit a village once every three months, but interviewsrevealed that eighteenof twenty-sevennurses had made only one round in the previous six months.

* In Senegal, two-thirds of ninety-twosupervisors interviewedhad cancelled planned supervision visits within the previous six months.

* In Zaire, only 21 percent of fifty-sevenvillage health workers reported receiving a supervisory visit within the previous three months (Nicholasand others 1991).

Unsatisfactorytrining is manifestedin several important ways, not least of which is a mismatch between the content of training and priority health needs and problems. in Benin, Togo (World Bank 1991j),and Zaire, to mention but three countries, training remains oriented to clical work and hospitalpractice, in spite of governent policiessupporting primay care. In Ethiopia many trnig facilities are in a poor state of repair and are poorly designed for their function (World Bank 1988, p. 6). In Guineahealth training qualityhas been poor due to the low level of secondary education, inadequateteaching staff and facilities, inappropriate curicula, and excessivelylarge enrollments(World Bank 1987b, p. 4). In Zaire the overall quality of medical training declinedduring the entire decadeof the 1980s, with deteriorationof training facilities, equipment,and systems(World Bank 1989h, p. 43).

An inappropriatemix of skills among health sector personnel in most African countries fiurter contributes to poor utilization of available human resources. Managing the thousands of personnel who work in the health sector in Africa requires professionalmanagers yet, as noted previously, human resourcematters are currently the responsibilityof physiciansor other health care workers in ministries of health with little training in management. Ministries of Health and other public health institutionsalso face serious shortagesof planningand evaluation spcialists, policy analysts, financial analysts and economists, maiace and sanity eng s, architects, statisticians, demographers, legal and above all management and administraive professionals,including personnel specialists. A review of the staffingsiuation in Zimbabwe(World Bank 199Ik) foundcritical vacanciesfor equipmentmaintenance personnel, physiotherapists,dental therapists,phamacists and X-ray operators. 82 The human resourcesprograms in the health sector in a number of African countries are plaguedby excessivemedical specialization. In Cote d'lvoire, for example, over 40 percent of physicians are specialists. Governmentscan address this issue by eliminating subsidies for specialisttraining and practice, and by reviewingcurricula.

Dependenceon expatriate health care personnel completesthe vicious circle of under- utilization, attrition, emigrationof staff, and imbalancesin the compositionof the health sector workforce in African countries. Large numbersof foreign personnelwork in the health sector in virtually every African country, many under technical assistance projects in operational positions and some at the national or regional level. When they work in the public sector, they often act as districtmedical officers of health, as in Swaziland,Lesotho, Malawi, and Botswana. Or, they may work as technical assistance experts or advisors in ministries or externally supportedprojects (World Bank 1987a). In Rwanda60 out of 247 doctors and 130 out of 337 high ranking nurses were foreigners in 1985. In Zaire, one-third of the 2,500 physicians were non-nationals;in Mozambiqueit was estimatedin late 1986 that over half of the physicianswere expatriates (World Bank 1990c, p. 51); in Burundi an estimated 40 percent of physicians serving in health facilities were expatriatesin the late 1980s (World Bank 1987a, p. 11). As qualiied and committed as such individualsmay be, their employmentcan be at odds with sustainable human resources for health when they are associated with vertical programs administeredby donors, receive higher salaries than their national counterparts, and contribute to high rates of turnover. What is Mssing?

Since the Alma Ata Conferencein 1978,only a handfulof countries, includingBotswana, Congo, Nigeria, and Zimbabwehave formulated comprehensive health sectorpersonnel policies. Tanzania has been among the most successfulin this respect (see Box 1). Clearly, this is the first step to coming to grips with the kinds of problems reviewed thus far. Equally important is to consider how morale, motivation, compensationand supervision might be addressed through decentralizationto the district level.

Box 1. PlanningHuman Resources for Healthin Tanzania.

Tanzania is among the African countries that have been relauivelysuccessfutl n the preparaton and implementationof plans for healthpersonnel. The ArushaDeclaration of 1967resulted in the preparationof a plan with explicittargets for variouscategories of healthhuman resources for te period 1972to 1980. 13,000new healthworkers were trained, with a heavy emphasis on the training and utdlation of 10,900 health auxiliaries and 2,100 health professionals. These targets were met and even exceededin some categories,especially uWalmedical aides, health assistants, mnedicalassistants and MCH aides. Tanzania's work on the developmentof career streaus and upgrading courses for health care personnelhas been particularlyimportant.

Despite past successes, however, personnel planning has been based on excessively simple assumptions concerningstaffing standards for various types of health care facilites, without referenceto variadons in workloador disease patternsor to the resourcesavailable to financeassociated salary costs or supportcomplemeatary inputs to make health care personnelable to work effectively. Thus, the staffi standardsof 1987, whichdoubled those previonslyin effect, are beyondd -, resourcecapacity of the healthsector (World Bank 1990b,pp. 13-14). 83 Without suitablytrained health workers in appropriatelylocated health care facilities,the basic health care services so central to this report cannot be provided. Resolving training problems will not be enough, however, as compensationmust be increased and competent supervisionprovided to assure that staff motivationis not dissipated on the job. Ministries of Health need also to engage themselves in the long-term struggle for civil service reform, decentralization of personnel management, and especially career management decisions. Effective personnel managementcalls for true leadership, both locally and at the national level (see Chapter 7). Opportunities at the Primary Care Level

Well-functioninghealth centers, first referral hospitals, and district health management teams - as described in Chapter 3 and 7 - have successfully addressed a number of the problems that plague health sector personnel management. Incentive payments in well- functioninghealth centers have become a feature of systemsof communityfinancing of health care in a number of African countries, includingCongo, Kenya, Guinea and Nigeria. With 64 health centers covering over 900,000 people, Guinea appears to have the most widespread practice of local incentive payments (UNICEF 1992c, p. 6). Resources mobilized by the communityto pay incentives have ranged from around ten to nearly fifty percent of normal salary levels. Successfulhealth districtshave also applied a variety of techniquesto recognize the best performers. In Ghana the Ministry of Health has establisheda prize fund to provide incenves for superior performance by individualhealth workers and health teams. In Mali health districts are reauired to meet a set of specificperformance criteria in order to receive full governmentand donor support for the implementationof their district health plans.

A number of African countries have demonstratedthe feasibility of improving local personnel managementand supervision. Under the health decentralizationprogram in Guinea, supportedby the World Bank, UNICEF and other agencies, advances have been made in the developmentof tools for supervision,monitoring, and evaluation. Projects in Benin, Kenya, Nigeria, Lesotho,and Ghana are improvingdistrict health informationand supervisionfiucdons. An integrated system of in-servicetraining is being introducedat the district level in Mali; in- service training in managementat the district level is being provided to senior district health workers in Lesotho (World Bank 1989d); similarprograms exist in Senegal(Unger 1991) and Ethiopia.

Successful health districts have informationand managementsystems that allow both providersand clients to identifyp.irformance problems, to analyze them, and to take immdiate corrective action on their own authority. Providers utilizing these systems have been able to acquire a sense of control and personal growth which is a powerful source of motivation. In Kinshasa, Zaire, such a systemwas establishedin the mid-1980s,covering 60 health centers and representingless than two percentof health care costs (ProjetSant6 pour Tous 1987). In Guinea and Benin, the entire managementinformation system has been revised under the Bamako Initiative, working bottom up. Although a considerable amount of time has been spent on registering patients, children, drugs and receipts, most health center staff consider this an important part of their functions (Knippenbergand others 1990, MSP Benin 1990, MSPAS Guinea 1990). 84

Box 2. DemonstratedLeadership at the DistnctLevel .n Ghana

African couatriescan providean environmentwhich encouragessocial entrepreneurshipfor health, as in this examplefrom Tema, an industrialcity and seaportin Ghana. The Tema HealthDistrict is servedby a networkof health centers, healthposts and industrialclinics which are backedby a district hospital,the T-"ua GeneralHospital. After an acute deteriorationof services with attendant low staff morale in the mid 1970s, a senior medical officer with demonstratedleadership skilts was assigned. The problemsidentified by the district medicalofficer were (i) low staff morale and lack of disciplineamong hospital staff; (ii) poor managementin the various sectionsof the hospital; (iii) absence of liaisonbetween the hospital and the industrialcommunity - one presumedbeneficiary of hospitalservices: and (iv) lack of supervisionof healthfacilities (health centers, health posts, and clinics)in both the urbanfindustrhland ural pans of the district, by the medicalstaff.

To address these problems, the district medicalofficer establishedthe followingagenda:

* visit all the factoriesin Tema to learn about their healthproblems;

* familiarizeinstituions visited with the needs and problemsof the hospital;

* convenemonthly meetings of an Ad-hoc ManagementAdvisory Group of Tema residentswith managementexpertise;

* visit all the health posts and health centersin the district to establishactive workingreladonships of staff, especiallyof govermmentclinics, with the hospital;

* organizemonthly meetings of seniorclinical and managementstaff to discussissues affectingthe care of patients, concerns of staff and efficient runningof health services within the hospital and the district as a wholeand to fimdsolutions to them;

* conduct daily administratve rounds to ancilary hospital departments, such as catering and maintenance,to learn aboutoperational problems.

Withinsix months, a discernableimprovement was observedby staff of the hospital,the RegionalDirector of Heath Setvies, the headquartersof the Ministryof Healthand generallyfrom personsseeking care at healt facilites in the District. Servicesoffered free to the hospital,thank to the inittive of the local healthleader, included: a) the loan of a tractorfor the hospitalgarden; b) the sale of essentialprovisions to staff at concessionaryprices on the hospital prmises; and c) the donationof materil to nmakebedsheets, bed-spreads and pajamasfor padents. By workingdirecdy wi institutions nmhis area, the disti medicalofficer was able to tap resourcesnormally not avaiable to the Minity of Health for local use.

Source. Anionoo-Lartsen1990.

Deploymentof a sbstantial share of bealth care personnel to the periphery in rural and pai-urban ars, is further assured in district-basedhealth care systems. Priority is given to sgt g health centers and first referral hospitals. The concentrationof health care at elth centers and first referral hospitalsdiscourages medical specialization and concentrationof stff in urban areas. Furthermore, health centers, first-level referral hospitals and district health managementteams are better siuad tan central-levelinstitutions to bridge the gap between traditional and modem health care.

The final and most critical dimension of success m health centers and fist refefrral hospitals is leadership (see Box 2). While much will depend on individual skills and personalities, district health managementteams most effectivelyprovide such leadershipwhen they are given autonomy, training and support by national health policymakers. Ledership 85 skillsshould be an importantcriterion in theselection and performanceevaluation of district healthteam managers. The FacilitaftngRole of Government

Humanresource planning for healthis an essentialpubli.c sector activity - a publicgood as defind in Chapteri. It is neededby geographicalarea, by expertise,by categoryof worker, by gender, and by differenttime honzons,all reconciledwith economicrealities (see Box 3). Nearlyevery Africancountry needs to strengthenits capacityfor humanresource planning, particularlystaffimg needs at healthcenters and districthospitals. Technicalskills in preparing projections,de#tmining norms, designingand managingsystems of performanceplanning, reviewand deploymentof publicsector staff are needed. Estimatesof cost and proposalsfor financingtraining are importantparts of this work. As healthcare systemsbecome more diversified institutionally, it is importantthat public sector planningencompass the entrety of Africancounties' healthpersonnel, including staff eagagedin the privatesector, in non-profitor charitableinstitutions such as religiousmissions, and other relevantprograms. Particularattention is meritedto trainingsenior cadres for health leadershipand research in the areaof publichealth. The rangeof disciplinesto"^hing on health leadershipis wide, from physiciansand mursestained in publichealth through pharmacists, economists,financial analysts and engineers,also with public health training, who can co*laborativelydefine, design, and wherenecessary, deliver public goodsand servicesin the health sector. Ministriesof Health can further nure the public health.perspectve by facilitatingthe establishmentand strengtning of voluntaryassociations of public health personnel.

Box 3. StrengtheningHunan Resources Plannng and Managemem n Lesotho'sMinisny of Health

Lesothois undertakinga systemaicprogram to strengthenis bealthpersonnel management functon (World Dank1989d). Actionsbeing taken include:

* development,implementation, and maintenance of humanresourcemanagement infonmaton systems for personneladministration, planning, and traiig * on-de-jobtraining for thedevelopment of the personnelplanning process in theMinisty of Health to providesenior managers wthb the informaion and planning framework necessay to makedecisions on staffingand tng priorities

* designand implementationof a systemfor selection,placement and monitoring of trainingactivities * developmentand use of a personmelmanual * designand implementaionof a compuerizedpersonel managementinformation system (PMIS). in coordinationwith the Mintry of PublicService * trainingof Ministryof Healthstaff in usingcomputers and in runningthe PMIS.

Sorce: WorldBank 1989d. 86

Box 4. Cooperationbetween Traditional Healers and Modern Health Care Providers.

The establishmentof registeredassociations of traditionalhealers is an initialstep towards collaboration between the informalsector and modem health care systems in Africa. Over 20 African countrieshave registeredassociations of traditionalhealers includingNigeria, Ghana, Senegal,Benin, CMted'lvoire, Zimbabweand Zambia. The degree of cooperationbetween traditional and modernpractices of care varies from countryto country. However,a number of collaborativeprograms betweenbiomedicine and African indigenoushealth practitionersexist, such as the Araromi program in Nigeria, the MampongCenter for ScientificResearch into plant medicine, the 'Alkaloid Unit' at the Universityof Scienceand Technologyin Kumasi,and the PrimnaryHealth Trainingfor IndigenousHealers (PRHETIH) at Techiman, all in Ghana. Researchin plant medicineand traditionalhealing is also taking placing in Niger and Zimbabwe.

Much more needs to be done to promote the developmentof approp;iate training for traditionalproviders, including especially traditional birth attendants. Research and disseminationof informationon the strengths and limitationsof traditional medicine is also needed to enable modem health workers to understand the social and psychologicalrationale behind traditional practices, to becomesenshive to traditionalbeliefs concerning health and health care, and to collaboratewith thesepractitioners. Studieshave shownthat traditionalhealers are skilledin helping people to cope with the psychologicaland social stressthat often accompanyrapid social and economicchange. Policies need to build on the culturalnorms and practiceswhich facieitate this processin order to promfte greater cooperationamong practitionersin the informalsector and those in the modernsector.

Arican governmentsalso need to take into accounttraditional healers in planninghuman resources for health. In Zambia there are approximately10,000 traditionalhealers and over 3,000 traditionalbirth attendantswho practice activelyin the informalsector in all communities. The Ministry of Health has set up a unit to gain understandingof their roles and to weed out harmful practices. About 12,000 traditionalhealers are registeredin Zimbabwe, out of a total of 20,000. A significantshare of the ruril populationdepends solely on them'in Ghana, Benin, Nigeria, Senegaland Zambia, among other countries. While some modern health care givers systematicallyreject traditional healers, Nigeria's health policy makes room for rtaining traditional practitioners so as to increase their skills and effectiveness,and to promote their integrationinto the existingnational health system. In Ghana, Nigeria, and Zimbabwe,training programs make it possiblefor some traditionalhealers to use modem treatmentmodalities such as oral rehydration (see Box 4). Also, AIDS preventionand control programs are increasingly drawing upon traditionalhealers.

It would be unrealistic, however,to expect public sector health care workers to increase their workloadsignificantly without additional compensation and reliable payment of wages and salaries. Because civil service salaries are unlikely to undergo significant improvements in the near future in most Africancountries, national authoritieswill need to exercise imaginationand allow greater autonomyto local health managersto help resolvethe problem. Cost recoveryand retention of fees at place of collection is a means of fostering fnancial autonomy and more regular payment of salaries at well-functoninghealth centers (Chapter 8). Other possibilities include allowances and incentives for night duty and for working on holidays, or incentives includingthe provision of housing to enable critcal staff to live near the health facilities they operate. Resources needed to finance such indirect increases in compensationmust largely be found through budgetary savings in Ministriesof Health, by reducingthe numbers of unskilled support personel and by purging from payroll those who have moved or died, as is being done in Guinea. Salary administrationshould also be decentralized,so that decisionson compensation and supervisory responsibilityare brought together at the district level with involvementof the community, rather than run as two separate sets of acdons. 87

Box 5. DevelopingHuman Resources for HealthLeadership and Researchin Africa

Despitethe evidentneed, seniorlevel traininginstitutions and opportnities for health leadershipand research in Africa are scarce. There are few universitiesor other institutionsthat offer trainingto preparepeople for these roes. In recogition of the unraet need, new and strengthenedgraduate programs have been establishedin some African countrieswith emphasis on field-orientedtraining, based on partnershipsbetween universities and governmentdepartments responsible for public health programs. The developmentof such programs is responsiveto the need to emphasize practically-orienteddisease preventionand developmentprograms at the district level.

In anglophonecountries, the increasingemphasis on public health has been nurtured by trainingin community medicine. This has existedfor manyyears in Ghana,Nigeria, Kenyaand Uganda. New programsin public healthhave been created or are in developmentat the Universitiesof Ibadan, Accra and Nairobi. New public health training programs have been developedat the Universityof the Western Cape in Capetown and through the University of Zimbabwe.

Amongfrancophone countries, several training programs have evolvedfrom a WHO-sponsoredschool of public health in Cotonou. The Universityof Kishasa openeda schoolof publichealth in 1986,and the Universitiesof Abidan and Dakarhave developedtraining programs at the diplomaor masterslevel. A schoolof public healthhas been initiated at the Universityof Brazzaville(CIESPAC).

Buildingon these and other initiatives,governments and donorsneed to collaborateat both the nationaland inter-countrylevel to prepare and financeplans to strengthenhealth leadershipand researchcapacity. Fortunately,new programswhich have evolvedover the last five years are being increasinglyrecognized by donorsas suitablealternatives to trainingoutside Africa.

Source: Bertrand 1992.

Training currcula need to be adaptedto the practical needs of health services at both the district and comnumitylevel, and health training needs to be extendedto staff in related sectors, especiallyto school teachersand agriculturalextension workers. Much more attentionis needed to the study of society, demography, and the community, as well of principles of health leadeiship, and training needs to be less orientedtowards Western models of medical practice. Governmentspursuing decentralizationto district based systems also need to rationalize and consolidate health trmnig schools, to make them multi-disciplinary, and to foster the developmentof the district health team concept and health leadership at al levels in its health training programs. Madagascar is moving in this direction with decentralizationof training functionsand linking them to supervisionin the field (World Bank 1991a,p. 26).

Finally, as part of the long-term investment in capacity building, male and female teachers in health care training and education institutions need to have the opporunity to periodicallyimprove their skills, and should at least have access to the basic journals in their field. The compensationand incentivesprovided to teachersat health traininginstitutions should be part of the review and improvementof salaries and incetives for other health workers. Conclusion

While their numbershave grownmarkedly since independence,health workers in Africa remain fewer on a per capita basis than those in other areas of the worid. The compositionof skills remains imbalancedin relationto needs in most countries, and deployment,compensation, and motivation are weak. Many more health leaders and managers are required to carry out critical policy analysis, planing and budgeting functiom.- 88 The situationcalls for actionat both the local and nationallevels, first to improvethe udlizationof availabletaied staffand secondto increasethe long-termsupply of appropriately tained personnel. This chapterargues that distict hospitalsand districthealth management teamscan successflly addressa numberof the problemsthat plagueeffective health sector pe l manageme. The most importantarea for actionis supervision,with potentialto improvemotivation of healthcare personneland increaseproductvity. A majorresponsibility for healthsector personnelmanagement will remainat the nationallevel, however,so as to createan environt for effectivemanagement and supervision at the facilityand district level. Personnelpolicies and planningincluding job descriptionsand supervisionnorms are centralto thk work. Theynecessitate carefdul collaboration across units within Ministries of Health,with Ministies of Finance,Planning, and with Civil ServiceCommissions to ensureconsistency, commitment,and capacityfor implementation. Change will not be easy. The agendais a long-termone. It requiresdealing with insttutionalrigidities, achieving effective inter-ministerial cooperation, and overcomingthe conservaim of manyhealth care professionals. Support for changewill be foundamong public healthpersonnel, in Ministriesof Financeand Planningcharged with using public resources more effectively,among beneficiaries of publicproviders of healthcare, and amongdonors. CHAPTER 6: INFRASTRUCTURE AND EQUIPMENT

]Introduction

Better health in Africa caUsfor the operationand maintenanceof thousandsof buildings with a wide range of sophisticatedand largelyimported equipment and vehicles. New buildings must be constructedas well, involvingarchitectural and locationaldecisions that are compatible with health goals and resource consbaints. If infrastructure and equipment are allocated inefficiently or inequitably, the delivery of health care services will be undermined. And without proper maintenance, existng facilities and equipment will fall into disrepair. This applies equally to facilities in the private and public sector.

Challenges facing the public sector are particularlyimmense becausegovernments tend to be heavily involved in financingand operatinghealth facilities. Many countries face high infcture costs, especialy the poorer countrieswith lower populationdensities. In the Sahel countries, construton costs are estimated to be twice as high or even more than in other African counties. Public resources for health have also been concentrated on tertiary infastucture and equipment, when greater health benefits could have been provided to the population as a whole through lower level facilities. In Cameroon, the Ministry of Health allocated only 22 percent of its investmentbudget to health centers in the early 1980s, while hospitalsreceived 66 percent (World Bank 1984a,p. 48). Under-fundingof recurrent resource needs for maintenancehas been particularlyproblematic. In Ethiopia, for example, building maintenancebudgets for health care facilities in the mid 1980s were only 10 to 20 percent of appropriate levels (World Bank 1985a, p. 28). With these patterns of expenditure, African commitmentsto primary care will necessarilyremain symbolic.

This chapter begins with a review of the state of health infrastructureand equipmentin Afica. Two problemsdominate: inappropriateand insuiffcientexpansion, ad poorplanning. Reviewingthe present situation sets the stage for sizingup what is missing and what is needed to fill critical gaps in the planning and managementof physical facilities. Performance

High popplationgrowth rates have made it difficultfor African countriesto expand and, in some cases, even to maintain existing coverage with health facilities. For example, just to maintain current low levels of coverage, and assumingthat one health center can serve about 5,000 people, Mali would need, in the 1990s, to increase the number of its health centers by 242. This is nearly five times the increase of 52 health centers achievedduring the 1980s(see 90

Tabkle1. he Growthof HealthCenters in SelectedAfrican Countries and the ChallengeAhead Numberof HealthCenters ActualNumber NumberNeeded in Year2000 To Reach60% 1980 1990 To MaintainCurrent Coverage Coverage

BurkinaFaso 169 860 1,100 1,400 Mali 470 522 760 1,300 Niger 240 460 630 1,270 Senegal 470 690 900 1,200

Souce: World Bank 1992a.

Table 1). Other countries, including those beyond the Sahel, face similar challenges. In Tanzana, population growth has led to a gradual decrease in health service coverage (World Banik1990d, p. 4).

Respondingto the needs impliedabove, somecountries have activelypromoted expansion of facilities at lower levels in the health system. To illustrate:

* Botswanahas given specialattention to developmentof health infrastructureat the bottom of its health care system. Clinics grew from 40 in 1974 to 150 in 1986 and health posts from 22 in 1974 to 227 in 1986; over the same period, the number of referral and district hospitalsincreased by less than ten percent (World Bank 1989a,Annex 3.3, p. 1).

* In mainland Tanzaniathe number of lower level facilities known as dispensaries rose from 1,847 in 1976 to 2,600 in 1980 and 2,935 in 1988 (World Bank 1989g).

* In Mozambiquethe nmnber of facilitiesequivalent to health centers rose from 326 in 1975 to 1195 in 1985; similarly,the number of districthospitals rose from 120 in 1975 to 221 in 1985 (World Bank l990c, p. 37).3

For the most part, however, priority has been given to inappropriatetertiary and other inpatientfacilities. In Ethiopiathe number of people per hospital bed fell from 3,500 in 1970 to 3,400 in 1980, and in Rwanda from nearly 800 in 1970 to 650 in 1980. Sao Tome and Principe enjoys one of the highest hospital bed ratios in the developingworld. In 1990 there was roughly one hospitalbed for every 190 people, twice as high as in Nigeria and nearly three

3. In Mozambique these faciiides ae known as health posts' and health centers' respectively;however, they are approximatelythe same types of buildingsas the health centersand distict hosphals discussedin Chapter 3. 91 timesas high as in Colombia(World Bank 1991b, p. 10). Theseaccomplishments have come at a high price, tend to be concentratedin urban areas, and are of disproportionatebenefit to relativelywell-to-do households (see Chapters 3 and 8).

Poor planningis visiblein an inappropriatelocation of facilitieswithin nural and peri- urban areas, uncoordinatedcommunity initiatives for facilityexpansion, and weaknessesin projectdesigii and execution. In Guinea-Bissau,for example,one regionhas more than five timesthe numberof hospitalbeds per personthan another, more populatedarea (WorldBank 1991d,Annex I-3, p. 17). In Burundithe populationserved by healthcenters varies from 870 to over 17,000,with a meanof around2,500 people per center(World Bank 1987a). Even in Taraa, where a specialeffort has beenmade for healthequity, a sampleof primarycare facilitiesin 1984revealed that somedispensaries served only about1,500 people compared to the targetof 6,500, whileothers were expected to servepopulations many times larger than the target (WorldBank 1990d,p. 4.).

Poor locationalplanning is particularlyapparent in imbalancesbetween urban and rural areas. A studyof healthstations in Ethiopiain 1985-1986found they servedonly 16 patients per day, manyfewer than the 90 to 100anticipated, and concluded improper location of facilities was responsiblefor low coverageand patientreferral. In rural Nigeriamore optimallocation of maternaland child health facilitieswas estimatedto be able to increasecoverage by 20 percent(Kloos 1990). In fourteenAfrican countries for whichdata are available,less than 50 percentof the rural populauionare reportedto havehad accessto healthcare facilitiesin six countries,whereas 90 percentor more of the urban populationin eight of the countrieshad accessto facilitiesin the sameperiod (see Table mI. Tablell. Access to Health Gare Faciles, Lack of coordinationbetween the public SelectedAfrican Countres, Late 1980s,and the sector and non-governmentalproviders has NeedforLocation Planning complicatedmatters. Decisionson the location of public sector facilities need to take into Country UrbanAccess RuiiAcc account planning of non-govermmental providers. In somecountries such as Uganda, Botswana 90 85 privateprivate. voluntary organizations (church CongoBurina Faso 97Sl . 48...... 70 missions) are visibly active, endeavoringto COted'Ivoire 92 45 meet the needs of the underserved in mrual Kenya 80 53 areas. Governments can build on, or Liberia 50 30 complementsuch networks, with appropriaxely Madagascar 90 30 plannedpublic facilities. Malawi 90 69 Mauritius 99 99 Lack of coordination between Nigeria 87 62 governmentproviders and community initiatives Rwanda 60 25 is anothermanifestation of weakplanning. In Somalia 50 15 a numberof countries,health centers have been Tanzania 94 73 built by communitieswith the understnding Togo 60 20 that the publicauthorities would take them over Zimbabwe 90 80 and operatethem, but adequateresources have Source:Saisi Appndix. 92 seldom been set aside for this purpose. In Mauritania, with the official encouragementof community participation, health posts have been built by local communities following no particular coverage plan. In some regions, the proliferation of health posts has resulted in excessive demand on personnel and other material resources (World Bank 199le, p. 5). Financial and other constraints have fquently inhibitedthe assumptionof responsibilityfor operationsby public authorities and de-motivatedthe communitiesconcerned.

Poor project design and executionare a final manifestationof weak health infrastructure planning in Africa. The range of constructionstandards and execution methodologiesand the lack of norms for health facilities and other social infrastructureleads to over-sizedfacilities, substandard construction, and high unit costs. Unit costs for almost identical health center buildingsin Mali, for example,varied by a factor of four in the late 1980s(World Bank 1992a, p. 9). In the Sahel countries constructioncosts range from US$750to $1,200 per square meter for constructionof primary care facilities,compared with more reasonablecosts of US$350-450 per square meter in other African countries (Porter 1992). In the absence of norms fog detrming catchmentareas, those responsiblefor planningconstruction programs at the central level have often been unable to identify the type and size of infrastructure needed to accommodatehealth care services.

The Decline of Health lfrastructure and Equipment

Over the past decade, exiting health facilities have suffered gready in most African countries. A 1985 study in Tanzania found that only 660 out of 1,800 rural govermment dispensarieswere in good condition, while 810 were fair and 330 in bad condition(World Bank 1989g, p. 54). A srvey of 15 Kenya Ministry of Health hospitalsin 1990-1991found that 40 percent of the buildingswere in poor or unsatisfactorycondition (Porter 1992). Somehospitals, such as the Tres de AgostoHospital in Guinea-Bissau,have declinedbeyond the point of repair (World Bank 1991d, Vol II, Annex 1-3, p. 4). In Equatorial Guinea there is an extensive network of health facilitiesin most cites and small towns, but they require major repairs to make them usable (World Bank 1992f). And in countriessuch as Angola,Mozambique, Somalia, and Sudan, damage inflictedby civil war has exacted an immensetoll on health structures.

Deterioration applies to health equipment as well as to buildings. In Nigeria, for example, one study found that close to one-thirdof the equipmentin health care institutionswas not in service (Erinosho 1991)(see Table o). Studiesof secondaryhospitals in Nigeria carried out in 1992 suggest that around $47 million of total equipment assets of $150 million would require repairs and that another $35 millionwould be needed for re-investmentin essential items (Porter 1992). Studies of thirteen Ministry of Health hospitals in Kenya found 40 percent of total equipment out of order and 40 percent of operating room equipment in need of repair (Porter 1992). A 1987 survey of seventeenhospitals in Uganda found that only 20 percent of inventoried equipmentwas in working order, while only 30 of the remaining 80 percent was worth repairing (Porter 1992).

The use of vehicles in health services bas been greatly impededdue to a lack of fuel, maintenance,and repairs. In Ghana a 1987inventory of Ministy of Health vehiclesfound that only 167 out of 660 were road-worthy, 230 needed extensiverepair, and 263 were worthless 93 Tablem. HealthCare Equipment Not in Servicein Nigeria,1987

Astudy in Nigeriafound a sgnificantshare of the equipment in healthcare facilities notin use. In general,the more sophisticated the health care facility, the more equipment was out of usi andthe longer it wasout of service.

Peces of Eqi4mentNot in Serice oared wth Ihose in Use Univrsity Prlmawy Teaching State.Owd Nongovermental Healt Hospals Hospials Hospitals centers Total Piees in w() 69 S 7 78 90 70 Pices out of order(%) 31 43 23 10 30

Durationta Eqpment Was Out of Service Duradon < 2 years() 19 22 33 40 20 24 yeas (%) 40 24 67 60 38 > 4 years(%) 41 54 - - 42

Souwe: Brinosho 1991.

(WorldBank 1989c, p. 41). In Guinea-Bissauduring 1990, 42 percentof the Ministryof Health vehicleswere inoperable,needing repairs and spare parts. The Ministy has had no vehicle maintenanceprogram since 1986(World Bank 1991d, pp. 28-29). Yet, mobilityis essentalfor effectivehealth care, for staff involvedin preventiveand communityoutrach progms, for personnelresponsible for supervision,and for an effectivereferral system. Africa's tertiay hospitals,though disproportionatelyfavored in Ministryof Health exenditures, have not escapeddecline. This is typifiedby a report on QueenEiizabeth II Hospitalin Lesotho, which found buildingsin poor physicalconditon, shortagesof basic eqipmnt, lack of mintenae capability,uneven distribution of workloads,weak planming, little staff developmentand supervision,and poor fnancial management(World Bank 1989d, p. 10.).

Under-financingof maintnce and repairs- virually universalin Africanhealth care sysm - is particularlyapparent in public sectorfacilities. In Nigeria,a studyof one state foundthat public hospitalsand maternitiesspent only S to 8 percentof their budgetson non- personnelitems sch as maintnane, transport,and suppliescompared with only 17 to 18 percentin private sectorfaciities (WorldBank 1991c, p. 62). In Dar es Salaam,Tanzania, the budgetfor preventivemaintenance of healthfacilities in the late 1980swas lessthan one pernt of requirements(World Bank 1990d, p. 5). In Guinea-Bissau,the budgetof the Ministryof Healthfor preventiveand routinemaintenance in 1989was only $5,000for the entire country (World Bank 1991d, p. 11). A study of six district hospitalsin Malawi found that an average of only 1.5 percentof recurent expenditureswere devotedto buildingmainten and 0.2 percentdevoted to equipmentmaintenane in 1987-1988(Mills 1991, Table I). The problem 94 is frequently complicated by division of responsibility: building maintenance is often the responsibilityof ministriesof works.

The low priority given to developing skills for maintenance and repairs further exacerbatesthe deteriorationof physical infrastructure. In some cases, such as Senegal, civil service personnel assignedto maintenancedo not perform adequatelybecause suitable skills and appropriate supervision are lacking. In Zimbabwe, equipment maintenancepersonnel are in desperately short supply; of all categories of workers in the Ministry of Hea!L, the highest vacancy rate in 1990 was for medicalequipment technicians (World Bank 1991k, p. 12). Vhat is Missig?

Physical proximityto health care facilities is only the beginningof effective health care coverage at the commnity level. It does no good to have a health facility, even within a short distance of one's home, if the necessaryequipment and services are unavailableor inoperable. In many Africancountries this problemhas arisen partlybecause plans to constructnew facilities failed to take into account financialcapacities to operate them. Some of these problems can be addressedby cost recovery and improvementsin the qualityof care at lower level facilities, as discussed in Chapter 8. What remains critical, however, is to improve on the planning of infrastructure, equipment choice and operation, and the fnancial and human resources that underpin health facilities.

Efficiency gains are possible in many areas, at health centers, district hospitals and terdary facilities. The challenge facing health facility planners is to come to grips with a lack of investmentin facilitiesand equipment; lack of recurrent expenditurebudgets to operatethem; over-sized or otherwise inadequate buildings; inappropriate plant or equipment; defective facilities and equipment; and poor maintenance. Effective management of facilities and equipment at the health center level, for example,requires far less technicalknowledge than for teriary care. The balance of this chapter provides rough guidelines on how management infrastructure and equipment might be improved, based on lessons learned in a number of African countries.

Steps to Greater Efficiency

Cost-effectiveallocations of fnial resourcesfor infrastuctr and equipmenttend to be those that give priority to rehabilitationover new investment, and to health centers and district hospitals over terdary facilities. Rehabilitationneeds are widespread. Rehabilitation planning requires careful analysis of existing investmentsand a clear randng of priorities compatiblewith policy commitmentsto preventiveand primary healthcare. Mali, for example, has begun to establish a foundationfor this kind of analysis with a data bank on existing inftructure, equipment,and associatedhealth care services, to be publishedperiodically by local health authorities in a carte sanitaire (World Bank 1991g, Annex 3-8).

Norms, skills and proceduresfor the locationof health facilitiesand for the maintenance of buildings, equipment, and vehicles also need to be established and carefully monitored. Norms sbould cover physical maintenanceand financialresources for maitenance and should 95 apply to non-governmentalas well as public sector facilities. As a general nrle, African couties shouldexpect to spendbetween 2 and 3 percentannually of the replacementcost o healthcenters and hospitalbuildings on maintenance.A detailedstudy of Kenya,for example, led to an estimateof 2.6 percent(Porter 1992). Specificstandards for equipmentmaintenance, repair, and replacementare also needed. As a rule-of-thumb,devoting anmnal expenditure to maintainand replace equipment equivalent to 20 percentof the valueof the stockof equipment has beensuggested (Bloom and Temple-Bird1988). Anotherway to look at the same issueis in terms of the recurrentcost of operations. As a generalrule, around 10 to 15 percentof recurrentcosts will likelybe requiredto maintaina first referralhospital (Barnum and Kutzin 1991).

Standardizedequipment lists for varioustypes of healthcare facilitiesare also needed, along with norms for maintenanceand repair. WHOhas preparedglobal normsin a number of relatedareas, such as the estimatedannual cost of maintainingspecific types of medical equipmentas a percentageof capital cost (Kleczkowskiand Pipbouleau1983). Ghana is planningto go beyondthic in a HospitalEquipment Maintenance Service. The Servicewill have definedfunctions at differentlevels of the system,workshops, equipment and tools, vehicles, pareparts and staff and trainig programs(World Bank 1990b). Mozambiqueis establishing a nationalnetwork of healthfacility and eqwpmentmaintenance centers (World Bank 1989e,p. 27). The experieDceof non-governmentalpartners is oftenrelevant (see Box 1).

Box 1. SuccessfudMaintenance in Zmbian Mine Hospitals

Thepublic sector in Zambiais facing great difficulties in providingand sustainingmedical equipment services. in publichospitals, about 20 percentof medicalequipment is workingat faultand 40 percentis completelyout of operation.Zambia Consolidated Copper Mines (ZCCM) has established a healthcare system of its own,separate from the pubticsector and consistingof 11 hospitalsand 58 healthcenters. It has developeda goodmaintenance system for its medicalequipment, which is aboutthe sameage as thatin thepublic sector. Its abilityto do this hasbeen due to the followingfactors- * It hasestablished an autonomousbody. the Medicaland Educational Trust, to operateall healthcare facilities and trainhealth care and operationalpersonnel.

* It hasestablished work practies which encourage good staff performance, combined with strong supervision and incentives.It offersbetter conditions of servicethan the publicsector and has higherstaff retention rates. * ZCCMhas recognizedthe importanceof maintenancein its operationsand healthcare activities. Mine hospitalsare significantlybetter financed than their public sector counterparts and thereforereceive adequate maintenancebudgets and foreignexchange. * It has separatedmedical equipment maintenance and safety policies from its operational actvities and wisely appliedtechnicat and human resources. maintenance, and management expertise from industrial instrumentation to medicalapplications. * Initialtraining in managementand maintenancefor healthcare specialistshas been conductedby mine operationalstaff. Someoperational maintenance staff have been seconded to minehospitals.

Source: Temple-Bird1991. 96 Whenhealth center facilities and equipmentare wellmanaged, local communites tend to be involved. The basic principleunderlying these arranements is that facilitiesplanned withoutthe activeparticipation of beneficiarieswill, at best, be treatedwith indifference.If appropriatelyplanned, partnershipsconstitute .a powerfulinstnuent for promotingloWal initiativesand stengtheni managent trough a senseof ownership. As part of a World Bank-financedhealt and populadonproject in Mali, for example,a cost-shringformula -50 percentgovenmment and 50 percentlocal communities - is supportingconstuction and pLanned maintenanceof 120 communityhealth centers over a five-yearperiod. The Spedal Problemof T ry Care Fadities

The managementof teriary levelhealth facilities merits special attention in viewof the drainthey place on publicexpendibues (see Chapter 8). For the foreseeablefutue, theprincipal publicpolicy concern with tertiarycare infrastrucureshould be to increaseefficiency without increasingbudget allocations from government budgets in real and, if possible,even in nominal tems. Managementaudits can help this process. They shouldlead to the establishmentof specifictrgets for efficiencygains, sponsored by ministiesof health. At the KenyattaNational Hospitalin Nairobi,for example,perfonnance targets include: reducingthe averagelength of inpatientstay from 8.6 days in 1989-90to 7.1 daysin 1995-96;a nearly20 percet reduction in staff per 1,O0 patientdays, from 5.4 to 4.0; andan inease in the ratio of maintenanceto recurrent expendiures from 2.2 percent to 6.0 percent. Malawi has prpared five-year efficiencyplans for its thrmemajor hospitals,with proposalsfor cost reductionscovering transport,udlity systems,other expenditureitems, and improvedaccounting and expendtu controlcapacity (WoJd Bank 1991f,p. 41). The designationof one hospitalas a center of excellence,to help train staff of other hospitals and health facilitiesthrough a program of study visits, bas particular appeal. Mozambiqueplans to movein thisdirection and is organizngspecial seminars and short training coursesto thisend (WorldBank 1989e). Cautionis needed,however, to ensurethat centersof excellenceavoid becoming sources of healthcare servicesthat are not consistentwith the disinct role theyare intendedto ply. Asessing TechnologyChoice

In manycountries, even in the leadinghospitals and medical schools, modem technology is rarelyused properly(Free 1992). Technologyis muchmore thanequipment and machines. To be put to gooduse, it needsan environmentin whichevery component interacts at the right place and at the right time. The morecomplex the technology,the greaterthe risk that some linksin the chainwill breakdown. Introductionof technologyshould thtefore be seen as the transfer of a packagewith multiplecomponents: equipment, training, maintnance, quality control,capacity to translatethe resultsof qualitycontrol analyses into decisions,and human, finaial, and otherresources reqired to implementthe decisions. New technologiesare rapidlyextending the scope and rangeof possibleinterventions dtou ut the healthsystem, from the primarycare levelto the referralhospital and beyond. 97 * Computers now make possible the processing, retrieval, and presentation of large amounts of vital statistics and health data needed for planning, implementation,and evaluation of health programs, assessingrisks, and conductingepidemiological surveillance at the district, regional, and national levels. Mangement of pharmacetical supplies can be made more efficientthrough computerized updating of inventories,thus preventingwaste and reducingcosts. Computersare only helpful, however, to the extent that they support a managementinformation system with adequatesoftware and maintenance.

* Radio-communicationhas proved essential in mobilizing appropriate resources followingthreats of epidemicsor natural disasters. Health activitiesin rural areas can be better integated into district health care, using two-ways radios, particularlyif transport is available for patient evacuationwhere necessary. Consultationfor diagnosisand treatmentimproves the efficacy of services and reduces the cost of referral.

* New diagnostictests for diseases with high prevalencesuch as dipsticksfor HIV and other STDs, or tests using saliva, may bring diagnostictechnologies to the communitylevel which were previously restricted to high performancespecialized laboratories.

o Non-invasivediagnostic techniques with both high sensitivityand high specificitysuch as ultrasound, have considerablyimproved the diagnosticpotenual at the district level. Less invasive treatment regimes, employing "key-hole" surgery technology, for example, can minimin trauma to patients and reduce average length of stay in hospitals. A shift to "day- suery" with improvedtechnologies and care practices,as is now being done in many industial countries, could help to containthe demandfor increasingnumbers of hospitalbeds and facilites (Porter 1992).

* The developmentof drugs administeredin a single oral dose has drasticallymodified the therapeutic approach to diseases such as helminthiasis and amoebiasis. Similrly, thermostable vaccines requiring a single oral dose have increased the hope for controlling children's diseases such as measles and polio. Drug kits and blister packs fall in the same category.

Notwiitsndig commercialinterests, the greatest challengeto improvingthe mix and use of technology in Africa is "technologyphilanthropy" - the unplannedand uncoordinated donation of equipment by foreign agencies and charities. This process leaves developing countries almost defenseless, as it is hard to refuse donations even though they are often ill- swted to the needs of recipientcountries or break down for a lack of spare parts. One potential sohltionwould be to devise "donationprotocols" whereby the kindsof equipmentand technology offered and accepted would follow a model, paralleling, for example, the selection of drugs using essential drugs lists (Porter 1992). Much of the work on technology assessment and choice lends itself to inter-country cooperation, since the cost of undertaking researh and preparing appropriate recommendationsis likely to exceed the capacities of most individual African counties. At the internationallevel, some support for such work exists, includinga joint Technology Introduction Panel inaugurated by UNICEF in 1988 with involvementof UNICEF, WHO, and other internationalagencies (Free 1992). 98

Box 2. AcquiringNew Technologies

There Is generallyno establishedmechanism in African countriesfor planningthe acquisitionof new health technologies. Awarenessof technologiesper so is not a problem, since there is a sufficient pool of knowledgeat universities, among staff retumingfrom abroad, and among consultantsand donors. It is the process of technology transfer that is problematic,usually made on an ad hoc basis, accordingto vestedinterests, pressures,and prejudices.

When there is some form of planning, the acquisitionof new technologiesis to a large extent rolled by physicians,and more likely than not by clinicianstrained abroad. They are generallynot the best persons to perform this task. Whilethe medicalprofession can readily pinpointa problem, it generallyhas little idea of the complexityand extent of the engineeringproblems and of the level of trainingassociated with the technologiesneeded to solve them. Rather, a team is needed, includingpublic and non-governmentalhealth care providers, engineers,planners, and social scientits - to ensuretha the broadercultural, social and economicdimensions are considered. Public,private voluntary and private commercialperspectives are all usefulto this end.

Becausehealth technologies are the fundamentalunits of resourceallocation in healthcare, Africangovernments need to supportoperationally-oriented research that will facilitatedecisions on whetherto introducenew tests, treatments. and their associatedtechnologies into their countries' health care systems. Factors to be considered include the appropriatenessof the intervention,the ease of its use and maintenance,its trainingrequirements, and its life-timecost. A cautious attitude towards uncontrolleddiffusion of medical technologyis emerging increasinglyin the industrial countries,and African policy-makerswould do well to exerciseprudence in the face of quite understandablepressures for investment. Selectionof appropriateequipment, and arrangementsto limit the number of suppliers, to ensure maintenance,are appropriateministry of healthroles. Trainingof personnelfor healthtechnology assessment and for maneance and repai of physicalasss is cric.

Conclusion

Strengtheningthe managementof infrastructure,equipment, and technologyis a requisite to achieving health goals in Africa. The successfuldelivery of a basic, cost-effectiveset of health car services to the vast majorityof Africans requires it. One concretestep would be for governmentsto assign a senior Ministry of Health official to assume responsibilityfor health facilities, equipment, and technology. Another would be to establish norms for designig and equipping health facilities at different levels in the refefral system and to support research on the most cost-effective technologies available. Budgetary provisions for maintenance and operating costs need to be established,particularly in public health facilities. And, since the financialresources required to provide basic health care services are so inWimatelylinked with cost ovefruns and inefficiencies at the tertiary level, more efficient use of technologies, equipment, and facilities in hospitalsshould be a priority concern. A WHO global action plan for the management,maintenance, and repair of health care equipmentmay assist in this area. CHAPTER 7: MANAGEMENT CAPACITY AND INSTITUTIONALREFORM

Introduction

Effectiveinsttutons and integratedsystems of healthcare are productsof an evolutionary process. Most countries in Africa inherited health systems from colonial regimes with management practices and admn)istrative structures that were highly centralized, both geographicallyand hierarchically. Since then, they have been graduallyevolving in reactionto performance problems, leaming-by-doing, financial and human resource constraints, and experimentationwith different forms of health care delivery. Yet, systemicproblems remain deeply entrenched. Restructuringand reform must be accelerated if national capacities and institutional effectivenessare to speak more directly to the health needs of households and communities.

Perhaps the most visibleproblem is that Ministriesof Health tend to be preoccupiedwith activitiesfor which they are ill-equipp.Aand have little comparativeadvantage, rather than being fully engaged in managingpublic health goodsand services. Maagement of cental or tertiary level hospitals is a classic example. Hospital management is increasingly recognized as a speialized discipline in industrial countries, and only a few African countries, such as Zimbabwe, have begun to develop and utilize hospital managementexpertise. Such entities require administrativeand managementskills suitableto running large corporations,and involve decisionsabout exceedinglyexpensive medical technologies. Ministriesof Health were neither designed, nor staffed with the expertise to manage such facilities, with the result that govermens are frequently indicted for poor hospital performanceand cost overmns. In the process, financialand humanresources required to managethe financingand provisionof public health services tend to be depleted.

A second, and related problem, is that institutional arrangements conducive to an inersectoral approach to health are seldom in place. This applies particularly to the planning, budgetng and coordiation of financial requeme, involving Ministries of Planning and Ministries of Finance. As discussedin previous chapters, Ministriesof Health cannot achieve beter health in Africa alone. Sustinable outcomesrequire provisionsfor safe drinking water, sanitation, nutrition, and health education which are outside the traditional purview of the medical profession. Without coordinating mechanisms and incentives, particularly at the regional, district, and community leveis, the planning and implementationof inter-sectoral intrventions will remain haphazard. 100 A third problem is that health systems continue to be fragmented by programs and projects that have been "tackedon" as addendain the service of particular interest groups, and shifting goals and priorities. Many such initiadvesoriginate from the donor community,in the form of special programs and resolutions.In Ghana one study observed that donors compound managementproblems by preparing programsaccording to their own priorities and perceptions (World Bank 1990a, p. 5). They often by-pass or explicitlyavoid addressing systemic issues with staff, goals, and budgets that are almost independentof existing health systems. Failure to integrate such activities as part of a comprehensivenational policy results in problems of duplication, overlap, lack of consistencyin standardsand procedures, and inconsistentor dis- jointed policy recommendations.

Fourth, symboliccommitments to preventiveand primarycare continueto be undermined by overly centralizedadministrations which have failed to provide appropriate organizatonal frameworks, managerialprocesses, financialand human resources, incentives, and support to lower levels. In Benin the organizational structure of the Ministry of Health has been characterizedas over-centralizedand manageriallyweak (WorldBank 1989f,p. 10); in Bunmdi, the planningprocess has been described as overly-centralizedand too rigid to respond to the specific needs of communities(World Bank 1987a, p. 16); and in Cote d'Ivoire the health care system has been observed to be highly centralized, with decision-making the exclusive responsibilityof the state. Variousmodes of health service decentralizationhave been attempted in African countries, but successhas been underminedby ambiguouslinkages between various levels of governmentand inadequateexpenditure authority at the local level.

Fifth, advantages of community involvementare only beginning to be realized as a linchpin of better health in Africa. If hundreds of thousandsof communitiesin rural and peri- urban areas are to be more than just objects of health care delivery, they must take their proper place as participants in shaping and managing local health services, thus counterbalancing weaknesses in capacity at the national level. Yet, the prerequisites and conditions for community involvementare lacking in many countries despite symbolic commitments and international conferenceson the subject. The most critical requisites are sustained political commitmentand, where necessary, retraining of staff (WHO 1988a,p. 56). Medical officers at the local level often fail to appreciate the value of communityparticipation, nor are they sufficientlytrained or motivatedto facilitatecommunity involvement. Receptivity of the political environment is yet another issue. In Senegal studies of health facilities in the Dakar metropolitanregion revealed a low level of confidencein communitymanagement committees, on the suspicionthey were dominatedby politicians(African PopulationAdvisory Committee 1993).

Sixth, the potentialbenefits of information,education, and communicationprograms for change in health-relatedbehavior at the householdlevel are hardly being exploited in many African countries. In this sense, over-concentrationof health policies and programs on health care systemsis at the expense of micro-levelimprovements. To prevent this from happening, new efforts to disseminatebeneficial health informationneed to be directed to behavior change at the individual and householdlevel (see Box 1). 101

Box 1. Infonmaton,Education, and Communicaionand the HealthBehavior of Individualsand Households

Informadon,education, and communication (IEC) programs for healfhhave begunto assumeincreasing attention in Africa as a means of improvingknowledge about self-care and best pracdtes. This is a two-way street however. Effective IEC programs aim to establish what sorts of healthactivities will engagethe cooperation,or lack of it, of households. The unportanceof changingbehavior also has gained greater attentionin health circles as a result of the HIV pandemic. A few examplesof success:

* The Happy BabyloUery campaign in The Gambiataught mothersthe proper mixingand administrationof oral rehydrationsalts (ORS), to reduce child mortality caused by dehydrationfrom diarrheal disease. An independentevaluation after two years showedthat, in diarrheacases treated at home, the sharetreated with ORS increasedby 22 to 94 percent.

* The Man is Health program to educate villagers in Tanzaniaon disease control led to the constucdon of hundredsof thousandsof latrines and to significantinreases in sdes of mosquitonets. Approximately2 million adults followedthe Man is Health radio programn.

* Social marketing,using commercialmarketing techniques to sell sociallydesirable products and services below their full cost, shows promisefor expansionbeyond population. family planing and condompromotion for AIDS prevention,into other healthareas. A pilot project to demonstrateits feasibilityto treat and prevent sexuallytransmitted diseases has been underwayin Cameroonsince 1991.

Consultingbeneficiaries and taking their views into accountis an especially importantaspect of efforts to promotechanges in health-relatedbehavior. Programplanners too often operate withintheir own paradigts and make unrealisticassumptions about the values and desiresof peoplewhom they intendto help. Contay to the frequentdesire of health professionalsto keep the modernand traditionalsystems of care separate,a beneficiaryassement in Lesotho led to decisionsto bring traditionalhealers into the nationalhealth system, to give them basic health courses, and to provide villagehealth workers with aspirin and other simpleremedies to facilitatetheir interactionswith beneficiaries. (Hall and Malesha 1991)

Analysis is needed to fonnulate and test effective IEC strategiesand messages. Essental tools for changing behavior includeorganized inter-personalcommunication programs and media-disseminatedinformation - as distinct from formal classroomlearning - provided in ways that are comprehensibleand acceptableto the varied audiencesin Africa, and backed by social scienceresearch on differentmessages. And, despitethe evident imporlanceof reaching people in their own language,a survey of twelve countriesin eastern and southernAfrica revealed tha none possessed sub-ntonal or regionally-based,local languageradio statimnsthat were geared to communityprogramming (Johnston and Zeeuw 1990).

And finally, institLtionalcapacities for research on multiple dete s of health are extra-ordinarily limit in Africa. An Independent Commission on Health Research for Developmentfound there were 62 reseahers per million people and a total of over 8,500 researchers in Brazil compared with only 7 researchers per million people and a total of 300 researchers in Ethiopia, 14 and 125, respectively,in Zimbabwe,and only 1 and 10, respectively, in Mali. More generally, the Commissionfound that research capacities suffer from limited opporunities for professional development and career advancement, weak and unstable instiutonal enviroments, insufficientand erratic funding, and lack of appreciationfor research (Commissionon Health Research for Development1990, p. 51).

Reform and restructuringrequire a systematicapproach involving careful assessmentof country-specificconditions, planning, and a timetablefor change. As the experience of many African countries shows, deeply enrenched problems cannot be resolved over-night. 102 Fre 1. D 1medoof CapacltyBuilding for Health

> ~~~PolicyAnalysfs <

t/1

Monitoring Management Planning & &~~~ Evaluaton Instftutional Progmmmng / ~~capacity/

Commitmentto the reform process and measurablesteps on the transition path are, however, essential. Nor is a single recipe likely to be appropriatefor all countries. This chapter begins by aizng lessons learned about forms and processes of public administration and managementthat are compatiblewith carrying out the functionsdescribed in Figure 1. It then takes a closer look at management practices associated with district health systems, and communityinvolvement in their operation. This draws on the experienceof growing numbers of Afican counties that are promotingdecentralization to district-basedhealth systems, and is consistnt with the approach featred in this report. Initiaig Reform

To strengthen managementand institutionalcapacities at the central, regional, district, and especiaUythe communit level, sudies by African governments,the World Bank, and other donor agencies suggest that reforms need to be initiated on at least six major dimensions (Vaillancourtand others 1992; North 1992). 103

Optmizing Performanceof Eisting Institutions

The process of strengtheningmanagement and institutionalcapacity should start with a situationalassessment of existing structures. Institutionalperformance is often undermineddue to unforeseen bottlenecks. Weak links can be strengthenedthrough internal reorganization, management changes, and if need be, changes in legal status affecting decision-makingand institutional coordination. The challenge is to replace piece-meal assessments of various components of the health system or single institutions,with more comprehensiveassessments by those involvedin its daily operation.

Comprehensiveassessments can be informed by internally driven diagnosis of current versus desired structures, functions, and skills. A situationalanalysis has been launched in Guinea, Benin, and Togo, informed by a strategic vision of the future (World Bank 1993c). Three groups of "stakeholders"have been involved, workingtogether on commonproblems in a seminar enviromnent. One group consists of communityrepresentatives who speak in the interests of clients of health services. A secondgroup consistsof health personnel, who often feel helpless in modifying the system at large yet seek to improve their credibility in the functionsthey perform, by workingtogether for change. A third group consistsof policymakers and planners at the regional and central level.

Workshops have been convened to develop a paradigm of how systems are currently perceived to operate, gaps in their performance, and what is needed to fill the gaps. In the workshopconsisting of higher level officials, for example, the diagnosticprocess begins with an assessmentof needs as reflectedby data on the epidemiologicalsituation, human resources, and financing. It then assesses the sectoral programs and financing to meet those needs. Finally, participantsdeliberate on strategiesto close gaps. The procedure typically followsthe six steps described in Box 2, and is responsiveto the overall cycle set out in Figure 1.

The benefitsof this approach are unambiguous:

* The workshopshave enjoyed wide and enthusiasticparticipation, includiig high-level officials and heads of departmentsin Ministriesof Health, Finance, and Planning.

* A situationalassessment of systemicproblems is yielding a critical mass of sector managers who agree on terms, speak the same language, and generate consensus on major bottlenecks.

* The tendency to attribute long-standingproblems, such as high infant and maternal mortality, to a lack of financialresources is being replacedby a more detaileddiagnosis of what is required to resolve those problems - in terms of strctures, logistics, managementskills, personnel, facilities, and financing.

* Detailed ledgers of objectives, strategies,and programs - products of the workshops - are accumulating,generting a blueprint of importantcomponents of the health system, how they are perceived to funv,ion, and how they might be improved. 104

Box 2. DiagnosingHealh System Performancein Gmunea,Benin and Togo

ST7S SUATIONAL ANALYSIS

Step I AnalyzeCurent Reviewof polickies,stategies, and contes of acual progrm s; Performanceand - Idendficationof strengths& weaknessesin thesystem; Maor Conditions Reviewof health services,their locationand distribudon; AffectingSector Analysisof systemsof financingand resouvcealloction; Assessmentof fomnationand deploymentof personnel.

Step 2 Identifyand Inadequaciesin current u of policiesand stategies; Priorize Problems _ Mamgemnt, evaluation,coordinadon problems in programs; and Constrais Resourceallocation and budgetmanagement problems; Mering Ateion Operationalproblems at variouslevels of serviceprovision; Pesonnel managementpmblems.

Ste 3 RefIct on Improvedmanageen and coordinationsystems AppropriatStrategies - Decentr on and mechanismsof conmunityparticipation; and SectoralPams Resourcemobilizaton through cost recovery; Improvingstndards and normsin health care delivery; Trainig and redeploymentschemes for personnel. Stop4 Prioritie and Deine Womenof reproductiveages; pregnantwomen; TalrgetGoups MMothers and infantsaged 0-5years; Youngadults, the old and infirm; Groupssusceptible to pardcularmaladies.

Step 5 DetermineIdicators Total numberof sick needingbhath care; of Performancefor * Disadvantagedgroups; Monitoringand Meawmesof reformsundertaken; EvahlatingPrgtrss Managemettiformaon systemsused for project evation; Heathstisties; rates of covenge; Monitoringand evaluationof decenmalizaionpracties.

Some: World Bank1992c.

DevelopingPolicy and Planin Sklls

Institutions cannot be rn effectvely unless managers are skilled, not only in policy analysis but also in planing, proging, and budgeting. Such skills are required to tmnslate policy into i.plementable projects and programs, to ensure the availability, distribution, and managementof human and financialresources, and to makeavailable sound project and program managementfor implemenation.

In Ghana a review of the health sector in 1990 found an almost complete absence of planng capacities in the Ministry of Health, almost no rational manageme proceduresused in the day-to-dayrunning of the Ministry, and a lack of records of decisionstaken. It went on to concludethat withouta radicalr g of the systemof administrationand managemet inchling the appointmentof a core group of qualifiedmanagers to key positions, no significant improvementcould be expected in the defiveiy of health care services (World Bank 1990a). Folowig tis assessment, the Mitisry of Health decided to create new planng units with 105 clearlyidendtfied work programs, staffimg and recriitment needs, and a managementinformation systemto monitorperformance.

In Nigeria,following the civil servicereform of 1988,Ministries of Healthat both the stateand federallevels have established departments of plannng. Qualifiedpeople have been hard to find, however. To help to fill thisgap, three federaluniversities - Benin,Ilorin, and Maiduguri- are colaboratingto run an acceleratedthree month program in healthplaning and management.Curriculum and training manuals for the programwere jointly developed with the Universitiesof York, Leeds, and Keele in the United Kingdom,and the Johns Hopkins Universityin the United States. Nigeria's Federal Ministryof Health has been intent on conductingthe programoutside the facultyof healthor medicalsciences in the three institutions. so as to insurea multi-disciplinryapproach, with teaching staff frommanagement, social, and healthsciences. Between1990 and 1992,close to 400 medicaland non-medical staff fromthe local, state, and federalgovemments have been trained in the three institutions. Institutionaleffectveness cannot be assessedor investmentallocations be determined unlessmanagers have the capacityto collect,compile and analyze demographic, epidemiological, and financialinformation. In Ghanalike manyother African countries,the monitoringof primalycare has beenstalled partialy becauseof poorlyfunctioning statistical and data systems. Ghana'sCenter for HealthStatistics is currentlyresponsible for collectingonly limited data from hospitalsand heath centers. Reportg is substialy incomplete;and institutionsoutside the public sector are only pardy included. Most availabledata has neither been analyzed, disseminated,or used systemicallyfor policymaking(World Bank 1990a). Skillsand methodologiesin publicfinance and informationcollection and management are particularlyimportant, so as to developthe following: 9 Health expendiuredata. Expenditureson healthneed to be compiledby use and especiallysource - householdand otherpnvate expenditures,public expenditures, and donor funds. Informationon sourceof expendituesis particularlyimportan to enablepolicymakers to assessthe potentialfor privatefinancing and cost recoveryand the capacityof government to financepublic healthactivities and providesubsidies. Time series data of tis type were availablefor this reportfor only aboutone-third of Africancounties (seeChapter 8). * Comprehensivehealth sector financial plans. Such plans need to encompassboth public andnon-governmental outlays. While such plans are gradually becoming more widespread, such as in Senegaland Zimbabwe,they remain non-existent in manyAfrican countries, thms rendering analysisof plannedversus realizedexpenditures piece-meal and incomplete. They need to encompassrecurrent and capital expenditures, as wellas costestimates for futureprograms and targets. In this way, shortfallscan be anticipatedand plans to fill gaps formulated. A particularlyimportant area is informationon both present and future ruent expenditure reqiremnts of existng investments(see Chapters5 and 6). * Managementinformation systems (MIS). To facilitatehealth planning, information on both the costof servicesand health outcomes is requiredto determinecost-effectiveness of basic health services. MIS shouldalso cover revemnecollection and monitorthe cost of medical 106 contactsby provideror instittidon.In Chad, for example,the Ministryof Healthand Social Affairshas designeda healthinformation system that has beenoperating successfully for several yeas. Annualreports are preparedwith national-levelinformation on healthstatus, health services,and health facilities functioning. Information from the system is beingused in planning at the nationaland provinciallevel, as wellas in some districts(R6publique du Tchad 1992). EncouragingInstituional Pluralsmand Inter-SectoralCooperation Prior chaptershave arguedthat govenunentshave a mandate,as wellas a comparative advantageto financeand ensureprovision of public healthservices such as demographicand epidemiologicaldata collection, health education and information, policy analysis and evaluation, monitoringand evaluationof targets, and settingof norms, standards,and regulations(see Chapter1). Yet the tasks involved,being exceptionally demanding, can hardlybe undertaken by governmentsalone and can benefitimmensely from the activitiesof privatevoluntary and other non-governmentalorganizations (NGOs). The same appliesto the importantrole that NOOsplay in bringinghealth care to underservedpopulations. Inter-sectoral cooperation is an equally importantdimension, since public servicesfor health require interventionsthat go beyondthe reach of the healthsector alone.

The encouragementof institutionalpluralism - and the willingnessof govermmentsto acceptnon-governmental bodies outside of directstate control - needsto be seen in the wider conext of broadeningcivil society. The healthsector can makeimportant contributions in this respect. A first step is simplyto refrainfrom harassingprofessional and private voluntary associationsby meansof unnecessaryregulations (Landell-Mills 1992).

Benefitsof institutionalpluralism are apparentfrom the followingexamples:

3 A CoordinatingAssembly of NGOsfor primaryhealth care has been establishedin collaborationwith the Ministryof Healthin Swaziland,and a PrimaryHealth Care Forumhas beenestablished for collaborationamong the government and NGOs in Zimbabwe.These bodies includetask forceson healtheducation, water and sanitation, and health orientation and training. Partnrships of this nature help public and non-governmentalbodies to share objectivesand identifycommon targets. Theycan alsofacilitate the removalof barriersto the formulationand operationof privatevoluntry organizations,such as legalrestrictions.

* Nationalassociations of publichealth professionals have been formedin Botswana, Kenya,Lesotho, Mozambique, Tanzania, Uganda, Zambia, Zaire, and Zimbabwe, in somecases in cooperationwith the CanadianPublic Health Association. The formationof such bodies facilitatesconsensus-building among health care providers on future health policies and statgies. Gaining their support and participationin the development,monitoring, and evaluationof healthpolicies can go a long way towardimproving effectiveness, especially in viewof the multi-disciplinarynature of publichealth activities. These associations are members of the World Federationof Public Health Associations,an internationalNGO working to improve ithehealth of peoplethroughout the world. Regionalpublic health associations are also evolving,inchding an East and Cental AfricanAssociation serving anglophone countries with headquarts in Aroslia,-and a FrancophoneSub-Regional Association based in Kalimba. 107 * Collaboration between governments and religious missions has been particularly important to developing health partnerships in Africa. At the district level in Zaire, for example, 50 percent of 306 health zones establishedby the Five Year Health Plan of 1982-86 are managedby NGOs, or are in close collaborationwith NGO assistance. At the national level the SANRU Basic Rural Health Project has combined the efforts of the Protestant Church of Zaire and USAIDto develop 100 health zones throughoutZaire, 75 percent of which are being managed in collaborationwith diverse local NGO groups. At the internationallevel, upwards of 100 different intemational NGOs assist medical work in Zaire, largely by channeling assistancedirectly to hospitalsor health zones. About half of the 65 member "denominations" of the Protestant Church are receivingassistance for their medical work from sister churches overseas (Sambe and Baer).

* Women's groups in Africa are striving to ensure that women's health issues receive adequate attention and support, and to encourage govemments, international agencies, and religious organizationsto take women's perspectivesinto account in designinghealth programs. In Uganda, for example, a group of women's NGOs formed a consortium in 1989 and are implementinga community-levelprogram to reduce maternal mortality and morbidity, with funding from the World Bank and other agencies. Women's groups in Tanzania, Ethiopia, Uganda, Kenya, and other countries have taken the lead role in combattingharmful traditional practices such as female genital mutilation,through public informationand advocacytargeted at national policy-makersas well as local decision-makers. In Ghana, the Ghana Registered MidwivesAssociation provides a significantproportion of matemal health and family planning services, and is a key member of a task force that is advising the government on ways to improve the quality of maternalhealth services.

Lack of intersectoral collaboration is one of the most widely lamented features of prevailinghealth systems. Comprehensivehealth policies need to be formulatedat the national level, and inter-ministerialcommittees need to be establishedto translate their inter-sectoral aspects, regarding water and sanitation, for example, into country-widestrategies and targets. The organizationalframework for structral adjustmentprograms can help facilitateinter-sectoral cooperation for health. In Benin, for example, an inter-ministerialsubcommittee for the strucural adjustment program overseas sectoral reforms to ere coherence with macroeconomicpolicies. Anotherinterminiserial committee coordinates and monitorsthe health sector reform program. This committee is chaired by the Minister of PubLicHealth, and includes the Ministers of Planning and Finance as vice-chairmen,and representativesof the Ministriesof Justice, Defense, Transportand Equipment,Labor, and Rural Development(World Bank 1989f, p. 17). Similar arrangementsare in place in Togo.

To encourage action on as many fronts as possible, central and regional authoritiescan furter act as catalysts to facilitate inter-sectoralcollaboration at the local government,distict, and communitylevel. Here, too, the cooperationof core agenciesresponsible for planning and finance is essential. Distrct developn. it committees,comprising public sector representatives in health, education,nutrition, and public works (water, sanitation, and roads) can be mandated to assess the health implicationsof "non-health' investmentsand to prepare district-levelplans for complementaryhealth, water, sanitation,nutrition, and other investments. 108 Pmoting Decettralization

Mhedecentalization of decision-makingand managementauthority is viewedby many, if not most developingcountries, as a viablemeans of achievinggreater efficiency and equity in health. Somecountries have pursued decentralization aggressively and haveredefned roles and responsibilitieswhich, in principle,should fill gaps. The pace at whichcountries pursue decentralization,and their understandingof its content, however,are conditionalon the interactionof manyfactors, some pushing hard for decentralization,others resisting it. Among these are (North1992):

* Changing attitudes towards governace and international trends favonng decentralizationin supportof primarycare, but counteredby bureaucraticresistance to shiftsin decision-makingpower by the politicaland medicalestablishment. * Increaseddemands for controlof budgetaryresources at provincialand locallevels in view of poor delivery of publiclyfinanced and providedhealth services, with inertia and bureaucraticresistance from centralgovernments that have traditionallycontrolled the purse stringsfor health. * Motion to attunehealth programs to localcultures and traditionalhealth practices m reactionto top-downprograms that havesought to changebehaviers with insufficientregard for socio-cultralconcerns.

v Desireto moveaway from donordriven agendas and investmentprograms associated with donors,to nationallydetermined priorities with inputsfrom participants and beneficiaries rightdown to the communitylevel.

Decentralizationto thedistrict level, as discussedthroughout this report,can be expected to bringmajor changes in institutionalroles and management responsibilities. A cleardistinction needs to be makebetween administrative supervision, technical supervision, and advisoryand guidanceroles, all withina contextof hierarchicalresponsibility. Functions typically performed at variouslevels of decentralizationare summarizedin Box 3. Most importantis to establish the levelto whichpower and authorityare to be decentalized;the policy instruments to be used to effectdecentralization; and the types of activityto be decentralized(Conyers and others 1992, p.6 ). Even if discretionaryauthority is legallyassigned to local authorities,the de facto structureof financialincentives and responsibilitiesfor salariesand careers may confilnueto remain with central ministries. In Tanzania,despite formal decisionson decentralization, verticalprograms tend to set nationalobjectives before district health teams fix theirs, leading to distortionsin resourceallocation (World Bank 1989g, pp. 61 and 105). Experiencegained thus far stronglyindicates that successfuldecentralization requires definitionof the specificobjectives sought, a clear delineationof funcdonsat each level, mechanismsfor commuicationand coordiaton amongthe various levels, and sufficient trainingto enablefull assumptionof decentralizedresponsibilities (Vaillancourt and others 1992). In district-basedhealth systems, for example,central and regionalstaff will have to re-orient thdr work, sils profiles, and attitudesfrom exercisingcontrol as direct supervisorsto 109

BDx3. Roles and ResponsibilidiesUnder Decentralization of Ministnes of Health

Decenralizationnecessitates clear and specificdelineation of responsibilitiesat each level of the healt care systen, While there is inevitablyvariation among countries, Ministries of Healthtend to be responsiblefor:

* healthpolicy formulation ^ productionof nationalhealth plans and regionaland localhealth planningguidelines * advice on allocationof resources,pardcularly capital fnds * publichealth budgetanalysis and formulation * high level technicaladvice for specificprograms * monitoringof pharmaceuticalpolicies, drug quality,avaiability, and distribution * planning.taining and regulationof healthpersonnel * regulationof private profit and non-profithealth care providers * oversightof health care organizationsand health researchinstiutes with a nationalmandate * norms and standardsconcerning health infrastructure,equipment and technology * liaisonwidt internationalhealth organizationsand aid agencies

Regionsand/or Provincestend to be responsiblefor:

* regionalhealth planningand program monitoring * coordinationof publicand non-governmentalregional health acdvities * monitoringand, in some cases, employmentof public sector health manpower * compilationof health expenditurebudgets * approval of large scale capital projectsoutside the publicsector * supervisionof district healthteams * provisionof logisticalsupport to district healthteams

Ditricts tend to be responsiblefor:

* managementof all public sector health facilitieswith local responsibilities * monitoringand, often, implementationof community-basedhealth programs * managementand control over local healthbudgets t coordinationand supervisionof all government,NOO and private health services • promotionof active links with tocal governmentdepartments X promotionof communityparticipation in loal healtbservices planning, implementation, and monitoing - preparationof annual health plansand reports * raismgadditil local funds * in-servicetraining, especiallyon-the-job support, of healthworkers * supervisionand control of communityhealth workers * collectingand forwardingroutine health informationto regionaland centraloffices dialoguewith beneficiariesof health servicesand their representatives

Source:Adapted from WHO 1988a.

emphasizingpolicy formulation,strategy development,resource allocation,and technical backspping. Suchfunctions are in keepingwith the Mandateof Minisies of Healthto provide publicgoods and services,as teviewedin Chapter1. Theyare also amongthe weakt links in district-basedsystems today. In Ethiopia,for example,an evaluationof decentalizaton to the disati level foundthat progress has beenundemied by a Ministryof Healththat was not concepually,technically, and manageriallystrong enough to supporta distict-basedsystem. DistrictHealth Committees received insufficient guidance from the regionaladministrative and healthoffices regarding the rangeof problemsthey shouldaddress, and the Ministryof Health 110 failed to sufficientlyto pave the way for intrsectoral collaborationat the districtlevel (Ethiopia 1991).

1ucouragIngand Strengthening CommunityOrgaizations

Since the Alma Ata Declarationand the promotionif "Health for All by the Year 2000", the concept of commnunityinvolvement in health has been proclaimedas an antidote to problems plaguing the health sector. Predominantamong them are the following(WHO 1988a, p. 56):

* Health strategies often fail to encouragepeople to think or act for themselvesand do not foster self-reliance.

* Inadequatetraining at the communitylevel undermines effectiveness of servicesbecause they camot be sustaied by local knowledgeand resources.

* Communitycontributions in terms of resourcesand personnelare seldom accompanied by active involvementin the design, implementation,and supervisionof projects and programs.

The evidence is overwhelmingthat the participationof local commumtygroups in the design and implementationof health sector activities has an important impact on success and sustainability(Vaillancourt, Nassun, and Brown 1992;Mburu and Boerma 1989). In Senegal, for example, the problems noted above are manifestedin difficultieswith the legal status of community health organizations, problems of ensuring suitable representation in their management,and the need for changes in the design of systems, permittingco-management of revenuesfrom cost-sharing(World Bank 1991h,p. 13). The participationof communitygroups in Benin, on the other hand, has led to increasingawareness of health problems among target populations,and this increasedthe likelihoodthat people wouldturn to health centers for support when ill (Grimaud 1992, p. 60).

As caretakers of their own health, communitymembers can be mobilizedto participate in a wide range of basic health care and inter-sectoralactivities for health, including needs identification,project design, and adaptationof projectactvities and technologiesto local needs. To illustrate:

* In Ethiopia community groups played an important role in mobilizing people for immunization,in tracing defaulters, in providing transport for immunizationsessions, and in educatingpeople about the importanceof immunization(District Health DevelopmentStudy Core Group 1991).

* In Guinea and Lesotho communityrepresentatives have formed health management committeesto participate in the developmentof programsto strengthennutrition and maternal and child health in bealth centers, and to defne the role of cost recovery in meeting financing needs (World Bank 1985b and 1987b). 111 In Benina villagemanagement committee made decisions about the abilityof people to pay, writingoff costsof indigentseven though exoneration mechanisms do not officiallyexist.

Communitygroups can also participatein informationcollection, monitoring and evaluation,promotion and management of local-levelservices, and maintenance of infrastructure. n Iringa,Tanzania, communuities have participated in monitoringand assessing their children's growth pattern, thus encouragingthem to take action to reduce malnutntion. In Benin communitiestook responsibilityfor preparingappropriate storage conditions for essentialdrugs suppliedby the government.Within three Yorubavillages in westernNigeria, at least28 small and non-bureaucraticlocal organizations were available to mobilizecommunity involvement in healthcenter activities(Mebrahtu 1991). And in Zaire communitymanagement committees graduallyassumed full responsibilityfor the operationof healthcenters (Lamboray and Laing 1984). Finally,community groups can play a vital role in monitoringenvironmental problems and mobilizingresources in supportof inter-sectoralinterventions. Among the hundredsof thousandsof communitiesin Africathat are not servedby publicworks, such as pipedwater and sewersystems, community initiatives to instal handpumps and pit latrinescould have a decisive effect on the sustainabilityof health outcomes. In Ghana communitygroups made viable recommendationsfor improvingenvironmentl sanitation, the most strikingof whichwas to establishcommunity-level environment tribunals to enforcepublic compliance. In Guineaand Benin the role of local health managementcommittees has alreadybeen extendedbeyond preventivehealth interventions to environmentalhealth, water supply, and other matters (World Bank 1992b). ManagingHealth Servicesat the District Level In over a hundredcountries throughout the world, and in thousandsof districts, the conceptand practiceof the districthealth system is in force,or in process,as a provenvehicle for primarycare. A reviewconducted by the UnitedNations Development Program claims that the districthealth system - as a widespreadmanagement movement - capturesmuch of what is centralto contemporarydevelopment thining. "It lies squarelyin the area of basic human development.It touchesthe life of all: in the cities and the countryside. It vaultsover the metropolitanbarrier that confinesmost external cooperationwithin central ministriesof government. It is lodgedin a sensiblelevel of decentalizaion; it is smallenough in most instnces to be a practicalmanagement unit; its targetsare modestenough so that achievingself- sustaning growthcan be a real possibility."(Joseph and others1992).

In Afica, districtbased health care - as describedin Chapter3- is practicedwidely in countrieslike Botswana,Tanzania, and Zimbabwe, partally in countrieslike Benin,Guinea, Mali, andNigeria, and on a experimentalbasis in countrieslike Burundiand Senegal. Day-today managementof healthservices is carriedout by a DistrictHealth Team (DHI), whereas inter-sectoralcollaboration is facilitatedby a DistrictManagement Committee - comprisingthe headsof local departmentsrepresenting, for example,health, education, and publicworks. 112 In Zimbabwe,DHTs are comprisedof a representativeof eachhealth center or hospital, the district administratorand his staff or representatives,district councilrepresentatives, a representativeof villagehealth workers, a resettlementofficer, community and women's affairs representatives,nutrition coordinators, the familyplanning group leader, a psychiatrynurse, and a communitynurse. Prior to the developmentof the districtsystem in Zimbabwe,functions wereperformed by a provincialteam which had up to sevendistricts to lookafter. It is widely agreedthat the introductionof the districtsystem has improvedservices and achievedhigher levelsof coverage(World Bank 1993c). Backedby the authorityof the Ministryof Health,DHTs have a particularlyimportant role to play in assuringa basicservice package. This can be done by influencingdecision- making,setting local standards, and monitoringperformance. Within a frameworkof national policiesand norms,DHTs can be authorizedto take decisionson the locationof new public sectorand non-governmentalhealth care facilities,determine the profileof basic healthcare servicesto be providedby healthcenters and the districthospital, set standardsfor thepersonnel mix in local health care facilities,define stadards for fncial managementto ensure accountability,fix fee schedulesand perhaps mininmm salary levels, and determine management norms. The approachof DHTsshould be to encouragethe maximumengagement in provision of basic servicesby all potentialhealth care providers,whether public, private voluntaryor private-for-profit.Competition among providers can stimulatequaity improvementsas wellas the responsivenessto clients.

Box 4. Trainingand Development of HealthDistinct Teams in Ghana

In ha Disrc HealthTeams (DHTs) have exisledfor some tme, but with mcreasingdeenaizaton of die country's healt system,skll requrems for plannig and managinghave expanded. To Increasedie capacityof DHTs to undertakeproblem anaysisand stg management,the govemmentInid a taing prgram m 1988, with the assae of the UK Overeas DevelopmentAdmistio the Fnnish iternatn Dev opm Agency,the Ministryof Publc Healt of Austri, and the Unitd NationsDevelopment Pmgam.

Witbina pedod of three years.65 of 110districts coveing over 75 percentof the country's pqladon, were involvedin the pram. It consits eentially of three stages:

* A start-up worshop". incudig sessaonson problem iden problem analysis, stategy development, and fobrulation of action plans. Duringthe next three to four monthsthse plans are acinaiy Implemeted.

* A "reviewworkshop" to assess the expeience of participantsin tryig to impement their plans, anablzingachievemems and constraints.Lessonskearmdforeffecdve plannigand iemenonae revewed, poblem s mt reformuated,and smategies reviewedand revised. The relationsi betweenmanagem stengtheninganddte implementadonoftechnical progums is alsoanalyzed at this stage. Patcipans then draw up revisedor new acion plans to be implementedover the next six to sevenmonts.

* An "advanced review wodhp" takes participants throgh anothet review and refornulaton process and introduces them to a morecomprehensivefomat foraction planning. he new formatrequires that teamsgive greater emphasisto developingindicators for monhorin their achievements.A fhial reviewmeeting is hdd at the end of the six to sevenmonths implementaion period.

Assessmet of this progam - now fullydocumented in s handbookfor the World HealthOrganization (Cassels and others 1991) - sugest it is havingseveral positve effects. FMst,it buids a sense of ownershipas patcins analyzeand tackle problems theythemwelves perceive to be importan Second, It fosters teamwodr,as responsiblies for implemenmonare sharedby dffferent team membe rathertan just Disct Mal Officers. Third, it fosters incrementalleanung as the workshopsare staucmredso that mm buid on initi achievementsand nw ideas ae introducedas they become relevant (Ghana, MOH, 1992). And fourth, _"opmmand panning skillsteid to be ingained thugh tepetition prce withsttegy deveopment, andreviews of performance. 113 Experiencesuggests that the performanceof district health teams will either be facilitated or constrained depending on whether (i) rationalizationand integration of different health services and support programshas taken place at the central level - particularly in respect to vertical programs, (ii) sufficient decentralizationhas been achieved, allowing the district to manage human and financial resources independently,and (iii) communitycontrol structures have been established. The latter point is particularly important to promoting equity and beneficiary confidence and utilization of the health care system: in Mali, for example, democratic procedures were introducedto elect community representativesto district health teams, thus preventingdomination by local elites (World Bank 1993c).

Expertise in carrying out the administrative, planning, and managerial functions of District Health Teams (DHTs)cannot be created overnight,however. A numberof governments in Africa are currently involvedin a step-wiseprocess, first educatingplanners and policymakers at central, regional, and district levelsabout what is involved, then reachingconsensus on roles and responsibilities,then commencingtraining in skills required to cany out needed functions. This evolutionary process is being assisted by internationalorganizations and donors. And, becausedonors tend to be novices in this area as well, successesin building national capacities are products of an evolving partnership between African govenmmentsand the international community(see Box 4).

District Health Teamsalso have an importantrole to play in coordinatingdifferent public and non-governmentalservice providers at the district level, so as to assure basic services of minimnumquality for all. Experience in countries such as Zaire, Togo, Ghana, Zambia, and Kenya reveals significantvariability in the performanceof private voluntary organizationssuch as religious missions,and private-for-profitproviders such as privatepractitoners or drug shops. Problems arise over different conceptsof service provision, often resultmg in patchy coverage and weak support services; poor accountability to local communities; failure to mobilize communitiesfor health promotion;and weaknessesin managementsystems (World Bank 1992e). To address this type of problem in Swaziland,DHTs include both governmentofficials at the district level, and representativesof missionswithin the district. Through planningworkshops and regular meetings, the DHTs set priorities for the combinationof govermmentand mission services, coordinating use of both sets of resources and identifyingdistrict budget needs for submissionto the cental level. In the Kigoma regionof Tanzania, and the Bungomadistrict of Kenya, district planning workshops brought together DHTs and NGOs for joint analysis of health needs, as well as the strengths,weaknesses and potentialof each of the providers. This stimulatedinterest and commitmentamong the missions to re-orient their services to be more supportiveof district priorities (World Bank 1992i).

Consultationson the perfornance of district-basedhealth systemssuggest that, once the incentivesare sound, formal agreements,conventions, and contracts are likely to help DHTs to perform their coordinatingfunctions. Conventionscan be used to define the obligationsof the public sector towards private voluntary and private-for-profit providers of health care (for example, if buildings, equipment,personnel, or training are to be provided, and according to what standards), as well as the obligationsof the health providers towards governments(for example, upkeep of buildings, reporting, and ensuring continuation of public services). Contrcts can be used to define mutal obligationsof public and private providers regarding 114 implementationof governmentprograms, such as vaccinationand TB control. A number of countries, such as Malawi, have long had such agreements,and Ghana has recently concluded one (World Bank 1990b, p. 13).

Community Participation

In many African countries,community involvement in the managementof health facilites is emerging as an importantaspect of district-basedhealth systems. Placing greater decision- making in the hands of communityrepresentadves tends to be associatedwith more rapid and comprehensiveidentification of health needs and expectations;more reliable identificationof the poorest households in the community; easier adaptationto cultural and religious preferences; unbureaucraticemployment of localor communitystaff; greater flexibilityin executingactivities outside normal work hours (for example, nights, weekends); use of non-conventionaland creative methodsto promoteeducation and information(for example,theater, animation,dances, and film producdon); and practical developmentof technologiesthat can be adapted to local conditions (for example, locally produced ceramic water-reservoirwith simple tap to avoid secondary householdcontamination) (World Bank 1992e).

In a district-basedsystem, with centrl, regional and district-levelfunctions as described in Box 3, complementarycommunity management functions commonly include the following (WHO 1988a):

- recruitment, payment, and supervision of communityhealth workers and trained traditionalbirth attendants

Box5. Accowntabilityand Transparencyin the Useof CommwztyResources

When heat centers use cost-sharingor drug revolvingfunds wih communityresources, asparency is vital for establishingaccountabilty and trust betweenhealt providersand clients. Transparencycan be faciliated by posting fee schedulesand statments of receiptsand expendituresfor all to see. Whenpersons are treated, the diagnosiscan be enteredin hislher individualuteant booklet,along with a receiptof the fee paid. Literatemembers of the household or community,as weDlas supervisorscan then verify whetherwhat was paid correspondsto wat is noted, as well as posted. Community participationin the mngement of funds generated through user fees also means that both supervisorsand communitymembers can comparethe balance in accountswith receiptsregistered at the healthfacilty.

Recent studiesof communityfimancing of healthcenters in Rwanda,Zaire, Guinea,Benin and Mali revealthat a great many collaborativemanagement mechanism are evolvig. These includecommunity control of moneythrough accountswith doublesignar, and doublelocks on dmg stockswith the communitycommittee and ihehealth staff each holding the keys to only one, and stamps or photos on registrationcards to identiy householdsthat have paid local insurance fees. Efficiencyindicators associated with these measuresfurher show that, so far, there has been little leakage' in these systems.

In Botswana,District Councils, agenciesof local governmentrather than of the Ministry of Health, assure oversight over local health care providers, prevent skeholders from capting the services, and ensure local accountability.Armagements such as this givebeneficiries *voice' in managementof the care on whichthey rely. The option of "exit to no-governmentalhealth care providers - an elementof compeion - contributestransparency by making clear which providersare most favorablyperceived by patientsand their families.

Source of Country Studies: Galland 1990;Bitran 1986; Miller 1987; KnXpenberg1990; Gbedenou 1991; MOH, Mali 1990; Shepard and ohers 1990. 115 * provision of communityfinancial support toward the cost of health services * contributionof labor and materials for the constructionof clinics and staff housing * participationin local health planning initiatives * organizationand promotionof preventivehealth care, particularlyactivities concerned with maternal and child health, immunization,and oral rehydration.

As noted in other chapters, such functionsare typicallyperformed by conmnunitymanagement committeesin the operationof community-basedhealth centers (Chapter3), drug revolvingfunds (Chapter 4), and insurance schemes(Chapter 8).

From a broader perspective,community management conunittees nirror the strengthsof District Health Teams, and can be expectedto improve the performanceof health systems for at least four reasons. First, they can play a major role in holding health care providers accountableto their clients. Indeed, accountabilityand transparency, based on a continuous dialogue and interaction between service providers and communitiesare criteria of a well- functioning health center (see Box 5). Second, involvement of community management committeeshelps contributeto good governancein the sensethat diverse kin, ethnic, social, and cutural groups have an opportunity to present their gnevances and can collaborate in overcomingthem. Third, participatorydecision-maldng develops a sense of ownership. When communitymanagement committees participate in adopting a particular approach to resolving problems, such as nutritional monitoring, they are more likely to become engaged in the activities involved, assessingresults, and monitoringprogress. And fmally, when communities are involved in managinghealth facilities, relationshipsof empathy and trUStare more likely to evolve between health care providers and clients.

Building on community strengths is not only a matter of inviting communities to participate in management. Part of the challenge is to attune health care providers and the medical professionsto the advantagesof getting communityrepresentatives involved. In some countries this challengeis being met by re-orientingformal medicaltraining to include practice and research in communitysettings. Medical studentsare being exposed to community-based reseach at the University Centre for Health Sciencesin Cameroon, the University of Nairobi, Kenya, the Universityof Dar es Salaam, Tanzania,the Universityof Zambia, and the University of Zimbabwe. To earn the degree of Doctor of Medicinein Cameroon, studentsmust produce a report based on an internship in "integratedcommunity medicine" (Aleta 1992).

Monitoring and EvaluatingDistrict Level Services

As District Health Teams and CommunityManagement Committees progressively work together to improve the quantity and quality of health services, parallel processes need to be establishedto facilitate day-to-dayproblem identificationand resolution of bottlenecks. Even the best designedsttures - on paper - can default due to unforeseenproblems at times of operationalizaton. Processesof monitoringand evaluationare critical, therefore, especiallyat the local or bealth center level. Criteria may vary, but usually include some combination of availabilityof services (for example,essential drugs and vaccines); measuresof access (linked for example to communityaccess); actual utilizationof services; and overall quality standards (Tanahashi 1978 and Knippenberg1990) (see Box 6). 116

Box 6. Monitoringthe Provisionof Health Care Serices at the District Level in Guinea

In Guinea,lal monitoringof health care serviceshas helpedhealth care providersto identifyspecific problems and botwlenecks,and to determinethe actionsrequired to address them.

As shownin the figure, health center staff monitoredthe followingvariables:

Availability:the percentageof time during which the resources requiredto implementan interventionare physicallyavailable at the healthcenter.

Accessibility:the percentageof the target populadonliving sufficientlyclose to have easy acces to service delivery points.

Utization: the percentageof the target populationcoming into contactwith the service, as measuredby use at least once.

Adequatecoverage: the percentageof the poputation receivinga complete intervention,such as the total numberof vaccinadonsrequired.

Effiectivecoverage: the percentageof the populadonreceiving services of standardizedand verified quality, reflecting, in the case of vaccinatons, adherenceto dte cold chain and use of unexpiredvaccines.

The figure revealsthat nearly 60 percentof pregnantwomen udlized some prenatal care in SeredouDistrict, over the period covered, but that only one quarter received adequatecare, as measuredin this case by the standard of three consultations.This suggeststhat active follow-upin the communityon the qualityof patient-providerinteractions might meritexamination. In conrast, in Sino District problemsin ensuringeffective coverage of pregnantwonen with tetanus toxoid vaccinationswere principaly attributableto low geographicalaccessibility to healthcare. As less than 40 percent of the populationare withineasy accessof healthcare, there is a need to intensifyoutreach.

100 00 X 100 90 90 8s 80 70 70 60 60

50 50 40 40 30 30 20 20

10 I 0 0 0 Target AvailainliV AccessibilitV Utzation Adequate Effectve Population Coverage Coverage

- * Prenatal Care (inclufing tetanus and toxoid * Prenatal Cae in Seredou District vaccinations) in Sinko District

Source: Knenberg 1990. 117

Locallevel monitoring and evaluationacross health facilities has beenwidely practiced in Beninand Guineawith at least three positiveresults. Theyhave helped to identifycommon problemswhich have required assistance at the district,regional or nationallevel. Theyhave contributedto an exchangeof experiencesconcerning corrective actions. And, they have fosteredcompetition between facilities in resolvingcommon problems. Indeed, the motivational benefits of such monitoringand evaluationcannot be overstated, especially when the identificationand resolutionof problemsyields a senseof empowermentthat changeis possible at the locallevel. DevelopingResearch Capacities

Virtuallyall of the roles and responsibilitiesdescribed thus far require supporting researchand policy analysis.To improveon the dismal state of health researchand policy analysis in Africa (and other developingregions), the IndependentCommsion on Health Researchfor Developmentrecommended: * nvesXt in long-termdevelopment of the research capacity of individualsand institutions,especially in neglectedfields such as epidemiologyand managementresearch * Seting nationalpriorities for research,for usingboth domestic and external resources

* Giving professionalrecognition to good research and building career.paths to attract and retain able researchers

* Developingreliable and continuinglinks betweenresearchers and researchusers at national,district, as wellas communitylevel

* Investingat least2 percentof nationalhealth expenditures and 5 percentof externally fundedprograms in essentialnational health research. Withoutsuch commitments, prospects that African counties willbe ableto establishtheir own policy agenda,target householdsmost in need, improvemgement of decentralized systems,and monitor and evaluate progress will remain slim. Botswanahas stronglyencouraged developmentof healthresearch capacity for preciselysuch reasons. A HealthResearch and DevelopmentCommittee, established in 1984, has played a cmcial role in promotingand supportig healthsystems research. A HealthResearch Unit in the Ministy of Health,set up in 1985, serves as secreariat to the Committee. Factorscontributing to the developmentof health research capacity in the country includepersonal commitmentby senior officials, establishmentof a clear focal point repordng directdyto the Permanent Secretary, the motivationalimpact of usingresearch findings to improvehealth, and recognitonthat time for reach must be includedin the anmnalwork plans of distict healthteams (Owuor-Omondi 1988,p. 27). A wide range of agenciesand institutions,including private foundationsas well as bilateraland multlateraldonors, are availableto supportthe developmentof healthresearch 118

Box 7. A Health Research UnitMakes a Differencein Ghana

OftenMinisiries of Healthin Africanare blamedfor makingdecisions that are not scientifically informed.This is frequentlydue to failureto useavailable information, especially research information that existsin academicinstitutions and scientificjournals. Ministriesof Healthoften perceive themselves as serviceproviders with little or no role in research,and researchfindings are oftenexpressed in a way that is not digestibleto decisionmakers. To addressthis problem,as part of an on-goingrestructuring exercise. the Ministryof Healthin Ghanacreated a HealthResearch Unit. It is responsiblefor creatingawareness for the needand usefulness of resewachinformation at all levelsof the healthsystem and articulating the researchneeds of the Ministry of Healthto professionalresearchers. It is alsoinvolved in buildingcapacity for operationsreseach in the Ministry,conducting health systems research and ensuringthat healthresearch information is disseminaed andutiized. Withintwo yearsof its establishment,the ResearchUnit had determineda researchagenda and circulatedit to all universitydepartments and researchinstitutions concered. It had developeda research policyfor the Ministryand supported over 20 completedresearch projects. It alsoconducted workshops on researchproposal writing and analysis for regionaland districthealth teams.

Toensure utilization of researchfindings, the ResearchUnit has supportedconsultation meetings at the nationallevel on topicslike safe motherhood,decentralization of healthservices, and community health worker programs,at whichresearch findings are presented. Programguidelines have been preparedfor implementorsfollowing such consultations. The ResearchUnit workswith an eighteenmember Advisory Committee made of stafffrom the Ministryof Health,the Ghanastatistical services, academic institutions, research bodies, local government authonties,non-governmental organizations, and the NationalCouncil of Womenand Development.

Source: Adjei1993.

capacityin Africa. In 14 countriesin southernAfrica, health workersfrom national,provincial, and district levels have been trained in the developmentand implementationof health systems research proposals, with the participation of WHO, the Dutch Government Technical Cooperation,and the Royal TropicalInstitute of Amsterdam. Over fifty researchproposals have been supportedwith smallgrants, and a technicaladvisory committee has been establishedfrom focal points on health systems research from each of the participatingcountries (Aleta 1992). Subsequently,universities in Tanzania, Zambia, and Zimbabwe, are engagedin developingand implementng proposals through their Faculties of Medicine. The Rockefeller Foundationhas provided grants for such activitiesfor decades, and is currently supportingthe establishmentof national epidemiologicaladvisory boards in Cameroon, Mexico, and Thailand.

The InternationalHealth PolicyProgram (IHPP), supportedby the Pew CharitableTmst and the Carnegie Corporation of New York in cooperationwith WHO and the World Bank is noteworthyfor its support of a network of interested developingcountry researchers seeking ways to use resources more effectivelyto improvethe health of the disadvantaged. The IHPP supportsresearchers in a number of African and Asiancountries. World Bankand International DevelopmentAssociation comnnitmentsto population, health and nutrition projects in Africa have almost always containedprovisions for rese h, amountingto roughly 2 percent of total commitmentsof $1.2 billion ftmugh 1992. 119 The researchagenda for better healthwill undoubtedlyvary from countryto country. In mostAfrican countries it is likelyto includework to gaina betterunderstanding of the lowest levels of the health care pyramid- self care, the intra-householddynamics of health, and community-basedactions for healthimprovement. The endeavorsof international,national, and localNGOs are particularlyrelevant to understandinghealth behavior at this level. As but one example,a women'shealth research project in SouthAfrica is promotinggender awareness and encouragingwomen's input and participationin healthpolicy making. The project involves participativeresearch, developmentof a national network of over 600 individualsand organizations,production of a newsletter,and running health information workshops (Tumwine 1993). A women'stime allocationstudy is attemptingto informpolicy and enablewomen to demandcreche faclities, accessto landand agricultural training. It is alsoexamining the impact of the domesticdivision of labor,especially fetching water and fuel, on women'shealth. Conclusion

Realizingthe benefitsof health investmentsin Africa requires more than simply improvingthe quantityand quality of inputs such as pharmaceuticals,personnel, infrastructure. equipment,and technology.How those inputs are planned,allocated, organized, and managed can detenrine whether the services are cost-effectiveand make the differencebetween sustainableand ninable outcomes. How institutionsrationalize functions and devolve decision-makdngauthority to variousadministrative levels can mean the differencebetween integrated,well-functioning systems and piece-mealapproaches confounded by duplication, overlap,and lack of intersectoralcoordination. How health and related personnel see theirroles at cental, regional,district, and communitylevels can makethe differencebetween a structure featuringclear incentives and teamwork, and a structureimmobilized by fmstration,apathy, and pursuitof cross-purposes.And, howcommunities are involvedin localmanagement decisions can makethe differencebetween health systems that treat peopleas objectsand thosebuilt on communitypartnerships and ownership. The challengefacing African governmentsis to acceleratethe process of institutionaland managementreforms affecting health services. Specific responsibilityfor capacitybuilding and monitoringinstitutional reforms might be assignedto a seniorMinistry of Healthofficial. Clarificationof managerialand decision-making roles and responsibilitiesat the central,regional, district, and communitylevel wouldbe an importantpart of this work. CHAPTER 8: COSTING AND PAYING FOR THE:BASIC PACKAGE

Introduction

Commitmentsto expand preventive and primary care to a greater number of people in Africa raise funamental questionsabout the resources required to do so. Providers of health care might well extrapolateresource needs on the basis of past expenditurelevels, but this would clearly be infenor to determining resource requirements for more cost-effectiveapproaches. There is a great demand for indicativecosts of a basic package of health services - based on real experiences - especially when some countries in Africa have participated in those experiences and others wish to learn about them.

This chapter provides a perspectiveon the likely wuitcosts involvedin providinga basic package of health care at the district level, as weli as complementarymulti-sectoral inputs such as safe drinking water and sanitation (as described in Chapters 3-8). Two.sets of costs are presented. One set pertains to low-incomecountries in Africa, hereafter "low-incomeAfrica". They have been derived from the cost of basic health care and intersectoraliterventions in rural and peri-urban areas in several countries. The other set pertains to a "bigher incomecountry", showing how costs are likely to change with higher levels of income, wages, and price stucur. These costs are based on the experienceof Zimbabwe.

The costng exercise performedhere provides grounds for opfimismthat real progress can be made in extending quality health services to the majority of African households. Establishing a benchmark of $13 per capita for a basic package of health services in "low income Africa" is valuable as a means of promptingreflection on what householdsare getig now for the amount they pay; how resources might be reallocated to usher in a more cost- effectiveapproach; and additionalresource requirementsto assure that the poorest countriesand poorest groups within countries could afford such a package. A Building Block Approach

Costs for a basic package of services - as describedin this sdy - have been determined by pooling recurrent and annualizedcapital costs for health care as well as multi- sectoral inputs at the communitylevel. It is at the communitylevel where packages of basic health care and supporting services can best be deermined, given the demographic and epidemiologicalprofile of householdsto be served. The community,comprising hundreds of households, can also realize scale-economiesby poolingresources for, say, safe drinking water 121 or sanitation. This is particularly important in most African countries where hundreds of thousands of communitiesdot the countryside, or make up peri-urban areas beyond the reach of other water and sanitationsystems.

Annual per capita costs for "low-incomeAfrica' have been extrapolatedfrom data on well-functioninghealth centers, district hospitals, and intersectoral interventions in several African countries. Costs have been annualizedby adding yearly costs for recurrent items, such as salaries and essential drugs, to amortizedcosts for capital investmentssuch as buildingsand equipment. Amortzation is required to translate large initial outlays for buildings, equipment, and training into an annual amount, thus yielding informationabout yearly financingthat would be required to pay off the outlays over time (presuminga loan were involvedto finance them). Capital costs have been annualizedon the basis of the economiclife of the assets, at a 4 percent discount rate (World Bank 1993a).

Pooled recurrent and capital costs have then been divided by the resulting population served, to derive an average unit cost on a per capita basis. These per capitacosts can then be aggregatedto produce total costs for the combinedpopulation of several commuities; a rural or peri-urbandistrict (assumingits populationis given); for a network of districtsthat comprise a region; or for all people nation-widethat live in districts comprised of rural or peri-urban populations. This is the approach adoptedhere.

Qualificationsare in order. First, no pretense is made that the cost scenariospresented here are definitive or applicableto all African countries. Most important is to illustrate the process by which they are determined,and to encourageAfrican countriesto prepare their own estimates. For this reason, the methodologyemployed and data used in this chapter are fully documented in backgroundstudies to this report (World Bank 1993a). Second, the indicative costs presented here are most relevantto the large majorityof Africansliving in rural and peri- urban areas, rather than large urban areas or cities. Third, costs for particular services can be expected to change as pattns of disease, incomes, and health expenditureschange over time - the so-called demographic-epideniologicaltransition - implying that relatively static approachesto estimatingcosts should give way to more dynamic approaches.

Low Income Africa

Indicative costs for "low-incomeAfrica" are presented in Table 1. These derive from an "input" approach, or what goes into providing a basic package of services in terms of salaries, infrastruture, drugs, training, managementand other materials necessaryto provide the basic package efficiendy. Health planners and budget officials find this approach useful becauseit provides cost estimatesfor line items that are similar in structure to traditionalbudget documents. The total per capita cost of $13.22 is comprisedof three components;bealth care and facilities (about 60 percent); intersectoralinterventions (about 30 percent);and institutional support (about 10 percent).

Health Care and Facilities:Based on argumentspresented in Chapters3 through 7, well- functioning health centers and a first referral hospital are capable of accommodating approximately98 percent of preventiveand curative health care needs in an average rural or 122

Table 1. Annual Indicative Per Capita Costsfor a District-BasedHealth Care System:Input Approach

[DistrictProfile: 150,000 Inhabitants; 15 HealthCenters (10,000 in EachCenter]

Higher Low Income Income African Africa Country Difference ($) ($) (%) A: HEALTHCARE AND FACILITES - LevelI: HealthCenter (15 HealthCenters) 4.60 6.72 46 - OperatingCosts 3.78 4.84 28 - CapitalCosts 0.73 1.75 140 - In.ServiceTraining 0.09 0.13 44 - LevelI: DistrictHospital 3.14 4.03 28 - OperatingCosts 1.75 2.24 28 - Capital Costs 1.35 1.73 28 - In-ServiceTraining 0.04 0.06 50 Sub-Total 7.74 10.75 39 B: INTERSECTORALINTERVENTIONS Water 2.56 2.19 -15 Saniation 1.42 1.36 4 Sub-Total 3.98 3.55 -11

C: INSTITUTIONALSUPPORT - DistrictHealth Care ManagementTeam 0.29 0.40 38 - OperatingCosts 0.15 0.24 60 -capital Costs 0.13 0.16 23 - i-Service Training 0.01 0.01 0 - NationalManagement Suctue 0.82 1.15 40 (15 of % TotalHealth Care Costs) - Initil Training(5% of Total 0.27 0.38 41 HealthCare Costs) - InctementalSalary Bonus 0.12 0.14 17 (15%of TotalSalaries) Sub-Total 1.50 2.07 39 TOTAL 13.22 16.37 24

Note:Total Operating Cost 7.86 9.50 25 Note:Total Capital Cost 5.36 6.87 23

Source:Adapted from World Bank 1993a. 123 peri-urbandistrict. The sub-totalfor health care and facilitiesin Table 1 is $7.74, or about 60 percent of the total.

It is assumed that health care services are organizedwithin administrative districts, each district comprising one district or referral hospital, 15 health centers on average, and serving an averagepopulation of 150,000. It is at this level that householdstypically make first contact with modem health providers and where equity can be most effectivelypromoted in access to services. Each of these facilitiesrequires informationon operatingor recurrent costs, on capital costs, and on in-servicetraining costs. In the case of health centers and a first referral hospital, this means determining the profile of staff, infrastructure, and equipment (as described in Chapter 3, Boxes 3 and 4), and assigningindicative costs to them. Details on the demographic compositionof the population served and kinds of services rendered in the health center and first-referral hospitalhave been provided in Chapter 3.

Intersectoral Interventions: The costs for these reinforcing interventions are also presented on an annual per capita basis. Indicativecosts are derived specific to communities, then averaged for a prototype district population of 150,000. They pertain to recurent and caplial costs of safe drinkingwater and sanitation. The sub-totalfor intersectoralinterventions is $3.98, or 30 percent of the total package.

Determiningcosts for multi-sectoralinterventions is extremely demandingof data. The estimates provided here combine available evidence for several African countries as well as expert opinion. Several important qualificationsare in order.

* The cost of supplyingwater services in a rural area will vary considerably,depending on the technology selected, the communitysize, housingdensity, hydro-geologicalconditions, local drilling costs, water consumption, and pumping system (manual, electrical, diesel, or solar). The least cost alternative,and that used in this study, will generallybe a hand pump in small communitiesof less than 1,000 people. It is assumedthere are 250 persons per handpump and that costs involve the drilling of a borehole, borehole equipmentand maintenance,with an annual life of about 20 years.

* The cost of providingadequate sanitation services in rural areas will vary considerably dependingon the technologyused, the type of building materials, constructioncosts, housing density, groundwaterand soil conditions,and the size of the family being served by the facility. The technologychosen for the prototype communityin this study is a ventilated improved pit (VIP) latrine made from local buildingmaterials. It is assumedthat for a populationof 10,000, each family of ten people on average, would have its own facility. Constructioncosts include labor and materials, as well as planing and mobilizationat the end of the first four years when a new latrine will have to be constructed.

Institional Support:Liaison of the health facilitieswith the Ministry of Health, as well as important local governmentsupport or administrativefunctions, would be provided by a District Health ManagementTeam (DM1). This would includesupervision and monitoringof the district health care system, in-servicetraining to hospital and health center staff, logistical support to the hospital and health ceters, and liaison on behalf of the district with local, 124 regional, and, as necessary, central authorities. As described in Chapter 7, the DMT would consist of a staff of seven, assumed to consist of one medical doctor, one pharmacist, one registered nurse, one managementstaff/accountant, one water and sanitation specialist, one sociologist or "information, education, and communication"specialist, and one driver; and infrastructureconsisting of one building,two vehicles,and other equipment,including furniture.

The district system would also require overhead support from higher levels within the health system, includingregional authoritiesand the Ministryof Health. Servicesat the higher levels would include health research, policy analysis and formulation, logistical support, administration,and coordinationbetween the districts and infermationsystems. Also included would be coordinationwith other govenumentsand internationalagencies, and initial training of personnel. In turn, a nationalmanagement structure would be required to coordinatefunctions of the DMTs, as would some provision for initial training of personnel - both health and administrativepersonnel - to contribute to a smootherrunning system.

It is assumedthat these managementoverheads can be accommodatedby a provisionof 15 percent of total operating, capital and in-servicetraining costs of all personnel and facilities at the district level. Initial training costs at the nationallevel are treated in similarfashion. As initial training is consideredto be a capital cost, a provisionof 5 percent of total district costs has been included to provide for the annualized costs incurred. Finally, in view of the importanceof monetaryincentives for staff as well as laggingsalary structures in most countries, an incrementalsalary bonus has been providedamounting to 15 percentof all salaries. The total cost for the various components of institutionalsupport is $1.50, or 11 percent of the total package.

Complementaryto the indicativecosts for "inputs"provided in Table 1, is the profie of "outputs" or services to be rendered to households(Table II). To illustrate, at the health center level, Table II informs us that maternal services comprisingpre-delivery care, delivery care, post-deliverycare, and nutrition for pregnant and lactatingwomen are provided as part of the basic package. On average, the share of these maternalservices in the total cost of the packdge for low-incomeAfrica is about $.47, or 3.5 percent of $13.22.

Thoughnot very useful for budgetingpurposes, establishing costs by outputsis conducive to detrmining priorities and estimatingthe cost-effectivenessof interventions; is the community acquiringthe optimum level of health benefitsby spendingX dollars on a certain intervention? The output approach allows for a more thorough analysis of costs and health-outcomes. For example, it is easier to relate the cost of providing well-babyservices to improvementsin the health status of babies than it is to relate the capital cost of the health center to the health status of babies.

Higher lncome Country

Zimbabwe has been selected for comparatve purposes because its per capita GNP is more than double the average of "low-incomeAfrica"; health care in Zimbabweshares some of the feates of the cost-effective approach described in this study, and data are relatively abundant. Unit costs for Zimbabweserve the purposeof illustating what low-incomecountries 125

Tabkl . Amual Icadve Per Capa Costsfor might expect to pay as they move along a a Distid-Based Health Care System: Owput developmentpath in the fuure. Indicativecosts Approach for Zinbabwe are also presented in Table 1. -DstoProfile: -- 0 eTelsLOWInco total per capitacost is $16.37, comprised (DtrhictProfile:10.0 inhabaCOntser)1fLOW of health care and facilities (66 percent), inremental intrvenions (22 percent), and IEVDVIDL HEALTHCEERC institutionalsupport (12 percent). - Maena Services 0.47 *Nedelivery Car DeliveXryae At $16.37per capita,costs in Zimbabwe Post-deliveryCae re only24 percenthigher than those estimated NuWtrl-Biabton:w 1.f2 for 'low income Africa'. They are * Expad Program of Immunizadon(EPI) considerably higher for the health care NuMidon:(0-S) component(39 percent higher), than for the * Suppeientay feeding(0-2) intersectoralinterventions (11 percentlower). -SchoolChildren Health Progrm 0.21 oe) * Andi-helinthicservices (5-14) Featuresthat remainessentially the samein the * VitaminA + iodine,as reded two contextsinclude the menuof basic health CuratB Care(especiay childen 05) 0.46 care servicesoffered at both the healthcenter Malaria and first referral hospital, as well as the *Diarrhoe i Oppouni ifctns (AIDSrelad) demographiccomposition and epidemiological Otherlocal infedons profileof thecommunites served. What differs LTBeen 0.11 is the intensity by which people seek out or * Other demandcertain preventive(but not curative) -sTh services(tetin and ftratnt) 0.13 -FamilyPlannvig 0.87 services in "high-income Africa". This is Provisionof conaeptves influencedby higherlevels of educationand use * Incrementalfamily planing - JEC(for nution, famiyplanning. HV/STID)0.82 of various services, reinforced by higher Sub-Totl(Level I-.HeIath Centr) 4.60 income levels and expectations that such LEVEL2: DISTRICTHOSPffAL - n-pain care 2.20 servicesshould be made available. Greater * Obstticsand acoogky demandfor preventiveand primaryhealth care • Pediatrics * Mediine:IbftIous ds translates into additonal staff, expansionof • Basicsurey facilities, higher drug costs per capita, and Outtentce . additional equipment. While Zimbabwe has bR Levl 2 begun to enter the health transiton, its priorties Sub-Total(Level 2: District Hospitl) 3.14 SUB-TOTALA: ndividualCare Sevimces remain the provision of a basic package of B: NTERSECTORALINTERVENTIONS services to all. The future challenge for Water 2.56 Zimbabwewill be to adapt its servicesto the Sanition 1.4 needs of populationsat various stages of the SUB-TOTALB: IntersectomlInterventions 2 he C: INSTTTUIONALSUPPORT heth tr ition whie cowning costs by - NatonalManagement Support inudes: 0.82 whatthe countrycan reasonablyafford. * Surnuan11, monitoriglevaluaton * Nationalcapacity buDding initialTaininsg 0.27 Featuresof healthcare that changemost Distict HealthManaement Team 0.29 - District4evelSalary Bonus dramatically- judging from the Zimbabwe (15%of Tolalarbs) I experience- are salarylevels, additional funds SUB-TOTALC hmftdomi- SWort 115-0 to coveradditional staff, and housing provisions TOTALCOST OF BASICPACKAGE 13.22 for staff (a built-inexpectation in Zimbabwe). soe: Adapedftom Word Bank1993a. For example, four staff membs in a Zimbabwehealth center would be paid about 126 US$10,500 per year, versus $5,700 for the same number in "low-incomeAfrica". Salaries of doctors at the first referral hospitalwould be about $12,000 each per year, comparedwith about $4,300 per doctor in "low-incomeAfrica". In Zimbabwe, access to two staff housing units would be provided to four people at the health center, with 18 units being available to 42 staff at the first referral hospital. Drug costs are about 30 percent higher in Zimbabwethan in "low income Africa". For these reasons per capita costs of health care and facilities,combined with institutionalsupport ate about 38 percent higher in the "high-incomecountry" than in "low- income Africa".

In the case of multi-sectoralinterventions, costs are 11 percent lower in Zimbabwethan in "low-incomeAfrica". This is because the technologiesfor safe water (bore hole and pump) and sanitation (pit latrines)are widely availableand scale economiesof productionhave helped to keep prices down.

Who Should Pay for What

Unansweredas yet is the question, "who should pay for what" in the basic package of care. This is importantbecause the basic package containsa combinationof health goods and services. Some are of a public nature (institutionalsupport), others a mixed public-private nature (preventiveand individualcurative services,especially for communicablediseases), and still others a more private nature (clinicalcare for chronic diseases, water supply). Moreover, govermnentswill be inclined to concentratepublic funds on services for the poor, and others will be required to pay part or even all of the cost.

Resolving this question is no easy task because alternate approaches, each having advantages and disadvantages,can be used to demarcatepublic versus private responsibilities. On the one hand, an "interventionapproach" seeksto identifythe inherentpublic versus private nature of each health intervention. For example, district managementand health information and education costs could be assumed to be 100 percent public goods, while STD testing and treatmenthave both public and privatebenefit dimensions. A disadvantageof relying solely on the interventionapproach to decide "who shouldpay" is that a huge varietyof interventionsmust be identified, costs assigned, and public versus private aspects of each agreed upon.

On the other hand, a "targedngapproach" concentrates on identifyingappropriate target groups - such as core poor groups who, otherwise, might be excluded from benefits of the entire package. For example,target groups might consistof those living in low-incomeregions or neighborhoods,children participatingin social action programs, or those seeking help for problems associated with poverty, such as chronic malnutrition. A disadvantage of relying solely on this approach is that allocatingan entire basic package of services to target groups completely ignores the public extemality/privatebenefit dimension of the interventions or services involved.

A compromiseis to use a two-step process, drawing on each of the approachesabove, so as to identify an appropriate fmancingmix. From the list of interventions/servicesin the basic package, the first step is to identify pure public goods. These would be financed 100 percent by public funds. All remaining interventionsare relegatedto an "other" category, and 127

TableIII. Who Pays For WhatIn The Basic Package:A CombinedIntervention and TargetingApproach Type Of Public Public Private Private Service: Financing Financing Financing Financing Cost Publicor Other Share Amount Share Amount TYPE OF SERVICE ($) (%) ($) (%) ($) A: Indhidual Care Servies Level 1: Health Center (15 Centers) * Matemal Services 0.47 Other 80 0.38 20 0.09 * Wel-Baby Services 1.52 Other 80 1.22 20 0.30 * SchoolchildrenHealth Program 0.21 Other 80 0.17 20 0.04 Curative Care (especiallychildren 0-5) 0.46 Other 60 0.28 40 0.18 * Limited ChronicCare 0.11 Other 60 0.07 40 0.04 * STDIHIVServices 0.13 Other 60 0.08 40 0.05 * FamilyPlanning 0.87 Other 70 0.61 30 0.26 * JEC (for: nutriion, FP, HIV/STD) 0.82 Public 100 0.82 0 0.00 SUB-TOTAL(Level 1: Health Care 4.60 79 3.69 21 0.96 Center) _ _ _ _ - _ - - _

Level2: District Hospital I-Patient Care 2.20 Other 50 1.10 50 1.10 *out-patint Care 0.94 Other 40 0.38 60 0.56 SUB-TOTAL(level 2: DistrictHospital) 3.14 47 1.48 53 1.66 SUB-TOTALA 7.74 66 5.12 34 2.62

B: Intersectral Intevenons * Water 2.56 Other 30 0.77 70 1.79 * Sanitation 1.42 Other 30 0.43 70 0.99 SUB-TOTALB 3.98 30 1.20 70 2.78

C: Instituona Support * NationalMangement Support 0.82 Public 100 0.82 0 0.00 * initial Trahiing 0.27 Public 100 0.27 0 0.00 * District Healti ManagementTeam 0.29 Public 100 0.29 0 0.00 * District-LevelSalary Bonus 0.12 Public 100 0.12 0 0.00 SUB-TOTALC 1.50 100 1.50 0 0.00

TOTAL (nnn of Basic Package) 13.22 59 7.82 41 5.40 sorce: Adapted from World Bank 1993a. 128 includemost of the so-calledmixed goods for whichit is difficultto assigna public/privategood component. The second step is to examineall of the "other"goods and servicesfrom the targetingperspective - whatproportion of theircost shouldbe coveredby publicresources so as to insuresufficient coverage of targetgroups, especially the poor. Followingthis rationale, an indicativefinancing mix for the basicpackage of servicesfor low-incomeAfrica is providedin TableIm. Servicesin partsA andB yielda mixtureof private goods and public externalities.For this reasonthey are labelled"other" rather than "public" services. For example,at the levelof the HealthCenter (Part A, Tablem) it is estimatedthat aboutfour-fifths of the basicpackage will be financedby the publicsector, while about one-fifth will be paid for by households,in view of their low-incomes. Servicessuch as water and sanitationare estimated,on thisbasis, to havea 30 percentpublic component and a 70 percent privatecomponent (Part B, TableIE). Servicesincluded in Part C are deemedto be pure public goods, and as such wouldbe financedprimarily by the publicsector. The way in which public versus private responsibilitiesfor financing have been apportionedin Tablem is not intendedto serveas a modelthat all countriesor districtsshould follow. It is, rather, presentedto ilustratea methodologythat can help resolvea criticalissue facedby financialplanners in health. Each countryand districtwill haveto apportionits own public and private configurations,so as to identifyan appropriatefinancing mix, within a frameworkthat gives maximumattention to privatedemand, concentrates public resources on public goods and services,increases the mobilizationof domesticresources for health, and protectsthe poor. Affordabflity TableIV. Groupingsof SelectedAfrican Countries by Relaive Levelof E itureson Healh 1990

First impressionsare that costs to County Grouping providea basicpackage of healthservices in Co.t low-incomeAfrica ($13 per capita), are chmes High Mediun Low Totl within reach in most countries. This assessmentis based on expenditre data in Population(Millions) 14.1 95.5 230.7 3403 TableIV. Countriesfor whichreliable data AverageGDP/Capita $757 $443 $248 $324 havebeen available over thelast decade have E4ped Per Capita' been clusered into three groupsaccording to their relative levels of per capita GDP and - Privae $19 $7 S4 expenditures on health. Grouping counties - Government $40 $6 $2 in this way, though somewhatarbitrary, is coniuciveto analyzingdifferences in health - Donor $9 $3 $2 expendituresamong countries that differ in ToW $68 $16 $8 incomelevels. Hlgh Coun&ries:Botswana, Lesotho, Swaziland, Zimbabwe. Countriesin the "low"group spend $8 Medium Countries: Burundi,Camoon, Ganbia, Ghana, per capita, on average, from all sources. Kea L _a N Rna m This does not include public and private somaiia,Sierra Leone, Zaire, Uganda expenditueson waterand samtation. Private Note: 1. Expendkwresare in currentUS dollars. expenditureson healthin thisgroup are about Sourve: UnitedNations Development Pogramme and World BankI992; and WorldBank 1993e. 129 $4 per capita. Assuminga sufficientlevel of privatedemand, and that privateexpenditures could be mobilizedand reallocated,a major part - though far from all - of the costs of the basicpackage of healthservices could be met.

Governmentsand donorsboth spendanother $2 in the "low"group. But most of this mightnot easilyor quicldybe freed up, givenprior commitmentsto specificprojects, public commitmentsto supportcentral level and teachinghospitals, and past patternsand obligations to financeor provideservices not includedin a district-basedpackage. Part of the shortfallcould be coveredwere governments in the "low"group to raisetheir financialcommitments to health,to levelsthat are at leastcomparable to the averagefor all less developingcountries. As set out in Table V, this would result in a doublingof health expendituesby governments,thus providinganother $3 per capita. A siml;aramount might reasonablybe solicitedfrom donors, were govermmentsto have soundhealth reform programs and demonstatedcapacity and commitment to implementation.This wouldraise another $5 per capita. It shouldsuffice to coverfinancial shortfalls, especially when pnvate expenditureson water and sanitationare factoredin. Makingbetter use of the existng private expenditures wouldbe an importantpart of the financialpackage. Te "medium"group spends$16 per capita, on average,from all sources. For this group the most importantquestion may be, whatare the prospectsof reallocatingfunds from currentuses to the approachcosted here. Privateexpenditures in this group are $7, almost doublethose in the "low"group. As per capitaincome in this group is almostdouble that of the "low" group, however,it seemsreasonable to expect that householdsmay be able and willingto spendmore, especially were a cost-effectivepackage of basichealth services offered. Further, were countriesin this groupto followMalawi's example, and raise their government expenditurelevels on health,as a shareof totalgovernment expenditures, by a modestone-half to one percentper year, the $6 per capitathat is now availablefor healthcould be doubled withinten years (assuming one-half of onepercent increase per year). In thiscase and assuming that the otherneeded reforms were well-formulated with credibleimplementation plans, donors mightalso increasetheir participation.These countries should be ableto closethe gap without major difficulty. The "high"group spends $68 per capita,on average.Reallocation of expendituresis the key issue in this case,and it is appropriateto ask whethercountries are receivingthe samelevel of benefitsfor $68 per capitathat couldbe providedfor around$16 per capitain a countrylike Zimbabwe.Private expenditures in this groupare about$19, and are clearlysufficient to pay for the basicpackage of healthservices described here. Manyof the countriesin this groupare now movingaggressively to applyuser fees at all levelsof healthfacilities, and are exploring waysof expandinginsurance schemes to coverexpensive curative care in hospitals.This should facilitategreater concentrationof governmentand donor fundson public health gcods and services. 130

Table V. Rough Estimates of AdditionalRevenue Effortfor Health by Governmentand Donors in Low IncomeAfrica

Addithnd Funds (MtWions/Year) 1. Governmentsmore than doubletheir expenditureson healthas a percentage of total governmentexpenditures, raising per capita expendituresfrom $2 to $5; - Additionalfunds S3$ X 328 millionpeople = $984

2. Donors doubletheir aid for low-incomeAfrica from $2 to $4. thus nearly natchingthe governmenteffort; - Additionalfunds = $2 X 328 millionpeople = $656

Assumption:Just as the 'low' group represents68 percentof the total populationof all countriesin Table IV, it is assumedto represent68 percentof all people in Sub-SaharaAfrica in 1992 (S02 million, and projectedto increaseto 634 millionby 2000). This impliesan averageof 386 million people (68 percenttimes the average of 502 and 634 million).The total rural and peri-urban populationis assumedto be 85 percent times 386 million,or 328 million.

TotalAddidonal FundsPer Year Over the Next Ten Years $1,640

Gap

Assumingthe public sector - governmentsand donors - were willing to increase their reource commitmentsin the ways suggestedabove, what additionalresources would be raised for beter health in Africa? Based on the rough estimatesin Table V about $1.6 billion annually needs to be mobilizedto help meet the healthneeds of over 300 millionAfricans in the rural and pen-urban areas of all low income and low-healthexpenditure countries in Africa. Assumng concentrationof donor resources in these countries, the donor share, comprising about $650 million per year, would raise external assistance by about 50 percent above the level of $1.2 billion attained in 1990.

Another way of assessingfinancial implicationsis to compare the per capita cost of a basic package of services, as a percentageshare of per capita GDP, with what is being spent now as a share of per capita GDP. Among countries in the "low" group in Table IV, the basic package of services ($13 per capita) represents about 5.2 percent of average per capita GDP ($248). This compares with actual per capita health expendituresfrom all sources and for all purposes, of about 3.2 percent of per capita GDP in low incomeAfrica. Closing the gap is not simply a matter of boosting expendituresby another 2.0 percent of GDP per capita. A major challenge involvesreallocating expenditres from current patterns to more cost-effectiveends, determining the share of public health goods and services, and apportioningresponsibilities to the various stakeholdersto fill gaps (see Chapter 9).

For countries in the "medium" group in Table IV, the per capita cost of the basic package of services amounts to about 2.9 percent of average per capita GDP ($443). This 131 compares with per capita expenditureson health from all sources of about 3.6 percent of per capita GDP. Again, reallocatingexpenditures to cover costs of the basic package of services will be a major challenge to countries in the "medium" group, but the task is not insurmountable. Countries in the "high" group have far greater prospectsof reallocatingfunds; their current expenditureson health from all sources amount to nearly 9 percent of per capita GDP, comparedwith about 2 percent of GDP that would be required for the basic package. Conclusion

The pace at which cost-effectivepackages of basic health services could be made more widely available in the three groups of countriesabove is, of course, a critical issue. There will undoubtedly be considerable variation among countries in their commitmentto reform and capacity for implementation,and thus inevitably in the nature of the transition. In almost all cases, a phased-inapproach makes the greatestsense. Somecountries are alreadyexperimenting with a district-basedsystem of health care, such as Benin, Guinea, and Nigeria, with the implicationthat part of the costs of providing a basic packageof services are already in place. As lessons are learned, groundworkcan be carefully planned for expansion into new areas, mnvolvingiformation campaigns about basic services to be provided, the rationale behind charging fees, communityinvolvement in mobilizingresources and making provisions for the poor, and so on. Other countries are recovering from polidcal upheaval such as Angola, Mozambique,and Uganda, and may wish to lay the groundworkfor an approach favoring well- finctioning health centers and first referral hospitals as part of the process of restoring and rehabilitatingdamaged health facilities. Still other countriesmay wish to bring public providers of health care progressivelytogether with private voluntary providers in the pursuit of cost- effectiveapproaches.

As each country determinesits own particular developmentpath, so too must resource requirements be assessed and attempts made to reconcile financial needs with prospects for domestic and internationalresource mobilization. Initially, expenditurerequirements are likely to be most demandingwhen capital costs for new facilitiesrequire loans (and loan guarantees), or intersectoral services must be launched. It is in such contextsthat donor financial support will play a critical role. Equally importantwill be to map out the pace and direction at which health expendituresmight reasonablybe reallocatedtowards more cost-effectivebasic services. Once a country has deliberated on a basic package of services to be offered through health centers and first referral hospitals,a first step in determiningfmancing might be to convene an expert or consultativegroup, comprisingofficials of the public and private sectors. This group would assess the willingnessof householdsto pay for each componentof the agreed services, consider the extent to which external benefits extend beyond the immediate recipients, and review the public goods aspects. Weightingbenefits in this fashioncould be used to determine the relative roles of government,donors, and householdsin financingthe gaps discussedhere. CHAPTER 9: OPTIONS FOR RESOURCE MOBILIZATION

Introduction

Financial resources for health are in jeopardy in many African countries. To combat shortfalls, and to mobilizeresources for the basic packageof care described in Chapter 8, action will be required on several fronts simultaneously. In the public sector, more revenue is clearly needed in most countries for public health goods and services. This can partially be achieved by mobilizingresources from tax and non-taxrevenues and strengtheningpolitical commitments to public spendingon health. It is equally importantto make better use of public funds available by reallocatir; them from expensive interventionsprovided largely through tertiary care, to preventive - d primary care. Prevailing inefficienciesin the use of public funds are partially to blame for insufficientcoverage and the decliningquality of public health services, as well as pressures for more resources to produce them. This places a premium on restructuring the financing and provision of health care so as to shift from crisis managementtoday to more sustainablesystems of cost-effectivehealth care in the future.

There is convincingevidence that African householdsare willing to expend substantial out-of-pocketsums for qualityhealth services, and that strategiesto mobilizethese resourcescan help alleviate budgetary shortfalis among public providers, stimulate private financing and provisionof health care, and contributeto equity in the process. Cost-sharingstrategies can help free up public resources for public ends, especiallyby recoupingpublic expendituresat tertiary level hospitals. Private financingcan also substitutefor governmentinvolvement, such as when large, urban-basedemployers sponsor pnvate health insuranceor financeprivate health facilities. In addition, public-privatecollaboration can help diversifythe way that basic packages of care are financed, thus providing a stimulus to private-for-profitproviders and private voluntary organizations.

Prior to consideringbroad options for resourcemobilization, the first part of this chapter describesexpenditure levels and trends by governments,households (out-of-pocket), and donors. The evidencereveals that many governmentsin Africa lag behind other low-incomedeveloping countries in their budgetary commitmentsto health. Evidence is also provided to show that households spend substantial funds for health care, thus providing a sounder logic for cost- sharing to help finance basic packages of quality care. There also appears to be considerable scope for improving the impact of external assistance, especially if donors collaborate with governmentsto restructure systemsof health care to feature more cost-effectiveapproaches. 133 The secondpart of this chapter indicatesbroad optionsfor resourcemobilizaton that are likely to benefithouseholds by renderingservices more efficient, equitable,and sustainable. The evidencesuggests that user fees and cost-sharingcan be employedin public facilitiesto generate more revenue, augmentthe qualityof services, and provide pricing signalsfor a more effective referral system. Prospects for raising revenuesthrough public and private insuranceprograms are also explored, and the need for subsidies and exemptions for the poor is stressed. The chapter concludes by sketchingout an incrementalapproach to resource mobilizationand urges strong governmentleadership to bring it about. Part I: ExpenditureLevels and Trends

Government Expenditures

Because governmenthas primacy in overall policy-makingand strategic planning for health, it might be assumed that governmentsare the major actors in health expendituresand financing. Yet, government's share in total health expenditure varies widely throughout countries of the world. Among fifteen African countries for which data are available, in only hree - Burundi, Kenya, and Zimbabwe- did governmentexpenditures account for more than half of all health expenditures. Conversely, the private sector accounts for more than three- quarters of all health spendingin the Sudan, Uganda, and Zaire. Donors also play an important role in several countries, accountingfor 20 percent or more of health expendituresin Bumundi, Somalia, and Botswana.

The reason why government expenditures are important to health in Africa and elsewhere,is that they can be pooled, controlled, and allocatedby healthpolicymakers, they can be used to support public health services with immense benefit to society, and they can be tigeted to provide subsidiesto the poor. For these reasons when public finance is unstable or public funds are used for non-publicpurposes, health outcomes suffer.

11 Table I summarizescentrl govermmentexpenditures on health for twenty-six African counties for which data are available from 1980 to 1990. These expendituresexclude foreign aid, loans, and contributionsfrom internationalNGOs. Countriesare clustered into three groups according to their relative level of per capita governmentexpenditures on health and per capita GDP. Grouping countries in this way, though somewhatarbitray, is conduciveto analyzing changes in health expendituresamong countries that differ in income levels.

There is a fifteen- to twenty-folddifference in central govermmenthealth expenditures per capita betweenthe "high' and "low" group during the 1980s. This is far out of proportion to the fourfold difference in average per capita incomesbetween the two groups. Expenditures by the "high" group also increased from one period to the next, 1980-85 to 1985-MR(MR meaning 'most recent year for which data are available), whereas those of the middle group declined slightly and those of the low group stayedthe same.

Table I also reveals that central governmentexpenditures on health, as a percent of GDP, are smaller in the "low" and "medium"groups than in the "high" group, and show little absolute change over the period 1980-85 to 1985-MR. Compared with the performance of all less 134

Table 1. Groupingsof SelectedAfricanCountries by RelativeLevel of Central GovernmentExpenditures on Health, PopulationWeighted Averages, 1980s

Country Grouping Country Characteristss High Medium Low

Population(Millions) 21.4 94.7 218.3 Average GNP/Capita $818 $395 $225

Central Governnent Health Expenditures Per Capita (1987 ConstantDollars)

1980-85 $15.3 $5.4 $1.1 1986-MR $20.7 $4.9 $1.0 % Change +35.3% -9.3% -9.1% Central GovernmentHealth xpendituresas a Percent of GDP (% of GDP)

1980-85 2.3% 1.3% .5% 1986-MR 2.9% 1.3% .6% % Change +26.1% 0.0% +20.0%

Cnrl Government Health Expendituresas a Pemnt of Total Central Government Expenditures (as % of Total Expenditures)

198085 5.9% 5.6% 2.8 1980-MR 6.6% 5.4% 2.6 % Change +11.9 -3.7% -7.1%

HigbConties: Botwana,Lesotho, Mauritius, Swaziland, Zimbabwe. Aedim Countries:Burundi, Cameroon, Gambia, Ghana, Kenya, Liberia, Malawi, Niger, Rwanda, Senegal, Togo, Zambia. Lw Countries:Burkina Paso, Ethiopia, Mali, Nigeria. Sierr Leone,Sonalia, Uganda, Zaire Note:MR -most ecet available.This table was designed to showchange over ime, andthus has nformatonin constant1987 dolars. For tibsmason the data are not fullycompamble with the curent dollarestimates for 1990in Chapter8. TableIV. Source:United Natons Deveopment Pregramme and Wodd Bank 1992.

developed countries, world-wide, where the share of central govermnent expenditures on health is about 1.5 percent of GDP, the "medium" group falls short by .2 percent, and the "low" group falls far behind by .9 percent. This means that in the "low" group expenditures on health as a share of GDP are only one-third the level in all developing countries.

Table I further reveals that central government expenditures on health as a share of total cental government expenditures are between 6 and 7 percent in the "medium" and "high" groups, but less than 3 percent in the low group. Since all developing countries, world-wide, spent about 5 percent of their government budget on health, the performance of the "low" group is about one-half the norm. Furthermore, the health share in central government expendiure fell in the 1980s. Because central governments have full control over the proportion of public funds they devote to health, the relatively poor showing of the "low" income group on this measure is a clear indication of weak government commitment to maintaining spending on health. 135 Judgingfrom these data, a major resourceissue facing governmentsin Sub-Saharan Africais to raise more fundsfor the healthsector, in viewof the large populationrepresented by low income,low healthexpenditure countries. Thoughpart of this goalcan be achievedby allocatinga greatershare of total governmentexpenditures to health,the crux of the challenge in the low-incomecountries is to raiseabsolute levels of spending,and thus revenues. The first step for the "low"and even "middle'expenditure countries is to arrestthe declinein real per capita healthexpenditures by the centralgovenmment revealed in Table I. Each countrywill need to examineits own individualperformance in this respect. For the high-incomecountries and, to an extent,the middle-incomecountries in TableI, reallocationof existingexpenditures is likely to be most relevant.

Expla ing Shortfalls Why some Africangovernments have committedless to publicexpenditures on health than othersis difficultto determinewith precision. Threepoints are worthstressing however. First, economicconditions come into playbecause government expenditures on healthderive largely from generaltax revenues,including duties on importsand exports. Analysisof the performanceof countriesin the "high"group in Table 1 - in termsof averageannual growth rates of GNP per capitaover the period1965 to 90- revealsthat all experiencedpositive rates of growth. The crudeaverage for the group was 3.7 percent. For the "medium"expenditure group, more than 60 percentof the countriesexperienced positive rates of per capitagrowth, the groupaverage being 0.5 percent. For the low" group,however, 60 percentof the countries experiencednegligible or negativegrowth, the groupaverage being minus 0.5 percent. When thesefigures are combinedwith the differencesin per capitaincome between groups, it is clear that economicconditions have major significancein publicexpenditure levels on health.

The secondpoint concernsmacro-conomic disequilibria and the possibleeffects that structuraladjustment programs (SAPs) may have had on health expenditures.Controversy surroundsthis issue,one positionbeing that SAPsare responsiblefor cut-backsin government expenditureson socialservices, such as health. A counter-argumentis that SAPsaim to combat long term structual barriers to economic growth, and therefore present governmentswith an opporunity of restructuringtheir health systems towards greater efficiency,equity, and sustainability. Several studiessuggest that structuraladjustment is not a principalcause of low or declininggovernment expenditures on health in Africa (see Box 1). For example,central governmentexpenditures on healthas a shareof GDP remainedalmost the same in "adjustment" years as in "non-adjustment"years in a sampleof countries,though the meanvalue of health expendituresper capitawas five to sixpercent lower in adjustmentyears than in non-adjustment years. Furthermore,central governmentexpenditures on health as a share of total central governmentexpenditure was sevento eight percenthigher in the adjustmentthan in the non- adjustmentyears (Serageldinand others 1993).The latter findingis particularlysignificant becauseit impliesthat healthexpenditures were not reducedin the adjustmentprocess to make way for substantialincreases elsewhere. In Lesotho,for example,the governmenthas shown a strong commitmentto protectsocial servicesand has emphasizedinternal restructuring to improveefficiency - as part of structnaladjustment, rather than in reactionto it. Healthand 136

Box 1. MacroeconomicChange, Structural Adjustment, and Health

FoRowingrapid deterioation in the macroeconomicand sectoralperformance in Sub-SaharanAfrica since the mid- 1970s,reaching crisis proportions in the early 1980s,many countries started comprehensive economic reform programs witb finacial support from the IMF and the World Bank. Most of these countriesstarted the adjustmentprocess from a positionof low and decliningreal income, sluggishor deterioratinggrowth rates, mountingexternal debt and debt service, very low savingand investmentto GDP ratios, decliningextemal competitiveness and growth in export volumes. mountingcurrent accountdeficits, and rapidlydeclining agricultural output per capita (Elbadawiand others 1992).

Between 1980 and 1990, seventypercent, or thirty-twoof forty-fiveSub-Saharan African countries implemented structuraladjustment progms. Somecountries, such as Mauritius,Senegal, COte d'lvoire, Kenya, and Nigeria, were relatively more stable than others, such as Burundi, Central Afican Republic,Congo. Mali, Niger. Somalia, Zaire, Benin, Cameroon,and Ethiopia,and started the adjustmentearlier with strong adjustmentmeasures. Others abandone4 their efforts towardsadjustment after one or two initialloans, such as BurkinaFaso, EquatorialGuinea, Sierra Leone, and Sudan. In sum, the adjustmentprocess was rarely completed. For these reasons, as well as gaps in data required for statisticalanalysis, it is difficultto assess the effectsof adjustmenton developmentin Africancountries in the 1980s. Nonetheless,extensive reviewsof availabledata and literaturesuggest that the empiricalbasis is weak for claimsthat adjustmen policies have multiplenegative effects on health (Preston 1986; Behrnan 1990; Sahn 1992; World Bank 1992d).

In the health sector, consensusappears to be emergingon the followingpoints:

* Analysisof public expenditre data from African and Latin Americancountries suggests that social expenditures, Wluding health, have sufferedless than expenditureson economicservices, and that recurrentexpenditures - the bulk of health outlays - have suffered relativelyless than capital expendituresfor infrastructure(Hicks 1991).

* Analysisof ten countriesof Sub-SaharanAfrica undergoingadjustment suggests that neithereconomic crisis nor resultingadjustment poficies have had a major impacton critical healthindicators. A study using householdsurvey data on C6te d'Ivoire found no overall significanteffect of either the pre- or post-adjustmnentperiods on neonatal or post- neonatalmortality. In contast, an adverseeffect for the adjustmentperiod on the post-neonatalmorality of the urban non-poorwas observed(Diop 1991). A studyof Ghanafound no significanttime periodeffects on mortalityrisks in the neonatal or child age ranges, whereas for post-neonatal nortality, the protective effects of maternal education were reduced in both the economiccrisis and adjustmentperiods (Saadah 1991).

* Those most vulnerableto negative, short-termeffects of macro-econonucadjustment policies are not necessarily the poorestgroups in society. Most people in Africa live in relativelyscattered rural communitieswhich, unlbrtunately, have not benefittedgreatly from pubUcexpenditures and subsidies,and therefore have been relativelyinsulated from changesin goverment expenditures. Rather,groups most vulnerabletend to reside in urban areas, and tend to be those who have benefited disproportonatelyfrom public servicesand subsidies,often urban civil servants and other urban middl-income groups (Sirageldinand others 1992).

* Adjustmentappears to be relatedto the decline in the real value of civil servant salariesand may sometimeshave squeezed non-personnelexpenditures - especiallyfor pharmaceuticals. While this is a cause for concern, it is also promptinga reassessment,and is providinggrounds for restructuringhealth care systemsto tackle fundamentalproblems involved. Government surveys of civil service employment,for example, report overly heavy concentrationsof employeesat the center, redundancies,and the phenomenonof ghost workers, meaningsalaries are collectedby recipients not on the job. Iwfficienciesin currentprocurement, prescription, and use of medicinesappear to be far more significant than the effectsof prices and incomes(see Chapter 4). Minitry of Healdt budgetsare predominntly beingeaten up by expensivecurative care in hospitals,undermining government's capacity to finance recurrentexpenditures in primary healft services. And the preoccupationof donors in the past with financingcapital developmentprojects has not been accompnied by susainable provisionsto meet recurrentcost requirements.

* Governmentsshould restructuretheir health sectors as part of, and not in response to, structral adjustment programs, taking measuresto protect social priorities and operationalzingsymbolic commitments to preventiveand primary care with public health funds intendedfor such purposes. As the Minister of Health of Zimbabwe put it, ^Recession(and) stuctal adjustmentpolicies and planshave providedus wih opportunitiesfor creativity,innovation, and boldness (Stamps 1993). 137 welfare received about 6 percent of total governmentexpenditures in 1982183,rising to about 10 percent in the early 1990s. Over the same period, education's share increasedfrom about 15 percent to 20 percent. In contrast, commitmentsto less productivesectors, such as military spending, were reduced from about 24 percent of total governmentexpenditures in 1982/83 to about 10 to 12 percent during the early 1990s.

Nor does the performanceof the three groups of countriesclassified in Table 1 appear correlated with the presence of SAPs. Averagingthe total number of years that SAPs were in place between 1980 and 1990 in countries in the *low" group results in an average of 2.6 years per country. Comparablefigures for the "medium"and "high" group are 4.3 and 1.0 years, respectively. Further analysis,employing multi-variate analysis of countriesin the three groups, reveals that structural adjustmentis not significantlycorrelated with governmentexpenditures on health (as a share of total governmentexpenditures), or governmentexpenditures as a share of GDP. This particular analysis not only controls for levels of per capita GNP, but assesses the lagged effects of SAPs between 1980 and 1985 on health expendituresbetween 1985 and 1990, again showingno significantcorrelation.

Third, most governmentsin Africa clearly do have the means at their disposal to make substantialimprovements in public expenditureson health. This is apparent from the priority they give to public expenditureson defense. Juxtaposedto the mass of evidencerevealing that investmentsin health are essentialto developmentstrategy, there is little evidenceto suggest that defense expenditures contribute positively to economic growth or sustainable development. Governmentsof six out of seven countries in the "low" group in Table 1 allocate two to four times more public expendituresto defense than to health. In the "medium"group, eight out of thirteen countries for which data are available allocate more public funds to defense than to health, with three out of six countries in the "high" group doing so. Merely acknowledging these facts, as well as prospects for improvement(as in Lesotho and Ghana) casts a more realistic light on the "disabling"environment faced by many Ministriesof Health. Core agencies of finance and planningcan serve as allies of Ministriesof Health in the search for possibilities for resource reallocationacross sectors, especially away from military outlays.

Combatting Inefficiencies and Inequity

As has been argued throughoutthis report, scarce governmentresources for health must also be examined in terms of whether they are being allocated efficiently and equitably. Evidence from public expendituresurveys and health sector reports by the World Bank suggest that large shares of governmentresources for health are eaten up by relativelycost ineffective interventions, especially for tertiary care, that use of public funds for non-public ends underminesgovernment's comparative advantage in financingpublic goodsand services, and that such behavior is antthetical to symboliccommitments to primary health care.

In Kenya almost 70 percent of the public health budget went io curative care between 1985 and 1991, versusonly 4.5 percent for diseaseprevention and health promotion. In Malawi between 72 and 82 percent of the public health budget went to curative care between 1983 and 1988, versus only 5 to 9 percent for preventive care. In Nigeria, inadequate emphasis on preventive and primary care has been decried in health policies since the mid-1970s. 138 Nonetheless,in eightstates for whichdata are available,curative care increasedfrom 72 percent to 81 percentof the public healthbudget during 1981to 1985. Only in recentyears has the goverment madea majoreffort to changethe situation. Other countriesin whichcurative services account for 60 percentor more of public healthexpenditures include Tanzania and Uganda. In the caseof Uganda,well over half of this spendingwas devotedto curativecare of the ten majorkillers and causesof morbidityin the country,despite the fact that mostof thisspending could have been avoided had public resources beenused on preventivecare and communityservices. The challengeis to translatesymbolic commitments to primaryand preventivecare into acion by wrestlingaway public resources from costly curative care and capturing the redistributiveand equitybenefits of spendingfunds on publicgoods and services. This is the shortestroute Xocaptring large positiveexternalides. Otherwise, shortfalls in the supplyof servicesor the realizationof publicpolicy targets for healthmay be spuriouslyattributed to a lack of finds, whenthe real culpritis misallocationand cost overrunsassociated with hospital- basedcurative care. Misallocationof publicfunds to non-publicends can be partiallycorrected by comprehensivefimancing strategies that clearlystate how public fundsfor healthare to be used. No prtnse is madethat governmentexpenditures on publiclyoperated hospitals could be drasticallycut backovernight. However,a clear visioncan be established,and monitorable steps in this directioncan be fixed. Progressiveintroduction of full cost recoveryfor curative care, includingboh cairectand indirectcosts at higherlevel facilities,as discussedshordy, is an importat step forward,and promisesto releasepublic revenues for publichealth activities and district-levelcare. Summningup, the fal capacityof governmentsin manyAfrican countries has clearly been unined by poor economicperformance, rapid populationgrowth, and instabilities stmming from politicalupheaval. These factors do not, however, constitutea suffi-cient expanation for low or declining government expendiures on health as a share of total governmentexpenditures. This is somethinggovermnents can changeas they have complete controlover this dimensionof healthspending. Structuraladjustment programs may well be correlatedwith austeritymeasures, but they cannotbe invokedas a root causeof declining governmentcommitments to health. Rather, adjustmentlendinig has increasinglysought to protectsocial expendiures and promotetheir use for largelypublic health goods and services. If systemsof helth care are restrutured as part of structuraladjustment programs rather than in reaction to them - as in Lesotho and Ghana, for example- these positivedimensions might be pushed a good deal further. And as difficultas it may be to mobilizepolitical will, governmentsdo havethe powerto channelmore resourcesto publichealth activities and the basic packge of care featuredin this report, especiallywere they willingto dip into their defensebudgets.

Private Expendiures

Surveysof householdexpenditures, including direct paymentsto privatepractitioners, taditional healers,private pharmacists, and so on, leavelittle doubt that Africanhouseholds expendsubstantial out-of-pocket sums for health(Table 1). In C6ted'Ivoire whereper capita 139 GNPwas about$900 in 1985,household expenditures on healthaveraged about $19 per capita, whereascentral govermnent expenditures averaged about $8.20 per capita. In Ghanawith a considerablylower per capita GNP of $240 in 1987-88,per capitaexpenditures were also relativelyhigh at about$7.30 in 1986,when compared with centralgovernment expenditures of about$4.20. In Nigeria whereper capitaGNP was $400 in 1985-86,average per capita expenditureswere about $15, whereascentral government expendires are thoughtto lie somewherein the vicinityof $1 to $2 per capita. At the very least, the publicsector has a responsibilityto makeavailable information and to educatehouseholds to betterallocate - and where necessaryreallocate - these substantialout-of-pocket expenditures to cost-effective packagesof healthservices.

Out-of-pocketexpenditures vary considerablybetween the poor and non-poorwithin countries. For countriesin Table II, each quintilecontains 20 percentof the households, arrayed from lowestto highestexpenditure levels. In Ghanahousehold expenditures varied fivefoldacross quintiles, ranging from about$15 per capitain the highestquintile to $2.60 in the lowestquintile. In Coted'Ivoire household expenditures varied eleven-fold across quintiles, rangingfrom about $46 per capitain the highestquinle to $3.99 in the lowestquintile. In Senegal,household expenditus variedfifteen-fold across quintiles, ranging from $62.00 in the highestquintile to $4.90 in the lowest.

TaNbleII. Per Capita HouseholdExpenditures on Health in SelectedAfrican Countries Ghana CMted'lvoire Guinea Bissau Nigeria Senegal HouseholdQuintile 1987-88a 1985a 19 91b 1985-86c 1991_92d Lowest $2.55 $3.99 $3.88 $2.58 $4.90 2nd Quintile 4.25 6.59 4.36 5.88 10.27 3rd Quintile 6.19 14.33 5.38 10.07 13.44 4th Quintile 8.54 17.04 7.44 14.08 25.34 5th Quintile 14.83 46.38 8.34 35.16 61.82 Average 7.27 18.88 4.74 15.05 23.14 Per Capita Income 239.00' 911.31- 196.00 400.00 393.00 Average as Share of Per 3.0 2.1 2.4 3 8 5.9 Capita Income(%)

Note:Honsehold expenditures include traditional and modernhealth services and medicines.

* IMF Report. ** Grootaert1985-1988. lhe Evoluionof Wefareand PovertyDuring Structural Change and Economic Recession - he Caseof CAe d'Ivoire. 140 The evidence in Table II suggestsconsiderable scope for cost-sharingof basic packages of care, especially in contextswhere publiclyprovided services are currently provided 'free', side-by-sidewith non-governmentalproviders. Furthermore, becauseper capita expenditures on health tend to be much higher among the more well-to-dogroups than others, cost recovery would appear to be especiallyjustified for more sophisticatedand cosdy hospital-basedcare. In Ogun Statein Nigeria, for example,53 percentof the highest incomegroup who seek medical help fir go to public facilities,with 27 percent alonegoing to public hospitals. A lower share, 21 percent, of the lowest income group first seek care in public hospitals. in Cote d'lvoire expenditureson health by urban householdsin the highest incomequintile are about four times the highest quintile in rural areas. Stimulating higher income individuals to absorb a substantiallygreater share of the cost of the hospital services they use thus represents one way of increasingequity and freeing up public resources to fiace primary care.

To conclude, there are clear indicationsthat householdsand communitiesare able and willing to expend substantialout-of-pocket sums for health. This suggestsan importantrole for public informationand educationon cost-effectivepackages of health services,and indicatesthat there is much that can be done to mobilizeprivate resourcesfor health, especiallyamong higher income quintiles.It also underscoresthe important role that public subsidiesare likely to play to assure access to basic packagesof care by lower income households. As discussed shortly, exemptions and subsidiesare merited for the poorest segmentsof the population.

International Aid

Donorshave becomeimportant as financingagents, especiallyin Africancountries where governmentshave been unable to meet health needs due to shortfalls from domestic sources. Between 1981 and 1986, external assistance for health from official and private voluntary sources averaged more than $1.50 per capita, equivalentto more than 20 percent of average central governmentexpenditures on health(Tchicaya 1989; UNDP 1981-86). By 1990assistance had climbed to a total of over $1.2 billion, or almost $2.50 per capita. However, wide variations are apparent among countries, ranging from $0.60 in Nigeria to $7.00 in Benin (see Table E). Furthermore, the limited informationavailable suggeststhat more aid per capita is going to countries in the high and medium groups than to the low group discussed in Table I.

During the late 1980sfunding by bilateral donors amountedto 62 percent of total health assistance in Sub-SaharanAfrica, while multilateral agencies provided 32 percent and non- governmentalagencies provided6 percent. On average, 44 percent of donor funds have been directed towards capital investment,22 percent to technicalassistance, 13 percent for operating costs, and 2.4 percent for training. Variationsare wide however. In Lesotho,donor fmancing coveredabout 80 percent of the MOH capitalbudget between 1987and 1992. In Ugandadonors financed 87 percent of total public developmentexpenditure in 1988-89(PER 1991). In Mali the share of donor funding for developmentexpenditures was 63 percent in 1990 (World Bank 1991g).Since, on average, each $100 of capital investmentin the health sectorgenerates annual operating costs of $30, internationalfunds not only determine govermnenthealth investment, they also shape how the health budget will be spent (Heller 1979). 141 In response to financialcrisis, donor aid Tablellf. ExternalAssistance for the Health has also been meeting an increasing share of Sector,Selected Affican Countries, 1990 public recurrent expenditures, especially for High, Medium,or Low Per Capita essential inputs such as drugs and emergency Country ExpenditureCountr Aid (US$) and supervisory transport. Donors pay for 8enin ., 7.0 vimrtuallyall drugs imported in Tanzana for BurkinaPaso L t.. dispensaries and health centers, for example. Bunindi M There are also a growing number of cases CamAeroon M where donors are financing salares for Republic incremental health workers (in Malawi, for Chad .. 5.8 example), particularly community outreach Cote d'lvoire .. 0.9 workers and nurses in rural primy health care Ehiopia L 0.8 centers. Recurrent expenditure grew from Ghana M 1.9 about 13 percent of donor assistance for health Guinea *- 3.5 in Africa at the beginningof the decade, to 35 Kenya M 3.5 percent at the end, while capital expenditure Madagasa .5 support declined from about 55 percent to 35 Mali L 4.3 percent(McGrory 1993). Mozambique .. 2.9 Niger M 5.6 At the same time that donor assistance Nigeria L 0.6 has played an invaluable role in shoring up Rwanda M 4.1 public initiatives for health, so too have Senegal M 4.9 negative side effects emerged that are at odds SiefraLeone L 1.7 Somalia L 3.5 with the central messages of this report. Sudan 1.5 Prominentamong these are the following: Tanania 2.1 Togo M 3.9 The Organization for Economic Uganda L 2.8 Cooperaion and Developmentreports that "in Zaire L 1.3 spite of their stated coimmitmentto primary Zambia M 0.7 health care, relatively large resources are Zimbabwe 4.2 devoted by donors ... to sophisticatedurban- 2.5 based facilities icluding hospitalsand specialist WeightedAverage chnics" (OECD 1989). This suggeststhe need for closer scrutinyof the impactof healthaid Notes: a. Source of county classifcaton: Tabe 1, flows, as well as greater use of external fine Chapter9. b. Estmates for developmentassislance for heal are to establish and run projects in remote or expressedin offic exchangerate U.S. dollars. Toal aid underserved areas. Examples include the flowsrepresent the sumof al healthassistance for healthto provisionand distribution of essentialdmgs that eachcountry by bilateraland multilateralagencies and by are intendedprincipally for consumptionby less intrnatonalagencies and by nteational nongovernmental well served populations, as supplied, for Source: World Bank1993e, TableA.9. example, by DANIDA in Tanzania and Medecins sans Frontieres in Mali.

* External fmancinghas often worked against sustainabilitywhen it has been used for vertical programs or inappropriatecapital or developmentexpenditures, rather than recurrent costs of operations. Though such fuding may havwthe goal of expandingcoverage and quality 142 of services,the recurrentcosts necessaryto sustainthe capitalinvestments are often very high andbeyond the government'sability to finance. Almostevery African country has at leastone big investmentproject, such as a large hospital,that is unlikelyever to functionas originally plamed due to lack of an adequaterecurrent expenditure budget. Underutilizedfacilities include,for example,the Maidugeriand Ibadanteaching hospitals in Nigeria.

* Whilemost donors have provided aid throughspecific projects without conditions for explicitpolicy reform,the prioritiesthat are implicitlyimbedded in the fundinghave virtually driven the selectionof healthstrategies in Africa. In somecases heavyreliance on external assistance has led to virtual abdicationof responsibilityfor health policy formulation. Furthermore,donor funding priorittes are constantlyshifting - tendingto favorspecific health themesat internationalconferences that detractattention from the needto strengthenbasic health services. In Rwanda,for example,over 20 percentof donorfinancing for healthhas recently been earmarkedfor AIDSalone, out of proportionto total healthneeds (Overand Piot 1991). The push for universalchildhood immunization between 1985 and 1990, whichwas "jump- strted" largelywith external financing from UNICEF, Italy, WHO, and Rotary in Africa,vastly improvedvaccination coverage throughout the continent.Yet, decliningrates of coveragemore recentlyindicate that healthsystems are unableto maintainthe momentumwithout continued injectionsof outsidefunds. Africangovernments are increasinglyrecognizing this problem; and some,such as Nigeria,are callingfor Africangovernments to assumefrom donors responsibility for vaccinefinancing (WHO/AFRO 1993).

* Governmentinformation regarding large numbersof externalassistance programs is often weak, with the result that coordinationand monitoringof donor activitiestends to be ineffective. Externalevaluations are often conductedwithout involving the recipientcountry (Engelkes 1993). Moreover, governmentand donor definitionsof health programs and accountingrequiements frequently differ, so that healthplanners and policymakers often do not knowthe overallpurposes, locations, and amountsof externalresources being used. Summingup, externalassistance for healthcan help to bridge funnial gaps in Africa in ways that are far more efficient,equitable, and sustainablethan in the past. Additional support for the basic packageof care featuredin this report is preciselyone such avenue. External fundingsources need to re-examinetheir activitiesand emphasizea longer time horizon,broader programs of intersectoralassistance, and national capacity building, rather than individualproject-based support. In turn, governmentsshould play a vital role in this process by developingcomprehensive health policies,increasing their commitmentto primarycare, establishingoverall health sectorfinancial plans, and emphasizingcost-effective packages of basic services,rather than moldingnational strategies around availabledonor funding. It is preciselythis kind of orientationthat can bringmore donorson board, with greaterfinancial commitmentsto improvesystems of healthcare. In Guineaand Benin, for example,national action plans and comprehensivefinancing plans are being drawn up by governmentsin 143 collaborationwith donors so as to better determineboth capital and recurrent cost requirements.

Governmentscan firther reduce dependency-relatedproblems by takdngthe lead in donor coordination. In Ghana, for example, the Ministry of Health has organizeda Local Assistance Group on Health which functionsas a quarterly forum with donor agencies to resolve health strategy issues. In Kinshasacoordination led to stndards for health center activities and user fee schedulesrespected by all participatinghealth care providers. Part II: Resource Mobiization

To shore up laggingrevenues, and to assure adequatefinancing of basic packagesof care, a growing number of countries are moving to increase user charges for government health services, such as Lesotho and Zimbabwe,or to establishnationwide fee systemsto replace free care, such as Uganda and Kenya. Other countries, such as Guinea, Benin, Nigeria, and Rwanda, are promotingthe creation or strengtheningof community-fmiancingschemes for health services. On other fronts, alternativearrangements are filling gaps, such as communityhealth insurance schemes. Lessons learned are that a wide variety of approachesare needed. Much more can be done to mobilizeprivate and especiallyhousehold financialresources for health, and interactionsof the private sector and publicly-providedand financed services need to be clearly fleshed out in national financingstrategies for health.

User Fees and Cost Recovery

Non-tax sources of revenue, such as user fees and cost recovery, are becoming increasingly commonplace in African countries as a means of tackling several problems simultaneously. Cost recovery directly addresses the problem of persistent under-fundingof govermmenthealth facilities. By charging user fees for services that primarly benefit the user, such as tertary level curative care, governmentscan free up and reallocatetax-financed health expendituresto actvities that extend benefitsbeyond the individual. These includepublic health services directed to communityhealth, immunizations,and comnmnicablediseases (see Chapter 2). User fees also represent a tool for reinforcing the referral system and managing health facility ufilization. When prices are zero or uniformly low across a health care system, from the most expensive hospital services to the least expensive immunization,consumers have no reason to pay attention to costs when they use the health system. Their naturalinclination might well be to use the most costly services because they weigh benefits against zero price (Griffen 1992, pp. 1-13) This is one reason why multi-tieredsystems of care and referral systemshave not worked well in many African countries (see Chapter 3).

User fees make sense on economic grounds. The demand for health care tends to be mcomeelastic, meaningthe more moneypeople have, the more they are able and willing to pay for bealth. For any given level of prices, it is reasonableto expect that a disproportionateshare of health care consultationswill be made by higher income people, compared to the general population. Charging wealthier people for services they demand and can afford, and pooling revenmesto subsidizethose least able to afford care, is also an important means of promoting equity. And, when user fees becomepart of the process of upgradingquality of health seces, 144 for example by helping to cover salaries and drug costs, they can actually work to reinforce demand (more on this later).

The demand for health care, especially curative care, also tends to be price inelastic meaning an increase in user fees will result in a less than proportionatedrop in demandand an increase in revenue. An increase in the price of public health care may reduce demand, but most people will still seek care from some source, particularly if there are competing private providers of better quality. Moreover, when user fees charged by public sector facilities are modest, they tend to be a very small proportion of the total cost of using health care. Transportationcosts for people living far away, and the cost of taking time off work to seek care, may be far more costly to the beneficiarythan user fees.

Without user charges, many public and most private voluntary providersof health care would cease to exist. Yet, in public facilities,user charges have tended to be very low in the past. In two-thirds of African countries for which data are available, their contributionto total governmentrecurrent expenditureson health has been less than 5 percent (see Table IV). This implies considerablescope for expansion. In Ghana, for example, a large upward adjustment in prices, adopted in 1985, increasedcost recovery receipts as a share of Ministry of Health revenue from 5.2 percent to 12.1 percent by 1987.

User Fees in Hospitals

Prospects of recovering costs in public hospitals take on monumental importance if systems of health care are to be restructuredto feature preventiveand primary care services. High capital and TableIV Revenuefrom User Charges recuent costs of hospitals dictate that if curative as a Percentof RecurrentGovemnment senrices are financed by governments,then their health ExpenOtureson Health budgets wi1l be skewed toward hospital services no matter what their statedpriorities may be. Furthermore, Percentof Recurrent if the typical residentdaland income characteristicsof cou't'y Expendiue those receiving such care - predominantlyurban, well- Botswana,1979 1.3 to-do families - are "superimposed"on the subsidy BurwkiaFaso, 1981 0.5 pattern implied above, then an equity problem is almost Burundi,1982 4.0 imminent. Urban residents will capture a Cte d'lvoire, 1986 3.1 disproportionate share of the government's health Ethiopia,1982 12.0 subsidy because they live near the hospitals and use Ghana,1987 12.1 them. It is bard to envisionhow governmentscan alter Lesotho,Kenya,1984 1984 2.05.7 the status quo unless these problems are resolved (see Malaw, 1983 3.3 Box 2). Mali, 1986 2.7 Mauitania, 1986 12.0 Acknowledgingthat limits on hospital spending Mozambique,1985 8.0 are exceptionallydifficult to impose, the application Of Rwafdan41984 7.0 use fees is a userviable 1~~~~~~~~~~~~~ alternative to open-ended~Swaziand, support Senegal,1986 1984 2.14.7 from Minry of Health budgets. Hospitalsalready have Zimbabe, 1986 2.2 accountan, proceduresfor fimncial control, and access to the banking system, meaning thqe are in a relatively Sre: Vogel 1988 and 1989. 145

Box 2. ThreeStories of CostRecovery in Hospitalsand OtlherFacilities: Ghana, Senegal, and Malawi

GHANA:In 1983the price structure for healthservices was judged to betoo lowin Ghana,resulting in a large upwardadjustment in pricesin 1985. By 1987,cost recovery receipts as a percentof the Ministryof Healthrecurrent budgethad climbedfrom 5.2 percentto 12.1percent. A key to Ghana'sprogress appears to be in the structweand applicationof prices,as wellas in the administrativeprovisions of thecost recoverylaw. Pricesare hierarchicaland directlyrelated to thesophistication and expenseof thehealth care delivered. The price of curativecare at the hospital levelis a largemultiple of curadvecare at the healthcenter. Thisfeature of the pricingstructure gives a strongprice signaland reinforcementto usethe referralsystem. Yet,facilities are obligedto differentiatethe poor from non-poor, and to give freecare to the poor.

Anotherkey to successin Ghana'scost recovery experience has been the administrativeprovision that a portion of the proceedsshould remain at the siteof collection,towards improving quality and stirnulatingincentives to collect fees. Thegeneral formula used is that 50 percentof userfee revenuegoes to theMinistry of Finance,25 percentto the Ministryof Health,and 25 percentis retainedby thefacility that collects the fee. SENEGAL:In Senegal,there is no costrecovery at largenational hospitals. Cost recovery is beingintroduced at someregional hospitals, and is mostlypracticed at the primarilylevel of the healthcare system. A consequenceof thispolicy is that it givesthe wrongsignals from a systemicpoint of view. To illustrate,people may be inclinednot to seekcare at a health.center in a suburbof Dakar,where they must pay for thatcare, when they can easily take a businto Dakarand receivefree care fromthe DantecHospital. Giventhis asymmetry in usercharge policy, hospitals such as Dantecare operatingat morethan 100percent of capacity,while local treatment facilities are underutilized.This, in tum, distortspublic sector investment policy. Almosthalf of the projectexpenditures in Senegal'sthree-year investment plan are for renovationsor additionsto the DantecHospital.

MALAWI:The government has determinedthat cost sharing is an urgent,viable policy which can be usedto acquire resourcesfrom users of medicalservices, then redeployedto extend and improvehealth care deliveryto rural- basedfamilies in the periphery.A phasedapproach is beingimplemented over three years, commencing April 1992, to introducethe cost sharingsystem to centralhospitals, then to generala.id districthospitals, and finallyto healthcenters - all phases to be accompaniedby improvementsto strengthenquality. Severalconcerns are behindthe costsharing strategy. One is to increasethe efficiencyand utilizadon of the central/generalhospitals and distrct hospitalsby introducinga systemto discouragethe poputationfrom using hospitals as theirentry point to thehealth system. Another is to improvethe referral system by encouragingthe population to enter the appropriatelevel of services - h4lth centers. A related concem is to strengthenprimary care with trained manpowerand continuousavailabilty of essentialdrugs.

Source:World Bank. better sation to deal with administrativetasks associatedwith cost recovery. The ability to price discriminate if necessay - to increase revenuesand lower prices to the poor - is most feasible in hospitals, where many different services are offered. And, the most expensive hospitalstend to be located where people are most likely to have accessto insuranceand where employment-basedrisk sharing systemsare mest likely to exist.

The experienceof private-for-profitand privatevoluntary hospitals provides an indication of the possible scope for user fees in public hospitals. Religious missions in CMted'Ivoire, Ghana, Mali, and Senegalhave been successfulin coveringa large percentageof their opeating costs with user charges for a populationthat is similar to that served by public facilities. A suvey of non-governmentalfacilities in Tanzaniarevealed that 57 percent of hospitalsexpected more than 50 percent of their revenue to come from user fees (Mujinja and Mabala 1992). 146 From 50 to 80 percent of their recurrent costs for drugs, salaries, repairs, and maintenancewere financed by user fees. Even while public facilitiesprovide "free" health care, groups visiting fee-chargingNGO dispensariesand hospitalsin greatest number were peasants, the employed, and traditional healers. Non-governmentalhospitals in Uganda have long relied on the willingnessof households to pay for services and have recovered anywhere from 75 to 95 percent of hospital costs (World Bank 1992g).

Even small fees in public hospitalscan produce revenues that dwarf those generated by high fees at ciinics. In Wad Medani, Sudan, a 0.25LS entrance fee at the main hospital generated gross revenues of 325,900LS in 1984, compared with 8,200LS generated by three evening clinics nearby that charged four to eight times the hospitalentrance fee (Griffin 1988). In Mali one hospital increasedits revenuesby 7 percent over the previous year by demanding that a single govenmmentdepartment pay its bill for services rendered to its civil employees (Vogel 1987a). In Senegal total funds recovered in the hospital sub-sector equalled only 6 percent of the Ministry of Health budget allocationto hospitals,yet they were sufficientto pay for 50 percent of hospitaldrug supplies, equivalentto one-third of total drug expendiures at the hospital level by the Ministry.

Introduction of user fees at hospitalscan also contribute to efficiencies in the referral system, stimulationof the private sector, and greater use of public resourcesfor the most needy (see Box 2). In Zimbabwe, for example, fees increase accordingto the hierarchyof facilities, so that consumers seek care where the services can be provided at lowest cost. The basic outpatient charge for adults is Z$5 at a central hospital, Z$3 in a provincial general hospital, and Z$1.50 in a district hospital. In Cameroona desired by-productof introducingfees has been to motivatewell-to-do patrons of public facilities(where fees were non-existent)to obtain private care, assumingthey can better afford the travel and other costs involvedin doing so. This met the social objective of making public resources more available to the poor. In Lesotho the governmentexplicitly sought to induce patients to switch from public to private care as part of its higher user fee policy in 1988.

Anotheroption is to turn hospitalsinto parastatalsor entirely autonomousbodies that will have reduced access to government budgets, or to privatize selected services in national hospitals. In Burundi, for example, the Ministry of Health is pursuing an innovativeapproach in its endeavor to give full autonomyto hospitals. Beginningwith a hospitalwith 120 beds, the Ministry first transferred a lump sum to cover the hospital's full operating costs. Each year thereafter, the Ministry is reducing its contribution by 20 percent. Based on the positive outcome of this experience, the Ministry is now applying the same procedure to its central hospital with 600 to 700 beds. Simultaneousaction is also being taken to stimulate the expansion of insurance schemes, under the assumptionthat hospitals would not be able to recover full costs and remain viable without them. A similar approach is being planne in Rwanda. In both Rwanda and Bumndi a fundamentalpremise is that ministriesof health were never designedto manage hospitalsand almost always do so poorly.

Privatization of selected hospital services is under way in Tanzania, where there are private pay beds in governmenthospitals. In Mozambiquegovernment medical staff run special hospital-basedclinics outside normal working hours. The Kenyatta National Hospital (KNH) 147 in Kenya has taken a number of steps away from the traditionalmodel of direct cental hospital managementby the Ministry of Health, towards a greater role for private sector models and acdvities. Its recently adoptedPrivate Practice Plan calls for a private wing in KNH to generate a surplus and thus augmentKNH's revenues. The real fmancialreturn on the Plan is estimated at 8 percent.

Cost-Sharing in Health Centers and Dispensaries

User fees or cost-sharingstrategies in publicly operated health centers and dispensaries take on immense importancebecause it is at this level where the demand for preventive and primary care is most immediate, fuids are relatively scarce, and quality improvementsare desperatelyneeded. It is also at this level where the communitycan becomeactively involved in mobilizingand managingresources for health. Recognizingthis situation,the World Health Organization,in a meeting in Bamakoin 1987, adopteda resolutionto endorse communitycost sharing mechanismsin support of primary care. Since that time UNICEF has spearheadeda "BamakoInitiative" involving from one to fifty districts in thirteen countries, some 1,800 health facilities, and about 20 million people. In almost all cases, regular suppliesof essential dnigs have been used as a mechanismof cost recovery.

Experiencefrom the BamakoInitiative and related endeavors suggeststhat cost-sharing can pay significantdividends. In countrieslike Benin, Guinea, and Nigeria - where experience has been closely monitored- approximately40 to 46 percent of local operatng costs (including salaries) are being covered by fees. According to one study, up to 100 percent of local recurrent costs (excluding salaries) are being covered - for essential drugs, maintenance, equipment,other supplies, and services (Parker and Knippenberg1991).

Cost-sharingin health centers and dispensarieshas given rise to a number of principles, or lessons learned:

* Clients' willingnessto pay fees, or higher fees, for publicly provided health services is strongly conditional on whether the higher prices are preceded or accompanied by improvementsin quality.

In Cameroon utilization increased signficantly across all economic groups at health centers that simultaneouslyinitiated fees and quality improvements,compared to those that did not (see Box 3). Furthermore,utilization by poorer people rose proportionatelymore than by the wealthier (Litvack ;092). This perspectiveagrees with a comprehensivesurvey of public health facilities in Ogun state of Nigeria. If public sector prices are raised on a user fee basis, the probabilityof clients seekingpublic sectorcare changesonly marginally- dependingon the response of the private sector - but the revenue gains are large.

On the other hand, if pnce increases are not matched with quality improvementsin srvices provided there is likely to be a loss of demand for such services that could overwhelm the revenue expectations (World Bank 1991c). The introduction in user fees precipitated a decline in user rates for public services in Swaziland, Mozambique, and Lesotho, largely 148 becase the revemnes raised were not Box3. Useof HealthCeriers by the Poor immediatelyreinvested in the facilitiestowards in Cameroonafter Introducing Cost recovery improvingservices. and Qulity Improvements

* Retentionof a substantialportion of A controlledexperiment at fivepublic health the revenues at the site of collectionis an facilitiesin Cameroondemonstrated hat thepoor may benefitmore than the relativelybetter-off population importantincentive to collectfees and improve fromconcomitant introduction of cost recoveryand quality of services, particularly where qualityimprovements. community representatives monitor the collection,colecton,accuntngand accounting an uses madeaeo of thshw healthceters In a introducedapretest-posttest"a userexperiment, fee and qualitythree funds. improvement(for example, reliable drug supply), and werecompared with two similar facilities without such Enabling facilitiesto rettainfees helps to changes. Two roundsof householdsurveys were supplement shortfa}ssuppleentshrtfall in tethe publcpublic budgtbudget and households,hconductedinto 25measure villages,the percentageeach withof about ill people 800 allowsfacilities to tailorservices to localneeds. seekingcare before and after the changes. The A World Bankstudy of costrecovery in Nigeria experment was tightly controled by conductng recommended that a significantportion of the monthlyobservations at eachstudy site. fees collected(50 to 75 percent)could be made Resultsindicate that the probability of using availableto improvethe qualityof care at the the healthcenter increased significantly for peoplein facility,WithoUt any CommenSUrate redUction in the wtreatment'areas comparedto those in the the governmentallocation that it received. The 'control"areas. Contay to previousstudies which havefound that the poorestgroups are mosthurt by remaining 25 to 50 percent of fee revenues user fees.,this study found that the probabilityof could be divided amonghealth authoritiesto poorestgtoups seekmgcare increasedat a rate enable increased spending on preventive proportionatelygreater tan therest of thepopulation. Traveland time costs involved in seekingalternatve services and for improvingquality at facilities sourcesof care are too high for the poorestpeople that might not initiallyintroduce fees because andthus they appear to benefitfrom local availabiliy they were in poor areas. of drugsmore tdan others.

In contrast, when little financial Source:Litvack 12. autonomy is permitted, efforts at administradve decentralization in the collection of fees and monitoringof cost recoverypersonnel appear to be hampered. The user charge systemsof Cote d'Ivoire, Mali, and Senegal require that funds be almost entirely remitted to the Finae Ministry. From the perspective of health facility providers, this resembles a "tax" of 100 percent of cost recovery receipts, and thus discouragescollection (Vogel 1988).

* Drug revolvingfunds are an appealingcost recovery mechanismbecause customers are satisfiedby a more regular and sustainablesupply of drugs, while health facilities may generate a surplus from drug sales.

Dmg revolvingfunds tend to manifestseveral positiveeffects such as assuringcontinuity of supplies of essental drugs, increasing the population's confidencein the health facility to deliver drugs, and boosting revemnesgiven the relatively large share of medicines in the recurrent expenditures of health facilities. In Benin, for example, a comparison of monthly utilization of health facilities one year before and after a revolving drug fund was established shows an increase in utilization of 129 percent. Increasesin utilizaton following the start-up 149 or duringthe courseof a costrecovery program for drugsare alsoseen in Nigerand Liberiaand in somecases in Guinea,Nigeria, Senegal, and Zaire (World Bank 1992d). An important lesson is to introduceprice increasesgradually over time,giving clients the opportmity to observeand appreciateservice delivery improvements (Blakney and others 1989). * Goodadministrative and managerial practices are importantto successfulcost recovery. Thoughlittle is knownabout the additionalcosts of administeringan expandedcost recoverysystem, conditions for successfulcollection at healthcenters and hospitalsappear to include:(i) well-defimedentrance points to the healthservice, whether they be at the entrygate of the healthfacility itself, or at the entry point for each serviceat larger institutionssuch as hospitals,(ii) a clear statementof the fee structurefor servicesavailable, (iii) the issuanceof somepaper instrument,such as a ticket, with duplicatecopies, that servesboth as a proof of payment and as a managementcontrol device, (iv) a dghtly controlledmechanism for ascertainingwho are the truly poorand whoare not, andthe eliminationof exemptionson any other basis, (v) carefultraining of the care-givingstaff to ensurethat treatmentis not rendered unlessa ticketor certificateof indigenceis producedby the patient,(vi) spotchecks by someone m an accountingor administrativecapacity to ensure compliance,(vii) periodic audits of fiancial transactions,and (viii) a fairly high level of local retentionof fees. One study concludedthat the amountsof revenueraised appear to be a functionof the vigor with which costrecovery is pursuedat the nationaland local level, and of the competenceand commitment of localhealth administrators (Vogel 1988). Fee Structures and ProvIsionsfor the Poor Thejoint issuesof whatservices should be chargedfor, andhow much should be charged are relevantlargely to the public sector, as well as to private voluntaryorganizations and to privatfor-profit providersthat receivegovernment subsidies. The majority of private-for-profit providers,on the other hand,levy fees determinedby marketforces of supplyand demand. In the public sector, a 'rule of thumb' can be appliedto detrmine whetherrevenues shouldcover costs: Is the serviceprovided largely a privateor public good. Most curative healthcare is private and peopleare willingto pay for it, with the implicationthat full cost recoveryis a reasonablegoal over the long-rin. In contrast,public health goods and services such as healtheducation and preventionof communicablediseases are public goodsor have strongpositive externalities. Thus, they are often providedfree or at reducedcost. Improvementsin socialequity resulting from user feeswill also be partiallycontingent on introducingdifferental charges based on income. On the one hand, policiesthat exempt certa privilegedgroups, such as civilservants and the military, from paying fees can contribute to ineyq. In severalWest Africancountries, public employees are fullyor partiallyexempt from payingfees. On the otherhand, if user fees deter the utilizationby low-incomegroups, thenprovisions may be neededto ensureaccess through subsidies, waivers, sliding fee systems, or other appropriatemeans. 150 The concermsabove give rise to a number of broad principlesthat can help determinethe general shape of a user fee policy. Zimbabwe is an illustrative case. First, to the extent possille, prices aim to reflect the type of service offered. Health services that largely provide private benefits, such as curative care, are to be priced at or near cost, whereas services with major externalities- such as immunizationsand family planning- should be free or provided at reduced cost. Second, higher-incomegroups, especially the 5 percent of the population covered by health insurance, should pay a much larger share of the actual costs of health services provided to them. At the same time, very low-incomehouseholds should be able to obtain basic health care at little or no cost. Third, prices in Ministryof Health facilities should be structured to encourage efficiency. The price differential between levels of the referral system could be established as a signal, but a stronger argument is that it should reflect differences in the costs of providing services, which will encourageclients to go to the lowest- cost level (Hecht and others 1992).

The main practical issue in applyingsliding fee systemsor exemptionsfor the poor is the administrativefeasibility of assuring that those who need them receive them. Without strong political support, firm screening criteria, and retention of some portion of fees at the point of collection, health personnel will have little incentive to perform means tests, and exemption mechanismsmay experienceconsiderable slippage. Becausethere are no established rules to follow, a certain amount of "learningby doing" is inevitable. Exemplaryapproaches include:

In countries participatingin the BamakoInitiative, the philosophyof user fees in health centers is that "everyone should pay something', no matter what their income status. At the same time, however, the level and structure of fees reflectsthe fact that most clients tend to be low income and can afford little. Thus, for some primary care services, such as pre-natal consultations,prices are almost nil, whereas for drugs, cost recovery is common, but charges vary according to the cost and dosage of the prescriptionsinvolved.

* The governmentof Malawihas recognizedthe need for low-incomeexemptions as it phases in cost recovery, first at central hospitals, then district hospitals, and fmally health centers. The governmentof Malawihas recognizedthe need for low-incomeexemptions. It has determined that the "core poor" shall be exempt from the Ministry of Health cost sharing scheme, and has examinedthe stmcture of landholdingto determine such households(Ferster and others 1991). Core poor are familiesfarming less than 0.5 hectaresand have been estimated to comprise 500,000 households,or 18 to 20 percent of all householdsin Malawi. Rather than working out a complicatedsliding fee schedulein areas where people are predominanly poor, a lower and more affordable schedule of fees has been determined in collaborationwith the communitiesserved. Communityinvolvement is particularlyworthwhile in this task, because communityrepresentatives are in a far better position to determinewho can and cannot pay than, say, a central governmentofficial removed from such realities.

* In everyday practice, NGO hospitals and dispensaries in Tanzania found that approximately70 percent and 40 percent of patients, respectively,were unable to pay their full fee (Mujinja and Mabala 1992). Only 10 percent of hospitalsand 5 percent of facilities said they offered no exemptions,while many facilitiesaccepted alternative forms of payment. Some allowed deferred payment, payment in-kind with crops, temporary employment(without pay), 151 or assigned tasks for the client to perform. The proportion of hospitals and dispensaries exemptingthe disabled were 90 and 75 percent, respectively,those over 65 years of age (9 and 20 percent, respectively), poor people (86 and 85 percent), children under five (36 and 30 percent), those with chronic diseases (23 and 5 percent), and retired workers (9 and 10 percent).

Summingup, user fees and cost recovery almostcompletely sustain private providers of health care and are a potential means of increasing the financial sustainability of public providers. Correct applicationof fees can help unburdenMinistry of Health expenditureswhich disproportionatelygo to urban-basedcurative services, thus paving the way for a reallocation of funds to primary care and greater use of public funds for public health services. Of course, were Ministries of Finance to offset the positive revenuegenerating effects of user fees with a correspondingreduction in Ministryof Healthbudget allocations from the CentralTreasury, then these benefits of cost-sharingwould not be realized.

User fees and better use of price signalscan also contributeto the efficiencyof refernI systems and the reduction of excess demand for relatively simple out-patent services at expensive hospital-basedfacilities. And, when fees are retained at the site of collection, at health centers for example, they can contributeto qualityimprovements and offset the negative effects that higher prices might otherwise have on client demand. User fees can be introduced in ways that serve equity concems by removingexemptions for relativelywell-to-do clients, and providing targeted subsidies or waivers to those least able to pay. Finally, giving maximm autonomy to communitiesthat are working with health districts to determine fee levels and exemptionsmakes sense. Combinedwith local retentionof revenue, this will niake fees more likely to reflect what householdsare willing to pay and can afford.

Heath Insurance

User fees are an importantpart of cost recovery, but to cover full costs of major hospital and in-patientcare, large parts of the populationwould eventuallyhave to be covered by some form of health insurance. Insurance is a method of pooling the risk of becoming ill. In prepayment systems, all participants regularly pay a fLxedamount. Funds are then pooled, allowing insurance providers to pay for all those needing care, especially the high costs associated with hospital-basedcurative care.

Though health insurance is not intendedto be a mechanismfor resource mobilizationor for achieving equity between high- and low-incomegroups, it has significantimplications for both. Groups tbat are insurablein Africa are often relativelybetter off comparedto the rest of the populaion. Through insurance, these individualscan self-financethe level of health care they demand. Schemesto promoteinsurance can therefore help relieve the governmentbudget of the high costs of expensive curative care, releasing funds for preventive and primary care.

Similarly, heath insurance is not intendedto be a mechanismfor purging inefficiencies in the financing of health services, though it can contribute to this process through cost contaiment. With approprate incentives, health insurers take a strong interest in containing 152 reimbursement levels for health care and are TableV. Percentageof Popution Coveredly inclined to negotiate with suppliers to keep fees HealthInsurance in SelectedAfrican Counies down. Populaton Percent Covered Only a small proportion of the (miions) by Isurwace population is currently covered by health BurkinaFaso (1981) 6.7 0.9 inrae in Africa today. Coverage ranges Burundi(1986) 4.9 1.4 from virtually nil in Uganda to 13 percent of Kenya(1985) 21.2 11.4 the population in Senegal (see Table V). 1.6 1.4 However, there is potential to gradually Mali(1986) ?.6 3.3 increasethe share of the populationcovered. In Nigeria (1986) 103.1 0.04 counties like Kenyaand Senegalcoverage bas Sgal (1991) 7.2 13.0 doubled since the mid-1980s. Uganda(1991) 16.8 0.0 EncouragingRPisk Sharing Zambia(1981) 5.6 6.1 Zimbabwe(1987) 8.7 4.6 One form of health insurance in low income Africa is govermnent-sponsoredsocial Source:Vogel (1990) and World Banksector reports. insrance, financed by general tax revenues. Enthusiasm over national insurance schemes follows from the assumptionthat they representa meansof transferringwealth from the healthy to the sick, and from the rich to the poor. This assumesthat contributionsare based on income and benefits are providedaccording to need. In reality, however,universal systemshave fallen far short of goals in Africa. A predominant reason is the tax base tends to be weak and unstable, underminingpublic revenues. Improved performancein collecting taxes, especially direct taxes which tend to be progressive,could help resolvethis situation,contrbuting to equity in the process. In addition, governmentsponsored social insrance schemes in Africa have tnded to have a very high share of adminishadveexpenses-as much as50 percent in Mali for example.

A more promising route is to impose mandatory inurance payments on employed workers as a percntage of their wages, and to levy a similar or somewhat higher payroll tax on their employers. Examplesinclude compulsorysocial security for the entire formal labor market in Senegal and Mali, compulsoryprograms for public employees in the Sudan, and governmentmandated employercoverage of health care for employeesin Zaire.

By making health insurancecompulsory for employeesin the formal sector, govermnents can encouragerisk sharing in a number of attractiveways. A larger mnmberof enrollees spreads rsks more widely and makes the system more viable and fairer. Compulsoryisurance also creates a large market that may encourage private suppliers to enter and introducea range of alternative risk-coverageplans to attract customers. Under such a system, governmentshave the choice of collectingcompulsory premims while allowingconsumer to subscribeto any one of a number of public or private risk-sharingsystems. Finally, with compulsorycoverage the problemof adverse selection- the tendencyof the healthyto avoidjoining or paying a premium - is effectively avoided. 153 Enployer-sponsored plans are a secondform of coverage. They provide care directly through employer-owned,on-site health facilitiesor rely on contracts with outside providersor health maintenanceorganizations. Examplesinclude employer-provided medical care in Zambia and Nigeria, as well as in the rubber forests in Liberia and Zaire. In Senegal employeesare covered under two insurance programs: a systemknown as Institut PrevoyanceMaladie (IPM) for 53,000 wage earners and their families; and the Institut de Prevoyance et Retraites du Senegal (IPRE3S)for 60,000 retirees. Approximately445,000 family members are covered under these two schemes. In Nigeria five large parastatalsoffer comprehensivecare for their employees and their families, either at their own proprietary health care facilities or by contractingwith private hospitalsand doctors.

A third category of risk-sharingis prepaymentplans. Prepayment schemes have the advantageof a one-time,annual collectionfee. This avoids the need to adjust rates on the basis of assessments of individual risk (Eklund and Stavem 1990). Examples include personal prepaymentplans, communitysponsored plans (sucb as village funds for purchasingmedicines or a broader self-supportingnetwork of local clinics),and programssponsored by cooperatives. In Kenya an estimated2.1 millionemployees and their familiesearning more than KSh 1000per month contribute a flat rate of KSh 20 per month to the INationalHospital Insurance Fund (NHEF). When they are hospitalized,the NHIF will pay out KSh 200 per day for up to 180 days of care. In Guinea-Bissaua system of prepaymenthas worked well, limited to prenatal care and treatment with a few essentialdnrgs. In Zaire the Bwamandahealth insurancesystem provides a model for the operationof community-basedinsurance (see Box 4).

Fourth, there is private insuranceto cover fees of private providers. Private insurance representsa means of earmarkingfamily savingsfor the self-financingof health care by selected groups, thus freeing up public resourcesfor the poor. In countries like CMted'Ivoire, Ghana, and Senegal, private-for-profitinsurance plans cater to upper incomegroups that are willing to pay for a level or quality of care that their governmentdoes not, and cannot, finance, given prevailingfiancial constraints. In such cases, privateinsurance schemes can help free up public resources by paying for what is otherwisepublicly subsidizedtertiary care. Private insurance is perhaps the most promisingmeans availableof stimulatmggreater private sector involvement in health servicesprovision. In Senegalrapid developmentof private insuranceover a three year period resulted in the enrollmentof 15,000 people in plans offered by eight companiesby 1990. In other countries, such as Zimbabwe,private health insurancehas grown well, in part because it is subsidizedby the tax system (Vogel 1990).

Role of Government in Insurance

Governmentscan play a criticalrole in encouragingrisk shaing. Perhapsmost important is to recognize that the willingnessto pay for health insurance is likely to be weak in countries where publicly providedhealth services are currently "free", and a traditionof cost recovery is not in place. When user fees become an establishedpractice in the public sector, households begin to take interest in spreadingthe risk of substatial health expendituresover time and across a wider population. With the subsequentevolution of risk-sharingfinancing mechanisms, a key obstacle to private provision of services - such as expensive hospital care - can then be gradually lifted. 154

Box 4. CommunityLevel Insurance Pklas: Lessons from Zaire

PRACTICE:

The Bwamandahealth insurnce system in Zaire has severalfeatures whichhave contributedto its success. Offeredby the healthcare provider, it avoidsproblems of settingprices for servicesand of transferringmoney from an insuranceplan to the healthcare provider. The combinationof simple fee structuresand the requirementthat patients be referred, helps minimizeoveruse of the system. The scheme also benefits from a good marketingstructure, as reflected in its high enrollment. Health center nurses, who enjoy high levels of access to the community,are given financialincentives in the form of a small percentageof premiumswhen they recruit new participants.

The insurancecovers 80 percent of the standardcharge for hospitalizationor treatmentof a chronic disease. Althoughassociated with a hospital,the accountiogof the insuranceprogram is kept separately,with the hospitalbilling the scheme for chargesmnurred by the beneficiaries.All hospitalcases require referral througha health center, which serves as the site for verificationof the requirementfor treatmentand of enrollmentin the insuranceplan. Premiums are collectedonce a year in the period followingthe harvest, so the schemehas an importantpre-payment dimension. To prevent inflationarylosses in the value of funds collected,the moneyis investedwith interestor used to buy drugs.

Communityenrollment rose from an initial 30 percent in 1986 to 60 percent in 1989. Cost recovery through user fees at Bwamandahospital went from 50 percentof recurrentexpenditures in 1986 to 80 percent in 1988. Health insrance and interest income exceededexpenditures under the plan in 1987, 1988, and 1989; 89 percent of funds collected went to hospital charges, 6 to 7 percent to health centers, and 5 percent to administrativecosts. Although admissionrates for insuredpatients are somewhathigher than for uninsured,the high rate of enrollmentof the eligible populationin the programallows absorptionof this cost.

LESSONSLEARNED:

Studies of a variety of entirely auonomouscommunity insurance schemes in Zaire have identifieda number of preconditions or correlatesof success(Shepard and others 1990):

* Most successfulplans have modest premiums. Where premiumsare beyond the finuncialmeans of potential members,partciation rates will be low.

* A preconditionfor successis that healthservices be of acceptablequality.

* Sensitizationof potentialbeneficiaries can help reducethe tendencyof any voluntaryscheme to concentrateits members (unintentionally),among those predisposedor most eligibleto join, or those most likely to fall ill.

* Committed,decentralized management provides flexibility and accountability.

* Simplecontrol methods, such as stampsfor enrolledmembers and phoo-identificationof beneficiaries,can help reduce error and fraud.

* Enrollmentof all familymembers, rather thanindividuals, increases the size of the pool of peopleamong whom risks are to be spread.

* Appropriateinvestment strategies are neededto preservethe value of premiumincome in periodsof inflation.

e Strong accountingsystems are critical to effectivefincdoning.

* A financialguarantee can be an importantcaalyst to launchinga successfil start-upphase.

Sburce: Shepardand others 1990. 155

Within compulsoryand other insuranceprograms, governmentcan encouragethe use of deductiblesand co-payments. If those covered by compulsoryinsurance can receive services at no cost at all (no deductible),they will likely overusecostly services. Requestinga deductible (meaning an amount that users must pay before their insurance coverage begins), as well as a copayment(meaning a percentageof total costs above the deductiblepaid by the user), can help prevent overuse of scarce personnel, equipment,and supplies. Even small deductibles,such as 1 percent of yearly household income, or small copaymentssuch as 10 percent of the cost of services received can go a long way towards reducing unnecessaryuse of medical care by patients.

To minimize administrive costs of insurance programs and to broaden the range of options offered, govermnentscan encouragecompetition among risk-sharing schemes. The point is that governmentsshould avoid crowdingout private insurers. To this end govermmentsmay consider subsidizing private insurers for a limited period, permitting firms to opt out of compulsorypublic sector health insuranceif they provide a satisfactoryalternatve, or reducing risks that private insurers face through stop-lossprovisions and re-insurance.

Governmentscan also take steps to satisfy criticismthat insuranceschemes can reinforce a maldistributionof health resourcesbetween rural and urban areas. With somejustification it has been argued that the extra funds generated by insurane programs in low-mcomecountries of Africa typicallybenefit urban, employedworkers and their families, while leaving the large rral populationseven further handicapped. This situationcan be aggravatedespecially if public nsurance promotes or reinforces hospital-based,doctor-entered, curative health care. One compensating measure is to assure that public finds freed up by insurance schemes are reallocated to prmary care facilities in pen-urban and rural areas (Mills and Gilson 1988). Another is to subsidizethe cost of insurancepremiums throughvouchers to the poor. The main practical problem with all such measures is to identify the poor - an administrativedifficulty everywhere since means tests are difficult to apply (World Bank 1987d).

Summing up, there is considerable scope for expanding health insurance in Africa, particularly at the communitylevel. The main benefit of public and private insurance is that individuals can pool the fiancial risks of costly medical care, while entirely self-financing programs can help reduce pressure on the public budget, leaving more resources available for the poor. Conclusion:Resolving Crises

As countries of Sub-Saaran Africa strive to generate adequate resources to expand quality health services, it is important to consider how the various partners in better health should go about it and at what pace. Again, no single recipe can be advocatedas each country faces a different configurationof problems, prospects,and priorities. There is much to be said, however, for proceedingin incrementalfashion, along a developmentpath that is cognizant of the need to tackle deeply entrenchedproblems in a progressiveand systematicway, and to spur the private sector and householdsto assumegreater responsibilityfor health. Governmentscan take a leadership role on several fronts simultaneously,and work towards national health 156 finaning strategieswhich bring public and private financialresources for health together in a continuouslyevolving framework.

First, governments have control over the share of the total resource envelope they allocate to the health sector. This study shows that many countries in Africa lag behind other developingcountries in their expenditureson health as a share of GNP, as well as in their public expenditures on health as a share of total public expenditures. Action can be taken to progressively restore commitmentsof public funds for health in countries where they have diminishedor to raise such commitmentsin recognitionof the immenseimportance of health for sustainabledevelopment. To illustrate, in Mauritaniawith a per capita incomeof around $500 per year, the governmentincreased the budgetaryallocation to health from 4.8 percent of the total government budget in 1992 to 8.9 percent in 1993, under a medium term health plan prepared within the frameworkof its structural adjustmentprogram.

Second, governmentshave control over how governmentexpenditures are allocated, and can have an immense impact on the enabling environmentfor health by spending public funds on public health goods and services. This study shows that large shares, and sometimes the majority, of public funds for health are not being used to finance or provide public goods and services. Action can be taken to progressivelymatch symboliccommitments to preventive and primary care with reallocationof public funds away from expensive,urban-based curative care. To illustrate, in Madagascar,the governmenthas succeededin movingaway from its emphasis on hospitals, increasing investmentand operatingresources to primary care, endemic disease control and drug supplies. Between 1986 and 1991, public expenditureson secondary and terdary level care fell from 51 percent to about 36 percent, or by about 3 percent per year. In Nigeria the Fifth National DevelopmentPlan set out a strategy to begin moving federal funds away from expensivehospital programs. The reallocationof public funds is facilitatedby a clear restatement and ordering of priorities - favoring primary care, water supply, sanitation, and health education. The share of federal funds going to hospitalprograms was to be reduced by about a third by 1992 from levels establishedin the early 1980s.

Third, governmentscan progressivelyimplement user fees and cost recovery to help ensure financial sustainabilityof publicly fianced health care. This study shows there is considerable scope for expandinguser fees and that householdsare willing to pay, provided quality improvementsaccompany higher prices. Though revenuesgenerated at the outset may be modest, improvementin cost recovery is an essential part of any health fimancereform program because (i) retention of fees at the point of collectioncan be an incentive to hospital and clinic managersto enhanceboth revenuecollections and servicequality, (ii) purely on equity grounds, patients from higher incomehouseholds (many of whom will have health insurance), should be required to pay for the health care they receive, and (iii) research has revealed that even middle- and low-incomehouseholds are prepared to pay for most curative services, especially if service quality is positivelyaffected.

To illustrate, in Malawi, a strategy for cost sharing is being introducedin three phases, with fees progressivelyintroduced gradually across stages to cover various services in hospitals, urban-basedhealth centers, and rral health centers. A critical elementof the first stage is an informationand communicationstrategy to explain the reasons, approach, and timing of user 157 fees and exemptionsto the population. Gradually introdcing the user fees also has the explicit intenton of stengtenin the referral system and facilitatingthe expansionof well staffed and equipped facilities at the primary health care level. In Zimbabwe improved collecton procedures in the current system of cost recovery have the potentialof raising revenues from Z$9.16 million to Z$11.82 million, whereas price adjustmentsfor inflation have the potential of raising another Z$20.09 million in revenues, representing11.4 percent of recurrent hospital spending in 1990.

Fourth, govertments can create conditions for the expansion of health insurance programs, generating increased revenues for the health sector in general, and stimulating expansion of private providers of health care. This study shows that prospectsfor expanding communitylevel insuranceare good. A requisiteof all healthinsuce programsis to introduce user fees so that possible private providers are not in competitionwith free health care. Governmentsmay mandatecompulsory insurance for salariedworkers, and encourageexpansion of private or employerprovided insuranceproams.

To illustate, in Senegal schemes under the social security fund, modern enterprise insurance programs, and private health insurancehave been encouragedduring the 1980sto the extent that total insurane financingincrased from 4.4 billion CFAF in 1981 to 8.8 billion by 1989, an increase of 100 percent. Transfers through health insurancenow amount to about 20 percent of total health expenditures, compared with 14.9 percent in 1981. While formal insuranceprograms are limited to employeesin the modern sector, informal associationsat the communitylevel - called -tontines" - have also been encouragedto contribute resources to a 'community savings pool' from which contibuting memberscan draw funds if needed. Such efforts particularly merit encouragement.

Fifth, governmentscan progressivelypromote public-private collaboration as a means of increasing efficiency and fostering developmentof private-for-profit and private voluntary organizaions (see Box 5). Subsidizingreligious missions has paid handsomelyin Africa as a means of providig for indigentsand serving areas where public and private-for-profitfacilities

Box 5. Public-PrivateColaboraion

Increasingly,African government are deliberatelyfostering collaboraton widt the privatesector in the financing and provisionof heal cArebecause increased private sector activitycan easepressure on the public budget. The private sector is also more responsiveto marketforces, and thereforemore efficientthan the public sector. A shift in tde balance of health needs to more individual-levelcare among higher incomegroups furer signals an expandingrole for private providers,with insurancemeims to protect gainstcatastroph financiallosses. In thearea of financing,public support can take the formof publicsubsidies to privatevoluntary organizations, contratingout to non-governmentalproviders, and a varietyof incentives(World Bank 1987d). For example, in Rwanda wheremissions provided from 2S to 33 percentofhealth care services during the 1980s,the governmentreimbursed them for a largeshare of the salariesof Rwandesestaff. Thesepublic subsidies accounted for about5 percentof recurrent publichealtbh spending. In Zimbabweabout 4 percentof the centralgovernment health care spending wem to subsidize missions,representing about 85 percentof theirhealth service revenues in theearly 1980s.This was provided in support of the missos' workin servingindigents. In Nigeria laboratory services have been contacted out, and in Zimbabwe, equipment,maintenane, laundry services, and invoicingof iosuredpadents have been contacted out. 158 are scarce. It also makes sense in view of the co-subsidieswhich come from abroad, paying salaries of mission staff, providing essentialdrugs, and building and maintainingfacilities. In Zimbabwe and Nigeria, for example, tax relief is granted to private voluntary providers. Contracting out to private providers is becomningincreasingly commonplace and is producing savings, especially in the hospital sector. Certain responsibilitiescan be shifted to the private sector such as providing drugs; in Zimbabwethe role of the private sector in providing non- essential drugs is emphasized. Steps can be taken to legalize private practice; in Tanzania legislationprohibiting private practice has recentlybeen repealed;and in Mozambiquelegislation has been adoptedto allow private voluntarybodies to establishhealth care facilitiesand to allow private firms to establishenterprise clinics for employees.

Finally, govemmentscan reap far greater sustainablebenefits through the use of available extemal funds than they have in the past. This study has argued that donor initiatives and lending, while valuableon a numberof criteria, have had problemsachieving sustainable effects, and have often been criticized for fragmentinghealth systems rather than building national capacities. Instead of molding nationalstrategies around available donor funding, governments should be developingnational health policiesand strategiesto direct donor assistance. In Guinea and Benin, for example, national action plans are being developedby government,followed by the identificationof financial resources together with donors on the basis of comprehensive financingplans. And, becausethe reallocationof nationalbudgets is cumbersome,African states can use external funds to experimentwith new strategiesthat are more conducive to national capacity building - such as the district based approach described in Chapter 3 and costed in Chapter 8. Africanpolicy-makers can further reducedependency-related problems by taking the lead in developingdonor coordmationmechanisms. CHAPTER 10: TIMETABLEFOR CHANGE

Introduction

As a foundationfor sustainabledevelopment, better health in Africa requires a long-term vision and political commitment. Priorities must be guided by careful policy-analysisand planningof the socio-economicenabling environmentfor health, the many systemiccomponents of health care delivery, the fmancing of health services, and institutionalperformance. A timetable for change needs to be establishedwith priorities for completionover the short-term, others over the medium-term,and still others requiring commitmentsover a much longer time horizon.

Diversity among African countries further requires that priorities and action be tailored to differencesin the severityof conditionsaffecting health, the qualityand quantityof public and individualhealth services, access to external assistance,and so on. In some countries, such as Mozambique,Somalia, and Uganda, civil war has taken an immensetoll on health systems,with the implication that a timetable for change will be preoccupied with basic assessments and improvementsacross almost all determinantsof health outcomes. In other countries such as Renin, Guinea, Mali, Malawi, and Nigeria, experimentationand positiveexperiences linked to well-functioningdistrict health systemscan serve as a basis for extendingwell-conceived plans in the past. And in still other countries, like Botswana,Lesotho, and Zimbabwe, where per capita incomes and health expendituresare considerablygreater, changes will be required to augment the capacity of health systems that are working relatively well, by encouragingthe provisionof health insuranceto larger shares of the population,providing fuller coverage of the poor, and privatizing hospitalservices.

While the pace and direction of change will depend to a large extent on the leadership role played by Africangovernments, and the activeparticipation of householdsand communities, so too will sustainableoutcomes depend on the cooperationand actionsof the donor community. As partners in better health in Africa, external fundingcan play a vital role in buildingnational capacities, particularly in low-incomeAfrica where poverty is widespread.

This chapter begins with a rough timetablefor change, summarizingmajor concernsand recommendationsthroughout this report, as thoughall counties faced a similarprofile of health challenges. In fact, the commitmentsto reform and capacities for implementationwill vary gatly from country to country, meaning that each country will need to determine its own particular agenda and timetable. The chapter goes on to provide a dynamic perspectiveon how key health priorities can be expectedto differ among African countriesas they move from low 160 to relatively higher levels of socio-economicdevelopment. This sets the stage for considering how internationalassistance might be used most effectively. Action Agenda

Priorities for action are summarizedin Table 1, includingdesignations for "short term" action, meaning that completionof a particular activity is anticipatedwithin about one year or so; "mediumterm", implyingcompletion within around five years; and "longer term", with a ten to fifteen year time horizon to completion. For example, a governmentcan formulate an operationally relevant health policy relatively quickly, even if data on demographic and epidemiologicalconditions are somewhat incomplete. Such a task requires expert opinion, collaboration among providers of health services, engagement of beneficiaries or their reprentatves, and coordinationand leadershipby government. It is therefore designatedin Table 1 as an activity that can be undertaken for action over the "short term" - though continual revision and updatingwill be required over time.

Developinga comprehensivedemographic and epidemiologicaldata base, on the other hand, will take considerably more time. Surveys have to be designed, questionnaires enumerated,data processed, and satistics preparedfor policy analysis. This says nothingof the training required to facilitatesuch work. This priority has therefore been designatedin Table i as an activity that can be undertakenover the "mediumterm", thoughagain data bases require contimualupdating and refinementover time. To date, nationaldemographic and health surveys have been undertakenin only twelve of forty-five African counties.

"Longer term" activitiestend to be more demandingof financialresources required, for example, to progressivelyconstuct new district hospitals in underserved mral areas, or to progressivelyexpand intersectoralservices so vitalto health, such as water and sanitation. Also involved is the evolutionof political commitmentsin support of institutionalpluralism and the rturing of strong and sustainablenon-govermental organizationsas partners of better health in Africa. Each country will need to determine its own agenda and the completiontimes that are reasonable in its particular circumstances.

Short Tenn: The priorities sketchedout here concerninitiatives to be taken by the public sector, given government's critical leadership role in creating an enabling environment for health, and its involvementin health care delivery. Priorities for the "short term" fall largely in the domain of public health goods and services, and include:

* Formulatingcomprehensive health policiesand strategiesin support of an inter-sectoral approach to health. This should includestatements on how the enabling environmentfor health will be strengthened;prescriptions for the role of governmentin financingand providingpublic health activities and other public goods and services, and a research agenda to help fill critical gaps in knowledge.

* Identifyingthe most disadvantagedgroups, establishinghealth targets, and agreeing on indicators for monitoring and evaluating improvementsin their health stats. In particular, 161 methodologiesand screeningmechanisms should be developedto establishwho should qualify for fee exemptions and health subsidies. Communityparticipation in this process is vital.

* EstaUishingnational drug policiesand essentialdrug lists, and reviewingthe legalbasis for their execution. Particular attentionis needed to quantifynational drug needs over a given time, to use cost-effective criteria in selecting and purchasing them, to pursue competitive bidding for genetic drugs, and to consider- to the extent that trade and exchangeregime might require - the desirabilityof inter-ministerialagreements on reservationof guaranteedforeign exchange for drug purchases.

* Formulatingnational human resource plans for health by geographicarea, by expertise, by category of worker. In particular, attentionshould be paid to the staff profile required to manage and operate district-basedsystem, includingdistrict health managementteams, staffing of first referral hospitals, and personnelin health centers.

* A comprehensiveassessment of present buildingsand equipmentand future needs. In particular, attentionshould focuson rehabilitationneeds of existingbuildings, establishing norms and proceduresfor locatingnew health facilities,especially at the district level, and establishing an advisory panel to assess technologychoice in the fuure.

* Initiatng institutionalrefomn and assessmentsof managementcapacities and needs. Trhiscan be facilitatedby participant/beneficiaryassessments of current health systemsand their operation, establishingmanagement information systems to monitor and evaluateprogress, and strenghening communityinvolvement in managementof lower level health facilities.

3 Establishingcoordinating mechanisms,under the joint leadership of the Ministry of Health, Ministy of Planning, and Ministry of Finance, to assess the profile and cost- effectiveness of donor actvities and to develop a coherent approach to wo.k with donors. Particular attention is needed to developa more systematicapproach for donor participationin decentralizationand developmentof district health systems.

Medium Term: Becausemost goverments in Africa are involvedin the direct financing and provision of health care, a timetable for change over the "medium term" needs to incorporateactivities aimed at making public provisionand financingmore efficient, equitable and sustainable. Priorities for completionover a medium-termhorizon include:

* Developing demographicand epidemiologicaldata bases, so as better to determine, monitor and evaluatecost-effective approaches to better health amongdifferent demographicand socio-economicgroups situatedthroughout the country. In particular,emphasis should be placed on unveilinginequalities in health status betweenethnic groups and geographicareas. Attention should also be concentratedon disseminatingresults of surveys to public health oficials and private voluntary agencies, as well as universitiesand think tanks, in ways that help facilitate institonal pluralism and strengthenpolicy analysis, planning, and service provision. 162 Table 1. Action Aenda and Timetablefor Change Action Agenda Short Term Medium Tern Longer Term PolCy Aasis, Data Colection, and Target Setting * Formulate/reviewcomprehensive health policies * Develop demographicand epidemiologicaWdata bases 0.0 * Establish/reviewhealth targets Go* * Identify most disadvantagedgroups ... * Establishresearch agenda and critical gaps in knowledge ... Enabling Environment for Better Health * Increaseprovision of availablehealth infonnationto the public and ... to the healthcare provider

* Identfy ways to contnute to behavioralchanges by households ccc and individuals,through IEC methods * Pogressively encourageand assist sustainableinterventions at ... communitylevel, particularlyin areas of waterand sanitation HealthCae Deivr * Strengthenquality of primary care servicesthrough well- ... funcdoninghealth centersand first referral hospitals * Improve referral system with regulations,price, and quality signals .*

* Reduce concentrationof MOH resourcesat terdary level, and 000 devolve MOH involvementin their management * Substan y imprve supervision *"*

e Increaseaccess to health servicesby the *core"poor ccc

. Establishnadonal drug policiesinvolving; - reviewof legal basis and strucure for their execution - reservationof guaranteedforeign exchangefor drug purchases **

* Adopt essentialdrug lists ** * Reduce ineffciency and waste through; - selectionand purchaseof drugs using cost-effectivenesscriteria **- - quantication of nationaldrug needs over a giventime - competitivebidding for genericdrugs eec - improvestorage and management ceo counter irrationalprescription with trainingad information - improvepatient compliancethrough infbrmation/communication *-- * Develop and support drug revolvmgfumds *eo Persnnel Maagemen and Trainig

* Formulatenational human resource plan for health by geographic e*- area, by expertise, by gender and categoryof worker.

* Generatebudgetary savings, improvecompensation, by reducing ego ineffectualcivil service workersand rewardingproductive ones

* Expand trainingin health managementand admstation *

*Adapt t!iN curricula to distic and communitytevel services cO* 163

Acffon Aenda WShotTerm Medium Tenm Longer Term Realmh naruu and Equipment - Estblish rehabilitationplans for existingbuildings and equipment - Establishnorms/procedures for new health facilitiesand equipmentmatena, especiallyat distrkt level - Designateone hospital as center of excellencefor training Int_ donal Reform and Mangement * Perfbmi participantassessmt of current system and its operadon

*Pursue decentalization and redefineroles and responsibilitiesof e.g central, regional,district and communitylevel

* Develop managementskills for planningand budgeting 'cc * Poster institutionalpluralism, especially between government and NGOs * Form and strengthencommunity organizations

' Undertake trainig and other preparatorywork for district health cei teams * Undertake trainig/preparatory work for communitymanagement commitees * Establish Inormaton ManagementSystms through; - assesmet of needs by componentof health system ego - trainingrequired - implementationof systemsand prcurement of neededequipment *Initiate health JEC programs,backed by social research * Developcapacity for essentialnadonal health research -. _inadg Heath Cae - Increase governmentcommsmen to healthexpendiu

' Reallocategovernment expendues to public heath geO goods/serices *Implement user fees and cost recovery in public faciities - at terdary hospitals e - as first rerral hospitals ego - at health centers * More rigorousidentification of, and subsidiesfor the poor 000

* Encourageexpansion of insuranceschemes, especially employer- *0O based, and at the communitylevel ' Promote public-privatecollaboraton *0 DonorColaboratton ' Establish coordinatng mechanisms,headed by government 000 * Assess profile and cost-effectivenessof donor actvities 000 * Establishdonor role in cost-effectiveapproach to better health *-- featuringhealth centersand first referral hospitalsat district level

* Progressivelyincrease donor fundingto primary and first referral eec carein low-incomeAfica . 164 Supportingtrainig and educationprograms for seor public health managers, health plamers, and managementinformation specialists, as well as through curricula atuned to the specific needs of health services at the district and communitylevel. In particular, emphasis should be on getting professionalstrained in health managementand administrationinto key policy, planning, and budgetingpositions in Ministries of Health. Also importantis to sensitize and educate district level managementon potentialbridges between "modem" and "traditional" health paradigms.

* Progressively increasing govenmuent conumitmentsto health expenditures, and earmarking larger shares of public funds for public health goodsand services, preventive care, and primary care for the poor. In particular,govermnents should redressdeclining commitments to health, as reflected in falling shares of governmentexpenditures on health as a share of total governmentexpenditures. Real per capita expenditureson health will also have to be increased in many countries.

* Matching symbolic commitmentsto primary care with a progressive reallocationof public funds away from expensive,urban-based hospital care to well-functioninghealth centers and first referral hospitals.

* Progressively implementingcost-sharing, first at the tertiary level facilities where clients with health insuranceare more likely to prevail, and where those who by-passthe referral system can be assessed full costs. This can be progressivelycomplemented with cost-sharing at health centers and first referral hospitals, with a pre-determinedamount to be retained by the facility collectingthe funds withoutsubjecting the overall Ministryof Health allocationfrom the Ministry of Finance to corresponding reductions. Particular attention needs to be paid to increasingquality of services at the same time that fees are being increased;and with full cost recovery levied against those who by-pass the referral system, the entire referral system can be expected to perform more efficiently, reinforcedby appropriateprice and quality signals.

* Launchingprograms to contribute to the reductionof inefficienciesand waste in the prescriptionof drugs (throughtraining and informationof providers), patient compliancein the use of drugs (through infonnation,education, and communication);and generalknowledge about the utility of generic drugs.

* Information,education, and communicationprograms (IEC) have a critical role to play, and if designed and targeted appropriately, can have immense influence on the demand and supply behavior of health services providers and consumers.

* Generating budgetary savings and improvingcompensation of health personnel by cutting back on ineffectualand unneededworkers in the civil service, and rewardingproductive workers of primary care facilities,first referral hospitals,and in District Health Teams. At one end of the continuumthe process can begin by systematicallyweeding out "ghostworkers" and other redundanciesat the central level. At the other end retentionof fees for service at site of collectioncan be used to help supplementincomes of health center staff. 165 *Layingthte groundwork for institutionalreform and decentralization by redefing roles and responsibilitiesat thecentral, regional, district and community level, includingdevelopment of managementskills for planning, programming,and budgeting associatedwith such decentralization.In particular,emphasis needs to be placedon fosteringinstittonal pluralism in supportof decentralization- with stronginvolvement of NGOsand communities;training and other preparatotywork for districthealth teams and communitymanagement committees; and design of managementinformation systems to monitor and evaluate personnel, infrastructure,and equipmentneeds. * Evolvingsustainable forms of communityfinancing of health,including drug revolving fundsat well-fumctioninghealth centers, and communityinsnce schemes. * Promotingpublic-private cooperation, thus paving the wayfor privateproviders to play a more prominentrole in healthcare, and releasingpublic funds for public healthgoods and services,as well as subsidiesfor the poor. Experimentingwith entirelynew formsof public- privatecooperation, may also prove appropriate.

* Increasingdonor funding to primarycare in low-incomeAfrica, corresponding to the generalparameters set out in Chapter8. In particular,attention is requiredto assurethat donor funing is usedto complementand reinforcenational strategies, and that the absorptivecapacity of fledglingsystems of healthcare is anticipatedand provided for in the rate of disbursements.

* Devolvingthe managementof tertiarylevel hospitals from the Ministryof Healthand major reductionsof publicexpenditures on tertiarylevel care. In particularemphasis should be placedon getftingMinistries of Healthout of the managementand fincing of teriary level hospitals,perhaps through gradual privatization, and mostcertainly through progressive cost recovery,especially among clients who can be coveredby healthinsurance. Longer Term:Priorities over the longer-terminvolve features of health systemsthat requireplanning, progressive expansion, and financialcommitments over time, so as to achieve sustainableimprovements in healthand widercoverage. Theyinclude: * Implementingsustainable interventions affecting the enablingenvironment at the communitylevel. Accessto safe water,sanitation, nutrition, and familyplanning would thus be withinreach of a large majorityof Africansin rural and peri-urbanareas. * Strengtheningthe qualityof primarycare servicesand extendingcoverage, through well-functioninghealth centers and first referralhospitals throughout district based systems. This impliesconstruction of neededhealth centers and first referralhospitals and increased public-privatecollaboration in their staffing,operation, and maintenance.

* Carryingout effectiveprograms of information,education, and communication(IEC) for healthbehavior change at the individual,household and communitylevel. Suchprograms shouldbe backedby soundsocial research and caefully monitoredand evaluated. 166 * Strengtheningcapacity for essential nationalhealth research in ministries, universities, and private voluntary organizations. Dynamicsof Change

The challenges implied in Table 1 will differ across African countries, depending on prevailing socio-economicconditions and political stability,changing epidemiologyand health care services, and financialconstraints. Some African countriesare relativelyahead of others in laying the groundworkfor efficient, equitable, and sustainablesystems of health care. This can be ilustrated by comparingthe situationof three countries- Uganda, Mali, and Botswana. The messageis simply that African countriesare not homogeneousin the health problems they face: each country needs to determine its own agenda and timetable for refonn.

Uganda:The situationin Uganda is not untypicalof several African countries that have suffered from recent political, social, and economicupheaval. Health indicators,such as infant mortlity, have shown little improvementover the last 10 to 20 years; fertility rates have remainedconstant if not increasedover the last decade; and the economyhas experiencedmajor setbackswith unstableand decliningpublic funds for socialservices during the 1970sand 1980s. Political tumoil and civil strive have resulted in profound disruptionof the health care system, reducing one of Africa's most effective and efficient health services during the 1960s to near total collapse. Health finance is in disarray, with individualgovernment-owned facilities taking unilateraldecisions on fees to prevent outnght collapseof their services. Profoundmanagement problemsabound throughoutpublic sector health care delivery, where capacityutilization is 50 percent lower than in non-governmentalhealth facilities. And to make matters worse, Uganda's fledgling system of health care is burdenedby the AIDS epidemic.

Uganda faces the immensechallenge of taking action on virtuallyall items listed in the Timetable for Change in Table 1. Governmentplays almost no role in assuring public health goods and services, there is an urgent need for a sharp rise in public financialcommitments to health, and public expendituresneed to be reallocatedfrom terdary-levelhospital care to primary health care. This is the time to rethink the country's health systementirely, and to emphasize the use of donor assistance in ways that contribute to an integratedsystem of health care.

MaH: The situation in Mali is typical of a handful of African countries that are progressivelyimproving health outcomesunder binding fnancial constraints. Health indicators such as infant mortality and life expectancyare improving, though slowly; low per capita incomesare graduallyincreasing; and the country enjoys somewhatgreater social and political stability than many other African countries. Though the Ministry of Public Health has traditionallyfocused on the direct provision of health care through vertical programs, and has neglected its role in policy formulationand planning, it is achieving a gradual expansion of district-basedhealth care. Currently, the country's network of district-basedhealth centers provides accessto care for 45 percentof the populationand is expectedto increaseto 52 percent by 1997. To promote public-privatecollaboration, the governmentlifted its ban on private practice in 1987. 167 Mali also needs to take action on most of the items in Table 1, but with the distinct advantage that the groundworkhas been laid for decentralizingservices to the district level. Moreover, donors have been quite active in supportingdistrict-level care and appear willing to expand on the positive lessons learned. Perhaps the greatest challengefacing the country is to rationalizehealth sectorexpenditure patterns, increasegovernment commitments, promote cost- sharing as part of a strategyto financerecurrent costs of public health facilities,improve quality of services and regular suppliesof essentialdrugs in public facilities,sustain gradual expansion of services and stimulst:enon-governmental provision of health care.

Botswana: The health situation in Botswanais shared by a few African countries such as Zimbabwe, Mauritius, Lesotho,and perhaps Kenya. It can also serve as a "road map' to the kinds of challenges likely to be faced in the future by poorer African countries. Health status has been improvingrapidly, rising incomesand expenditureson publicgoods and servicesreflect incrases in per capita GNP, illiteracy and fertility rates are on the decline, and the country enjoys a good measure of social and political stability. Access to health facilities is relatively good, and decentralizationto the districtand sub-districtlevel has been in place for some time. Public expenditureson health are also relativelyhigh - well over $30 per capita annually. This compares with an estimated$16 per capita, per year, to provide a basic packageof services for a relatively "high income' African country (see Chapter 9). Furthermore, health planning is given prominence in the organizationand work program of the Ministry of Health, and the country has a solid tradition of cost sharing f4tr pVuEbliCkIypro-vidd services (though revenues constitutea small share of total govemmentexpenditures).

Predominantamong the challengesfacing Botswana are privatizationor full cost recovery at hospitals, encouragingthe expansionof public and private insurance schemes,strengthening health researchand researchcapacity, and reducingdonor involvementin stride with Botswana's growing financialand institutionalcapacities. Botswanawill also want to compare the profile of publiclyprovided health servicesnow availableto uraland peri-urbanhouseholds (associated with governmentexpenditures of over $30 per capita), with the cost-effectivepackage of basic services costed in this study. Links with the IntermationalCommunity

Partnerships for better health in Africa need to encompass international as well as domestic perspectives, the views of multi-lateraland bi-lateral agencies engaged in financing health services, and focus on the relationshipbetween macro-economicissues and health. A challengefaced by virtuallyevery Africancountry is to reap far greater sustainablebenefits from dono- funding fian have been achieved in the past (see Box 1). Rather than mold national strategiesaround availabledonor funding, governmentsneed to develop national health policies and strategies to direct external assistance.

African leadership is essential to initiate the process of consensus building. Several African countries are beginning to steer donor coordination more actively, under the :hairmanshipof the Ministry of Health or Planning, by bringing together a diverse group of donor agencies to work with national health staff to build nationalcapacities for health over the longer-termgoals. In Guinea and Benin, for example,national action plans are being developed 168 by governments,followed by the idertification Box 1. Inernational Iniiatives and of financial needs and obligationsto be shared SustainableOutcomes by donorsplans. This is preciselythe approach favoredby this report, and promisesto address In the 1980s,approximately half of extenal a major pitfall of donor assistancein the past - assisnce for heath in Africa was commit_dto namely, sustainabilitynamel,sutainailit of eternllyextenally fndedfunded program.intenationgly The conceived list ofand initativesexecuted, ismulti-country long and programs for health. impressive: the Expanded Progrm of Immunization (EPMof WHO, UNICEFand USAID;the Diarrhoeal The donor community, on the other DiseasesControl Program of WHO;WHO's program for control of Acute RespiratoryInfections; the Safe hand, needs to extend its time honzon in MotherhoodInitiative; the Gobal Program on AIDS; sUpporting government efforts to develop the Child Survival programs of UNICEF and the integrated systemsof healthcare. Once donors United States; the OnchocerciasisControl Program; become involved in funding health sector the International Drinking Water Supply and Sanitaton Decade; and the Special Program of activities - p4ticularIy in countries with Researchand Trainimgin Tropical Diseases. extremely low expenditure levels and institutional capacity - they should expect to The 1990 World Summit for Children, par sfor at least a deade. Though sponsoredby UNICEP, was an inernatonal initative remain partrsremam for at least a aecaae. lnougll for overal improvementsin thehealth and welfareof pressureSfor measurable health gains over the children, at the highest political level. Its goals are short term are undestandable, SUCCtuMbing to fully consistentwith the proposalsin this report. them is likely to be counterproductiveto long- Vauableas suchinitiatives have been on an term efforts. Donors also need to concentate idi,riua,. basb-,ii is also wioelybeiievea that, their resources and efforts for health collectively,they have had the unintentionaleffect of improvement on those African counies that are fragmeg systems of health care delivery, fiurmlycommimed to and sustain e effort of analysisundermining and national planning, capacities and discouragingin health policy,the reform. A development-orientedvision of developmentof local health leadershipwithin Africa external support to improvethe health of all the (seeChapter 2). people on a sustainable basis should The processsof follow-upon the World increasingly replace a welfare-oriented Summit for Chdrn through National Plans of perspectivethat successfuly improvesthe health Acon, implemento of the BamakobIiative, the and health care of the few with limited, WHO Three-Phase Scenario for development of unplicablemodels. district health systems, and other initiatives, merit unrepllcablemode s. pursuiton an integratedbasis, wWdn a frameworkof local adaptation, leadership and monitoring and Areas where futre international evatuationof sustainableoutcomes, assistance in health can make a relativelygreat contributionto better health in Africa are: * Supportfor long-termcqpacity building ad institutionalreform, especially in the areas of policy analysis and formulation and execution of essential national health research.

* Supportfor the provusionandcfinancing of sustainablecost-effective packages of basic healthcare servicesat the districtlevel, with emphasison the developmentof humanand institutional i, if necessary at the expense of immediate gains in health statuc. 169 * Supportfor inter-countryprograms ofpublic healthtraining and practically-oriented research,includg technologyassessment.

* Supportfor inter-sectoralactions for health. Theseactivities can reachbeyond the health sector and its "internationalcounpat", the World Health Organization, to encompassother multi-lateral agencier such as UNICEF,and the WorldFood Program. The prioritiesset out aboveare few but their implicationsare complex. The push to extend Africa's physical infrstructurefor health is a case in point. Direct support for its expansionshould not be among the highestpriorities for iternational assistancein most countries. Rather,rehabilitation of xistingifrastuc and equipmentneeds to be ensured. Theaftr, donorsupport for facilityexpansion should be providedwithin a frameworkof health sectorfinancing that considersnot only proposedcapital investments, but their implicationsfor rerent expenditurein the futureas well. Undersuch arangements, recurnt cost financing shouldbe increasinglyacceptable to the donorcommunity as part of an overallfinancing plan for healthservices. Afican expertson these issuesneed to initiatethe work of consensusbuilding at the country-level,and provideintelletal leadershipin puttingforward proposals for "compacts" betweenAfrican countries and the inteaional community.Sch compactsmight over time envisage, in those African countriesmost in need, a doubling of governmentresource mobilizationeffort for healthand comparableincreases in donor mupport,as well as programs for measurableefficiency gains in healthservices. The secific agendafor inclusionin such compactscan be expectedto vary considerablyfrom country to county. A forum might also be established,extending beyond the country level, to ensure coordinationof internationalinitiatives for tranng and operationallyoriented research. Such a group could pnoritize actions,and monitorthe modestlevels of financialsupport that are likelyto be needed. It couldalso assume a responsibilityfor reviewingactions for healthreform takenat thecountry level, and facilitatingthe exchangeof experience.Benchmarks, to facilitate monitoringand evaluationof the overallprogram for healthimprovement, would needto be established.A comprehensiveindependent evaluation of progess, nationallyand internationally, couldbe undertakenafter, say, five years. A ConsultativeGroup on Healthin Africacould be responsiveto these needsfor well- orchstratedactions for healthimprovement, perhaps following the linesof the so-calledDonors to AfricanEducation - a groupthat has broughttogether Africans and donorsfor consultations on a widerange of educationissues. Anotherexample is the GlobalCoalition for Africa,a high level group of Africansand donorsthat seeksto identifyand monitorsupport for actionson issuesthat havepreviously received inadequate support. Consensusbuilding of thisnature, both nationallyand internationally,could amount to an unparalleledeffort to assist Africa in overcomingintolerable levels of suffering,premature death, and waste stemming from ill-health. STATISTICAL APPENDIX Table 1. Health and Development Indicators

Annuwa Cnd Crwe ToW Uif Mid- Rat of Orh Dea* Fetlit Expec- Adutn Year Popu- Ra Rab Rats tay GNP Literacy Popu- taion (Per Per (P.r 1000 at Per Rate talon Gh tOOO 1000 Women With Capita (000s) M I Pop.) PeD.) 15-49) Iii e± ToF Country f 1992 1992 1992 1992 71992 1992 1991* j jO 190 Angda j 9.732 2.8 47 19 6.6 4S/48 ... 28 42 Bonin 5,042 90 46 16 6.2 49/52 80 16 23 Botawana 1.360 3.0 36 6 4.7 6/70 2.SS0 65 74 SurkinaFaso 9,537 2.9 47 17 6.5 47/50 290 9 18 Burundi 5.818 2.9 46 17 6.8 46150 210 40 50 Cameooo 12.245 3.0 42 12 5.6 5558 850 43 54 CapeVerde 3P 2.3 36 7 4.3 67169 750. CentralAican Rep. 3.166 2.5 42 18 5.8 45/49 S90 25 .38 Chad S,977 2.5 44 18 5.9 46149 210 18a01 Comoros 510 35 47 11 6.7 56S7 500 40 46 Congo 2,428 3.3 49 16 6.6 49/54 1.120 44 57 Coted'vore 12641 8.6 45 12 6.6 58159 e90 40 54 Djibouti 465 3.2 46 16 66 47151 ..... Equatol Guinea 437 2.3 41 1i S55 4/500 330 37 50 Ethiopia 54.790 3.4 52 18 7.5 47150 120 Gabon 1.201 2.8 43 15 5.9 52W58 3,78o 48 61 Gambia 929 2.9 47 20 6.5 44/45 360 16 27 Ghana 16,824 3.2 44 12 6.1 53/57 400 51 s0 Guinea 6,048 2.8 48 20 8.5 44/44 460 13 24 Gulnea-Blssau 1.022 2.0 46 25 0 38/39 t80 24 3E Kenya 2s,e98 S.S 45 10 6.4 57161 340 58 69 Lesotho 1.860 2.5 36 10 5.1 5863 56o 84 73 Ubedia 2,719 3.0 44 14 6.2 53657 450 29 39 Madagascar 12.384 2.8 42 14 6.15015 210 73 80 Malawi 9,085 3.1 5U 21 7.6 44/45 230 31 42 Manielm8,962 2.9 50 18 7.1 47150 2k0 24 32 Maurita 2.082 2.8 49 18 68. 4B6/0 510 21 34 Mawrus 1.099 1.1 16 7 2.0 67173 2.410 75 82 Morambkpue 16,565 2.7 46 19 6.5 45148 80 21 33 Niger 6,171 3.3 52 19 7.4 44/48 300 17 28 Nigeda 101,384 2.9 43 14 5.9 WM/5 340 39 5i Rwanda 7,310 2.2 40 17 6.2 45/48 270 37 50 SaoTome and Prinipe 121 2.6 38 a 5.0 6/0 400 42 58 Senegal 7.845 2.7 43 16 6a1 46/49 720 25 38 Seychelbs 69 0.9 23 7 2.7 08/75 5,110 95 88 SieraLeoe 4,354 2.6 48 22 6.5 40/45 210 11 21 Somalia 8.302 &.I 48 17 6.8 47/50 170 14 24 Sudan 28.567 2.9 44 14 6.2 81/5 40 12 27 Swaziland 860 3.6 49 12 s6 59 1.050 65 100 Tanzan 25.965 3o 45 15 6.S 4W 100 88 90 Toga 3,99 32 45 1S 6.5 555 410 31 43 Uganda 17,475 S3. 52 19 7.8 45/46 170 35 48 Zaire 39,794 3.0 44 14 6.2 220 61 72 ZnmbIa 6,589 9.1 48 17 6.5 464 . 420 65 73 Zimbabwe 10,352 2.6 84 8 4.6 56/6 65o 60 67

Worl 5.441.205 1.6 26 9 3.2 64/68 4.000 55 65 Leessdewkpdcwon 4.213,796 2.0 29 9 S.6 am/5 800 52 63 Ma SaLoped - t.226we1 56 0.5 1 . 1 9 m71 0 95 # Note: * talfiguresfor ddusicountisare19904GNP. Table 2. Population Projections (Standard/Medium)

A,,a 3I P.p. t. Ag.e, md-Yow of Populn Stuuure Ufbar. Puataon Grow1h TOW Fd _ rft Popuat (Thoulsta ) V dt) R d 0-114 65+ 0-14 1 6S+ * Perotn CounbY 20 225 2000 1 2s 16 1 125 2025 1970 19 1 2r Angola 12.326 26.104 .2 2.5 0.8 4 4? 3 41 3 15 28 10 ae"l 6.375 1O091 2.8 1.6 5.6 2.0 48 9 40 9 18 38 46 8.eswana 1,04 2.00 2.6 1.3 3.9 L1 40 3 31 5 8 29 37 wuvldnaFaao 12,047 22,746 2.0 2.0 6.4 9.5 45 3 so 4 6 15 24 6Bmadi 7,S05 14.041 2.0 21 0.7 3.8 46 3 38 4 2 5 7 Caneroan 15.604 28.685 3.0 1.8 5.5 20 45 4 37 4 20 40 40 Cap"Verd 470 72e 2.2 1.4 37 2.1 44 4 27 4 20 29 s6 Cemn alfloan Rep. 3.07 7.330 2.7 2.2 0.2 4.0 42 3 so 3 30 47 55 Chad 7.353 13.622 2.7 2.0 6.1 3.8 42 4 37 4 12 32 42 Ceomeos 674 1.6 3.4 2.1 0.1 3.2 48 2 40 3 1, 28 34 Cao" 3.162 6.474 3.2 2.4 66 3.s 45 4 ao 3 33 41 47 Cdo d'lvre 16.878 81.140 a.3 L0 6.2 a.1 48 3 4a 3 27 40 47 D1bouti 6o0 1.175 3.2 2. 6.5 3.6 45 3 40 4 62 81 84 EquatolaOulnea a2s 83" 2.3 1.5 3.4 2.9 40 4 37 4 27 20 33 Eth1oota e7.485 143a1 3.3 2.0 7.4 4.5 46 3 40 3 0 12 15 Gabo 1.1441 2.96 8.0 2.3 0.4 _37 a VI 4 i 4 4 Gambil 1,167 2.210 2L 2.2 6s 4.1 44 a 36 4 15 23 20 Ghan 20.334 36.221 3.0 1.7 LS 2.0 47 3 36 4 20 34 3a Guinea 7.578 14.471 LO z1 6.s 4.1 47 3 40 3 14 26 34 Guinea-Bisau 1.107 1.038 2.1 1.6 6. 3.7 43 3 37 4 I5 20 25 Kiwya 34.001 728ssa 3.4 o6 5o 4.0 40 3 a5 4 10 24 32 Losoho 2.282 1*47 2.S 1.3 4.5 2.2 43 4 32 6 9 1a 27 Lbeia 3.480 204 2.0 1.8 8A. . 45 4 3 4 20 45 55 o15.33 25.850 2.6 1.0 5.5 2L 45 3 30 3 14 24 31 malearI 11.555 24.40 3.0 2.7 7.6 52 47 3 41 a 8 12 18 mapi 11.430 21.700 3.2 2.5 7.0 4.2 47 3 40 3 14 24 30 2.628 L415 Lo 2 C.6s 4.4 45 3 so 4 14 47 50 Maudulus 1,102 1.400 1.0 0.6 2.0 .0 3o 5 20 13 42 41 42 Mosamblque 20,768 43.063 3O 2A 6.0 4.5 44 3 30 4 a 27 41 Nioer 10.737 24.286 3.5 2.0 7. 5.2 48 2 41 a 0 20 27 Nigeia 127806 216A000 2.7 1.6 5.0 2.8 47 2 66 4 20 35 43 Rwanda 8.702 16.701 2.7 2.0 6.2 3.8 40 2 42 2 3 6 8 SaoTom*andPldneip 10 230 2.6 1.3 4.4 22 so 5 28 7 .. 42 Sene 90.809 17.018 2o 1.8 5.0 3.2 45 3 66 4 33 40 45 Sevelehs 74 87 1.0 1. 2.3 2.1 34 7 23 8 ...-.. 50 SbnaLeone 5.370 10.070 27 21 6.s 4.1 43 3 30 3 18 32 40 Somaa 10.648 21.004 3.1 2.2 6.6 3.8 46 3 40 3 20 24 28 Sudan 33.680 60.335 2. 1.7 as8 3 45 3 37 4 16 23 27 Swazland 1.137 2.179 3.3 2.0 .0 31 45 3 13 5 10 26 36 Tann 320 S.85O 2.8 1.7 5.8 3.0 47 3 41 3 7 21 28 Too 4.080 0.04 1.0 1.0 5. A0 45 3 38 4 13 29 34 Uganda 22.551 4.223 3.2 2.7 7.3 4.9 46 3 40 2 8 11 14 Zsir 50.856 100.27 3.1 2 0.2 Ls 47 9 41 a 30 28 31 ZambiR 10.067 20.730 2.0 2.1 .7 3.o 48 2 40 2 30 42 45 zlmbabwe 12.1360 17.61 1.8 1.1 3.5 2.2 45 2 St 4 17 29 30 t______888%41 2Ze2_2.__0.U_8S_4 ' '_ 28__84A Worwd 6104841 84319,501 1.4 1.0 .0 2.4 12 9 26 10 37 43 LOeed*A*p*d 4.887.021 6.046.332 1.7 1.1 3.2 LS 16 I 66 8 25 34 40 MeredUppSo 1.272,866 1.373.160 0.4 1.0 Lo. 21 17 in8 i 6 t8 73 Table 3. Population Projections (Rapid Fertility Decline)

AnnuW afs (% of moded women Age Mid-Year of Popub00an am Is=9" btuchne Populaton Growih Toul Fevll Est- P u l for 1% frhousand s R_ae mated ROnd Decne 0-14 G5 + Countrv 2000 i 2025 80t)2 qa2 2000 205 1990 1 2000 2025 2025 2025 Agoa 12.128 17.752 214 1.2 5%4 2.4 9 33 69 29 4 BonEr, 6,240 7.073 2.3 1.2 5.0 2.4 6 40 71 29 4 Botswana 1.655 2.410 1.9 1.2 2.9 2.1 35 65 75 26 5 BuddnsFaso 11.850 17.164 2. 1.2 5.2 2.4 3 98 66 29 3 Buturii _7_ ? 1910.264 212 1_ 5.S 2e4 S 40_ 72_ 29_4 Camoroo 15.380 22.907 2.5 1.3 4.8 2.2 2 29 72 28 4 CapeVerde 417 652 1.6 1.2 28 2.1 26 4 Contrl Aican Reop. 3.801 5.153 1.9 1.1 4.9 2.4 13 88 6S 80 3 Chad 7.228 9.996 2.0 1.1 4.6 2.4 17 48 71 28 5 Comaros 669 1.057 2.9 1.5 5.3 2.2 28 4 Conav 3.086 4.937 2.9 1.4 6.0 2.3 11 S0 74 30 S Cobad'vlro 16,815 27.319 3.0 1.4 5.6 2.2 3 80 74 90 4 DOibu 596 875 2.5 1.2 5.8 2.4 28 4 Equaodal Guina 507 660 1.4 0.9 3.9 2.4 28 5 5hlopla 66.450 104.549 2.8 1.3 6a3 2.4 4 34 73 30 3 Gabon 1.501 2.328 2.7 1.3 5&a 2.3 31 40 76 29 5 Gambia 1.148 1.598 2.2 1.1 5.8 2.5 0 33 65 29 5 Ghwta 19.813 29.610 2.5 1.3 4.9 2.3 13 45 73 28 4 Guie 7.452 10.593 2.2 1.1 5.3 2.6 0 82 64 80 4 Qulina-Skaau 1.196 1.571 1.7 1.0 54 2.7 19 36 68 31 S Kna 32.395 47.744 23 1.3 4.0 2.2 28 67 60 28 4 loo 2Z229 3.174 1.9 1.2 3 2.2 19 48 78 2 6 Ubeds 3.420 6.167 2.5 1.3 5.0 2 7 41 72 27 5 Madagasa 15.206 21.982 2S 1.2 4.9 2Z4 0 37 6G 26 4 Mdlav 11.619 17.521 is5 1.S 6,4 2L6 7 35 74 31 S Man 11.241 17.715 2.6 1.4 6.9 24 5 95 71 29 S Maurlarda 2.566 3.711 2.3 1.3 5,6 2.4 0 85 68 29 4 MaurIlus 1.192 1.450 1.0 0A 2.0 L0 80 61 77 20 13 Mozanblqu 20.44- 29.453 2.3 1.2 5.4 24 0 29 67 28 4 N!ner 10.62; 16.709 2i6 1.3 6.3 2L 0 30 70 31 3 NigerI 127,800 187.427 2.4 1.2 4.7 2.3 7 so 73 29 4 Rwanda 8.621 12.166 2.0 1.1 5.0 2.5 14 s8 78 80 3 GmoTomoand Pdnclpe 146 208 2.0 1.2 !A4 2.1 . 25 a sgal 9.634 18.802 2.8 1.2 4.9 2LS 15 46 79 29 3 ¶eyh 74 Ss 0.9 0.9 2.2 2.1 22 Slwra Leone 5.277 7.26 2.0 1.1 5.8 2.5 4 39 67 29 4 Smali 10,472 15,488 25 1.3 5.4 2.4 0 35 69 28 4 Sudan 33.368 49.362 2. 1.3 5.1 2.3 3 so 6S 26 4 Swaziland 1,127 1.743 2.9 1.4 5.2 2.2 27 a Tanzards 32.839 47.951 2.4 1.3 5.1 2.4 3 84 70 go 3 Togo 4.38 7.444 2.6 1.3 62 2L2 84 57 a 28 4 Ug§ana 22.162 38.549 2.6 1.3 61 25 5 35 73 82 2 Zare 50.426 80.267 2.6 1.3 5.6 2.e 14 34 73 30 S Zambia 10.688 14,991 2.2 1.2 5,4 2. 3 29 72 S1 2 Zhbebwo 12.192 16.410 1.5 1.0 3.0 2.2 46 71 80 28 4

World 6150.000 7.650.00 1.3 0.7 2.7 1.9 54 65 74 22 III LowdevoE 4.880.000 6.560.000 1.6 0.8 3.0 20 51 64 75 23 9 m uwI'm 1270,0001.20.000 0.8 -0.1 1.7 1t. 71 71 06 Is 20 Table 4. Mortality

IAdUftM1vUIyEha Medisi tJgdw-FIvs~~~~~~~5Age a

coun1970ol I 9I2 IsU dcw 19h 1950w Is 1990 11990 1990 NW 180~~~IS 125 81 281 214 24 434 381 Berdn 155 110 go 228 170 25 387 3166 9aWiAs 101 85 65 il1 48 By.7...... Baadk Raso 176 182 26 254 159 37 429 352 4 Bimidi 188 106 28 209 18 14 44 367 11 128 el 52 14 125 86 SB 256 1a CaemVod 7 40 54 188 52 61 .....- Po*.AItMRWp 188 1I5 24 209 132 37 346 2Is1 Chad ~~~~ ~~~~122 ~~~~17129 271 212 22 445 358 7 Comoros ~~~~ ~~~67 ~~~14188 175 188 24 128 114 10 208 175 11 - Cobdlwir ~~~~ ~~~94 ~~~135s0 194 150 23 3a2 2771 DAsim 180 Ill 31 ... 194 .. ... EqualdulGCvAaa 165 116 80 250 208 22 15$ 12 "I 262 197 25 404 3294 10 51 ~ 224 los ... Gamble 185~~~~~~~~~le182 28 295 281 22... Ohuis Ill St 27 169 170 -1 844 282 Guln 181 138 27 291 288 19 452 395 2 Gtin.-ssmj 1I5 147 21 .297 261 1"I ...... Kw" log~~10 as as 139 as 40 81 259 1 LmsoUfo 134 79 41 172 185 22 - LambeI 178 131 26 a44 185 24 Madapusaw ~~~~ ~~~so ~~16149 200 170 1s 389 33 1 Mahut 195~~~~~~~~~~s142 26 313 201 36 426 36 4 204 169 22 Ml1 200 so 41361 4 WwIhnIm 165~~~~~~~~ls117 29 25 205 21 ... .. - L%Uftn8s Is 70 as 25 62 MaianWequ 171 147 14 280 280 0 490 421 2 Nkw ~~~~170 123 28 no0 82 0 518 454 8 Nkp In~~~18 64 40 195 191 4 406 S54 7 FWM ~~~~142 110 28 223 22 0 458 3958 beTou"WidPfn*le ... as ... - as - .. SmipI 138 60~~~~~~~~~~~~~s42 26 158 41 39? 34 1 197 148 27 375 35 4 58 436 2 Sonija 159~~~~~~~~~la182 17 262 214 Is 448 390 4 Sudsn ~~~~ ~~~of ~~~~14934 152 104 82 267 284 13 arIutd 140 108 28 168 148 21 422 354 11 Tn~~~~~~ida~~~~~~132 115 13 202 185i 18 379 885 5 095 ~~~~ ~~~65 ~~~37 ~~134193 143 28 32 2687 Uganda ~~~~ ~~~~118 ~~~109-8 173 185 -7 434 367 4 7*. ~~~~ ~~~~~~91 27 ~~128228 190 15 387 819 a ZambIa 105~~~~~~~~lo107 -1 167 190 -14 - ______GB~~~a 47 51 120 a5 52 269 218 26

vvam~ ~ ~ 97 6835 135 go 29 4 19 L£dswupedomz*l 111 70 87 182 108 30 250 199 39 4f~Mw~m.dcou*Ia24 14 42 25 5 40 186 88I7 Nab: * IPteswepv1r00M Table5. Incomeand Poverty

veaeAnnual AverageAnnual EP Poereu Sbm of PopulmIa Populaton D3loW urwUiRot* of Raft @f Annal catu8-01* 'Doendany Ra Absolut, Povehlv GOP M Ifltlos M *oitt LOWwatM960es %of wermig age Level.1985C countif 70-601 W6-91 70-501 '50-91 1 S1-91 20% 20% 1970 1W9 UhrbanIRUia Angoab - ...... 4 loG lenin 1.2 2-4 10,.3 1.0o 09 .. .. 9at 08a.s . 6 soltwana 14.5 0.8 11.6 13.2 2.580 5.0 1.4 60.4 l16 so 40 8 Bwldinafas, 4.4 4.0 8.6 8.8 290 1.* ... . so so Rwundi 4.2 4.0 10.7 4.8 210 1.8 .. .. 92 95 655 8 Camaroon 7.2 1.4 9.8 4.5 000 -1.0 .. ... 84 93 i5 40 CapeVW"d ..- 1.0 0.4 0.4 75 2.8 ... III1 93 - - Con*alAfrcan Rep. 2.4 1.4 12.1 5.1 S90 -1.4 .. - 79 es ... 1 Cad 0.1 5.0 7.? 1.1 210 3.0 . 8 2 as 80 so ~'omoro .. -1.0 .. SW.0 -1.0 ...... 9 108 .. Congo 5.8 3.8 8.4 0.4 1.120 -0.2 ... 3a.~ a5 CGotadIGvoI 6.6 -. 5 13. 3.8 390 -4.6 78 4,2.2 93 104 30 2

equatalal Guinea . 2.8 .. -. 33Z. . .. 79 87 sbIaI 1.0 -1.6 4.8 2.4 120 -1.0 8.6 41.8 so es s0 a5 Gabon 0.0 0.2 17.8 1.5 8,780 -4.2 -- .... 6 64 Gam"bia -.. -0.1 10.6 18.2 860 -0.1 . #..I so ft---4 ~~-0.1 3.2 352 40.0 400 -0.8 7.0 44.1 93 03 so 37 Guinea...... 460 -.. -. ... 91 97 Guloe-3s,nau 2.4 8.7 5.7 04.2 Ig0 1.1 .- 6so.. 82 Kenya 6~~~~~~~4.2 ~~.410.1 9.2 340 0.3 2.7 60.0 109 100 10 as L*SdhO ~~~~ ~~~~8.65.6 8.7 18. 80 -0. 4.5 61.8 82 84 s0 55 Liberia ...... ~~~~~~~~~~o~.2 .. ~ 43o .... ~ as.3 es -. 28 Madagascar 0.5 1.1 0~~~~~~~~~~.916.8 210 -25as. ... 8 93 so 60 MOalw 8. 3.1 8.8 14.9 230 0.1 ... 0as. 104 25 85 "aD 4.9 2.5 9.7 4.4 280 -0.1 - .. 93 98 27 48 Usuatanl 1.9 1.4 9.9 8.7 510 -1.0 .. .. 84 01 - Mauwkius 6.8 0.7 15. 8.1 2.410 6.1 ... 8so- 54 12 1 Moamublque -.. -0.1 ...- 87.6 80 -1.1 . ... 8 G1 18 86 Nige 1.7 -1.0 0.7 2.8 80 -4.1 ... . 4 101 ... 5 NIg*i 4.0 1.9 15. 18 34 -2.3 ... es0 100 -.. - Rwanda 4.7 0.6 15.1 4.1 270 -2.4 0.7 39.0 so 107 80 00 OS. FGmeand Ptknick .... -3.8 4.0 21.5 400 -8.8 -.. - es8 -- - Senegal 2~~~~~~.88.1 8.5 c.0 720 0.1 - go9 94 - 3.2 16.g 3.51 5,101 3.2 - .. 73 - *srLeoao ~~~~ ~~~1.01.1 12.5 59.3 210 _1.86 .. 88 91 -.. 65, Somalia - ... ~~~~~~~~~~~15.249.7 170 -- .. . 92 so 40 70 Sudan 5.6 ... ~~~~~~~~~~~~14.5-.. 840 ....-- a; -- S~~~~id .... 3.1~~~~~~&12.8 103 1.050 8.W 92 92 TanzanIa 3.0 ~~~~ ~~~~~2.914.1_ 25.7 100 -0*9 2.4 62.7 07 06St . Togo 4.0 1.8 8.9 4.4 410 -1.8 -.. 8as 9 42 Uganda -- -...... 170 -- 8.5 41.9 as 106 ... Zake - -. 31.4 60. 12 - ... -.. so 101 -- 8 Zan"i 1.4 0.8 7.6 -.. 420 -. ~ . -. 94 108 a5 Zlmabow. 1.6 8.1 94 12.5 650 -0.2 ... . 108 s0

WGrld 3L5 8.0 11.2 18. 4.000 Ii2.. .. 75 as LO"sdeudepoe----- 8.8 3.3 21A9 93. 1.000 1.0 .. .. 4 ay .. NW ~~~,= , 8. 2. 9.0 4.3 2.0 . .. .. 7 Wale: ' LateastawiabIedata far Despeolbdperiod. Table6. Education

I ~~~~ ~~~ToWdPwanu. ToWd Feint. TowFeal Tesafte Ratio ______1900 1W 19 1980La190! 1WM 1970 18 1970MMt 1W 19701 1980 1970 1Wi IAngoI& 42 - I

*otewuAvm. 74 -- 5o as 110 67 111 7 46 0 47 66 a1 Bsuuidnapaso Is 0 I3 36 10 go I 7 1 S 44 57 aumini 37 so is 40 60 72 20 64 2 5 If 4 67 67 'o~ ~~Wom - 54 43 as lOt1 75 93 7 10 4 21 4$ Si co"e Verde CaotmlMicamRep,. 33 so it t5 60 67 41 51 4 11 a 6 64 so Chand s0o Ia 8 5 57 17 35 2 7 0 3 65 6 Cnemm. 46 -. 40 -- Cawg 35 67 24 44 -62 6 CotedIWaI 20 64 - 40 11S 45 0 45 36

Squd atodalune 37 50 - 37 --- ialais I 0 85 0 30 4 15 a 12 -46 36 Ganabla 20; 27 12 I'S1 Ghana 80 so0 51 64 7 4 6 4 3 1 3 Gustan 1-4 - 13 33 37 21 24 is 10 5 5 44 40 Glulnea-Ususau 10 351 18 24 s0o5 IS 41 6 7 6 4 45 Kauya 47 60 8 6 5 4 46 a1 0 3 10 64 31 Leola. - 73 - 60 ST 107 101 115 7 25 7 31 48 55 Ubeulso - to - - . - Mdadagasca so0 - 76 60 92 a2 s0 12 16 9 16 65 4 Maloaw 42 - 1 - 71 60- - a5 43 6 lieu 32 ~~ ~~~14 ~~~-22 24 I5 17 5 a 4 40 42 Matailtanla ~~~~34- 11 14 51 5 42 2 i6 a l0 24 45 masnlth. 70 62 72 75 60 106 as 104 60 51 g5 as St 21 Mazanabqua, 331 33 as in 47 so 43 a 7 - 5 so a6 moor 10 26 6 17 14 29 10 1" 1 7 1 4 30 42 NIgeda 34 51 as so f7 72 27 63 4 20 3 17 64 41 Rwnaro so 50 60 37 as as so so 2t 7 1 0 6o 57 6aoT*,eandPds*op 56 - 42 ------. Senega 36 2 5 41 56 62 40 10 I6 6 it 45 as

Sycheloe - 65 95~~~~~~f- -- -4

Sanafla ~~ ~~024 s 14 -- Sudan - 27 la 6o 45 to 7 0 4 47 3 Swszilnd Ss-- Taiwanla 64 53~ ~~~27 ~~~63 ~~3 ~~~4 2 4 47 35 T"og 4331 7 103 44 6 7 21 S 10 so so Uganda 52g 48 40 a5 $3 76 60o 4 Is a 64 3 Zak*e 54 72 67 61I- Zu" ~- 73 - 65 60 a 60 m 1s 80 6 14 47 4 ZW*abm 07 es 60 74 117 56 116 7 60 6 a - so

*V~ - 52 7n~~6 10" 604 0 14 61 is a9 85 - 96 96~~~a 1106 0 106 10 7"0 726 06 16 17 Table 7. The Health and Status of Women

No. of Maternal P_r1_enaa ElOt. Pregnanc Women of MHadly Hamm MenAeWk Wome CI AOi AfficanSale Chid- (peg Care ByTrehabdEmaaad I_ Prog. ParSesto Hum_ baulhg 100.000 Coverag HenEb fM Women Selo Esrolres PAhIs Coeue na Age15-410 Ome Re P _lno Td_m (S B_o 0%maeal_ 100 chadron' ve .na (1,ooost at. (% es ) M9i - tnr) + PdM Iofdu Riab - RiO "t Country 1990 1988 1B8-90' 1S95-90' 1985-9t1' t970-9Os t9 :t YOM year Angola 2.087 20 30 s0 ..... 1001 108 tIn 1,008 00 04 45 es 55 ....- of Doiana 200 250 74 79 02 . 105 110 WnudanPaso 2.0es $co 40 33 26 25 eo S0 1000o 108 Stund 1_252 800 30 If go 70 85 65 1sso Cameroon 2.480 450 so 25 a5 10 85s 65 Capevatd 04 110 so 40 90 -. .-- CWriulAlianRep. 715 60 6o8 50 6s es 35 - had 1.329 1.000 22 21 42 40 45 20 1000 C,anEWs 104 6s00 s 24 so --. -- - Congo 50. 45 60 as 70 10 CobdUcke 2527 1,000 50 es e6 35 70 45 1i01 ODbouti 9S 750 75 s0 10 -o.. 1o Equw lube 64 450 to 4 - . -. _ 1048 Elioopi _ _ _ __ 10.174 5 14 0 6 10 es 65 - 1081 Gabon- 20 209 77 a .. - 1000 1083 Gambia 200 1.500 72 0 77 .__ . -_. 1000 Ghana S.2S7 1.000 e5 42 3a es 80 S0 1t00 1088 Guba 1.318 1.000 so 26 25a 45 30 1000 1082 Guinea-Bsau 2J0 33 72 44 55 so 10S0 1S05 Kenya 4^0&O 2002e o00 -. 37 eo e5 75 1084 Leocha 410 370 So 40 - - 120 IS 1000 - Ubeia 553 S 85 s0 20 _ __ .-. 1 1084 Madaga_car 2.542 400 76 71 17 -. 7 00 191 100 .alawI 1.040 420 76 41 70 S0 S0 55 1001 1S MaD 1*50 2.300 11 14 G6s 55 45 100o 106 MUtabnla 455 1.100 s9 20 40 70 46 Maus 306 100 so 0 77 on 08 100 1090 1084 Uoanrablque 1ses5 s0o 54 to 30 60o 75 0 1000o" Nifflo 1.704 700 33 21 44 s0 55 40 1000- - Nberia 25.710 800S 78 45 s8 45 75 75 1001 1085 Rwanda 1i515 400 as 22 s - as of 1081 SaoTOMeandPrlnclpe 27 76 es 48 -. S a 1645 00 21 40 a3 65 7o 5so 0w0 1085 [s_whelIe 17 -9 00 sso..00 8 _...... low1 Siaone 04 _ 30 25 77 45 70 55 1000 1s0 Somalia Is3 1.1o 2 2 5 75 - - Sudan 5.562 6o 40 -- 10 35 75 60 1o 9waland *172 150 76 67 e3 - - - Tanzl 5."44 340 0o0 6o 40 o0 es 75 1081 Tog- 823 720 8S S0 61 45 es 3s 1S00 1068 Uganda 8.78 6s5 8S 25 31 .- 100 1086 Zaie 8.092 s 0 85 29 45 _ _ 100 1086s ZambI 1S0 150 s0 43 es as 00 00 10 1065

Wd 1.312040 40 e67 a 3a 42 84 70 -- LOWd.swdomm 1.008*56 450 es 42 43 50 e1 71 - .AedwlcMou mm ,,17 0 4 0 10_)

Nut: * labataalbi.dalforUaspecid peid Convanlin ons RtgMbot ts ChiLd L**halrna Convoaon anthe Eaa neo efOlocdamInfion stWeVeAL + Elachvafort eraspa vis bul not specid ye *Mdnto VW PEW dinld. Table8. Food and Nutriton

GaN*Monobi i*asm V ~L Feed supply FoodOpl w UbSa I hhx E j buh

AMM - is~~~~~~~1... 2 .0ao 1.725 3.01m ... 14 .. 10 St 101 110 110 2.145 2.33 51 a6 3akwm 37 6 at 6 106 13 130 104 2.15 2.20 71 so SWliMPamO so 11 1it~. so 79 so 107 1.616 axle 66 46 D.,rni 46 S as 16 102 Go .3 1.4 0 a cwmroon ~43 2 70 13 127 1IN 106 607 230 2206 go a o"p.Verde go a - - so as 54 62 2.637 2.7 @6 of CwAnWIbaRp.p -- 1is. 110 110 es go 2.I36 1*4 43 46 a"d Is3, 1 104 112 so 104 1.76 1*62 00" g7 5 12 11 7 3 07 .3 .3 41 4i coabl, oa 1n0o 17 is1 so 101 100 04 2.844 Io$6 so 64 viboa - ... - 0 ... .. - .. - ... - equel"ubl*ms - - 10 ...... - - -

43 10 ... is 112 114 100 100 1.7 1*- am*bi 24 7 - 10 171 so 62 73 2.101 2.0 50 5 Ohmn so a 61 a 132 100 OS 60 1.073 2.144 44 4 Gains...... - ~~~ ~~~~104 ~~~~110 ~~~~~~11101 102 2.16 2.24 G1I 6 G,Encs-Ulmsau 23 6 - ~~~ ~~~~I11 ~~~~~~1201 a0 10 170 .0

LoafaI St 8 - 10 133 I15 101 of 2.35 2.121 60 s0 Lherk 37 8 14 ... 106 102 100 64 RAW0 2.250 47 41 msdmpu. 56 17 - 10 lie 112 l1l5 01 2.47 2.153 so a3

Mma3.in ~~~ ~~~17 ~~~34-. 10 102 118 104 St 2.061 2.447 TI 74

MauMqam- .. 11 1la 181 106 so 1*61 1.60 Ss 81 m~ ~ ~ 30 1 117 11203 11059 10 110 .i02200 046 Rwwwkk S7 a 1 10O 112 118 so 2t06 1.913 a3 4 bsaTmmsaaPdiap. 5 -7 173 136 113 04 .0 2.11 46 4 8mnsgd 36 ~~ ~~~77 ~~~10 ~~~~~6155 of as 76 2.415 2,322 so 6

658.5 s0 40 11lie.-. 110 lot St I* 1,874 64 of sudan 82 13 84s1 134 1S2 11? 100 2.21 *.04 63 U 91OSIan s0 I 7 6, is 07 to UN46 1*4 64 6

aget 280 6 6 1 132,5 117o 1l05 110, 2.0 5 a" uganda 46 2 76 10 151 too 100 105 2.114 2.173 30 61 Zak. 1 3 64 18 100 100 102 90 2.13 2.110 aS 8 ZLambi 50 10 72 14 1SO 110 100 so 2.136 2W01 a 6

wow~42 la - 17 - - - 250267 6 Low saIhp 46 1s 47 10o - - - 1.24 2.47 so 6

NGOO: tA*Litd.bd ompeu5md kIi Table 9. Access to Water., Sanitation and Health Care Services

Aacor to Gate Water Acmto eanitatio Facuitfio Acorn to Healt Care (percnt) (percent SewIce (percenit) (1985-1090)' 1 (19G6-1090 (198-1990) co! !m Total ILfoi Ia Rurl La! iI &VWa I Rwra Total urban IRural NW ea~~~~1 75 1922 25 2024 .. ambI 50 79 85 41 so 51 32... Dabwimn 56 so 46 88 96 20 as 90o6 SuklnaFao 67 72 44 10 35 6 49 51 48 ftuedl se 92 34 57 so Is 48 cii~~~~ 34 47 w- ... 5 16 41 44 39 Cap Verde 74 67 Ss 1e 36 9 el... OesnIA*k. Rep. 12 14 It 20 86 II as 78 17 Chad 29 30 27 14 ... 2go. CunwOs 70 75 52 as906 82...... mw- ~~~~20 42 7 40 .. .. 88 97 70 cab d%VkOi as 98 75 se as 20 60 92 45 DOjIbu 43 S0 21 76 94 20 47 95 40 squaImIslutna 47 -.. ... 28 --.. Rtmh is~~1 701 17 87 7 55 .. Gobw '12 ~~~~90 so ...... 87 GambIa1 77 92 73 77 .... 8 50o8 Ohas 56 Ss 86 80 63s1 76 .. GuInes 83 Ss 25 24 65 9 32 Gufn.-SIma. 25 27 18 21 SC "I 80 .. rAnya as~~1 6 25 46 75 39 se 90o 5 Lava"i 46 59 44 22 28 14 80 90 30 Libel. 50~~~~~~~~~S98 22 15 24 a 34 50 80 Uadqaaa.r ~~~ ~~~el ~~~3117 .. 12 .. 41 so 30 UmIawi 51~~~~~~~~~S6o 49 86 -~. so..8 90 69 28 48 17 Z8s.. 5 27 60 25 Maudtani. 66 67 65 .... 4 .. 40 mahtw" go 100 98 se 100 96 99 99 9e Mozamblqus ~~~ ~~~44 ~~2217 1s e1 11 27 50 15 NIOW 6~~~9 61 52 9 se 8 so 75 17 N%Wb ~~~32 60 20 13 30 a or 87 62 Reanda 64 66 62 61 62 45 27 S0 26 SeaTomeandPMndIpa .. 33 .. 10 13 6 63 SWauIW 53 79 se 82 87 2 40 imh n-96 100 97 as 96 19 89 se 6 GNMLOM ~~43 83 22 43 89 15 80 61 it saifts 26 so 22 12 41 5 26 50 15 Sudan 84 so 20 12 40 5 51 so 40 o*ndw 30 .. 7 a8 42 25 55 Tazmank 52 75 45 76 77 75 so 94 73i @6@- 70 6go.. 28 42 16 86020 Uggnds 15 45 12 13 40 10 41 44 89 Zak. 34 59 17 14 1s 13 ziqmbiaf 59 76 43 55 77 34 75 -. .hdmbab se 99 14 42 se 22 68 so 8

Wafd SI~~8 98 72 as as 54 St Lodw .aamm75 se as se 72 48 se

NMa: * LdgvbhbkwspadUded -. Table 10. Immunization

Immunization (per 100 children under one year old) 1 96a0 I1 99 1 County BC DPT3 POL31 Meastes CG I DPT3 I POLS Measles Angola 47 9 7 17 54 27 26 4 Behib 37 20 45 6 61 68 88 60 Stawana 76 70 71 68 92 86 82 78 BurkinaFaso to 2 ^ 23 60 38 38 36 Bunmd 65 Se 6 S0 a8 83 89 75 Camiieroon 8 5 5 16 48 34 34 35 CapeVerde 64 31 39 54 99 87 86 76 ContlrAimcanRep. 22 13 13 14 79 46 45 46 Chad ...... 59 20 20 32 Conmors 53123099 94 94 87 Congo 92 42 42 49 66 74 74 64 COed'ivoke ... 42 34 28 47 37 37 47 DPbotz 5 6 6 15 95 85 65 65 EquatoialGunea 28 3 4 11 97 8o 80 79 E~thiopia 6 3 8 5 57 44437 Gabon 50 14 44 598 6 78 78 76 GambIa 92 80 53 71 97 85 89 87 Ghana 9 7 7 15 55 39 39 39 Gunea 5 2 1 9 47 35 35 33 GuLnea-Bnsa 38 15 11 a5 94 63 63 82 Kenya- so....5 41 45 38 Lsatho 81 s6 54 49 76 75 74 78 Ubeda 41 17 26 40 62 28 28 55 hedagearsu 23 34 8 15 67 50 49 40 Malawi 86 58 28 49 96 81 78 78 Mail 19 18 0 10 68 34 34 39 awlutania 57 18 18 45 60 26 26 29 Mhurfflus 88 87 87 34 87 91 91 s6 IrambIlque 46 56 32 32 6S 42 42 50 Nkwe 28 6 6 119 26 17 17 23 NMae"i 23 24 24 55 57 44 44 46 Rwarda 51 17 15 42 94 85 85 61 SaoTomrnandPfndp* 95 42 48 25 9S 78 77 66 Senegal 22 34 34 22 69 51 51 46 8evchellea 67 13 16 26 98 82 82 89 Siena Leone 34 13 10 29 71 56 57 54 Somnlia 5 5 5 5 31 16 18 S0 Sudan 3 1 1 1 73 62 62 57 sweisid 59 30 22 30 71 a6 87 60 Tanmnla 69 55 Su 49 69 79 74 75 Togo 44 9 9 47 79 61 61 51 Uganta 18 9 a 22 99 76 76 73 Zalre 34 18 18 24 65 32 31 31 Zambia 71 44 S0 21 96 a5 70 69 Zlmbabw _ 64 a 38 86 8T 83 81 63

Wodld .- 20 ...... 88 62 64 60 LasedewkW.d*ceordnd - ..... 89 82 84 79 hkbwdewloekhd¢coI.s . . . .82 8385 62 Table I11. Health Care Personnel

AssiamW to

Dcotmr+ medic Nwses+ nkiuln worse riclans Deetr N4W" Raft Countr '5 90 5-88 1985-90* '50 1980-88* '5-88 1.970 '55 19.70 '5-8W,0i198-90 xiiw ..... I= ...... &8.50 15.Q 4, 6,W sernk 28 1.70 50 1.000 300" 29000 13,00 4,000 2.00 6 sotscne 240 10 2.000 0 900 1,700 15.W 4.O00 50SW.. 10 SwSIs Fe. 130 160 1.800 30 1.600 280 96,000 50,00 15,000 4,000 14 swmdI 280 130 1.20 so 450 90 59,000000I 0 14,00 4,000 4 cgwoai - 940 2.00 6,0 300 5.000 30 30.000 11.000 4,000 2.0006 Ca. erden 100 So0 250 20 150 30 12,000 4.000 4,00 1,500 3 CeitaAfflcaRep. 110 150 500 70 500 100 44,000 25,00 2.50 5.000 5 Chad 135 80 1SO 200 1,000 30 62,000 35.OW ... 30.OW0 I Coamom. 70 2 800 50 650 15,000i? 6.000 9,00 1.500 4 Congo 500 30 2000 250 3.800 800 10.000 4.000 1I50 1.000 4 Cot.dIo~$ 700 .. 3.30 18,0D 15.00 3,000 3.000 5 OjIbuf 80 8..00 100 250 4,000 5.000 1,000 1.500 4

Ehovb IA1.50 220 3.50 850 700 .. 92,000 _2900 21T 12,000 2

GaMbia 60 ... 700 200 700 ... 25.000 13.000 2.00 1.50 12 Ghwia 800 380 5.100 1.200 10.000 ... 13.000 15,000 1.000 2.000 7 GuIne 130 .... 550 180 1.30 400 51,000 40,000 10,000 4 Gufnc-Ussau 120 20 300 150 1,80 800 1800 6.0 .00 2,000 3

Leech. 110 ... 50 50 50SW .. 30.000 1i.0 3.000 3.30 5 Ubeda 220 150 1.20 ...... 1.00 10.00 2.O0O 2.000 5 Madagascar 1.40~~lA01.700 5.000 450 6000 550 10.00 8,00 9.000 2.000 4 MukwlR 260 350 850 250 1.8600 650 7700 7.0 5,00 14,00 2 Md ~~~~44090o 1.1I 500 3,700 300 45000 18.000 6-500 7,000 3 Mauifmnlh 200 400 900 80 1*00 750 18.000 9.00 6.00 2,000 5 MMu"t~ GM0 .. 3,30 530 500 80 4500 1,200 520 320 4 Monembiqus ~~~~~280100 3.700 280 350 850 19,000 80,00 500 4,00 13 mmae 220 40 2.50 280 9,500 200 60.000 35.000 11.00 3.000 11 NIgdri 18,000 -.. 97,00 4.200 16.000 1.200 21.00 6.000 2.00 1.000 a Rennda 160 350 300 680 1.500 420 60.00 35.000 10.000 20.000 2 SeaTomeandPtin*aslp30e 3 ~ 20 .O 0 Senega 410 250 1.100 400 7.O00 ... 1.00 16.O00 1.500 7.000 3 ~~ 30 .....~~~~~s 350 ...... 0 2.0 170 200 12 %,%MLme ~ 260 135 1.30 IGO 250 - 18,000 13,0 3.50 3.0 Somalia 480 70 S,50 130 SW ... 36.000 15.000 2,00 2.00 Sudan 2.100 2.70 5,60 1,300 IS0= .. 14.00 10,00 4,500 4.500 3 GNozbrtd 6 .... .80 ... 100 - SA00 9.000 8a0 600 16 E'nuADl 7 950 5.0 200 1.400 .. 23.000) %900M0 4,000 7 TgOP2 150 1.700 730 1,30 200 29.00 10.00 RAW0 2.0* 7 Uogad 600 600 6,80 1,000 .. 550 9,00000 00= 13.000 2.50 11 Mae 2.50 150 5.10 1.100 1300 200 2.00 14,00 4.600 7,000 2 Zambi 860 1300 4.300 450 4,000 550 14,00 7,000 4,300 2.000 5 ZmbeAbw IA 3M0 0 900 10.000 250 6,S0OW 0 780 lo00 6

T 6.200000..... 9*00.000 .~~tq ARmoo 570

LowdeekWedaa 2.0000 .. , 2,30.00- 1.500 1,700 0.6 £fa'.dmefceedooru*kL3.400,000 6i0§00 - ...... 0.1...2. Now.: AMtcafweoicdelfnedocSu-Saw&only Nows: + Docta'swsomedicaddocf.rso*Nly. orsso agitrdms smldatvescrdya.n eter ered * LatetWoIebdais ifcrliespedled pwkxod Table 12. Health Care Facilities

Numbe of H _can. PeaDhsa p.putatJ. It a H~~~~~~ealthConiesad Others* Nuamberof soda Per Bed

cog= aeog gunal TowD .t. Ohr *0 -Tt.1 lbial o Tcbta AAgohA 8a -.. ... U 1.131 1.418768

lGtotaaa 36 7 48 IT 26 38 ..... 50 Burkin Pa.. 3 a 7 St~ 6.008 6,064 2.700 G."0 3.000 1,400 Blurundi 34 1i a6 218 114 312 3.100 5.:00 1.600 go0 icamearow. .. . s 106IM 1643,0lw-.....66 400 capevwYad 25 4 37 41 -.. Centra Afrkan Rep. Is go 41 as 17 183 1.600 4.000 11.800 70 mmd 23 311 36 363 386 4.000 1.863 camao. ..- -.. 7 73 71 .. Congo 48 ... .. 0 16 007 6.700 7.'0 35 300 Cab divoire 30 71no.., 6 No 7.000 6.700 1.600 1.100

Elqu.taiialtunea Is 3 2 ...... FIboiona as 41 126 140 1.63 1G 3.500 Gabon 37 .. ... as 433 48o.0 .10 5 200 Gambia 3 4 a 119 07 66$.. Ghana a 124 133 180 --.. --.. .- 700 Guinea U9 ... .. 63 361 GIs 1.200 . 4.600 1.700 Gulnca-Dlaum 7 10 117 136 181 307... KenYa - . -.. 38 183 1.817 311,0 33.000 700 65 MOSCOWh 30 -. .. In~...3 3.310 ... 0 Llbark 1s 1s 10 30 27 10 .. Madagascar ~~ ~~~73 ~~776 so So1 660 .... ,... 110 malawi 51 ~-. . 44 6101 654 750 1260oo 0 MaD 10~~~~~~~~~l4 14 333 3.144 2.477 3.60 5.000 3.000 1.500 Mammals 15~~~~~~~l13 28 148 67 30 1,36 -.. 1.400- Maurlthas ~~~ ~~4 ~~1721 24 126 183 I.7M 3.96 400 350 Masamblque 10 as 6 gas 946 1.171 61,30 13,000 2.000 1.000 Nkwe 6 I 10 43 567 94 .... 8.M0 .... * Nigeria ... ,, .. .~~~~~~~~~~~~~~ 705 OM64 7.30 61,000 01.000 1,700 1,300 Rwmda1 U 5 170 74 344 10.300 -.. 5 See Tom. and Prlncip. ... 3to. 16 44 .. Senegl.. 0 . 47 1,117 1.164 s,410 .600 3.00 1.250

Sierra Lean. 51 37 63~~~~~~~~I57 163 220 36200 3.600 1.100 O50

Swazilad . . a 113 III... Tanzcania 30 104 130 600 10 453 11 753 000.... log, 3~~~ - ~ ~~~-. ~ ~~3317 403 716 4.300 6GM.. Uganda ~~~ ~~~~.. ~~75.. 404 ...... 1,5 Zaire - 163~~~~~~~~~la... 1,066 8S6W.7 0.0 .. 0

llmbabwa 3~~~~~~ 135 ~~016let ... @6 .0 1,90 So0

Lee d.reop.d--- - .. .- ..- ----..

Ne:* TotlIncudes heaU emigandw alieb (maiwaDe,dlspeowloa,obblee.hepaosh. OdaaMOafor mos tecen yeams *'Tota beds Include bedsIn h@aphtals,beaD OeNtes mooaftarns,dispensaieS Table 13. Health Expenditures

Ald Rlow aso%of Hoeft Exalnditum It( 0 ToWl PW Hha1 EOW. tur. o a Heo. IMlillonsU0use Coo Pe_mma. ot GDP (1691 Erxnd#U CoonPuble IdR IPvA bt _ILel Puhc I AidRosI PfWa I To IAfl190 SenIn 20* 90 A 80.4 80* 17 11 1. 17 1 4A 8 abwid 110.0 =A0 4. 104.0 155 1.0 is 6.2 17 bSlaFao. 21.3 186.0 43A * 5 G .1 1.7 8A 71 B'auni 18.s 8.4 6* 8.0 51 1A4 0* 0.0 Is Ceont 75f 86. 10 808.8 20 0.7 0* 1 Of 11 Cap VWdb* 3* 81t 18o 48 1. 8A4 1s OJ 82 C*RAeanftp. 14J 19.7 MA 5.6 16 1.1 1. 1a 4.2 5 Chad 20S 18. ISA 75 13 17 8a 1. 62 47 Comm 6 1 1J1 54 24 CoGo . 1. A4 110.6 400- 1 3 S0 12 C0bofivoke 101* 11 161.0 384.1 15 t* 01 1J 8 8 D u - -. - 10.1 45 - - - EqudorlaGuia 42 4. 22 113 a? 2 3.8 1.4 7 4 !Ihum..1 6$. 431 07.8 225 I 1.6 0.7 1.6 8* Is Gdbon 100 1. 78.1 196J 172 Z2 0Q 15 8. 7 Gambe 72 tao 4.0 9I 2o 2x1 8A I 7.4 M2 Ghan 71 u5s 1a" 204.0 14 1* 1s 8. 13 GuInea 4. 21.5 40.5 108 1i 1. 0. 1i 38 2) t_na-slsau 5. to Z7 15* 10 2 4.1 1.4 80 81 Ke 101 8.1 14.1 875.2 1 1., 1.0 1. 4. 25 LAoU 18J5 17.0 1Z8 454 27 8 20 2 83 8 Lbi.k 1. 62 1 10. 4 1t 8.6 18 0.0 62 Madeamw 22L 169 86.0 78.7 7 0. O* 13 20 at Mali 32.5 2.5 I1 11 .t1 5. 21 825 8.0 0* 10815 1* 1. 5 a.s MUalnis 11A 12.0 10.7 40.1 20 1.1 1.1 16 3A 8 muufj ------Mlml_e 17.7 45.1 24.0 S. 0 12 .1 1.7 6. 82 48.9 43.0 u 114. .7 1.7 1. 4. 84 830.0 86* 7a.7 O 5OB 10 1.0 0.o 1.7 2.0 Rwar4k 11. 0 20*2 8u 74 11 0. IA 1t Y 7 87 SwaoTaniandfrko IA as 00 4.8 41 2a7 6 1.7 9.4 5 Seng Y2 * 8. 20.1 8o 1.7 0. 1.5 8A 1

]_4 tOB A t1.0 5 0. tO41 4

Sudan 82.6 18* 5"* 2IIA 12 0* 02 2* sa 5 sw8mnd 24.7 IOA t11 55* 70 25 1is 7.1 35 Tomimnl 15. se.0 41.6Ga 1168507 26 1 5.0 51 T e Mt1 J14° 2A7 010 19 1.7 Oa 1.6 4.1 Ug9tr It au. 50* GU 6 0.8 1.2 1. 8.4 84 Zoo 1U 47* 15"0 gm. 6 O 2.1 2.0 2 znb 76.5 4. a8 117.1 14 2.1 0.1 1a *2 4 mba!!!C . _ _ _ 16S7 .7 45* _ . 201. 416* 4 2 0.,7 8a M. 11

waft 1.1821 .12 606 10,2.41 82 4* 0.0 Le23. 0x Lowde Vap. 76B766 8*2 90.467 170,115 41 L1 0.1 2. 4.7 Is e51.10B 0 5.2 152.840 1.80 0.0 8I.8 8. 0.4 Technical Notes

In all tables, Africa is definedas Sub-SaharanAfrica. It excludesEritrea and Namibia(due to lack of data) and La Reunionand South Africa (due to differencesfrom other Sub Sahara countnes). Africa-widevalues are population-weighted,unless the context indicatesotherwise.

"More Developed"countries comprise Europe, the countriesof the former USSR, North America (USA and Canada), Australia, New Zealandand Japan. "Less Developed"countries comprise the rest of the world.

Unavailable data are denotedby "......

The principalsources of the data are: World Bank and United Nations DevelopmentProgramme, 1992, African DevelopmentIndicators (AD192); the World Bank's Population,Health and NutritionDepartment (PHN); World DevelopmentReport 1993 (WDR93);the World Health Organization- Geneva Headquartcrs(WHO) and Afian Rogional Office (WHO/AFRO);the United Nations (UN); and the United Nations Children's Fund (UNICEF).

Table 1. Healft and DevelopmentIndlicators

Population numbersfor mid-1992are WorldBank estimates. These are normallyprojections from the most recent populationcensuses or surveys,which, in somecases, are very dated. Refugeesnot permanentlysettled in the country of asylum are generallyconsidered to be part of the populationof their country of origin.

Populatio growth rates are calculatedfrom the midyearpopulation by the exponenialmethod. The rates are expressedin percent.

The cride birth rate and crude death rte indicaterespectively the number of live births and deaths occurrig per thousand populationin a given year. They are World Bank estimates, based on various sources includingthe United Nations.

The total fertlity rate representsthe numberof childrenthat would be born per woman, if she were to live to the end of her childbearingyears and bear childrenat each age in accordancewith currendy prevailingage- specificfertility rates. Data are from the UN (PopulationDivision and StatisticalOffice) and the World Bank(PHN Depatment) based an demographicand health surveys and informationfrom country statisticaloffices.

Life expectanc at birth is the numberof years a newborninfant wouldlive if subjectedthroughout life to the curent age-specificmortality rates. Data are presentedfor males and females separately. The sources of data are the UN and the World Bank.

GNP per capita figuresin U.S. dollars are calculatedaccording to the World BankAtlas method. Gross natonal product (GNP) measuresthe total domestic and foreign value added claimed by residents. It comprises gross domestic product (GDP, the total dollar value of all goods and services produced in the country), with adjustmentsfor the value of goodsand servicesproduced by nationalsabroad and by foreignersresiding within the county. The Atas conversionfactor for any year is the averageof the exchangerate for that year and the exchange raes for the two precedingyears, after adjustingthem for differes in relative inflationbetween the country and the U.S. The resulting GNP in US dollars is dividedby the midyearpopulation for the latest of the three years to derive GNP per capita. Data are from WDR93.

The adult litercy rate is the proportionof the populaton 15 years old and over who can read and write a short, simple statementon their everydaylife. The data are from WDR93. 187 Tables 2 and 3. PopulationProjections (standad and rapid fertilitydedle)

Popuation estimatesand projections are thosemade by the WorldBank, with midyear 1990 as the base, fromdata providedby the UN,countty statscal offices,and other reliable sources. The projectionsfor 2000and 2025are madefor eachcountry separately by thecompont method,based on previoustrends of fertility,mortality and migration. Notethat the data reflectthe potentiallysgnificant impact of the humanimmunodeficiency vhus (HIV)epidemic. A full descriptionof the methodsand assumptions used to calculatethe estimatesis containedin the WorldBank's World Population Projections, 1992-93 Edition.

Annual rateof populationgrowth. Seenoe to Table1. Thepopulation projections for rapidferlity declineassume that each countrywill increasethe use of contraceptivesat the maximumpossible rate.

Totl fertility rate. Seenote to Table1.

Popuaon age structurefor under15 and65 andover is expressedas thepercentage of totalpopulation. Dataare fromthe WorldBank data files, 1993;and the UN(World Population Prospects, the 1992Revision, UN 1993).

Thedata on urbanpopulation as a percentageof total populationare fromthe UN'sWorld Population Prospects,the 1992Revision, supplemented by data fromthe WorldBank. Becausethese estimates are basedon dierent nationaldefinitions of whatis urban,cross-country comparisons should be interpretedwith caution.

Contaceptive use is the proportionof marriedwomen of childbearngage (15-49)in familiesusing contaception. Thedata are fromAfrican Population Advisory Committee (APAC) 1993a.

Table 4. Mortalt TheInfant mortality rate is the numberof infantswho die beforereaching one year of age, per thousand live birthsin a givenyear. Thedata are fromthe UN as wellas fromthe WorldBank. Theunder-five mortalt r-Aeis theprobability of dyingbetween birth and age S, expressedper thousand live births. The rates wereobtained from a specialbackground paper preparedfor WDR93and UNICEF. The methodologyis describedin the Hil and Yazbeckbackground paper cited in WDR93.The underlying information comesfrom the UN (ChildMortality aince the 1960s,1992), augmented by recendyavailable census and survey dat. The adult morta rate age 15-59is the probabilityof an adult age 15 dyingbefore reaching age 60. The figurehere is per thousand.The rates weredenrved from the child mortalityestimates for the sameyear, combinedwith assumptionsabout the relationsp betweenchild and adult mortalitybased on country-specific projectionsby the WorldBank. Medianage at death is the age belowwhich half of all deathsoccur in a year. Theindicator is affected by severalfactors, including the age structureof the populationand the age patternof mortalityrisks in the population.It does not representthe averageage at whichany group of individualswill die, and it is not directly relatedto life expectacy. SinoeAfrican counties are characteridd by varyyoung populations (with nearly 50% of populationunder 15 yearsold, due to high total fertilityrates) and high infantand child mortalityrates, the medianage at deathis very low (only5) comparedto that of developing(39) and moredeveloped countries (74). The data are from WDR93. Table S. Incomeand Pove

Averageannual growthrate of GDP.GDP meses the totalouWut of goodsand services for finaluse producedby residentsand nonresidents, regardless of the allocationto domesticand foreign claims. Thedata are 188 obtaied fromnational sources, sometimes reaching the WorldBank through other international organizations but more oftencollected during World Baink staff missions. The data are fromWDR93.

Averageannual rate of bnflatiois measuredb:' the growthrate of the GDPimplicit deflator for each of the periodsshown. The GDPdeflator is firstcalculated by dividing,for eachyear of the period,the valueof GDPat currentvalues by the valueof GDPat constantvalues, both in nationalcurrency. The least-squares method is then used to calculatethe growthrate of the GDP deflatorfor the period. Thismeasure of inflation,like any other,has limitations. It is used,however, as an indicatorof inflationbecause it is the mostbroadly based measure, showinganmual price movemets for all goodsand services produced in an economy.The data are fromWDR93. GNP per capita.See noteto Table1. Thedata are fromWDR93.

Percentshare of Incomeis the shareof the lowestand highest population quintiles in total incomeor consumptionexpenditure. The data refer to differeatyears between 1981 and 1991,andare drawnfrom nationally representativehousehold surveys. The data havebeen compiledfrom two main sources:government statistical agenciesand the WorldBank (mostly from the LivingStandards Measurement Surveys). For furtherdetails, see Chen,Datt, and Ravallion,1993. Pbopuationdependency ratio is calculatedas the numberof personsunder age 15 andat age 65 andover (dependentages) for every 100persons aged 15-64(economically productive ages). It givesa roughindication of howmany persons are economicallysupported by each 100persons who are economicallyactive. The sourcesof data are the sameas for totalpopuation (Table 1).

Absolutepoverty levd is definedas thecountry-specific income level below which adequate standards of nutition, shelter,and personal amenities cannot be assured. The data are fromAD192.

Table6. Educaion Dataare fromthe WorldBank data files (WDR93& AD192). Adult liteWr rate. Seenote to Table1.

Pimary schoolenrollmet dataesdmat, the nmmberof childrenof all agesenrolled il primaryschool. Figuresare expessed as the ratio of pupilsto the populationof school-agechildren. Although many countries considerprimary school age to be 6 to 11 years, othersdo not. For some countrieswith universalprimary education,the grossenrollment ratios can exceed100 percent because some pupils are youngeror olderthan the country'sstandard primary school age. The data on secondal schoolenrollment are calculatedin the samemaner, but againthe definitionof secondaryschool age differsamong countries. It is mostcommonly considered to be 12 to 17 years. Lateentry of moremature students as well as repetitioncan influencethese ratios. The pr_may pupil-teacherratio is the numberof pupilsenrolled in schoolin a country,divided by the numberof teachersin the educationsystem.

Table 7. TheHealth and Stats of Women Womenof cb3idbeaing age are thosein the 15-49age-group.

The matea morlit rate refersto the numberof femaledeaths that occurduring childbirth, per 100,000live birdhs.Because deaths duing childbirthare definedmore widely in somecountries than in others,and manydeaths are nevr recorded,the figuresshould be treatedwith extremecaution. The data are drawn from diversesources: WHO/AFRO country reports; Materal andChild Health, WHO/AFRO, 1990; UN Demographic Yearbooks;UNICEF; and mostlyfrom Maternal Mortality, A GlobalFactbook, WHO 1991. 189 Prenatal Heal Care CoverageRate is the percentageof pregnantwomn whoattended prenatal care cinics in a givenyear. The data suggestthe servicewas utilizedbut do not implythat coveragewas adequateor effective. The data are fromthe Healthfor AUdata base, WHO6/92; GlobalHealth Situation and Projections, WHO1992; WHO/AFRO computer print-out, 1990; and WHO/AFRO country reports. Births attendedby trainedhealth pesonnel. Trainedpersonel includephysicians, nurses, midwives, trainedprimary health care and otherhealth workers, and trainedtraditional birth atendants. National coverage levels are drawn from official estimatesand samplesurveys. Where no direc fgures were available, the percent of birthsin healthcare institutionshas beensubstltuted as a conservativeestimate. The data are fromthe Health for AUdata base,WHO 6/92; GlobalHealth Situation and Projections, WHO 1992; WHO/AFRO computer print- out, 1990;and WHO/AFROcountry reports. Pregnant womenimmunized for tetanus is the percentageof womengiving birth in a givenyear who receivedtetanus toxoid injections during pregnancy. The data are ftomthe Healthfor All database, WHO6/92; GlobalHealth Situation and Projections,WHO 1992; WHO/AFRO computer print-out, 1990; and WHO/AFRO country reports.

Prvalence of anemiaIn pregnantwomen (% bdow the uoxmfor hemoglobin).Women are classified as anemicwhen the bloodhemoglobin level is belowthe WHOnorm of 110grams per liter. The data are from WDR93. Schooleorollmen (females per 100 males)shows the extentto whichfemaes have equal accessto schooling.The data are fromWDR93. AfricanStates Pardes to HumanRigts Conventions.The Conventionon the Rightsof the Childand the InternationaConvention on the Eliminaionof Discriminationagainst Women contain provisions relevant to the staus of women. The data indicatethe yearswhen the counttyratified the Convention(s).The data are as of February,1992, from the UnitedNations Center for HumanRights, Geneva.

Table 8. Food and Nutrition NutritionStau: wading(low weight for height)and dunting (lowheight for age)refer to the percent of childrenwith less than77 percent(2 stamdarddeviations) of the medianweight-for-height or height-for-ageof the U.S. NationalCenter for HealthStaistics (NCHS) reference populaton. Mild/modeatemalnutrition is between 60 and 80 percentof the norm. Severemalnutrition is less than60 percentof the norm. Chronicmalnutrition is measuredby stunting,and acuteor short-ermmalnutrition is measuredby wasing, whetherthe causeis inadequate foodintake or infectiousdisease or both. Mildor moderatemalnuition is not considereddisease, but all degrees of mautrition increasethe risk of deathin children. The dataare fromWDR93. Peentage of childrenfuly breatfed is definedas thosegiven breast milk with or withoutwater, juice, or otherliquids but no foodor nonbreastmilk before age 4 months. T'e data are fromWDR93. Babieswith low birthweight is the proportionof childrenbom weighing2,500 grams(5.5 pounds)or less. The data are fromWDR93.

Ihe Indexof ft .I productionper capita relatesfood production from 1975 to 1991to thatof 1987. The value of the latter withineach countryis taken as 100. The data are from the WorldBank data files, 1993 (STARS93). Food Supply:Calories per capita per day werecalculated by dividingthe calorieequivalent of the food suppliesin a couty by the population.Supplies include domestic production, imports less exorts, and changes in stocks. The data are fromthe Foodand AgricultureOrganization Yearbook (Production), 1991. 190

Food Supply: Protelu per capita per day (gams) indicatesone of the nutrientelements of food supply. Data are from the FAO Yearbook,1991.

It is imporeantto note that the quantities of food available relate to the quantities of food reaching householdsbut not necessarityto the amountsof food actuallyconsumed. The quantityconsumed may be lower than the quandty shown, due to losses of edible food and nutrients in the householdand to issues in the intra- householddistribution of availablefood. The data representonly the averagesupply for the populationas a whole.

Table 9. Accessto Water, Sanitationand Health Care Facilites

The data are from the HealthFor Alldata base, WHO6/92; Global HealthSituation and Projections,WHO 1992; WHO/AFROcomputer print-out, 1990;and UNICEFdata file 1993.

Accessto safe water is the proportionof the populationwith reasonableaccess to safe water sources. Safe water commonlyincludes treated surfacewaters or untreatedbut uncontamiiatedwater suchas that from protected boreholes, springs, and sanitary wells. Reasonableaccess in urban areas is defined as a public fountainor stand post locatednot more than 200 meters from a dwelling. In rural areas, reasonableaccess implies that membersof the householddo not have to spend a disproportionatepart of the day in fetchingthe household's water need,.

Accessto sattion faciUtiesis the proportionof the populationwith adequatesanitary facilities in the home or immediatevicinity. The WHOindicators and definitons changedin the late 1980s,and caution is needed in intupretingthe data,

Accessto health care servicesis now defined in the WHO Healthfor All data base as the proportionof the populationhaving treatmentfor commondiseases and injuriesand a regularsupply of the essentialdrugs on the nationallist availablewithin one hour's walk or travel. Caution is neededin interpretingthe data.

Table 10. lImmunization

Data are from the Health For All data base, WHO 6192;Global HealthSituation and Projections,WHO 1992; 'WIHO/AFROcomputer print-out, 1990;UNICEF data file 1993;and AD192.

Immunizatiloncoverage is the percentageof childrenin a given year who were fully immunizedagainst each disease or group of diseasesby age 1. The requirementsfor full immunizationdepend on the type of disease. The vaccinationschedule recommended by WHO, which is used in this table to measure full immunization,is as follows:

Tuberculosis: I injectionof BCG (BacteriumCalmette-Guerin), which can be given at the time of birth.

Diphtheria, Pertussis, Tetanus: 3 injectionswith DPT vaccinebefore age 1; the first is recommended 6 weeks after birth followedby 2 more at 1-monthintervals.

Polio: at least 3 doses of oral polio vaccinebefore age I, given 1 month apart. In areas where polio is endemic,the first dose is recommendedat the time of birth, followedby 3 more doses at the same time as the DPT injections.

Measles: 1 injectionof measlesvaccine, given after 9 monthsof age.

Table 11. Health Care Personnel

The data is this table are from WHO (StatisticsAnnual, 1988; HumanResources data base 1992;Global HealthSitation and Projein, 1992);WHO/AFRO (ConVuter print-out 1990)and WHO/AFROcountiy reports); and, World Bankdata files 1993 (PHIN,WDR93). As explainedin the WHOstatitics annual,military pernne 191

who do not provide assistance to the civil health services are not included in the data, but expatriate staff are included. Because definitionsof various categories of health care personnel vary among countries and the definitionsgiven below lack precision,cross-country comparsons of the data must be madewith extremecaution.

Doctors are graduatesof a medical schoo!or faculty aetually working in any medical field (practice, teaching, administration,research, laboratorv,etc.). The practitionersof traditionalmedicine are not included in this category.

Paramedics are staff whosemedical trainirg is less than that of qualifiedphysicians but who nevertheless dispense similar medical services, includingsimple operations.

Nurses (professional,high level) are graduatesof a nursing schoolworking in any nursing field (general nursing,specialized clinical nursing services in mentalhealth, paediatrics, cardiovascular diseases, etc., publichealth or occupationalhealth, teaching,administration, research, etc.). These personnelare qualifiedand authorizedto provide the most responsibleand competentprofessional nursing service. Also included in this category are midwives (professional, high level), who are graduatesof a midwiferyschool actually working in any field of midwifery (practicein institutionsand communityhealth services,teaching, administration, private practice, etc.).

Techniciansare graduatesof healthtechnical school. Theyperform duties in laboratory,X-ray department, dental department,phamacy, environmentalhealth, etc.

Assistant nurses (middle level) are personnelproviding general patient care of a less complex nature in hospitalsand other health services,in principleunder the supervisionof a professionalnurse. These personneldo not have the full education and training of a professionalnurse. Also included in this category are assistant midwives (middle level), who are personnelcarrying out the midwiferyduties of normalobstetric care, in pnnciple under the supervisionof a professionalmndwife. Assistantmidwives do not have the full educationand training of professionalmidwives.

Assitant technicians (middle level)are health servicespersonnel carying out dutiesother than those of assistant nurses or assistant midwives. In principle, they work under the supervision of a technician. These personneldo not have the full educationand training of a professionaltechnician.

Population per doctor or per nurse representsthe number of people served by 1 doctor or by 1 nurse. The data show only the averageavailable for the populationas a whole and must be interpretedwith cautionbecause of the concentrat'4nof highly qualifiedhealth staff in urban areas.

Tables 12. Health Care Facilities

The data are from WHO/AFRO(Computer print-out, 1990); WHO/AFRO country reports; and from World Bankdata files (WDR93). Note that, in some respects,the definitionsare not fuly consistentwith the usagein the text. Furthermore,terminology and definitionsvary substantiallyfrom countryto country, and thus inter-country comparisms must be made with caution.

Hospitals are establishments permanently staffed by at least one physician that offer in-patient accommodaionand provide medicaland nursing care. Establishmentsproviding principally custodial care are not included.

Central/regional hospitalsare hospitals--otherthan local or rural hospitals-providingmedical and nursing care for several medicaldisciplines.

Districtrural hospitalsare, in principle, first referral facilities,usually in rural areas, permanentlystaffed by one or more physicians,which provide medicaland nursing care of a more limitedrange than that providedby central or regionalhospitals. 192 Healthcenters are, in pinciple, the firstpoint of contct of the populationwith the forma healthcare sytm. Theyare notpemanently staffed by physiciansbut by medicalassistants, nurses, midwives, etc. Usually, they are smadunits (sometimes also known as nrualhealth centers), which offer limited in-patient accommodation and providea limitedrange of medicaland nursing care. Others includematernities, dispensaries, and health posts. Theyfunish a verylimited ange of medical and nursingcare notprovided by professionalstaff.

Beds. A hospiblbed is situatedin a wardor a partof the hospitalwhere continuous medical care for n- patientsis provided.The total of suchbeds constitutes the normallyavailable bed complement of thehospital. Cribs andbassinets maintained for use by healthynewborn infants who do not requirespecial care are not included. b_puationper bed representsthe numberof peopleserved by I hospitabed or otherhealth care facility bedin the country. It isonly an averageand must be intepretedwith caution becase of the concentrationof health care facilitieswith beds in urbanareas. Table 13. Health Expendtu Heslth mditumsinclude outlays for preventionof disease,health promotion, rehabilitation, and individualand public healthcare services;population programs; nutrition activities; program food aid; and emergencyaid specificallyfor health. In thistable, heath expenditu do not includewater and saniation. Per capia expendituresare basedon World Bank midyearpopulation estimates. Totalhealft eqnd e is expressedin officialexchange rate USdollars. Dataon publicand privatehealth expenditre are fromnational sources, supplemened by Govenment FinanceStatistics (published by the Intational MonetayFund), World Bank sector studies, and otherstudies. Publicexpendiures include goverment health expenditures and parastatal expenditures. They do not includeaid flows. Psivate expendiures a based on householdsurveys camed out by the RD and other sources, supplementedby informationfrom United Naions National Income Accounts, World Bank studies, and other studies publishedin the scientificliterature. Estmatesfor countrieswith incomplete data, includinga numberof Africancountries, were calculated, in a specia exerciseundertaken for WDR93,in three steps. First, wheredata on either prvate or public expenditureswere lackig, the missingfigures were imputed from data fromcountries for whichinformation was vailable. The imputationfollowed regressions relating public or privateexpenditure to GDPper capita. Second, for a county withno healthexpenditure data, it was assumedthat the sbareof GDPspent on healthwas the same as the averagefor the correspondingregion. Third, if GDP was unknownbut populationwas known,it was assumedthat per capitahealth spending was the sameas the regionalaverage. Aid flowsreprent the sumof all healthassistance to eachcoumtry by bilateraland muldtlaal agencies and by internationalnon-government organizations (NGOs). NationalNGOs were not includedbecause the availableinformation was not sepately avaiableby recipientcountry. The esdmatesof aid in dtis tablewere preparedfor WDR93by the HarvardCenter for Poplationand Development Studies. BIBLIOGRAPHICAL NOTES

IS I Better Health in Africa is the productof many people. Contributorsto *hestudy included: B. Abeille, 1. Aleta, R. Amadi, R. Bail, A. Bhargava,G. Bloom, P. Brudon, A. Correia de Campos,J.L. Dubois,0. Dukes, A. E. Elnendorf, J. Hammer, R. Hecht, K. Hill, I. Z. Husain, M. Kinnani, R. Knippenberg. J. Kutzin, T. Lambo, J. L. Lanboray, P. Landell-Mills,M. Lechat,M. Lioy, J. Litvack, T. McCarthy,J. McGuire, T. Marek, R. Ngong, R. Niimi, L. Obeng, S. Ofosu-Amaah,D. Peters, G. Phanm Kanter, D. Porter, W. Roseberry, P. Shaw, 1. Silverman, D. Vaillancourt, W. Van Lerberghe, M. Venkataman, and Z. Yusuf. S. Kim. A. Bohon,H. Dao, K. Dugbatey, 0. McGroty, A. N'Diaye, and C. Stombergassisted in the research; and J. Shafer, A. Bohon, K. Goodwin,M. Thurston-Greenwalt,D. Jaekel, A. Kamau, M. Verbeeck,M.- C. Verlaeten, J. Watlington,and C. Yee provided administrativesupport. M. Vu and A. Sy prepared the statisticalappendix.

I. Ajayi, R. Bitran, K. Subbarao,and H. Wassefhelped in the initl framingof the study. L. Boya, E. Brown, M. Dia, K. Dugbatey, M. Kirmani, M. Malonga, A. Nyamete, S. Ofosu-Amaah,M. Tall, D. Vaillancourt, and A. Williams assisted R. Amadi, in reflections on culture and health. M. Blackden,P. Daly, M. Kirmani, E. Morris-Hughes,M. Kinnani, and A. Tinker, helped on womenand health; 3. Doyen, D. Gray and J. Leitman, on the environent and health; and M. Lechat, on technologyand health; G. Dukes, a pharmaceuticals;S. Ofosu-Amaah,on human resources for health; G. Pham-Kanter,on health service outputs; A. Tchicaya and G. McGrory, on external assistancefor health; J. Silverman,on managementcapacity and decentalization; and E. Heneveld and M. Zymelman,on educationand health.

Conunentatorsfrom outside the WorldBank included:S. Adjei, F.S. Antezana, F. Baer, R. Bail, K. Bezanson, G. Bloom, J. Davis, G. Dablgren, J. Decaillet, J. Desmazieres,L. Erinosho, M. Fargier, R. Feacham, S. Foster, H. Gilles, H. Gorgen, J. Grant, R. Heyward, D. Hopkins, R. Hore, M. Jancloes, R. King, R. Korte, M. Lechat, A. Lucas, C. Melvin, A. Mills, N. Mock, G. L. Monekosso,M. Moore, D. Nabarro, F. Nkrumah, H. Ntaba, S. Ofosu-Amaah,T. Park, E. Perry, T. Rothermel, J. Roy, F. Sai, D. Sambe, J. Seaman, D. Shepard, M. Skold, H. Sukin, A. Tchicaya, H. Van Balen, A. Vernon, G. Walt, and J. Wolgin, D. Yach; and from inside: M. Ainsworth, J. Armstrong, M. Azefor, J. Baudouy, D. Berk, J. L. Bobadilla, E. Boostrom, E. Boohene, L. Boya, E. Brown, N. Bumett, A. Colliou, L. Domingo, H. Denton, F. Golladay, R. Heaver, E. Heneveld, A. Hill, I.Z. Husain, D. Jamison, E. Johnston, S. Jorgenson, J. Kutzin, P. Landell-Mills,D. Mahar, A. R. Meashm, P. Musgrove, 0. Pannenborg,D. Peters, M. Pierre-Louis,M. Plessis-Fraissard,D. Radel, J. Salop, J.-P. Tan, and R. Vaurs.

The study benefittedgreatly from earlier work undertake by F. Golladay with the assistanceof T. Asefa from workhops, facilitatedby P. Gittingerwith the assistance of J. de Jong, held with African colleagues in Abidjan, Accra, Bujumbura, and Lilongwe;and from an internalWorld Bank staff workshopin September,1992. Aside from the backgroundpapers and other sources mentionedbelow, the study drew also on World Bank population,health and nutritionsector and project appaisal reports. BEMTFRHEALTH IN AFRICA

BackgroundPapen 1. Abosede,Olayinka, and JudithS. McGuire.1991. Improing Women'sand Children'sNriWton in Sub-SaharanAfrica. Worldng Paper No. 723. WorldBank, Population and Human Resources Depatmt, WashingtonD.C. 2. Amadi, Regina. 1992. CWdturaDitenesins in Better Heath in Africa. Africa Technical Depamen. WotldBank, Population, Health and NutritionDivision, Washington D.C. 3. Brut-Jailly, J. 1991.Health Fdcing in the PoorCowaries: Cost Recovery or CostReduction? PRE WorkingPaper Series No.692. World Bank. Washington, D.C. 4. Dejong,Jocelyn. 1991.Nongovernmenal Or8anizations and Heath Deliveryin Sub.Saharan Ajfrca. WorldngPaper No. 708. WorldBank, Populationand HumanResources Department, WashingtonD.C. 5. Dejong,Jocelyn. 1991.Traditional Medidne in Sub-SaharanAfrica. Working Paper No. 735. WorldBank, Popuation and HumanReso-irces Department, Washington D.C. 6. Diop, Francois, KennethHill, and Isnail Serageldin.1991. Economic Oisis, Structuwal Adjstnen, andHealth in Africa.Working Paper No. 766. WorldBank, Population and Human ResourcesDeatmen, WashingtonD.C.

7. Eldund,Peter, and Knut Stavem.1990. Prepaid Flnancng of PrimaryHealth Care in Guinea- Bissau.Woring Paper No. 488. WorldBank, Populationand HumanResources Deprtent, Washigton D.C.

8. Foster, S.D. 1990.Ihproving the Supplyand Useof Esential Dnrgs in SubSaran Afiica. WorkingPaper No. 456. WorldBank, Population and Human Resources Department, Washington D.C.

9. Liese,Bernard H., BruceBenton, and DouglasMarr. 1991.The Onchocerciasis Control Program In West Africa. WorkingPaper No. 740. World Bank, Populationand Human Resources Dqernt, Washnon D.C. 10. Mwabu, Germano.1989. Fin g Healh Serices in Africa: An Assessmentof Alterntve Approache.Working Paper No. 457. World Bank, Population and Hman ResourcesDepartment, WashingtonD.C.

11. Tchicaya,Anastase J.R. 1992.L'Aide Extrieure d la Santi dans les Paysd'Afrique au Sud du Sahara.Africa Technical Department. World Bank, Population, Health and NutritionDivision, WashingtonD.C. 12. Vaughan,Patrick. 1992. Health Personnel Development in Sub-SaharanAfrica. Working Paper No. 914. WorldBank, Population and HumanResources Deatment, WashingtonD.C. 198

Bacgrud Papen

13. Vogel, RonaldJ. 1989. Trendsin HealthEpenditures and RevenueSoiurces in Subaharan A..ca. WorldBank, Population and Hunan ResourcesDepartment, Washington D.C.

14. Vogel,Ronald 1. 1990.Health Insurance in Sub-SaharanAfrica. Working Paper No.476, World Bank,Population and HumanResources Departm, WashingtonD.C. 15. World Bank. 1993.A PFrneworkand IndicativeCost Analysisfor Better Healthin Afrfica. TechnicalWorking Paper No. 8. AfricaTechnial Department,Human Resources and Poverty Division,Washington D.C. 16. Yusuf,Zia. 1993.A Frmeworkand Intdcaive CostAnalysis for BetterHealth in Zimbabwe. Unpublishedmamuscript, Africa Technical Department, Human Resources and PovertyDivision, WashingtonD.C. BETrER HEALTHIN AFRICA

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