A- A1 in ,ica A i' . - 'iT < NJ~A 7~ A A 4 S ~ ~ " - i " -rn j,-r - (lZELAth 1o'417'''lnS rC - \ F 1 ; , ,. E.xperience and lIessons Learned r~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~r E A -s, NJ~~~~~~~N' _ l ',2 \ < 4 4~ ~~ . ...A -7........... . DEVELOPMENT I N P R ACTIC E Better Health -n Africa Better Health in Africa Experience and Lessons Learned THE WORLD BANK WASHINGTON, D.C. © 1994 The International Bank for Reconstruction and Development/m4E WORLD BANK All rights reserved Manufactured in the United States of America First printing September 1994 The Development in Practice series publishes reviews of the World Bank's activities in different regions and sectors. It lays particular emphasis on the progress that is being made and on the policies and practices that hold the mostpromise of success in the effortto reduce poverty in the developing world. The findings, interpretations, and conclusions expressed in £his study are entirely those of the authors and should not be attributed in any manner to the World Bank, to its affili- ated organizations, or to members of its B oard of Executive Directors or the countries they represenL The boundaries, colors, denominations, and other information shown on any map in this volume do not imply on the part ofthe World Bank Group any judgment on the lIegal status of any Litory or the endorsement oracceptance of such boundaries. Coverphoto: Curt Carnemark WorldBank staff Ubrary of Congress Caraloging-in-Publication Data Better health in Africa: experience and lessons learned. p. cut-(Developmentinpractice) Includes bibliographical references (p ). ISBN 0-8213-28174 1. Public health-Africa. 2. Health planning- Africa 3. Medical policy-Africa. 4. Medical economics-Africa. L International Bank forReconstruc- tionandDevelopment, II Title. IIL Series: Develop- mentin practice (Washington, D.C.) RA545.B48 1994 362.1t'096-dc2O 94 18249 CIP Contents FOREWORD xiii A C K N O W L E D G M E N T S xvii 'ACRONYMS xix 1 Introduction and Overview 1 Obstacles to Better Health 2 Underpinnings ofa Cost-Effective Approach to Health 4 The Cost of the Package 6 Resource Mobilization 7 The Role of Govemment 8 A Call to Action 9 2 Health and Development 12 Health Status 12 Causes of Death and Illness 15 Persistent and New Health Threats 18 Combating Demographic Pressures 20 Impact on Economic Development 24 3 Creating an Enabling Environmentfor Health 29 Safe Water and Sanitation 30 Food and Nutrition 32 v vi BETTE R H EA LT H IN A FRI CA Female Education 34 Special Roles and Status of Women 36 Culture 37 Households at the Center 37 Setting the Stage for Health Reforn 39 4 Revitalizing National Systems of Health Care 45 African Health Care Systems Today 45 A Brief History of Primary Health Care Strategies in Africa 49 Health Care System Realities 54 Underpinnings of a Cost-Effective Approach 56 S The Ihportance of Pharmaceuticals and Essential Drug Programs 67 The Performance of African Pharmaceutical Mark-ets 68 Constraints and Opportunities 71 A Supply-Side Perspective 74 Overcoming Obstacles 78 The Role ofNational Governmcnts 80 6 ManagingHumanResourcesforHealth 85 The Contasting Problerns of Undersupply and Underuse 85 Causes and Consequences 88 Achieving Effective Management of Health Care Personnel 90 Opportunities atthePrimary CareLevel 91 TheRole of Govermment 93 7 Infastructure and Equipment 98 Infrastructure and Equipment Problems 98 Renewing Health SectorInfrastructureand Equipment 103 The Special Problem of Tertiary Care Facilities 104 AssessingTechnologyChoice 105 8 Management Capacity and Institutional Reform 109 Assessment of the Existing System 111 Equipping Managers with Needed Skills and Methodologies 112 Promoting Decentralization 114 Enhancing Comrnmunity Participation 120 Encouraging Institutional Pluralism 124 CONTENTS vil 9 Costng and Paying for the Basic Package of Health Services 128 Low-Income Africa 129 Costs in a County with Higher Income 132 Who Should Pay for What? 135 Affordability 138 Closing the Financing Gap 140 10 Mobilizing Resources to Pay for Better Health 143 Govemment Expenditures for Health 144 Private Expenditures 150 Intemational Aid 1.52 Raising Additional Domestic Resources 1s5 UserFees as a Cost-Recovery Method 155 Fee Structures and Provisions for the Poor 162 Health Insurance 164 Conclusion: Resolving Crises 168 11 Timetable for Change 171 AgendaforAction 175 The Dynamics of Change 178 Developing GreaterResearch Capacides 179 Links with the International Community 181 STATI STI CA L AP P EN D IX 185 St B LI O G RA P H I C AL NOTES 221 vii BETTER H EA LTH IN A F RICA Boxes 1-1 The Enabling Environment forHealth 3 1-2 Maximizing Commuiiity Effectiveness 6 1-3 Priorities for Public and Private Expenditure on Health 10 2-1 Violence against Women as a Global Health Issue I8 2-2 Health Benefits of Family Planning 22 3-1 The Environmental Dimension of Health: The Case of Accra 32 3-2 Nutrition Deficiencies and Stunting 34 3-3 Information, Education, and Communication and the Health Behavior of Individuals and Households 38 3-4 World Summit for Children: Health Goals for 1995 and 2000 40 4-1 Why Primary and Preventive Care Should Not Be Provided by Hospitals 47 4-2 Cost-Effective Health Interventions 56 4-3. ComparativeAdvantagesofHealth Centers 58 44 Prootypical Health Center 60 4-5 Prototypical First-Refernl Hospital 63 4-6 AlDs and Health Care Reform in Africa 65 5-1 Improving Pharmaceutical Markets through Govemment Action 82 5-2 Evaluation of Drug Needs in Africa Need Not Be Difficult 84 6-1 PlanningHuman Resources for Health in Tanzania 91 6-2 Demonstrated Leadership at the District Level in Ghana 92 6-3 Strengthening Human Resources Planning and Management in Lesotho's Ministry of Health 94 6-4 Cooperation between Traditional Healers and Modem Health Care Providers 96 6-5 Developing Human Resources for Health Leadership and Research in Sub-Saharan Africa 97 7-1 Maintenance in Hospitals of Zambia's Mining Corporation 105 7-2 AcquiringNew Technologies 107 8-i Knowledge-Based Management and Planning 115 8-2 Roles and Responsibilites under Decentralization of Ministries ofHealth 116 8-3 Training andDevelopment of District Health Teams in Ghana 118 8-4 Accountability and Transparency in the Use of Community Resources 122 8-5 Monitoring the Provision of Local Health Care Services in Guinea 124 1§-1 MacroeconomicChange, Structural Adjustment, and Health 148 10-2 Three Stor.es of Cost Recovery in Hospitals and Other Facilities: Ghana, Senegal, and Malawi 158 CONTENTS Ix 10-3 Use of Health Centers by the Poor in Camneroon after Introducing Cost Recovery and Quality Improvements 161 10-4 Community-Level Insurance Plans: Lessons from Zaire 168 10-5 Public-Private Collaboration 170 11-1 A Health Research Unit Makes a Difference in Ghana 180 11-:2 International Initiatives and Sustainable Outcomes 182 TextTables 2-1 Key Health Indicators, Sub-Saharan Africa and Other Countries, 1991 13 2-2 Distribution of Causes of Death within Age Groups in Africa, 1985* 16 2-3 Child Morbidity by Selected Socioeconomic Characteristics, Selected African Countries 17 2-4 Rank and Share of Malaria, AIDS, and Other Diseases in the Total Burden of Disease and Injury, Africa, 1990 19 2-5 Economic Burden of Illness, Three African Countries 25 4-1 Single-Purpose Interventions: A Review of Studies 51 4-2 Review of VHW and CHW Programs 55 5-1 Expenditures on Pharmaceuticals in Selected African Countries, Mid-1980s 70 5-2 PerCapitaHouseholdExpenditures on Medicines, Ghana, 198748 72 5-3 Average Drug Costs perTreatment Episode by Level of Care, Selected African Counrifes and Years, 1983-88 73 6-1 Supply of Human Resources in Health Services, 1985-90 86 7-1 Health Care Equipment Not in Service in Nigeria, 1987 99 7-2 The Growth of Health Centers in Selected African Countries and the Challenge Ahead 101 7-3 Percentage of Population with Access to Health Care Facilities, Selected African Countries and Years, Late 1980s 102 8-I Diagnosing Health System Performance in Guinea, Benin, andTogo 112 9-1 Annual Indicative Per Capita Costs fora District-based Health Care System: Input Approach 130 9-2 Annual Indicative Per Capita Costs for a District-based Health Care System: Output Approach 133 9-3 Who Pays for What in the Basic Package: An Indicative Intervention and Targeting Approach 136 9-4 Selected African Countries Grouped by Relative Level of Expenditure on Health, 1990 139 9-5 Rough Estimates of Additional Revenue Effort for Health by Govemment and Donors in Low-Income Africa 141 x BETTER H EA LT H IN A F RICA 10-1 Selected African Countries Grouped by Relative Level of Central Government Expenditure on Health, Population-Weighted Averages, 1980s 145 10-2 Per Capita Household Expenditures on Health in Selected African Countifes 151 10-3 External Assistance for the Health Sector, Selected African Countries, 1990 153 104 Revenue from User Chargcs as a Share of Recurrent Government Expenditure on Health, Selected African Countries 157 10-5 Share of Population Covered by Health Insurance, Selected African Countries and Years 165 11-1 Action Agenda and Timetable 172 Figures 2-1 Geographic Variations in Under-five Mortality Rate, Sub-Saharan Africa, 1991 14 2-2 Estimated HIV Infections, Sub-Saharan Africa, 1990 21 2-3 The Specter of 1.2 Billion People by 2025 23 2-4 Potential AIDS Treatment Cost as Share of Total and Government Health Expenditures, Various African Countries, 1987-89 26 3-1 Per Capita Income and Under-five Mortality in Eight Countries, 1990 30 3-2 Services Contributing to Health of Households 31 3-3 Under-five Mortality and Level of Female Education, Selected African Countries, 1985-90 35 4-1 Performance of Expanded Programme of Immunization (EPI) under Different Conditions 53 5-1 Inefficiency and Waste in the Supply of Drugs from Budget Allocation to Consumer 76 6-1 Undersupply and Underuse of Human Resources in Health Services: Per- centage of Deliveries Attended and Not Attended by Trained Personnel, Rwanda, 1985 88 8-1 Some Dimensions of Capacity Building 110 CONTENTS xl Statistical Appendix Tables A-1 Health and Development Indicators 186 A-2 Population Projections (Standard/Medium) 188 A-3 Population Projections (Rapid Decline in Fertility) 190 AA4 Mortality 192 A-5 Income and Poverty 194 A-6 Education 196 A-7 The Health and Status of Women 198 A-8 Food and Nutrition 200 A-9 Access to Water, Sanitation, and Health Care Services 202 A-10 Immunization 204 A-I I Health Care Personnel 206 A-12 Health Care Facilities 208 A-13 Health Expenditures 210 Foreword H1GH rates of disease and premature mortality in Sub-Saharan Africa are costing the continent dearly. Poor health causes pain and suffering, reduces human energies, and makes millions of Africans less able to cope with life, let alone enjoy it. The economic consequences are immense. Poor health shackles human capital, reduces returns to learning, impedes entrepreneurial activities, and holds back growth of gross national product (GNP). Better Health in Africa presents African countries and their external part- ners with positive ideas on how to improve health. It argues that despite tight financial constraints, significant improvements in health are within reach in many countries. Experiences in countries as diverse as Benin, Botswana, Kenya, Mauritius, and Zimbabwe testify to this claim. This report documents lessons learned and "best practices" in four major areas. First, to achieve better health, African households and communities need the knowledge and resources to recognize and respond effectively to healtil problems. Publicly sponsored programs that inforn households and commu- nities about threats to health and the services that can respond to them are essen- tial. Formal and nonformal education play a major role, providing information and practical guidance on self-care, cleanliness, food preparation, and nutrition. The central position of women in household management and reproductive health must be emphasized. Intersectoral interventions to complement and sus- tain health improvements, such as the provision of safe water, are important. So too is local and community participation in the management of health services. These factors, this report argues, make crucial contributions to an "enabling environment for health." They are as important to health as improving income. Without them, the efficacy of medical interventions is greatly reduced. Second, Better Health in Africa shows that much health improvement can be achieved by reforming health care systems to use available human and finan- xlii xlv BET TE R H EA LT H IN A F R ICA cial resources more productively. Correcting the many sources of waste and inefficiency takes top priority. Inefficiencies in the procurement, storage, pre- scribing, and use of drugs are so extensive, for example, that consumers in some countries get the benefits of only $12 dollars' worth of drugs for each $100 spent on drugs by the public sector. Inequities prevail to the extent that poor house- holds in many countries have no access to quality care at times of serious illness orinjury. Critically important to health system reform is better management of phar- maceuticals, health sector personnel, and health infrastructure and equipment. Ministries of health are working on this in a number of countries. By giving more attention to the formulation and implementation of national policies and devolvintg responsibilities for health care provision to decentralized entities and the nongovemment sector, they can spur reform. In many countries, private voluntary organizations already assume a large share of the responsibility for providing health care, and can do more. Legal and regulatory environments are becoming increasingly conducive to the provision of health services by the private sector. Third, this report shows that cost-effective packages of basic health servic-elivered through networks of local health centers and small hospi- tals in rural and periurban areas-can go a long way to respond to the needs of households and reduce the burden of disease in Africa Experience suggests that a package of such services can be provided in a typical low-income African country for as little as $13 per capita per year. This compares with average per capita expenditures on health from all sources in Sub-Saharan Africa of $14, ranging from $10 or less per capita in countries like Nigeria and Zaire to more than $100 per capita in Botswana and Gabon. The key to improving the use of resources is to reallocate funds to the most cost-effective services. Fourth, Better Healtd: in Africa envisions that with about $L6 billion per year in additional funds, those living in Africa's low-income areas can obtain basic health services. Cost-sharing can make an important contribution to health equity and the sustainability of health services. It can also stimulate the provision of quality services in rural and urban areas. User fees and health insurance are now a reality in many countries and merit increasing roles. Evi- dence in this report shows that African households axe willing and able to pay for quality services. Larger commitments of domestic resources from government, nongovem- ment partners, and households can also lead to more financial support from donors. According to a scenario presented in this report, Africa's low-income countries would increase their total annual spending on health by $1 bilion-a goal within reach through gradual increas;es in government financing and rising participation by hoaseholds. For their part, donors mnight be expected to con- FOREWORD xv tribute somewhatover $600 million, representing a 50 percent increase in exter- nal assistance for health in Africa today. Donor support would be directed chiefly to low-income countries that are implementing the actions necessary for better health. The transition to better health will obviously vary from country to country and no one formula would apply to all. At the same time, however, no country should delay committing itself to the task. The first step on the agenda is to establish an action plan and yardsticks to measure progress. Indicative actions and yardsticks are provided in this reporL At the international level, a consultative group of Africans and donors could be formed to review progress and ensure coordinated support for interna- tional training programs, operational research, and other aspects of follow-up. A consultative group could further serve as a forum to exchange experiences among African health leaders, and to strengthen mutual support in addressing difficult issues. A ministerial meeting could help to launch the consultative group, determine an initial action agenda, and establish monitoring and evalua- tion benchmarks. Such a meeting could bring African ministers of health and senior personnel from ministries of finance and planning together with senior staff from donors and other international agencies. Initiatives in these areas have already commenced with the participation of African health experts in the review of this study and discussions with health officials from countries like Cameroon, Centrl African Republic, Congo, Cote d'Ilvoire, Gabon, Guinea, Kenya, Sierra Leone, Tanzania, Uganda, andZambia. An Independent African Expert Panel on Health Improvement in Africa has also reviewed the report and made important suggestions for improvemenL The panel, co-sponsored by the African Development Bank, the Swedish Interna- tional Development Agency, The United Nations Children's Fund (uNcEF), the World Health Organization (wHo), and the World Bank, is chaired by Pro- fessor 0. Ransome-Kuti, former Nigerian Minister of Health and former Chair- man of the wHo Executive Board. Some major health commitnents have al- ready been made at the 1990 World Summit for Children and in the Consensus of Dakar, where African govemments and intemational donors agreed in No- vember 1992 on a core of mid-dcecade health goals and reiterated support for the year 2000 goals. Better Health in Africa was written by World Bank staff, in close coopera- tion with many other individuals and institutions. It complements World Devel- opment Report 1993: Investing in Health by emphasizing operationally ori- ented strategies. In so doing, it draws on important initiatives by the World Health Organization, such as its Three-Phase Scenario for Health Development and its support for district health systems, and the National Plans of Action to implement goals of uwcEF's 1990 World Summit for Children. Stafffrom the xvi B ETT E R H EALTH IN A FR I C A WHO Regional Office for Africa, from wHo Headquarters, and from UNICEF Headquarters and its Regional Offices for Africa assisted in the conception, preparation, and review of the study. The analyses and messages also reflect the views of these three organizations, which will worktogetherin helping African countries adapt the report's recommendations to local circumstances and carry them ouL G. L. Monekosso, M.D. E. V. K. Jaycox James P. Grant Regional Director for Africa Vice President Executive Director WorId Health Organization Africa Region United Nations The World Bank Children's Fund Acknowledgments Better Health in Africa was written by R. Paul Shaw and A. Edward Elmendorf. The study ream was managed by A. Edward Elmendorf and Jean- Louis Lamboray, under the general direction of Ishrat Z. Husain. Pierre Landell-Mills and Kevin M. Cleaver provided management support. Jean- Louis Lamboray and Reiko Niimi contributed to the conceptual design of the study, the preparation of initial drafts of Chapters 3, 4, and 8, and coordinated a review of inputs of external partners. Zia Yusuf contributed to the design of the costing and financing framework used in Chapter 9. My Vu and Ali Sy prepared the statistical appendix, and James Shafer had principal responsibility for pro- cessing the text Consultations and workshops with many African health leaders, including policymakers, analysts and health care providers, contributed to the final prod- uct The Regional Director of wHo for Africa provided invaluable advice and moral support in the task. His African Advisory Committee on Health Develop- ment, the wHo/African Regional Office "Health for All" team, wHo Head- quarters International Cooperation Division (ico) personnel, and uNcIE. staff members at Headquarters and in the field made substantal contnbutions at the design, writing, and review stages. Donors to health improvement in Africa, and nongovemment organiza- tions aiding health in Africa, were consulted on the study. Preparation of the study was also aided by a series of background papers, as well as the contribu- tions and comments of many other people inside and outside the World Bank. wHo/ico contributed to the financing of the study. FINNIDA financed the workshops held in Africa, and the Swedish International Development Agency financed the African expert review panel. The governments of Belgium, Fin- land, Japan, and the Netherlands contributed consultant support Support was also received from the Center for Health and Development at The George Washington University and the International Organization Fellows Program of the United Nations Association/National Capital Area. xvii Acronyms AACHD African Advisory Committee on Health Development (wHo) AIDS Acquired immune deficiency syndrome AMA Accra Metropolitan Area APAC African Population Advisory Committee AM Acute respiratory infection B CG Bacillus of Calmette and Gu6rin vaccine (to prevent tuber- culosis) CHW Community health worker CIESPAC Centre Inter-Etats d'Enseignement Superieuren Sant6 Publique d'Afrique Centrale DALY Disability-adjusted life year DANIDA Daanish International Development Agency DHT District health team DPTr Diphtheria, pertussis, tetanus vaccine EPI Expanded Programme of Immunization FAO Food and Agriculture Organization of the United Nations FINIDA Finnish International Developrnent Agency GDP Gross domestic product GNP Gross national product Hlv Human immunodeficiency virus EC Information, education, and communication inP, International Health Policy Program IMF International Monetary Fund IPRE Institutde PrevoyanceetRetraites du Senegal has Management information system MR Most recent year for which data are available MIu Magnetic resonance imaging xix ACRONYMS xS MSH Management Sciences for Health MSP Ministbre de la Santd Publique (Benin) MSPAS Minist6re de la Sante Publique et des Affairs Sociales (Guinea) NCHS National Center forHealti Statistics NGO Non government organization NHIF National Hospital Insurance Fund NPA National plan of action ODA Overseas Development Administration OECD Organization for Economic Cooperation and Development ORS Oral rehydration salts ORT Oral rehydration therapy PHC Primary health care PHN Population. Health, and Nutrition PIMIS Personnel management information system PRHETIH Primary Health Training for Indigenous Healers SANRU Sante mrale (Zaire) SAP Structural adjustment program SIDA Swedish International Development Agency STD Sexually transmitted disease UJND United Nations Development Programme UNICEF United Nations Children's Fund USAw United States Agency for International Development VHW Village health worker VIP Ventilatedimprovedpit6atrine) WHO World Health Organization WHOIAFRO World Health Organization African Region Office WHO/ICO World Health Organization International Cooperation Division (Headquarters) CHAPTER ONE Introduction and Overview G OOD HEALTH is basic to human welfare and a fundamental objective of social and economic developmenL Yet most of Africa's forty-five countries lag far behind other developing countries in the vital task of improv- ing health.' Infant mortality is 55 percent higher and average life expectancy is eleven years less in Sub-Saharan Africa han in p e rest of the world's low- income dcveloping countries. Maternal mortality, at 700 women per 100,000 live births, is almost double that of other low- and middle-income developing countries and more than forty times greater than in the industrial nations. Tens of millions of Africans suffer from malaria each year, an estimated 170 million are afflicted by tuberculosis, and the AIDS epidemic seriously threatens several of the continent's countries. It is no surprise therefore that ill health has a powerful effect on the region's economic progress. Productivity in some countries could increase by up to 15 percent were illness and disability attacked more strenuously. A substantial re- duction in maternal illness and deaths wouId greatly increase women's contri- bution to economic development Better control of disease would allow expan- sion of agriculture into lands previously uninhabitable. Investments, in education would yield a greater return because of longer life expectancy. Greater control over reproductive health outcomes, through reduced infant mortality, for example, would pave the way for the demographic transition that 'The terms Africa and Sub-Saharn Africa are used synonymously in this bookE Becauschealkh and socioecooomic conditions in South Africa differ so greatly from those in the rest of Sub-Sahanm Africa, that country is not discussed explicitly in this study, and data presented as (Sub-Saharan) Africa-wide averages do not include South Afria. 1 2 B ETTE R H EA LTH I N AF R I C A is essential to economic progress. And pressures on households to borrow and use up savings during times of illness would be greatly reduced. The challenge facing African societies today is to empower households and communities with the knowledge and practical support needed to reduce suffering, illness, and mortality more effectively than in the past. The health of household members is affected (among other things) by the nutritional value of the food they eat, the safety of their drinking water, their habitual self-care practices, their purchase and use of pharmaceuticals, and their visits to tradi- tional healers and providers of modem health care. These behaviors are pro- foundly influenced by the "enabling environment" for health (Box 1-1). Some African countries are already taking important steps toward creating an "enabling environment" for health, and these successes play a prominent part in the lessons learned and recommendations of this report But in many other countries, progress has been hanpered by weak political commitment to health reform and mismanagement of national health systems. In some cases, these problems have been compounded by political instability, macroeconomic shocks, civil war, and natural disasters. Nonetheless, this study proposes that the health of Africa can be dramatically improved despite serious socio- economic and financial constraints. The rest of this chapter provides a brief overview of obstacles to better health iv Africa, a cost-effective approach to combating effects of illness and disease, options for financing an action agenda, and the role of government in encouraging change. Obstacles to Better Health The obstacles to better health in Africa are not limited to such shattering but nonetheless transient events as civil conflict, drought, and falling commodity prices. if these factors alone mattered, Africa would have made more progress in improving the health of its people. Rather, an enabling environment for good health has been impeded by more deep-seated problems, which are only tou- ched on here and are discussed in greater detail in subsequent chapters. One obstacle has been the weakness of political commitment to better health. Although African countries over the last two decades have made numer- ous protmises to adopt one of the prime elements of an enabling environment- namely, better primary and preventive health care-they have seldom made the institutional and financial changes necessary to bring it about. In most countries governments still devote most of their attention and funding for health to high- priced curative care and relatively cost-ineffective services provided through hospitals. Such services not only consume a large share of ministry of health resources but tend to benefit a small share of the population. I NTR O DUCTIO N AN D O VE RV I EW 3 BOX I-1. THE ENABLING ENVIRONMENT FOR HEALTH Personal health care services Physical environment. In u, population growth households, and Pua and structure, culture, communities aPublic healthactivities and politics the key actors in health National income, education, water, sanitation, food security, and nutrition Better health in Sub-Saharan Africa hinges on the ability of households and com- munities to obtain quality health servioes at less cost and to use them more effec- tively This requires: * A strong political commitmentto improving health, as reflected in preferen- tial governmentspending * An intersectoral perspective in planning and operating systems of health care, including provisions for safe drinking water, sanitation, and health education * An appropriate organizationalframeworkand managerial process * An equitable distribution of health resources * Communityinvolvementatall levels. Anothersign of insufficientpolitical commitmenthas been a general disin- clination to appropriate a larger share of government funds to health purposes. Pooreconomic conditions clearly play some role, but they do not totally explain the often-observed tendency to give health services short shrift in funding. As a result, publicly owned and operated infrastructure and equipment are visibly aging in many countries. Stock-outs of drugs are frequent, especially atpublicly 4 B ETTE R H E ALTH I N A FR I CA run urban health centers and village health posts. Inefficiency and waste in the procurement, storage, prescribing, and use of drugs are so extensive that con- sumers in some countries get the benefits of only $12 worth of drugs for each $100 spent on drugs by the public sector. To some extent donor funding has compensated for low funding of health in national budgets. And, in some countries donor-funded projects have been the driving force in health planning, even when these projects have not truly addressed the country's dominant health problems. An unwelcome side effect however, has been the fragmentation of systems of health care and lack of gov- ernment leadership. Another deep-seated obstacle is the hierarchical and centralized structure of rninistry of health programs and policies. Several African countries have made notable progress in recent years toward devolving responsibilities for program development and implementation, but an entrenched opposition to the decentralization of authority often prevails. A chief argument of this report is that better health in Africa depends on an overall decentralization that encour- ages African households and communities to become more responsible for their own health and more capable of achieving it. The consequences of all these obstacles are frequently compounded by other encumbrances that are no less significant-for example, rapid population growth, gender inequalities, and pervasive poverty. In combination with poor economic performance, rapid population growth has contributed to negligible rtes of growth in gross national product per capita in more than half of the African countries over the past two decades. As better health in Africa carmot be divorced from the implications of rapid population growth, the benefits of spacing and limiting of births for the healthy mother and child are stressed throughout this report. Underpinnings of a Cost-Effective Approach to Health Africa's households and communities could become much healthier through three mutually reinforcing improvements that would enhance the effectiveness of each dollar spent on health. The first requires broad use of cost-effective "packages"' of services designed to deal with the most common health prob- lems (Chapter 4). The second involves decentralization of health care delivery, especially through expansion of district-based health care networks composed of health centers and first-referral hospitals (Chapter 8). The third requires im- proved management of the essential inputs to health care-pharmaceuticals (Chapter 5), health sector personnel (Chapter 6), and health sector infrastruc- ture and equipment (Chapter 7). I NTR O DU CTION AND OVE RV I E W 5 The purpose of the cost-effective package is to provide better health at the lowest cost. Emphasis in the package is on basic personal health2 care (Box 1-1). This includes prenatal and delivery care, management of high-risk pregnancies, postpartum care, well-baby services, family planning, outpatient care for such common afflictions as diarrhea, and ongoing care of certain chronic illnesses. Each of these inputs is relevant to the demographic and epidemiological profile of most African countries. People at greatest risk tend to be members of vulnerable groups, including newborns, infants, toddlers, and women of repro- ductive age. High-risk groups tend to be afflicted disproportionately by infec- tious and parasitic diseases. Basic health care would also cover vaccinations, oral rehydration therapy, administration of drugs to malaria victims, prevention of iron deficiency, and treatment of common urinary and gynecological infections. Essential drugs to be used would be those that are effective against Africa's chief afflictions, in- cluding malaria, tuberculosis, diarrhea, respiratory infections, measles, polio, and sexually transmitted diseases. These basic health care inputs would be supplemented by much greater attention to providing supporting services to enhance the value of contacts be- tween health care providers and patients. A broad range of information, com- municaion, and education services would be included, as noted in Box 1-2. Thus a woman who brings her child to a health center for treatment of chronic diarrhea would be expected to leave not only with an oral rehydration salt but also with information on better nutrition and on the advantages of family plan- ning methods. Such supporting services help maximize the value of personal health caret Basic health care and stronger supporting services, in turn, would be sup- plemented by much greater attention to intersectoral interventions. These would include in particular the construction and operation of safe water and sanitation facilities in the many regions of Africa that now lack them. In this report, intersectoral interventions constitute improvements to the enabling en- vironment for health (Chapter 3). The effectiveness of basic health care inputs, supporting services, and in- tersectoral interventions depends largely on the degree to which all of the parts-private as well as public health activities-come together at the commu- nity level. What counts most is the geographic proximity of services and system responsiveness to households and the community. That is why Box 1-2 i; titled "Maximizing Community Effectiveness." When offered by well-functioning health centers, the aforementioned package has reduced total hospital admissions in some communities in Africa by up to 50 percent and has cut hospital admissions for such illnesses as mea- sles, tetanus, and diarrhea by up to 80 percent. B ETTER H EA LT H IN A FRI CA BOX 1-2. MAXIMIZING COMMUNITY EFFECTIVENESS Maximizing community A+B+C effectiveness A. Basic package of health EPI, ante- and postnatal care, treatment of care inputs maternal morbidity, family planning outpatient care, and so on + B. Supporting services Information, education, and communication to improve screening and diagnostic accuracy, provider compliance, and patient oompliance + . C. lntersectoral interventions Safe drinking water and sanitation The Cost of the Package A major goal of this study has been to determine the indicative cost of such-a package in low-income, low-wage African countries. The cost framework pre- sented in Chapter 9 describes the process by which decisions were made about the right inputs for a cost-effective approach. The framework is also used to illustrate how costs would change (probably upward) for African countries that enjoy higher levels of income. This study estimates that a package of basic health care inputs, important supporting services, and intersectoral interventions could be provided for ap- proximately $13 per capita per year in low-income African countries. This has been disaggregated into health care costs ($7374 per capita), intersectoral inter- ventions ($3.98 per capita), and supporting services ($1.50 per capita). No pre- tense is made, however, that it is possible to calculate a single, universally ap- plicable cost. One reason is that the cost will be highly conditioned by differences among countries in wage and price levels, technologies in use, per capita incomes, and health aspirations. Another reason is that socioeconomic change modifies the age structure of the population, epidemiological condi- dons, and societal priorities to the extent that the burden of disease and cost to combat it may change. Thus, a parallel exercise for an African country with a higher income, also presented in Chapter 9, suggests that the approximate cost would be about 20 to 25 percent higher, or about $16 per capita per year. Establishing the indicative figure of $13 per capita is valuable as a means of prompting reflection on what people in African countries are getting now for what they pay (which varies greatly from country to country), how resources I NTRO DUCT IO N AND O V ER VIEW 7 might be reallocated to usher in a more cost-effective approach, and the addi- tional resources needed to ensure that the poorest countries and the poorest groups within each country can pay for the package. For example, per capita expenditures on health from all sources are $14, on average, in Sub-Saharan Africa. They range from $10 or less per capita in countries like Nigeria and Zaire, to more than $100 per capita in countries like Botswana and Gabon. Accordingly, Chapter 9 also.discusses how to finance the package in countries that differ in terms of gross national product and per capita expenditures on health. Assuming that, with active household support, the entire public sector- that is, all of the African governments and the donors-was willing to increase its commitments in ways suggested in Chapter 9, an additional $1.6 billion per year could be mobilized for better health in low-income Africa. The donor share, at about $650 million a year, would be about double the amount now provided by external sources. Resource Mobilization All countries (including the rich industrial countries) face serious financial con- straints in their efforts to mobilize and sustain additional resources for health. Many African countries trail other developing countries in expenditures on health as a share of GNP. Equally if not more important, many African govem- ments have reduced their per capita health sector expenditures. This trend should be reversed. This study finds, moreover, that large percentages of public funds commit- ted to the health sector are not being used for cost-effective goods and services. Action must therefore be taken to match symbolic pledges to preventive and primary care with actual allocations and use of funds, along with reductions in public funds for expensive and urban-based curative care. Such care, whatever its virtues, is not cost-effective. User fees and other types of cost recovery are important to ensure the fi- nancial sustainability of publicly provided health services. This study reports considerable scope for expanding user fees. Revenue generated may be modest at first, but it can be expected to increase when quality of services are improved, and households perceive the benefits of paying. Research reveals that even low- income African households are prepared to pay what is necessary to obtain basic curative services, especially if the quality of the services is good. The retention of fees at the point of collection, moreover, is an incentive to hospital and health center managers to strengthen revenue collection and service qual- ity. Moreover, and purely on equity grounds, patients from African households with higher incomes (some of which have health insurance) should be required to pay for the health care they receive. In particular, charging better-off patients S BSET TER HE ALT H IN A F RICA at publicly financed or operated hospitals (as discussed in Chapter 10) affords ministries of health the opportunity of freeing up scarce resources for realloca- tion to primary and preventive care. Furthermore, governments can create conditions lhat will lead to the ex- pansion of both public and private insurance programs, generating increased revenues for the health sector in general and stimulating expansion in the num- ber of nongovernment providers of health care. This study found that the pros- pects for expanding health insurance are promising, especially at the commu- nity level. One possible approach is for governments to mandate compulsory insurance for salaried workers and to encourage expansion of private insurmnce programs. Another possibility is for governments to promote greater collaboration between the public and nongovernmenl sectors as a means of increasing efri- ciency and fostering the expansion of private providers and especially of pri- vate voluntary organizations. Subsidizing health services provided by religious missions, for example, has worked effectively LO provide such services to indi- gents and serve arcas where public and private-for-profit health facilities are scarce. Fostering community control and ownership of health facilities and fi- nancing mechanisms-such as prepaid community-based insurance-has also workcd to mobilize revenues in rural areas. Finally, African governments can reap far greater sustainable benefits through better use of available external funding. This study argues that donor initiatives and lending, while no doubt valuable, have produced few permanent successes thus far and have sometimes caused counterproductive imbalances in the operation of health systems without significantly enlarging national capacities. The Role of Government Government's first priority should be to use its comparative advantage to fi- nance cost-effective public health activities and other public goods -and ser- vices. The figure in Box 1-3 provides a visual depiction of ideal expenditure priorities in the public sector and serves as a fiamework for this report. Broad]y speaking, this means financing public goods known to have an immense impact on the enabling environment for health, such as safe drinking water, sanitation, and health education. Such expenditures are less likely to be mobilized by the private sector. Rather, they are usually financed and sometimes-undertaken by governments because collective action is required to make investments beyond the capacity of individuals alone. These expenditures are called public goods because they tend to benefit the community as a whole, and no individual can be excluded from their benefits. I NTR O D U CTIO N AN D O VE RVI E W 9 Govemment also enjoys a comparative advantage in such tasks as health system planning, health education, regulating the health professions, collecting epidemiological data, and preventing communicable diseases. If national de- mographic and health surveys had not been] carried out in several African coun- tries, for example, it would not be known that 70 to 75 percent of deaths in the youngest age groups are caused by problems at or soon after birth, and by pre- ventable infectious and parasitic diseases. Such information is crucial in setting health targets. Globally, government's- primary role should be leadership-identifying and promoting cost-effective approaches to health and facilitating the activities of public and nongovernment providers. This is not to say that governments should be the main providers of health care. Rather, priorities for action by African governments include the following: * Establishing appropriate programs of public health services, and financing them before supporting other health services * Deterrnining which package of health services, if adequately used, would be the most cost-effective * Reducing direct government engagement in provision of health care where nongovernment providers show potential for an in- creasing role, and reallocating public financial support for health care from relatively cost-ineffective curative care interventions to the basic package a Subsidizing the package of services for the poor and, in the ab- sence of nongovemment willingness to provide services on ac- ceptable terns, directly providing these services to the poor * Subsidizing those components of the package that result in the largest numberof direct and indirect benefits for the largest num- berof people (e.g. immunizations) * Providing information to the public that will stimulate demand for the basic package, empower citizens to choose wisely among pro- viders, and assist households to make sound use of the package. A Call to Action Who stands to benefit and who will be motivated to take action in keeping with the major themes of this report? Obviously, African households and commu- nities will 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 approaches emphasized here provide a framework for organizing their work more efficiently, equitably, and 10 B ETT ER H EA LT H I N A FR ICA BOX1-3. PRIORTES FOR PUBLIC AND PRIVATE EXPENDITURE ON HEALTH Lowest priority Private Demand o Highest priority Prvate participation \ ~~~~~~~~~~~in financing the \ ~~~~~~~~basic package Public / \ :\ Tertary Cost-effective package of hospital activities basic hcalth servces with -cgare and positive externalities (for o.ther exmpe inuiztins Highest priority 4 S Lowest priority SocieW Denuand The waron disease in Sub-Saharan Africa cannot be won by individually oriented health care services alone. It must involve interventions to control the transmis- sion of disease and disease vectors in the physical environment where they thrive. These interventions, such as health education and information and the eradication of malaria from swamp areas, are usually supported and some- sustainably. Policy analysts associated with professional health associations, universities, and think tanks can benefit in their endeavors to devise strategies for better health in Africa. Core agencies, such as ministries of planning and finance stand to benefit given their interest in restructuring health care systems, as well as increasing efficiency and equity, in ways that countries can afford without compromising progress to beaer health. And the donor community can be counted on to play a supporting role given the promise that domestic health expenditures will be usedfar more cost-effectively than in the past. Hard decisions on health are needed now, to convert the vision set forth in this study and other declarations for better health into realistic plans of action, I NT R OD U CTION A N D OV ERVI EW 11 Box 1-3, continued times undertaken by govemments because collective action is required to make investments beyond the capacity of individuals alone. They are called public goods because they tend to benerttthe community as a whole and no individual can be excluded from their benefits. It is equally important to finance and, where necessary, provide other public health services, such as epidemiological data collection and analysis, health system planning, provision of health information to health care providers and consumers, health education, regulation, licensing, and prevention of communicable disease. As depicted in thefigure, expenditures on public health activities and other public goods should be a high priority of govremments, reflectng a high level of societal demand. Indeed, without commit- ment to public health improvements and an enabling environment for better health, high levels of per capitaincome cannot ensure good health. Govemrnments also have a critcal roleto play in supporting actvities thatsome- times benefitindividuals directly (thus qualifying them more as private goods) but also construe large benefits to society at large. These indude family planning, matemal and child health, infant nutrition, immunization and treatment of com- municable diseases. In the endeavor to assist the poorest households, govem- mentsupportforcost-effective packages of basic health care will almost certainly include such services. In the figure, this is conveyed by the large circle, suggest- ing that govemments have a strong interest in identifying and partially financing cost-effective packages of health care. Finally, the lowest public priority; and, conversely, the highest private priority, is to allocate funds to tertiary care services, and hospital "hotel" services. An implication isthat charging fees and full cost recovery are mostfeasible at oentral hospitals because such tertiary-level services benefit individuals and people are most willing to pay forthem. a and to move from planning to implementation. Governments have a responsi- bility, as well as the mandate, to take action to reduce unnecessary suffering, increase human resource potential, and contribute to a major foundation of sus- tainable development. Chapter 11 of this report offers an agenda of the actions needed for better health and a timetable for the probable sequence of actions. CHAPTER TWO Health and Development AFRICA is host to a number of major disease vectors. Their trans- mission is aided by a warm, tropical climate and variable rainy seasons. The mean number of infective malaria bites per person can be ten times higher in the forest or savannah areas than in the Sahel or more mountainous areas. In agri- cultural communities, exposure to infection, especially diarrhea, malara, and guinea worm, tends to be greatest during the wet season, when food is in short- est supply and high prices prevail. This chapter describes the main epidem- iological and demographic conditions affecting health in Africa, and the eco- nomic losses caused by these conditions. Health Status Africa's struggle to overcome illness and disease over the past quarter century has had mixed results. On the positive side, the infant mortality rate has been cut by more than one-third, and averge life expectancy has increased by more than ten years. At the beginning of the period, only one in seven Africans was supplied with safe drinking water, whereas twenty-five-years later-about 40 percent of the African population was obtaining drinking water from a safe source. By the end of the 1980s, around half of all Africans were able to travel to a healti care facility within one hour (urncEr 1992b). On the negative side, however, life expectancy in Africa in 1991 was only fifty-one years, compared with sixty-two years for all low-income developing countries and seventy-seven years for the industria countries. Africa's infant mortality rate is almost 50 percent higher than the average for all low-income countries and at least ten times higher than the rate in the industrial countries. Maternal mortality in Africa is twice as high as in all low-income developing countries and six times higher than in the middle-income developing countries (Table 2-1). 12 HEALTH AND D EVELOP ME NT 13 Mortality differentials among African countries are no less striking. The mortality of children under five ranges from more than 200 deaths per 1,000 live births in Mali, Angola, and Mozambique to fewer than 100 in Botswana and Zimbabwe (Figure 2-1). Maternal deaths per 100,000 live births have been esti-' mated to range from 83 in Zimbabwe to more than 2,000 in Mali. Adult mortality-the risk of dying between ages fifteen and sixty-has been estimated to range from 18 percent in Northern Sudan to as high as 58 percent in Sierra Leone (Feachem and others 1992). In many countries, more than 30 percent of females and.40 percent of males of working age will die before age sixty. Mortality also varies widely within countries, revealing inequalities in health status between urban and rural residents as well as between socio- economic groups. In Zimbabwe, for example, childhood rnortality in urban areas is 45 percent less than the rate in rural areas and is up to 20 percent less among urban dwellers in Sudan, Togo, and Uganda. The children of marnied women wit a secondary education are 25 to 50 percent less likely to die before age five than are the children of women with no education. Differentials be- tween residential areas with higher and lower incomes have given rise to the so- called "ten to twenty" rule of thumb, meaning that in most settings the life expectancy of the nrchest 10 to 20 percent of the population is somewhere on the order of ten to twenty years higher than that of the poorest 10 to 20 percent (Gwatkin 1991). Ethnicity also ranks as a powerful correlate of infant and child mortal- ity differentials, even after education and occupation are taken into account (Akoto and Tabutin 1989). In Cameroon, for example, the mortality of children less than two years of age between 1968 and 1978 ranged from 116 per 1,000 live births in one ethnic group to 251 in another. In Kenya, child death rates ranged from 74 for one ethnic group to 194 for another, while in Ghana they ranged Table 2-L Key Health Indicators, Sub-Saharan Africa and Other Countries, 1991 Counrry group H(1gh- Middle- Low- Sub-Saharan Indicator income income income Africa Life expectancy at birth (years) 77 68 62 51 [nfant mortality (per 1,000 live births) 8 38 71 104 Maternal mortality (per 100,000 live births) - 107 308 686 -Not avaiMlble. Source: World Bank 1993c. 14 s BETTER HEALTH IN AFRICA I' igure 2-L GeographicVariations in Under-five Mortality Rate, Sub-Saharan Africa, 1991 IUBD 26042 V -~~~' .w _t ' -J _ 200 - 24-P- ' . - 2 . . . _ ' ,- S 0 A ' A £*E THAN I 0 .....4..4 .:- *y-t .... : S ii *-''-1=tSTA 00 'E'-'' LP..on r-s-"ur MORE ThAN o50 I "A term "bild mrL200 - 2is alousd , ,, ,:.1;::; 3 NO DATAeD^S >r IeC r irtra _ r IUNE IW9 * Duzaptormo the crcationdf thceindepeudentcounzryof Ethics Nine: Under-five wortalityis the probablihy ofrdyloghetween birth am! agec5, eXxpressed per 1,000 live binhs.The term "child mortality is also used. Source:UNicEF 1993. H EA LTH AND D EV ELOPMENT from 74 to 1584 and in Senegal from 261 to452 (Akoto andTabutin 1989). These ethnic differentials may be attributable in part to different attitudes conceming illness and nutritional practices, access to and use of modem health services, and dependlence on modem versus traditional healers. But they are also due to schisms among ethnic groups that produce unequal access to social and eco- nomic opportunities. Causes of Death and Illness Although the major causes of death and illness vary by age group, certain health problems affect Africans at every age (Table 2-2). Perinatal, infectious, and parasitic illnesses are responsible for 75 percent of infant deaths. Infectious diseases and- parasitic afflictions are also responsible for 71 percent of the deaths of children age one to four and 62 percent of the deaths of children ages five to fourteen. Child health in Africa is threatened particularly by diarrhea, acute respiratory infections, malaria, and measles (Table 2-3). The incidence of disease among children can be profiled as follows (Fea- chem, Kjellstrom, and Murray 1992): U The typical African child under five has five episodes of diarrhea per year. a 10 percent risk of suffering from diarrhea on any given day, and a 14 percent risk of dying from a severe episode. Diarrhea accounts for 25 percent of all illness in childhood and 15 percent of admissions to health facilities. The World Health Organization (wHo) estimates that 37 percent of all cases of diar- rhea in the world occur in Sub-Saharan Africa, wh.ere only 50 percent of chil- dren benefit from oral rehydration therapy, compared with 70 percent in Asia and North Africa (wHo 1990). * The typical child appears to have approximately ten acute respiratory infections (Am) per year and a25 percent chance of suffering from Amr on any particular day. It is estimated that such infections are responsible for 25 to 66 percent of childhood illness, and for about 17 to 41 percent of visits and admis- sions of children to a health facility. K Vaccine-preventable diseases are implicated in the deaths of 20 percent of all children. In 1985, before ArDS began to affect adult mortality, about half of all deaths of adults age fourteen to forty-four were also due to infectious and parasitic diseases. Now, according to WHO, one in every forty Sub-Saharan African adults is infected with the human immunodeficiency virus (EImv), which causes AIDs. In many hard-hit African countries, AIDS is the major cause of adult deaths in this age group (see below). Among older adults (those over forty- Table 2-2. Distribution of Causes Or Death within Age Groups In Africa, 1985 Proportioni of zotat deaf/is wtir/ili; a cuegr * (percenti) hadaisDas ~~~~~~~~ ~~~~~~~ ~~~Total eleatJhs pcarArs Caise of leadil (I 1-4 5-14 14-44 45-64 65f+ (i/,n.ronds) (perenitage of total) Perinatal 30.0 0.0 0.0 0.0 0.0 0.0 627 9.3 Infection and parasitic 45.0 71,0 62,0 53.0 28.0 19,0 3,403 47.2 Cancer 0.1 0.3 1,0 3.0 14.0 9.0 42 3.4 Circulatory system 1.0 2.0 6.0 12,0 34.0 41.0 909 12.6 Maternal 0.0 0.0 0,0 4.0 0.2 0.0 48 0.7 Jnjury and poisoning 1.0 3.0 6.0 12.0 5.0 2.0 294 4.1 Otlier 23.0 24.0 24.0 16.0 18.0 28.0 1,635 22.7 Total 10,0 100.0 100.0 1001.0 100.0 100.0 7,203 100.0 Sosrce: Bulatao and Stcphcns 1992. H EA LTH AND D EVE LO PM ENT 17 Table 2-3. Child Morbidity by Selected Sodoeconomic Characteristics, Selected African Countries (percentage of children ill) Eduncadon Disease Sex Residence Secondary and country Male Ferale Urban Rural None Prinary or highrer Diarrkteaa Ghana 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 39.4 Feverb Ghana 37.4 35.4 33.1 37.6 34.5 38.5 31.6 Senegalc 61.9 60.1 46.6 68.9 64.8 48.1 33.3 Zimbabwe 7.1 7.0 5.7 7.5 8.0 6.8 6.9 Respiratory problemsc Ghanad 20.8 20.4 18.6 21.4 18.9 21.9 215 Senegal - - - - - - Zimbabwe 51.5 47.6 47.0 50.4 48.6 49.8 49.6 -Notavailable. a. Children les than two yes old with diarrhea in die two weets prceding the survey. b. Children less than five years old with fever in die fourweeks preceding dhe survey. c Data referto malaria duing the last cold season, zero to six mondis preceding the survcy. d. Severe cough or difficult breahing. c. Rapid or difficult breathing. Source: Boemna. Sommxerfel. and Rutstein 1991. five), circulatory system diseases are the most important causes of mortality. Surprisingly, injuries appear to be an unimportant cause of death, although the accuracy of the data is doubtful A large proportion of deaths in all age groups (23 percent) is lumped under "other causes" in Table 2-2, reflecting the weak- ness of the data. Maternal mortality rates in Africa are higher than anywhere else in the world due to a number of afflictions, including hemorrhage, infections, ob- structed labor, anaemia, hypertensive disorders of pregnancy, unsafe abortions, and violence (Box 2-1). These problems ae exacerbated by substandard prena- tal care, patient tardiness in seeking treatment when infection occurs, and a higher risk of sexually transmitted diseases due to multiple sexual partners. In Angola the national rate of maternal mortality was 570 per 100,000 live births; in areas like Kuando Hubango and Huarnb in the early 1990s, the rate exceeded 1,600 per 100,000 live births. Although comprehen;ive data on abortion in Af- 18 B ETTER H EALTH I N AF R I CA rica are lacking, a recent study estimated that there were approximately 75,000 abortions in Kenya in 1990. Exttmpolation to Sub-Saharan Africa suggests that there are up to 1.5 million abortions each year in the region as a whole (Rogo 1991). Studies on Ethiopia and Nigeria have indicated that almost 50 percent of maternal dcaths result from complications due to flawed abortions (Rogo 1991). African countries have some of the highest adolescent pregnancy rates in the world. By age eighteen, more than 40 percent of girls give birth in COte d'lvoire, Nigeria, and Mauritania. (Population Reference Bureau 1992). Large shares of pregnancies among unmarried women age fifteen to nineteen are un- intended: 87 percent in Botswana, 77 percent in Kenya, 74 percent in Togo, and 63 percent in Uganda (Senderowitz 1993). v survey of fifteen- to twenty-four- year-old females in Uganda revealed that 7 percent had had an abortion (Ageyi and Epema 1992). Early entry into reproductive life increases the risk of such health problems as anaemia, malnutrition, and sexually transmitted diseases (Wasserheit 1989). Persistent and New Health Threats Malaria is Africa's largest and most persistent disease problem (Table 24). Pregnant women, fetuses, and young children are particularly susceptible to malarial infection. wHo estimates the global number of malaria cases per year at 110 million, with nearly 80 percent of them occurring in Sub-Saharan Africa and only 1,000 cases in North Africa. A review of more than 400 studies on the subject suggests that malaria accounts for 20 to 50 percent of all admissions to African health services per year, although only an estimated 8 to 25 per- BOX 2-1. VIOLENCE AGAINST WOMEN not comply with men's sexual and AS A GLOBAL HEALTH ISSUE childbeaing demands. Where spou- sal consent is required before contra- Violence against women is a signifi- ceptives can be obtained, women can cant cause of female morbidity and be at increased risk of violence. In mortality in Africa and elsewhere.. Kenya, women have been known to Such violence indudes sexual abuse forge their partner's signature rather of children, physical and sexual as- than risk violence or abandonment. saults, and certain culture-bound When family planning clinics in Ethio- practices, such as female genital muti- pia removed their requirement for lation. A study in Kenya found that 42 spousal consent, clinic use rose 26 percent of women were "beaten regu- percent in justafew months (Cookand lady" (Raikes 1990). Women are often Maine1987). beaten or otherwise abused if they do HEALTH AND DEV EL OP M ENT 19 cent of persons with malaria visit health services (Brinkman and Brinkman 1991). Malaria now appears to be worsening in much of Africa as malaria para- sites become more resistant to chloroquine and other malarial drugs. Annual growth rates of the disease by country include 7 percentforZambia, 10 percent for Togo, and 21 percent for Rwanda. The data for Burkina Faso show a down- ward trend of 15 percent during the period from 1973 to 1981 but an 11 percent increase each year since then. Hospital data from Zambia indicate that mortality from malaria is rising 5 percent a year among children and almost 10 percent among adults (Brinkman and Brinkman 1991). The incidence of tuberculosis is also rising in Africa, due in part to the interaction between TB and AIDS and in part to a breakdown in surveillance and management of cases. By some estimates there are approximately 171 million Tm carriers in Africa, and 10 percent of all deaths from tuberculosis occur in children under age five (wHo 1991b). AIDS is the most dramatic new threat to health in Africa. More than 8 mil- lion African adults are estimated to be infected with the AIDS virus, HIV, With more than 1.5 million estimated to have full-fledged AiDs, although only 210,000 adult and pediatric AIDS cases have been officially reported to WHo. Table 2-4. Rank and Share of Malaria, AIDS, and Other Diseases in the Total Burden of Disease and Injury, Africa, 1990 Female Male Occurrence by Share Occurrence by Shtare rank order (percent) mnk order (percent) I Malaria II I Injuries 13 2 Respiratory infections II 2 Respiratory infections 11 3 Diarrhea] diseases 10 3 Malaria 11 4 Childhood cluster" 9 4 Diarrheal diseases 10 5 HIV/AIDS 6 5 Childhood clusteru 10 6 Perinatal 6 6 Perinatal 9 7 Matemal 6 7 HIvIAIDs 6 8 Injuries 6 8 Tuberculosis 5 9 Tuberculosis 4 9 Other rrDs 2 10 Other sTDs 3 Other causes 23 Other causes 28 Total 100 Total 100 a. Perussis. polio, diphtheria. measles, and te-tanus. Source: World Bank 1993e. 20 B ETTER H EA LTH IN A F RI CA There are large geographic variations in the prevalence of HIV (Figure 2-2). Approximately one-half to two-thirds of HIV infections have occurred in East and Central Africa, an area that has only one-sixth of the total populadon of Sub-Saharan Africa. Infection rates in men and women are close to equal. Young girls and commercial sex workers are particularly vulnerable. Moreover, and in contrast to malaria and many other causes of excess adult mortality in Africa, AIDS does not spare the elite. High levels of other sexually transmitted diseases, such as chancroid, syphilis, and gonorrhea, and the high rates at which new and unprotected sexual encounters occur in Africa appear to be important factors in HIV transmission. Thus, the prevalence rates of STDS other than AiDS are probably good indicators of the potential spread of HIV in countries where HIV infection rates are still low. Recent data suggest that the HIV pandemic has continued to spread, par- ticularly in Southern and Western Africa. More than 600,000 people are esti- mated to be infected in Zimbabwe alone. In the major urban areas of Botswana, HIV prevalence exceeds 18 percent among adults. In CBte d'lvoire the preva- lence of HiV among pregniant women in Abidjan is reported to have risen from 3.0 percent in 1986 to 14.8 percent in 1992. Sentinel surveillance from Nigeria shows that the epidemic has spread throughout the country. In nine of the eleven states in which sentinel surveillance has been instituted anong people attending sTD clinics, HIV prevalence is reported to range from less than 1 percent to 22 percenL Combating Demographic Pressures Rapid population growth exacerbates critical gaps in basic health services, es- pecially when economies are growing slowly or per capita incomes are in de- cline. This conjunction of factors produced negative average annual growth rats per capita for almost one-half of all African countries between 1965 and 1990. This is one reason why the ratio of people per doctor in Africa increased at only half the rate of other low- and middle-income countries over the past twenty-five years. - Africa is a continent of exceptionally high fertility and very low contracep- tive use. In 1992 the total fertility rate (average number of children ever born to women of reproductive ages) was approximately 6.5, compared with about 3.6 for all developing countries. Contraceptive use rates were only 11 percent on average, compared with approximately 51 percent for all developing countries and 71 percent for the industrial countries. Low rates of contraceptive use deprive couples of the health benefits asso- ciated with family planning. Good spacing of births and the integation of famn- H EA LT H AND DE V EL O PM ENT 21 Figure 2-2. Estimated HIV Infections, Sub-Saharan Africa, 1990 B11D 2043 ar t ~tr l w C;f;>7 - J ' 5 ' * .r X~- ',/t_rA S\ -'4 1 URITANIA ' ' ; *r i P.'~~~~~~~~~~~~~~H% S I DOT - 500 INECllN5 1 r IDT 00INFtkON -2r TOTAL INFECrIONSS- A. MILLION '* / *~~~~ r*"' " ,*g a , .... ,AO K RS NIG!t,/ j a 516 I,Owoo JUNE 1IV4 D3taprior to cw.aton oftheindepexndenitcountryof Eritma. Data for Liberia.Somnalim6 and Madagascarwere uraavaitable. Soursc: Rcproduced from Chin 1991. . . _ _ . . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ -5 . 22 BETT ER HE ALTH IN A FRICA ily planning services with maternal and child health cure lead to reduced infant, child, and maternal mortality (Box 2-2). The AIDS epidemic provides an additional reason for including family planning and STD services as part of a cost-effective set of interventions. Women with sexually transmitted diseases (STDS) ar estimated to be ten to fifty dimes more likely to contract the AIDS virus than those without STDS. According to a recent World Bank/wiio study of women at a prenatal clinic at Malago Hospital in Kampala, Uganda, syphilis and gonorrhea were found in 11 percent, chiamydia in 5 percent, and trichomoniasis vaginalis in 37 percent. High fertility rates also mean that growth in the numbers of particularly vulnerable demographic groups is likely to outstrip the capacity of private and BOX 2-2. HEALTH BENEFITS OF ranging from 22 to 40 percent of mar- FAMILY PLANNING ried women. Closing these gaps will clearly enhance the critical role The most widely confirmed health women have to play as agents of benefits of family planning derive from change for betterhealth. more efficient birth spacing. This can Fortunately, awareness regarding be achieved through modem methods the hazards of rapid population growth of family planning, helpinig women to has risen greatly among African improve their health and to increase policymakers. Twenty-five African chances that children will survive. To Il- countries have developed, or are in the lustrate, infant mortality rates are 69 process of developing, national popu- percent higher among women in latfon policies, and most African gov- Uganda who have a child less than two ernment leaders are signatories of years after a previous birth, than seminal declarations by parliamen- among those who wait two to three tarians in support of slowing rapid years. The same survey shows that population growth. The Report of the child deaths before five years of age South Commission, written by leaders are 27 percent higher among women from Nigeria, C6te d'lvoire, Mozam- who had their first birth before age bique, Zimbabwe, and Senegal, took a twenty, than those aged twenty to particularly strong stand on population twenty-nine. Inadequate birth spacing (South Commission and Nyerere also places women at risk of oieath 1987). Chaired by.'ulius K. Nyerere of themselves. Tanzania, the commission concluded That women want such services, yet that not only do high rates of popula- do not have sufficient access to them, tion growth r:..duce the resources isapparentfrom national demographic available per capita, making it difficult and health surveys in nine Sub- in some countries to maintain subsis- Saharan African countries, which re- tence levels, buttheyalso limitthe abil- veal unmet need for such services, ity to raise productivity. HE ALT H AND DE V E LOP ME NT 23 public health care providers. Between 1990 and 1995. approximately 75 million newborns will have joined Africa's population, or 14 million each year. Assum- ing "business as usual," World Bank projections indicate that the population of Africa will grow from 502 million in 1992 to 634 million by the end of the decade and to more than 1.2 billion by 2025. More optimistic projections, in- volving a rapid fertility decline scenario, suggest substantially reduced num- bers (Figure 2-3). Some countries have shown considemble awareness of the problems posed by high fertility rates. As of 1993, the governments of seventeen Sub-Saharan Africa countries had adopted official population policies, nine having done so since 1990 (African Population Advisory Committee 1993b). Figure 2-3. The Specter of 1.2 Billion People by 2025 Population (in millions) 1,400 - 1,203 1,200 - 1,000 - 933 800- 626 634 600 ~502 502 400- 200- 0 1992 .2000 2025 U Standard fertility decline E] Rapid fertiliy decline MAeo: Rapid fertility decline: underthe right circumstances Africa's population could grow farmore slowly, with approximately 88 million fewer births by the end of this century and 270 million fewer by 2025. This would imply a decline in Africa's population growth rate from its current level of 3.0 percent peryearto 1.3 paercnt per year by 2025. To accomplish this rapid fertility decline. family planning would havc to become an integral part of health care delivcry. with contraceptive prevalence rates rising from about 11 pezeent to about45 percent by the end of thedecadeandto75 percentby2025 (McNamara 1992). Morc than halfof this increaecouldbeachieved byac- commodating thdunmetneeds ofthe20 to40 pcrcentofsexually a-tive women who wantto limit theirfertility butwholackaccesst family planning. Source: Statistical appendix in this volume. 24 B ETTER H EA LTH IN A FRI CA The importance of raising contraceptive use rates sharply throughout Af- rica, especially over the next ten years, cannot be overstated. Reduced fertility would hold back population momentum and improve the age distribution of the population. Some countries, such as Botswana, Kenya, Mauritius, and Zim- babwe, are moving aggressively in this area. Such actions would help provide breathing space to governments currently unable to meet gaps in the demand for basic health services. Impact on Econiomic Development The effects of poor health go far beyond physical pain and suffering. Leaming is compromised, returns to human capital diminish, and environments forentre- preneurial and productive activities are constrained, And, in view of the demon- strated importance of human capital to economic progress, it comes as little surprise that no country has attained a high level of economic development wit apopulation crippled by high infant and matemal mortality, pervasive illness of its work force, and low life expectancy. Evidence showing that poor health imposes immense economic costs on individuals, households, and society at large is strong worldwide. A selection of findings makes a compelling case that better health can contribute positively to economic outcomes in Africa. U Household surveys in eight developing countries show that the eco- nomic effects of adult illness are substantial; tree of the four study countries with the highest incidence of adult illness are in Africa-COte d'Ivoire, Ghana, and Mauritania (King and Yan Wang 1993). In C8te d'Ivoire, 24 percent of the adult labor force experienced an illness or injury during the month prior to the survey, and 15 percent became at least temporarily inactive. These workers lost nine full days of work, on average, and the cost of treating them amounted to about 11 percent of their normal monthly eamings. Given the costs of treatment and the adjustments made elsewhere in society, the total cost of illness equaled almost 15 percent of per capita GDP. Similar losses occurred in Ghana and Mauritania (Table 2-5). * Studies of malaria in Rwanda, Burkina Faso, Chad, and Congo suggest that the direct and indirect costs of an average case were equivalent to about twelve days' output. Accordingly, the annual economic burden of malaria in 1987 was estimated at $800 million and was projected to rise to $1.7 billion by 1995. The economic costs of malaria represented about 0.6 percent of GDP in 1987, and were projected to rise to 1 percent by 1995 (Shepard and others 1991). The latter figure exceeds average govemment expenditures on health in several Sub-Saharan African countries during the mid-1980s. H EA LT H AND D EVE LO PMENT 25 Table 25. Economic Burden of Illness, Three African Countries C&re dVvoire Glwna Mauritania (1987) (1988-89) (1988) Burdenfor laborforce ages 20-59 years Workers experiencing illness/injury (percent) 24.1 44.4 18.4 Workers inactive due to illness/injury (percent) 14.8 26.4 17.2 Avemge work days 0ost to ill or injured workers 8.6 4.8 9.4 Share of nonnal inonthly earnings used to treat illness/injury (percent) 10.9 6.7 17.6 Costs of illness or injury averaged across all ivorkers Income losses due to illness as a share of total income of all adult labor force members (percent) 6.4 6.4 6.5 Income loss as a share of per capita GDP (percent)a 15.3 13.5 16.1 a. Incnme Ioss as a percentage of percapita cDP is higherthlan income loss averaged across all adult labor fione members because in the farmrermeasure, ODP per .mpita is reduced by pooling workers and nonworking depcndents. Source: King and Wang 1993. I In Nigeria, Guinea worm disease temporarily incapacitated 2.5 million Nigerians in 1987. A cost/benefit study in one area revealed that, apart from shortages of financing for agricultural activities, the disease was the chief im- pediment to rice production. It was estimated that the net effect of the disease was to reduce rice production by $50 million. It was also estimated that the benefits of a worm control program would exceed its costs after only four years (UNICEF 1987). * Diseases such as onchocerciasis and malaria are location-specific and have been shown to discourage settlement on and development of fertile land. By some accounts, trypanosomiasis has made one-third of Africa unsuitable for cattle raising, which in turn has aggravated protein deficiency problems (Ka- marck and World Bank 1976; Wells and Klees 1980). Onchocerciasis contrib- uted heavily to the depopulation of river valleys in Nigeria (Bradley 1976) and Ghana (Hunter 1966). Malaria and trypanosomiasis are inhibiting migration and resettlement of new lands in Uganda. 26 BETTER H EA LTH IN A FRI CA U AIDS will have immense economic consequences in Africa as the years pass because it is fatal and primarily strikes adults in their most productive years. The deaths of parents from AIDS will lower the incomes and well-being of their households, thus reducing the consumption level of survivors (Over and others 1991). Household savings and productive assets often have to be li- quidated to pay for medical care and funerals. The rise in mortality caused by AIDS will have particularly harsh effects on women, who in many African soci- eties are not entitled to inherit the property of their deceased husbands. The children of AIDS victiMs will often be forced to leave school early and go to work, thus weakening their economic prospects. The elderly will also suffer. Thus, the AIDS epidemic threatens to create large new pockets of poverty. FMgure 2-4. Potential AIDS Treatment Cost as Share of Total and Government Health Expenditures, Various African Countries, 1987-89 .70 - 60 - 50 - 40- 30 20- 1 0 0 Zimbabwe Kenya Malawi Tanizania Rtwanda E AIDs/Total health expenditure A oios/Govemment health expenditure Sourc: Ainswonh and Over 1992. H EA LTH AND D EVELO PM ENT 27 AIDS will also have a broad and negative impact on African economies. Figure 2-4 shows the potential cost of treating all persons infected by AIDS in five selected countries in the late 1980s. The cost of treating AIDS cases in Rwanda, for example, was potentially the equivalent of 60 percent of the public health budgeL In severely affected countries, the work force is likely to become younger, less skilled, and less experienced. In Tanzania and Uganda, for example, AIDS has already increased absenteeism and lowered productivity. Most models of the macroeconomic impact of the disease suggest that adult deaths from AIDS will cause per capita economic growth to be lower than it would have been otherwise. (Ainsworth and Over 1992; -World Bank 1991a; African Population Advisory Committee 1993c). * Using up savings and borrowing often take place during illness to fi- nance medical care and maintain consumption. West African households with family members suffering from onchocerciasis, for example, used assets like bridewealth to finance medical care (Evans 1989). In CMte d'Ivoire, average medical expenditures by households at the time of illness exceeded the loss of full-time employment eamings (at the local minimum wage) during illness (Corbett 1988). Sales of livestock and land are also frequently cited as a coping response to illness (Over and others 1991). One study of coastal Kenya found that ill health was the reason for a fourth of all land transactions (Chambers 1982). * Other mechanisms for coping with illness produce other economic ef- fects. A study of 250 Sudanese tenant families (Nur and Mahram 1986) found that healthy family members took time away from their other activities to main- tain farm production by performing the work offamnily members suffering from malaria and schistosomiasis. Other studies of malaria have found that a loss in work days by the affected individuals was partly compensated for by work by other members of agricultural households (Conly 1975; Castro and Mokate 1988). In urban areas, companies with high absenteeism due to employee health problems have lost many of the benefits of mass production (Over and others 1991). The negative effect of poor health on economic activity is unambiguous. By extension, improved health can be expected to have a positive impact on the economic well-being of families by lowering the costs of treatment for disease and easing demands on famnily members to care for the ill or for their survivors. Better health also helps employers by minimizing the absence of workers with key skills and experience. 28 B ETTER H EA LT H IN A FRI CA Conclusion This chapter has provided an overview of the epidemiological, demographic, and socioeconomic conditions affecting health in Africa. It has identified im- portant links between health and development High levels of mortality and morbidity cost Africa dearly in the quality of life and the capacity of its human resources. Poor health increases suffering and reduces people's alertness and their ability to cope with and enjoy life. Poor health shackles human capital and undermines socioeconomic environments conducive to entrepreneurial activities. CHAPTER THREE Creating an Enabling Environment for Health A CURSORY inspection of the world health picture suggests that the single most important factor determining survival is income. Yet a central message of this study is that even within existing levels of per capita income, health in Sub-Saharan Africa can be dramatically improved by strategies that create an enabling environment for health. That income is not the sole determining factor in health status is apparent from an analysis of cross-country variations in life expectancy that simul- taneously assesses the effects of income and other influences. Only one-half of the total gain in life expectancy over the thirty-year period from 1940 to 1970 could be accounted for in terms of changes in per capita income, adult literacy, and calorie intake (Preston 1980, 1983). It is equally important to realize that wealth does not necessarily bring health. Figure 3-1 shows that the mor- tality rate of males under age five in Zimbabwe is approximately one-half that in Cote d'Ivoire, even though Zimbabwe's per cajpita income is lower. And in Kenya, with a per capita income one-half that of Cote d'Ivoire, the male child mortaliqt rate is again lower, at 112 per thousand, compared with 144 for C6te d'Ivoire. Almost a decade ago, the Rockefeller Foundation sponsored a concerted effort to determine why health in China, Costa Rica, Sri Lanka, and the State of Kerala in India had improved so markedly despite very low annual per capita incomes. The conclusion was that poor countries could achieve good health through a pnlitical commitment to equity that took the form of policies and programs assuring wide access to food, education, and basic health services. Case studies of the three countries and Kerala showed that their govenments had managed to overcome the social and economic barriers that prevented the 29 30 BETTER H EA LT H IN A F R I C A Figure 3-1 Per Capita Income and Under-five Male Mortality in Eight Countries, 1990 Under-five mortality per 1,000 live births 300 Malawi 250 - 200 Nigeria 150 - Zaire 0 C6te d'lvoire zaire ~~~~~~~~SenegalU 100 - Kenya U Ghana 50 Zimbabwe 0I I I I I I 150 250 350 450 550 650 750 850 Per capita income (U.S. dollars) Source: World Bankdat. disadvantaged from obtaining those essential elements of health. With refer- ence to specific widespread physical ailments, such as diarrhea, the studies found that a multifaceted approach had been put into place that included social and environmental interventions as well as widespread access to a modem and well-managed system of health care (Halstead, Walsh, and Warren 1985). Figure 3-2 places the commitment to health in perspective as it relates to the simultaneous use of other inputs known to affect health at ihe household and community level. The kinds of benefits from creating an enabling environment for health can be illustrated with regard to safe water and sanitation, food secu- rity and nutrition, education, the special roles and status of women, and culture- Safe Water and Sanitation Safe water is an essential pillarof health. Yet large shares of Sub-Saharan Afri- can populations are deprived of safe drinking water. Poor sanitation and dis- C RE ATI NG AN E NAB LI NG ENV I R ON M.EN T 31 Figure 3-2 Services Contributing to Health of Households Smmunity F t HEALTH posal of fecal matter complicate matters, particularly in rural areas and periur- ban slums where seepage and runoff can contaminate ponds, streams, rivers, andwells (Box 3-1). A review (Esrey and others 1991) of findings from 144 studies revealed that improved water supply and sanitation often reduces child diarrheal mortality by 50 percent, and sometimes as much as 80 percent, depending on the type of intervention and on the presence of risk factors such as poor feeding practices and matemal illiteracy. Improvements in the rural water supply in Africa have resulted in a remarkable reduction in the number of cases of Guinea worm. In Nigeria, for example, 640,000 cases were reported in 1989; this number de- clined to 282,000 in' 1991 as a result of a combination of improved water supply and treatment and education. It is also evident that improved excreta disposal has a major impact on health, as does improved personal, domestic, and food hygiene. According to one study, improvements in excreta disposal reduced diarrhea morbidity by 22 percent compared with improvements in water quality (16 percent) and water availability (25 percent) or both together (37 percent). Studies in Lesotho re- corded a 36 percent reduction in diarrhea related to improved excreta disposal (Daniels and others 1990). The study concluded that interventions to improve excreta disposal would have a greater impact than improvements in water qual- ity, particularly in highly contamninated environments where the prevalence of diarrhea is high. Fecal-oral transmission of disease becomes a more serious problem as population densities increase. A study (Bradley and others 1992) comparing 32 B ETTER H EA LT H IN A F RICA BOX 3-1. THE ENVIRONMENTAL * Overcrowding in economically DIMENSION OF HEALTH: THE CASE OF depressed neighborhoods--e.g., with ACCRA average occupancy rates of 4.4 per- sons per room in the low-income resi- The Accra Metropolitan Area (AMA) dential area of James Town- had an estimated 1990 population of facilitates the spread of communicable 1.6 million, which is expected to grow disease and puts enormous pressure to more than 4 million by the year on shared resources such as kitchens, 2020. Accra is characterized by over- bathrooms, and laundres. Poor drain- crowding, inadequate municipal ser- age forces sullage, or wastewater dis- vices, and substandard housing. Al- charge, toflowthrough holes in house- most half of the population have hold walls onto the ground outside and incomes below the World Bank's abso- gives rise to stagnant pools for mos- lute poverty threshold. In this environ- quitos and moist soils in which hook- ment cholera cases are increasing worm ova readily develop. Malaria is steadily: between July and September the single most widespread disease, 1990, 113 cases were reported; in No- with 92,046 reported cases in the AMA, vember, another 354; and, within the or more than 40 percent of disease re- first two weeks of December alone, ports at outpatient facilities (Leitmann 239. - 1992). Almost half of the significant dis- * Where excreta disposal systems eases that are reported in Accra (ma- are poorly developed-especially in lana, measles, enteric iever, food poi- slums, squatter settlements, and peri- soning, tuberculosis, diarrhea, urban areas without convenient ac- leprosy, polio, guinea worm, typhus, cess to public facilities-defecation in and cholera) can be linked to the fol- public space, beaches, and water- lowing problems: courses is common. infection with helminths in an urban slum in Lagos, Nigeria, with infection in a rural district showed that 95 percent of school children in the urban study area were infected, compared with 52 percent in the rural area. Differences were attributed to the urban area's higher population density, lower level of hygiene, inferior drainage, and absence of excreta dirposal facilities. Food and Nutrition Malnutrition underlies more than one-third of infant and child mortality in rural and urban districts of many African countries (McGuire and Austin 1986) and 20 to 80 percent of matemal mortality. Protein-energy malnutrition, nutritional anemia, vitamin A deficiency, and iodine deficiency disorders have been iden- CR E ATI NG AN EN AB LING ENV I R ON MEN T 33 Box3-1 tconinued were not washed prior to eating; (b) swarms of disease-spreading flies * In slum areas where water is fre- around street food vendors and small quently purchased or the water supply restaurants (chop bars); and (c) the is irregular or both, daily per capita absence of enforceable legislation on consumption is about 60 liters, or less food quality and hygiene. than half of middle-income neighbor- n Accra's high temperatures and hoods. While water quality is generally considerable rainfall also favor dis- good at the source, its risk of contamn- ease vectors, of which the most prob- ination during transport, and low likeli- lematic are malaria-transmitting mos- hood of being boiled for sterilization, quitos, houseflies, cockroaches, bed raise the incidence of water-borne bugs, and lice; rodents are also preva- diseases. lent. Unfortunately, toxic pesticides * Until recently, illegal garbage can also have negative health dumps have choked the roadside, consequences. drains, and open spaces around These environmental health prob- households and provided breeding lems arise from a combination of inad- grounds for insects and rodents. Incin- equate infrastructure and services, erating refuse has resulted in air pollu- lack of settlements planning, and cul- tion and acute respiratory diseases tural practices. The result: 70 percent within the community. of the economic cost of health prob- a Poor hygienic food preparation lems in Ghana has been attributed to and handling in Accra lead to higher environmentally related diseases- prevalence of communicable dis- taking account of lost labor and the eascs, as noted in (a) a 36 percent cost of resources (doctors, nurses, prevalence of diarrhea among children technicians, administration, equip- in households where their hands ment, and drugs). tified as the most serious problems. Inadequate quality and quantity of food intake (including breastmilk) cause growth failure, decreased immunity, learn- ing disabilities, poor reproductive outcome, and reduced productivity (Box 3-2). Nutritional rehabilitation can be effectively undertaken as part of a district-based basic package of health services- In Tanzania, for example, the Iringa Nutrition Program and child survival and development programs in other regions succeeded in reducing severe malnutrition from a preprogram level of about 6 percent to a postprogram level of 2 percent. According to FAO estimates, the average per capita dietary energy supply worldwide reached 2,600 calories per day in 1985, but currently only 2LOO calories are available to each person every day in Sub-Saharan Africa (FAO 1991). Though increases in incomes of the poor may lead to increases in calorie 34 BETTER HE ALT H IN A FRI CA BOX 3-2. NUTRITION DEFICIENCIES infants be breastfed exclusively until AND STUNTING they are four to six months old, but in Nigeria, for example, only 1 percent of Nutritional deficiencies represent an such infants are exclusively breastfed. extremely serious health problem in In contrast, in Uganda, 70 percent of Africa. Stunting, which reflects the children age four to six months chronic, long-standing undernutrition, were exclusively breastfed during this is more widely prevalent than wasting, period, despite the fact that older in- which reflects acute nutritional cnrsis. A fants and young children are widely series of demographic and house- undernourished. Similarly, WHO rec- holds surveys in the 1980s revealed ommends that, by the age of six more than 20 percent of children from months, all infants should receive solid three months to thirty-six months old to foods in addition to breast milk. Yet, be stunted, compared with only 2 per- only 45 percent of infants from six to centin a reference populafton. nine months old in Mali, and 57 per- Poor feeding practices are at the cent in Ghana, receive breastmilk and heart of child nurition issues, reflect- solid foods. ing once again the importance of Source: U.S. Agency for Interna- household behavior for health im- tional Development 1993, Figure 2, provement. WHO recommends that all p. 5. consumption over and above the general population, improved income alone cannot be expected to raise calorie intake. Nutnrtion policy can make a differ- ence by: offering nutrition education parallel to income-generating activities to influence purchasing and feeding practices, providing women with functional literacy classes using nutritional themes, and targeting food subsidies. In addition to stressing household food security, intervention could empha- size the immunological and nutritional benefits of breastrmilk in African coun- tries, where the proportion of infants three months of age and under, exclusively breastfed, varies from about 2 percent to 89 percent A breastfed baby is only one-twentieth as likely to die from diarrheal diseases and one-quarter as likely to die from pneumonia as a baby who is bottle-fed (UNICEF 1992a). Female Education The education of females is so important to health improvement thrt it merits special attention in any reformulation of health policies that aim to improve health outcomes rather than solely improving the delivery of health care ser- vices. Women with more education marry and start having children later, make better use of health services, and make better use of information that will im- C RE ATI NG AN EN AB LING EN VI R ON ME NT 35 prove personal hygiene and the health of their children. Household surveys in Ghana, Nigeria, and Sudan show that the single most important influence on child survival is the level of a mother's education (Figure 3-3). 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 in- fant mortality in a given family by as much as 50 percent. Finally, having an educated adult female population can significantly increase the effectiveness of government expenditures on health; without an educated female population, the impact of govemment expenditures on health appears to fall dramatically (Bhargava and Yu 1992; Stomberg and Stomberg 1992). Female participation in primary and secondary schools has improved sig- nificantly in Africa over the past thirty years, but it has a long way to go to deliver the kinds of health benefits reviewed above. At the primary level, fe- Figure3-3. Under-five lortality and Level of Female Education, Selected African Countries, 1985-90 Under-five mortality rate per 1,000 live births 200- 150- 100 50 1 0 Senegal Uganda Ghana Toga Sudan Kenya * None |ij Primary complete O Secondary and higher Source: National Denagraphicand HcailhSurveys 1935-90. 36 BBET T ER HE ALT H IN A F RICA male participation rose from 24 percent in 1960 to 61 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 secondary education from 4 to 32 percent.) These levels compare poorly with the rest of the world. In 1985, for example, female primary enroll- mcnt in Africa was 58 percent, compared wiLh 92 percent for low-inicome econ- omies as a whole, Furthermore, the chances for girls to pursua higher levels of schooling worsen as they progress from grade to grade. Seventy-six percent of girls start school, compared with 86 percent of boys, but only 36 percent of the girls finish primary school, compared to 44percent of the boys. Of the girls who finish primary school, only 41 percent continue to secondary school, and-of this group-only 18 percent finish secondary school. These low levels of edu- cation are further reflected in the median literacy rates among Sub-Saharan African countries, which were only 38 percent for females in 1990, compared with 50 percent for all adults. Special Roles and Status of Women Women occupy a special place in efforts to improve health because they partici- pate in, and often manage, many activities that affect the health and well-being of their families. Women perform an estimated 60 to 80 percent of all agri- cultural labor in Africa, thus placing them in an important position to contribute to food security anid nutrition. Women are also largely responsible for fetching water and fuelwood, thus placing them in an important position to ensure safe drinking water and adequate cooking and preparation of food. In Kenya, for example, 89 percent of rural women over age fourteen, but only 5 percent of the men, report fetching water and fuelwood as one of their normal tasks (Cleaver and Schreiber 1993). Research on the determinants of infant mortality further shows that "the mother is the most important health worker for her children" (Schultz 1989). This conclusion not only reflects the strong correlation between female literacy and lower infant mortality, but agrees with studies of government expenditures on health showing that their effects are likely to be greater when they interface with an educated female population (Bhargava and Yu 1992; Stomberg and Stomberg 1992). Time availability is one of the most important constraints affecting the ability r women to produze healthy children. Surveys in Central African Re- public, C6te d'lvoire, Sudan, Tanzania, and Zambia show that rural women in Africa work more than ten hours a day, even without counting child care and health care responsibilities (Leslie 1987). Policymakers need to bear in mind that the supply of health care services, or even pharmaceuticals, may not lead to CREATING AN ENAB LING ENVIRO NM ENT 37 use if their availability does not respond to women's sense of priorit:cs and imposes unacceptable time costs for travel or time away from work. Culture Africans have long placed a high value on health care because good health is seen as the basis for development and societal gmwth. Traditional notions of disease and their origins are well established and can determine when, where, how, or even if treatment will be sought Traditional African societies categor- ize some diseases and illnesses as man-made or "spiritually" induced. For in- stance, in the Groun and Yoruba regions of Benin and Nigeri.i, respectively, smallpox was considered to be the manifestation of a super.,atural power, Segbata-a punishment inflicted by the goddess on those who had incurred her anger. Instead of being isolated, the sick person was taken from one place of worship to another in an effort to appease the goddess and, being in constant contact with the worshippers of Segbata, spread the disease unnecessarily to a greater number of people. In contrast, smallpox among some communities in Burkina Faso, Niger, and Chad was considered natural in origin and not the result of sacred or supernatural sourCes. As a result, people practiced a combi- nation of vaccinations and isolation of the sick. Yaws is not considered a disease in some parts of Cameroon, and goiter, which is an indicatio-, of a malfunction- ing thyroid gland, is not regarded as an illness in many traditional Nigerian and other African communities. So important are culture and ethnicity to health outcomes, that even if structural constraints are removed in the health sector, desired results are un- likely to be achieved unless the cultures of communities, health policymakers and planners, and providers of health care are taken into consideration. Indeed, increased attention by policymakers to these issues increases the chances of success in implementing policy. If this is done, providers will be less likely to display an ambivalence toward the use of traditional medicine; and users will be less likely to vacillate between modem and traditional medicine (Amadi 1992). Households at the Center The health benefits of policies to promote safe drinking water and sanitation, increasing levels of education, improved food security and nutrition, family planning, and health care depend on efforts by the individual and the house- hold. For drinking water to be safe and beneficial, households must be able to distinguish safe from nonpotable water, filter water when necessary, and en- sure that their members rely exclusively on these supplies for consumption. Addressing malnutrition requires appropriate storage, preparation, and shar- 38 B ETT ER HEALTH IN A FR ICA ing of food. The management of individual food supplies and use of food resources can only be undertaken at the household level, occasionally with community support. Self-care for illness can only be promoted by ensuring that households have access to sound health information and, in schools, suitable health educa- tion. The importance of self-care is indicated by a study in a Nigerian town that revealed that more than 80 percent of the illness episodes over a twelve-month period had been managed by the household (Brieger, Ramakrishna, and Ade- niyi 1986). Finally, without the active involvement of households in identifying symptoms of illness, providing information on the history of the illness to health care providers, and complying with treatment plans, even the best indi- vidual health care will have no impact on illness. *Engaging households and communities in health, and responding to the health-related demands of the public, must therefore be central to the concerns of Sub-Saharan African govemments for health improvement (U ox 3-3). There are important implications for health in Africa: BOX 3-3. INFORMATION, EDUCATION, showed that, in diarrhea cases treated AND COMMUNICATION AND THE HEALTH at home, the share treated with oRs in- BEHAVIOR OF INDIVIDUALS AND creased by 22 percent to 94 percent HOUSEHOLDS (Rasmuson 1985). a The Man Is Health program to ed- Information, education, and communi- ucate villagers in Tanzania on disease cation (lEc) programs for health have control led to the construction of hun- begun to receive increasing attention dreds of thousands of latrines and to in Africa as a means of improving significant increases in sales of mos- knowledge about individual self-care quito nets. Approximately two million and best practices. This is a two-way adults followed the Man Is Health radio street, however. Effective IEC pro- program (Hall 1978). grams also aim to establish what sorts * The importance of changing be- of health activites will engage the co- havior also has gained greater atten- operation, or lack of it, of households. tion in health circles as a result of the Afew examples of success: HIv pandermic. Social marketing, using m The Happy Baby lottery cam- commercial marketing techniques to paign in The Gambia taught mothers sell socially desirable products and the proper mixing and administration services below their full cost, shows of oral rehydration salts (ORS), to re- promise for expansion beyond popula- duce child mortality caused by dehy- tion, family planning, and condom pro- dration from diarrheal disease. An in- motion for AIDS prevention, into other dependent evaluation after two years health areas. A pilot projectto demon-. CR E ATI NG AN ENA BL ING ENV I RO NM ENT 39 * Provision of sound health information, in forms that are readily comprehensible by and credible to households, is a central re- sponsibility ofrAfrican govemments. * The impact of improved health care services on health outcomes of households and communities will be either greatly facilitated orconstrained, d!tpending on conditions in the socioeconomic and cultural enabling environment. Setting the Stage for Health Reform The international conference sponsored by the Rockefeller Foundation in 1985 proved that commitments to create an enabling environment for health arc integral to successful health strategy. The application of that model to all African countries would go a long way toward bringing Sub-Saharan Africa's health up to the level of health in the more prosperous countries. To do so means setting the stage for health reforms that would include the following elements: ox 3-3,contUnued untrained village health workers with- aspirin and other simple remedies to strate itsfeasibilitytotreatand prevent facilitate their interactions with bene- sexually transmitted diseases has ficiaries (Hall and Maleshal9gg). been underway in Cameroon since Analysis is needed to fornulate and 199t1 test effective lEc strategies and mes- Consuling beneficiaries and taking sages. An essential tool for changing their views into account is an espe- behavior is media-disseminated dally important aspect of efforts to pro- information-as distinct from formal mote changes in health-related behav- classroom learning-provided in ways ior. Program planners too often that are comprehensible and accept- operate within their own paradigms able to the varied audiences in Africa, and make unrealistic assumptions and backed by social science research about the values and desires of people on the cost-effectiveness of different whom they intend to help. Contrary to messages. And, despite the evident the frequent desire of health profes- importance of reaching people in their sionals to keep the modem and tradi- own language, a survey of twelve tional systems of care separate, a ben- countries in eastem and southem Af- eficiary assessment in Lesotho led to rica revealed that none possessed decisions to bring traditional healers subnational or regionally based local- into the national health system and to language radio stations that were give them basic health courses. It also geared to community programming led to a decision to provide almost (Johnston and deZeeuw199O). 40 BETTER HE A LTH IN A FRI CA BOX 3-4. THE WORLD SUMMIT FOR African goverments presented their CHILDREN: HEALTH GOALS FOR 1995 NPAS and reaffirmed their commitment AND 2000 to mobilize national resources for im- plementation, including thorough re- The Declaration and Plan of Action structuring of existing public expendi- adopted at the 1990 World Summit for tures. They also committed them- Children incorporate priority health selves to a set of intermediate goals by goals for children and women. Some the end of 1995. forty African countries have prepared The mid-decade health goals national plans of action (NPAS) adopt- adopted by African governments com- ing and adapting these goals to their mitthemto: national situation. Implementation is * Raise immunization coverage to a major problem in most countries, 80 percent against diphtheria, per- requiring ranking of national re- tussis, tetanus, poliomyelitis, and sources and sustained international tuberculosis support. a Ensure 90 percent immunization At the Organization of African Unity against measles as well as against (OAU) International Conference on As- tetanus for women of childbearing sistance to African Children in 1992, age Strong Political Commitment to BetterHealth Since the pivotal Alma Ata Declamtion of 1978, representatives of African countries have attended a number of international conferences, which, like the one at Alma Ata, were designed to stir action to improve the environment for health. All of the conferences ended in agreement that action was necessary, and pledges to act were made. Generally speaking, however, those agreements and pledges have remained mere symnbols of good intentions. Prior to 1990 only seventeen African govemments had prepared health pol- icy statements that could be called comprehensive and operationally relevant Only five of the seventeen-those of Botswana, Mali, Nigeria, Swaziland, and Tanzania-discussed problems in the enabling environment and outlined pro- grams to correct them. Following the 1990 World Summit for Children, sponsored by UNICEF, many African countries began preparing national plans of action (NPAS) cover- ing many aspects of the enabling environment. According to WHO (Monekosso 1993), twenty-nine African countries had adopted policies on the provision of basic health care by the middle of 1993. However, these policies ignore many elements of the enabling environment. CR EAT I NG AN EN AB LIN G E NVI R ON M ENT 41 Box3-4contfnued caused by acute respiratory infections * Achievement of at least 90 per- m Achieve 80 percent use of oral re- cent immunization coverage of one- hydration therapy year-old children, as well as universal * Virtually eliminate iodine defi- tetanus immunization for women of ciency disorders and vitamin A childbearingage deficiency * Access for all women to prenatal * Encourage exclusive breastfeed- care, trained attendants during child- ing for four to six months following birth, referral for high-risk pregnancies childbirth and sustain breastfeeding and obstetric emergencies, and halv- ior up to two years of age and beyond. ing of maternal mortality rates The goals fortheyear200O include: * Elimination of dracunculiasis and * A reduction to 70 per 1,000 in the eradication of polio. mortality of children less than five In the process of building basic yearsold,orbyathirdofthe1990leveI health systems that lead to improve- if it is already lowerthan 70 ments in health, the challenge is to use * A 50 percent reduction in. child goals such asthose of the World Sum- deaths caused by diarrhea and a re- mitforChildren to setpriorities and en- duction by one-third in child deaths sure accountability. To demonstrate a real commitment to the creation of an enabling environ- ment for health. governments need to formulate comprehensive, operationally oriented health policies that include explicit health goals and targets, statements on how all the elements of the enabling environment will be strengthened, and specific arrangements for monitoring and evaluating progress. More Cost-Effective and Equitable Use ofPublic Funds Public spending on health needs to be guided more stringently by cost- effectiveness and equity criteria. Correcting the most obvious inequitry-the overfinancing of curative medical care and the underfinancing of primary and preventive care-would also go a long way toward correcting inefficiencies in the allocation of public spending for health. Redirecting spending away from curative care to combat the majority of diseases and illnesses that are prevent- able or relatively easily treated has obvious appeal on cost-effectiveness grounds. The argument for greater equity in health spending is a particularly strong one, given the widespread poverty and the many political and economic conditions that make for unstable household incomes. Just as important to good health are the public services known to have an immense impact on health such as safe water, sanitation, and prevention of 42 BETTER HEALTH IN A FRI CA communicable diseases. Such services benefit the community at large but the investments are frequently so costly that people are unlikely to be motivated to provide them for themselves on an individual basis. Thus, if these services are to be provided, local or national governments will be the only agents capable of ensuring that they are provided. Moreover, national and local governments are often the only institutions that have the necessary legal authority to do so. Public services targeted to those who have not previously benefited from them have redistributive effects. Hence commitments to provide such services are in accord with the goal of health equity. In most African countries, equity and efficiency considerations are fully consistent. More Effective Incentives Households and health service providers need financial and other incentives to encourage increased ernciency in using health resources. When the cost to households of using hospital-based services is no greater than using local health centers, as discussed in detail in subsequent chapters, people will naturrIly turn to hospitals. Yet the cost to society of pro- viding care in hospitals is usually much higher than at health centers. Appropri- ate price signals combined with quality care at health centers can create the right incentives forhouseholds to use services where they can be provided most cost-effectively. Health service providers also need to face incentives to provide high- quality services at low cost. Transparency, local accountability, and local retention of revenues from fees can establish incentives among public sector, private voluntary, and private for-profit providers, to furnish high-quality and low-cost services. More Pluralistic Decis:onmaking. One of the chief elements of any strategy to improve health in Sub-Saharan Africa must be a commitment to recognize and encourage the decisionmaking on health issues of households and communities. Put another way, the tradition of hierarchical decisionmaking in matters affecting health must give way to more pluralistic decisionmaking. This is not a new concept with respect to African health. As long ago as the Alma Ata Declaration of 1978, the notion of greatercommunity involvement in decisionmaking was proclaimed as one of the antidotes to illness and disease. As time has passed, more and more evidence has accumulated that the partici- pation of local community groups in the design and implementation of health and health-related activities has a significant impact on success and sus- tainability. Success and sustainability, in turn, arise in part from the recognition that tradition is an important factor in community life and must be taken into account. But tradition is hardly the only reason for greater community involve- CR EATING AN E NAB LING ENV I RON M ENT 43 ment. Those who live in local communities have a good view of their own health problems and, therefore, can make valuable contributions to solving them. Moreover, local communities themselves have become more assertive be- cause of poor delivery of publicly financed and publicly provided services. This assertiveness has been accompanied by stronger demands for control of public resources at the provincial and local levels. Given that hierarchical decisionmaking is also a tradition in Africa, such impulses toward greater pluralism in health have encountered resistance from many in established political and medical circles. Nonetheless, this report is based in large part on the belief that households and communities, because they are the heart of the health system, must be not only recipients of medical ser- vices but also active participants in determining, funding, and managing the wide range of health interventions. The most important prerequisites for achieving these goals are a sustained political commitment to them and (where necessary) retraining of civil servants (WHO 1988a). Medical officers at the local level, forexample, often fail to appreciate the value of community partici- pation. Even when they understand its importance, they often lack the training needed to facilitate community involvement. Greater recognition of the voice of the public will be enhanced by adminis- raive decentrlization-that is, giving public officials at the regional and local levels greater authority in decisionmaking. Overly centralized public administra- tion in many African countries has meant failure to provide the organizational framework, managerial processes, and financial and human resources needed to make longlasting successful attacks on health problems. The organizational stricture of Benin's ministry of health, for example, has been characterized as overcentralized and managerially weak. Under Cote d'Ivoire's health care sys- tem, decisionmaking used to be the exclusive responsibility of the state. Although various methods of health service decentralization have been attempted in a num- ber of Sub-Saharan African countries, success has often been undermined by unclear linkages among the various levels of government and by inadequate au- thority at the local level to make expenditures. These and other aspects of institu- tional decentralization are discussed in greater detail in Chapter 8. Better Use of Donor Funding to Build National Capabilities Donor funds now account for about one-fifth of the spending on health in Af- rica. This eases the financial burden for countries often hard-pressed by factors beyond their control. Unfortunately, however, donor funding in too many in- stances has been a case of the tail wagging the dog. The donors-mainly multi- lateral and international institutions, and national governments in the industrial 44 BETTE R H EA LT H IN A F RI CA world-have sometimes had their own agendas, and in carrying out these agendas the donors' wishes have tended to dominate the health agendas of the recipient countries or else complicated the implementation of national agendas by setting up projects and programs outside national purview. In many cases donors' actions have tended to fragment the health sectors of the African coun- tries. In other words, the frequent failure to integrate donor-financed activities as part of comprehensive national policy has resulted in duplication, overlap, lack of consistency in standards and procedures, and inconsistent or disjointed policy recommendations. The time has come for Sub-Saharan African countries to put donor funding to work in sustainable ways to make dynamic improvements in health. In the long run, onlv African countries themselves can make the right decisions about their health goals and the means necessary to achieve them. CHAPTER FOUR Revitalizing National Systems of Health Care W HEN PEOPLE are struck by serious illness, effective use of the health care system plays a large role in their recovery. Yet it is equally true that recovery-or, in many cases, the ability of people to obtain preventive care that forestalls illness-depends on whether existing health care systems are operating efficiendy and equitably. But many health care systems in Africa are unable to provide preventive and primary care near where a majority of their people live and work, which is in rural and periurban areas. The need, therefore, is to expand health care services and to provide care in more cost-effective ways. And to promote equity, the use of public resources for health care must produce greater benefits for the poor. This chapter describes Africa's current health care systems and identifies ways to revitalize their lagging performance. A careful look at recent experi- ence in several African countries strongly suggests that household welfare and the cost-effectiveness of health care improve when preventive and primary ser- vices are offered by well-functioning health centers working in coordination with small first-refernal hospitals in rural and periurban areas. African Health Care Systems Today The health care systems inherited by African countries at -independence were equipped to provide personal care to only a small fraction of the population. During colonial rule, control of endemic diseases was the main concern of the French and British regimes. The French made serious efforts to deal with vector-borne diseases through programs organized on a paramilitary basis, while -the British placed greater stress on controlling fecal contamination of 45 46 B ETT ER H EA LT H IN A F R I C A food and water. Hospitals were built principally for the benefit of colonial ad- ministrators and settlers, and rural clinics were usually the by-product of mis- sionary activities. From time to time, a few elite Africans were invited to use the modem facilities establishedforoutsiders, butsuch matters as health educa- tion, mass immunizations, screening of populations for disease, and good nutri- don played only a small part in colonial policies. Progress since independence has varied greatly from country to country. When access to personal care, for instance, is defined as the patient being no more than an hour away from a health facility by local means of transportation, only 11 percent of the rural population in C6te d'lvoire, 15 percent in Somalia, 25 percent in Rwanda, and 30 percent in Liberia, Niger, and Nigeria have such access. Some African countries, however, have made a concerted effort to im- prove access by emphasizing the delivery of prmary health care in rural areas. wHo reports that some 99 percent of the rural residents of Mauritius have such access, as do 85 percent in Botswana, 73 percent in Tanzania, and 70 percent in Congo. Within most African countries, though, access to personal health care tends to be highly unequal across administrative districts and between rural and urban areas. Among thirty states in Nigeria, the number of health facilities ranges from one per 200 people in Lagos State to one per 129,000 in Benue State. Three-fourths of the country's public and private health facilities are located in urban areas, which contain only 30 percent of the population. In Angola the supply of hospital beds ranges from 4 per 10,000 people in the province of Malage to 42 per 10,000 in Luanda Norte. In Kenya there is one doctor on average per500 people inNairobi, compared with one perlf6,OOO people in the rural Turkana district. Periurban areas are also underserved, especially squatter- tpe settlements, which also lack basic water and sanitation services. The geographic imbalance in access to health care is reflected by the im- balance in public spending on health care. Major urban hospitals (so-called tertiary facilities) often receive half or more of the public funds spent on health and commonly account for 50 to 80 percent of recurrent health sector expendi- tures by the government In the mid-1980s, for example, the major hospitals' share of public recurrent health expenditures was 74 percent in Lesotho, 70 percent in Somalia, 66 percent in Burundi, 54 percent in Zimbabwe, and 49 percent in Botswana (Barnum and Kutzin 1993). In .Adition, major urban hospitals often employ the largest proportions of highly trained health personnel. In Kenya, for example, 60 percent of all physi- cians and 80 percent of all nurses are assigned to such hospitals (Bloom, Segall, andTh.ube 1986). inpatient spending at major hospitals, however, is often devoted mainly to paying the costs of treating conditions that could have been managed or even REV I TA LIZ ING N ATI ON AL SYS TE MS 47 prevented by primary care. These include malaria, tuberculosis, unwanted pregnancies, digestive ailments, ill-defined fevers, respiratory infections, and skin infections. Among the ten leading causes of admission to hospitals in Mal- awi and Nigeria in the mid-1980s, forexample, parasitic and infectious diseases ranked first. It would appear that at least a third of all hospital expenditures in Africa could be avoided if more cost-etffective strategies than remedial care- such as vector control, environmental protection measures, and construction of household sanitation facilities-were used to reduce the incidence of infectious and parasitic diseases. The disproportionate assignment of professional medical personnel to ma- jor urban hospitals, the use of more expensive inputs in outpatient services, and their more reliable supply of drugs often means that such hospitals compete with, rather than complement, health centers and small rural hospitals (Box 4-1). The Multitiered System ofHealth Care Health sector problems in Africa can be traced in large part to the continued hierarchical organization of health care. In most African countries, personal health care facilities reflect the country's administrative hierarchy, which oper- ates from the top down. In theory, village health posts, local dispensaries, health centers, and small rural hospitals are intended to provide the preventive and primary care needed by the people living in rural and periurban areas. This is where the bulk of Africa's population lives, it is where demand is greatest. and it is where preventive and primary care would have the greatest positive impact BOX 4-1. WHY PRIMARY AND linked to congested outpatient depart- PREVENTIVE CARE SHOULD NOT BE ments and overworked laboratories PROVIDED BY HOSPITALS performing hundreds of so-called rou- tine tests. * Provision of primary and preven- * The pressure of primary care on tive care by hospitals is uneconomical; hospital facilities also distorts health treatment cost per illness is much program development at the commu- moreexpensivethanatahealthcenter nity level because it fixes attention on or dispensary. By some estimates it the distressed hospital, creating the can be ten to twenty-five times as impression that further extension and much. development is required, when the * Provision of primary care distorts real need is for a very large increase in a hospital's functions. Many of the ap- the number of effectively functioning parent shortcomings of hospitals are health centers. 48 SET TER HE A LTH IN AFRICA on national health. But at these lower levels of the health care hierarchy, bureau- cratic authority is weakest and spending is lowest. Neither private providers nor private voluntary organizations have filled the resulting gaps in the provision of health care. Although private voluntary organizations, such as mission hospi- tals and clinics, often are effective providers in local areas, they account for only 5 to !O percent of all health expenditures in most African countnes. The poor quality of care in many rural and periurban areas is often the result of shortages of qualified staff, lack of essential supplies (such as effective generic drugs), unreliable health data, and insufficient numbers of health facili- ties. In some cases, though, administrative weaknesses become apparent be- cause facilities are underused and overstaffed. Some rural health centers in Tan- zania, for example, were found to employ twenty health workers who treated only three orfourpatientsa day. Lack of standards for facilities and procedures complicates matters. As a result of lax building standards, basic health faciliides in Sahelian countries range anywhere from 46 to 1,734 square meters in floor space, thus contributing to an uneven infrastructure across communities (Ab- eilld and others 1991). Given the absence or inadequacy of many village clinics, health care cen- ters, and small rural hospitals, they often are bypassed by potential clients who decide to seek better care at full-fledged urban hospitals (Bocar 1989). As a result, overqualified staff and expensive facilities are used in ways their plan- ners did not contemplate. Most major hospitals in Sub-Saharan Africa now commonly provide primary and preventive health care services, such as vac- cinations, growth monitoring, and prenatal care (Van Lerberghe, Van Balen, and Kegels 1989), becoming in effect direct competitors with lesser facilities. While the quality of care provided by large hospitals may be quite good, the social costs are high. In addition to longer travel time to and longer waiting time at these hospitals, clients from rural and periurban areas are deprived of the personal attention and the more frequent follow-up visits that could be provided by a local facility. The Perfonnance ofMajorAfrican Hospitals Major Affican hospitals, often referred to as central or tertiary level hospitals, are at the top of the personal health care system in most African countries. They are often associated with a medical school and are designed to offer clinical services highly differentiated by function, technical capacity, and skills-for example, cardiological services and ragnetic resonance imaging (MRI) units. The numberof beds in these hospitals ranges from 300 to more than 1,500. The greater complexity of the cases that these hospitals were designed to handle and their more expensive inputs commonly translate into much higher REV I TALI ZING N ATI ON AL SY STEMS 49 operating costs than at lower levels ol the medical care hierarchy. However, the extent to which resources are concentrated in these hospitals often goes beyond what they need to fulfill their curative functions (Barnum and Kutzin 1993). In Zambia, for instance, the country's three large central hospitals used 30 percent of all Ministry of Health resources and an estimated 45 percentof the ministry's total hospital resources in the 1980s. The remaining 55 percent was spread among thirty-nine lower-level hospitals. In Kenya, the Kenyatta National Hos- pital accounted for almost 20 percent of the ministry's recurrent financial spending in 1986-87, and Kenya's provincial hospitals used another 24 percent. In Zimbabwe, 45 percent of the ministry's allocations were used for recurrent expenditures at four central hospitals. But upper-level hospitals arc less cost-effective in reducing mortality or morbidity than facilities lower in the hierarchy. In Ghana, for example, the leading causes of morbidity are upper respiratory tract infections, diarrhea, parasitic diseases, and accidents. The leading causes of mortality are vaccine- preventable diseases, respiratory diseases, malnutrition, diarrhea, and acci- dents. Hospitals do notplay a significant role in reducing years of life lost due to any of these causes except accidents (Barnum and Kutzin 1993). Africa's major hospitals, as noted earlier, are usually located in metropoli- tan areas. Thus, even when their stated purpose is to provide tertiary care (that is, specialized, second-referral care) for a broad population base, they actually provide large amounts of primary and first-referral care to a disproportionately urban clientele. Moreover, urban residents in Africa generally have higher in- comes than those living in rural areas. Surveys of patients at Niamey National Hospital in Niger, for example, showed that outpatients had a higher median income than inpatients, whose median income was comparable to or slightly higher than that of other urban residents. Urban residents, in turn, had higher incomes than rural residents (Weaver, Handou, and Mohamed 1990). The concentration of resources at the tertiary level in urban areas, with benefits going disproportionately to households with higher incomes, defeats the objective of providing equitable and cost-etkctive care throughout the country to people at every income level. This does not mean that tertiary hospi- tals should be disregarded. They play a necessary role in curing illnesses whose successful treatment requires specialized medical procedures. The point, rather, is that tertiary hospitals should play this role within a larger system designed to meet the health needs of the entire population. A BriefHistory of Primary Health Care Strategies in Africa The 1978 Alma Ata Declaration stressed the importance of providing primary health care for everyone in the developing countries and the need for strong so B ETT ER H EA LT H IN A F R I C A community participation in achieving that goal. In subsequent years, low- ever, efibarts to providc primary health care have taken the form of either highly selective, "vertical" programs designed to deal separately with spe- cific health problems, or broader programs involving community or village health workers (cHws or VHWS). In most African countres, neither of Jhese strategies has done much to persuade policymakers to shil't resources away from curative care to a well-defined package of cost-effective primary and preventive care services. Usually developed with the strong support of international and multi- lateral donors, vertical programs have focused on specific problems, such as controlling outbreaks of contagious childhood diseases through mass immu- nizations, or encouraging greater use of family planning mcasures. Narrow targets and assured funding made it possible to use many means (including mobile teams) to provide quality care and to gain community acceptance of these specific interventions. Some of the vertical programs have proved worthwhile. The most striking success was the eradication of smallpox in 1977, after the world's last known case showed up in Somalia. Vertical programs also appear to have been cost- effective when crises have occurred in the form of threatened epidemics follow- ing earthquakes and floods. But these highly selective programs have had minuses as well as pluses. To administer these programs, vertical administrative endties have been set up that often had little contact with the national agencies or local officials charged with responsibility for health care administration. Because of minimal coordination between separate vertical programs in the same country or region and little .integration with the rest of the health care system, selective, single-purpose interventions have sometimes proved disappointing (Table 4-1). Reviews of progrmms in Burkina Faso, Mali, Niger, and Central African Republic have uncovered various problems: * District health teams have sometimes included as many as ten coordina- tors for ten different vertical programs, each supervising health personnel and reporting to a different administrator, when one or two coordinators would have been enough. * AIDS screening kits and EPI vaccines have been transported in separate "cold chains" (refrigeration facilities) when both could have been distributed through the same chain. * Administration of Zaire's family planning program was artificially split between two national agencies, and the ensuing competition between them did litde to increase contraceptive prevalence rates. REV ITA LIZ ING N ATIO NA L S YST EMS 61. Table 4-1. Single-Purpose Interventions: A Review of Studies Study design n terventi ln Conclusion Longitudinal with Measles vaccinalion Reduction in measles deaths control group (Kasongo, Zaire) partly wiped out by delayed excess monality from other causes in vaccinated group Before/after Oral rehydration Impact on under-five mortality (Several studies) lower than expected from reduction of diarriea deaths Time series Community-based nutrition Under-five mortality gains (Iringa, Tanzania) reversed due to malaria Before/after Malaria control and measles Reduction in undcr-five vaccination (Saradidi, Kenya) mortality attributed to measles vaccination, not malaria control Before/after Measles vaccination Impact on under-five mortality CMvumi, Tanzania) wiped out by malaria Source;- Knippenberp. Ofcnu-Amvh. and Parker 1990. U Some vertical programs have attracted large amounts of resources from donors and governments, while other causes of mortality and morbidity have been largely ignored. One study found that up to 15 percent of the women in some regions where vertical AIDS programs were in operation were suffering from untreated syphilis, a disease that creates a particularly receptive environ- ment for H iv. * Routine health care can be disrupted and national capacity weakened when vertical programs temporarily or permanently lure away specialists from national health systems. On a more positive note, selective PHC programs have enjoyed positive and robust resalts in situations where health centers and under-five clinics offer integrated child care. High levels of immunization have been sustained and significant reductions in infant and child mortality rates achieved by integrating maternal and child health care services in health facilities in Guinea and Benin. The principal shortcoming of vertical programs is that they are not in- tended to and cannot provide steady and ongoing care. A child born after a mobile team spends a week in a community to vaccinate children against an immunizable disease may not be immunized until another team comes along six 52 BETTER H EA LTH IN A F RICA months latcr. Meanwhile, the child may get the disease. What is needed are health facilities that give vaccinations regularly. The Expanded Programme of linmunization (EPI) in Togo, Senegal, Ivory Coast, and Congo (UNICEF 1990a) only temporarily increased the number of children vaccinated because vaccina- tions were not a part of the daily responsibilities of health centers (Figure 4-1, upper panel A). In Zimbabwe (Cornea. Jolly, and Stewart 1987), Botswana, and Cape Verde (UNICEF 1990a), in contrast, immunization coverage was high and significant reductions in infant and child mortality were achieved when immu- nization and maternal and child health services became the ongoing responsi- bility of permanent health facilities. In Benin, a strategy of simultaneously im- proving health care service and immunization coverage led to a steady and sustained increase in Epi coverage (Figure 4-1, B). Village Health Workers Attempts have also been made to expand primary health care by establishing networks of village or community health workers (VHW or CHW) modeled on China's success in using "barefoot doctors" to enlarge the geographic scope of health care. VHW programs are aimed at extending health care to unserved re- gions, while CHW programs are principally intended to be catalysts for commu- nity development and involve a more holistic approach to health that includes such tasks as developing safe water supplies. : These programs have performed relatively well when their role as inter- mediaries between the community and the health care system is clear, and when they receive visible support from health centers. This has been the case in Les- otho, where more than 4,000 trained village health workers are supported by local development councils; in Zimbabwe, wheie more than 6,000 CHWS re- ceive stipends as general development workers; and in Zaire, where CHWs are persons selected by their communities to act as liaisons to the health establish- ment (Reynders and others 1992). The contribution of VHW or CHw workers to community involvement in the planning and management of health services has also been documented in Kenya, Tanzania, Zaire, and Somalia (Beza and others 1987; Leneman and Fowkes 1986,4; Vaughn, Mills, and Smith 1984). VHW and CHW programs have not worked well when their links to the health system and to communities have been weak. In Burkina Faso, Gambia, Ghana, Niger, and Tanzania, community health workers were trained on a mas- sive scale in the 1980s to be the principal providers of primary health care. Because of their limited training and nebulous connection to the formal system of health care, these CHWS were forced to rely on support and supervision from cadres of specialized coordinators, often organized by nongovernmental organ- A E£ ITA LIZ ING NAT IONA L SYSTEMS 53 Figure 4-1. Performance of Expanded Programme of Immunizatlon (rr1I) under Different Condiffons A. EPi through campaign or mobile strategies Percent coverage 80- 70- 60- 40- 30- 20- 10 0 Burkina Faso Cbte d'lvolre Mauritania Togo B. EPI through strong network of health centers Percent coverage 100- 90- 80- 70- 60- 50- 40- 30- 20- 10- 0 Benin Botswana Cape Verde Rwanda Zimbabwe Ea1986 E1987 *1988 *1989 I|j1990 SoUrCe: WHO Infonmation System 1993. 54 eBE TT ER H EA LTH IN A F RICA izations (NGOs) or externally funded projects. The potential contribution of community health workers has been blunted by lack of constant support and supervision (Sauerborn, Nougtara, and Diesreld 1989: Walt 1988; Walt, Perera, and Heggenhougen 1989). Table 4-2 summarizes the findings of a number of studies that reveal that VHW and CHW programs have produced mixed results. If they have no clear connection to the existing health system, community health workers are often bypassed by household members who consult providers at the first level of the formal system. Their presence may even delay access to professional care rather than deter unnecessary consultations. High attrition rates among CHW workers, exacerbated by dwindling donor support for the programs, suggest that the value of these programs should be reexamined. Health Care System Realities T he reality in many African countries is that health care systems are not provid- ing cost-effective services in ways that would have the gmatest impact on the major causes of illness and death. For households, this means low confidence in the health system and barely marginal improvements in health. For govern- ments, this means that a large share of public expenditures on health is wasted. For private providers, this often means trying to deal with a vast number of unmet needs with little guidance, assistance, or even competition from the pub- lic sector. Chronic shortages of drugs. infrequent equipment maintenance, inade- quate logistical support, and weak supervision further contribute to ineffi- ciency. Also lacking are procedures or systemns to monitor and evaluate the quality of health care and to ensure that providers are accountable to clients. National standards that would make it possible to ascertain progress in resolv- ing health problems across communities, districts, and countries do not exist (Smith and Bryant 1988; Pangu 1988). Thus, it is difficult to know whether a particular health intervention is having a discernible impact on major health problems. It might seem obvious that first-referral hospitals should be a vital part of an effective health care system. In the years after Alma Ata, however, many policymakers seemed to think that district hospitals were irrelevant. In Tanzania, for example, the Essential Drugs Program provided donor- funded drug kits to dispensaries in rural areas but not to first-referral hospi- tals. PHC policies have done little to divert public resources away from major urban and teaching hospitals, while severely weakening peripheral and rural hospitals. REV I TA-L I Z ING NAT IO NA L SYSTEMS 55 Table 4-2. Review orvniw and CHW PrOgMrMS Coutmy or region Metlhd Findings Africa Review of 1,000 publications Problems in all aspects of the fiunctioning of VHIwS (tasks, selection, recruitment, training, remuneration, and, most seriously, support). West African Desk review Same observations. countries Senegal and other Case studies Same observations; questioned West African relevance and sustainability. countries Tanzania Multipiicity of methods used Below a certain level of support to gather information on the the quality of community-based acceptability, quality, and health services is very cost of the CHW program questionable. Niger Systems analysis combined Training of rnore than 13,000 questionnaires from VHWS, vHws provided additional mothers, supervisors, and access to primary health care in community representatives; 45 percent of the villages of structured observations of Niger. but low quality of care service delivery and support was linked to weak support activities, and focus group discussions with villagers Burkina Faso Representative. household Presence of village health posts survey on MCH did not increase use of MCII care. The Gambia Mortality surveys to assess No impact of TBAS on maternal the impact of a TBA program mortality. on maternal mortality Ghana Study of community clinic Problems related to the selec- attendants (vHws) in nine of tion, training, abuse of the ten regions of the country functions, lack of remuneration, shortage of drugs, and supervision; the program generally failed to achieve its objectives. Note: CHW. community health worker. MCH. maternal and child Walth: ITA, trained birth attendant: VHw, village health worker. Source: Knippenberg. Ofoso-Amaah. and Parker 1991. 56 BETTER H EA LTH IN A F RICA Underpinnings of a Cost-Effective Approach Well-functioning health centers, working in conjunction wiLh first-referral hos- pitals, has e the capacity to manage more than 90 percent of health care de- mands. Experience in a number of African countries shows that the most funda- mental element of such an approach is a limited and flexible, cost-effective package of basic services that can be delivered at the community level. The first element of the package is a basic set of health care inputs. The second is a battery of supporting services that aim to ensure that households make the most effective use of such inputs. Tbe third consists of multisectoral inputs to better health. The basic services emphasized in this report are those needed largely in countries that have not yet passed through the "health transition." This means a shift in the demographic and epidemiological makeup of a country, and associ- ated social conditions and attitudes, from an environment dominated by high fertility, high mortality, infectious disease, and malnutrition to a low-mortality. low-fertility environment with a disease profile increasirngly weighted toward noncommunicable conditions of adults and the elderly. Although some popula- tion groups within individual African countries, particularly among the clite, have entered or passed the health transition, the package concept still applies to all countries and populations. Both the content and the cost of a basic package BOX 4-2. COST-EFFECTIVE HEALTH lower the unit cost to gain one DALY, INTERVENTIONS the greaterthe valuefor money offered by the intervention. The cost-effectveness of many of the Only a small number of the thou- health interventions recommended in sands of known medical procedures this study has been substantated in have been assessed using the cost- the World Bank's Worfd Developmont effectiveness criteria described above, Report 1993: Investing in Health. but the approximately fifty studied Given a common currency for measur- would be able to deal with more than ing cost and a unit for measuring half the world's disease burden. Just health effects, the World Development implementing the twenty most cost- Report compares the costs required effective interventions could eliminate for different interventions to achieve more than 40 percent of the total bur- one additional year of healthy life. Out- den and fully three-quarters of the comes are expressed in terms of health lossamongchildren. disability-adjusted life years (DALYS). Several public health activities The ratio of cost and effect or the unit stand out as being particularly cost- cost of a DALY, is called the cost- effective: the cost of gaining one OALY effectiveness of the intervention. The can be remarkably low-sometimes REVITA LIZI NG NAT IO NA L SY STEMS 57 w.ll vary according to a country's epidemiological proflie. social priorities, and income levels. A number of public health interventions have been documented to be par- ticularly cost-effective, and include health and nutritional cducation aimed at personal behavior change. control of environmental hazards, immunization, and screening and referral for selected infectious diseases and high-risk preg- nancies. A review of disease control priorities in developing counuies includes the following among the most cost-effective interventions: breastfeeding pro- motion, DPT plus polio immunization; measles immunization; smoking preven- tion; antibiotic treatment of acute respiratory infection in children; and support- ing therapy, including vitamin A (BoK 4-2). Health facilities may be publicly operated; private, for-profit; or private voluntary organizations, such as mission facilities. When they function well, they respond to local health and ci anomic conditions by "bundling" services into basic care packages. Packages may change over time to adapt to evolving epidemiology or changing resource availability. For example, oral rehydration therapy (ORT) has been strongly promoted in well-functioning health centers as a low-cost tech- nology to manage cases of diarrhea. As the incidence of diarrhea decreases, more people learn to use ORT at home, or clean drinking water becomes more Box4*Z0ontinued vices to ensure pregnancy-related care (prenatal, childbirth, and postpar- less than $25 and often between $50 tum); family planning services; control and $150. Activities in this category in- of sexually transmitted diseases; tu- dlude immunizations; school-based berculosis cotitrol; and care for the health services; information and se- common serious illnesses of lected services for family planning; children-diarrhea] disease, acute programs to reduce tobacco and alco- respiratory infection, measles, ma- hol consumption; regulatory action, in- laria, and acute malnutrition. formnation, and limited public invest- These interventions form the core of ments to improve the household the package of health care services environment; and AIDs prevenfion. recommended in this study. Provided Although the cost-effectiveness of by well-functioning health centers and clinical services will vary from country first-referral hospitals, they have the to country, depending on local health capacity to (a) manage more than 90 needs and the level of income, five percent of health care demands and groups of interventions are highly cost- (b) reduce the national burden of dis- effective and address very large dis- ease by up to 30 percent. ease burdens. These include ser- Source:World Bank1993e. 58 B ETT ER H EA LT H IN A FRI CA accessible, health workers will spend less time on treatment and more on pre- vention. As coverage rates for immunization increase-through sustained un- derstanding and demand by the population-vaccinations will continue to be important, buttheir place in the health worker's daily caseload will be reduced. To combat frequently occurring illnesses and health conditions, such as malaria, hypertension, diarrhea, respiratory infections; measles, polio, STDS, and malnutrition, a regular supply of essential drugs is also needed. Making drugs, contraceptives, and vaccines more available to the commu- nity is not enough, however. It is also important to ensure that clients' ills are diagnosed correctly, that providers prescribe or apply the right services, and that clients use the drug or service correctly. While these caveats may sound obvious, problems of diagnosis, drug prescription, and client use of drugs or other treatment regimens are sufficiently prevalent in Africa that the effective- ness of potentially good solutions can be reduced by up to 50 percent (Box 4-3). Bringing these services together in well-functioning health facilities can benefit households in a number of important ways: Box 4-3. COMPARATIVE ADVANTAGES Overprescription is also less com- OF HEALTH CENTERS mon in health centers than in hospitals. In Ghana, for example, a study found Most health problems, ranging from thatthe average costof drugs per per- common illness to measles, malnutri- son, per episode was $.20 at hospitals tion, tuberculosis, or sexually transmit- compared with $.07 at health centers, ted diseases, can be treated with the with the lower oosts explained by less technology and competence available sophisticated prescription and better to well-functioning health centers. And management of drug stocks (Hoger- in 80 to 90 percent of preventive work zeil and Lamberts 1984). and for most curative cases, the heaflth The health center's comparative center can outperform hospitals in advantage lies in its accessibility and terms of continuity, comprehensive- potential for communication with the ness, integration, and costof care. community. Its scale of operations The small scale of the health center permits nurses to become acquainted also favors integration of various pro- with the households and their social grams. Major gains in vaccination cov- environment, thus preventing drop- erage or family planning can be made out and facilitating reestablishment of when the health center staff consults a contact if the patient stops treatment sick child's growth monitoring chart The small scale of the health center and vaccination record. Conversely, at cannot guarantee greater interper- a hospital, outpatient care is a service sonal communication and empathy separate from vaccination, growth toward clients, but it makes it pos- monitoring, orfamily planning. sible. REV I TA L IZI NG NAT IONA L SY STEMS 59 U Comprehensive care. This means that the health care provider deals not only with the immediate illness but also its underlying causes. For example a battered child will receive more than a painkiller or a cast for a broken leg. His family situation will become a matter of concem to the health care provider as well. For a child suffering from micronutrient deficiencies, the health care pro- vider will not only provide vitamin supplem,rnts but also look into the child's daily diet. * Contrzuiy of care. This means that a specific health care provider will interact with household members as long as such interaction is necessary to have a longlasting impact on health. A tuberculosis patient, for example, will not only receive a drug prescription but will be asked to discuss her work and family situation so that an appropriate long-term treatment program can be es- tablished for her. If she stops treatment prematurely, the health service will try to reestablish contact by visiting her home or contacting other members of the household. Continuity of care also implies that community health workers and health care providers will make sure that cost-effective preventive and primary care services are made available at opportune times. For example, children less than one year old are identified during home visits, a practice in well- functioning health facilities in Ghana (Ofosu-Amaah and others 1978), Zaire (Niimi 1991), Benin (Alihonou and others 1988), and Nigeria (Ransome-Kuti and others 1990). * Integrated care. By moving from project-based to program-based ap- proaches, the health care provider is able to perform several tasks concurrently, cognizant of the household's time constraints and cultural background. The provider may link preventive and curative care so that a pregnant woman who arrives at a health center to be treated for malaria will have a prenatal consulta- tion before going home- And her children's immunization records will be checked so that vaccination can be given if necessary. In Kenya, integrated care resulted in increased use of clinics, fewer consultations, a more balanced use of health staff, a reduction in unmet demand, and a striking incrase in immuniza- tion rates (Dissevelt 1978). The Role of the Health Center The concept of the health center as a necessary part of health care was well articulated in the 1960s (Fendall 1963; King 1966; Roemer 1972). During the 1970s and 1980s, health centers with community outreach began to appear in Africa, launched with donor assistance in Danfa (Ghana), Pahou (Benin), Ma- chakos (Kenya), Pikine (Senegal), Kasongo (Zaire), Kinshasa, and Lagos. To make health centers more effective, planners have developed ways to tackte the 60 B E TTER H EA LTH I N A F R I C A problems of accessibility (Van Lerberghe, Pangu, and Vandenbroek 1988), ac- ceptability, intensity of use and compliance with medical instructions, quality of care (Kasongo Project Team 1982), recurrent costs (Pangu and Van Ler- berghe 1988), and community ownership (Jacobson 1989; Kaseje and others 1989; Matomora 1989).i In many African countries, the health center (sometimes known as health post or dispensary) is a physical entity at the hub of community life and is the first level of contact with the formal health care system. Community participation, and especially the participation of women, in deciding the location and operation of health centers is critical to their success. By serving communities of 5,000 to 15,000 people, health centers justify the employment of a critical mass of person- nel and services, thus providing a strong underpinning for cost-effective health care. Health centers have also gained attention because they have performed more effectively and at less cost than hospitals in providing primay care. BOX 4-4. PROTOTYPICAL HEALTH CENTER Demographic profile ofcommunithyserved Total population 10,000 Children <1 year (4 percent of the population) 400 Women ages 15-49 years (20 percent of the population) 2,000 Children <15 years (50 percent of the population) 5,000 Package of care and services pro vided Maternal services * Predelivery care, delivery care and postdeliverycare * Breasffeeding IEC * Micronutrientsupplements (iodine for pregnant women) * Supplementaryfeeding (pregnantand lactating women) Well-baby services * Expanded Programme of Immunization (EPI) * Micronutrientsupplements (iron, iodine, and vitamin A) * Nutritionalrehabilitation(childrenagesO-5) * Supplementaryfeeding programs (children ages O-2) School health * Antihelminthictreatment (children ages 5-14) * Vitamin A plus iodine, as required Curative care (especially children 0-5) * Basic trauma * Malauia REV ITAL I ZI NG NAT IONA L SYSTEMS 61 An essential precondition for well-functioning health centers is that the communities they serve be well-defined. For example, when a given health center serves about 10,000 people in an area with a high fertility rate, the staff can safely estimate that about400 babies are likely to be born in the community each year (Box 4-4). To meet the objective of universal immunization, E3PI plan- ning can therefore be based on serving roughly thirty-five new children a month. When district-based health systems are in place, health centers can ob- tain information useful for patient management. Though largely ignored for such purposes by national health systems, household files can be used by health center nurses to contact individual households, to make a profile of the commu- nity to be served, and to measure the impact of health care within the district Nutrition services targeted toward malnourished children and feeding pro- grams for preschool children, pregnant women, and lactating mothers can also be organized effectively at the district level. Information available to this study ox44, continued * Diarrhea * Otherlocalinfections Umited chronic care * Tuberculosis treatment sTOS and AIDS * srD testing, treatment, and IEC * AIDS prevention (provision of condoms and IEC for high-risk groups) Family planning * Family planning iEc * Provision of contraceptives Staffprofile * Doctoron visiting basisfrom DistrictHealth ManagementTeam * One registered nurse; two assistant nurse/mnidwives, one community ser- vice (FP/nutrition) assistant; one clerk Infrastructure profile * One building (approximately 125m2; includes sanitation facilities); one housing unit tfor staff * Two bicycles, one refrigerator, and otherrmedical and office equipment Note: IEC includes ongoing dialogue during consultation and outreach visits to villages and groups served by the health center. Source:Adapted from World Bank 1 993a. 62 BET T ER H EA LT H IN A F RICA suggests that nutritional services of this kind can be provided for about $1.30 per capita a year (World Bank 1993a). Health centers are also in a position to generate their own informnation on community coverage and use. When combined with in-house assessments of staff work load and costs, a balance can be established to ensure reliability, accuracy, and affordability of services (Imboden 1980; DeSweemer and others 1982; Jagdish 1985; King 1984). For example, a low-cost health management infonnation system (MIS) in Zaire has been developed to trigger timely man- agement decisions and actions by health centers and communities (Beza and others 1987). In Guinea and Benin, the entire MIS was revamped and simplified so that health center staff could use it to integrate and manage their own ser- vices. Forms, files, and registers were redesigned first to serve supervisors and local monitoring needs (including feedback to communities) and second for reporting to agencies at the provincial and national level (Knippenberg and others 1990). Although registering infonnation and performing periodic analy- sis are time-consuming tasks, most health center staff consider them an impor- tant responsibility and do not suggest a reduction in the quantity of forms and files (Ministre de la Sante Publique IMSp], Benin 1990; Ministere de la Santd Publique et des Affaires Sociales [MsPAs], Guinea 1990). Any attempt to generalize about the characteristics of well-functioning health centers must. of course, take into account different conditions, resources, and needs among and within countries. At the same time, however, it is helpful to visualize what may be involved. A prototypical health center is depicted in Box 4-4 in terms of demographics of the community serviced, care and services provided, staff profile, and infrastructure. The Role of the First-Referral Hospitl The first level of referral for problems beyond the scope of a health center is typically a district hospital. Health care systems with these two tiers have dem- onstrated the capacity to provide comprehensive and effective care (WHO 1992b; Hamel and Janssen 1988; Van Lerberghe, Van Balen, and Kegels 1989; Barnum and Kutzin 1993; Mills 1991; Van Lerberghe and Lafort 1991). In Ka- songo (Zaire), for example, the network that provides comprehensive primary care clearly reduces hospitalization rates, Rural dwellers' hospital admission rates were 50 percent lower in areas with health centers than in areas without. Treatment for illnesses targeted in the past by selective prograims, such as mea- sles, tetanus, and diarrhea, dropped by 86 percent when health centers provided vaccinations, oral rehydration therapy, and chloroquine as well as general out- patient care for amoebiasis, skin diseases, and accidents. Conversely, patients who needed hospitalization benefited from easier access to hospital care (Van Lerberghe and Pangu 1988). REV I TAL IZ ING NAT IO NA L S YST E MS 03 Judging from the perlobmance of L mber of rural hospitals in central Africa, a staff composed of three physicians, pcrhaps one surgeon, and a sup- port staff of about fifteen can provide the following services at an affordable cost and with reasonably good results: - Outpatient care: treatment of emergency cases and patients re- ferred fi m health centers. A nurse may provide primary care equivalent to what can be obtained at a district health center, but such care would carry a high consultation fee to discourage pa- tients from bypassing the health center. BOX 4-5. PROTOTYPICAL FIRST-REFERRAL HOSPITAL Demographicprofile of community to be served Inhabitants served by the 15 health centers 150,000 Children c1 year (4 percentof the populaton) 6,000 Women ages 15-49 (20 percent of the population) 30,000 Children <15 years (50 percent of the population) 75,000 Package of care and services offered Inpatient care * Obstetrics and Gynecology * Pediatrics * Medicine: infectious diseases • Medicine: limited surgery Outpatient care * Emergencies * Referred patients Otherservices * Basic laboratory • Blood bank Staff profile * Three medical doctors; ten registered nurses; twenty-five assistant nurses; three medical technicians * Two managementstaff (including accountant) * Fifteen support staff (including driver); two clerks Infrastructureprofile * One building (approximately4,00GM2; 140 beds) * Three vehicles (including two ambulances) * Cold storage facilities * Medical equipment * Other equipment (including beds, furniture, and so on) Source: Adapted from World Bank 1993a. 64 BET T ER HE ALT H IN A F RICA * Inpatient care: wards for pediatric pLitienits. patients with standurd se- rious diseases, surgery, gynecologicail cuses, und delivery of babies. * Luboratory services: biood microscopy, direct exaiminaLtion of' core- brospinal fluids, urine Land lincces tcsLs, vaginul smears, and blood grouping. The hospital produces its own intravenous fluids, hias a blood bank, and perl'ormis blood translusionis. Also importunt is microscopy, primarily for thc delection of tuberculosis. * Radiography and fluoroscopy nrextremitics, skull, chest, stomach. and bowel. There is, of course, grcat variation in district size7, inf'rastructure, and per- sonnel, within and umong countrics. Based on the median of' two surveys of eighty-nine and forty hospitals, and average figures from oflIicial sources, a "typical" rural district hospital serves 110,000 to 160,000 inhalbitants aind has 140 beds, 3 physicians, and 15 health centers in its district. It conducts about 1,000 deliveries and hospitalizes 4,000 to 5,000 patients a year on average. Size varies from as little as thirty to forty beds in Mozambique, for example, and catchment areas of tens of thIousands, as in Lesotho, to hundreds of thousands, as in Ethiopia or Tanzania (Van Lerberghe, Van Balen, and Kegels 1989; Hamel and Janssen 1988). More important than the number of beds or staff size is that the first-referral hospital functions at full capacity and is neither underused (bypassed) nor overcrowded (because it competes for patients with health cen- ters). A prototypical first-referral hospital is depicted in Box 4-5, again with the caveat that its community profile, services, staffing, and infrastructure are at best indicative. Well-functioning healt'h care centers and first-referral hospitals will also make it easier for African healtlh care systems to cope. with the otherwise un- manageable task of responding to the HiV epidemic (Box 4-6). Thte Role of the Large Central Hospital Central-level hospitals in urban areas would be expected to provide technical backup and support by training health personnel for service in district-based facilities and to perform relatively rare interventions, such as cataract opera- tions. One such hospital might also be developed as a "centerof excellence," as was done in Mozambique. The challenge is to enlist central hospitals as partners in providing more efficient and equitable health care in Africa instead of enabling them to act as competitors with lower-level facilities. Their consumption of resouarces then jeopardizes the provision of basic care to the endre population. Since central hospitals have benefited from elitism in national systems of health care, their actual contribution should be reexamined so that their links with the rest of the REV I TALI Z ING NAT IO NA L SY STEMS 65 BOX 4.6. AIDS AND HEALTH CARE starts with prevention. The top prlority REFORM IN AFRICA Is to use available public financial and human resources for carefully tar- The burden of AIDS underscores the geted public education and condom importance of reforming African health promotlon campaigns, and for the de- care systems. Despite the incurable tection and treatment of other sexually character of the disease, AIDS patients transmitted diseases. For those af- have begun to overwhelm hospitals in fected by the opportunistic infections a number of African capital cities, in- associated with AIDS, the first point of cluding Bujumbura, Harare, Kampala, contact in a well-functioning health Kigall, Kinshasa, and Lusaka. These care system will be health centers for patients displace others who can be drugs, counseling, and relief of suffer- cured, further reducing the effective- ing. As the afflicted develop full-blown ness of the health care system. The AIDS, they may need referral to a hos- development and introduction of pital. In the final stages, they tend to guidelines for treatment and care of become bedridden at home and are AIDS patients for use by health care best served at the community level by personnel are critical. WHO'S Global family members and outreach from Program on AIDS has done important health centers. Making the health care work on this subject to help developing system functon as it should can be ex- countries. pected to reduce what would other- An appropriate public policy re- wisebecorneanunbearableburdenof sponse by African govemments to the AIDS patients on African hospitals. public outcry to combat HIV infection system can be better articulated. Instead of being treated as special institutions quilifying for disproportionate shares of resources, central hospitals should be scrutinized to determine whether those who need specialized procedures are actually benefiting from them, and the costs at which these services are pro- vided. Despite a dearth of studies on the subject, few administrators of large hospitals in Africa would deny that much of their staff's time is devoted to providing primary and first-referral care. Governments need to consider ways to enforce the use of the referral sys- tem. One option is to issue bills for charges incurred by those who deliberately bypass the referral system, assuming that well-functioning health centers and first-referral hospitals are in place. All African governments also need to consider imposing substantial user fees at central hospitals, or else--at least in part-privatizing them, to shift additional public resources to the primary health interventions that are most cost-effective. One hundred percent cost recovery atcentral hospitals would not be an unreasonable goal. A possiblc first step would be to freeze existing budget 66 BETTER H EA LT H IN AFR ICA levels lor tertiary care, instead of increasing them in parallel with population growth and inilation. Prospects and methods of cost recovery are taken up in Chapter 10, and it will suffice to say here thaL cost recoveTy from patients for care at central hospitals is quite defensible, given that (i) patients are generally willing to pay for hospital care for acute problems, (ii) the demand for such care tends to be price inelastic, meaning that higher prices do not denate demand, (iii) the clients of tertiary-level hospitals tend to be from the middle- and upper- income echelons of society, and (iv) hospitals are more likely than health cen- ters to have the administrative capacity to assess and collect fees. Conclusion Far greater headway is likely to be made in resolving Sub-Saharan Africa's health crisis ir systems of health care feature cost-effective packages of basic services, well-functioning health centers and first-referral hospitals at the dis- trict level, and community participation. Emphasis on basic health care services is precisely what is needed given the demographic and epidemiological profile of African societies. Development of well-functioning health centers and first- referral hospitals is compatible with the goal of promoting equity by extending services to underserved households in rural and periurban communities. By improving efficiency of health care services at the first level of contact and getting the referrl system working well, prospects of bringing down skyrocket- ing hospital costs improve. A distinctly community focus helps to overcome weaknesses in capacity at the national level and offers the opportunity of deter- mining a locally relevant health care package, enhancing accountability between providers and clients of health care, and mobilizing resources for intersectoral inputs to health. Finally, support from public health services can play a critical role in building more effective communication between health care providers and consumers with regard to health legislation andregulation affecting facilities and services, and thus ensure provision of health information to the public. CH APTER FIVE The Importance of Pharmaceuticals and Essential Drug Programs MEDICINES offer a simple, cost-effective answer to many health problems in Africa, provided they are available, accessible, affordable, and properly used. From the household perspective, the availability of medi- cines is one of the most visible symbols of quality care. In Senegal between 1981 and 1989, for example, household expenditures for drugs accounted for half (48 percent) of all health expenditures. Africa's health care providers also see a regular supply of drugs as a funda- mental component of a well-functioning health system. At public and private health facilities in Africa, phamnaceutical expenditures typically make up 20 to 30 percent of total recurrent costs, ranking second only to personnel costs (World Bank 1992d). They also represent a sizable share of per capita expendi- tures on health. The importance of drugs to consumers and health providers alike is also illustrated by what happens when drugs are unavailable: visits to health facili- ties decline precipitously. Studies in Nigeria, for example, showed that when health facilities ran out of commonly used drugs, visits by patients dropped by 50 to 75 percent. Because pharmaceuticals are a highly marketable product and such a vital component of health care, and because more than 90 percent of the phar- maceuticals used in Sub-Saharan Africa are imported, African governments often intervene in drug markets. Their aim is to make sure that the pharmaceuti- cals used in their countries will be effective and are purchased at the lowest possible cost Some African govemments have formulated national drug policies, cre- ated lists of essential drugs, and instituted quality controls. Since consumers 67 68 B ETBE Tr ER HE ALT H IN A F RICA seldom choose a particular drug themselves, relying instead on medical person- nel or vendors of drugs, Alrican governments also disseminate much informa- Lion on drug safety and use. This chapter begins by documenting problems that are undermining the potential contribution of pharmaceuticals to better health in Africa. Inefricien- cies and waste in the management of pharmaceuticals are highlighted. This sets the stage for a discussion of more efficient, equitable, and sustainable drug practices. Broad guidelines for action are then suggested for inclusion in gov- ernment programs of health care system reform. The Performa2ice of African Pharmaceutical Markets In the mid-1980s, the World Health Organization conducted a survey of 104 developing countries to deternine the domestic availability of essential drugs (wFio 1988d). In seventeen countries (including Nigeria), with a combined population of about 200 million people, about 70 percent had no regular access to essential drugs. In another fourteen countries, also accounting for about 200 million people, an estimated 40 to 70 percent of the population had no regular access. And in nine countries with a combined population of 50 million people, an estimated 10 to 30 percent had no regular access. These data, along with information from other sources, suggest that up to 60 percent of the inhabitants of Sub-Sahan Africa has no regular access to the drugs they need. Shortages of appropriate drugs afflict public sector health facilities in many African countries, especially at the lower levels. Drug stock-outs due to management, logistical, and financial problems have been widely documented, especially in periurban and rural areas. In Angola, drug stock-outs are frequent, even at major hospitals. In seven provinces for which data are available, only 48 percent of the communities reported regular health staff visits (controlo sazi- tario visits) to resupply local health facilities with drugs and other supplies. In Tanzania, underfinancing of drug purchases by the Ministry of Health has led to shortages of medicines in hospitals and reliance on foreign aid to provide drugs forrural primary care. Private-for-profit facilities in Africa experience fewer problems with drug shortages. They have the funds to buy for their limited (and hence high-cost) markets because their clients tend to be upper-income households in urban areas. Trained pharmacists are few, and they generally prefer to open retail pharmacies in urban areas and to trade largely in western specialty drugs. Wholesalers, and representadves of industrial country drug firms, thus also pre- fer to work with the private pharnacies in large cities. In Niger, for example, 46 percent of all private drug salts in 1986 took place in Niamey, the national capital, and another 35 perc at were concentrated in the capital cities of smaller P HA R MACE UTICA LS AND DR U G PRO GRAMS 69 regions. Only about 20 percent occurred in rural areas, even though about 80 percent of the population lives in the countryside. The organized private sector also benefits from a widespread belief that its products are superior and thus worth a much higher price. In Sierra Leone in 1983, for example, the markup on private sector sales of chloroquine ranged from 400 to 800 percent. Moreover, a common inisconception among con- sumers (as well as prescribers) is that generic or low-cost drugs supplied through public agencies are inferior to those sold in the private sector. This is rarely the case, but the misconception often leads to wasteful drug decisions. In Kenya, for example, it was found that some patients traded in their free generic drugs at pharmacies to buy identical specialty drugs, which they believed were better (Ministry of Health, Kenya 1984). The residents of periurban and rural areas generally find that irregular pri- vate suppliers are more accessible sources of drugs, but the quality of their services is often poor. Moreover, drugs sold by these suppliers have frequently been stolen from the public sector or imported from neighboring countries where quality control is absent (Whyte 1990). Irregular suppliers cannot be ignored, however. In Togo in 1989, for example, they were estimated to account for 35 percent of the supply of antimalarial drugs. Medicines that do reach their destination are often inappropriately pre- scribed. A survey in Mali found that the average prescription called for ten drugs, sometimes including duplication of the same drug under different names. In many cases, it is likely that one or two drugs would have sufficed (Foster 1990). A study oF the treatrnent of a large number of patienis with diarrhea in Nigeria found that drug expenditures were some thirty times higher than necessary, largely be- cause of the prescribing of specialty antibiotics that were more potent than neces- sary (Isenalumnhe and Ovbiawe 1988). Although drug injections are standard treatment for only a minority of patients, a study in Ghana found that 96 percent of the patients were given at least one injection and then were given prescriptions that called, on average, forthe use offour different drugs (Dabis and others 1988). Even essential drugs are often misused because limited understanding leads to poor compliance with prescribed regimens (Foster 1990). Many developing countries have launched essential drug programs (EDPS) to improve availability, affordability, and proper use. To help facilitate these programs, the World Health Organization has prepared a model list of about 250 essential drugs thatcan effectively treat, atreasonable cost, a large majority of the ailments frequently experienced in Africa and other regions of the world. In Angola, an EDP was launched in 1987, supported by the Swedish Interna- tional Development Agency (SIDA) in cooperation with UNICBF. An evaluation of Angola's EDP by SIDA and the Ministry of Health in 1990 revealed problems common to a number of African countries: Table 5-1. Expenditures on Pharmaceuticals in Selected African Countries, NMid-1980s Esrittiaredptublic Estimated Phannraceutical phanrmaceutical per capita expenditures as e.xpenditutres Estiniatedprin'are Estimated loala pharmaceutical share of Gop (miilions of pharmaceLtfcal phannaceutical expenditures (estimate) CoutnJry Year US. dollars) ewpenditures earpenditures (U.S. dollars) (percent) Burkina Faso 1981 5.5 10.1 15.6 2.19 1.38 C6ted[voire 1985 2.7 81.5 84.2 8.63 0.57 Ethiopia 1986 8.7 33.8 42.5 0.95 0.86 Kenya 1986 16.0 34.0 50.0 2.36 0.84 Mozambique 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 Tanzav:ia 1987 19.9 10.7 30.7 1.32 1.00 Zimbabwe 1988 15.1 6.5 21.5 2.42 0.38 Weighted average 2.10 0.76 Source: World Bank 1992d. P H AR MACE U TICALS A ND DR U G PRO GRAMS 71 * The EDP was a vertical program with very little coordination with other programs. * The 13P was not supplemented by a training program for heal th care providers. a The information and fcedback system on EDP perfonnance was complicated and of little practical use, partially because the re- sponsibilities and tasks of the National Pharnaceutical Director- ate and the National Directorate of Public Health were poorly coordinated. e The country did not have a well-defined pharmaceutical policy, although a National Drug Commission exists. The experience of Ethiopia confirms that adoption of an essential drugs list is not enough. Such a list was adopted in 1985. Two years later, however, a complete selection of these essential drugs was found in only 7 percent of the country's health centers. A much more basic list of ten drugs was available at only 38 percent of the centers (Hodes and Kloos 1988, Constraints and Opportunities The performance of pharmaceutical markets is shaped by the interaction of a variety of demand and supply factors. Some of these present greater obstacles to resolving shortages of drugs than others and require coordinated action. In most African countries, private expenditures dominate pharmaceutical mar- kets, as in Burkina Faso, C&te d'Ivoire, Ethiopia, Kenya, Niger, and the Sudan. A clear indication that private expenditures, consumer preferences, and ability to pay are important determining factors in the availability of medicines is ap- parent from Table 5-1. In six of nine countries for which data are available, private expenditures on drugs easily exceed public expenditures. On the demand side, the most important factors are income, price. disease patterns, and the educational levels of consumers. * Income. Differences in household expenditures on drugs closely follow differences in per capita GNP. In Ethiopia, where the average per capita GNP was about $130 in 1987, pharmaceutical expenditures at the time were about $0.95 per capita. In Sudan and Kenya, each with per capita GNP of about $330 in 1987, pharmaceutical expenditures were about $2.30 to $2.40 per capita. And in CMte d'Ivoire, with a per capita GNP of about $740, expenditures on drugs were about $8.60 per capita. As might be expected, moreover, expenditures on drugs by high-income households greatly exceed those of the poor. Survey data on Ghana, for exam- ple, show that per capita household expenditures on medicines are seveml times 72 BETTER HE ALT H IN A F RICA larger in the highest income quintile than in the lowest (Table 5-2). Hence, effective demand for drugs is likely to be relatively weak among the poorest groups in periurban and rural areas. Because such groups tend to rely dispropor- tionately on public sector health facilities, they suffer most from disruptions in the supply of medicines at government facilities. As a rule of thumb, a 10 percent rise in GNP per capita means an 11 to 13 percent increase in per capita drug expenditures (Dunlop and Over 1988; Vogel and Stephens 1989; Gertlerand van derGaag 1990). And just as higher income tends to raise consumption of pharmaceuticals, a decline in per capita income can have the opposite effect. Since the per capita incomes and real purchasing power of African households generally declined during the 1980s, the implica- tion is that railing incomes were at least partly responsible for changes in drug expenditures. Among the seven African countries for which time-trend data are available for at least four years, a drop in the share of pharmaceuticals in the recurrent expenditures of health facilities was apparent in Botswana, Kenya, Ethiopia, and Cbte d'lvoire. U Price. Available evidence suggests that demand for medicines is rela- tively inelastic with respect to price-that is, demand remains relatively steady even when prices go up (World Bank 1992d). An experiment in Cameroon showed that use of public sector healthi facilities by poor households actually grew when price increases were accompanied by improvements in health ser- vices, including greater drug supply reliability. There is also evidence to show, however, that demand falls more sharply with rising prices among the poor than among more affluent groups, as happened in Cote d'Ivoire (Gertler and van der Gaag 1990; Mwabu 1984). Table 5-2. Per Capita Household Expenditures on Medicines, Ghana, 1987-88 (U.S. dollars) Household income quintile Expenditures 1 1.45 2 221 3 3.32 4 4.24 5 8.50 Average 3.93 Source: Boateng and others 1989. P HA R MACE UTICA LS AND DR U G PRO G R A MS 73 U Disease patierns. Changes in pattems of discase and mortality have an cffect on the kinds of drugs in greatest demand and, sometimes, the cost of particular kinds of drugs. Mortality and morbidity in Sub-Saharan Africa are dominated by perinatal, infectious, ard parasitic health problems, which sug- gests that it is possible to create a stardard package of essential drugs that can handle a sizable majority of the health problems in Africa. The World Health Organization has quantified drug costt on the basis of available morbidity data and information on past consumption in several African countries. The results, summarized in Table 5-3, show that a standard supply chest of thirty to forty drugs in a well-functioning health centerresults in a drug costof about$0.31, on- average, per treatment episode. Treatment of more complex illnesses with com- mensurate drug regimes is estimated to cost about $0.47 at a hospital outpatient department. WHO concluded that the range of drug costs portrayed in Table 5-3 is surprisingly low when compared with expenditure levels that prevail in many countries, although these average cost estimates assume a degree of supply efficiency that is rare in most Sub-Saharan countries (wHo 1988c). * Educational levels. Consumers with higherlevels of education use over- the-counter medications more appropriately and seek care earlier than those with limited education (Haynes and others 1976). In view of the high levels of illiteracy in Africa, especially among females, this suggests that additional in- formation, education, and communication programs could make an immense contribution to more efficient drug use. Table 5-3. Average Drug Costs Per Treatment Episode by Level or Care, Selected African Countries and Years, 1983488 (U.S. dollars) Hospital ouwpadient Countryand year Health center departnent Kenya 0.20n 0.50b Sudan, 1985 0.32 0.59 Burundi, 1986 0.37 Gambia, The, 1987 0.35 0.50 Guinea-Bissau, 1987 0.31 Uganda, 1988 0.29 0.29 Average 0.31 0.47 -Not available. . 1984. b. 1985. Souce: WHo 1988c. 74 BETTER HE ALT H IN A F RICA A Supply-Side Perspective It is frequently argued that shortages of drugs in Sub-Saharan Africa are the result of disincentives for domestic production and barriers to imports. Some analysts contend that local production would lead to savings of scarce foreign exchange, allow drugs to be produced at less cost (local labor being cheaper)t and eliminate the risk of paying foreign companies forout-of-date drugs. These arguments are questionable, however. Although independent studies of local drug production costs are rare (especially by type of drug), expert opinion sug- gests that international drug makers typically realize full economies of scale with higher quality standards atnon-African production facilities than would be possible in most African countries in the foreseeable future. The extremely competitive world market for generic drugs makes it doubt- ful that production should be started now in countries without a pharmaceutical manufacturing tradition. The only exceptions would be products whose trans- port costs when imported are disproportionately high, as in the case of certain intravenous fluids. Where there is a nucleus of local production, a phased ap- nroach is likely to show the most promise, starting with the tableting and pack- aging of widely used items, such as aspirin and chloroquine. Intermediate phases involve increasingly comnplex production processes until, ultimately, lo- cal industry begins to create and produce pharmaceuticals (World Bank 1985). This pattern can be seen in such countries as Ethiopia, Sudan, Kenya, Ghana, and Zimbabwe, all countries where local companies were producing a growing share of total domestic consumption by 1992. In Kenya, for example, supplies of the first essential drug kit (composed of about twenty pharmaceuticals de- signed for nial health facilities) were imported, but supplies of the second (with twelve items) are largely produced locally (London School of Hygiene 1989). In Ethiopia, about 30 percent of domestic demand for drugs is,now met by domestic production using imported raw materials. Thus, while the pros- pects are slim that economically competitive, large-scale domestic production can be relied on to meet shortfalls in essential drugs, many African countries should be able to expand the production and packaging of certain drugs over the next decade or so. Given Africa's reliance on pharmaceutical imports, the availability of for- eign exchange constitutes another important supply-side constraint. Because the accumulation of foreign exchange is contingent on export earnings and temnns of trade, it is not surprising that extemal resources have been needed to sustain Africa's pharmaceutical imports. Major parmers include DANIDA, SIDA, ODA, USAID, the World Bank, and the Drug Action Program Of WHO. Total known assistance exceeds $160 million per year, though the actual amount may be several times higher. PH AR MACEUTI CA LS AND DRUG PR OG RAMS 75 Still, the level of international assistance is small when compared to the size of the African market, which was estimaled at somewhere between $850 million and $1.5 billion for 1989 (World Bank 1992d). Moreovcr, foreign ex- change can be squandered if the private sector imports expensive specialty drugs that are no better than generics. Assuming that the willingness of donors to provide support cannot always be foreseen, the availability of foreign cur- rency rcsources, as well as their use for public and private sector drug imports, needs to be evaluated critically. Inefficiency and Waste in Pharmaceutical Markets Since pha.maceutical markets in Africa are heavily influenced by private and public expenditures, income levels, and drug prices, it is tempting to attribute. shortages to insufficient funding, particularly in periods of economic decline. And because pharnaceutical markets will continue to rely heavily on imports, it is tempting to seek remedies in donations, loans, and the allocation of more public funds fordrugs, especially in view of uncertainties over future economic growth. Yet studies published as far back as 1984 claim that full drug coverage could be achieved in Africa for less than $1 per person a year (Kasongo Project Team 1984; Steenstrup 1984; Jancloes and others 1985). These impressions are supported by evidence marshaled by WHO and shown in Table 5-3. Although world commodity prices have risen since 1985, the $1 figure. re- mains generally valid because intemational comnpetition in the generic drug market has intensified and drug prices have actually gone down. And $1 per capita is clearly below the average per capita expenditure of about $2.10 com- puted for the nine countries in Table 5-l. This suggests that demand and supply constraints, as important as they may be, are nor the main cause of drug short- ages in Africa.. The most important problem is inefficiency and waste. In Nigeria, for ex- ample, technical reviews of public sector health facilities revealed that ineffec- tual and even dangerous drugs had frequently been procured, that brand-name rather than less expensive generic drugs are purchased, that drugs are often purchased locally in small quantities instead of in bulk from foreign producers, that many drugs become unusable because of faulty storage practices or disap- pear because of inadequate stock control procedures, and that health personnel tend to prescribe excessive numbers of drugs for patients in their auempt to treat a number of possible diseases simultaneously. Because of widespread inefficiencies and waste, patients at public sector health facilities in Sub-Saharan Africa may be effectively receiving the benefits of only $12 worth of quality drugs for each $100 of tax money spent for them. 76 B ETT ER H EA LTH IN A FRI CA Figure S-t IneMclency and Waste In theSupply of Drugs from Budget Allocation to Consumer Budget allocatlon Value received for drugs L> D > > D [ D P D byconsumer; U.S. dollars 100- 80- $76 60- 40- 20- $15 $1 0 1 0~~~~1 U Remaining value Cumulative losses Source: WHO md World Bankdata. What follows is an explanation of the factors that produce this meager return on investment. First, the selection of drugs teinds not to be based on cost-effectiveness criteria. Prices for differe"L drugs for the same condition commonly vary by as much as five to ten times and, in some cases, by as much as 130 to 150 times. Investigation of the drugs used in African countries in the 1980s, for example, reveals that high-cost drugs purchased for urinary tract infections, arthritis, and inflammation were six, eight, and twelve times more expensive, respectively, than their low-cost altematives. An assessment of drug practices in Africa dur- ing the 1980s by WHO suggests that the absence of cost-effective selection was responsible for a tO percent loss in spending power (wHo 1988c). As illustrated in Figure 5-1, this is equivalent to reduicing the postulated $100 to $90. PHARMACEUTICALS AND DR UG P ROGRAMS 77 Second, few attempts are made to quantify the amounts of any drug that will be needed over a given period (usually a year). When drug needs havc been quantified on the basis of morbidity pattems, large quantities can be bought at substantial savings. It has been estimated, for example, that a system for calcu- lating essential drug requirements could have reduced Gabon's drug expendi- tures in 1986-87 by up to 45 percent (Soeters and Bunnenberg 1988). On aver- age, failure to order on this basis can result in a loss of $13 for every $100 spent In Figure 5-1, $77 now remains of the original $100 for drugs. Third, procurement is rarely based on competitive bidding for generic drugs. Direct imports from high-priced sources tend to be "arranged." Yet as- tute buying on the world mar-ket has sometimes reduced the average cost of drugs imported by African countries by up to 40 percent (Marzagao and Segall 1983; Hogerzeil and Moore 1987; Yudkin 1980). A WHO study (1988c) of buy- ing practices in Nigeria found that by shifting from brand name to generic drugs, costs could be reduced by another 25 percent. On average, losses from inefficient proarement of drugs have been estimated to amount to about $27 of every $100 spent. In Figure 5-1 the balance is now $49. Fourth are poor storage and management practices. It has been estimated that 15 to 25 percent of the drugs imported by some countries remain unused until their shelf life ends (WHO 1986; Management Sciences for Health 1984). A study in Cameroon revealed that central medical stores lost 35 percent of their- drugs because of poor storage and poor inventory control (Van der Geest, Sjaak, and Whyte 1982). In Uganda, a third of all drugs are thought to be lost to theft and corruption. In Cameroon, 30 to 40 percent may be "withdrawn for private use" by staff. In 1984 in Guinea, an estimated 70 percent of the government drug supply disappeared (Foster 1990). In Tanzania, the rate of pilferage for drugs not included in the essential drugs program was estimated at about 30 percent. On average, losses from poor storage and distribution have been esti- mated to amount to about $19 of every $100 spent. In Figure 5-1 the balance is now $30. Fifth, irrational pmscription of drugs contributes further t" inefficitncies. A study conducted in the Kivu Region of Zaire found that a "typical" prescrip- tion filled by a private pharmacy for treatment of bronchitis in young children listed five or six drugs, including an antibiotic, cough syrup, a tranquilizer, vitamins, aspirin, and, if fever was present, antimalarials, for an average cost equal to approximately one month's per capita incorr.,. Studies in 1992 of health care facilities in Nigeria and Tanzania found, on average, 3.8 and 2.2 drugs, respectively, per prescription (WHO 1993b). On average, losses from irrational drug prescriptions have been estimated to reduce drugs effectively made available to patients by 50 percent. In Figure 5-1 the balance is now re- duced from $30 to $15. 78 BETTeR H EA LT H IN A F RICA Sixth, incorrect use of drugs by patients reduces the proportion of drugs that are used effectively. Researchers in Zimbabwe concluded that self- medication with chioroquine for malaria prophylaxis was common but that the drug was often wrongly used, tind diat bettcr public information was necded to make sclf-medication cfTective (Stein, Gora, and Macheka 1988). In other cases, essential drugs show poor results because patients fallcd to comply with the proper drug rcgimens (Foster 1990). On uveragc, losses from poor compli- anc reduce drugs etTectively used by 20 percent. This cuts the reinaining amount in Figure 5-1 tojust $12. The Essential Problem The reality in many African countries is ilat pharmaceutical markets arc not efficicnt, equitable, or sustainable. Commitments to primary health care be- come merely symbolic when reliable supplies of medicines are noteasily avail- able in periurban and rumr areas. This prompts households to buy medicines from itinerant traders or to travel to intermediate-level facilities and hospitals where they are available. Cost-effective care is further compromised because chronic illnesses are not treated by relatively simple regimens of essential dnrgs that can be procured in bulk at far less cost than when individual consumers purchase them. Because of inefficiencies and waste, far more is being spent on phar- maceuticals than is necessary, erroneously reinforcing the view that the answer to drug shortages in Africa is more money. Far greater headway is likely to be achieved tlrough more effective use of existing resources. At the same time, though, ways must be found to sustain the revenues that are needed to pay for drug supplies, particularly those used by public sector health care providers, and to ensure that foreign exchange reserves are available to pay for imports. Overcoming Obstacles It has been estimated that the annual per capita cost of essential drugs at a well- funcdoning health center in Africa ranges from $0.10 to $0.25 (Wnrld Bank 1993a). When drug needs at the district hospital level are added, the cost rises to about $1 per person a year. This is enough to pay for the essential generic drugs needed to treat 85 percent of the illnesses most commonly found in Africa. Expanded diagnosis and treatment of sexually transmitted diseases, a need brought about by the AIDS epidemic, could reasonably be expected to raise the figure to about $1.60 per person (Chapter 8). This is less than the per capita expenditure on drugs in six of the nine countries in Table 5-1 and is also close to the amount spent by those in the lowest income quintiles in Ghana (Table 5-2). P HA R MACE UTI CA LS AND DRUG P-R O GR AM S 79 To improve drug distribution in low-income areas, many African countries (Kenya, Tanzania, Uganda, Sierra Leone, Zambia) buy prepackaged drug kiEs assembled by wholesalers. The contents of the kits are determined by average patterns of use. The kits eliminate some of the managerial problems that now afflict centralized distribution systems. Care is needed, however, to make sure that the kits take into account differential patterns of morbidity by region. Gov- ernment officials must also make sure that the kit system is not sabotaged by new fonns of waste and corruption. Drug distribution problems could also be reduced by estimating the quan- tities of basic pharmaceuticals needed at different levels of the referral system. Generally speaking, only twenty to forty pharnmaceutical items are indispens- able for primary care at health centers (Brudon-Jakobowicz 1987). Quantifica- tion of requirements is relatively easy at this level because demographic and epidemiological profiles can be readily determined and actual practices at health centers and district hospitals can be assessed. Tnie limited range of prod- ucts needed also increases the likelihood that prescription practices will be guided by standard treatment protocols. In well-functioning health centers, one-to-one transmission of infonnation to consumers by providers has been shown to improve compliance with drug regimens. As part of this process, prescnbers at health centers can be held ac- countable by a community clientele that provides feedback on drug effective- ness, undesirable side effects, and so on. In response to the declining availability of public resources for financing pharmaceuticals, a growing number of communities have adopted cost recov- erv and self-financing schemes. Many such schemes have evolved under the Bamako Initiative. In Benin, for example, attempts to resolve financial short- ages produced an experimental scheme under which patients pay for the essen- tial drugs they receive. The fee was set at three times the actual cost of the medications used and covers 85 percent of local operating costs, excluding sal- aries. Over a three-year period, fee receipts increased as the public gradually accepted the system and its generic products. A popular form of community financing is the so-called drug revolving 'fund. This is begun with an initial stock of drugs donated by the community, the govemment, or some other donor. Ihe drugs ar then sold to community mem- bers at prices that allow for full cost recovery, and the revenues are used to replace stock and finance otreroperating and distribution costs. Drug revolving funds can be operated on a public, private-voluntary, orprivate, for-profit basis. Such funds have been introduced in Benin, Cameroon, the Central African Re- public, Chad, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, Sudan, Tan- zania, anrd Zaire. 80 BETTER H EA'LT H IN A F RICA Experience offers several lessons about the operation of drug revolving funds: * Sharp price increases should be avoided, especially in areas where the population is not accustomed to puying for public sector services (Blakney, Litvak, and Quick 1989). Gradual price increases over time, accompanied by service improvements, will be more successful. Another approach is to estab- lish a set of declining subsidies over the years rather than carry out an immedi- ate switch to full cost recovery. * A few experiments with revolving drug funds in Senegal, Niger, and Mali have run into problems because patient contributions were insufficient to maintain program momnentum (Cross and others 1986; World Bank. 1992d). These problems tend to reflect a failure to establish an effective scheme for the collection of payments or to provide realistically for the indigent. They may also be the result of an overambitiotus national program introduced without a period of testing through small pilot projects. * Cost recovery programs based on the amount of drugs sold may create incentives for overprescription and inappropriate use of drugs. Standard treat- ment protocols, external supervision, and payment by illness episode can help reduce these incentives (McPake and others 1992). The Role of National Governments Improving the impact of medicines on health in Africa requires a facilitating environment in which public officials, suppliers and distributors of drugs; and providers of health care act together to promote effective use of drugs. This means making them available and affordable. Governments have an especially important leadership role to play in instituting and maintaining quality controls, disseminating information on the proper use of drugs to prescribers and con- sumers, and monitoring drug reform (Box 5-1). Governments should also take the lead by establishing a national drug policy, overseeing the planning, pro- gramming and budgeting of national capacity in the pharmaceuticals area, and identifying suitably trained personnel to implement financial management and drug information systems. National drug policies also need aftnm legal basis. Existing laws and regu- lations tend to be concerned largely with quality control or new drug approv.r'I A small but efficient drug authority, with a degree of autonomy and close links to govemment and nongovemment bodies involved with drugs, is likely to re- sult in a more coordinated and consistent multisectoral effort. Much can be accomplished through information, persuasion, and incentives for all parties, coupled with a modicum of effective control to counter abuses. Least effective PH AR MACE UTICALS AND DRUG PROGRAMS 81 is to base policies on prohibition and repression. Unhealthy practices in the drug field are most effectively countered by offering acceptable alternatives. The case of drug peddlers in Kenya is typical. They largely lost their disreputa- ble trade in malaria remedies once village health workers were adequately sup- plied with antimalarials (Mburu, Spcnser, and K:aseje 1987; Whyte 1990). Ongoing estimates of drug needs are required to ensure that the vast major- ity of the population has access to cost-effective medicines. Purchasing too much, or importing the wrong drugs, is obviously wasteful, but inadequate pur- chasing will result in shortages, which in tum can lead to emergency buying on the private market at inflated prices. Needs estimates are best made by a joint group of health professionals and resource managers convened by a drug au- thority (Box 5-2). The estimates can be published, and invited commentary by providers and users at national, regional, and community level can be construc- tive. Guidance on pnces and sources of good-quality drugs is available from regularly updated drug price lists issued by the WHO Essential Drugs Pro- gramme, UNICEF, Management'Sciences for Health (MsH), and the Interna- tional Dispensary Association, a nonprofit wholesale procurementorganization that purchases drugs and medical equipment for noncommercial health care projects. Encouraging thc development of tze private noncommercial sector, includ- ing religious missions and such humanitarian bodies as Mddecins sans Fron- tiures and the Red Cross Pharmacies in Ethiopia, is anothermeans of expanding drug coverage. Various religious missions in Africa are considering cooperat- ing with one another to establish their own organizations for purchasing, ware- housing, and distributing drugs, priinarily to rmission hospitals. In Zaire, con- crete proposals were made in the early 1980s, and were widely endorsed in church circles, to establish a nonprofit pharmaceuticals purchasing group. These are often efficient operations, reflecting idealism and pragmatism. In. several instances they have been guided into the essential drugs approach and use of generics to make better use of their resources (Hogerzeil and Lamberts 1984; Hogerzeil and Moore 1987). Governments can also foster the private commercial sector by authorizing health services and hospitals to purchase drugs from private firms whose terms are more attractive and supplies more consistent than those of centrl medical stores. The pnrvate sector has the same access to the world generic market as the public sector, and is often capable of obtaining better prices through its intema- tional commercial contacts and profit-maling incentives. The expansion of so- cial marketing of essential pharmnaceutical products, such as contraceptives, can further stimulate development of the private commercial sector. Where there is no viable nongovernment alternative, African governments will need to continue to correct the principal defects of public sector phar- 82 B ETT ER H EA LTH IN A F RICA BOX 5-1. IMPROVING PHARMACEUTI- Information on the proper use of CAL MARKETS THROUGH GOVERNMENT drugs, for prescribers and consumers, ACTION isapublicgoodmerting farmore atten- lion from African governments than in Instituting and maintaining quality con- the past. Initiatives to address poor use Itols isa widelyneglectedpublic role in of drugs include promoting better drugs. Expired or poor-quality phar- teaching to medical students and maceuticals represent a waste of re- others on drugs. For example, a model sources as well as a threat to health. problem-solving course in prescribing Some countries receive major flows of has been developed and tested in Eu- false or spurious drugs. In the Ad- rope and is being implemented and amaoua province of Cameroon, forex- evaluated in fifteen other universities, ample, it is reported that most market including two in Nigeria and Tanzania drugs sold have been smuggled into (De Vries 1992). Publicabons can be is- the country from Nigeria; many are sued on the proper use of widely pre- fakes. Quality control can be under- scribed drugs. Successful approaches taken jointly by countries, involving ex- include a pocket-sized national fomniul- change of information on suspect ary, recommended treatment schemes sources or products and establish- for common conditions, and regular ment of joint quality control centers. A drug information bulletins such as the precedent for this type of collaboration Zimbabwe and Cameroon drug bulle- is a regional quality control laboratory tins. Model texts, efither for physidians for countries of southem Africa, situ- or field workers, are readily available ated in Zimbabwe (Huff-Rousselle from WHO, Health Action Intemational, 1990). and the Intemational Sociey of Drug maceutical entities while providing incentives for creating private sectorbodies to compete effectively with them. The ultimate balance between the public and private sectors cannot be predicted, and will probably vary from country to country. In some, the private sector may well develop to the point.where it entirely supplants public mechaiisms. However, a public system to purchase and distribute drugs should not simply be replaced by an unregulated private monopoly or cartel. In some cases, efforts to increase the efficiency of public sector pharmaceutical entities can be justified as part of a program to prepare parastatal bodies forsale to the private sector. Finally, assuming that the willingness of donors to provide supporit cannot always be foreseen, govermnents need to evaluate critically the availability of foreign currency resources and the extent of their reliance on imported drugs. In the absence of an open trade and exchange regime, a firt step could be to estab- lish inteniinisterial agreements on reserving foreign exchange for drug pur- chases, a practice followed by Zimbabwe. A commitment to concentrate PHA.RMAC E UTIC ALS AN D DRU G PR OG R AM S 83 Box=5.continued constraints imposed by distance, irregular distribution, or financial bar- Bulletins. Information can be pro- riers, to at least 80 percent of the moted through television and other population. media, and governments can take * The efficiency with which re- steps to counter misleading informa- sources are used in pror . ; -nt, by tion. Intemational standards for ethical determining (a) wheth% onsive advertising have been established by specialty drugs are being n.,junrted in the pharmaceuticals industry and by cases where a high-quality generic WHO. drug is much cheaper, and if so, why, Governments also have a critical and (b) the price paid for a standard role to play in monitoring drug reforrns. mixed drug sample compared withthat Monitoring of reforms can be guided paid elsewhere. by., n Eficiency of prescribing. Sample X Plans for drug reform, detailing drug use studies can be car. ied out anticipated improvements in effi- using well-established methods, as in ciency, mobilization of the private sec- Zimbabwe (van der Geest and Whyte tor, establishment of improved training 1988). The African "Drug Utilization and drug information for medical per- Research Group" sponsored by wHio sonnel, and provision of drug informa- provides guidance in this area. Von to the public. n Assessments of the ability and * The proportion of drugs on an willingness of consumers to pay far. agreed national essential drug list that drugs, analyzed for various socio- are accessible, without unreasonable economic groups. use of foreign exchange on drugs used at health centers and district hospitals may help. Long-term agreements can sometimes be negotiated with donors. This is far more likely, however, if donors are satisfied that care at health centers is improving and waste is being reduced. This subject is revisited in the costing and financing of basic health services in Chapters 9 and 10. A variety of new models for cooperation among interested parties is emerging, as in Benin and Cameroon. The essential characteristics are gov- ernment leadership on policy, operational responsibility and program execu- tion through a private voluntary association, and transparency of manage- ment of resources. Conclusion Drugs are essential to health improvement in Africa, but informational asym- mterries, the separation of financiers from decisionmrakers at the consumption 114 BETTER HEALTH IN A F RICA BOX 5-2. EVALUATION OF DRUG NEEDS Results were expressed per 1,000 in- IN AFRICA NEED NOT BE DIFFICULT habitants a year. Results proved to be reproducible. The method is so simple that after brief training it could easily be In Bobo-Dioulasso (Burina Faso), of- used by trained nurses. It resulted in ficials used the WHO method to evalu- important corrections of preconceived ate drug needs, based on morbidity ideas about what was needed. For ex- figures at three dispensaries exam- ample, the need for injectable prod- ined over a six-to-twelvo-month pe- ucts proved to have been overesti- riod. ftwas assumed thatstanrdardized mated (Malkin, Carpenntier, and scnemes of treatment would be used, Lefaix 1987). level, and poor management of drug supplies render pharmaceutical markets in most countries of Sub-Saharan Africa highly inefficient. Hence, there is great potential for increasing drug coverage while reducing costs. There is promising evidence that essential drugs can be provided for around $1.60 per capita annu- ally for clients of well-funcdoning health centirs and district hospitals and that community-managed drug revolving funds can help assure sustainability of supplies- Actions to reduce waste are required at all stages of the supply chain, from domestic distributic-i policies to the prescription practices of medical per- sonnel and the use of drugs by patients. Monitoring of drug reform, and peri- odic assessments ofprogress, areessential. The assignment of public policy responsibility for drug management to a national drug authority is needed. Consensus-building should be its style. Oper- ational responsibilities for wholesale drug purchase and distribution need to be increasingly assigned to the nongovermrnent sector. To help facilitate this pro- cess, governments should foster the development of the private commercial and noncommercial drug sectors, reinvigorate public sector distribution efficiency, and promote cost-effective means of supplying essential drugs on a sustainable and affordable basis to the poorest groups in society. CH A PTER SIX Managing Human Resources for Health T O PERFORM effectively, Sub-Saharan Africa's health systems need professionally trained and strongly motivated personnel who are paid fairly forwhatthey do. Unless these conditions prevail, thequantity andquality of health services will be severely compromised. They can makeor break other- wise cost-effective approaches to health care. Personnel costs constitute the largest item in ministry of health budgets. On average, more than 60 percent of all public funds for health are allocated to wages and salaries. Since most of those who provide health services in Africa have been trained at public expense, those selected for such training must be carefully chosen, and government actions that affect their subsequent careers must be rational and wise. This chapter documents Africa's serious and wide- spread health personnel problems and assesses their causes and consequences. The rest of the chapter deals with what can be done to rectify the problems as part of countrywide health system reforn programs. The Contrasting Problems of Undersupply and Underuse One of the chief problems that must be overcome if African health is to be improved to a satisfactory level is an undersupply of sufficiently trained per- sonnel. High rates of attrition are often part of the cause. Attrition is especially damaging when public funds have been used to train personnel who later leave the public sector. In Zimbabwe, for example, it was projected that roughly 1,500 registered nurses would leave public service between 1991 and 1995, an annual attrition rate of 7.1 percent Uganda lost about 40 percent of the nurses in public service and 50 percent of the medical assistants in public service in 1986. An- a5 86 BETTER HEALTH I N A F R I C A other group with high attrition is female health workers, who leave theirjobs to marry and raise children (Vaughan 1992). Large numbers of health personnel have left African countries altogether in recent years. Those who emigrate are mainly highly trained staff, such as physi- cians, nurses, pharmacists, and senior laboratory technicians. The emigrds leave in hope of finding better salaries and working conditions in other coun- tries while escaping from political and social problems in their home countries. Since senior personnel are those most likely to emigrate, medical training, health research, and management capabilities are weakened. Emigration of health personnel whose training was financed by the gov- ernment also means that the government suffers a direct financial loss. It has been estimated, for instance, that the average loss incurred when a doctor emi- gratedfromNigeriawas $30,000 (Ojo l990). m Table 6-1 shows that the population to doctor ratio in Africa is about six times higher than the ratio for all developing countries, although the situation has improved quite a bit over the last thirty years. In 1970 there were 19,000 persons per physician and 3,000 persons per nurse or riiidwife in Sub-Saharan Africa, but the most recent data show that the ratios had improved to 10,800 persons per physician and 2,100 persons per nurse or midwife. The supply of trained personnel remains woefially inadequate. however. Over the period 1988 to 1992, for example, fewer than 40 percent of African mothers had assistance from a doctor, nurse, or midwife during childbirth. The averages shown in Table 6-1 conceal great variations from one country to the next. In 1987, for example, Gabon had one doctor per 3,000 inhabitants while Ethiopia had one per 29,000 inhabitants. In Botswana, there was one nurse or midwife for every 500 people but in Rwanda only one for every 20,000. Although improvements in the supply of health personnel occurred in the 1960s and 1970s, the situation deteriorated in the 1980s. Between 1980 and Table 6-L Supply of Human Resources 1n Health Services, 1985-90 All developing Indusnial Item Sub-Saha ran Africa countries coutnries World Population per doctor 10,800 1,400 300 800 Population per nurse" 2,100 1,700 170 530 Nurses per doctor 5.0 1.0 2.0 1.5 Note. Doctrs ar= MDs onlp; mrses are registerd nurses and registered midwives only. a. Indudesniidwives. Sourer wHO 1988. 1992a. MAN AG ING HUM A.N RES O UR C ES F OR HE ALT H 7 1986, Sub-Saharan Africa was the only region of the world where the number of doctors for every 10,0(00 people fell. A second problem, which might seem unlikely in Sub-Saharan Africa, is underuse of trained personnel. Underuse, as shown below, takes various forms: U High-level administrative positions in ministries of health are often filled by medical doctors rather than by professionals trained in management, planning, and budgeting. In Ghana, for example, the official view is that most of the top management positions in the Minisiry of Health should be held by physicians. In Niger in 1984, nineteen out of the fifty-two doctors employed by the Ministry of Health also served as full-time or part-time administrators. But assigning physicians to managerial work means that their medical exper- tise is wasted. Their ability to deal with medical problems is underused, even though the country may lack the number of physicians it needs. The prestige of physicians, in short, leads to their being given tasks that they are seldom prepared to perform successfully. * In Uganda in 1990, doctors in Ministry of Health hospitals saw far fewer patients per day (1.3) than doctors in private voluntary hospitals (6.7). According to a government study, unideruse was so prevalent that Uganda would be able to reduce the number of its health care personnel by 30 percent- without affecting the quality of service (Republic of Uganda, Ministry of Health 1991). Similarly low productivity levels have been reported among public sector health personnel in Mali. Such low productivity, it should be noted, is frequently caused by lack of equipment and supplies. * If Rwanda's 500 midwives were fully used (meaning each urban mid- wife would attend around 300 births a year and each rural midwife about 200), about 36 percent of all deliveries would be assisted by trained staff. In fact, only 18 percent of all deliveries are attended by trained personnel. This suggests that around half of Rwanda's midwives are significantly underused (Figure 6-1). In view of the above, it may seem ironic that a number of African countries are beginning to experience a surplus of health care providers. Even though the number of health personnel completing their education and taining has risen, the demand in some countries for new staff in the public sector has fallea In Tanzania, 1,500 doctors and other health school graduates used to be absorbed into public service annually, but this is no longer true. Mozamnbique also guar- anteed public sector employmnent to graduates of health training institutions in the past but has had to cut back the number of trainees in recentyears. Benin, Madagascar, Mali, and Zaire now absorb only a fraction of their health school graduates through public employment In Mali in 1987, the gov- 68 BBET T ER H EA LTH IN A FRI CA Figure 6-L Undersupply and Underuse of Human Resources in Health Services: Percentage orDeliveries Attended and Not Attended by Trained Personnel, Rwanda, 1985 ~~~18° Deliveries for which: Trained personnel ! Trained personnel E Trained personnel unavailable available but not available and in in attendance attendance Source.-WorldBankdata.- emment recruited only four of the country's sixty new physicians, only one out of the thirty-five pharmacy graduates, and nineteen out of the eighty-five new nurses. Projections made in the late 1980s showed that at prevailing rates of absorption in the public sector, Madagascar might have a cumulative surplus of 2,600 to 3,200 physicians in ten years. WAhile there are sometimes too many physicians and other health care spe- cialists, the supply of specialists in administrative posts is often perilously thin. Ministries of health and other public health institutions face serious shortages of planning and evaluation specialists, policy analysts, financial analysts and economists, maintenance and sanitary engineers, architects, statisticians, de- mographers, and legal and managementprofessionals, including personnel spe- cialists. A review of the situation in Zimbabwe, for instance, found a great need for equipment maintenance personnel, physiotherapists, dental therapists, ohar- macists, and X-ray machine operators. Causes and Consequences The problems of underuse and undersupply can be traced in part to compensa- tion problems, especially in the public sector. Wages and salaries tend to be so MAN AG ING HUMAN RE SO UR C ES F OR HE ALT H 89 low that morale and motivation are affected adversely. A study of fifteen Afri- can countries showed that the index of civil service salaries for the lowest grades fell from 100 to an average of 53 between 1975 and 1985, and, for the highest grades, to an average of 41 (International Labour Office 1989, Table 4.1: 84). In Tanzania, salaries for workecrs in the lowest grades declined by 56 per- cent between 1981 and 1987 and by 75 percent for those at the highest levels. In Madagascar, entry level salaries in 1988 were only 20 to 25 percent of 1975 levels. That was too little to support even a small family. Health professionals in public service in Africa therefore often find themselves forced to find addi- tional paid work of some kind. Poor management, weak supervision, and unsatisfactory training are also to blame. Poor management is reflected in the creation of numerous categories of health personnel whose functions overlap or are ill defined. A 1991 study in Uganda found fifty-seven different job categories for personnel in the health sector, fifty of them clinically oriented (Republic of Uganda, Ministry of Health 1991). While Mozambique has reduced the number of categories, there were still around twenty in 1990. The large number of such categories interferes with effective personnel management and makes it hard to staff health centers and district hospitals because they need health care generalists rather than carefully classified medical specialists. The problem is compounded by the continuous addition of new categories, often created under new donor-funded projects. Large numbers of low-level (and often superfluous) functionaries further demonstrate the weakness of managerial control. Prior to a restructuring in Ghana in 1987, the Ministry of Health had 38,000 employees. Twenty-two thousand of these were nontechnical workers who, accounted for 53 percent of the budget. It was estimated that the nontechnical staff could be reduced by 8,000, producing a 19 percent savings in the budget. In 1991 Uganda's Ministry of Health found that around 4,000 of its 18,000 employees were "ghost workers"-people on the payroll who did no work. It concluded that up to 10 percent of total personnel expenditures might have been lost through poor man- agement (Republic of Uganda, Ministry of Health 1991). Undersupply and underuse problems are often compounded by the absence of standard managerial procedures. Clear and specificjob descriptions, perfor- mance criteria, and supervisory guidelines are frequently nonexistent. Practical training in supervisory skills is lacking. In addition, budgetary restrictions in many countries have all but eliminated transportation and two-way radio an d telephone communication between health officials in the cities and paraprofes- sionals in rural areas. In Niger, forexample, nurses are supposed to visit a health center once every three months, but interviews revealed that eighteen of twenty-seven nurses had made only one visit in the previous six months. In Senegal, two-thirds of ninety-two supervisors had canceled planned supervi- o B E TT ER HE ALT H IN A F R [-C A sion visits within the previous six months. And in Zaire, only 21 percentof fifty- seven village health workers reported a supervisory visit within the previous three months (Nicholas, Heiby, and Hatzell 1991). Unsatisfactory training appears in several ways, not the least of which is a mismatch between the content of training and actual health needs. In Benin, Togo, and Zaire, to mention but three countries, medical training remains ori- ented to clinical work and hospital pmctice despite government policies that emphasize primary care. In Ethiopia, many training facilities were poorly de- signed and are badly maintained. The quality of health training in Guinea was found to be poor because of weaknesses in secondary education, inadequate teaching staff and facilities, inappropriate curricula, and excessively large en- rollments. In Zaire, the overall quality of medical training declined throughout the 1980s and was accompanied by deterioration of training facilities and equipment. A number of Sub-Saharan African countries are plagued as well by ex- cessive medical specialization. In C6te d'Ivoire, for example, more than 40 percent of the physicians are specialists. Govemments can address this issue by eliminating subsidies for specialist training and practice and by reviewing curricula. Dependence on expatriates is yet another type of imbalance in the health sector work force of various African countries. Large numbers of foreign per- sonnel work in the health sector in virtually every African country, many in vertical projects sponsored by donors. Foreigners in the public sector often act as district medical officers of health-for example, in Swaziland, Lesotho, Malawi, and Botswana. Other foreigners are found as technical assistance ex- perts or advisors. In Rwanda in 1985, 60 of the 247 doctors and 130 of 337 high-. ranking nurses were foreigners. In Zaire, one-third of the 2,500 physicians were non-nationals. It was estimated in late 1986 that more than half of the physicians in Mozambiqueswere expatriates. In Burundi in the late 1980s an estimated 40 percent of the physicians serving in health facilities were expatriates. As quali- fied and committed as such individuals may be, their employment can be at odds with creating sustainable human resources for health when they are asso- ciated with vertical programs administered by donors, receive much higher sal- aries than their national counterparts, and contribute to high rates of turnover. Achieving Effective Management of Health Care Personnel Without suitably trained workers in appropriately located facilities, basic health services will remain unavailable to many millions of Africans. Resolving train- ing and health facility problems will not be enough, however. Compensation for health workers must be increased, and competent supervision must be provided MAN AG ING HUM A N R ES O UR C ES F OR HEA LTH 91 to ensure strong staff motivation. Ministries of health must engage themselves in the struggle for civil service reform, decentralization of personnel manage- ment, and especially career management decisions. Since the Alma Ata Conference in 1978, only a handful of countries have formulated comprehensive health sector personnel policies. Tanzania has been among the most successful in this respect (Box 6-1), but others, including Bot- swana, Congo, Nigeria, and Zimbabwe, have also begun to address this issue seriously. While lormulating a comprehensive national policy is the first step toward coming to grips with the kinds of problems reviewed here, it is equally important to consider how problems of morale, motivation, compensation, and supervision could be addressed through decentralization. Opportunities at the Primary Care Level A number of Sub-Saharan African countries have demonstrated that it is possi- ble to improvc local personnel management. A health decentralization program in Guinea, supported by the World Batik, UNICEF, and other agencies, has broughtadvances in the developmentof tools forcommunity-level supervision, monitoring, and evaluation. Projects in Benin, Kenya, Nigeria, Lesotho, and BoX 6-1. PLANNING HUMAN work on the development of career RESOURCES FOR HEALTH IN TANZANIA streams and upgrading courses for health care personnel has been par- Tanzania is among the African coun- ticularlyimportant. tries that have been relatively suc- Despite past successes, however, cessful in preparing and implementing personnel planning has been based plans for health personnel. The Ar- on excessively simple assumptions usha Declaration of 1967 resulted in conceming staffing standards for var- preparation of a plan with explicit tar- ious types of health care facilities, gets for various categories of health without reference to variations in work human resources, for the period 1972 load or disease pattems or to the re- to1980.Thirteenthousand newhealth sources available to finance associ- workers were trained, with a heavy ated salary costs or support comple- emphasis on the training and use of mentary inputs to make health care 10,900 health auxiliaries and 2,100 personnel able to work effectively. health professionals. These targets Thus, the staffing standards of 1987, were met and even exceeded in some which doubled those previously in ef- categories, especially rural medical fect, are beyond the resource capacity aides, health assistants, medical as- of the health sector. sistants, and MCH aides. Tanzania's 92 B I TT E R H EA LT H IN A F RICA Ghana are improving district hcalth information and supervision functions. An integrated system of in-service training is being introduced at the dlistrict level in Mali. In-service training in management at the district level is beingprovided to senior district health workers in Lesotho. Sitnilar programs exist in Senegal (Unger 1991) and Ethiopia. Successful health districts have information and management systems that allow providers and clients to identify performance problems, analyze them, and take immediate corrective action on their own authority. Providers using these systems have been able to acquire a sense of control and personal growth, which arc powerful sources of motivation, Such a system was established in Kinshasa in the mid-1980s, covering sixty health centers and accounting for less than 2 percent of health care costs (Beza and others 1987). In Guinea and Benin, the entire management information system has been revised under the EBamako Initiative. Although health center staff spend considerable time regis- tering patients, children, drugs, and receipts, most of thein see this as an impor- tant part of theirjob (Knippenberg and others 1990, Ministbre de la Sante Publi- que [MSP], Benin 1990; Minist&re de la Santd Publique et des Affaires Sociales [MSPAS], Guinea 1990). BOX 6-2. DEMONSTRATED LEADERSHIP management in the various sections of AT THE DISTRICT LEVEL IN GHANA the hospital; (c) absence of liaison be- tween the hospital and the industrial African countries can provide an envi- community-one presumed benefici- ronment that encourages social entre- ary of hospital services; and (d) lack of preneurshipfor health, as in this exam- supervision by the medical staff of ple from Tema, an indusirial seaport health facilities (health centers, health city in Ghana. The Tema Health Dis- posts, and clinics) in the urban/ trict is served by,a network of health industrial and rural parts of the district. centers, health posts, and industrial To address these problems, the dis- clinics that are backed by Tema Gen- trict medical officer established the fol- eral Hospital, a district hospital. After lowing agenda: an acute deterioration of services, with * Visit all the factories in Tema to attendant low staff morale in the learn abouttheirhealth problems mid-1970s, a senior medical officer * Familiarize institutions visited with with demonstrated leadership skills the needs and problems of the hospital was assigned. The district medical offi- * convene monthly meetings of an cer identified the following problems: Ad-hoc Management Advisory Group (a) low staff morale and lack of disci- of Tema residents with management pline among hospital staff; (b) poor expertise MAN AG ING HU MAN RES O UR C ES FO R H EA LT H 93 By assigning the highest priority to giving health centers and first-referral hospitals adequate numbers of motivated personnel. African countries will at the same time discourage medical overspecialization and disproportionate con- centration of health personnel in urban areas. Good leadership is the most critical dimension if health centers and first- referral hospitals are to achieve the goals of decentralization. While much will depend on individual skills and personalities, district health management teams must be given greater autonomy, training, and support by national policy- makers. Leadership skills should be an important criterion in selecting and evaluating the performnance of district health team managers (Box 6-2). The Role of Government Human resource planning for health by geographic area, type of expertise, cate- gory of worker, gender, and various time horizons is an essential public sector activity (Box 6-3). Nearly every African country needs to strengthen its ability to perform such planning, particularly to determine staffing needs at health centers and district hospitals. This means that national govemrnments must have employees with technical skills in prepanng projections, setting norms, and Box 6-2, continued provement was observed by staff of the hospital, the regional director of * Visit all the health posts and health services, the headquarters of health centers in the district to estab- the Ministry of Health, and generally lish active working relationships of by persons seeking care at health fa- staff, especially of govemment clinics, cilities in the district. Services offered with the hospital free to the hospital, thanks to the ini- u Organize monthly meetings of se- tiative of the local health leader, in- nior clinical and management staff to cluded loan of atractorforthe hospital discuss issues affecting the care of pa- garden; sale of essential provisions to tients, concerns of staff, and efficient staff at concessionary prices on the running of health services within the hospital premises; and donation of hospital and the district as a whole and material to make bedsheets, bed- tofindsolutionstothem spreads, and pajamas for patients. By .- Conduct daily administrative working directlywith institutions in his rounds of ancillary hospital depart- area, the district medical officer was ments, such as catering and mainte- able to tap resources normally not nance, to learn about operational available to the Ministry of Health for problems. local use. Within six months, a discernible im- Source:Amonoo-Lartsen 1990. 94 BE TT E R H EA LT H IN A F R ICA designing and managing systems of performance planning and evaluation. Cost estimates and financing proposals are importmt parts of this work. As health care systems become more diversified institutionally, it is impor- tant that public sector planning take into account all health personnel, including those working in the private sector and those who work for nonprofit or charita- ble institutions, such as religious missions. Particular attention should be paid to training senior cadres to provide better leadership on health matters, includ- ing research. Leadership in health requires not only a comprehensive knowl- edge of health matters as such but also some fundamental knowledge of such related subjects as pharnacology, economics, financial analysis, and public works construction and maintenance. Ministries of health should also encour- age the establishment and work of voluntary associations of public health personnel. It would be unrealistic, however, to expect public sector health care workers to increase their work load significantly without addition.al compensa- tion and reliable payment of wages and salaries. Because civil service salaries are unlikely to undergo significant improvements in the near future, national authorities will need to give local health managers greater autonomy in salary decisions. Local retention of fees is one means of increasing compensation and ensuring regular payment of salaries at well-functioning health centers- Other salary possibilities include wage supplements for night duty and holiday work BOX 6-3. STRENGTHENING HUMAN vide senior managers with the infor- RESOURCES PLANNING AND mation and planning framework nec-' MANAGEMENT IN LESOTHO'S MINISTRY essary to make decisions on staffing OF HEALTH and training priorities *Design and implementation of a Lesotho is undertaking a systematic system for selection, placement, and. program to strengthen its manage- monitoring of training activties ment of health personnel. Actions U Development and use of a per- planned include: sonnel manual * Development, implementation, * Design and implementation of a and maintenance of human resource computerized personnel managemenit management information systems for information system (PMIs), in coor- personnel administration, planning, dination With the Ministry of Public and1training Service * On-the-job training for develop- a Training of Ministry of Health staff ment of the personnel planning pro- in using computers and in running the cess in the Ministry of Health to pro- Pmis. M ANAG I N G H UMA N R ESO U R CES FOR H EALTH 95 and supplying housing so that key staff members can live near the facilities where they work. The resources needed for such changes must in part be found by reducing the numbers of unskilled support personnel and by purging from the payroll the names of those no longerworking. This is being done in Guinea. Incentive payments in well-functioning health centers have become a fea- ture of systems of community financing of health care in a number of African countries, including Congo, Kenya, Guinea, and Nigeria. With sixty-four health centers for more than 900,000 people, Guinea appears to have the most widespread practice of local incentive payments (UNICEF 1992c). Resources mobilized by the community to pay incentives have ranged from around 10 percent to nearly 50 percent of normal salary levels. Successful health districts have also applied a variety of techniques to recognize the best performers. In Ghana, the Ministry of Health established a prize fund to provide incentives for superior performance by individual health workers and health teams. In Mali, health districts are required to meet specific performance criteria to receive full governmentanddonorsupportfortheirdistricthealth plans. Training must be adapted to practical needs at the district and community levels, and health training should be given to others in the community, espe- cially schoolteachers and agricultural extension workers. Much more attention should be paid to the study of society, demography, and the comimunity, as well as to the principles and practices of health leadership. At the same time, taining should be less oriented toward western models of medical practice- Govem- ments trying to build up district-based systems also need to rationalize and cansolidate health training schools, make them multidisciplinary, and show them how to foster the development of the district health team concept and better health leadership. Madagascar is taking action along these lines by de- centralizing its training functions and putting them underfield supervision. Flnally, as a part of long-term investment in capacity-building, male and female teachers in health care need to have periodic opportunities to improve their skills. They should also be able to obtain basic academic journals in their fields. Better compensation of teachers at health training institutions should be part of the improvement of salaries and incentives foralI health workers. African governments also need to take traditional healers into account in planning the use of human resources forhealth. There are approximately 10,000 traditional healers in ZCaire and more than 3,000 traditional birth attendants who practice actively in the informal sector. The Ministry of Health has set up a unit to gain a better understanding of their roles and to weed out harmful practices. About 12,000 trditional healers are registered in Zimbabwe. A significant share of the rural population depends solely on teem in Ghana, Benin, Nigeria, Senegal, and Zambia, among other countnes. While some modern health care givers systematically reject traditional practices, Nigeria's health policy makes 96 BETTER H EA LTH IN AFRICA BOx 6-4. COOPERATION BETWEEN Research in plant medicine and tradi- TRADITIONAL HEALERS AND MODERN tional healing is also taking placing in HEALTH CARE PROVIDERS Nigerand Zimbabwe. Much more needs to be done to pro- The establishment of registered asso- mote development of appropriate ciations of traditional healers is a first training for traditional providers, espe- step toward collaboration between the cially traditional birth attendants. Re- informal sector and modern health search and dissemination of informa- care systems in Sub-Saharan Africa. tion on the strengths and limiations of More than twenty African countries traditional medicine are also needed to have registered associations of tradi- enable modem health workers to un- tional healers, including Nigeria,' derstand the social and psychological Ghana, Senegal, Benin, Cote d'lvoire, rationale behind traditional practices, Zimbabwe, and Zambia. The degree to become sensitive to traditional be- of cooperation between traditional and liefs concerning health and health modem practices of care varies from care, and to collaborate with these countryto country. However, a number practitioners. Studies have shown that of collaborative programs between traditional healers are skilled in help- biomedicine and African indigenous ing peopleto cope with the psychologi- health practitioners exist, such as the ca and social stress that often accom- Araromi program in Nigeria, the Main- panies rapid social and economic pong Center for Scientific Research change. Policies need to build on the into plant medicine, the 'Alkaloid UnitX cultural norms and practices that facili- at the University of Science and Tech- tate this process, to promote greater nology in Kumasi, and the Primary cooperation among practifioners in the Health Training forindigenous Healers informal sector and those in the mod- (PRHErIH) at Techiman, all in Ghana. em sector. room for training traditional practitioners to increase their skills and effective-. ness and promote their integration into the existing national health system. In Ghana, Nigeria, and Zimbabwe, retraining programs have made it possible for some traditional healers to use modem treatment modalities, such as oral re- hydration (Box 6-4). Also, AIDS prevention programs are increasingly drawing on the help of traditional healers. Conclusion Although the numbers of those who deal with health problems have grown markedly since independence, there are still fewer on a per capita basis in Sub- Saharan Africa than in other areas of the world. The numbers of those with health skills in most countries remain imbalanced in relation to needs, and de- MAN AGING HUM AN RE SO U RC ES FOR HE ALT H 97 BOX 6-5. DEVELOPING HUMAN development at the Universities of RESOURCES FOR HEALTH LEADERSHIP Ibadan, Accra, and Nairobi. New pub- AND RESEARCH IN SUB-SAHARAN lic health training programs have been AFRICA developed at the University of the Western Cape in Capetown and Despite the evident need, senior-level through the University of Zimbabwe. training institutions and opportunities Among francophone countries, sev- for health leadership and research in eral training programs have evolved Africa are scarce. Few universities or from a wHo-sponsored school of pub- other institufions offer training to pre- lic health in Cotonou. The University of pare people forthese roles. In recogni- Kinshasa opened a school of public tion of the unmet need, new and health in 1986, and the Universities of strengthened graduate programs are Abidjan and Dakar have developed being established in some African training programs at the diploma or countries, such as Zimbabwe and master's level. A school of public Nigeria, with an emphasis on field- health-the Centre Inter-Etats d'En- oriented training, based on partner- seignernent Superieur en Sante ships between universities and gov- (cIEsPAc)-has been initiated at the emment departments responsible for University of Brazzaville, and one is public health programs. The develop- underconsideration in C6te d'lvoire. ment of such programs is responsive Building on these and other initia- to the need to emphasize practically tives, governments and donors need oriented disease prevention and de- to collaborate at the national and in- velopment programs at the district tercountry levels to prepare and fi- level. nance plans to strengthen health In anglophone countries, the in- leadership and research capacity. creasing emphasis on public health Fortunately, new programs that have has been nurtured by training in com- evolved over the last five years are munity medicine. This has existed for being increasingly recognized by do-. many years in Ghana, Nigeria, Kenya, nors as suitable alternatives to train- and Uganda. New programs in public ing outside Africa. health have been created or are in Source: Bertrand 1992. ployment, compensation, and motivation are weak. Many more trained people are needed to carry out the tasks of policy analysis, planning, and budgeting (Box 6-5). The parount need is for better supervision at the district level. The task at the national level will be to create an environment for effective management at the lower level. Personnel policies, including preparation ofjob descriptions and supervision norns, are central to this work and will require genuine collab- oration within ministries of health, and with ministries of finance and planning, and civil service commissions. CHAPTER SEVEN Infrastructure and Equipment T HOUSANDS of vehicles and buildings and a wide range of sophisticated equipment (much of it imported) are used each day in Africa for health purposes. As populations grow, new buildings, vehicles, and equipment will be needed. If funds for this infrstructure and equipment are allocated inef- ficiendy or inequitably orare poorly used, the delivery of health services will be severely impaired. The challenge facing the public sector is pardcularly immense because most African governments are heavily involved in building, operating, and maintaining health facilities. Many Sub-Saharan countries, and especially poorer ones with low population densities, face high infrastructure costs. In the Sahel countries, for example, construction costs are estimated to be double or even more than those in other African countres. The next section of this chapter discusses the status of Africa's health infra- structure and equipment Three problems dominate: insufficient maintenance, inappropriate and insufficient expansion, andpoorplanning. This review of the current situation makes itpossible to determine whatis missing and what health system reformns are needed to improve the planning and rnanagement of physi- cal facilities devoted to health purposes. Infrastructure and Equipment Problems Existing health facilities in many African countries have deteriorated in recent years. A study in Tanzania found that only 660 out of 1,800 rural government dispensaries were in good condition, while 810 were in fair and 330 were in bad condition. A 1990-91 survey of fifteen hospitals operated by the Kenya Minis- 98 IN FRASTR UCTU RE AND EQU I PM ENT MT try of Health found that 40 percent of the buildings were in poor or unsatisfac- tory condition (Porter 1992). Some hospitals, such as the Tres de Agosto Hospi- tal in Guinea-Bissau, have crumbled beyond the point of repair. Equatorial Guinea has an extensive network of health facilities in most cities and small towns, but they will need major repairs to make them usable. And in countries such as Angola. Mozambique, Somalia, and Sudan, numerous health structures have been severely damaged by civil war. Health equipment has also fallen into disrepair. In Nigeria, for example, one study (Erinosho 1991) found that close to one-third of the equipment in a series of health care institutions was not being used. In general, the more so- phisticated the health care facility, the more equipment was out of use, and the longer it was out of service (Table 7-1). Studies of secondary hospitals in Nigeria carried out in 1992 suggest that equipment worth around $47 million (out of a total of $150 million) would require repairs, and that another $35 million is needed for reinvestment in essential items (Porter 1992). Studies of thirteen Ministry of Health hospitals in Kenya found 40 percent of all their equipment out of order and 40 percent of operating room equipment in need of repair (Porter 1992). A 1987 survey of seventeen hospitals in Ugandafound that only 20 percent of inventoried equipment was in working order, while only about a third of the remaining 80 percent was worth repairng (Porter 1992). The use of vehicles in the health sector has been greatly restricted by short- ages of fuel, lack of maintenance, and repairs. A 19247 inventory of 660 MInistry of Health vehicles in Ghana found that 167 were roadworthy, 230 neededexten- sive repair, and 263 were wortWess. In Guinea-Bissau, 42 percent of the Minis- Table 7-IL Health CareEquipmentNot In Service in Nigeria, 1987 (percent) University Non- Primary teaching Suate-owned government health item hospials hosp -W ls hospitals centers Thtal Pieces in use 69 57 78 90 70 Pieces out of order 31 43 23 10 30 Share of equipment out of order for given duration <2 years 19 22 33 40 20 2-4 years 40 24 67 60 38 >4 years 41 54 - - 42 -Notavailable. Source: Erinosho 1991. 100 BET.TER HEALTH IN A F R I C A try of Health's vehicles were inoperable in 1990. This was not unexpected, since the ministry's vehicle maintenance program had ended in 1986. Africa's tertiary hospitals have not escaped decline either. A report on Queen Elizabeth H Hospital in Lesotho found that its buildings were in poor physical condition and that it had other problems, including shortages of basic equipment, lack of maintenance capability, uneven distribution of work loads, weak planning, little staff development and supervision, and poor financial management. Underfinancing of maintenance and repairs-virtually universal among African health facilities-is particularly apparent in public sector facilities. A study in one of Nigeria's states found that public hospitals and maternity clinics spent only 5 to 8 percent of their budgets on nonpersonnel items, such as main- tenance, transport, and supplies, compared with private sector spending of.17 to 18 percent on such items. In Dar es Salaam, Tanzania, the budget forpreventive maintenance of health facilities in the late 1980s was less than 1 percent of what should have been spent In Guinea-Bissau, the total Ministry of Health budget allocation forpreventive and routine maintenance in 1989 was a mere $5,000. A study of six district hospitals in Malawi found that an average of only 15 per- cent of recurrent expenditures was devoted to building maintenance and 0.2 percent to equipment maintenance in 1987-88 (Mills 1991). The maintenance problem is frequently complicated by division of responsibility because build- mig mainterance is often the responsibility of other ministries. The low priority given to training people in maintenance and repairfurdler exacerbates the deterioration of physical infrastructure. In Senegal, civil ser- vice personnel assigned to maintenance do not perform adequately because suitable skills and appropriate supervision are lackdng. In Zimbabwe, equip- ment maintenance personnel are in desperately short supply, and of all catego- ries of workers employed by the Ministry of Health, the highest vacancy rate in 1990 was for medical equipment technicians. The same factors that have caused poor maintenance have made it difficult. for African countries to expand the health sector infstructure. Assuming that one health center serves about 5,000 people, for example, Mali will need to increase the number of its health centers by 242 in the 1990s. This is nearly five times the actual increase of fifty-two during the 1980s (Table 7-2). Other coun- tries face similar challenges. In Tanzania, population growth has led to a grad- ual decrease in health coverage. Some countries, however, have strongly promoted expansion of health fa- cilities at levels below the national level: U Botswana has given special attention to improving its infrastruc- ture at the lowest levels. The number of clinics grew from 40 in IN FRASTR UCTU R E AN D EQU I PME NT 101 Table 7-2. The Growth of Health Centers in Selected African Countries and the Challenge Ahead (number of centers) Number needed in 2000 Actual number To mantain To reach 60 1980 1990 1990 coverage percent coverage Burkina Faso 169 860 1,100 1,400 Mali 470 522 760 1,300 Niger 240 460 630 1,270 Senegal 470 690 900 1,200 Sourre World Bank 1992-. 1974 to 150 in 1986, while health posts grew from 22 in 1974 to 227 in 1986. Over the same period in Botswana, the number of district hospi- tals increased by less than 10 percent s In mainland Tanzania, the number of dispensaries rose from 1,847 in 1976 to 2,600 in 1980 and 2,935 in 1988. * In Mozambique, the number of "primary facilities" (the equivalent of health centers) rose from 326 in 1975 to 1,195 in 1985. Similarly, the number of district hospitals rose from 120 in 1975 to 221 in 1985. For the most part, however, govermnments have made the funding of tertiary and other inpatient facilities their leading infrastructural priority. I Ethiopia the 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 Tomd and Principe enjoys one of the highest ratios of hospital beds to population in the developing world. In 1990 that small African country had roughly one hospital bed for every 190 people, which was twice as high as in Nigeria and nearly three times as high as in Colombia. These accomplishments have come at a high price, tend to be concentrated in urban areas (Table 7-3), and provide disproportionate benefits to relatively well-to-do households. Poor infrastructure planning is evident in the location of health facilities, in uncoordinated community initiatives for facility expansion and in weaknesses in project design and execution. In Guinea-Bissau, for exarnple, one region has more than five times the number of hospital beds per person found in another, more populated region. In Burundi, the population served by health centers varies from 870 to more ihan 17,000, with a mean of around 2,500. Even in Tanzania, where a special effort has been made to achieve equity in the health sector, a sample of primary care facilities in 1984 revealed that some dispens- 102 BE TT ER H EA LT H IN A F R ICA Table 7-3. Percentage of Population with Access to Health Care Facilities, Selected African Countries, Late 1980s Country Urban Rural Botswana 90 85 Burkino Faso 51 48 Congo 97 70 Gabon 97 70 Ghana 92 .45 KCenya 80 53 Liberia 50 30 Mauritius 99 V 99 Nigeria 87 62 Rwanda 60 25 Somalia 50 15 Tanzania 94 73 Togo 60 60 Zaire 40 17 Zimbabwe 90 80 Source Sttistical appcndix in tls volumce aries served only about 1,500 people, compared with the target of 6,500, while others were expected to serve populations many times larger than the target figure. Poor planning is particularly apparent in imbalances between urban and rral areas. A study of rural health stations in Ethiopia in 1985-86 found that they served only sixteen patients per day, many fewer than the ninety to 100 anticipated, and concluded that improper location of the facilities was responsi- ble. Another study (Kloos 1990) found that more optimal location of matemal and child health facilities in rural Nigeria would have increased coverage by 20 percent. In the fifteen African countries for which data on the matter are avail- able, six are countries where less than 50 percent of the rural population has access to health care facilities. In seven of the countries, however, 90 percent or more of the urban population had access to health facilities in the same period (Table 7-3). Lack of coordination between the public sector and nongovernment pro- viders has complicated matters because decisions on the location of public sector facilities need to take into account the planning of the nongovernment providers. In Uganda, church missions have built clinics to meet the needs of the populaton in rural areas. Governments can build on, orcomplement, such networks. IN FR A STR U CTU RE AND EQ U I PM ENT 103 Lack of coordination between government officials and community leaders is another manifestation of weak planning. In a number of African countries, health centers have been built by communities with the understand- ing that public authorities would operate them, but adequate resources have seldom been set aside for that purpose. In Mauritania, where community partic- ipation was encouraged by the government, health posts were built at random locations by local communities. In some regions, the proliferation of health posts has resulted in shortages of personnel and material resources. Financial and other constraints have frequently prevented the government from assuming responsibility for operations at health centers and have made local communities cynical about the national government Poor project design and execution are another manifestaion of weak infra- structure planning. A wide range of construction standards and methodologies, combined with a lack of norms, has led to oversized facilities, substandard con- struction, and high unit costs. Unit construction costs for almost identical health centers in M.ali in the late 1980s, for example, varied by a factor of four (World Bank 1992a). Construction costs in the Sahel countries range from $750 to $1,200 per square meter for primary care facilities, compared with $350 to $450 per square meter in other African countries (Porter 1992). In the absence of norms for designing catchment areas, national officials responsible for plan- ning health sector construction have often been unable to. idetitify the type and size of infrastructure needed to provide.health services to local communities. Renewing Health Sector Infrastructure and Equipment Physical proximity to health care facilities is only the beginning of effective health care coverage. A facility that is nearpeople's homes will have little value if it lacks basic equipment In many African countries this problem has arisen partly because plans were made to construct new facilities before determining whether the money was available to operate them. Some of these problems can be resolved by charging fees and making improvements in the quality of care at lower level facilities. What remains critical, however, is to improve infrastruc- ture planning, selection of equipment, and equipment maintenance. Cost-effective allocations of financial resources for infrastructure and equipment tend to be those that give priority to rehabilitation over new invest- ment, and to health centers and district hospitals instead of tertiary facilities, as discussed in Chapter 4. Rehabilitation needs are widespread, but effective rehabilitation requires careful analysis of existing investments and a clear ranking of priorities com- patible with a commitment to preventive and primary health care and to cost- effective interventions. Mali, for example, has begun to establish a foundation 104 B E TTE R HE ALT H IN A F RICA for this kind of analysis through the creation of a data bank on existing infra- structure, equipment, and associated health care services that will be available to local health administrators. Norms, skil Is, and procedures for determining where to build health facili- ties and for the maintenance of buildings, equipment, and vehicles also need to be established and carefully monitored. The norms should cover actual mainte- nance work as well as its financing, and should apply to nongovernment as well as public sector facilities. As a general rule, African countries should expect to spend between 2 and 3 percent of the replacement cost of health centers and hospital buildings on maintenance annually. A detailed study of Kenya, for example, led to an estimate of 2.6 percent (Porter 1992). Specific standards on spending for equipment maintenance, repair, and re- placement are also needed. It has been suggested as a rule of thumb that a sum equivalent to 20 percent of the value of existing stock should be allocated annu- ally to maintenance, repair, and replacement (Bloom and Temple-Bird 1988).. Another way to look at the issue is in terms of the recurrent expenditures of operations. As a general rule, around 10 to 15 percent of recurrent costs will be required to maintain a first-referral hospital (Barnum and Kutzin 1993). Sandardized lists of the equipment used in the various types of health care facilities are also needed, along wit norms for maintenance and repair. WHO has prepared such norms in a number of related areas, such as the estimated annual cost of maintaining specific types of medical equipment as a percentage of their capital cost (Kleczkowski and Pipbouleau 1983). Ghana is planning to set up a hospital equipment maintenance service with workshops, equipment and tools, vehicles, spare parts, and training programs. Mozambique is'estab- lishing a national network of health facility and equipment maintenance cen- ters. The experience of nongovemment partners is often relevant (Box 7-1). When health center facilities and equipment are well managed, local com- munities tend to be involved. The basic principle underlying this arrangement is that facilities planned without the active participation of beneficiaries will, at best, be viewed with indifference. If appropriately planned, partnerships consti- tute a powerful instrument forpromoting local initiatives and strengthening man- agement through a sense of ownership. As part of a Worid Bank-financed health and population project in Mali, for example, a cost-sharing formula (50 percent govemrnment and 50 percent local conmnunities) is supporting construction and planned maintenance of 120 community health centers during a five-year period. The Special Problem of Tertiary Care Facilities The management of tertiary-level health facilities (meaning mostly major urban hospitals) merits special attention. Improving efficiency at such facili- INFRASTR U CT UR E AND E Q U I PM ENT 105 BOX 7-1. MAINTENANCE IN HOSPITALS that encourage good staff performance, OF ZAMBIA'S MINING CORPORATION combined with strong supervision and incentives. It offers betterservice condi- The public sector in Zambia is facing tions than the public sector and has great difficulties in providing and sus- higher staff retention rates. taining medical equipment services. In U ZCCM has recognized the impor- public hospitals, about 20 percent of tance of maintenance in its. operations .medical equipment Is working poorly and health care activities. Mine hospi- and 40 percent is completely out of op- tals are financed significantly better eration. Zambia Consolidated Copper than their public sector counterparts Mines (zCCM) has established a health and therefore receive adequate mainte- care system of its own, separate from nance budgets and foreign exchange. the public sector, that consists of * It has separated medical equip- eleven hospitals and fifty-eight health ment maintenance and safety policies centers. It has developed agood main- from its operational activities and tenance system for its medical equip- wisely applied technical and human ment, which is about the same age as resources, maintenance, and man- that in the public sector. Its ability to do agement expertise from industrial in- this has been due to the following strumentationtormedicalapplications. factors: * Initial training in management and * It has established an autonomous maintenance for health care special- body, the Medical and Educational ists has been conducted by mine oper- Trust, to operate all health care facili- atfonal staff. Some operational mainte- ties and train health care and opera- nance staff have been seconded to tonal personnel. mine hospitals. m It has established work practices Source:Temple-Bird 1991. ties without increasing their budget allocations in real, or even nominal, terms would be highly desirable. Management audits can lead to the establishment of specific targets for efficiency gains. At the Kenyatta National Hospital in Nairobi, for example, the performnance targets include reducing the average length of an inpatient's period of hospitalization from 8.6 days in 1989-90 to 7.1 days in 1995-96, a reduction in staff from 5.4 to 4.0 per 1,000 patient days, and an increase in the ratio of maintenance to total recurrent expenditures from 2.2 percent to 6.0 percent. Malawi has prepared five-year efficiency plans for its three major hospitals that include reductions in funding for transport and utility systems, other items, and improved accounting and expenditure control. Assessing Technology Choice In many African countries, modem technology is often not used properly, even in leading hospitals and medical schools (Free 1992). It is complex technology 106 8 E T T E R H E ALT H IN A F RICA that requires every component to interact at thle right place and lhe right lime! but the more complex the technology, the greater the risk thait a link in the chain will break down. The introduction of any technology should therefore include the introduction of all the things needed to make the technology work: equip- ment, training, maintenance, quality control, and the capacity to translate the results of quality control analyscs into corrective actions. New technologies have expanded the potential scope of the heialth system; some examples follow. U Computerized systems make it possible to store and retrieve the large amounts of vital statistics and other data needed to assess risks and to plani, implement, and evaluate health programs. Pharmaccutical supplies can be man- aged more cfficiently through computerized updating of inventories, thus pre- venting waste and reducing costs. Computers are only helpful, however, to the extent that they support a management information system wiLh adequate soft- ware and maintenance. 3 Radio communication has proven essential in mobilizing the resources. needed to deal with epidemics and natural disasters. Health activities in rural areas can be bettcr integrated into district health care through the use of two- way radios, particularly if transport is available to evacuate patients when nec- essary. Supervisory consultation by radio improves the efficacy of services and. reduces the cost of referral. * New diagnostic tests, such as "dipsticks" to diagnose HIV and other sexually transmitted diseases, or tests using saliva, may give community health centers diagnostic powers that were previously restricted to specialized urban laboratories. * Noninvasive diagnostic tools with high sensitivity and high specificity,. such as ultrasound machines, may sharply improve diagnosis at the district level. Less invasive treatment-"keyhole" surgery, for example-can mini- mize patient trauma and reduce the length of hospital stays. A shift to one-day surgery with improved technologies and care practices, as is now being done in many industrial countries, could help to contain the growing demand for hospi- tal beds and other health facilities (Porter 1992). * The development of powerful drugs that can be effective when adminis- tered in a single oral dose has drastically modified the therapeutic approach to such diseases as helminthiasis and amoebiasis. Similarly, thermostable vac- cines that can be given in a single oral dose have increased the prospects for controlling common children's diseases, such as measles and polio. Drug kits and blister packs fall in the same category. INFR AS TR UCT UR E AND EQU I PM EN r 107 The greatest obstacle to improving medical technology in Africa may be "technology philanthropy"-the uncoordinated donadon of equipment to Af- rican countries by foreign agencies and charities. Given their often precarious finances, developing countries find it hard to refuse such gifts, even when they are unsuited to the country's immediate needs. One solution would be to devise "donation protocols," whereby the kinds of equipment to be donated would follow a model-paralleling, for example, the selection of drugs by using es-. sential drugs lists (Porter 1992). BOX 7-2. ACQUIRING NEW that the broader cuiltural, social, and TECHNOLOGIES economic dimensionis are considered. Public, private voluntary, and private There is generally no established commercialperspectvesareallusefil mechanism in African countries for to this end. planning the acquisition of new health Because the choice of health tech- technologies. Awareness of technolo- nologies determines the allocation of gies is nota problem, becausethere is human and financial resources in a sufficient pool of knowledge at uni- health care, African governments versities, among staff returning from need to support operationally oriented abroad, and among consultants and research that will facilitate decisions donors. It is the process of technology about whether to introduce new tests, transfer that is problematic, since it is treatments, and their associated tech- -usually made on an ad hoc basis nologies into their countries' health according to vested interests, pres- care systems. Factors to be consid- sures, and prejudices. ered include the approprateness and When there is some form of plan-. cost-effectiveness of the intervention, ning, the acquisition of new technolo- its links to the basic package of health gies is to a large extent controlled by services, its impact on health equity, physicians and, more likely than not, the ease of its use and maintenance, by clinicians trained abroad. They are its training requirements, and its life- generally not the best persons to per- time cost A cautious attitude toward form this task. While the medical pro- unoontrolled diffusion of medical tech- fession can readily pinpoint a problem, nology is emerging in the industrial it generally has little idea of the com- countries, and African. policymakers plexity and extent of the engineering would do well to exercise prudence in problems or the level of training asso- the face of quite understandable pres- ciated with the technologies needed to sures for investment Selection of ap- solve them. Rather, a team is needed, propriate equipment, and arrange- including public and nongovernment ments to ensure its maintenance, are, health care providers, engineers, plan- approprate ministry of health roles. ners, and social scientists-to ensure 108 . * B E T.T E R H E A LT H I N A F R I C A Much of the work of technology assessment will require intercountry co- operation, because the costs of undertaking assessments and preparing appro- priate recommendations are likely to exceed the capacity of most individual African countries. Some support for such work exists at the international level, including ajoint Technology Introduction Panel inaugurated by UNICEF in 1988 in cooperation with wHo and other international agencies (Box 7-2) (Free 1992). Condusion Strengthening the management of infrastructure and equipment is one of the several health system reforms needed to achieve health goals in Afric One concrete step would be for govemments to assign responsibility for decisions - about health facilities, equipment, and technology to a senior ministry of health official. Another would be to establish norms for health facilities at different levels in the system and to support operational research on the most cost- effective technologies available. Budgetary standards and provisions for main- tenance and operating costs need to be established, particularly in public sector health facilities. Since the fimancial resources required to provide basic health services are frequently depleted by cost overruns and-inefficiencies at the ter- tiajy level, more efficient use of technologies, equipment, and facilities in large urban hospitals should be a priority. African ministries of health might take a look at the global action plan devised by wno for the management, mainte- nance, and repair of health care equipment. C HA PTER EI G HT Management Capacity and Institutional Reform PUBLIC administration in rniny African countries continues to remain weak despite changes made in the 1980s. Widely observed shortcom- ings are: * Govremment ministries and other agencies tend to wield authority and make spending decisions in a highly centralized fashion. As a result, local gov- ernments have little authority to make decisions and few methods of raising the tax revenues they need to be effective (Silvennan 1992). * Public ministries and other agencies often employ far more employees than they need, and managers are ineffective in motivating and disciplining staff members. Overstaffing is often the result of a desire to provide stable and reasonably well-paid jobs, but the end result is waste of public funds and de- moralization among employees who have no productive duties. i Public agency managers often have a poor understanding of the institu- tions they are supposed to manage or the broader context in which their agen- cies operate. * It is extremely difficult to determine the effectiveness of government spending because of inadequate transparency (how money was spent) and poor accountability (who decided to spend it). For the most part, these systemic shortcomings need to be addressed as part of comprehensive public sector reform programs. It is difficult to reform one ministry on its own, but these constraints need not inhibit reform-minded health leaders. In any case, institutional reforms and greater decentralization require a systematic approach involving careful assessment of institution- and country- la9 110 BETTER H EA LT H IN A F RICA specific conditions and the establishment of a timetable for change. As the ex- perience of many African countries shows, deeply entrenched problems in the health sector cannot be solved overnight. Nor is a single recipe likely to be appropriate for all. This chapter summarizes lessons learned about reforms of the administra- tive and managerial functions shown in Figure 8-1. Recognizing the drawbacks of relying too heavily on centralized public bureaucracies, several African gov- ernments have considered various degrees of decentralization to the local and community level in the management and delivery of services including health, education, and public utilities. Success is particularly apparent when the plan- ning and delivery of cost-effective health services are combined with commu- nity participation and public support at the district level. From the perspective of ministries of health, districts can also serve as effective administration units for communities to exert influence "upward." Figure 8-L SomeDimensionsofCapacityBuilding Policy analysis formulafion : ~ __ _ _ L$ Monitoring Management Planning and ~~~and and ~~~~~~~~~~and evaluaton instutional programming capacity ____ _ I | B~~~~Eecution < MANAGE MEN T AND IN ST I TUTI o NA L RE FORM 111 Several initiatives, discussed in this section, are needed to strengthen health sector institutional capacities and management practices at the central, regional, district, and community level (Vaillancourt, Nassim, and Brown 1992; North 1992). Assessment of the Existing System The processes of strengEhening institutional capacity and improving manag- eriaI abilities need to start with a situational assessment of existing structures. Health system performance is often hampered by unforeseen bottlenecks. Weak links can be strengthened through internal reorganization, management changes, and, if need be, changes in legal status affecting decisionmaking and institutional coordination. Thechallenge is to replace piecemeal assessments of particular components of the system orof single institutions with more compre- hensive assessments by those involved in the sy'stem's daily operations. Situational assessments can be carried out through internally driven diag- noses of current versus desired structures, functions, and skills. This kind of assessment has been carried out in Guinea, Benin, and Togo (World Bank 1993b), where three groups of stakeholders (community representatives, health care personnel, and policymakers and planners who work at the regional and central levels) have been involved in identifying and resolving common prob- lems. One group consists of community representatives, who speak in the inter- ests of health services clients. A second group consists of health personnel, who often feel unable to modify the system at large yet seek to improve their cred- ibility in the functions they perform by working together for change. A third group consists of policymakers and planners at the regional and central levels. Workshops have been convened to assess how well the systems are per- ceived to be operating, gaps in their performance, and what is needed to fill the gaps. In the workshop forhigher-level officials, forexample, the process begins with an assessment of health needs as shown by current epidemiological data. That is followed by examination of the operations of sectoral programs and whetherthey need additional funding. Finally, the participants discuss potential strategies for closing the gaps. The procedure typically follows the five steps described in Table 8-1. This approach has produced several benefits: * The tendency to attribute long-standing problems to a shortage of financial resources is being supplanted by detailed diagnoses of what is required to resolve those problems. * High-level officials in health, finance, andplanning ministries have participated, resulting in a greater commonality of under- standing across ministries of the problems involved. 112 B ETTER H E A LTH I-N A FR I CA Table 8-1. Diagnosing Health System Performance in Guinea, Benin, and Togo Steps Situationalanalysis Step I Analyze current R Review of policies, strategies, and contents of actual performance and programss; identification of strengths and weaknesses in majorconditions the system; review of health services, theirlocation and affecting sector distribution; analysis of systems of financing and resource allocation; and assessment of formation and deployment of personnel. Step 2 Identify and - Inadequacies in current menu of policies and strategies; prioritize problems management, evaluation, coordination problems in and constraints programs; resource allocation and budget management meriting attention problems; operational problems atvarious levels of service provision; and personnel management problems. Step 3 Reflecton - Improved management and coordination systems; appropriate strategies decentralization and mechanisms of community and sectoral programs participation; resource mobilization through cost recovery; improving standards and norms in health care delivery; and taining and redeployment schemes for personnel. Step 4 Prioritize and define - Women of reproductive ages; pregnant women; mothers target groups and infants aged 0-5 years; young adults, the old and infirm; and groups susceptible to particular maladies. Step 5 Determine indicators Total number of sick needing health care; disadvantaged ofperformance for groups; measures of reforms undertaken; management monitoring and information systems used for project evaluation; health evaluating progress statstics and rates of coverage, and monitoring and evaluation of decentralization practices. a A corps of sector managers who speak the same language and share a conceptual framework is being created. The result should be a stronger consensus on how to break through majorbottlenecks. Equipping Managers with Needed Skil and Methodologies Health systems cannot be run effectively unless managers are sldlled in plan- ning, progrmming, and budgeting. Such skills are required to translate policy M AN A G E M EN T A N D I N STITU TI O N A L R E FO R M 113 into implementable projects and programs and to ensure the availability of hu- man and financial resources. More managers with such skills are needed in Africa. In Ghana, for example, a 1990 review of the Ministry of Health found an almost complete absence of planning capacity, few rational management pro- cedures in -place for day-to-day operations, and a lack of records on ministry decisions. The review concluded that no significant improvement could be ex- pected in the delivery of health care services unless a core group of qualified managers was appointed to key positions. The Ministry of Health then decided to create new planning units with work programs and defined staffing and a management information system to monitor performance. In Nigeria, Ministries of Health at the state and federal levels established departments of planning, following civil service reform, but qualified people were hard to find. To help meet this shortage; three Nigerian universities- Benin, Ilorin, and Maiduguri-began operating an -accelerated three-month program in health planning and management, using a multidisciplinary curricu- lum and training manuals developed with the Universities of York, Leeds, and Keele in the United Kingdom and Johns Hopkdns University in the United States. Close to 400 medical and nonmedical staff from Nigeria's local, state, and federal governments completed the program between 1990 and 1992. Managerial skills and methodologies in public finance and infonnation collection and management are especially important, to develop the following a Health expenditure data. Expenditures on health need to be compiled by use and especially source-household and other private expenditures, public expenditures, and donor funids. InforTnaion on source of expenditures is par- ticularly important to enable policymalcers to assess the potential for private financing and cost recovery and the capacity of government to finance public health activities and provide subsidies. Time series data of this type were avail- able for this report for only about one-diird of Sub-Saharan African countries. * Comprehensive health sectorfinancial plans. Such plans need to en- compass public and nongovernment outlays. While such analyses are gradually becoming more widespread, such as in Senegal and Zimbabwe, they remain nonexistent in many African countries, thus rendering analysis of planned com- pared to realized expenditures piecemeal and incomplete. They need to encom- pass recurrent and capital expenditures, as well, as cost. estimates for future programs and targets. In this way, shortfalls can be anticipated and plans to fill gaps formuIated. A particularly important area is information on present and future recurrentexpenditure requirements of existing investments. * Management information systems (MIS).- To facilitate health planning, information on the cost of services and health outcomes is required to determine 114 BETTER H EA LTH I N A F RICA the cost-effectiveness of basic health services. MIS should also cover revenue collection and monitor the cost of medical contacts by provider or institution. In Chad, for example, the Ministry of Health and Social Affairs has designed a health information system that has been operating successfully for several years. Annual reports are prepared with national-level information on health status, health services, and health facilities functioning. Information from the system is used in planning at the national and provincial levels, as well as in some districts (R6publique du Tchad 1992). Finally, institutional effectiveness cannotbe assessedorinvestnentalloca- tions determined unless managers have the capacity to collect, compile, and analyze more up-to-date demographic and epidemiological information. In Ghana, as in many other African countries, the monitoring of primary care has been stalled partially because of poorly functioning statistical and data systems. Ghana's Center for Health Statistics is currently responsible for collecting only limited data from hospitals and health centers. Reporting is substantially in- complete; and institutions outside the public sector are only partly included. Most available data have not been analyzed, disseminated, or used system- atically forpolicymaking (Box 8-1). Promoting Decentralization The pace at which countries pursue decentralization, and their understanding of its content, depend on the interaction of many factors. Some countries push hard for decentralization; others resist it. Among these factors are (North 1992): * Changing attitudes toward governance and international trends favoring decentralization in support of primary care, countered by bureaucratic resistance to shifts in decisionmalcing power by the political and medical establishment. * Increased demands for control of budgetary resources at provin- cial and local levels in view of poordelivery of centrally financed and provided health services, with inertia and bureaucratic iesis- tance from central governments that have traditionally controlled the purse strings for health. * Motivation to attune health programs to local cultures and tradi- tions in reaction to top-cown programs that have sought to change behaviors with insufficient regardforsociocultural concerns. * Desire to move away from investment programs associated with donor-driven agendas to nationally determrined priorities with in- puts from participants and beneficiaries down to the community level. MAN A GEM ENT AND INST IT UTIONA L R EFO RM 115 BOX 8-1. KNOWLEDGE-BASED of completeness of death registration MANAGEMENT AND PLANNING are only 10 to 25 percent These in- clude Botswana, Djibouti, Guinea- All acrossAfrica, health policymakers, Bissau, Kenya, Rwanda, Sierra planners, and researchers have been Leone, and Togo. hampered by the lack of accurate, reli- In the absence of needed informa- able, and timely data on households tion, health problems tend to be 'invisi- and communities. As a result, it is ex- ble" or "moving targets" from a man- tremely difficult to profile the health agement and planning perspective. status, needs, behaviors, and prefer- Moreover, household behaviors, in- ences of different demographic groups cluding self-diagnosis, self-treatment, within countries, let alone the epidem- and willingness and ability to pay for lological characteristics of different so- help from traditional healers and mod- cdoeconomic groups. em practitoners, remain poorly under-' Systems for registering births and stood. As a resultthe entire process of. deaths are very weak across Africa, monitorng and evaluating progress is thus deprving planners of atimely tally undermined. of births and deaths, by characteristic Knowledge-based management of and bygeographicarea (African Popu- the health sector has been further un- lation Advisory Committee, 1993a). dermined by failures to analyze data Only relatively small islands have vital that have been collected and to use registration systems that have been the resulting information effectively. In classified as "complete" (meaning some cases, health information has more than 90 percent complete). been suppressed; in others, epidem- These include Cape Verde, Mauritius, iological and other information has Reunion, Sao Tom6 and Principe, St been ignored in drawing up priorities Helena, and tihe Seychelles. Several for acton. Suppression of information other African countries have vidl reg- on the AIDS epidemic during the early istration systems but estimates 1980sis acase in point(Lucasl992). In Africa, district-based health care-as described in Chapter 4-is prac- ticed widely in such countries as Botswana, Tanzania, and Zimbabwe; partially in such countries as Benin, Guinea, Mali, and Nigeria; and on an experimental basis in such countries as Burundi and Senegal. The decentralization of health responsibilities to the district level can be expected to bring major changes in institutional and managerial roles. Clear distinctions need to be made, however, among administrative supervision, technical superiion, and advisor roles. The functions typically performed at various levels in decentralized systems are summarized in Box 8-2. The most important aspects of decentralization are to establish the level to which authority is to be decentralized, the precise authority being delegated, the 116 B ETTE R H E ALTH I N A F R ICA BOX B-2. ROLES AND icies and of drug-quality, avilability, RESPONSIBILITIES UNDER and distribution DECENTRALIZATION OF MINISTRIES OF * Planning, training, and regulation HEALTH of health personnel * Regulation of private-for-profitand Decentralization necessitates clear nonprofithealthcareproviders and specific delineation of responsi- * Oversight of health care organi- bilities at each level of the health care zatfons and- health research institutes system. While there is inevitably varia- with a national mandate tion among countries, ministries of * Norms and standards conceming healthtend to be responsiblefor. nealth infrastructure, equipment, and * Formulation of health policy technology * Production of national health * Liaison with-international health plans and regional and local health organizations and aid agencies. - planning guidelines * Advice on allocation of resources, Regions or provinces tend to .be re-. partcularlycapitalfunds sponsible for * Public health budget analysis and * Regional health planning and pro- formulation gram monitoring * High-level technical advice for a Coordination of public and. non- specific programs -. govemment regional health activities. * Monitoring of pharmaceutical pol- * Monitoring and, in some cases, - . -,., . policyinstrumentstobeusedtoeffectdecentralization,andthetypesofactivityto bedecentralized(Conyers Cassels,andJanovskyl992).Evenifdiscretionaryau- thorityislegally assignedtolocalauthorities, thedefactostructureoffinancialin- centivesandresponsibilitiesforsalariesandcareersmaycontinuetoremain under theauthorityofcentralministries.InTanzania,forexample,despiteformaldeci- sions to decentralize, vertical programs tend to establish national objectives be- foredistricthealthteamsfixtheirs,leadingtodistortionsinresourceallocation. Experience strongly indicates that successful decentralization requires definition of specific objectives, clear delineation of functions and decision- maldng authority at each level, mechanisms for communication and coordina- tion among the various levels, and sufficient training to enable frill assumption of new responsibilities (Vaillancourt, Nassim, and Brown- 1992). In district- based health systems, for example, central and regional staff will have to reor- ient their work to emphasize policy formulation and monitoring, strategy devel- opment, resource allocation, and technical and managerial backstopping. Such functions are in keeping with the mandates of ministries of health and are among the weakest links in district-based systems today. MAN AG E M EN T AND I N STIT UTI O N A L R E F o RM 117 Box6-2,conthnued U Coordination and supervision of all government, NGO, and private employment of public sector health health services& manpower * Promotion of active links with lo- * Compilation of health expenditure cal government departments budgets . Promotion of community partici- ! Approval of large-scale capital pation in local health services plan- projects outside the public sector ning, implementation, and monitoring * Supervision of district health n Preparation of annual health teams plans and reports a Provision of logistical support to * Raising additional local funds district health teams. * In-service training, especially on- the-job support, of healfth workers Districtstendto be responsiblefonr * Supervision and control of com- . Management of all public sector munity health workers health facilities with local respon- * Collecting and forwarding routine sibilities health information to regional and cen- ! Monitoring and, often, implemen- tral offices - tation of community-based health * Dialogue with beneficiaries of programs a health services and their repre- * Managerent and control over lo- sentatives. cal health budgets Soune.:Adapted from WHO 1988a. Day-to-day management of health services is carred out by district health teams (DarTs). In Zimbabwe, the DHTS are made up of a representative of each health center or hospital, the district administrator and his staff, district council representatives, a representative of village health workers, aresettlement offi- cer, community and women's affairs representatives, nutrition coordinators, the family planning group leader, a psychiatric nurse, and a community nurse. Prior to the development of the district system in Zimbabwe, managerial functions were performed by provincial teams responsible for as many as seven districts. It is-widely agreed that introduction of the new system has improved services and levels of coverage (WorldBankl 993c). DHTh have a particularly important role toplay in ensuring the availability of the cost-effective pack3ag descnibed in this repo' t Within a framework of na- tional policies and norms, DHM5 can be authorized to make decisions on the loca- tion of niew public and private, health care facilities, determine which services are to be provided by health centers and the district hospital, set standards for staffing local health care facilities, write financial management rules to ensure accounta- bility, fix fee schedules and perhaps minimum salary levels, and establish man- agement norms. . 118 B ETTER H EA LT H IN A FR ICA Experience suggests that the performance of district health teams will de- pend on whether (i) health services and programs have been integrated at the central level, (ii) the district has been given the authority to manage human and financial resources independently, and (iii) community control structures have been established. The last point is particularly important, especially to promote beneficiary confidence in the health care providers and equity in access of use of services. In Mali, for example, the introduction of democratic procedures made it possible to elect community representatives to district health teams, thus preventing domination by local elites (World Bank 1993c). Effective district health teams cannot, of course, be created ovemight A number of Sub-Saharan African governments are involved in a process that begins by educating planners and policymakers at central, regional, and district levels about what is involved, then focuses on reaching consensus on roles and responsibilities, and then provides training in the skills required to carry out needed functions. This process is being assisted by international organizations and donors (Box 8-3). Districthealth tcams also have an important role to play in coordinating the activities of public and nongovemment service providers at the-district level. Experience in Zaire, Togo, Ghana, Zambia, and Kenya reveals significant van- BoX 8-3. TRANING AND DEVELOPMENT 110 districts, covering over 75 percent OF DISTRICT HEALTH TEAMS IN GHANA of the country's population, were in- volved in the program. It consists es- In Ghana, district health teams (oFTs) sentially of three stages: have existedforsometime, butwith in- a A "start-up workshop," including creasing decentralization of the coun- sessions on problem identification, try's health system, skill requirements problem analysis, strategy develop- for planning and managing have ex- ment, and formulation of action plans. panded. To increase the capacity of During the next three to four months DHTS to undertake problem analysis these plans are actually implemented. and strategic management, the gov- * A "review workshop" to assess emment initated a training program in the experience of participants in trying 1988, with the assistance of the United to implement their plans, analyzing Kingdom's Overseas Development achievements and constraints. Les- Administration, the Finnish Interna- sons teamed for effective planning and tional DevelopmentAgency, the Minis- implementation are reviewed, problem try of Public Health of Austria, and the statements reformulated, and strate- United Nations Development Pro- gies reviewed and revised. The rela- gramme. tionship between management Within a period of three years, 65 of strengthening and the implementation MAN AGE ME NT AND INS TIT UT IONA L RE FORM 119 ability in the perlbrmancc of private voluntary organizations and private-for- profit providers. Different concepts of basic health services often result in patchy coverge, poor accountability to local communities, failure to mobilize commu- nity. health endeavors, and weaknesses in management systems. To address such problems, DHTS in Swaziland include district-level oflicials and represcntatives of church missions within the district. Through planning workshops and regular meetings, the DHThS decide how to combine government and mission services, and identify budget needs. In the Kigoma region of Tanzania and the Bungoma dis- trict of Kenya, district planning workshops brought together DHTS and NOOS tO jointly analyze health needs. and the strengths and weaknesses of each type of provider. As a result, the Nros reoriented their services to be more supportive of district priorities (World Bank 1992e). Formal agreements can be used to help DHTS perform their.coordinating functions by defining the public sector's obligations to private voluntary and private-for-profit providers (forexample, if buildings, equipment, personnel, or training are to be provided, and according to what standards) and the obliga- tions of private providers to the government (forexample, maintaining of build- ings, reporting, and ensuring continuation of public services). Contracts can also be used to define the obligations of public and private providers in imple- Box 8-3. continued World Health Organization (Cassels and Janovsky 1991)-suggest it is of technical programs is also analyzed having several positive effects. First, it atthis stage. Participants then draw up builds a sense of ownership as partici- revised or new acton plans to be im- pants analyze and tackle problems. plemented over the next six to seven they themselves perceive to be impor- months. tant Second, it fosters teamwork, as * An "advanced review workshop" responsibilities for implementation are takes participants through another re- shared by different team members viewand reformulation process and in- rather than just district medical offi- troduces them to a more comprehen- cers. Third, it fosters incremental sive format for action planning. The leaming as the workshops are struc- new format requires that teams give tured so that teams build on initial greater emphasis to developing indi- achievements and new ideas are intro- cators for monitoring their achieve- duced as they become relevant. And ments. Afinal review meeting is held at fourth, management and planning the end of the six- to seven-month im- skills tend to be ingrained through rep- plementation period. ettion, practice with strategy develop- Assessments of this program-now ment, and reviews of performance. fully documented in a handbook forthe 120 BETTER HE A LT H I N A F R I C A menting govemnment programs, such as immunizations and T13 control. A num- ber ol'countrics, such as Malawi, hiave lonig had such agreenients, and Ghana recently concluded one. Finally, through. the process olf decentrailization and district-bascd ser- vices, intersectomi collaboration can have ai real impact on th heialth of Afri- cans. To make this a reality, comprehensivc healtih policies need to be estab- lished at the national level, and interministerial comminttes formed to translate intersectoral aspects of these policies into countrywide straLegies and targets. This sets the stage lor intcrsectoral collaboration at die local gov- ernment, district, and community levels. At this point, district development committees, made up of public sector representatives in hcalih, education, nutrition, and public works (water, sanitation, and roads), can realistically assess the health implications of "nonhealth" investments and prepare district-level plans for,complementary health, water, sanitation, nutrition, and other investments. Enhancing Community Participation There is overwhelming evidence that participation of local community groups in the design and implementation of health sector activities and the kinds of intersectoral interventions already described have a significant impact on suc- cess and sustainability (Vaillancourt, Nassim, and Brown 1992; Mburu and Boerma 1989). Moreover, community involvement in the management of health facilities is emerging.as an important aspect of district-based health sys- tems in many African countries. Giving appropriate legal.status to community management structures within African health care systems can facilitate their operation, especially in- the traditionally centralized systems of francophone countries where the accountability of public employees to local bodies is rarely recognized (Cosmas 1994)... Placing greater decisionmaking in the hands of -community representa- tives tends to be associated with more rapid and comprehensive identification of health needs and expectations; more reliable identification of the poorest households in the community; easier adaptation tb cultural and religious pref erences; unbureaucratic employment of local or community staff; and greater flexibility in executing activities outside normal work hours (for example, nights, weekends); use of nonconventional aind, creative methods to promote education and informnation (fpr example, theater, animation, dances, and film production); and practical development of technologies that can be adapted to local conditions (for example, locally produced-ceramic water-reservoir.with simple tap to avoid secondary household contamination) (World Bank 1992e). MAN AGE M ENT AND IN STITUTIO NA L R EFO RM 121 In a district-based system, with central, regional, and district-level respon- sibilities as described in Box 8-2, complementary community management functions commonly include the following (WHO 1988a): * Recruitment, payment, and supervision of community health workers and trained traditional birth attendants * Provision of community rinancial support toward the cost of health services * Contribution of labor and materials to construct clinics and staff housing * Participation in local health planning initiatives ! Organization and promotion of preventive health care, particu- larly activities concerned with maternal and child health, immu- nization, and oral rehydration * Participation in health information and communication programs, particularly by translating suitable material into local languages and dialects. Community management committees can improve the performance of health systems for four reasons. First, they can play a major role in holding health care prnviders accountable to their clients. Indeed, accountability and transpar- ency, based on continuous dialogue and interaction between service providers and communities, characterize well-functioning health centers (Box 8-4). Second, involvement of community management committees helps con- tribute to good governance at the subdistnict level in ihe sense that diverse ldn, ethnic, social, and cultural groups have an opportunity to present their griev- ances and collaborate in overcoming them. Third, participatory decisionmaking develops a sense of ownership. When community management committees participate in adopting a particular ap- proach to resolving local-level problems, such as nutritional monitoring they are more likely to become engaged in the activities involved, assessing results, and monitoring progress. And finally, when communities are involved in man- aging district health facilities, relationiships of empathy and trust are more likely to evolve between health care providers and clients. Building on community strengths is not only a matter of inviting commu- nities to participate in management. Part of the challenge is to attune health care providers and the health professions to the advantages of involving community representatives. In some counties, thiW, challenge is being met by reorienting formal medical training to include practice and research in community settings. For example, medical students are being exptosed to community-based research at the University Centre for Health Sciences in Cameroon; the University of Nairobi, Kenya; the University of Dar es Salaam, Tanzania; the University of 122 B ETT ER H EA LTH IN A F R ICA BOX 8-4. ACCOUNTABILITY AND tures, double locks on drug stocks with TRANSPARENCY IN THE USE OF the community committee and the COMMUNITY RESOURCES health staff each holding the keys to only one, and stampsorphotoson reg- When health centers use cost-sharing istrat!on cards to identify households or drug revolving funds with commu- that have paid local insurance fees. Ef- nity resources, transparency is vital for ficiency indicators associated with establishing accountability and trust these measures further show that so between health providers and clients. far, there has been little "leakage" in Transparency can be facilitated by thesesystems. posting fee schedules and statements In Botswana, district councils, which of receipts and expenditures for all to are agencies of local government rafter see. When persons are treated, the di- than of the Ministry of Health, ensure agnosis can be entered in their individ- oversight over local health care pro- ual treatment booklets, along with a re- viders. This prevents stakeholders from ceipt of the fee paid. Uterate members capturing the services, and ensures lo- of the household or community and su- cal accountability. pervisors can then verify whetherwhat Arrangerrents such as those outlined was paid correspondstowhatis noted, above give beneficiares a 'voice' in as well as posted. Community partici- management of care. The option of pation in the management of funds "exit?tonongovemmenthealth carepro- generated through user fees also viders-an element of competition- means that supervisors and commu- contributes to transparency by making nity members can compare the bal- clear which providers are perceived ance in accounts with receipts regis- most favorably by patients and their tered atthe health facility. fanrilies. Recentstudies ofcommun'tyfinanc- Source of Country Studies: Galland ing of health centers in Rwanda, Zaire, 1990; Bitran and others 1986; Miller Guinea, Benin, and Mali reveal that 1987; Knippenberg and others 1990; many collaborative management Gbedenou and others 1991; Ministbre mechanisms are evolving. These in- de la Sante Publique, Mali 1990; Shep- clude community control of money ard, Vian, and Kleinan 1990. through accounts with double signa Zambia; and the University of Zimbabwe. To eam a Doctor ofMedicine degree in Carneroon, students must serve as local intems and produce a report on "in- tegratedcommunity medicine" (Aletal992). As caretakers of their own health, community members can be mobilized to participate iii a wide range of basic health care and intersectoral activities for health, including needs identification, project design, and adaptation of project activities and technologies to local needs. To illustrate: MAN AG EM ENT AND INS T I TUTr IO NA L R EFO R M 123 * In Ethiopia, community groups played an important role in mo- bilizing people for immunization, tracing defaulters, providing transpor for immunization sessions, and educating people about the importance of immunization (District Health Development Study Core Group 1991). * In Guinea and Lesotho, community representatives have formed health managementcommittees to participate in the development of programs to strengthen nutrition and maternal and child health in health centers, and to define the role of cost recovery in meet- ing financing needs. * In Benin, village management committees have made decisions about the ability of people to pay and have written off the costs of caring for indigents even though formal exoneration mechanisms did not exist Community groups can also participate in information collection, monitor- ing and evaluation, promotion and management of local-level services, and maintenance of infrastructure. In Iringa, Tanzania, communities have partici- pated in inunitoring and assessing their children's growth pattems, thus encour- aging them to take action to reduce malnutrition. In Benin, communities took responsibility for preparing appropriate storage conditions for essential drugs supplied by the government. Within three Yoruba villages in western Nigeria, at least twenty-eight small and nonbureaucratic local organizations were avail- able to mobilize community involvement in health center activities (Mebrahtu 1991). In Zaire, community management committees gradually assumed full' responsibility for operating health centers (Lamboray and Laing 1984). Finally, community groups can play a vital role in monitoring environmen- tal problems and mobilizing resources in support of intersectoral interventions. Among the hundreds of thousands of communities in Africa that are not served by public works, such as piped water and sewer systems, community initiatives to install hand pumps and pit latrines could have a decisive effect on health and on the sustainability of health outcomes. In Ghana, community groups made viable recommendations for improving environmental sanitation, the most striking of which was to establish community-level environment tribunals to enforce public compliance. In Guinea and Benin, the role of local health man- agement committees has already been extended beyond preventive health inter- ventions to environmental health, water supply, and other matters (World Bank 1992b). As district health teams and community management committees work together to improve the quantity and quality of health services, parallel pro- 124 BETTER HEALT H IN AFR ICA cesses need to be established to facilitate day-to-day problem identification. Even the best designed structures can fail because of unforeseen problems. Again, monitoring and evaluation are critical, especially at the local or health center level. Criteria may vary, but they usually include some combination of availability of services (for example, essential drugs and vaccines); access to care; actual use of services; and quality (Tanahashi 1978; and Knippenberg and others 1990) (Box 8-5). Indeed, the motivational benefits of such monitoring and evaluation cannot be overstated, especially when the identification and res- olution of problems yield a sense that people at the local level have the power to change their lives. Encouraging Institutional Pluralism Improving management and institutional reform can hardly be undertaken by ministries of health alone. Cooperation with private voluntary and other non- government organizations is required, because they too manage health facilities BOX 8-5. MONITORING THE PROVISION Adequate coverage:the percentage OF LOCAL HEALTH CARE SERVICES IN of the population receiving a complete GUINEA intervention, such as the total number of vaccinations required In Guinea, local monitoring of health Effective coverage: the percentage care services has helped health care of the population receiving services of providers to identify specific problems standardized and verified quality, re- and bottlenecks and to determine the flecting, in the case of vaccinations, actions required to address them. adherence to the cold chain and use of As shown in the figure, health center unexpired vaccines. staff monitored the following variables: The figure reveals that nearly 60 per- Availability: the percentage of time cent of pregnant women used some during which the resources required to prenatal care in Seredou District, over implemert an intervention are physi- the period covered, but that only one- cally available atthe health center quarter received adequate care, as Accessibility: the percentage of the measured in this case by the standard target population living sufficiently of three consultations. This suggests close to have easy access to service that active follow-up in the community delivery points on the quality of patient-provider inter- Use: the percentage of the target actions might merit examination. In population coming into contact with contrast, in Sinko District, problems in the service, as measured by use at ensuring effective coverage of preg- least once nant women with tetanus toxoid vac- MAN AG EM ENT AND IN ST IT UT IONA L R EFO RM 125 at the district and community level. The same applies to private-for-profit pro- viders. Of the 770 health clinics in Malawi, for example, 35 percent are oper- ated by the Ministry of Health, 20 percent by private voluntary organizations (church missions), 13 percent by private companies and estates, .12 percent by the Ministry of Local Government, 13 percent by parastatals, NGOs, and other ministries, and 6 percent by private-for-profitproviders. The encouragement of institutional pluralism-and the willingness of gov- ernments to accept nongovernment bodies outside of direct state control- therefore needs to be -seen in the wider context of broadening civil society. Governments can help to tap the enornous potential of NCOs by providing an enabling legal environment for their establishment and facilitating their regis- tration. The health sector can make important contributions in this respect. A first step is simply to refrain from harassing professional and private voluntary associations by means of unnecessary regulations (Landell-Mills 1992). Box 8-5, cor;ntued health care. As less than 40 percent of the population is within easy access of cinations were principally attributable health care, there is a need to intensify to low geographic accessibility to outreach. Percent 100, 0- . -100 90 88\ ~ - 90 - \ so80 70-- ~~~~~~~~~~~~70 60-- 58 ~~~~~~~~~~~60 50 s0 40 .- \, \ - . 3840 30 ~~~~~~~~~~~~~30 320D- 1 21 320 10__ ~~~~~~~2 11 10 TaPp&t Availablity Accessibility Use Adequate Effective Populalion coverage coverage | - -Prenatal care (inchding tetanus tcxoid Prenatal care in Seredou District | vaceinations) hi Sirko Distct l Source: Knippenberg and others 1990. 126 BETTER H EA LT H IN A F R I C A The benefits of institutional pluralism are apparent from the following examples: B Collaboration between governments and religious missions has been particularly important in Africa. At the district level in Zaire, for example, 50 percent of 306 health zones established by the Five-Year Health Plan of 1982- 86 are managed by NGOS or closely collaborate with them. At the national level the SANRu (Santd Rurale) Basic Rural Health Project has combined the efforts of the Protestant Church of Zaire and USAID tO develop 100 health zones throughout Zaire, 75 percent of which are being managed in collaboration with diverse local NGO groups. At the intenational level, upwards of 100 different international NGOS assist medical work in Zaire, largely by channeling assis- tance directly to hospitals or health zones. About half of the sixty-five member "denominations" of the Protestant Church are receiving assistance for their medical work from sister churches overseas (Sambe and Baer, n.d.). * Women's groups in Sub-Saharan Africa are striving to ensure that women's health issues receive adequate attention and support, and to encourage governments, international agencies, and religious organizations to take women's perspectives into account in designing health programs. In Uganda, for example, a group of women's NGOS formed a consortium in 1989 and are implementing a community-level program 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 combating hamTnl traditional practices, such as female genital mutilation, through public information and advocacy targeted at national policymakers and local decisionmakers. In Ghana, the Ghana Registered Mid- wives Association provides a significant proportion of maternal health and family planning services and is a key member of a task force that is advising the govemment on ways to improve the quality of matemal health services. * A Coordinating Assembly of NGOS for primary health care has been established in collaboration with the Ministry of Health in Swazilafnd, and a Primary Health Care Forum has been established for collaboration between the government and local NGOS in Zimbabwe. These bodies include task forces on health education, water and sanitation, and health orientation and training. Part- nerships of this nature help public and nongovernrnent bodies to share objec- tives and identify common targets. They can also facilitate the removal of bar- riers to establishing and operating private voluntary organizations. * National associations of public health professionals have been formed in Botswana, Kenya, Lesotho, Mozambique, Tanzania, Uganda, Zambia, Zaire, and Zimbabwe, in some cases in cooperation with the Canadian Public Health M ANA GE M ENT AND I NSTI TUT IONA L R EFO R M 127 Association. The formation of such bodies facilitates consensus-building among health care providers on future health policies and strategies. Their par- ticipation in the development, monitoring, and evaluation of health policies can go a long way toward improving health sector effectiveness, especially in view of the multidisciplinary nature of public health activities. These associations are members of the World Federation of Public Health Associations, an intema- tional NGO working to improve the health of people throughout the world. Re- gional public health associations are also evolving, including an East and Cen- tral African Association serving anglophone countries with headquarters in Arusha, and a francophone subregional association based in Kalimba. Conclusion Realizing the benefits of health investments in Sub-Saharan Africa requires more than improving the quantity and quality of pharmaceuticals, health care personnel, and so on. How those inputs are planned, allocated, organized, and managed can determine whether the services are cost-effective and can make the difference between sustainable and unsustainable outcomes. How institu- tions rationalize functions and devolve decisionmaking authority to various ad- ministrative levels can mean the difference between integrated, well- functioning systems and piecemeal approaches confounded by duplication, overlap, and lack of intersectoral coordination. How health and related person- nel see their roles at central, regional, district, and community levels can make the difference between a structure featuring clear incentives and teamwork, and a structure immobiizted by frustration, apathy, and pursuit of cross-purposes. And, how communities are involved in local management decisions can make the difference between health systems that treat people as objects and those built on community partnerships and ownership. The challenge now is to accel- erate the process of institutional and management reforms, especially by clari- fying managerial and decisiomnaking roles, responsibilities, and authorities at the central, regional, district, and community levels. C HA PTER N IN E Costing and Paying for the Basic Package of Health Services .ANY PLAN to expand preventive and primary care in Africa raises the questions of how much itwill cost and where the money to pay for it will be found. It would be understandable if providers of health care estimated future needs on the basis of past expenditure levels, but that is clearly less desir- able than determining the financing requirements for more cost-effective ap- proaches. That is what this chapter does, because there is a strong interest among African countries in estimating the cost of the basic package of health services proposed in this study. Two sets of costs are presented here. One set pertains to low-income coun- tries in Sub-Saharan Africa (hereafter "low-income Africa") and presents the average costs of basic health care, supporting services, and intersectoral inter- ventions in rural and periurban areas on the basis of experience in several Afri- can countries. The other set shows how costs are likely to rise with higher levels of income, wages, and prices. This set is based on Zimbabwe's experience. The costing exercise for low-income Africa provides qualified grounds for optimism. It concludes that a basic package of health services can be made available to consumers at a cost of about $13 per capita. That figure should prompt reflection on what African households are getting now for the amount they pay, which in many cases exceeds $13 per capita. The next issues are how resources might be reallocated to produce more cost-effective results and where additional resources might be found to enable the poorest countries, and the poorest groups within countries, to pay for them. The annual per capita cost of $13 for low-income Africa was derived from data on the costs of operating well-functioning health centers and district hospi- 128 CO STING AND PAY ING 129 tals, and the costs of intersectoral interventions in several African countries. The overall cost was annualized by adding the yearly cosLs of recurrent items, such as salaries and essential drugs, to the amortized costs of capital invest- ments, such as buildings and equipmenL Amortization is required to translate initial outlays of capital into an annual amount, thus yielding infonnation about the yearly cost of paying off the outlays over time (assuming a loan was used to finance the capital outlay). Capital costs were annualized on the basis of the economic life of the assets at a 4-percent discount rate (World Bank 1993a). Pooled recurrent and capital costs were divided by the "catchment" population of district-based facilities to derive an average unit cost on a per -capita basis. These per capita costs can then be reconstituted to produce total costs for the combined population of several communities: a network of dis- tricts that make up a region; or for all districts made up of rural or periurban populations. Qualifications are in order. First, no pretense is made that the cost scenarios presented here are definitive or applicable to all Sub-Saharan African countries.. The purpose here is to give a rough order of the magnitude of costs, to illustrate the process by which they can be determined, and to encourage Afirican coun- tries to prepare their own estimates. (The methodology employed'and data used in this chapter are fully documented in World Bank 1993a.) Second, the indica- tive costs presented here are most relevant to people living in rural and periur- ban areas. Third, the costs of particular services can be expected totchange as patterns of disease, income, and health expenditures change over time, imply- ing that relatively static approaches to estimating costs should give way to more dynamic ones. Low-Income Africa Indicative costs for low-income Africa are presented in Table 9-1. These derive from an input approach-that is, what is needed to provide a package of basic services in terms of salaries, infrastructure, drugs, training, management, and related materials. (Health planners and budget officials find this approach use- ful because it provides cost estimates for line items that are similar to those found in traditional budget documents.) The total per capita cost'of $13.22 has three components: health care and facilities (about 60 percent); intersectoral interventions (about 30 percent); and institutional support (about 10 percent). Health care andfacilities: Systems composed of well-functioning health centers and a first-referral hospital are capable of responding to and accom- modating more than 90 percent of health demands in an average rural or periur- ban district at an annual per capita cost estimated at $7.74. It is assumed that these services are provided within administrative districts, each district having 130 B ETTER H EA LTH IN AFR ICA Table 9-l. Annual ndicative Per Capita Costs for a District-based Healt Care. System: Input Approach Cost (U.S. dollars) Higher- Low- income income African Difference 7vpe of service Africa country (percent) HEALTH CARE AND FACULIES Level 1: Health center 4.60 6.72 46 Operating costs 3.78 4.84 28 Capital costs 0.73 1.75 -140 In-service training 0.09 0.13 44 Level 2: District hospital 3.14 4.03 28 Operating costs 1.75 2.24 28 Capital costs 1.35 1.73 28 In-service training 0.04 0.06 50 Subtotal, health care and facilities 7.74 10.75 39 INTERSECFORAL INTERVENTIONS Water 2.56 2.19 -15 Sanitation 1.42 136 4 Subtotal, intersectoral interventions 3.98 3.55 -11 INSTITUTIONAL SUPPORT District health care management team 0.29 0.40 38 Operating costs 0.15 0.24- 60 Capital costs 0.13 0.16 23 In-service training 0.01 0.01 0 National management structure (15 percent of total health care costs) 0.82 1.15 40 Initial training (5 percent of total health care costs) 0.27 0.38 41 Incremental salary bonus (15 percent of total salaries) 0.12 0.14 17 Subtotal, institutional support 1.50 2.07 39 GRAND TOTAL COSTS 13.22 16.37 24 Total operating cost 7.86 9.50 25 Total capital cost 5.36 6.87 23 Note: District profilc 150J000 inhabitanLs 15 health centers (10,000 in each center).. Source: Adapted from World Bank 1993a. COST IlN G AND PAY ING 131 one district (or referral) hospital, fifteen health centers, and an average popula- tion of 150,000. Within such districts household members typically make their first contact with modem health care, and this is where equity can be effectively promoted. Health centers and hospitals should collect information on their op- erating costs, capital costs, and in-service training costs. That will make it pos- sible to determine the staff profile, infrastructure, and equipment, and to assign indicative costs to them. Inrersectoral interventions: The cost of intersectoral interventions is also presented on an annual per capita basis. This indicative cost was derived from actual costs in several African countries that were then averaged for a prototype district with a catchment population of 150,000. These actual costs were the recurrent and capital costs of safe drinking water and sanitation facilities. The overall cost amounted to $3.98 per capita. Several qualifications involved in making this calculation are noted below. * The cost of a water system in a rural or periurban area will vary consid- erably, depending on water source, community size, housing density, hydro- geological conditions, local drilling costs, water consumption, and pumping system (manual, electrical, diesel, or solar). The leastexpensive pumping alter- native (and the one used in this study) in communities of less than 1,000 people will generally be hand-operated pumps. It is assumed that 250 persons are served per handpump, and that the cost-includes. drilling a borehole and pur- chasing and maintaining borehole equipment with an annual life of about twenty years. * The cost of providing adequate sanitation facilities in rural and periur- ban areas will also vary considerably, depending on the design of the facility, the type of construction materials used, labor costs, housing density, groundwa- ter and soil conditions, and the size of the families to be served. It is assumed that for a population of 10,000, each family of ten people (on average) would have its own ventilated improved pit (vup) latrine made from local building materials. Total construction costs woulF include labor and materals as well as planning and mobilization for years hence, when replacement latrines would have to be constructed. Institutional support: The district health management team (DHT) would handle administrative and support functions. These would include monitor- ing and supervising the district health care system, in-service training of hos- pital and health center staff, logistical support for the hospital and health cen- ters, and liaison with local, regional, and central authorities. The DHT would have a staff of seven consisting of a medical doctor, a pharmacist, a registered nurse, a financial managerfaccountant, a water and sanitation specialist, a so- ciologist or communication specialist, and a driver. The infrastructure would 132 B ETTER HE ALT H IN A FR-I CA include one building, the necessary equipment (including furniture), and two vehicles. The district team would also need support at a higher level that would include health research, planning, program formulation, logistical support, ad- ministration, coordination between districts, and initial personnel training. A national management structure would be required to coordinate the activities of the DHTS and prepare national standards. It is assumed that these overhead costs would amount to 15 percent of total operating, capital, and in-service training costs at the district level. Initial training of personnel is considered to be a capi- tal cost amounting to 5 percent of total district costs. Fina;ly, in view of the importance of monetary incentives for staff, as well as the lag in salary struc- tures in most countries, an incremental salary bonus of 15 percent has been provided. The total costof institutional support would be $150. The indicative costs of these inputs (Table 9-1). are equal to the indicative costs of "outputs" (services to be rendered to households and communities, as well as institutional support) shown in Table 9-2. Matemal services, including predelivery care, delivery.care, postdelivery care, and nutrition for pregnant and lactating women, for example, would be provided as part of the package. These maternity services would cost, on average, about $0.47, or 3.5 percent of $13.22. Although "outputs" are not very useful for budgeting purposes, assessing outputs is helpful in determining priorities and estimating the cost- effectiveness of various interventions. For example, it is easier to determine the relationship between the cost of providing well-baby services and quantified improvements in the health of babies than it is to relate the capital cost of a health center to the health status of babies. Costs in a Country with Higher Income Zimbabwe was selected for comparative purposes because its per capita GNP i' more than double the average of low-income Africa. Health care in Zimbabwe shares some of the features of the cost-effective approach described here, and data are relatively abundant. Zimbabwe's unit costs illustrate how much low- income countries might expect to pay in the future. Indicative costs for Zim- babwe are also presented in Table 9-1. The total per capita cost is $16.37 and covers health care and facilities (66 percent), intersectoral interventions (22 percent), and institutional support (12 percent). Zimbabwe's costs are only 24 percent higher than those estimatexd for low- income Africa, but they are 39 percent higher for the health care componentand 11 percent lower for intersectoral interventions. The basic health care services offered at the health center and first-referral hospital remain essentially the same, as do the demographic composition and epidemiological profile of the COST ING AND PAY ING 133 Table 9-2. Annual Indicative Per Capita Costs for a District-based Health Care System: Output Approach (U.S. dollurs) 7ype ofservice, Lov-incoweAfrica [NDIVIDUAL HEALTH CARE SERVICES Level l: Health center Maternal services 0.47 Pre-delivery care Delivery care Post-delivery care Nutrition: pregnant and lactating women Well-baby services 1.52 Expanded Programme of Immunization (ER) Micronutrient supplements Nutrition: ages 0-O Supplementary feeding: ages 0-2 Schoolchildren health program -0;21 Antihelminthic services (ages 5-14) Vitamin A plus iodine, as needed Curative care (especially children ages 0-5) 0.46 Basic trauma Malaria Diarrhea Opportunistic infections (AiDs related) Other local infections Limited chronic care 0.11l Tuberculosis treatment sT services (testing and treatment) 0.13 Family planning 0.87 Provision of contraceptives Incremental family planning IEc (fornutrition, family planning, HIV/STD) 0.82 Subtotal, level 1 4.60 Table continued on next page communities served. While Zimbabwe has begun to enter the demographic transi- tion, its main priority still is to provide a basic package to all. What differs between Zimbabwe and low-income Africa is the intensity of demand for certain preventive services. This is influenced by higher levels of education among households, rein- forced by higher income levels. Greater demand translates into a need foradditional staff and equipment, expanded facilities, and higher drug costs. 134 B ETTER HE ALT H IN A F RICA Table 9-2., continued 73'pe of service Low-Icwnh e Africu Level 2: District hospital In-patient care 2.20 Obstetrics and gynecology Pediatics Medicine: Infectious disenascs Basic surgery Out-patient care 0.94 Emergencies Referrals Subtotal, level 2 3.14 Subtcwal, individual health care services 7.74 INTERSECTORAL INTERVENTIONS Water 2.56 Sanitation 1.42 Subtotal, intersectoral interventions 3.98 INSTITUTIONAL SUPPORT National management support 0.82 Surveillance, monitoring and evaluation National capacity building [nitial training 0.27 District health team 0.29 District-level salary bonus (15 percent of total salaries) 0.12 Subtotal, institutional support 1.50 GRAND TOTAL COST OF BASIC PACKAGE 13.22 Note: District profile: 150.000 inhabitants; 15 health centers (10,000 in each center). Source: World Bank data. Judging from the Zimbabwe experience, the costs that change the most as income :ncreases are salary levels, funds for additional staff, and provision of hous- ing for staff (a standard expectation in Zimbabwe). Four staff members in a health center are paid a total of about $10,500 a year, compared with $5,700 for the same number in a low-income county. Annual salaries of doctors at a first-referral hospi- tal are about $12,000 each, compared with about $4,300 per doctor in a low-income African country. Zimbabwean drug costs are about 30 percent higher. In Zim- CO STI N G AN D PAYtNG 135 babwe, two staff housing units are provided for the four staff at the he$lth center, and eighteen units are available to the staff at a first-referral hospital. The costs of intersectoral interventions are 11 percent lower in Zimbabwe than in low-income Africa because greater demand for safe water and sanitation systems has produced economies of scale in the production of boreholes and water pumps, and construction of pit latrines. Who Should Pay for What? The basic package of health services includes some that are public in nature (institutional support), others of a mixed public-private natur:' (preventive and curative services for communicable diseases), and still others private in nature (care for injuries and noncommunicable diseases). This raises the question: Who should pay for what? Altemate methods can be used to shed light on this question, each with advan- tages and disadvantages. One method, the "intervention approach," seeks to iden- tify the inherent public orprivate nature of an intervendon. Forexample, educadng the public about a communicable health problem (eg., measles) might be assumed to be an inherent public good that should therefore be paid for by the public. From this perspective, treatment of a padent's broken leg night be assumed to be of a private nature and therefore to be paid for with private fun-s, But most interven- tions in health have public and private benefits. Hence, using this approach means that a large number of interventions of various kinds must be identified and both the public and private benefits of each determine who will pay for what. A second method, the "targeting approach" to determnining public and pri- vate financial responsibilities, concentrates on identifying target groups in need of some type of health intervention. Such target groups might consist, say, of those living in low-income neighborhoods or all children suffering from a par- ticular illness. The disadvantage of this approach is that providing the package only to target groups is not always administratively feasible. Moreover, apublic intervention that produces mainly private benefits is essentially a subsidy, and therefore a relatively uneconomic use of public funds. The "targeting as- proach" addresses the issue from an equity perspective. - Each of these approaches is drawn upon to suggest an indicative financing mix. The first step is to identify pure public goods, which would be financed by public funds. All remaining interventions are relegated to an "'other" category and include most of the mixed goods whose public and private benefits, in proportional terrms, are hard to distinguish. The second step is to examine all of the "other" goods from a targeting perspective. What proportion of their cost should be covered by public funds, bearing in mind private demand, so as to ensure coverage of target groups, especially the poor? Table 9-3. Who Pays ror What In the Basfe Package: An Indicative Intervention and Targeting Approach Puoblicfinancing Prit afinancing Cost Amout Amount (Us, Plublic or Share (U.S. Share (U.S. 75pe of senice dollars) olihersenrvce . (percent) dollars) (percent) dollars) A. INDIVIDUAL HEALTH CARE SERVICES Level 1: Health center (15 centers) Maternal services 0.47 Other .80 0.38 20 0.09 Well-baby scrvices 1.52 Other 80 1.22 20 0.30 Schoolchildren health program 0.21 Other 80 0.17 20 0.04 Curative care (especially children 0-5) 0.46 Other 60 0.28 40 0.18 Limited chronic care 0.11 Other 60 0.07 40 0.04 ST/tiHV services 0.13 Other 60 -0.08 . 40 . 0.05 Family planning . 0.87 Other 70 0.61 30 0.26 IEC (for nutrition, Fp, EFv/sTD) 0.82 Public 100 0.82 0 0.00 Subtotal, level I 4.60 79 3.69 21 0.96 Level 2: District hospital In-patient care 2.20 Other 50 1.10 50 1.10 Out-patient care 0.94 Other 40 0.38 60 0.56 Subtotal, level 2 3.14 47 1.48 53 1.66 Total, individual care services 7.74 66 5.12 34 2.62 B. INTERSECTORAL INTERVENTIONS Water 2.56 Other 30 0.77 70 1.79 Sanitation 1.42 Other 30 0.43 70 0.99 Total, intersectoral interventions 3.98 30 1.20 70 2.78 C. INSTITUTIONAL SUPPORT National management support 0.82 Public 1O0 0.82 0 0.00 Initial training 0.27 Public 100 0.27 0 0.00 District health management team 0.29 Public 100 0.29 0 0.00 District-level salary bonus 0.12 Public 100 0.12 0 0.00 Total, institutional support 1.50 100 1.50 0 0.00 TOTAL FINANCING OF BASIC PACKAGE 13.22 59 7.82 41 5.40 Source: World Bank dala, 138 B ETTER HE A LTH IN A F RICA An indicative financing mix for the package of basic health services for low-income Africa is provided in Table 9-3. Most of the services in parts A and B yield a mixture of private goods and positive externalities. Under this ar- rangement. rough calculations suggest thatabout four-fifths of the health center package would be financed by the public sector and about one-fifth would be paid for by households. Services such as water and sanitation are estimated to have a 30 percent public component and a 70 percent private component. Ser- vices included in Part C are deemed to be purely public goods and as such would be financed exclusively by the public sector. Table 9-3 is not intended to serve as a model that all countries or districts should follow. Its purpose, rather, is to illustrate a methodology that can help resolve the issue of financing. Each country and district would devise its own public and private financing configurations. Affordability The package costs less than what is now spent on health by countries represent- ing about one-third of Sub-Saharan Africa's people. This statement is based on expenditure data in Table 9-4. Countries for which reliable data are available have been divided into three groups, according to their relative levels of per capita GNP and expenditures on health. Grouping countries in this way, though somewhat arbitrary, is conducive to analyzing differences in health expendi- tures and to making estimates of the affordability of the package of cost- effective interventions discussed in this report- - The "high" group of countries, representing only about one-twentieth of Africa's population, spends $68 per capita, on average, on health services. Re- allocation is the key issue here. Are these countries receiving the same benefits that could be provided for around $16 per capita in a country like Zimbabwe? Private expenditures per capita in this group are about $19 and, on average, are clearly sufficient to pay forthe package. A number of the countries in this group are now moving aggressively to institute or expand user fees at health care facilities and are exploring ways of expanding insurance to cover curative care. This should facilitate greater spending of government and donor funds on pub- lic health goods and services. Clearly, the basic package is affordable in these counties, assuming a reasonably equitable distribution of health expenditures. Indeed, these countries may soon be able to include services in the basic pack- age that other African countries cannot afford. The "medium" group of countries, representing nearly 30 percent of Sub- Saharan Africa's people, spends, on average, $16 per capita on health services. For this group, reallocation of sufficient funds from some of their current uses to ensure funding of the basic package is likely to be more difficult Private COSTING AND PAY ING 139 Table 9-4. Selected African Countries Grouped by Relative Level of Expenditure on Health, 1990 County gromping High Medisun Low item expenditure expenditure expenditure Country charmcteristics Population (millions) 14.1 95.5 340.3 Average GNP per capita (U.S. dollars) 757 395 225 Expenditure per capita (U.S. dollars) Private 19 7 4 Government 40 6 2 Donor 9 3 2 Total 68 16 8 Nore: High-xpenditure countries: Botswana, Lesotho, Swaziland. and Zimbabwe. Mediun-expcnditum coauntics: Burundi, Camemon, The anmbia. Ghana. Kenya. Liberia. Malawi, Niger. Rv.nda, Senegal. and 7ambia. Low-expenditure countres: Burkina Faso. Ethiopia. Mali. Nigeria. Sienm Leone, Somnalia, Uganda. and Zaire. $ource: United Nations Development Prograrnme and World Bank 1992; World Bank 1993c. expenditures per capita in this group are $7. Since per capita income in this group is almost double that of the "low" group, however, it seems reasonable to believe that households would be able and willing to spend more, especially if a cost-effective package of basic health services is offered to them (Chapter 10). If countries in this group followed Malawi's example and govemment expendi- tures on health were raised by a modest 0.5 to 1 percent per year, the $6 now available for health could be doubled within ten years. In that case, donors might also be expected to increase their participation if programs were well formulated with credible implementation plans. Overall, then, while a greater effort to reallocate and mobilize resources for health will be needed, the basic package is affordable in these countries. Countries in the "low" group, representing about two-thirds of Sub- Saharn Africa's people, spend on average $8 per capita on health services. This does not include public and private expenditures on water and sanitation. Private expenditures on health in this group are about $4 percapita. Assuming a sufficient level of private demand, and that private expenditures could be mo- bilized and reallocated, a major part-though far from all-of the costs of the package could be met Govemments and donors both spend anotier $2 in the "low" group, but much of this sum might not be available, given prior spending commitments to 140 BETTER HEALTH I N AF RICA specific projects, central and teaching hospitals, and other obligations. Part of the shortfall could be covered if governments in the "low" group raised their financial commitment to health to a level comparable to the average for all less developed countries. On the basis of calculations in Chapter 10, this would result in an increase in health expenditures by those govemments, from about $2 to $5 per capita, thus providing another $3 per capita. It is reasonable to think that another $2 per capita could be solicited from donors by governments that had sound health reform programs and a demonstrated commitment to imple- mentation. That sum would probably suffice to cover shortfalls, especially when private expenditures on water and sanitation are factored in. It is clear, in any case, that a major resource mobilization effort will be needed in and for those African countries with the lowest per capita incomes and health expenditures. Closing the Financing Gap How much in additional Lesources needs to be raisedfor betterhealth in Africa? Rough estimates in Table 9-5 suggest that about $1.6 billion more annually needs to be mobilized to help finance health services for the Africans in the low-income and low health expenditure countries. The donor share of about $650 million a year wouldr raise external assistance by about 50 percent above thelevel of $1.2 billion att2ined in 1990. Another means of assessing financial implications is to compare the per capita cost of the package as a percentage share of per capita GDP with what is being spent on health now as a share of per capita GNP. Among countries in the 'low" group, the cost of the package represents about 5.2 percent of average per capita GDP ($248). This compares with actual per capita health expendi- tures, from all sources ana for all purposes, of about 3.2 percent of per capita GDP in these countries. Closing the gap is not, however, simply a matter of boosting expenditures by another 2 percent of GDP per capita. A major chal- lenge involves reallocating expenditures from current uses to more cost- effective ends, determiining the share of public health goods and services, and apportioning responsibilities to the various stakeholders to fill gaps. For countries in the "middle" group, the per capita cost of the package amounts to about 2.9 percent of average per capita GDP ($443). This compares with per capita. expenditures on health from all sources of about 3.6 percent of per capita GDP. Here again, reallocating expenditures will be a major challenge. Countries in the "high" group have far greater prospects of reallocating funds. Their current expenditures on health from all sources amount to nearly 9 percent of per capita GDP. The basic package would cost about 2 percent of per capita GDP. CO STI NG AND PAY I N G 141 Table 9-5. Rough Estimates of Additional Revenue Effort For Health by Government and Donors in Low-Income Africa Additioealfunds Scenario (millions of U.S. dollars peryrar) 1. Govemments more than double their expenditures on health as a percentage of total government expenditures, raising per capita expenditures from $2 to $5. Additional funds = $3 x 328 million people 984 2. Donors double their aid for low-income Africa from $2 to $4, thus nearly matching the government effort. Additional funds = $2 x 328 million people 656 Total additional funds per year over the next ten years 1,640 Assump:ion:Jusl as the "low" group reprcsents 68 percentofthe tota populadon of all countries inTable9-4. it isassumed torepresent 68 pen ofall peop in Sub-Sahamn Africa in 1992(502 million, projected to increase to 634 million by 2000). This implies an avernge of386 million people (68 percent muldplied by the avemge of 502 million and 634 million). The total rural and penurban populadon is assumed to be 8S percent times 386 nmillion or 328 million. Source: World Bank data Conclusion The pace at which cost-effective packages of basic health services could be made more widely available is a critical issue. There will undoubtedly be con- siderable variation among countries in their commitnent to reform and capac- ity for implementation. and thus in the nature of the transition. In almost all cases, a phased-in approach makes the greatest sense. Some countries, such as Benin, Guinea, and Nigeria, are already experimenting with a district-based system of health care. Thus, part of the money needed to pay for the package is already on hand. As lessons are learned, groundwork can be carefully planned for expansion into new areas, involving information campaigns about basic services to be provided, the rationale behind charging fees, community involve- ment in mobilizing resources and making provision for the poor, and so on. Other countries are recovering from political upheaval and may wish to begin reconstructing their health sector by building health centers and first-referral hospitals. Still other countries may wish to take action to bring public providers of health care progressively together with private voluntary providers in the pursuit of cost-effective approaches. Initially, expenditure requirements are likely to be most demanding when capital costs for new facilities require loans (and loan guarantees), or intersec- toral services must be launched. In such contexts donor financial support will 142 B ETTER H EA LTH IN A FRI CA play a critical role. Equally. important will be to map out the pace at which health expenditures might reasonably be.reallocated toward more cost- effective basic services. Once a country has deliberated on a package of basic services to be offered through health centers and first-referral hospitals, a first step in detennining financing might be to convene an expert or consultative group, made up of officials of the public and private sectors. This group would assess the willingness of households to pay for each component of the services, consider the extent to which external benefits extend beyond the immediate recipients, review the public goods aspects, and consider targeting and equity issues. Weighing benefits in this fashion could be used to detennine the relative roles of govemment, donors, and households in financing the gaps discussed here. .CHAPTER TEN Mobilizing Resources to Pay for Better Health FINANCIAL resources for health are injeopardy in many African countries. To combat shortfalls and mobilize resources for the basic package of care described in Chapters 4 and 9, action is required on several fronts simul- taneously. More revenue for public health goods and services is clearly needed in most countries. This goal can partially be achieved by mobilizing resources from tax and nontax revenues and strengthening the political commitment to public spending on health. It is equally important to make more efficient use of public funds by reallocating them from expensive and relatively cost- ineffective tertiary care to cost-effective preventive and primary care services. The prevalent inefficiency in the use of public funds is partly to blame for insufficient health coverage and the declining quality of public sector health services, as well as the pressure to find more resources. Restructuring the fi- nancing and provision of health care to produce a shift from crisis management to more sustainable systems of cost-effective health care is crucial- There is convincing evidence that African households are willing to ex- pend substantial out-of-pocket sums for quality health services, and that strate- gies to mobilize these resources can help alleviate budgetary shortfalls among public providers, stimulate nongovemnment financing and provision of health care, and contribute to equity in the process. Cost-sharing strategies can help free public resources for public ends, especially by recouping public expendi- tures at tertiary-level hospitals. Private financing can also substitute for govern- ment involvement, as when large, urban-based employers sponsor private health insurance or finance private health facilities. In addition, public-private collaboration can help diversify the way that basic packages of care&are fi- nanced, thus pro4iding a stimulus to private-for-profit providers and, espe- 143 144 B E TTE R H EA LTH IN A FRI CA cially, private voluntary organizations. A wide variety of strategies is needed to mobilize resources to pay forbetter health. The first part of this chapter describes expenditure levels and trends by governments, households (out-of-pocket), and donors. The second part sug- gests broad options for mobilizing resources. The chapter concludes by sketch- ing out an incremental approach to resource mobilization and urges strong gov- ernment leadership to bring it about. Government Expenditures for Health Because national governments are responsible for overall health policy and strategic planning for health, it might be assumed that govemments are also the major sources of health financing and health expenditures. In reality. the gov- ernment's share of total health expenditures varies widely throughout the. world. Time series data on the government's share of health expenditures were available for this report for twenty-five African countries, and in only three- Burundi, Kenya, and Zimbabwe-did government expenditures account for more than half. Conversely, the private sector accounted for more than three- quarters of all health spending in Sudan, Uganda, and Zaire.-Donors play an important financial role in many African countries, and accounted for around 20 percent of health expenditures in Africa in 1990. Table 10-1, which covers the period from 1980 to 1990, summarizes central government expenditures for the twenty-five African countries for which data are available. It excludes foreign grants, foreign loans, and contributions from intemational NGOs. The countries were divided into three groups, according to relative level of per capita government expenditures on health and per capita GiNP. Classifying the countries in this way helps to show differences in govern- ment health expenditures among countries with different income levels. There was a fifteen- to twentyfold difference in central government health expenditures per capita between the "high" and 'low" groups. This was far out of proportion to the fourfold difference in average per capita incomes be- tween the two groups. Moreover, expenditures by the "high" group increased between the period 1980-85 and 1985-MR (most recent year for which data are available). Those of the middle group declined slightly, while those of the low group stayed nearly the same. TIuble 10-1 also reveals that central government expenditures on health, as a percent of GDP, were smaller in the "low" and "medium' groups than in the "high" group, and showed little absolute change over time. Compared with all less developed countries worldwide, whose share of central government expen- ditures on health is about 1.5 percent of GDP, the "medium" group fell short by 0.2 percent and the "low" group trailed by 0.9 percent. This means that in MOB I LIZI NG RES OUR C.ES 145 Table 10-1. Selected African Countries Grouped by Relative Level of Central Government Expenditure on Health, Population-Weighted Averages, M90s Count^, grouping High, Medittiu Lost Item evpenditure erpenditure expenditure Counrtt c/haracteristics Population (millions) 21.4 94.7 218.3 Average GNP per capita (U.S. dollars) 818 395 225 Central government health expenditutre per capila 1980-85 (1987 constant dollars) 15.3 5.4 1.1 1986-MR (1987 constant dollars) 20.7 4.9 1.0 Percentage change 35.3 -9.3 -9.1 Central government health expenditure as a percentage of cmO 198085 2.3 1.3 0.5 1986-MR 2.9 1.3 0.6 Percentage change. 26.1 0.0 20.0 Central goternmenrt health expenditure as a percentage of total central government expenditure 198085 5.9 5.6 2.8 1980-MR 6.6 5A 2.6 Percentage change 11.9 -3.7 -7.1 Note: mR. most recent available year. High-expenditure countci:e BoEwsana. Lesoho. Mauritius, Swazilard. andZimbabwe. Medium-cxpenditure countries: Burundi.Cameroon.lhe Gambia. Ghana, Kenya. Liberia. Malawi, Niger. Rwanda.Senegal.Togo. and Zambia. Low-expenditure countrics: Burkina Faso. Ethiopia. Mali. Nigeria. Sierr Leone. Somalia. Uganda. and Zaire- Because this table is designed to show change ovcrtime. data ame in constant 1987 dollars. Forthis reason the data are not fully comparable with the current dollar estimtnes for 1990 in Table 9-4. Sourc: United Nations Devel opment Progrmmne ani World Bank 1992. countries whose combined populations amounted to about two-thirds of the African total on which information is available, central government expendi- tures on health as a share Of GCDP were only one-third the average level of devel- oping countries as a whole. Table 10-1 also reveals that central government expenditures on health as a. share of total cental government expenditures were between 5.4 and 6.6 percent in the "medium" and "'high" grouprs but less than 3 percent in the "low" group. Since all developing countries worldwide spent an average of about 5 percent of their government budget on health, the performance of the "low" group was about one-half the norm. Furthermore, expenditures on health as a share of all central government spending fell in this group of countries in the 1980s. - 146 BE TT EP H EA LT H IN A F R ICA Although part of the shortfall can be overcome by allocating a greater share of government funds to health, the crux of the challenge in the low- income countries is to raise ahsolute levels of spending. The first step for the "'low" and even "medium" expenditure countries is to arrest the decline in real per capita health expenditures by the central government revealed in Table 10-1. Each country will need to examine its own individual performance in this respect. For the "high" countries in Table 10-I, and to some extent the "me- dium" countries, reallocation of some portion of current govemment expendi- tures is likely to be sufficient to satisfy the public sector's share of the cost of the package. Explaining Shortfalls It is not hard to say why some African governments have committed less to health than others. Three points are worth stressing. First, economic conditions matter, since government expenditures on health derive largely from general tax rcvenues, including duties on imports and exports. Analysis of the perfor- mance of countries in the "high" group in Table 10-l reveals that all of them had positive rates of economic growth, the averge being 3.7 percent per capita from 1965 to 1990. For the "medium" expenditure group. more than 60 percent of the countries experienced positive rates of per capita economic growth, the average being 0.5 percent For the "low" group, however, 60 percent of the countries experienced negligible or negative per capita growth, the group aver- age being minus 0.5 percent. The second point concerns the possible effects of structural adjustment programs (SAPS). These programs have aroused considerable controversy. Some argue that sAPs have been indirectly responsible for cutbacks in govern- ment expenditures on social services. The chief counterargument is that struc- tural adj ustment programs, whose purpose is to help developing countries over- come long-term barriers to economic growth, give governments an opportunity to restructure their health sectors. Sevetal studies suggest that structural adjustment is not a principal cause of low or declining government expenditures on health in Africa (Box 10-1). Cen- tral government expenditures on health as a share of GDP in those countries engaged in adjustment programs remained almost the same in "adjustment" years as in "nonadjustment" years, although the mean value of health expendi- tures per capita was 5 to 6 percent lower in adjustment years than in nonadjust- ment years. Furthermore, central government expenditures on health as a share of total central government expenditures were 7 to 8 percent higher in the ad- justment than in the nonadjustment years (Serageldin, Elmendorf, and El- Tigani, forthcoming). MOB I LIZ ING RES O UR C ES 147 That finding is particularly significant because it demonstrates that health expenditures were not reduced in association with adjustment lending to make room for increases in spending in other sectors. In Lesotho, for example, the government has shown a strong commitment to social services and has empha- sized internal restructuring to improve efficiency. Health and welfare received about 6 percent of total government expenditures in 198243, and about 10 per- cent in the early 1990s. Over the sarne period, education's share increased from about 15 percent to 20 percentL In contrast, commitments to Lesotho's less pro- ductive sectors, such as military spending, were reduced from about 24 percent of total government expetditures in 1982-83 to about 10 to 12 percent during the early 1990s. The health expenditure performance of the three groups of countries in Table 10-1 appears to have little correlation with structural adjustment programs. The average number ofyears that such programs were in place between 1980 and 1990 in countries in the "low" group was 2.6. Comparable figures for the "medium" and "high" groups were 4.3 and 1.0 years, respectively. Multivariate analysis revealed that structural adjustment was not significantly correlated with govern- ment expenditures on health as a share of total government expenditures, or with govemment expenditures as a share of GDP. This particular analysis not only controlled for levels of per capita GNP but also assessed the lagged effects of adjustnent programs put into effect between 1980 and 1985 on health expendi- tures between 1985 and 1990. Again, no significant correlation was found. Third, most African govenmuents appear to be able to make substantial im- provements in health expenditures. This-is apparent from the priority they have given to pu-blic expenditures on defense. Six out of the eight countries in the "low" group in Table 10-1 devoted two to four times more money to defense than to health. In the "medium" group, eight out of twelve countries allocated more public funds to defense than to health, with three out of five countries in the "high" group doing so as well. Whether public health officials have much chance of changing this situation remains to be seen, notwithstanding the reductions in defense expendi- tres in the 1980s. But reciting these facts, as well as pointing out improvements (as in Lesotho and Ghana), casts a more realistic light on the "disabling" environment faced by many African ministries of health. Juxtaposed with the mass of evidence revealing that investments in health are an essential element of development strat- egy, there is little evidence to suggest that defense expenditures contribute pos- itively to economic growth or sustainable development. Combating Inefficiency and Inequity Public expenditure surveys and World Bank health sector repors leave little doubt that large shares of the govemment resources allocated to the health sec- 148 BETTfER HE ALT H IN AF RICA BOX i1-1. MACROECONOMIC CHANGE, toward adjustment after one or two inl- STRUCTURALADJUSTMENT, AND tial loans, such as Burkina Faso, HEALTH Equatorial Guinea, Sierra Leone, and Sudan. In sum, the adjustment pro- Following rapid deterioration in macro- cess was rarely completed. For these economic and sectoral performance in reasons, as well as gaps In data re- Sub-Saharan Africa since the quired for statistical analysis, it is diffi- mid-1970s, which reached crisis pro- cultto assess the effects of adjustment portions in the early 1980s, many lending In African countries in the countries started comprehensive eco- 1980s. Nonetheless, extensive re nomic reform programs with financial views of available data and literature support from the International Mone- suggest that the empirical basis Is tary Fund and the World Bank. Most of weak for claims that adjustnent poll- these countries started the adjustment cies have multiple negative effects on process from a position of low and de- health (Preston 1986; Behrman 1990; dining real income, sluggish or deteri- Sahn1992; World Bank1992d). orating growth rates, mounting exter- In the health sector, consensus ap- nal debt and debt service, very low pears to be emerging on the following ratios of saving and investment tO GOP points: ratios, declining extemal competitive- * Analysis of public expenditure ness and growth in export volumes, data from African and Latin American mounting current account deficits, and countries suggests that social expen- rapidly declining agricultural output ditures, including health, have suffered per capita (Elbadawi, Ghura, and less than expenditures on economic Uwujaren 1992). services, and that recurrent expendi- Between 1980 and 1990,70 percent, tures-the bulk of health outlays- or thirty-two of forty-five, Sub-Saharan have suffered relatively less than capi- African countries adopted structural tal expenditures for infrastructure adjustment programs supported by (Hicks 1991). World Bank lending. Some countries, * Analysis of ten African countries such as Mauritius, Senegal, C6te undergoing adjustment suggests that d'lvoire, Kenya, and Nigeria, were neither economic crisis nor resulting relatively more stable than others, adjustment policies has had a major such as Burundi, Central African Re- impact on crifical health indicators. A public, Congo, Mali, Niger, Somalia, study using household survey data on Zaire, Benin, Cameroon, and Ethiopia, Cote d'lvoire found no overall signifi- and started the adjustment process cant effect of either the pre- or postad- earlier with strong adjustment mea- justment period on neonatal or post- sures. Others abandoned their efforts neonatal mortality. In contrast, an MO BI LIZ ING R ESO UR CESS 149 Box 10-1, co ilnued and is providing grounds for restruc- turing health care systems to tackle adverse effect for the adjustment pa- the fundamental problems involved. Hod on the postneonatal mortality of Government surveys of civil service tihe urban nonpoor was observed employment, for example, report (Diop 1991). A study of Ghana found overly heavy concentrations of em- no significant time period effects on ployees at the center, redundancies, mortality risks in the neonatal or child and the phenomenon of ghost age ranges, whereas for postneonatal workers, meaning salaries are col- mortality, the protective effects of ma- lected by recipients not on the job. In- ternal education were reduced in the efficiencies in current procurement, economic crisis and postadjustment prescription, and use of medicines periods (Saadah 1991). appearto be far more signif;antthan * Those most vulnerable to the the effects of prices and incomes negative, short-term effects of macro- (Chapter 4). Ministry of health bud- economic adjustment policies are not gets are predominantly being eaten necessarily the poorest groups in so- up by expensive curative care in hos- ciety. Mostpeople in Africa livein rela- pitals, undermining government's ca- tively scattered rural communities, pacity to finance recurrent expendi- which, unfortunately, have not bene- tures in primary health services. And fited greatly from public expenditures the preoccupation of donors in the and subsidies, and therefore have past with financing capital develop- been relatively insulated from ment projects has not been accom- changes in government expendi- panied by sustainable provisions to tures. Rather, the most vulnerable meet recurrent cost requirements. groups tend to reside in urban areas * Governments should restructure and tend to be those who have bene- their health sectors as part of, not in fited disproportionately from public response to, structural adjustment services and subsidies, often urban programs, taking measures to protect civil servants and other urban middle- social priorities and putting into oper- income groups (Sirageldin, Wouters, ation symbolic commitments to pre- and Diop 1992). ventive and primary care with public * Adjustment appears to be related health funds intended for such pur- to the decline in the real value of civil poses. As the Minister of Health of servant salaries and may sometimes Zimbabwe put it, "Recession [and] have squeezed nonpersonnel expen- structural adjustment policies and ditures-especiallyforpharrnaceuti- plans have provided us with oppor- cals. While this is a cause for concem, tunities for creativity, innovation, and it is also prompting a reassessment boldness" (Stamps1993). 150 BETTER H EA LT H IN A FRI C A tor are eaten up by interventions that are not cost-effective, that the use of public. funds for these ends impairs financing of public health services, and that this use of funds makes commitments to improve primary and preventive health care little more than symbolic. Between 1985 and 1991, forexample, almost 70 percentof the public health' budget of Kenya was used for curative care, compared with only 4.5 percent for disease prevention and health promotion. Between 72 and 82 percent of the public health budget of Malawi was allocated to curative care between 1983 and 1988, compared with only 5 to 9 percent for preventive care. Other countries in which curative services account for 60 percent or more of government health expenditures include Tanzania and Uganda. In Nigeria,.inadequate emphasis on preventive and primary care has been decried since the mid-1970s. Nonethe- less, in eight of Nigeria's states for which data are available, curative care in- creased from 72 percent to 81 percent of the public sector health budget during 1981 to 1985. Only more recently has the govemment made a major effort to change the situation. While it is true that the fiscal capacity of many African countries to finance health services has been undermined by poor economic performance, rapid populaton growth, and political upheaval, these factors do not constitute a valid explanation for low or declining percentages of government expenditures on public health. Structural adjustment programs may well be coupled with austerity measures, but they cannot be invoked as a root cause of low or declin- ing govemment.spending on health. Rather, adjustment lending has increas- ingly sought to protect social service expenditures. If health care expenditures are appropriately reallocated as part of structural adjustment programs-as has been done in Lesotho and Ghana, for example-these positive dimensions might be pushed a good deal further. Private Expenditures Surveys of household expenditures, including direct payments to private practi- tioners, traditional healers, private pharmacists, and others in the health sector, indicate that African households expend substantial out-of-pocket sums for health (Table 10-2), especially in relation to the $13 and $16 indicative per cap- ita cost estimates in Chapter 8. In COte d'lvoire, where per capita t3NP was about $900 in 1985, household expenditures on health averaged about $19 per capita, whereas central government expenditures averaged about $8.20 per cap- ita. In Ghana, with a considerably lower per capita GNP of $240 in 1987-8, per capita household expenditures on health were also relatively high, at about $7.30 in 1986, particularly when compared with central government expendi- tures of about $4.20. In Nigeria, where per capita GNP was $400 in 1985-86, MO B ILI Z ING RES OU CES 151 Table 10-2. Per Capita Household Expenditures on Health in Selected Arrican Countries (U.S. dollars) CMre d'Ivaire Ghana Guinea- Nigeria Senegal Household quintile 1985 1987-88 Bissau 1991 1985-86 1991-92 Lowest 3.99 2.55 3.88 2.58 4.90 2nd quintile 6.59 4.25 4.63 5.88 10.27 3rd quintile 14.33 6.19 438 10.07 13.44 4th quintile 17.04 8.54 2.44 14.08 25.34 5th quintile 46.38 -14.83 8.34 35.16 61.82 Average 18.88 7.27 4.74 15.05 23.14 Percapimaincome 911.31 239.00 196.00 400.00 393.00 Average as share of per capita income (percent) 2.1 3.0 2.4 3.8 5.9 Note: Household expendilturs includc trnditional and modern health services and medicines. Saurcer ForCote d'lvoireand GhaIn Segcldin. Elmendorf and El-Tigani, forthconling, exoept forpercapita incorne, from GrOotnert 1993 for COte d'lvoire and furm tvMdata forGhasna forGuinea-Bissau, 1.991 income and expenditue survey: for Nigeria. 198586 coasumercxpenditur survey. forSeneguL 199192 priority survey (Din ction de la Przvisian ctdc In SListiquc) average per capita household expenditures were about $15, whereas central government health expenditures were thought to lie between $1 and $2 per cap- ita. At the very least, the public sector needs to provide households with the information they need to allocate, or reallocate, these expenditures to cost- effective packages of health services. - Out-of-pocket expenditures vary considerably between the poor and the non- poor. In Ghana, household expenditures varied fivefold across quintiles, ranging from about $15 per capita in the highest quintile to $2.60 in the lowest In Cbte d'Lvoire, household expenditures varied elevenfold across quintiles. In Senegal, household expenditures varied fifteenfold across quintiles, ranging from $62 in the highest quintile to $4.90 in the lowestL The data in Table 10-2 suggest that cost-sharing to pay forcost-effective packages of health services is feasible. Because the more well-to-do groups spend significantly more on health, there would seem to be greater justification for cost recovezy from them, espe- cially since-at least in some countries-wealthier households tend to seek public care more often than those with less income. In Ogun state in Nigeria, for example, 53 percent of the highest income group who needed medical help went to public facilities first, including 27 percent who went to public hospitals 152 BETTER HE A LTH IN AFR ICA first. A smaller share (21 percent) of the lowest income group sought care first in public hospitals. International Aid Donors are important financiers of health care in Africa, especially where the government has been unable to meet health needs due to revenue shortfalls. Between 1981 and 1986; external assistance for health from official and private voluntary sources averaged more than $1.50 per capita in Sub-Saharan Africa, equivalent to more than 20 percent of average central government expenditures on health (Tchicaya 1992). By 1990, total assistance had climbed to more than $1.2 billion, or almost $2.50 per capita, although wide variations were apparent-from $0.60 in Nigeria to $7 in Benin (Table 10-3). Furthermore, the limited information available suggests that more aid per capita went to coun- tries in the high and medium groups than to the low group. During the late 1980s, bilateral donors accounted for 62 percent of total health assistance in Sub-Saharan Afiica, while multilateral agencies provided 32 percent and nongovernment agencies 6 percenL On average, 44 percent of donor funds were used for capital investment, 22 percent for technical assis- tance, 13 percent for operating costs, and 2.4 percent for training. Variations were large, however. In Lesotho, donor financing covered about 80 percent of the Ministry of Health capital budget between 1987 and 1992. In Uganda, do- nors financed 87 percent of total public development expenditures on health in 1988-89. In Mali, the share of donor funding for health development expendi- tures in 1990 was 63 percent. Since, on average, each $100 of capital investment in the health sector generates annual operating costs of $30, international funds not only deternined how the government would invest in health but also shaped recurrent spending (Heller 1.978). Donor aid has also been paying for an increasing share of recurrent expen- ditures, especially for drugs and emergency and supervisory transport. Donors pay for virtually all drugs imported by Tanzania for dispensaries and health centers, for example. There are also a growing number of cases where donors are financing the salaries of health workers, particularly community outreach workers and nurses in rural health care centers. Funds for recurrent expendi- tures grew from about 13 percent of donor assistance for health in Africa in 1980 to 35 percent at the end of the 1980s, while capital expenditure support declined from about 55 percent to 35 percent (McGrory 1993). At the same time that donor assistance has played an invaluzble role in shoring up public initiatives for health. such assistance has had negative side effects that are at odds with the central messages of this report. Prominent among these are the following: MOB I LIZI NG R ESO UR CE S 153 Table 10-3. External Assistance for the Health Sector, Selected African Countries, 1990 (U.S. dollars) Level af expenditire Per capita Counlry (10; tnediuna. or lbig/) aid Benin 7.0 Burkina Faso L 4.7 Bunindi M 2.8 Cameroon M 3.3 Central African Republic 6.5 Chad 5.8 CBle d'Ivoire 0.9 Ethiopia L 0.8 Ghana M 1.9 Guinea 3.5 Kenya M 3.5 Madagascar 1.5 Malawi M 2.5 Mali L 4.3 Mozambique - 2.9 Niger M 5.6 Nigeria L 0.6 Rwanda M 4.1 Senegal M 4.9 Sierra Leone L 1.7 Somalia L 3.5 Sudan 1.5 Tanzania 2.1 Togo M 3.9 Uganda L 2.8 Zaire L 1.3 Zambia M 0.7 Zimbabwe H 4.2 Population-weighted average 2.5 -Not available. Noge: For level of expcnditure classifications. see note to Tablc 94. Estinmtes of development assistance for health are exprcsscd in official exchange mite U.S. dollans. Totl aid flows represent the sum of all assistance for health to each country by bilateral and multilateml agencies. intenational agencies, and international nongovernmcntal organizations (Moos). Soarce: World Bank 1993e.Table A.9. 154 8 ETT ER H EA LT H IN A F RICA U The Organization for Economic Cooperation and Development reports that "In spite of their stated commitment to primary health care, relatively large resources are devoted by donors . . . to sophisticated urban-based facilities in- cluding ljospitals and specialist clinics" (OECD 1989). This suggests the need for closer scrutiny of the impact of health aid flows, as well as greater use of external finance to establish and run projects in remote or underserved areas. Examples include provision and distribution of essential drugs that are intended principally for consumption by less well served populations, as supplied, for example, by DANIDA in Tanzania and Medecins sans Frontieres in Mali. * External financing has often worked against sustainability when it has been used for vertical programs or inappropriate capital or development expen- diture. Although such funding may have the goal of expanding coverage and quality of services, the recurrent costs necessary to sustain the capital invest- ments are often very high and beyond the country's ability to finance. Almost every African country has at least one big investment project, such as a large hospital, that is unlikely ever to function as originally planned because of a lack of ongoing funding. Underused facilities include, for example, the Maidugeri and Ibadan teaching hospitals in Nigeria. * While most donors have provided health assistance without conditions for explicit policy reforn, the priorities implicitly embedded in donor funding have virtually driven the selection of health strategies in Africa. In some cases, heavy reliance on external assistance has led to virtual abdication of responsi- bility for health policy formulation. Furthermore, donor funding priorities are constantly shifting-tending to favor specific health themes at international conferences that detract attention from the need to strengthen basic health ser- vices. In Rwanda, for example, more than 20 percent of donor financing for health has recently been earmarked for AIDS alone, making itout of proportion to total health needs (Over and Piot 1991). The push between 1985 and 1990 for universal childhood immunization, which was "jump-started" in Africa largely by financing from UNICEF, Italy, wHo, and Rotary, vastly improved coverage throughout the continent Declining rates of coverage in recent years indicate that many health systems were unable to maintain momentum without contin- ued injections of outside funds. African govemments are increasingly recog- nizing this problem, and some (such as Nigeria), are calling forAfrican govern- ments to assume responsibility for vaccine financing (WHO/AFRO 1993a). * Government information on external assistance programs is often spotty, resulting in ineffective coordination and monitoring. External evalua- tions are often conducted without involving the recipient country (Engelkes 1993b). Moreover, government and donor definitions of health programs and accounting requirements frequently differ, so that health planners and policy- MOB I LI ZING R ESOU RC ES -55 makers often do not know the overall purposes, locations, or amounts of exter- nal resources being used. Governments can reduce dependency-related problems by taking the lead in donor coordination. In Ghana, for example, the Miinistry of Health has orga- nized a Local Assistance Group on Health, which functions as a quarterly fo- rum with donor agencies to resolve health strategy issues. .In Kinshasa, coor- dination led to standards for health center activities and user fee schedules respected by all participating health care providers. To sum up, external assistance for health can help to bridge financial gaps in Africa in ways that are far more efficient, equitable, and sustainable than in the pasL Extemal funding sources need to reexamine their activities and em- phasize a longer time horizon, broader programs of support to health sector reform and of intersectoral assistance,. and national capacity-building rather than individual project-based support. Sub-Saharn frican governments need to play a vital role in this process by developing comprehensive health policies, increasing their commitment to primary care, establishing overall health sector financial plans, and emphasizing cost-effective packages of basic services. This can help to persuade donors to make new financial commitments. In Guinea, Benin, Sierra Leone, and Zambia national action plans and comprehensive fi- nancing plans are already being drawn up by governments in collaboration with donors. Raising Additional Domestic Resources To ensure financing of the package of basic health services, a growing number of countries are increasing user charges for government health services (Les- otho, Zimbabwe) or establishing nationwide fee systems to replace free care (Uganda, Kenya). Other countries, such as Guinea, Benin, Nigeria, and Rwanda, are promoting the creation or strengthening of community-financing schemes. Alternative arrangements, such as community health insurance schemes, are filling gaps. These actions offer grounds for optimism that much more can be done to mobilize additional resources. User Fees as a Cost-Recovery Method Nontax sources of revenue, such as user fees, are becoming increasingly com- monplace in African countries. This method of cost recovery direcdy addresses the problem of underfunding of government health facilities. By charging fees for services that primarily benefit the user, governments can reallocate tax reve- nues to public health activities whose benefits go beyond the individual client User fees are also a tool for reinforcing the referral systern. When the prices of 1S6 BETTER H EALT H IN A F RICA all medical services are zero or are uniformly low, consumers have no reason to pay attention to costs. Their natural inclination, in fact, may be to use services whose cost to the government is high (Griffin 1992). User fees make sense on purely economic grounds. Demand for health care tends to be income elastic, meaning that the more money people have, the more they are willing to pay for health. For any given level of prices, a dispro- portionate share of the demand for health care will be made by people with higher incomes. Charging wealthier people for services and then pooling those revenues to'subsidize the costs of treating those least able to pay is also an important means of promoting equity. And when user fees are spent to expand and upgrade the quality of health services, they may actually reinforce demand. Demand for health care, especially curative care, also tends to be price inelastic, meaning that any increase in user fees will result in a less than propor- tional drop in demand and thus an increase in revenues. Moreover, most of those dissuaded from seeking care at public sector facilities because of an in- crease in user fees will seek care from some other source, particularly if non- government providers are price-competitive. Wthen the 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. In two-thirds of the African countries for which data are available, the contribution of user fees to recurrent government expenditures on health was less than 5 percent in the years for which data are available (Table 104). This implies considerable scope for higher charges. In Ghana, for example, a large upward adjustment in prices in 1985 increased cost-recovery receipts as a share of Ministry of Health recurrent expenditures from 5.2 percent to 12.1 percent by 1987, and with needed quality improvements the government could reasonably expect even betterperformance. User Fees in Hospitals If systems of health care are to devote greater attention to preventive and pri- mary care, the recovery of costs at public hospitals takes on monumental impor- tance. If the high capital and recurrent costs of hospitals are financed by the government, the government's health budget will be skewed toward hospital services no matter what the government's stated priorities may be. Further- more, if the typical residential and income characteristics of those receiving such care-predominantly urban, well-to-do families-are "superimposed" on this subsidy pattern, an equity problem is inevitable. Urban residents will capture a disproportionate share of the governLncrt's health subsidy because they live near the hospitals and use them. It is hard to see how African govern- MO BI LIZING RES O U RC ES 157 Table 104. Revenue From User Charges as a Share of Recurrent Government Expenditure on Health, Selected Arrican Countries Pemetuage of recurrnt Country and year expenditure BoLtwana, 1979 1.3 Burkina Faso, 1981 0.5 Burundi, 1982 4.0 Coted'lvoire, 1986 3.1 Ethiopia, 1982 12.0 Ghana, 1987 12.1 Kenya, 1984 2.0 Lesotho, 1984 5.7 Malawi, 1983 3.3 Mali, 1986 2.7 Mauritania, 1986 12.0 Mozamibique, 1985 8.0 Rwanda, 1984 7.0 Senegal, 1986 4.7 Swaziland, 1984 2.1 Zimbabwe, 1986 2.2 Source Vogel 19S8, 1989. ments can improve the health of all of their people until these problems are resolved. Because it is exceptionally difficult to impose limits on hospital spending, the logical altemative is to increase user fees for those able to pay more. Be- cause they offer many different services and have accountants, financial control procedures, and bank accounts, hospitals are better positioned than public clinics to recover their costs from patients. The experience of private-for-profit. and private voluntary hospitals also suggests greater possibilities for establishing user fees in public hospitals. Reli- gious missions in Cte d'[voire, Ghana, Mali, and Senegal have been success- ful in covering a large percentage of their operating costs through user charges. A survey of nongovemment facilities in Tanzania revealed that 57 percent of the hospitals expected that from 50 to 80 percent of their recurrent costs.for drugs, salaries, repairs, and maintenance would be financed by user fees (Mu- jinja and Mabala 1992). Even though public facilities provide free health care, those who visited private sector dispensaries and hospitals in the greatest num- bers were peasants, people with jobs, and traditional healers. Nongovemnment 158 BBETTER H EA LTH IN A F RICA hospitals in Uganda have long relied on the willingness of households to pay for services and have recovered anywhere from 75 to 95 percent of their costs. Even small fees can produce revenues for public hospitals that dwarf those generated by high fees at clinics. 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 hospital entrance fee (Griffin 1988). In Senegal, the money re- covered through fees in the hospital subsector was sufficient to pay for half of all hospital drug supplies. The introduction or raising of userfees at hospitals canl also make the refer- ral system more efficient, stimulate greater use of private sector hospitals, and make public hospitals more available to the most needy (Box 10-2). In Zim- babwe, for example, fees increase according to the hierarchy of facilities, which induces consumers to seek care where the services can be provided at lowest BOX10-2. THREESTORIESOFCOST ties are obliged to differentiate the RECOVERY IN HOSPITALS AND OTHER poorfrom the nonpoor and to give fre FACILITIES: GHANA, SENEGAL, AND care to the poor. MALAWI Another key.to success in Ghanas cost-recovery experience has been Ghana: In 1983 the price structure for the administrative provision that a por- health services was judged to be too tion of the proceeds should remain at low in Ghana, resulting in a large up- the site of collection, improving service ward adjustment in prices in 1985. By quality and stimulating incentives to 1987, cost-recovery receipts as a per- collect fees. The general formula used cent of the Ministry of Health recurrent is that 50 percent of user fee revenue budget had climbed from 52 percent goestothe Ministryof Finance, 25 per- to 12.1 percent. A key to Ghana's prog- cent to the Ministry of Health, and 25 ress appears to lie in the structure and percent is retained by the facility that application of prices, as well as in the collects the fee. administrative provisions of the cost- recovery law. Prices are hierarchical Senegal: In Senegal in the late 1980s, and directly related to the sophistica- there was no cost recovery at large na- tion and expense of the health care de- tional hospitals. Cost recovery was be- livered. The price of curative care at ing introduced at some regional hospi- the hospital level is a large multiple of tals, but was mostly practiced at the curative care at the health center. This primarly level of the health care sys- feature of the pricing structure gives a tem. This policy gives the wrong sig- strong price signal and reinforcement nals from a systemic point of view. To to use the referral system. Yet, facili- illustrate, people may be inclined to not MOB I LIZ ING RES OURCES 59 cost. The basic outpatient charge for adults is Z$5 at a central hospital, Z$3 at a provincial general hospital, and Z$1.50 at a district hospital. In Cameroon, a desired by-product of introducin; fees at public facilities was to encourage well-to-do patrons to obtain private care. This met the social objective of mak- ing public facilities more available to the poor. In Lesotho, the government explicitly sought to induce patients to switch from public to private care when it instituted a higher userfee policy in 1988. Another option is to turn public hospitals into parastatals or autonomous bodies with reduced govemment funding, or to privatize selected services in national hospitals. In Burundi, for example, the Ministry of Health is pursuing an innovative approach to giving full autonomy to hospitals. The ministry first gave a 120-bed hospital a lump sum to cover the hospital's operating costs. Each year thereafter, the ministry reduced its contribution by 20 percent. Based on the positive outcome of this experiment, the ministry plans to apply the same Box 10-2, continued. rural-based families in the periphery. A phased approach is being imple- seek care at a health center in a sub- mernted overthree years, commencing urb of Dakar, where they must pay for April 1992, to introduce the cost- that care, when they can easily take a sharing system to central hospitals, bus into Dakar and receive free care then to general and distrct hospitals, fromtheDantec Hospital and finally to health centers-all Given this asymmetry in user phases to be accompanied by im- charge policy, hospitals such as Dan- provements to strengthen quality. tec have been operating at more than Several concems are behind the 100 percent of capacity, while local cost-sharing strategy. One is to in- treatment facilities are underused. crease the efficiency and use of the This, in tum, distorts public sector in- central/general hospitals and district vestment policy. Almost half of the hospitals by introducing a system to project expenditures in Senegal's discourage the population from using three-year investment plan in the hospitals as their entry point to the mid-198Os were for renovations or ad- health system. Another is to improve ditions to the Dantec Hospital. the referral system by encouraging the population to enter the appropri- Malawi: The govrrnment has deter- ate level of services-health centers. mined that cost-sharing is an urgent, A related concern is to strengthen pri- viable policy that can be used to ac- mary carewith trained manpowerand quire resources from users of medical continuous availability of essential services, then redeployed to extend drugs. and improve health care delivery to * 160 B E TTE R HE ALT H IN A F RICA procedure to its central hospital, which has 600 to 700 beds. Simultaneous ac- tion is being taken to stimulate the expansion of insurance schemes, under the assumption that hospitals would not be able to recover their costs otherwise. A similar approach was planned in Rwanda. In Rwanda and Burundi, a funda- mental premise of the reductions in government funding for hospitals was that mih,;stries of health are not created to manage hospitals and usually do so poorly. Privatization of selected hospital services is underway in Tanzania, where some beds in government hospitals are private beds for whichi a fee must be paid. In Mozambique, government medical staff operate special hospital-based clinics outside normal working hours. The Kenyatta National Hospital in Kenya recently adopted a plan that requires a private wing in the hospital to genernte a surplus and thus augment hospital revenues. Cost-Sharing in Health Centers and Dispensaries User fees or cost-sharing strategies take on immense importance at publicly operated health centers and dispensaries because at this level the need for pre- ventive and primary care is most pressing, funds are relatively scarce, and qual- ity improvements are essential. It is also at this level that the community can become actively involved in mobilizing and managing resources for health. At a meeting in Bamako in 1987, the World Health Organization adopted a resolu- tion to introduce community cost-sharing mechanisms in support of primary care. Since that time, UNICEF has spearheaded a "Bamako Initiative" involving from one to fifty districts in thirteen countries, some 1,800 health facilities, and about 20 million people. In almost all cases, essential drugs have been priced to serve as a mechanism of cost recovery. Experience from the Bamako Initiative and related endeavors suggests that cost-sharing in local health centers can pay significant dividends. In countries like Benin, Guinea, and Nigeria-where experience has been closely monitored-approximately 40 to 46 percent of local operating costs (including salaries) are being covered by fees in facilities participating in the Bamako Initiative. According to one study, up to 100 percent of local recurrent costs (excluding salaries) are being covered (Parker and Knippenberg 1991). Cost-sharing at the local- level has given rise to a number of principles: U Clients' willingness to payfees strongly depends on whether thefees are accompanied by improvements in quality. In Cameroon, use increased significantly among all income groups at health centers that simultaneously initiated fees and quality improvements (Box 10-3). Furthermore, use by poorer people rose proportionately more than MO B I LIZI NG R ESO UR CES 161 BOX 10-3. USE OF HEALTH CENTERS ment was tightly controlled by con- BY THE POOR IN CAMEROON AFTER ducting monthly observations at each INTRODUCING COST RECOVERY AND study site. QUALITY IMPROVEMENTS Results indicate that the probability of using the health center Increased A study at five public health facilities in -significantly for people in the "treat- Cameroon demonstrated that the poor ment" areas compared with those in may benefit more than the relatively the "control" areas. Contrary to pre- better-off population from concomitant vious studies, which have found that introduction of cost recovery and qual- the poorest groups are most hurt by ity improvements. user fees, this study found that the In a "pretest-posttest" experiment, probability of the poorest groups seek- three health centers introduced a user ing care increased at a rate propor- fee and qualityimprovement (for ex- tionately greater than the rest of the ample, reliable drug supply), and were population. Travel and time costs in- compared with two similar facilities volved in seeWing altemative sources wvithout such changes. Two rounds of of care are too high for the poorest household surveys were conducted in people and thus they appearto benefit twenty-five villages, each wih about from local availability of drugs more 800 households, to measure the per- than others. centage of ill people seeking care be- Soure:Litvackl992. fore and after the changes. The exper- use by the wealthier (Litvack 1992). A comprehensive survey of public sector health facilities in Ogun state, Nigeria, produced similar results. If, on the other hand, price increases are not matched by improvements in service quality, there is likely to be a loss of demand. Introduction of user fees caused a decline in user rates at health facilities in Swaziland, Mozarnbique, and Lesotho, largely because the revenues were not immediately reinvested in the facilities U Retention of a substantial portion of tie revenues at the collection site is an important incentive to collectfees and improve the quality of services, par- ticularly whzere community representatives monitor collection and use of the funds. Allowing facilities to retain all or most of the fees helps to remedy budget cuts and allows the facilities to tailor their services to local needs. In contrast, efforts at administrative decentralization in the collection of fees and monitor- ing of cost recovery appear to be hampered when little financial autonomy is permitted. From the perspective of health care providers, the requirement to remit funds to the Finance Ministry resembles a tax and thus discourages fee 162 B ETT ER HE ALT H IN A F RICA collection (Vogel 1988). The user charge sysLems ol Cameroon, C6te d'lvoire, Mali, and Scnegal used to require that fees be remitted to the Finance Ministry. In Cameroon, legislation adopted in 1993 granted a special waiver lo health facilities, removing the requirement to remit the proceeds of the sales of drugs to the national treasury. Instead, the funds are retained and used to increase service quality by renewing stocks, * Drag revolviig fuids are a good cost-recovery mnecianisi becauvse thley etisure customers a rtgular supply of drugs: Meanwhil(e, drug sales generate a sit rplusfor thiefacility. In Benin, a comparison of health facilities one year before and one year after a revolving drug fund was established showed an increase in use of 129 percent. Increases in use following the start-up of a cost-recovery program for drugs have also been seen in Niger, Liberia, Guinea, Nigeria, Senegal, and Zaire (World Bank 1992d). It is important to increase prices gradually, thus giving clients time to become aware of concomitant improvements in services (Blakney, Litvak, and Quick 1989). * Good adninistrative and man2agerial practices are important to suc- cessful cost recovery. The conditions for successful collection of fees appear to include (a) well- defined entrance points to the health service, whether they be at the entry gate of the health facility itself, or at the entry point for each service at larger institu- tions, such as hospitals; (b) large public displays of the fee and service struc- ture; (c) issuance of some paper instrument, such as a ticket, with duplicate copies, that serves as a proof of payment and as a management control device; (d) a tightly controlled mechanism for ascertaining who is truly poor, who is not, and the elimination of exemptions on any otherbasis; (e) careful training of staff to ensure that treatment is not rendered unless a ticket or certificate of indigence is produced by the patient; (f) spot-checks to ensure compliance; (g) periodic audits of financial transactions; and (h) a fairly high level of local retention of fees. One study concluded that total revenue raised appeared to be a function of the vigor with which cost recovery is pursued at the national and local levels, and of the competence and commitment of local health administra- tors (Vogel 1988). Fee Structures and Provisions for the Poor Which services should be charged for, and how much, are questions for public sector institutions and for private voluntary organizations and private-for-profit providers that receive government subsidies. Most private-for-profit providers, of course, are unsubsidized and have fees that are determined by supply and demand. MOB IL IZIN G R ESOU RC ES 163 A rule of thumb can be applied to determine whether fee-for-service reve- nues in the public sector should cover costs: Is the service provided a private or public good? With the significant exception o1' highly contagious diseases, cur- ative health care is generally private in nature and people are willing to pay for it, meaning that full cost recovery is a reasonable goal over the long run. In contrast, public health goods and services have strong positive extemalities. Tbus, they are often provided free orat reduced cost. Improvements in social equity will also be contingent on differential charges based on income. Policies that exempt certain privileged groups, such as civil servants or the military, from paying fees can contribute to inequity. And if user fees deter low-income groups, the government may have to intro- duce subsidies, waivers, sliding-fee systems, or other appropriate means to rec- tify the situation. A number of broad principles are applicable in determining fee structures: * To the extent possible, the price should reflect the type of service provided and its cost. Private benefits, such as curative care, should be priced at or near cost. Services with major externalides (immunizations, family planning) and high cost-effectiveness should be free or provided at reduced cost. * Groups with higherincomes, especially those covered by health insurance, shouldpay amuch largershareof the actual costs of health services provided to them * Low-income households should be able to obtain basic health care at little or nu cost. * Prices at ministry of health facilities should be structured to en- courage efficiency. They should reflect differences in the costs of providing service to encourage clients to seek care at the lowest- cost level (Hecht, Overholt, and Holmberg 1992). The main practical issue in sliding-scale fee systems or exemptions for the poor is the administrative feasibility of ensuring that those who need subsidies receive them. Without strong political support, firm screening criteria, and re- tention of some portion of fees at th,e point of collection, health personnel will have little incentive to perform means tests, and exemption mechanisms may expenence considerable slippage. Because there are no established rules to fol- low, a certain amount of "'learning by doing" is inevitable. Under the Bamako Initiative, the philosophy of user fees is that "everyone should pay something," no matter what his or her income. At the same time1 however, the fee structure must reflect the fact that most clients are poor. For some primary care services, such as prenatal consultations, prices will be al-. 1U4 BETTER H EA LTH IN A FR ICA most nil. Cost recovery for drugs is common, but charges vary according to drug cost and dosage. The government of Malawi recognized the need for low-income exemp- tions when it began to phase in cost recovery, first at central hospitals, then at district hospitals, and finally at health centers. The government decided that the "corn poor" would be exempt from its cost-sharing scheme and examined the structure of landholding to determine which households qualified forthis status (Ferster and others 1991). These poor are families farming less than 0.5 hectares and have been estimated to account for about 500,000 households, or 18 to 20 percent of all households in Malawi. A fee schedule was devised in collabora- tion with the communities served. NGO hospitals and dispensaries in Tanzania found that approximately 70 percent and 40 percent, respectively, of their patients were unable to pay their full fee (Mujinja and Mabala 1992). Only 10 percent of the hospitals and 5 percentiof the other facilities said they offered no exemptions, while many fa- cilities accepted alternative forms of payment Some allowed deferred pay- ment, payment in-kind with crops, temporary employment (without pay), or assigned tasks to the client. The proportions of hospitals and dispensaries ex- empting disabled people were 90 and 75 percent, respectively; people over 65 (9 and 20 percent, respectively); poor people (86 and 85 percent); children un- derfive (36 and 30 percent); and retired workers (9 and 10 percent). Health Insurance User fees are an important part of cost recovery, but large parts of the popula- tion eventually must be covered by some form of health insurance if the full costs of inpatient care are to be recovered. In prepayment insurance plans, all participants pay a regular fixed amount. The money is pooled, allowing insur- ance providers to pay for all those needing care, especially the high costs of hospital-based curative care. While health insurance is a mechanism for sharing risks and is not intended for resource mobilization or for achieving equity between high- and low- income groups, it has significant implications for resource mobilization and equity. Those Africans who are insurable are often better off than the rest of the population. Through insurance, they can self-finance the level of health care they desire. Schemes to promote insurance can therefore help relieve the gov- emrnent budget of the high costs of expensive curative care, thus releasing funds for preventive and primary care. Health insurance is not intended to be a mechanism for purging ineffi- ciency in the financing of health services, although it can contribute to that goal. With appropriate incentives, health insurers have a strong interest in containing MO B ILI ZING RES OU RC ES 165 reimbursement costs forhealth care, and then negotiating with suppliers to keep costs down. Only a small proportion of the African population is currently covered by health insurance. Coverage ranges from virtually nil in Uganda to 13 percent in Senegal (Table 10-5). However, there is a potential to gm,dually increase the share of the population covered. In Kenya and Senegal, coverage has doubled since the mid-1980s. One form of health insurance in low-income Africa is government- sponsored insurance financed by general tax revenues or special employment taxes. Enthusiasm over national insumnce schemes is based on the assumption that they transfer wealth from the healthy to the sick and from the rich to the poor. This assumes that contributions are based on income and that benefits are provided according to need. In reality, however, universal government insur- ance systems in Africa have fallen far short of meeting the hopes of their advo- cates. One reason is that tax bases tend to be weik and unstable, undermining the predictability of public revenues. Improved performance in collecting taxes, especially direct taxes, which tend to be progressive, could help resolve this situation. In addition, government-sponsored social insurance schemes in Africa have tended to have substantial administrative expenses-for example, as much as 50 percent in Mali. A more promising route is to impose mandatory insurance payments on employed workers as a percentage of their wages and to levy a similaror some- what higher payroll tax on their employers, or to require employer covemge of care. Examples include compulsory social security for the formal labor market Table 10-5. Share of Population Covered by Health I=nrance, Selected African Countries and Years Poptdalion Cowunryandyear (mill;ons) Perceneage covered by insurance Burkina Faso, 1981 6.7 0.9 Burundi, 1986 4.9 1A Kenya, 1985 21.2 11A Mali, 1986 7.6 3.3 Nigeria, 1986 103.1 0.04 Senegal, 1991 7.2 13.0 Uganda, 1991 16.8 0.0 Zambia. 1981 5.6 6.1 Zimbabwe, 1987 8.7 4.6 Source: Vogel 19: World Bank sector reports. 166 BETTER HEALTH IN A FRI CA in Senegal, compulsory programs for public employees in Sudan, and govern- ment-mandated employercoverage of health care foremployees in Zaire. By making health insuranoe compulscry for employees in the fornal sector, gov- ernments can encourage risk-sharing in a number of ways. The large number of enrollees spreads risk more widely and makes the system more viable and more fair. When insurance is compulsory, a large market is created that may encourage entry by private suppliers. Under such a system, governments can collect pre- miums while allowing consumers to subscribe to any one of a numberof public or private plans. Finally, compulsory coverage eliminates the problem of adverse selection-the tendency of the healthy to forgo purchasing insurance. Employer-sponsored plans are a second form of insurance coverage. They provide care directly through employer-owned, on-site health facilities or rely on contracts with outside providers or health maintenance organizations. Ex- amples include employer-provided medical care in Zambia and Nigeria, as well as in the rubber forests of Liberia and Zaire. In Senegal, employees are covered under one of two insurance programs: a system known as Institut Prevoyance Maladie (1PM), for 53,000 wage earners and their families; and the Institut de Prevoyance et Retraites du Senegal (ipups) for 60,000 retirees. Approximately M5,000 family members are covered under the two schemes. In Nigeria, five large parastatals offer comprehensive care for their employees and their fami- lies, either at their own health care facilities or by contracting with private hos- pitals and doctors. A third category of risk-sharing is composed of prepayment plans with a one-time annual collection fee. This avoids the need to adjust rates on the basis of assessments of individual risk (Eklund and Stavem 1990). Examples include personal prepayment plans, conununity sponsored plans (such as village funds forpurchasing medicines ora broader self-supporting network of local clinics), and programs sponsored by cooperatives. In Kenya, an estimated 2.1 million employees and their families eaming more than K Sh 1000 per month pay a flat rate of K Sh 20 per month to the National Hospital Insurance Fund (NHnF). When employees are hospitalized, the NHIF Will pay out K Sh 200 per day for up to 180 days of care. In Guinea-Bissau a system of prepayment, limited to prenatal care and treatment with a few essential drugs, has worked well. In Zaire the Bwamanda health insurance system provides a model for the operaz tion of community-based insurance (Box 10-4). Fourth, there is private insurance to cover the fees of private providers. Private insurance represents a means of earmarking family savings to self- finance health care by selected groups. In countnies like CMte d'Ivoire, Ghana, and Senegal, private-for-profit insurance plans cater to groups with higher in- comes that are willing to pair for a quality of care that their government cannot finance. In Senegal, rapik development of private insurance over a three-year MO BI LIZ ING R ES OUR C ES period resulted in enrollment of 15,000 people in plans offered by eight com- panies. In other countries, such as Zimbabwe, private health insurance has also grown (Vogel 1990). The Role of Government in Health Insurance Governments can and must play a critical role in encouraging risk-sharing. The willingness to pay for health insurance is likely to be weak in countries where publicly provided health services are "free" and no tradition of cost recovery exists. When user fees become an established practice in the public sector, households begin to take an interest in ways to spread the risk of substantial health expenditures over time and across a wider population. With the subse- quent evolution of risk-sharing financing mechanisms, a key obstacle to non- government financing and provision of health services-such as expensive hospital care-can then be progressively removed. The government can also encourage the use of deductibles and copayments in compulsory and other types of insurance programs. If those covered by com- pulsory insurance can receive services at no out-of-pocket cost, they will proba- bly overuse costly services. Deductibles (an arnount that users must pay before their insurance coverage begins) and copayments (a percentage of total costs above the deductible paid by the user) can help prevent overuse of the systemf Even a small deductible, such as 1 percent of annual household income, or a small copayment (such as 10 percent of the cost of services received) can go a long way toward reducing unnecessary use of medical care. To minimize the administrative costs of insurance programs and broaden the range of coverage, governments can encourage competition among in- surers. To this end, governments may decide to permit private firms to opt out of the compulsory public health insurance plan if they provide a satisfactory alter- native, or reduce the risks faced by private insurers through stop-loss provisions and reinsurance. Governments can also respond to thecriticism thatinsuranceschemes may reinforce the mnaldistribution of health resources between rural and urban areas. It has been argued-and the argument does have, some justification-that the extra funds generated by insurance programs in low-income countries typically benefit urban, employed workers and their families, while doing little for large rural populations. This problem can be aggravated by insurance plans, paiticu- larly if public insurance promotes hospital-based and doctor-centered care. Thus, public funds that become available after insurance schemes are put into place should be reallocated to cost-effective packages of primary care at facili- ties in periurban and rural areas (M ills and Gilson 1988). Anotherway to ensure equity is to subsidize the cost of insurance premniums through vouchers for the 158 BBETTER HEALTH I N A F R ICA BOX 10-4. COMMUNITY-LEVEL or treatment of a chronic disease. Al- INSURANCE PLANS: LESSONS FROM though associated with a hospital, the ZAIRE accounting of the insurance program is kept separately. The hospital bills Practice: Several features of the Bwa- the scheme for charges incurred by manda health insurance system in the beneficiaries. All hospital cases re- Zaire have contrbuted to its success. quire referral through a health center, Offered by the health care provider, it which serves as the site forverification avoids problems of setting prices for of the need for treatment and enroll- services and of transferring money ment in the insurmnce plan. Premiums from an insurance plan to the health are collected once a yearfollowing the care provider. The cormbination of sim- harvest To prevent inflationary losses ple fee structures and the requirement in the value of funds collected, the that patients be referred helps mini- money is invested with interestor used mize overuse of the system. The to buy drugs. scheme also benefits from a good Community enrollment rose from an marketing structure, as reflected in its initial 30 percent in 1986 to 60 percent high enrollment. Health center nurses, in 1989. Cost recovery through user who enjoy high levels of access to the fees at Bwamanda hospital went from community, are given financial incen- 50 percent of recurrent expenditures in lves in the farm of a small percentage 1986 to 80 percent in 1988. Health in- of premiums when they recruit new surance and interest income ex- participants. ceeded expenditures underthe plan in The insurance covers 80 percent of 1987, 1988, and 1989: 89 percent of the standard charge forhosptalization funds collected went to hospital POOL The main practical problem with all such measures is to identify the poor. This is an administrative difficulty everywhere, since means tests are difficult to apply (World Bank 1987). Conclu'sion: Resolving Crises No single formulawill solve the problem of financing health services. for all of the people in African countries. Each country faces a different configuration of prob- lems, prospects, and priorities. There is much to be said, however, for proceeding in incremental fashion. Governments can take a leadership role on several fronts. First, each govemmentcontrols theamountof public resources allocated to the health sector. It is therefore up'to governments progressively to restore pub- lic funds for health in countries where they have diminished or to raise current commitments in recognition of. the importance of health for sustainable development. MO BI LIZ ING RESOURCES 169 Box 10.4, continued aries can help reduce the tendency of any voluntary scheme to concentrate charges, 6 to 7 percent to health cen- its members (unintentionally) among ters, and 5 percent to administrative those predisposed or most likely to fall costs. Although admission rates for in- ill. sured patients are somrowhat higher a Committed, decentralized man- than for those who are uninsured, the agement provides flexibility and high enrollment rate of the eligible accountability. population In the program allows ab- * Simple control methods, such as sorption of this cost. stamps for enrolled members and photo identification of beneficiaries, Lessons learned: Studies of a variety can help reduce error and fraud. of entirely autonomous community in- * Enrollment of all family members. surance schemes in Zaire have identi- rather than individuals, increases the fied a number of preconditons or cor- sizeofthe pool of people amongwhom relates of success (Shepard, Vian, and risks are to be spread. Kleinau 1990): * Appropriate investment strate- * Mostsuccessful planshavemodest gies are needed to preserve the value premiums.Wherepremiumsarebeyond of premium income in periods of the financial means of potential mem- inflation. bers, participaton rates will below. * Strong accounting systems are * A precondition for success is that critical to effective functioning. health services be of acceptable * A financial guarantee can be an quality. important catalyst to launching a suc- * Sensitization of potential benefici- cessful start-up phase. Second, symbolic commitments to preventive and primary care can be made into real commitments by reallocating public funds away from expensive and relatively ineffective urban-based curative care to cost-effective preventive and primary care services in rural and periurban areas. In Madagascar. between 1986 and 1991, public expenditures on secondary- and tertiary-level care fell from 51 percent to about 36 percent In Nigeria the Fifth National Development Plan set out a strategy to begin moving federal funds away from expensive hospital programs, and the share of federal funds going to hospital programs was to be reduced by about a third by 1992 from levels established in the early 1980s. Third, governments can progressively implement user fees and cost- recovery to help ensure financial sustainability of publicly provided health care. This study shows that there is considerable scope for expanding user fees and that households are willing to pay those fees, provided quality improve- ments accompany higher prices. 170 B ETT ER H EA LT H IN A FR ICA BOX 10.5. PUBLIC-PRIVATE outto nongovernment providers, and a COLLABORATION variety of incentives (World Bank 1987). For example, in Rwanda, where Increasingly, African govemments are missions provided 25 to 35 percent of deliberately fostering collaboration health care services during the 1980s, with the private sector in financing and the government reimbursed them for a providing health care because in- large share of the salaries of Rwan- creased nongovemment health sector dese staff. These public subsidies ac- activity can ease pressure on the pub- counted for about 5 percent of recur- licbudget.Despitethedistortionsthat rent public health spending. In characterize the private market for Zimbabwe, about 4 percent of central health care, the private sector is gen- government health care spending erally more efficient than the public wentto subsidize missions, represent- sector. A shift in the balance of health ing about 85 percent of their health needs to more individual-level care service revenues in the early 1980s. among groups with higher incomes This subsidy was provided in support further signals an expanding role for of the missions' work in serving indi- private providers, with insurance gents. In Nigeria laboratory services mechanisms to protect against cata- have been contracted out, and in Zim- strophicfinancial losses. babwe equipment maintenance, laun- In financing public support can take dry services, and invoicing of insured the form of public subsidies to private patients have been contracted out voluntary organizations, contracting Fourth, govemments can create the conditions for expanding health insur- ance, thus generating increased revenues for the health sector in general and stimulating expansion in the numbers of nongovemment providers of health care. Fifth, governments can promote public-private collaboration as a means of increasing efficiency and fostering the creation of new efforts in health care by private voluntary organizations and private-for-profit providers (Box 10-5). If private practice has been outlawed, it should once again be made legal. Finally, governments can reap far greater sustainable benefits from better use of available external funds. Instead of molding national strategies around available.donor funding, governments should develop national health policies and strategies, and then provide leadership to donors, to help put them into effect C HAPTE R E LE VE N Timetable for Change ACHIEVING better health in Sub-Saharan Africa, as this report makes clear, will require a large number of interrelated actions, ranging from the formulation of comprehensive health policies to the identification of disad- vantaged groups whose health needs must be clearly specified. Table 11-1 sum- marizes an action agenda under eightheadings, and offers an inforrnal timetable with actions classified as having short-tenn, intermediate, or long-term time horizons. Like the rest of the report, this table is indicative rather than prescriptive. It is, in fact, indicative in two senses. First, diversity among African countries means that the countries them- selves will have to decide their own priorities for action. These uvill depend on differences in the conditions affecting health, the quality and quantity of public and personal health services, access to external assistance, and so on. In some countries, such as Mozambique, Somalia, and Uganda, civil war has taken -an immense toll on health systems. In-the immediate future these countries will be preoccupied with malding basic asse'sments of the status of all the determinants of health outcomes and restoring and rehabilitating basic services. In other countries, such as Benin, Guinea, Mali, Malawi, and Nigeria, experimentation and positive experiences linked to well-functioning health systems can serve as a basis for broadening coverage. And in still other countries, like Botswana, Lesotho, and Zimbabwe, where per capita incomes and health expenditures are considerably greater, priority actions will include encouraging provision of health insurance to larger'shares of the population, providing fuller health cov- erage for the poor, and privatizing selected hospital services. Table 11-1 is also indicative rather than prescriptive in terms of the sug- gested time horizons. For example, a government can formulate an opera- tionally relevant national health policy relatively quickly through collaborative 171 172 BETT ER HE A LTH IN A F RICA Table 11-1. Action Agenda and Timetable Short Medium Long tenn term term Policyformulation and dRta c'.,llection Formulate and review nationat health policy f Develop demographic and epidemiological databases / Establish and review health targets / Identify the most disadvantaged groups / Establish a research agenda / Intersectoral interventions Provide more health information to the public and to health care providers / Produce behavioral changes by households and individuals through IEC methods :/ Carry out sustainable intersectoral interventions at the community level, particularly to improvewater and sanitation / Strengthen formal and informal education of girls and women Health caredelivery Identify cost-effective package of basic health services / Strengthen networks of health centers and fist-referral hospitals - inprove referral system through regulations, prices, and quality signals / Reduce concentration of financial resources at uttiary level and cevolve Ministry of Health involvement in hospital management / Improve access to health services for the 'core" poor- / Pharmaceuticals Establish national drug policies J Review legal basis and structure / Reserve foreign exchange for drug purchases / Adopt essential drug lists / Reduce inefficiency and waste through Use of cost-effectiveness criteria in purchasing drugs / Quantification ofnational drug needs / Competitive bidding forgeneric drugs / Improved storage and management / Better training and information forthose who prescribe drugs . Measures to improve patient compliance with treatnent regimens V T I META B LE F OR C HANG E 173 Tablell-l. continued Sliorn Medium Long term term term Develop and suppart revolving funds fordrugs / Personnel management and training Formulate human resource plans for health by geographic area, by experiise, and by gender and category of worker / Generate budgetary savings by reducing the numberof ineffectual civil service workers while improving compensation for productive workers / Expand training in health managementand administration / Adapt training curricula to district- and community-level services / Health infrastructure and equipment Establish rehabilitation plans for existing buildings and equipment , Establish normns and procedures for new health facilities, especially atthe disuict level / Designate one hospital as a center of excellence for training / Instiatdional reform and management Conduct assessmentofcurrent system and its operation - Pursue decentralization and redefine roles and responsibilities at the central, regional, district and community levels / Develop management skills in planning and budgeting / Fosterinstitutional pluralism / Stimulate and strengthen community organizations / Support training and other prepamtory work for district health teams Undertake training and prtparatery work for community management committees / Strengthen management information systems through: Assessment of needs by component ofhealth system / Training required / Implementation of systems and procurement of needed equipment / Develop capacity for essential health research / Table continued on next page 174 B ETTER HE A LT H IN A F RICA Table 11-1. continued Short Medium Long term term ten; Financing health care Increase per capita government health expenditumrs / Focus governmentexpenditures on public health goods and services / Implement user fees and cost recovery in public facilities At tertiary hospitals / At first-referral hospitals / At health centers / Identify the poor and subsidize health services for them / Encourage expansion of insurance schemes, especially employer-based and conununity-level schemes / Promote public-private collaboration / DonorcolLaboradion Establish coordinating mechanisms headed by government i Assess profile and cost-effectiveness of donor activities V Establish donor role in cost-effective approach to better health / Progressively increase donor funding for primary and preventive care / efforts involving health sector experts, providers of health services, and com- munity representatives. The demographic and epidemiological data used in for- mulating the plan need not be perfect, although they should be as accurate as possible underthe given circumstances. Over time, however, the initial national health plan will have to be revised as more complete demographic and epidemiological data are collected and the les- sons that can be derived from country-specific experience become clearer More- over, some African countries mnight conclude that the formulation of policies and plans at this time would be premature because of serious flaws in the existing data. Similarly, actions with a longer-term horizon tend, in general, to be more demanding of financial sources-for example, the construction of large num- bers of health centers. Some countries, however, may find themselves able to complete longer-term actions within a medium-term time frame. The next section of this chapter discusses the major actions listed in the table under the table's three time horizons. As will be evident, short-term ac- TIM ETAB LE FOR CHANGE 175 dons fall largely within the public domain, given the government's critical lead- ership role in creating an enabling environment for better health as well as its substantial involvement in the financing and delivery of health services. The second section provides a dynamic perspective on how key health priorities will change among the African countries as they move to higher levels of socioeconomic development. The penultimate section of the chapter deals with the need to expand re- search and research capacity on Africa's health problems. The chapter's final section deals with the question of how international assistance might be used most effectively. While African governments must take the leading role in achieving betuer health in Africa, donor funding can play a vital role, particu- larly in those countries afflicted by widespread poverty. Agenda for Action Short-TermActions These are actions that are likely to demand immediate priority: U Formulating comprehensive, operational health policies with explicit goals and methods of evaluating progress. These policies should include state- ments on how the enabling environment for health will be strengthened, pre- scriptions for die role of government in financing and providing public health activities, and preparation of a locally'relevant research agenda to help fill criti- cal gaps in knowledge. The policies should also include statements on how international initiatives will be integrated into national plans. * Identifying the most disadvantaged groups and ageeing on indicators for monitoring and evaluating improvements in their health status. In particular, screening mechanisms should be developed to establish who should qualify for fee exemptions or subsidies. Community participation in this process is vital. * Establishing national drug policies, including essential drug lists. Par- ticular attention is needed to quantifying national drug needs over specific time periods, using cost-effectiveness criteria in selecting and purchasing them, using competitive bidding for generic drugs, and considering the desirability of interrninisterial agreements on reserving foreign exchange for drug purchases. * Formulating human resource plans for health by geographic area, by expertise, and by category of worker. In particular, attention should be paid to drawing up a profile of the staff required to operate a district-based system of health centers and first-referral hospitals and reducing the number of job classifications. 176 BE TT ER HE ALT H IN A F RICA U Making a comprehensive assessment of existing health sector buildings and equipment and future needs. Particular attention should be paid to reha- bilitating current buildings and establishing norms and procedures for locating new health facilities (especially at the district level). * Initiating institutional reform and assessments of management capaci- ties and needs. These actions can be facilitated by participantlbeneficiary as- sessments of current health systems, establishing management informiation sys- tems (MIS) tO monitor progress, and strengthening community involvement in the management of lower-level henhth facilities. * Establishing coordinating mechanisms, under the joint leadership of the ministry of health, ministry of planning, and ministry of finance, to assess the profile and cost-effectiveness of donor activities. Particular attention should be paid to developing a systematic approach for donor participation in the devel- opment of district health systems. Medium-Term Actions Most governments in Africa are deeply involved directly in the financing and provision of health care, so this selection of items for change over the medium term incorporates activities aimed at making public spending more efficient, equitable, and sustainable. Actions with a mcdium-term horizen include: * Supporting advanced training programs for senior public health man- agers and devising training curricula attuned to the specific needs of health services at the district and community level. In particular, emphasis should be placed on getting professionals trained in health management and administra- ion into key policy, planning, and budgeting positions in ministries of health. * Progressively increasing government expenditures on health and ear- marking larger shares of funds for public health goods and services, including cost-effective preventive and primary care. In many countries, real per capita expenditures on health need also to be increased. * Reallocating larger shares of public funds forhealth to well-functioning health centers and first-referral hospitals. This would mean progressive de- creases in funding for relatively cost-ineffective services at urban hospitals. * Implementing cost-sharing, first at tertiary-level facilities, where those who bypass the referral system can be assessed full costs. This can be comple- mented with cost-sharing at health centers and first-referral hospitals, with a predetermined amount tn be retained by the facility. There should be no com- pensatory reductions in overall ministry of health funding because of cost- TIMETABLE F O R CHANGE 177n sharing. The quality of services should improve at the same time as fees are being increased. * Launching training and information programs to reduce inefficiency and waste in the prescribing of drugs and to improve patient compliance with instructions on drug usagge. * Using information, education, and communication (mc) programs to improve the health-related practices of individuals, householdr, and communities. * Generating budgetary savings by reducing the niumberof ineffectual and unneeded workers while improving compensation by rewarding productive workers. Fees charged for health services. can be. used to supplement Lhe in- comes of health center staff. * aLying the undwork forinstutional reform and decentralization by redefining roles, responsibilities, and authority at the central, regional, district, and community levels. Emphasis should be placed on fostering institwtional pluralism m support of decentralization. Training must be provided for health, teams and community mar.agement committees.: * Evolving sustainable forms of comrnunity health financing including drug revolving funds and community insurance schemes. * Promotingpublic-private cooperationto enable privatesectorproviders (especially private voluntary organizations) to play a more prominent role im health care. - Ensuring that donor funding is usecd to reinforce national strategies, and. increasing the capacity of health care systems to absorb donor funding. - * Devolving the management of tertiary-level hospitals from the ministry of health through various forns of decentralization and privatization, while gradually reducing public expenditures on tertary-level care.' Long-TernmActions Long-term actions include progressive expansion of health systems, and using financial commitments to make health systems more self-sustaining. They include: . -Uo Implementing sustainable intersectoral interventions at the commurnity. level. Particularly important are access to safe water, sanitation, nutrition, and - - family planning services- * Strengthening the quality and improving the quantity of primary care services by expanding systems of well-functioning health centers and first- :178 BETTER H E A L T H IN AFR ICA referal hospitals. This implies the construction of new health centers and first- referral hospitals and increased public-private collaboration in their staffing, operation,andmaintenance. * Strengthening the capacity for operationally relevant health research in ministries, universities, and private voluntary organizations. The Dynamics of Change The challenges implicit in Table 11-i will differ across countries, depending on theirsocioeconomic conditions, political stability, epidemiological conditions,. the effectiveness of health care services, and financial constraints- This can be ilhustrated by comparing the situations of three countries-Uganda, Mali, and- Botswana. Ugande Uganda is typical of several African countries that have suffered political, social, and economic upheaval in recentyears Health indicators, such as infant mortality, have shown little improvement over the last ten to twenty years. Ferfility rates have remained constant or have ncreased over the last, decade1 and economic setbacks have seriously impaired public funding for so-. cial services. Political tmoil and civil stife have reduced what once was one of Africa's most effective and efficient health services to near collapse. Health finance is in disarray, with individual government-owned facilities malkng urn- lateral decisions on fees to prevent outright collapse. Management problems abound in public sector health care delvery, where capacity utilization is 50 percent lower than in nongovernment health facilities. To make matters worse, Uganda's fledgling system of health care is burdened by an's epidemic. Uganda faces the challenge of taking action on virtually all of the items in Table ll-L The government plays little role in ensuring the provision of public'- health goods and services. There is thus an urgent need for a sharp rise in the public financial commitment to health, and public expendituresnecd to be real- located from tertiary-level hospital care to primary health care. This is the time to rethink the country's health strategies and health care system entirely and to emphasize the use of donor assistance in ways that contribute to an integrated system of health care. Mali. Thesituation in Mali is typical of ahandful of African countres att areprogressivelyimprovinghealdtoutcomesdespitetightfinancial constraints. Health indicators such as infant mortality and life expectancy are improving, though slowly. Low per capita incomes are gradually increasing, and the coun- 0 tryenjoys somewhatgreatersocial andpolitical stability than many otherAfri- can countries. Although theMinistry of Public Health has traditionallyfocused. on providing health care thrugh vertical programs and has neglected its role in policyformulationandplanning,itisachieving agradualexpansionofdistict- T I M E T A.B L E F O R CHANGE 179 based health care. The country's network of district-based health centers is ex- pected to increase access to health care to 52 percent of the population by 1997. To promote public-private collaboration, the government lifted its ban on pn- vate medical practice in 1987.- Mali also needs to take action on most of the items in Table 11-1, but it has the distinct advantage that the groundwork is being laid for decentralizing ser- vices to the district level. Moreover, Mali's donors are actively supporting the expansion of district-level care. Perhaps the greatest challenges facing the country are rationalizing heali sectorexpend' .e patterns, increasing the gov- ernment's financial commitment to health, promodng cost-sharing, improving the reliability of pharmaceutical supplies in public sector facilities, and encour- aging nongovernment providers of health care. Botswana Health status in Botswana has been improving rapidly. Rising incomes and expenditures on public goods and services reflect increases in per capita GNP, illiteracy and fertility rates are on the decline, and the country en- joys a good ineasure ofsocial andpolitical stabilty. Access to health facilities is relatively good, and decentralization to the district and subdistrict levels has been in place for some time. Public expenditures on health are also relatively high-well over the $68 per capita annually discussed earlier for high- expenditre countries. Furthennore, health planning is given prominence in the organization and work program of the Ministry of Health, and the countty has a solid tradition of cost-sharing forpublicly provided services (thiough such reve- nues constitute only a small share of total governrnent expenditures). Predominant among the challenges facing Botswana are encouragig priva- ization or full-cost recovery at hl spitals, encouraging the expanision of public and private misurance schemes, strengthening health research and research capac- ity, and reducing donoriinvolvement in light of Botswana7s growing financial and institutional capabilities. Botswana will also want to compare the profile of pub- licly provided health sericesnow available to rural and periurban households with the cost-effective package of basic services costed in tis study. I Developing Greater Research Capacities Virtually all of the actions described thus far require additional research and policy analysis. To improve on the dismal state of health research and policy analysis in Africa (and other developing regions), nn independent Commission on Health Research for Development recommended (Commission on Health Research for Development 1990): * Investing in long-term development of the research capacity of in- dividuals andinstitutions, especially in neglectedfields such as epidemiologyandmanagement ISO BETTER' HEALTH I N A F R I C A * Setting national priorities forresearch, forusing domesticandexternal resources * Giving professional recognition to good research and building career paths to attract and retain able researchers * Developing reliable links between researchers and the users of research atthenational,district,andcommunity levels * Investing at least 2 percent of national health expenditures and 5 percent of extemally funded programs in research activities. Without such a commitment to research, the prospects ar slim that African countries will be able to establish a policy agenda, identify, cost-effective pack- BOX11-1. A HEALTH RESEARCH UNIT Wrthin two years of its establishment, MAKES A DIFFERENCE IN GHANA the research unit had determin a re- search agenda and circulated it to uni- Ministries of health in Africa are often versffles andS research institutions It blamed for making decisions that are had developed a research policyforthe not scientificaly informed. This is fre- ministry. It also conducted workshops quently because of.a failure to use on researchproposalwritngandanaly- available information, especially re- sis for regional and district health search' information that exists in aca- teams. demic institutions and scientific jour- :To ensure use of research findings, nals. Ministries of*health often the research unit has supported con- perceive themselves as service -pro- sultation meetings atthe national level viders with litte or no role in research, on topics such as safe motherhood,. and research findings are often ex- decentralization of health services, pressed in away that is not intelligible and'community. health worker pro-: to decisionmakers. grams, at which research findings are To addressthis.problem, the:Minis-a presented. Program guidelines have. tryof Health in Ghaniacreatedahealth been prepared for implementors fol-. research unit. The unit is responsible lowing such consultations. for creating awareness of the need. The research unit works with an and usefulness of research informa- eighteen-member advisory committee tion at all levels of the health system made up of staff from the Ministry of and arficulating the research needs of Health, the Ghana staftistcal services - the Ministry of Health to -professional academic institutions, research researchers. Itis also involved in build -- bodies, local govemment authorities, - ing capacityfor operations research in nongovemment organizations, and the ministry, conducting health sys- the National Council of Women and tems research, and ensuring that Development health research information isdissem- Source:Adjei1993. inated and used. TUI ETA B LE F O R CHANGE ages of health services, target the households most in need, improve manage- ment of decentralized systems, mobilize the necessary financial resources for better health, and monitor and evaluate progress. Botswana can be cited as a country where health systems research on this type of issue has been encour- aged. Like Ghana, it has set up a Health Research Unit in the Ministry of Health. Numeros agencies and insdtuions are available to support the development of gater health research capacity in Africa. In fourteen countries in souhern Af- rica, health workers at the national, provincial, and district levels have been rained in the development of research proposals with the help of the Dutch Goverment TechnicaI Cooperton, the Royal Tropical Institute ofAnmra and wHo. More than fifiy research proposals have been supported with small grants, and a technical advisory committee has been established on health systens research from each of the participatng countie (Aleta 1992). Universities in Tanzania, Zambia, and Zmibabwe are engaged in developing and implementing reserch proposals through their faculties of medicine The Rockefeller Foundation has provided grants for such activities for severl decades and is currently supportng fte estab- lishment of a national epidemiological advisory board in Caneroon TheInternational Health Policy Progam (EHPP), supported by the Pew Char- itable Trust and the Carnegie Corporadon of New York in cooperation with wHo and the World Bank, is noteworthy for its support of a network of interested developing country resarchers seeking ways to use resources more effectively to improve the health of the disadvantaged. The IHP supports researcbers in anum- ber of African and Asian countries. World Bank and Intemational Development Association commiitments to population, health and, nutrition projects in Africa have almost always contained provisions for research, amounting to roughly 2 percent of total commitments of$L3 billion trough 1993. The research agenda for better health will undoubtedly vary from country to country. h most African countries it is likely to include work to gain a better understanding of the lowest levels of the health care pyramid-self care, the intrahousehold dynamics of- health, and community-based actions for health improvement. The endeavors of internationaL national, and local GJGos are par- ticularly relevant to understanding health behavior at this level. As but one example,aprojectin SouthAfricais promotingwomen's participation in health policymaking. The project involves participative research, development of a national network of more than 600 individuals and organizations, production of anewsletter, and health information workshops (Tumwine 1993). Links wih the International Community Virtually all African countries face the challenge of obtaining many more sus- tainable benefits from donor funding than they have in the past (Box 11-2). 182 SETTER H E A L T H I N A F R I C A Rather than molding national strategies around available donor funding, Afri- can govenmments need to develop national health policies and strategies on how to make the best use of extemal assistance. Several African countries, under the leadership of the ministry of health, ministry of finance, or ministry. of planning, are bringing -together a diverse group of donor agencies to work with national health staff to build national capacities for health over the long tenn. In Benin, Guinea, Sierra Leone, and Zambia, for example,. national action plans are being developed by govern- ments that will be followed by identification of financial needs and the obli- gations that will be shared by donors. This is precisely the approach.favored. by. iXis report, and promises to redress a major failing of donor assistance in the past-namely, the absence of sustainability in externally funded pro- grams for health.. The donor community needs to extend its time horizon in supporting Afri- can efforts to develop integrated hiealth systems. Once donors become involved BOX11-2. INTERNATIONAL INITIATnVES provements in the health and welfare: AND SUSTAINABLE OUTCOMES of chihiren atthe highestporfical level. Its guals are fully consistent with the In the 1980s, approxirmately half of ex- proposals in this report temal assistance for health in Africa Valuable as these many inffiiaves- was committed to intemationally con-, have been on an indMdual basis, it is ceived and executed multicountiy pro-' also widely believed that, collectively, grams.The rist of inriiatives is long and they have had the unintentional effect Impressive: the Expanded Programme: of fragmenting systems of health care of Immunization (EpI) of WHO, UNICEF, delivery; undermining national capaci- and USAID; the Diarrheal Diseases ties in health policy,, analysis, and Control Program of WHO; WHO'S pro- planning; and discouraging the devel- grarn forcontrol of acute respiratory in- opment of local health leadership fections; the Safe Motherhood Initia- withinAfrica. tive; the Global Program on AIDS; the At the country level, follow-up on the Child Survival programsof uNcEF and Wold Summitfor Children through na- the United States- the Onchoce:ciasis tional plans of action, implementation of Control Program; the International the Bamako lnitiative, the w-c Three- Drinking Water Supply and Sanitation Phase Scenariofordevelopmrentofdis- Decade; and the Special Program of trict health systems, and other initia- Research and Training in Tropical tives is merited. Followv-up should be Diseases. pursued on an intgrated basis, within The 1990 World Summit for Chil- aframeworkoflocaladaptadon,leader-- - dren, sponsored by UNICEF.was an in- ship, and monitoring and evaluation of ternational inifiative for overall im- sustainable outcomes. 1- ~ ~ ~ ~ ~ ~ T IMETABLE FOR C HAN GE 183 in funding health sector activities-particularly in countries with extremely low expenditure levels and institutional capacity-they should expect to re- main partners for at least a decade. Although pressure to achieve measurable health gains over the short term is understandable, succumbing to such pressure is likely to be counterproductive in the long run. Donors also need to support broad-basedi health sector programs and concentrate efforts on those African countries that are firmly committed to and sustain the effort to achieve health improvemenLt Future international assistance can make a significant contribution to better health in Africa in several areas: * Supportforlong-ter capacity-buildingandinstitudonalreform, especially in the areas of policy analysis and formulation * Supportfor identification, financing, and provision of sustainable - cost-effectivepackagesofbasic health care services at the district level * Supportfor intercounruyprograms ofpublic health training and practically oriented research a Support fori tersecsoralaczions for health. These activities can reach beyond the health sector and its "international'counter- part," the World Health Organization, to encompass othermulti- lateral agencies,suchasunacEFandtheWorldFoodProgram. The priorities set out above are few, but their implications are complex. The push to expand Africa's health ifrastructure is a case in point Direct sup- port for expansion should not be among the highest priorities for intemational assistance in most countries. Rehabilitation of existing infrastructure and equppment needs to be ensured first. Thereafter, donor support forifacility ex- pansion should be provided within a framework that considers not only pro- posed capital investments, but also their implications forrecurrent expenditures in the future and the requirements of the sector as a whole. Under such arrange- ments, recurrent cost financing should be increasingly acceptable to the donor community- Conclusion African experts need to intensify the work of consensus-building and provide intellectual leadership in putting forward proposals for "compacts' for better health between African countries and the international community. Such com- pacts might envisage, in those African countries most in need, a doubling of government efforts to mobilize resources for health and comparable increases in. donor support. The specific items for inclusion in such compacts can be expected to vary considerably from country to country. 184 B ETT ER HEALTH I N A F R I C A A forum might be established, extending beyond the country level, to en- sure the coordination of international initiatives for training and operationally oriented research. Such a group could determine priorities and monitor the modest levels of financial support that are likely to be needed. The forum could also assume responsibility for reviewing health reforms at the country level and serve as a support group for miwstries of health and other agents of change. To facilitate monitoring and evaluation, benchmarks would need to be established. A comprehensive independent evaluation of progress could be undertaken af- ter, perhaps, five years. A consultative group on health in Africa could be responsive to these needs for well-orchestrated actions for health. improvement, perhaps folowing the lines of the so-called Doniors to African Education-a group that has brought -: ttogether Africans and donors for consultations on a wide range of education. issues. Another example is the Global Coalition for Africa, a high-level group of Africans and donors thatseeks to identify and monitorsupportforactons on * issues that have previously received inadequate support - A first step would be to. build a consensus among African countries and. * their institutional partners on the mechanisms needed. Consensus-building of this natu, nationally and internationally, could amount to an unparalleled ef- fort to assist Africa in overcoming intolerable levels of suffering premature death, and waste stemming from ill health. . - :: : : - Statistical Appendix - - - : . ;. . . i .; S E r : . . . X . . , _ * i. . '; . . : - . * v 1., - . . : § - .. : , 0 . w * - - ; - : : - : ' ' . r, . . . 's] I . ,l z : : . . : w: ' , f .... .. . 0 lD - . | X |. '' '' < ' '' ' a ; '; |; 5 i ' ' ;- ';gs ' ' ', X ''' ' t, 7',;; / ,1 _ , . . ,. S ':, L :. ibble A-I Health and Dnevelopment Indicators Annual Cruide Cruide Total raeof i/. dah fertility Life POPE,- rate rate rate expec- CNP AdE ieayrt Midyear lotion pe (e (per tancy per POPuilation' growth 1,000 1,000 womian at birth. capla(prcnt (thou1sanlds) (percent) pop.) pop.) 15-49) (M/Fj (US$) Fempale Total Counltry, 1992 1992 1992 1992 1992 1992 109) 1990 1990 Angola 9,732 2847 19 6645148 -842 Benin 5,042 3.0 46 16 6,2 49/52 380 16 23 Botswana 1,3601 3,0 36 6 4.7 66170 :2,530 65 74 Burkino Faso 9,537 2.9 47 17 6.5 .47/50 290 9 18 Burundi .5,818 2.9 46 17 6.8 46/5 210 40 5 Cameroon 12,245 3.0 42 .12 5.8 55158 85 354 Ca'peVerde, 389. 2.3 36 7 4.3 67/69 .750 - - Central African Rep 3,166 2,5 42 8 5.8 45/49 390 25 3 Chad 5,977 254185946/49 210 18 3 Comaros 510 .547 I11 6.7 56/5750408 Congo . . ~~~~~~ ~~~2,428 3,3 49 166.6 49/54 1,120 44 . 5 C6:ed'Jvoire ~~~~~~~12,841 3.6 45 12 6.6 5/9690 40 54 Djibouti 465 3.2 .46 1 6 6.6 47/51 .--- Equatorial Ouinea 437 2,3 41 18 5.5 46/50 330 3750 Ethopia 54$,790 3,4 52 18754/0120 -- Gabon 1,201I 2.8 4315 7~5.9 52156 3,780 48 61 Gambia 929 ~~~~ ~~~ ~~~~2,9 47 20 6.5 44/45 36162 Ghana 15,824 3.2 44 .12 6.1 53/57 400 51 60 Guinea 6,048 2.8 4820 .65 .4/. 460 .13 24 Guinea-Bissau 1,022 2,0 46 25 6.0 38/39 180 24 36 Kenya ..25,838 3.3 45 10 6A4 57/61 340 58 69 Lesotho 1,860 -2,5 36 .10 5.1 . 58163 580 84 73 Liberia 2,719 3.0 44 14 6.2 53157 450" 29 39 Madagascar 12,384 2.8 4146.1 513210 73 80 Malawi 9,085 3.1 53 21 . 7.6 .44145 230 31 42 Mali 8,962 2.9 50 18 7, 75 8 432 Mauritania . 2,082 2.8 49 .18 6.8 4/0510 21.3 Maunitius 1,099 1.1 18 .7 2.0 67fl3 2,410 75 82 Mozambique 16,565 2.7 46 19 . 6.5 45/48 80 21, 33 * .. ~~~~Niger: 8,171 3.3 52 19 7.4 4/8300 172 Nigeria 101,884 .2.9. 43 .14 5.9 50/53 340 39 51 Rwanda 7,310 .2.2 40 17 .6.2 45148 27 750 Silo Tomd and Principe 121 2.6 36 8 5.0 . 65/70 400 42 58 Senegal 7,845 2.7 .43 16 6.1i 46149 720 25 38 Seychelles .69 0.9 23 . 7~ 2.7 675. ,10 95 88 Sierra Leone 4,354 2.6 .48 22 6.5 40145 210 1 1 21 Somalia 8,302 3.1 48 17 6.8 47/50 .170a 14 24 Sudan 26,587 2.9 44 14 .6.2 51/53 - 340a 12. 27 Swaziland . ..860 3.6 49 12 6.6 55159 1,050 65 100 Tanizania 25,965 3.0 45 15 6349/52 10 88 9 Toga 3,899, 3.2 45 1 3 6,5 53/56 410 .31 43 Uganda 17,475 3,3 5197.3. 45/46 170 35 48 Zaire'. 39,794 3.0' 44 :14 6.2 50/53 220" 61 .72 Zambia 8,589 3.1 .48 17 6.5 .46/49 420a. 65 73 Z2imbabwe .10,352 2.6 34 8 4.6 58/61 650 .60 67 Africa .501,932 3.0 45 i15 6.5 49/52 340 38 50 World 5,441,205 1.6 26 9 3.2 64/68 4,000 55 65 Less developed counties 4,213,796 2.0 29 9 3.6 62/65 900 52 63 Morcdev~1ojcdcuntries 1-2675 0514 1 0 1.9 71/78 20,000 95 96 -Not available * .. , aA~~0, 990GNP. . . . . Table A-2. Population Projections (Standard/Medium) Anmwl raze ~~~~Population age Midyear ofpopltdation SfItF Urban popultationi ,groivi Tozalferi'ility - (ecn)populaiion 41l:ousands) (percent) rate 0-4 64 04 5+(percent) County 2000 2025 2000 2025 2000 2025 1990 1990 2025 2025 1970 1990 20(00 Angola 12,325 26,104 3.2 2.5 6.8 4.5 47 3 41 3 1 5 28 36 Benin 6,375 10,931 2.8 16 56 29 43 40 3 1 8 38 46 Botswana 1,694 2,699 2.6 1.3 3.9 2.1 46 3 31 5 8 29 37~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~169 269 26 1. 39 .1 4 Burkina1Paso 12,047 22,745. 2.9 2.0 6.4 35 4 3" 39 4 6 15 24 Burundi 7,305 14,041 2.9 2.1 6.7 3.8 46 3 38 4 2 5 7 Cameroorn 15,604 28,655 3.0 1.8 5.5 2.9 45 4 37 4 20 40 49 Cape Verde 470, 726 2.2 1.4 3.7 2.1 44 4 27 4 20 29 36 Central African Rep. 3,867 7,330 2.7. 2.2 6.2 4.0. 42 3 39 3 30 47 55 * Chad 7,353 13,622 .2.7 2.0 6.1 3.8 42 4 7 4 12 32 4 Comoros 674 1,366 3.4 2.1 6.1 3.2 48 2 40 3 19 28 .34 Congo. 3,162 6,474 3.2 2.4 6.6 3.8 45 4 39 3 33 41 47 C6te d'Ivoire 16,878 33,140 3.3 2.0 6.2 3.3 48 3 43 3 27 40 47 Djibouti 606' 1,175: 3.2 2.1 6.5 3.6 45 3 40 4 62 81 84 Equatorial Guinea 525 839 2,3 i.5 5.4 29 4. 4 37 4 2 9 3 Ethiopia 67,465 143,568 3.3 2.6 7.4 4.5 46 3 43 9 12 15 Gabon ~~~~~~ ~~1,515 2,986 3.0 2.3 6.4 3.7 36 5 .37 4 2 6 5 Gambia .1,167 2,219 2. . , . 4 3 36 4 15 23 29. Ghana 20,334 36,221 .3.0 1.7 5.5 2.0 47 3 36 4 29 34 39 Guinea . 7,578 ~~~~~~~14,471 2.9 2.1 6.5 4.1 47 . 3 40 3 16 3 Guinea-Bissau"119 1,938 2.1 1.6 6.0 3.7 4 7 4 15 20 25 Kenya . 34,091 72,853. 3.4 2.6 5.9 4.0 49 3 35- 4 10 24 32 Lesotho 2,282- 3,647 *.2.5 .1.3 4.5 2.2 .43 :4 32 6 9 1 9 27 Liberia 3,450. 6,204 2.9 1.8 5.6 2.9 45. - 4 39 4 26 45 55 Madagascar 15,336 25,850 2.6 1.6 5.5 2.9 45 3 39 3 !4 24 31 Malawi 11,555 24,409 3,0 2.7 7.6 5.2 47 3 41 3 6 12 16 Mali .11,430 23,760 3.2 2.5 7,0 4.2 47 3 40 3 14 24 30 Mauritania 2,628 5,415 3.0 2.5 6.8 4.4 45 3 38. 4 14 47 59 Mauritius 1,192 1,450 1.0 0.6 2.0 2.0 30 5 20 13 42 41 42 Mozambique 20,768 43,063 3.0 2.5 6.9 4.5 44 3 39 4 6 27 41 Niger 10,737. 24,286 3t5 2.9 7.5 5.2 48 2 41 3 9 20 27 Nigeria . 127,806 216,900 2.7 1.6 5.0 2.8 47 2 . 38. 4 20 35 43 Rwanda 8,762 16,701 2.7 2.0 6.2 3.8 49 2 42 2 3 6 8 SRo Tomd and Principe 150 239 2.6 1.3 4.4 2.2 39 5 28 7 - 42 - Senegal. 9,809 17,918 2.9 1.8 5.9 3.2 45 3 36 4 33 40 45 Seychelles .. , 74 . 97 1.0 1.0 2.3, 2.1 34 7 23 8 - 59 SierraLeone 5,370 10,076 2.7 2.1 6.5 4.1 43 3 39 3 18 32 40 Somalia 10,648 21,004 3.1 2.2. 6.6 3.8 46 3 40 3 20 24 28 Sudan 33,659 60,335 2.9 1.7 5.8 3.0 - 45 3 37 4 16 23 27 Swaziland 1,137 2,179 3.3 2.0 6.0 - 3.1 45 3 33 5 10 26 36 Tanzania 32,901- 58,850 2.8 1.7 5.8 3.0 47 3 41 3 .7 21 28 Togo 4,980 9,294 3.0 1.9 5.9 3.0 45 3 38 4 13 29 34 Uganda 22,551 48,223 3.2 2.7 7.3 4.9 49 3 40 2 8 11 14 Zaire 50,856 100,287 3.1 2.1 .6.2 3.5 47. .3 41 3 30 28 31 Zambia 10,867 20,739 2.9 2.1 6.7 3.9 48 2 40 2 30 42 45 Zimbabwe 12,360 17,613. 1.8 1.1 3.5 2.2 45 2 32 4 17 29 36 Africa 633,540 1,202,642 2.9 - 2.0 53 3.5 4C 3 38 4 19 28 34 World 6,160,486 8,319,501 1. . 1.0 3.0 2.4 32 9 25 10 37 43 48 Less developed countries 4,887,621 6,946,332 1.7 1.1 3.2 2.5 36 7 26 8 25 34 40 More developed countries 1,272,866 1,373,169 0.4 0.2 1.9 2.0 21 17 18 8L 67 73 76 . . . .~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Table A-3. Population Projections (Rapid Decline in Fertility) Contracreptive use. (percentage of Populatioff Annual rule .~~~~~. married women age Midyear ofpopulation ages 15-49) stmeart e population growh/i Tozalfentiry Esti- Requiredfor(pn) (thousands) ~~(percent) rate mtd rapid decl inc 0714 65+ country 2000. 2025 2000 2025 2000 2025 1990, 2000 2025 2025 2025 Angola ~~~~~~~~12,128: 17,752 2.4 12 5.4 2.4 3 33 69 29 4 Benin 6,240 7,073 2.3 1.2 5.0 2A 6 40 7 1 .29 4 B3otswanaa 1,655 2,.4 10 1.9 1.2 2.9 2.1 35 65 75 26 5 Bui kina Faso 11,850 . 17,164 2.3 1.I. 2.4 .3 38 6 2 Burindi .7,189 10,264 2.2 1.2 5.5 2.4 9 ..40 72 29 4 Camcroon 15,380 22,907 2.5 1.3 4.8 2.2 2 29 72 28 4 Cape Verde 417 652 1.6 1.2 2.8 2.1 - -26 4 Central African Rzep. -3,801' 5,153 1.9 I.[ 4.9 '2A 3 34 9 3 3 Chad 7,228 9,996 2.0 1.1 4.9 2.4 17 43 71 28 5 Comoros 66 ,57 2915 5.3 2.2 --- 284 Congo ...3,088 4,937 2.9 1.4 6.0 2.23 I II 30 74 30 3 COte d'Ivoire . 16,815 27,319 3.0 1.4 5.6 223 30 7 04 Djibouti . 596 875 2.5: 1.2 5.3 2.4 - 28 4 Equatonial Guinea .507 .660,- IA 0.9 3.9 2A --- 28 5 Ethiopia . . 66,450 104,549 2.8' 1.3 6.3 2A 4 34 73 .30 3 Gabon ~~~~~~ ~~1,501 2,328 2.7 13 5.8 23 31 . 40. 76 295 Gambia 1,148 ~~~~~~ ~~~1,598 221.1 5.3 2.5 i0 33 65 2 Ghana . 19,813 29,610 2.5 1.3 4.9 1 23 13 45 73 28 4 Guinea 7,452 10,593 ..2.2 Al.1 5.3' .2.6 0 32 64 30 4 Guinea-Bissau .1,196 .1,571 .1.7 1.0 5.4 2.7 19 36 -68 31 3 Kenya 32,395 47,744 2.3 1.3 4.0 2.2 28 57 80 28 4 Lesotho .2,229 3,174 19 1. ,. 229 48 7266 Liberia 3,420 5,167 2.5 1.3 5023 7 41 72 27 5 Madagascar 126 2,92 .31.2 .49 2.4 .0 37 68 28 4 Malawi . 11,613 17,521 2.5 1.3 6.4 2,6 7 35 74 31 3~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~7,21 ,56. 26 7 Mali 11,241 17,715 2.6 .1.4 5.9 2.4 ..5 35 7 1 29 3 Mauritania 2,568 3,711 2.3 1.3 5.5 2.4 0 35 68 29 4 Mauritius 1,192 1,450 1.0 n.05 .2,0 :2.0 SQ 77 .20 1 3 * ~~~~~Mozambique 20,447 29,453 231,2 5.4 2.4 0 29 67 284 Niger 10,627 16,709 2,8 13.3 6.3 2,5 0 30 70 3!1 3 Nigeria .2780 187,427 2.4 1,2 4.7 2.3 7 38 73 29 4 Rwanda 8,621 12,168 2.0 , 1.1 5.0. 2.5 14 38 78 30 3~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~,611218 . 11 5. .514 83 SAloTom6 and Principe 146 208 2.0 1.2 3.4 2.1 - 25 8 Senegal 9,634 13,802 2.3' 1.2 4.9 2.3 15 46 73 29 3 Seychelles ..74 95 0.9 0.9. 2.2 2.1 --- .22 &8 Sierra Leone -5,277 7,296 2.0 *1.1 5.3 2.5 4 .39 67 29 4 Somalia .10,472 15,488 2.5 1.3 5.4 .2.4 0 35 69 28 4 Sudan 33,368 49,352 2.5 13,3 5.1 2.3 3 36 69 28 4 Swaziland 1,127 1,743 2.9 . 1.4 5.2 2.2 - .-27 5 .. . ~~Tanzania 32,639 47,951 2.4 1.3 5.1 2.4 3 .34 70 29 3 Togo 4,939 744 2.6 1 5. 22 34781 28 4 Uganda 22,162 33,549 2.6 1 .13 6.1 2,5? 5~ 35 73 32 2 Zaire 50,426 ~~~~~~~~~80,287 28 . 1.3 . 5.6 .2.3 14 34 73 303 . . ~~~~~Zambia 10,688 14,991 2.2 1.2 5,4 2,5 3 29 72 31 2 Zimbabwe .12,192 .16,410 1.5 [.0 3.0 2.2 46 .71 80 28 4 Africa .626,000 .930 251,3 ~ .3 11 45 75 294 World 6,150,000 7,850,000. 1,3 0.7 2.7 . 1.9 .54 65 74 22 11 Lesdeveloped countries 4,880,000 - 6,560,000 1.6 0.8. 3.0 2,0 5 1 64 75 23 9 Moredevelopedeountries * 1,270,000 1,2V0,000 0.3 -0.1 1.7 1.5 71. 7! 66 15 20~~~~~~~~~~~~~~~~~~~~~~~~ 27 00'' 129 00 -0. -01 .7 .571 Table A-4. Mortality Adul nwrnliy ate Median Under-five ~~(ages 15-59) aea Infanjt neortaity rate mionality rate . ae Femlale death Cou~ntry 1970. 1992, % Rednctlon 1975 1990 % Redaict ton 1990 1990 1990. Angola 180 125 3!1 .281 214 24 434 381 3 Benin 155 1W 2 228: 170 2538366 Botswana .101 35. .65 III 48 57 . - Burkina Faso 178 132 26 254 159. 37' 429 352 4 Burundi 138 106 23 209 180 14 .424 . 367 1 1 Cameroon 126 61 52 194 125 36 316 256 16 CupeVerdo 87 .~~ ~ ~~ ~~40 54133 526- - Centra African Rep. 139 105 24 29 132. 37 346 . 288 15 Chad 71 122 29 271 212 22 445 387 Comoros 141 87 38 175 1324--- C4ongo e 126 114 . 10.. 208 17.5 16 Djibouti *160 III 3 1 -194- - Equatorial Guinea 165 116 30 .259 203 22--- Ethiopia . 158 128 19 262 197 25. 404 329 4 Gabon 140 ~.92 34 224 -159 .29--- Gambia 186 13 9296~ 231 2 Ghana . . ~~~~ ~~III 81 27 169* 10l.344 282 7 Kenya 10 63 3 340 315 259 1 Le-sotho 134 79 4 1 172 135 22 .-- Libe.a 178 .131 26 244 185 24- Madagascar 181 93 49 200 170 .15 389 333 I I Malawi 193 142 26 313 '201 36 46369 4 Mali .204 159 22 321 200 38 417 361 4 Mauritania 165 117 29 2581 205 21 Mauritius 60 18. 70 65 25 62 Mozambique . 171 147 14 280 280 0 490 421 2 Niger 170 123 28 320 320. 0 513 454 3 Nigeria . 139 84 40 198 191 4 406 354 7 Rwanda 142 110 23 223 222 0 453 395 3 SAo Tomd and Principe - 65 - 55 - - - Senegal 138 80 42 265 156 41 397 340 15 Seychelles : 16 - - 21 - - -- Sierra Leone . 197 143 27 375 360 4 503 436 2 Somalia . 159 132 17. 262 214 18 443 390 4 - - . Sudan 149 99 34 152 104 32 267 234 13. Swaziland 140 108 23 188. 148 21 422 354 11 . Tanzania .- . 132 115 .3 202 165 18 379 335 5 Togo 134 85 37 193 i3 26. 325 268. 7 Uganda 109 118 -8 173 185 -7 424 367 4 :.. :: :;Zaire 125 91 27 223 190 15 387 319 6 Zambia 106 107 -I 167 190 -14 - - - Zimbabwe . . 96. 47 51 120 58 52 269 216 26 Africa 145 104 28 212 175 17 381 322 5 World 97 63 35 135 96- 29 234 169 55 Less developed countries 111- * 70 37 152. 106 30 250 199 39 Moredevelopedcountries 24 14 .42 25 15 -. 40 188 86 74 Nore. Rates are per 1,00O population. ¶hble A-5. Income and Poverty Population dependency Population OMp capIlta (UJf$) ratio belowv Average annual Averae annuiial Percentt shiare of (percentage absoalute poverty gwwevh rats of . rate of . Intonie (1981-91)' of . level, 1985 cocr(percent) (nlto pret ae. Laws ih st orking age) (percent) Country 1970-SO 1980-91 1970-SO. 1980-91 1991 1980-91 20% 20%l 1970 1990 Urban Ruiral Angola - --.-- - - - 84 100 - - Blenin 2.2 2.4' 10,3 1.6 . 380 -0.9 -92 98 -65 Botswana 14.5 .9.8 11,6 13.2 2,530 5,6 1,4 66.4 11.8 99 40 55 Burkina Paso 4.4 4.0 8.6 3.8 290 1,2 - -86 89 -- Burundi 4.2 4.0 10.7 4.3 210. 1.3 --92 95 55 85 Cameroon 7.2 1.4 9.8, 4.5 850 -1.0 --84 93 1 5 40 Cape Verde .-2.3 9.4 9.4 750 2.3 -III 93 - - Central African Rep, 2.4 1IA 12.1. 5,1 390 -1.4 - . -79 93 -91 Chad 041 5,5 . 7.7 II! 210 3.8 --82 88 30 56 COoros - 10 - -5 01.0 - 96 103 - - Congo 5.8 3,3 8.4 0A 1,120 -0.2 -, 88 95 - C8te d'lvoire 6.6 -05 13.0 3.8 69 46 .7,3 42.2 .93 104 30 2 Djibouti- -- -- -- - 8 1 92 - - Equaoria Guiea -28- -0.9 330 2.8 --78 87 - - Ethiopia 1.9 1.6 4.3 2.4 120 -1.6 .8.6 41.3: 89 95 7 60 .65 Gabon 9.0 0.2 ' IS1,5 3,780 -4,2 --62 6 OGambia .- -0.1 10.6 18.2 360 -0,, I - -I 89 - Ghana -0, 1 3.2 52 400 .400 -0.3 70 4. 3 9 9 3 Guinea'~ 460 - -9 1 97 - - Guinca-Bissau ' 2.4 3.7 5,7 56.2; 180 1.1 --69 82 - - Kenya . . 6.4. 4.2 10l1 9.2 340. 0.3.. 2.7 60.9 109 109 tO0 55 Lesotho: 8.6 5.5 ..9.7 .13.6. 580 -0.5 4,5 61.3 82 84 50 55 Table A-6. Educ~i1ton Adfult literacy rate Percerntage of age grousp entrolled prenof ages 15+)' Primary PeodayJrinmarypupill Total Femiale Total Fempale Thtal Female, reacher ruito Country 1980 1990 1980 1990 1970 1990 1970 1990 1970 .1990 1970 1990. 1970 1990 Angola - 42- 28 - -- - - - Bentn .28 23.~17 16.36.61 22 44 5'11 3 6 41 35 Botswana .74: 65 65 11O 67 :112 7 46 6 47 36 32 Burkina Faso - 18 -9 1 3 . 36 t0 28 I.7 1 5 44 57~ B urud 27 50 15 40 30 72 20. 64 2 5 1 4 37 6 Cameroon - 54 - 3 89 10 7 3 7 26 4 21 48 5I Cape Verde- - - - - - - -- -- - Central African Rep, 33 38 19 25. 64 67 4 1 5 1 -4 I I 2 6 64 90 Chad - 30 - 1 35 57 1 7 35 2 7 0 3 65 67 Comoros .. - 48 - 40 - - - - - - - - - - Congo 3557 24 44 62 66 M8e d'lvoire '20 54 - 40 58 -. 45 - 9 -4 -45, 36 Djibouti- - - - - - - - - - - - - - Equatorial Guinea 37 50 - 37 .- Ethiopia - - -16 38 1O 30 -4 IS 2 12 48 36 Gabon .- 61 - 48 - -- - - - - - - Gambia 20 27 12 16 - - - - - - - - - Ghana 30 60 - 51 64 75 .54 67 114 39 8 31 30 29 Guinea - 24 - .13. 33 37 .2 1 24.13 1O 5 5 44 .40 Guinea-Bissau 19 36 1 3 24 39 59 23 42 8' 7 6 4 45 Kenya 47 ~~~ ~~~ ~~69 35 58 58 94 48 92 9 23 5 1 34 31 Lesotho . . . ~~~ ~~73 - 4 87 107 11 15. 7 26, 7 31 46 55 Libenia ~39 - 29 - - - - ----- Madagascar 80 - ~ 73 90 92 82 90. 12 19 9 18 65 40 Malawi - 42 - 31 - 71 - 64 - 4 - 3 43 64 Mali - 32- 24 22 24 15 17 5 6 2 4 40 42 Mauritania~ .34 - 21 14- 51 8 42 2 16 0 10 24 49 Mauritius 79 82 72 75 94 106 93 104 30 52 25 53 32 21 Mozambique 33 33 23 21 47 58 - 48 5 7 .-5 69 58 Niger 10 *28 .6 17 14 29 10 21. 1 7 I 4 39 42 Nigeria 34 ~~~~51 23 39 37 72 27 63 4 20 3 17 34 4 Rwanida 50 50 39 37 68 69 60 68 2 7 1 6 60 57 SaloTomd andrPrincipe - 58 - 42 - - - - - -.- - - - Senegal . , .38 .- 25 4 1 .58 32 49: 10 16 6 I 1 45 58 Seychelles -88 -95 -- - - - - - - - - Sierra Leone. I 1 - 1 I 34 48 27 38 165 1 2 32 34 Somalia *6 .24 3 14 - Sudan - 27 - 12 38. 49 29 - 7 20 4 - 47 34 Swaziland - - 65 - - - - - - - - - - Tanzania . - - - - 34 63 27 63 3 4 2 4 47 35 Togo -~~~~~~~~43 - 31 71 103 44 80 7.2 0 8 5 Uganda 52 48 40 35 38 76 30 -4 132 -34 35 Zaire 54 72 37 .61 - - - Zambia . . - 73 - 65. 90 9.3 80 91 13 20 8 14 47 44 Zimbabwe . 69. 67 61 60 74 117 66 116 7 50. 6 46 36 Arrica - 50 - 38 46 68.36 61' 6 17 4 16 43.41 World - 65 - 55 83 104 71 99 31 65 28 46 33 33 Less developed countries - 63 - 52 79 104 64 98 24 6 1 1 8 39 35 35 More developed countries. 96 - 95 106.104 106 104; 74 93 73 96 26 17 Thhle A-7. The Health and Status of Women No. of Maternal. -Prenatal Births Pregniant of aniemiia IArcnane wvomien of miortality heatlth attendced wonien fIn pregnanit pftan rlstoatema chilld- (per care by trainied Imnwizoifed wvomien p4nrlmetrites convenition bearing 100,00 coeae health fo r. enreng age, 15-49 live rae personinel tetanuts beolow (enl/G Mls hdc' Wmn (Wiousandsl birtdisj (percent) (percenit) (percent) norin)1 Primairy Secondary rig Ins rIgIhts"d Coutmry 1990. 1988 J98S-9O'P 1985-90", 1989-91k1 1970-8Ss 1990 1990 Year Year Angola -2,087 1 7 16 36 30 - 1991 1986 Benin 1,068 800 64 45 83 55 -35 - Botswana 299 250 74 79 62 -105' 110- Burkina Faso 2,065 80 933 26 25 60 50 1990 1987 Burundi 1,252 800 30 16. 56 70 85 . 55 1990 Camneroon. 2,480 450 56 25 35 ID 85 65-- Cape Verde 94 110 99 49 90---- Central African Rep. 71 600 68 -50 65 65 35 . Chad 1,323 1,000 22 2 1 42 40 45 201990 Comoros 104- 500 69 24 53- --- Congo .506 900 -45 60 - 85 70 -1982 Cote d'lvoire 2,527 1,000, 50 6 35 357 51991 Djibouti .95 750 :75 80 1 0 -.* 1991 Equatorial Guinea 84 450 IS 84 -- -1984 Ethiopia' 10,174 500 14 9 6 tO 65 65 - 1981 GJabon. 269 200 77 - 86 - . 1990 1983 Gambia 200 1,500 72 65 77 ---1990 Ghana 3,287 1,000 6 5 42 33 - 65 80:.6 90 18 Guinea:. 1,315 1,000 36 25 25 -45' 30 1990 1982 Guinea-Bissau 233 700 29 39 44 .-55 50 1990 1985 Kenya~ . 4,980 200 90 -37 60 95 75 -1984 Lesotho 410 370. 50 40 -120 150 1990 Liberia 553 -85 50 20 - -1990 1984 Madagascar 2,542 400 76 71 17 - 97 99 1991 1989 * Malawi 1,946 420 76 . 41 76 S0 80 55 1991 1987 Mali 1,959 -2,300 I1 14 9 - 65 55 45 1990 1985 Mauritania 455 1,100 39 20 40 - 70 45 . - Mauritius. 306 100 90 90 77 - 98 100 1990 1984 Mozambique 3,653 300 54 29 30 60 75 60 1990 Niger 1,704 700 33 21 .44 50 55 40 1990 Nigeria 25,726 800 78 45 58 45 75 75 1991 1985 Rwanda 1,515 400 85 22 88 - 99 55 - 1981 Sio Tomd and Principe 27 -. 76 .63 48. , Senegal 1,645 950 21 40 33 55 70 50 1990 1985 Seychelles 17 -. 99 99 98 - - - 1990 Sierra Leone 945 - 30 25 77 45 70 55 1990 1988 Somalia 1,393 1,100 2 2 5 75 Sudan 5,562 660 40 - 10 35 75 80 1990 - Swaziland 172 130 . 76 67 63 - Tanizania 5,844. 340 90 . 60 40 s 80 99 75 1991 Togo .,. 823 720 83 56 81 45 .65 35 1990 1983 Uganda 3,789 550 85 25 31 - - - 1990 3985 Zaire 8,092 800 85 - 29 45 - 1990 1986 Zambia 1,800 150 . 80 . 43 68 35 90 60 1990 1985 Zimbabwe . 2,282 80 83 65 60 . - 99 88 -1990 - Africa -108,318 700 60 34 30 40 76 67 - - World . 1,312,949 . 400 67 55 33 42 84 76 Less developed countries 1,008,656 450 . 65 42 43 . 50 8I . 73 ' More developed --. . countries 305,605 17 99 99 0 4 95 100 a. Latest available data ror the specified period. b. Ench value refers to one parilcular but not specified year within tie time period denoted. c. Convention on the Rights orthe:. Child. d. InlematIonal Convention on the Ellmination or Discrimination agaitnst Womcn. ",Table AS8. Food and Nutrition Percentl Babies;Fo upy Percentage of ~childrel wivth lowv Food sopply: proteint per childirent ijectedi by fiully birth Index of calories capita per S111hinig;- WVdstigii breasifetl wieight food produtctolon per capita per capita dlay (24-59 ,,ios.) (12-23 titos.) (-3inios.) (percenrt) (1987=100) per dlay (gratins) Cowiiliy 1980-960 1980-~9LP 1985-904 1985-9t?. 1975 1980 1985 1991 .1980 .1989 1980 /990 Angola - -I 5 2,100l,725 - Benin *.-14 -10 92 102 110 120 2,145 2,383 5.1 56 Botswana 37 .6 39 8 196 ~139 129 104 2,155 2,260 7 1 69 B'jrkinaFago 28 11 - ~~~ ~~~ ~~~~~~~~1 2 9 79 96 107 1,815 2,219 58 68 Blurundi' 48 6 86 18 102 95 86 85 2,059 1,948 69 56 Camneroon 43 2 ..70 13 127 109 106 87 -2,340 2,208 59 55 Cape Verde 26 3 - - 60 88 54 62 2,587 2,778 68 5 Central African Rep, 1 8 120 110: 93 99 2,136 1,846 43 46 Chad ~~~13 It1 104 1I12 96 104 1,762 1,852 - Comoros ~ ~ -13 133 119 99 92 1,783 1,760 38 38 'Congo 27 5 -12 11O 97 99 7 2,235 2,295 41 47 Me cd'Ivoire 20 1 7 - iS 99 101 100 94 2,844 2,568, 60 54 Djiboutii 9 - - - -- -r - - Equatorial Guinea ---10 - . Ethiopia 43 1 9 -1 3 112 114 100 100 1,777 1,658 - - Gabon 18 I - 0 116 1 7 99 .96 *2,243 2,396 Gambia 24 7 I 10 171 80 82 73 2,101 2,290 50 57 Ghana 30 8 8 1 5 132 100 98 96 1,973 2,144 44 46 Guinea - - - Ii ~~~~~~~~~~~~~~~~~~~~104 110 101 102 2,268 2,242 I 5 Guinea-Bissau 22 .5 12 111i 91 .99 100 1,797 2,690 - - Kenya 32 5 48 :18 103 .99 97 105 2,148 2,064 57 56 Lesotho 32. 10 123 115 103 89 2,354 2,121 69 60 Liberia 37 3 14 - 106 102 100 64 2A400 2,259 47 41 Madagascar 56 17 - 10 118 :112 105 91 2,472 2,156 60 52 Malawi 61 8 - I 118 119 101 93 2,273 2,049 66 59 Mali 24 11 82 10 107 109 100 109 1,898 2,259 57 64 Mauritania 34 17 - 10 102 118 104 99 2,081 2,447 71 74 Mauritius 22 16 - 8 8t 79 92. 88 2,701 2,897 62 70 Mozambique . - - i 153 131 106 89 1,951 1,805 33 31 . . D Niger .. 38. 23 - 20 25 168 101 125 2,224 2,239 64 62 Nigeria 43 9 61 17 123 103 104 120 2,129 2,200 46 45 Rwanda 37 5 - 16 109 112 118 98 2,064 1,913 52 48 SaoTomd and Principe 26 5 7 173 135 113 94 2,060 2,153 45 43 Senegal 25 6 77 10 155 65 83 76 2,415 2,322 69 67 Seychelles 5 2 - - -. 2,282 2,356 65 61 SierraLeone 43 14 - 13 117 104 97 83 2,096 1,899 45 39 Somalia 30 40 - - 119* 110 102 52 1,942 1,874 64 61 Sudan 32 13 84 15 134 132 117 100 2,215 2,043 63 59 - Swaziland 30 1 - 7 88 99 97 90 2,462 2,634 64 63 Tanzania 46 5 - 13 110 105 107..: 8 2,239 2,195 54 55 - TTogop 29 6 60 20 125 117 105 102 2,266 2,269 49 53 Uganda 45 2 76f 10 151 105 103, 105 2,114 2,178 50 51 Zaire . 27 '3 64 13 109 03 102 96 2,133 2,130 35 34 Zarnbia 59 . 10 72 14 150 110 103 90 2,186 2,016 59 54 . Zimbabwe.. . 31 2 56 6 147 116 141 103 2,180 2,256 56 54 Africa 39 10s 6j3 14 120 108 101 94 2,123 2,100 54 53 World 42 12 - 17 - - - - 2,579 2,697 68 71 Less developed cbuontres 46 13 47 19 . - - - 2,324 2,473 56 .61 Morc developed - ; countries 4 3 . 7 . 3,287 3,404 99 104 a. Latest available data for the specified period. Table A-9 Access to Water, Sanitation, and Health Care Services (percent) A4ccess so safe ira fer Access to aiantrdlonfaclliiies *. Accests to heatth care sen-ices (1985-1990p, . 198-990pa (1988-4990y'4 * Contilry Total Ubn Rujral rthai Urban Rutral rohai Urban Rural * Angola 38 75 19 22 25 .20 24-- Benin 50 79 .35 41 60 31 32 - Botswana 56 98 46 38 98 20 88 90 85 Burkina Faso 67 72 . 44 10 35 6 49 SI48 Burundi .38 92 34 57 80.. 15 45- Cameroon 34 47 27 -.25 16 41 4439 Cape Verde .74 87. 65 16 35 9. 81-- Central African Rep. 12 14 I1I 20 36 I I 65 78 17 * Chad . 29. 30. 27 14 --26 - comoros 70 75 .52 83 90 80 82-- Cogo 20 42 .4--83 97 70 Cflted'lvoire 83 95 75 36 69 20 60. 92 45 Djibouti 43 50 21 78 94 20: 47 95 40 Equatorial Guinea -47 --28-- .- Ethiopia 18 70 11 17 97 7 55- Gabon 72 ~ 90 50 50 - -87- Gambia 77 92 .73 77 --30 50 30 * Ghana 56 93 7 39 3063 .15 7 Guinea 33 56 25 24. 65 9 32- Guinea-Bissau 25 27 Is 21 30 1 8 80-- * Keny 38 80 25 46 75 39 58 80 5 Lesotho .46 59 44 22 23 14 80 90 30 Liberia 50. 93 22 15 24 8 34 50 30 Madagascar 31 81 17 - 12 . - 41 90 30 Malawi. 51 - 66 49 . 59 .- . 80 90 69 Mali *23 48 17 23 - 5 27 .60 25 Mauritania . 66 67 65 - 34 40 - Mauritius 99 100 98 98 100 96 99 99 99 Mozambique 22 44 17 19 61 II 27 50. 15 Niger 59 61 52 9 39 3 30 75 17 Nigena 32 60 20 13 30 5 67 87 62 Rwanda 64 66 62 61 62 45 27 60 25 SaoTomdandPrincipe 33. - 10 13 8 88 - - Senegal 53 79 38 32 87 2 40- - Seychelles- . . 98 100 97 65 96 19 89 99 85 Sierra Leone 43 83 22 43 59 35 30 61 11 Somalia; . 29 50 22 12 .41 5 28 50 -15 Sudan 34 90 20 12 40 5 51 90 40 Swaziland. .30 - ; 7- 36 62 . 25 . 55 - : Tanzania 52 .75 46 76 77 75 80 94 73 Togo 70 - -60 23 42 16 30 60 20 Uganda 15 45 12 13 40 10 41 44 39 Zaire 34 59 17 14 15 13 Zambia 59 76 43 55 77 34 75 - - - Zimbabwe 36 99 14 42 99 22 83 90 sO Africa 37 68 26 26 51 16 54 71 45 World 81 93 72 66 89 54 91 Less developed countries 75 88 68 56 72 48 89 - - Moredeveloped countries 100 100 100 1O 100 100 100 a. Latest available fot the specified period. Table A-O Immunization Immunization (per- 100 children under ne aod 1980 1991 Country BCG DPT3 POL3 Measles BCG DPT3 PO13 mewritz Angola 47 9 7- 17 54 27 *26 40 Benin 37 20 45 6 .81 . 68 68 60 B~otswana 76 70 71 68 92 86 82 78 Burkina Faso :16 2 2 23 60 38 .38 36 Burundi 65 38 6 30 88 83 89 75 Cameroon 8 5 5 16 48 34 34 .35 Cape Verde 64 31. 39 54 99 87 88 76 Central African Rep. 22: 13 13 14 79 46 45 46 Chad , - . - - - ~~~~ ~~~~~~~~~~~~~~~59: 220 32 Comoros 56 31 . 32, 30 99 94 94 87 Congo 92 42 42 4.3 88 74 74 64 C8ted'Ivoire -42 3428 47 37 37 471 Djibouti 5 6. 6 15 95 .85 .85 85 Equatorial Guinea 28 3 4-. 11I 97 . 80 80 79 Ethiopia . .6335.74444 37 Gabon 50 14 44 58 96 ~78 78 76 Gambia 92 80 53 71 97 85: 89 87 Ghania 9 .7 7 15 55 .39 . 39 39 Guinea .5 2 1 9 473 533 Guinea-Bissau 38 1511 35 94. 63 63 52 Kenya - - - 50 41453 Lesotho :81 .56 .54 .49 76. 75 .74 76 Liberia 41 17 26 40' 62 28 28 55 * ~~~~~Madagascar 23 34 8 IS5 67 50 49 40 Malawi .86 58 28 49. 96 81 78 78 Mali 19 IS8 0 tO 68 34 34 39 Mauritania 57 18 IS. 45 60 26 26 29 Mauritius as 87 87 34 87 91 91 88 Mozambique ..46 56 32 32 63 42 *42 50 Niger 28 . 6 .6 19 26 17 17 23 * . . ~~~Nigeria 23 24 24 55 57 44 44 46 * ~~~~~Rwanda .51. 1 7 15 42 94 85. 85 SI Slo Tomd and Principe 95 42 48 25 96 78 77. 68 Senegal ~ ~ ~ ~~~~~.22 33422 69 .51 5 1 46 Seychelles 67 1I3 1 6 29 98 82 82 . 89 Sierra Leone 34 1 3 tO0 29 7 1 36 57 54 Somalia 5 5 5 5~ . 31 18 lB 30 *Sudan . 3 I I . I 73 62 62 57 Swaziland 59 .30 22 .30 7 1 86 87 80 * . . . ~~Tanzania 69 55 50 49 89 79 74 75. Tgo -44 9 9 47 79 61 6 1 5 1 Uganda lB 9 .8 2299 76 .76 73 Zaire 34 18 IS 24 65 32 31 31 Zambia .71 44. 50' 21. 96 65 70 69 Zimbabwe 64 39 38 5 87-8 81 8 Africa ~~~~29 22 .19 33 61 45 45 45 World .- 20 - . 55 82 84 80 * . . Le~~~ss developed countries .----89. 82 .84 79 Mrc de-veloped countries - 283 85 8 Table A-li Healthi Care Personnel Assistant ure Para- Tha,.Thi,. Popidtadon per Popuilation per doctors Doctorsh ntedles Nursesh ,ztlaians Nurses nitclansi doctor nuirse ratio Coutntry 1985-90' 1980-28' 1985-9& 1P98048'0 /980-88'1 98-88' 1970 1985-90" 1970Q 1985-91? 1985-90m Angola 480 -1,200 -- 8,500 15,000 4,500 6,000 3 Benin .280 -. 1,700 so 1,000 30 29,000 13,000 4,000 24500 6 Botswana 240 1 0 .2,500 700 900 1,709 15,000 4,000o 500 1 0 BurkinaPaso 130 160 1,800 30 1,600 280 96,000 . 50,000 15,000 4,000 14~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~30160 80 9600 0 1,00 4,0 Burundi 280 130 1,200 50450 90 59,000 15,000 14,000 4,000 4 Cameroon 940 2,000 6,000 300 5,000 300 30,000 1 1,000 4,000 2,000 6 Cape Verde 100 500' 250 20 150 30 12,000 4,000 4,000 1,500 .3 Central African Rep. ItO ~~150 500 7050 100 44,000 25,000 2,500 5,000 5 Chad 135 30 150 :200 1,000 30 62,000 35,000 - 30,000 Comoros 70 2 300 50 550 - 15,000 6,000 9,000 1,500 4 Congo Soo 30 2,000. 250 3,0 0 000 400 1,500 1.0004 ...Cated'[volre. 700 3,300 1 6,000 15,000 3,000 3,000. 5 Ethiopia ~~~~~1,500 220 350 50 700 - 92,000 29,000 2 1,000 12,000 2 Gabon 420 80; 1,500 - - 500 3,000 Soo0 4 Gambia 60 - 700 00700 - 25,000 J3,000 2,000 1,500 12 Gha-na 800 350 5,800. 1,200 10,000 - 13,000 :15,000 1,000 2,000 7 Guinea 130. - 55 8 ,0..400 51I,000 40,000 - 10,000 4 GunaIissau 12 030 150 1,0 0 8,0 ,0 :5,000 2,0003 Kenya ~~~~~~ ~~ ~~~~~~~~~~~~~3,100 -10,000 300 13,000 500 8,000 6,000 2,0 2503 Lesotho .10 -550 50 500 - 30,000 1,0 ,0 ,0 Liberia ~~~~ ~~220 .150 1,0 3000 10,000 2,000 2,000 5 * Madagascar 1,400 1,700 ~~~~~5,000 450 800 550 10,000 8,000 9,000 2,000 4 Malawi 260 350 550 250 1,600 650 77,000 27,000 5,000 14002 Mali 440 90 1,100 .500 .3,700 300 45,000 18,000 6,500 7,000 3 Mauritania' 200 400 900 60 1,200 750 18,000 900 600 2005 Mauritius 900 -. 3,300 530 500 80 4,500 1,200 520 -320 4 Mozambique 280 100 3,700 20350. 80 1,05000 ,000 4,000 13 Niger . .220 40 2,500 280 .9,500 200 -60,000 35,000 1 1,000 3,000 1 1 Nigeria . 16,000 - 97,000 4,200 16,000 1,200 21,000 6,000 2,000 1,000 6 Rwanda 160 350 300 680 1,500 420 60,000 35,000 10,000 20,000 2 'SHo Tom6 and: Princlp 60. 1 300 .70 200 30 4,500 2,000. 4,000 400 5 Senegal 410 250 1,100 400 7,000 - 16,000 16,000 1,500. 7,000 3 Sey:chelles .30 -350 -- - 4,500 2,500 170 200 12 Sierra Leone 260 150 1,300 160 250 18,000 13,000 3,500 3,000 5 Somalia 480 70 3,500 130 500 36,000 15,000 2,000 2007 Sudan 2,100 2,700 5,600 1,300 18,000 - 14,000 o10,00 4,500 4,500 3 Swaziland 80 -1,300 -100 - 8,00 .9,000. 500 600 16 Tanzania 770 950 5,700 200 1,0 A- 23,000 29,000 3,000 4,000 7 Togo 260 . 150 1,700 730. 1,300 200 29,000 10,000 2,500 2,000 7 Uganda 600 600 6,800 1,000 - 50 9,001,0 3,0 ,0 1 Zair .250 10 510 110 13,000 200 28,000 14,000 4,600 7,000 2 Zambia 880 1,300 4,300 450 4,000 550 14,000 7,000 -4,300 2,000 5 Zimbabwe .1,400 3,500 8,600 900 10,000. 250 6,500 6,000 .750 1,000 6 Africa 40,000 - 205,000 18,000 148,000 - 19,000 9,000 3,000 2,000 5 World 6,200,000 - 9200,000 -- -- 900 - 570 1.5 * Lecss developed countries *2,800,000 - 2,300,000 -- -- 1,500 - 1,700 0.8 More developed *. countries * 3,400,000 - 6,900,000 -- -- 350 - 180 2.0 a. Latest available data for the specirled period. b. Dociors arc medical doct~ors only. Nur'se amre rgistered nurses and registered midwives only, Table A.12. Health Care Facilities. NVumbter ozf hiealthi care facIifidesPouan Hospitals Heatlthcenters and othiers Numnber of beds .per bed Ceiurtr4l Disirictl Hfealith-Hpia Hospital Country Regionial Rurtal Total censters Othiers Totat only Tolald only TotaPh Angola 53 - . -226: 1,231 1,457 --- 850 Benin 12 9 21 364 392 756. Botswana .38 7 .45 37 299 336 - 2,200 - 500 Burkina Faso 2. 5 7 59 8,005. 8,064 2,700 5,600 3,000 1,400 Burundi 34 2 1 55 218 114 332 3,100 5,800 1,600 g00 Camieroon ---528 1,006. 1,534 - 29,000 - 400 Cap Verde:2 4 4 37 41 Central Afrcan Rep 152 15 7 13 1,600 4,000 1,800 700 Chad 9 22 .31 26 363 389 - .4,000 - 1,363 Comoros 5 - 7 72. 79---- Congo 45 -. -92 515 607 5,700 7,300 350 300 c6te d'[volre 20 7 71 9 1 - 690 690. 7,000 9,700 1,500 1,100 Djibouti - Equatorial Gulnea Li1 37 52 - Ethiopia ..86. . 42 128 140 1,820 11,960 - 3,500 * . ~~~Gabon 27 --33 423 456 3,100 5,300 350 200 - . ~Gambia* 2 4 6 1 9 67 86---- Ghana ~~ ~~~~ ~~~~~~9 124 133 '180 ----- 70 Guinea 29 --62 51 63 120- 4,500 1,700 Gia-Bissau .710 17 26 .181 307 ---- Kenya ---282 1,535 1,817 3100 3,0 0 650 Lesotho 20 ---- 135 2,250 - 700 Liberia 115 326 275. 301 - Madagascar 7 72 79 99 581 620 I1100 Madlawi 51 44 .610. 654 7,550 12,600 950 600 Mali 10 4 14 333 2,144 2,477 2,500 5,000 3,000 1,500 Mauritania IS 13 28 143 57 200 1,350 .- 1,400 - Mauitius 17 4 21 24 129 153 2,750 2,950 400 350 Mozambique 10 26. 36 223 948 1,171 : 6,300 13,000 2,000 1,000 Niger 9 1 10 43 597 640 - 3,200 - 24250 Nigeria . - 705 6,604 7,309 61,000 91,000 1,700 1,200 Rwanda 30 22 52 170 74 244 10,300 - 650 - Sflo Tomd and Prlncipe I . - 25 19 44 Senegal - 10 - 47. 1,117 1,164 3,450 5,500 2,0 1,250 Seychelles - SierraLeone, 51 37 88 57 163 220 3,200 3,900 1,100 950 Somalia - - I 1,250 Sudan* - -- --110 Swaziland 9 - - 8 113 121 - - - Tanzania 26 104 130 300 10,453 10,753 _ _ - 900 Togo 23 - - 317 402 719 5,300 650 - Uganda 75 _ . _ 404 _ . - 1,250 Zaire - 153 1,095 3,983. 5,078 60,000 - 500 - Zambia. . 12 .66 78 555 - . Zimbabwe 26 155 181 - 999 4,600 - 1,900 500 Africa - - - - - - - - - - I,IW . 901 World - - 280 Less developed countries - - - - - - - 500 Mare developed countries = - - - 110 a. Total beds Include beds In hospitals, health centers, matemides, dispensaries. b. Total includes health centers and others (matemitles, dispensaries, clinics, health posts). Data are ror most recent years. Table A-13. Health Expenditures Aldflow as HealtAh expendilsrcs (I990) percentage -Per Health espenditure as a heaaldi (:rillioais of U.S. dollars) etapitar perceitage of ezr(199O) .expenditure Coituitry Pt bile Aid Flows Private Total (U.S. tollars) Puilic Aid Flows Pr;vwte Tanal 1990 Angola _ - Benin 20.8. 29,6 30.4 80.8 17 1.1 1.6 1,7 4,4 37 Botswana 120.0 32,0 42.0 194.0 155 3.8 10 1.3 6.2 17 BurkinaPaso 21.3 158.0 43.6 222.9 25 0.8 : 6.1 1.7 8.6 71 Burundi 15.3 3.4 6.2 24.9 5 1.4 0,3 0.6 2,3 13 Cameroon :75.5 34.1 199,2 308.8 26 0.7 0.3 1,8 2.8 1 1 Cape Verde 3.6 9.3 5.1 18.0 48 1.3 3.4 1.9 6.6 52 CentralAfricanRep. 14.5 19.7 21.4 55.6 1 8 1.1 . 1.5 1.6 4.2 35 Chad : 20.9 36.0 18.9 75.8 13 1.7 3.0 1.6 6.2 47 Comoros 6.1 3,2 3,8 13.1 26 2.5 1.3 , 1.6 5.4 24 Congo 53.4 . 13,7 43.5 110.6 49 1.9 0.5 1.5 3.9 12 SCBzed'[voire 161.9 Q 11.3 161.0 334.) : 28 1.6 0.1 : 1.6 3.4 3 0 : Djibouti: 19.1 45 _ _ _ - EquatorialCulnea : 4,2 4.9 2.2 - 1.3 27 . 2.8 3.3 1.4 7.5 43 Ethiopia 94.6 43,1 97.8 235.5 5 1.6 0 0.7 1,6 3.9 18 Gabon 108.9 13.3 73.1 195.3 172 2,2 0.3 1.5 3,9 7 Gambia 7.2 13.0 4.9 25.1 29 2.1 3.8 1.5 7.4 52 Ghana 71.5 26.9 105.6 204.0 14 1.2 0.5 1.8 3.5 13 Guinea 41.3 21.5 . 40.8 103,6 I 8 1.5 0.8 1.5 3.8 21 Gulnea-Bissau - 5.0. 7.9 2,7 15.6 16 2.6 4.1 1.4 8.0 51 Kenya 16150.1 83.1 142.1 375.2 1 1.7 1.0 1.6. 4.3 22 Lesotlho . 18.5 . 17.0 12.8 48.4 27 3.2 2.9 2.2 8.3 35 Liberia 1.8 6.2 19 10.0 4 1.6 5.6 1.8 9.0 62 Madagascar 22.8 16,9 39,0 78.7 7 0.7 0.6 1.3 2.6 21 Malawi 32.4 21.5 38.6 92.5 11 - - 1.2 2.1 5.0 23 Mali 32.5 37.0 60.8 130.3 15 1.3 1.5 2A 5.2 28 Maurilania 11.4 12.0 16,7 40.1 20 1.1 1.1 1.6 3.8 30 Maurlilus Mozambique 17.7 45.1 24.0 86.8 6 1.2 3.1 1.7 6.0 52 Niger 43.5 43.0 38,2 124.6 16 1.7 17 1.5 4.9 34 Nigeria 330.9 55.2 573.7 959.8 10 1.0 0.2 1.7 2.9 6 Rwanda 11.0 29.2 38.2 78.4 -1 0.5 1.4 1.8 3.7 37 SloTomdand Prncipe 1,4 2,5 0.9 4.8 41 2.7 5.0 1.7 9.4 53 Senegal 96,4 36.2 87.6 220.1 30 1,7 0.6. 1.5 3.8 16 SeYchelles - - - - - , Sierra Leone 4.3 .10.8 6.8 21.9 5 0.5 1.2 0.8 2.4 50 Somalia - _- - - Sudan 32.9 13.6 253.3 299.8 12 0.4 0.2 2.8 3.3 5 Swaziland 24.7 19.4 1 1.8 5S.9 70 3.2 2.5 1.5 7.1 35 TanZan;na 15.7 59.0 41.6 1 16.3 - 5 0.7 2.6 -1.8 5,0 - 51 Togo 27.1 14.2 26.7 68.0 19 1.7 0. 1.6 4.2 21 Uganda 12.6 32.0 50.2 94.8 6 0.5 1.2 1.8 3.4 34 Zaire -15.2 47.8 159.0 222.0 6 0,2 0.6. 2.1 2.9 22 Zambia 76.5 4.8. 35.8 117.1 14 2-1 0.1 1.0 3.2 4 Zimbabwe, 167.7 45.8 202.9 416A 42 2.5 0.7 3.0. 6.2 1 1 Africa 19993 1,133 2,765. 5,910 14 1.5 0.9 2.1 4.5 19 World 1,018,221 3,252 680,982 1,702,455 323 4.8 0.0, 3.2 8.0 0.2 Less developed - countrleS 76,376 s 3,252 90,487 170,115 41 2.1 0.1 2.5 4.7 1.9 More developed countries 951,108 0 581,232 1,532,340 1,340 5.4 0.0 3.3 8.7 0.0 Technical Notes I-n all tables, Africa is defined as Sub-Saharan Africa. It excludes Eritrea and Nam-ibia (due to lack- of data) and LaMuAn ion and South Afirica (de to differences from oilier Sub-Saharan countries). Africa-wide values are population-weighted, unless the context indicates otherwise. 'More developed" countries include Europe, the countries odefrmer .... North America (U.S.-and Canada), Australia, New Zealand., and Japan. "Less developed" countries include the rest of the world.: Unavailable data are denoted by- The prinicipal so urces of the data ame: World Bank and United Nations Development Programme, 1992; African Development Indicators (Arn92): the World Bank's Population, Health and Nutrition Department (PHi); World Development Report 1993. (wDxt3): the World Health. Organization--Geneva Headquarters (wxo) and African Regional Offlice (wHo/Amo);.the United Nations (uN); and the United Nations Children's Fund (uNIaF). Table A-i. Health and DevelopmentlIndicator's Population numnbers for mid-1992 are World Bank estimates. These are normally * ~~~projections from the most recent population censuses or surveys, which, in some cases, are very dated. Refugees not permanently settled in the country of asylum are generally considered to be part of the population of their country of origin. * ~~~Population growth rates are- calculated from the midyear population by the -exponential method. The rates are expressed in percents. The crude birth rate and crude death rate, respectively, indicate the number of * ~~~live births and. deaths occurring per thousand population in a given year. They are World Bank estimates, based onvarious sources,including the United Nations. The tota fertility rate represents the number of children that would be born per woman, if she were to live to the end of her childbbcoring years and bear children at each age in accordance with currently prevailing age-specific fertility rates. Daita.are fronm the 212 S TAT I ST I C AL AP PEND I X 213 UN (Population Division and Statistical Office) and the World Bank (PHN) based on demographic and health surveys and information-from country statistical offices. Life expectancy at birth is the number of years a newbom infant would live if subjected throughout life to the current age-specific mortality rates. Data are presented for males and females separately. The sources of data are the UN and the World Bank. GNP per capita figures in U.S. dollars areca nJ'ated according to the World Bank Atlas nmethod. Gross national product (GNP) mt- e.es the total domestic and foreign value added claimed by residents. It consists of grss domestic product (r1p, the total dol lar value of all goods and services produced in the country), with adjustments for the .value of goods and services produced by nationals abroad and by foreigners residing within the country. The atlas conversion factor for any year is the avcrage of the -exchange rate for.that year and the exchange rates for the two preceding years, after adjusting them for differences in relative inflation between the country and the U.S. The resulting Gr4P in U.S. dollars is divided by the midyear population for the latest of the three years to derive GNP percapita. Dataare from wDR93. The adult literacy rate is the proportion of the population fifteen years old and overwho can read and write a short, simple statement on their everyday life. The data -re from W0R93. Tables A-2 and A-3. Population Projections (standard/medium and rapid. fertility decline) Population estimates and projections are those made by the World Bank, with midyear 1990 as the base, from data provided by the uN, country statistical offices, and other reliable sources. The projections for 2000 and 2025 are made for each country separately by the component method, based on previous twends of fertility, mortality, and migration. Note that the data reflect the potentially significant impact of the human immunodeficiency virus (HIV) epidemic. A full description of the methods and assumptions used to calculate the estimates is contained in the World Bank's World Population Projections. 1992-93 Edition. Annual rate of population growth. See note to Table A-1. The population projections for rapid fertility decline assume that each country will increase the use of contraceptives at the maximum possible rate. Total fertility rate. See note to Table A-l. * Population age structure for under fifteen and sixty-five and over is expressed as the percentage oftotal population. Data are from the World Bank data files, 1993; and the UN (World Population Prospects, the 1992 Revision, UN 1993). The data on urban population as a percentage of total population are from the UN'S World Population Prospects, the 1992 Revision, supplemented by data: from the World Bank. Because these estimates.are based on different national definitions of what is urban, cross-country comparisons should be interpreted with caution. Contraceptive use is the proportion of married women of childbearing age (15-49) in families using contraception. The data are from African Population Advisory Committee (APAc) 1993a. 214 BETTER HEALTH I N A-FR ICA Table A-4. Mortality The inftnt mortality rate is the number of infants who die before reaching. one year of age, per thousand live births in a given year. The data are from the UN as well as from the World Bank. The under-five mortality rate is the probability of dying between birth and age five, expressed per thousand live births. The rates were obtained from a special background paper prepared forwwt93 and uNIcEF. The methodology is described in the Hill and Yazbeck background paper cited in WDR93. The underlying infornmtion comes from the UN (Child Mortality since the 1960s, 1992), augmented by recendy available census and survey data. Theadultmortalityrateagesl5-59isthl probabilityofanadultagefifteendying - before reaching age sixty. The figure here is per thousand. The rates were derived from the child mortality estimates for the same year, combined with assumptions about the relationship between child and adult mortality based on country-specific projections by theWorld Bank. Median age at death is the age below which half of all deaths occur in a year The indicator is affected by several factors, including the age structure of the population and the age pattern of mortality risks.in the population. It does not represent the average age at which any group of individuals will die, and it is not directly related to life expectancy. Since African countries are characterized by very young populations (witl nearly. 50 percent of population under fifteen.years old, due to high totl fertility rates) and high infant and child mortality rates, the median age at death is very low (only five) comnpared with that of developing (thirty-nine) and industrial countries (seventy-four). The data are from wDR93. TableA-S. Income and Poverty Average annual growth rate of GDP. GDP measures the total output of goods and services forfinal useproducedbyresidents and nonresidents, regaidless of the allocation to domestic and foreign claims. The data are obtained from national sources, sometimes reaching the World Bank through other intemational organizations, but more often collectedduringWorldBankstaffmissions. ThedataarefromwDR93. Average annual rate of inflation is measured by the growth rate of the GDP implicit deflator for each of the periods shown. The GDP deflator is first calculated by dividing, for each year of the period, the value of GDP at current values by the value of GDP at constant values, both in national currency. The least-squares method is then used to calculate the growth rate of the GDP deflatorfor the period. This measure of inflation, like any other, has limitations. It is used as an indicator of inflation, however, because it is the most broadly based measue, showing annual price movements for all goods and services produced in an economy. The data are from wDR93. GNIP per capita. See note to Table A-1. The data are from WVDPf93. Percent share of income is the share of the lowest and highest population quintiles in total income or consumption expenditure. The data refer to different years between 1981 and 1991 and are drawn from nationally representative household surveys. The data have been compiled from two main sources: govenmment statistical. agencies and the S T A T I S T I C A L APPEND Ix 215 World Bank (mostly from the Living Standards Measurement Surveys). For further details, see Chen, Datt, and Ravallion, 1993. Population dependency ratio is calculated as the number of persons under age 15 and at age 65 and over (dependent ages) for every 100 persons ages 15-64 (economically productive ages). It gives a rough indication of how many persons are economically supported by each 100 persons who are economically active. The sources of data are the sanie as fortotal population (Table A-I). Absolute poverty level is defined as the country-specific income level below which adequate standards of nutition, shelter, and personal amenities cannot be assured. The data are from AD192. Table A-6. Education Dataare from theWorldBank data files (wDR93 and An92). 'Adult literacy rate. See note to Table A-I. Primary school enrollment data estimate the number of children of all ages enrolled in primary school. Figures are expressed as the ratio of pupils to the population of school-age children. Although many countries consider primary school age to be six to eleven years, others do not For some countries with universal primary education, the gross enrollment ratios can exceed 100 percent because some pupils are younger or older than the country's standard primary school age. The data on secondary school enrollment are calculated in the same manner, but again the definition of secondary school age differs among countries. It is most commonly considered to be twelve to seventeen;years. Late entry of more mature students and repetition can influence these ratios. The primary pupil/teacher ratio is the number of pupils enrolled in school in a country, divided by the number of teachers in the education system. - ¶lble A-7. The Health and Status of Women Women of childbearing age are those in the 15-49 age group. The maternal mortality rate refers to the number of female deaths that occur- during childbirth, per 1,000 live births. Because deaths during childbirth are defined more widely in some countries than in others, and many deaths are never recorded, the figures should be treated with extreme caution. The data are drawn flrnn diverse sources: wHotAFRO country reports; Maternal and Child Health, WIO/AFRO, 1990; UN. Demographic Yearbooks; uNIcEF; and mostly from Materal Mortality. A Global Factbook, wHo 1991. Prenatal health care coverage rate is the perentage of pregnant women who attended prenatal care clinics in a given year The data suggest the service was used but do not imply that coverage was adequate or effective. The data are from the Health for All data base, wnHo 6/92; Global Health Situation and Projections, WHO 1992; WHO/ AFRO computer printout, 1990; and WHO/AFRO country reports. Births attended by trained health personnel. Trained personnel include physicians, nurses, midwives, trained primary health care and other health workers, and trained traditional birth attendants. National coverage levels are drawn from official 216 B ETTER HEALTH I N A F R I C A estimates and sample surveys. Where no direct figures were available, the percent of births in health care institutions has been substituted as a conservative estimate. The data are from the Health for All data base, WHo 6/92; Global Health Situation and Projections. wuio 1992; WHO/AFRO computer printout, 1990; and wHo/AFRo country reports. Pregnant women immunized for tetanus is the percentage of women giving birth in a given year who received tetanus toxoid injections during pregnancy. The data are from the Health for All data base, WHO 6/9 Global Health Situation and Projections. WHO 1992; WHO/AFRO computer printout, 1990; and wHO/AFRO country reports. Prevalence or anemia in pregnant women (percent below norm). Women are classified as anemic when the blood hemoglobin level is below the WHO nonn of 110 grams per liter. The data are from wDR93. - School enrollment (females per 100 males) shows the extent to which females have equal access to schooling. The dataare from wDR93. African states parties to human rights conventions . The Convention on the Rights of the Child and the International Convention on the Elimination of Discrimination against Women contain provisions relevant to the status of women; The data indicate the years when the country ratified the convention(s). The data are as of February 1992, from the United Nations Center for Human Rights, Geneva. TableA-S.Foodand Nutrition Nutrition status: wasting (low weight for height) and stunting (low height for. age) refer to the percent of children with less than 77 percent (2 standard deviations) of the median weight-for-height or height-for-age of the US. National Center for Health Statistics (NcHs) reference population. Mild/moderate malnutrition is between 60 and:; 80 percent of the norm. Severe malnutrition is less than 60 percent of the norm. Chronic malnutrition is measured by stundng, and acute or short-term malnutrition is measured by wasting, whether the cause is inadequate food intake or infectious disease or both. Mild or moderate malnutrition is not considered disease, but all degrees of malnutrition increase the risk of death in children The dataare fromwDR93. Percentage of children fully breastfed is defined as those given breast milk with or without water, juice, or other liquids but no food or nonbreast milk before age four months. The data are from wDR93. Babies with low birth weight is the proportion of children bom weighing 2,500 grams (55 pounds) orless.Thedataarefrom wDR93. The index of food production per capita relates food production from 1975 to 1991 to that of 1987. The value of the latter within each country is taken as 100. The data are from the World Bank data files, 1993 (sTARs93). Food supplry calories per capita per day were calculated by dividing the calorie equivalent of the food supplies in a country by the population. Supplies include domestic production, imports less exports, and changes in stocks. The data are from the Food and Agriculture Organization Yearbook (Production), 1991. Food supply: protein per capita per day (gri) indicates one of the nutrient elements of food supply. Data are from the PAo Yearbook, 1991. S.TATISTICAL A PP EN D I X 217 -It is important to note that the quantities of food available relate to the quantities of food reaching household-s but not necessarily to the amounts of food actually consumed. The quantity consumed may be lower than the quantity shown, due to losses of edible food and nutrients in the household and to issues in the intrahousehold distribution of available food.The data represent only the avcrage supply for the population as a whole. Table A-9. Access to Water, Sanitation, and Health Care Facilities The data are from the Health for All data base. WHO 6192; Global Health Situation and Projections, wHo'1992; WHO/AFRO computer printout, 1990; and UNICEF data file 1993. Access to sure water is the proportion of the population with reasonable access to safe water sources. Safe water commonly includes treated surface water or untreated but uncontaminated watersuch as that from protected boreholes, springs, and sanitary wells. Reasonable access in urban areas is defined as a public fountain or standpost located not more than 200 meters from a dwelling. In rural areas, reasonable access implies that members of the household do not have to spend a disproportionate part of the day fetching the household's water needs. A Access to sanitation facilities is the proporion of th& population with adequate sanitary facilities in the home or immediate vicinity. The WHO indicators and definitions changed in the late 1980s, and caution is needed in interpreting the data. Access to health care services is now defined in the wwo Health for All data base as the proportion of the population having treatment for common diseases and injuries and a regularsupply of the essential drugs on the national list available within-one hour's walk ortravel. Caution is needed in interpreting the data. Table A-40. Immunization Data are from the Health for AIl data base, WHO 6/92; Global Health Situation and Projections, wHo 1992; WHOIAFRO computer printout, 1990; UNICEF data file 1993; and AD192. hnmunization coverage is the percentage of children in a given year who were fully immunized against each disease orgroup of diseases by age one. The requirements for full immunization depend on the type of disease. The vaccination schedule recommended by wno, -which is used in this table to measure full immunization, is as follows: * lTberculosis: one injection of BcG vaccine (Bacterium Calmette- Guerin), which can be given at the time of birth. * Diphtheria, Pertussis, Tetanus., three injections with DrT vaccine (DPT. 3) before age one; the firstis recommended six weeks afterbirth followed by two more at one-month intervals. * Polio: at least three doses of oral polio vaccine (POL 3) before age one, given one month apart. In areas where polio is endemic, the first dose is recommended at the time of birth, followed byithree more doses'at the same time as the DPT injections. 218 BETTER HEALTH I N A F R I C A * Measles: one inJection or measles vaccine, iven aftel nine months of age. Table A-IL Health Care Personnel The data in this table are from wiio (Statistics Annual, 1988; Human Resources data base 1992; Global Health Situation and Projections, 1992); WHO/AFRO (computer printout, 1990) and WHO/AlFRO country reports); and World Bank data files 1993 (PHNI wDR93). As explained in the WHO statistics annual, military personnel who do not pro- vide assistance to the civil health services are not included in the data, but expatriate statT are included, Because definitions of various categories of health care personnel vary among countries and the definitions given below lack precision, cross-country compari- sons of the data must be made with extreme caution. Doctors are graduates of a medical school or faculty actually working in any medi- cal rield (practice, teaching, administration, research, laboratory, etc.). Practitioners of. traditional medicine are not included in this category. Paramedics are staff whose medical training is less than that of qualified physi- cians but who nevertheless dispense similar medical services, including simple. operations. Nurses (proressional, high level) are graduates of a nursing school working in any nursing field (general nursing, specialized clinical nursing services in mental health, pediatrics, cardiovascular diseases, public health or occupational health, teaching, ad- ministration, research, and so on). These personnel are qualified and authorized to pro- vide the most responsible and competent professional nursing service. Also included in this category are midwives (professional, high level), who are graduates of a midwifery school actually working in any field of midwifery (practice in institutions and commu- nity health services, teaching, administration, private practice, and so on). Technicians are graduates of health technical school. They perform duties in labo- ratories, X-ray departmnents, dental departnents, pharmacies, environmental health, and soon. Assistant nurses (middle level) are personnel who provide general patient care of a less complex nature in hospitals and other health services, in principle under the super- vision of a professional nurse. These personnel do not have the full education and train- * ing of a professional nurse. Also included in this category are assistant midwives (mid- . - dle level), who are personnel carrying out the midwifery duties of normal obstetric care, in principle under the supervision of a professional midwife. Assistant midwives do not..: have the full education and training of professional midwives. Assistant technicians (middle level) are health services personnel- carrying out duties other than those of assistant nurses or assistant midwives. In principle, they work under the supervision of a technician. These personnel do not have the full education and -training ofa professional technician. Population per doctor or per nurse represents the r.umber of people served by oue doctor or by one nurse. The data show only the average available for the population as a whole arnd must be interpreted with caution because of the concentration of highly qualified health staff in urban areas.. ST AT I S Ti1 C A L AP P ENDI X 219 Tables A-12. Health Care Facilities- The data are from WHOIAFRO (computer printout, 1990); WHO/AFRO country re- ports; and World Bank data files (WDR93). Note that, in some respects, the definitions are not fully consistent with the usage in the text. Furthermore, terminology and defini- tions vary substantially from country to country; thus intercountry comparisons must be made with caution. Hospitals are establishments permanently staffed by at least one physician that offer in-patient accommodation and provide medical and nursing care. Establishments providing principally custodial care are not included. Centrallregional hospitals are hospitals-other than local or rural hospitals-that provide medical and nursing care for several medical disciplines. District/rural hospitals are, in principle, first-referral facilities, usually in rural areas, permanently staffed by one or more physicians, that provide medical and nursing care of a more limited range than that provided by central or regional hospitals. Health centers are, in principle, the firstpointofcontact ofthepopulation withthe formal health care system. They are not permanently staffed by physicians but by medi- cal assistants, nurses, midwives, and so on. Usually, they are small units (sometime"s also known as rural health centers) that offer lirmited ir-patient accommodation and provide a limited range of medical and nursing care. Others include maternities, dispensaries, and health posts. They furnish a very limited range of medical and nursing care not provided by professional staff. Beds. A hospital bed is situated in a ward or a part of the hospital where continuous medical care for in-patients is provided. The total of such beds constitutes the normally available bed complement of the hospital. Cribs and bassinets maintained for use by healthy newborn infants who do not require special care are not included. PopuIation per bed represents the number of people served by one hospital bed or other health care facility bed in the country. It is only an average and must be interpreted with caution because of the concentration of health care facilities with beds in urban areas. Table A-13. Health Expenditures Health expenditures include oudays for prevention of disease, health promotion, rehabilitation, and personal and public health care services; population programs; nutri- tion activities; program food aid; and emergency aid specifically for health. In this table, health expenditures do not include water and sanitation. Per capita expenditures are based on World Bank midyear population estimates. Total health expenditure is ex- pressed in official exchange rate U.S. dollars. Data on public and private health expenditure are from national sources, supple- mented by Government Finance Statistics (published by the Intemational Monetary Fund); World Bank sector studies, and other studies. Public expenditures include gov- emnment health expenditures and parastatal expendtures. They do not include aid flows. Private expenditures are based on household surveys carried out by the aLo and other sources, supplemented by infornation from United Nations Natioral income Accounts, World Bank studies, and other studies published in the scientific literature. 220 BETTER H EALTH I N A F R I C A Estimates for countries with incomplete data, including a number of African coun- tries, were calculated, in a special exercise undertaken for w0R93, in three steps. First, where data on either private or public expenditures were lacking, the missing figures were imputed from data from countries for which information was available. The impu- tation followed regressions relating public orprivate expenditure to GDP per capita. Sec- ond, for a country with no health expenditure data, it was assumed that the share of GDP : spent on health was the same as the average for the corresponding region. Third, if GDP was unknown but population was'known, it was assumed that per capitahealth spending was the same as the regional average. Aid nows represent the sum of all health assistance to each country by bilateral and multilateral agencies and by international nongovernment organizations (NGos)). Na- tional NMos were not included because the available information was not separately available by recipient country. The estimates of aid in this table were prepared for wD093 by the Harvard CenterforPopulation andDevelopment Studies. Bibliographical Notes. eitter Healthl in Africa is the product of the efforts of many people. Contributors to the study included B. Abeill6, L Aleta, R. Amadi, R. Bail, A. Bhargava, G. Bloom, P. Brudon, A. Correia de Campos, J. L. Dubois, G. Dukes, A. E. Elmendorf, J. Hammer. R.. Hecht, K Hill, L Z. Husain, M. KCirmani, R. Knippenberg. J. Kutzin, T. Lambo, J.-L. Lamboray, P. Landell-Mills, M. Lechat, M. Lioy, J. Litvaclk T. McCarthy,J. McGuire, T. Marek, R Ngong, R. Niimi, L. Obeng, S Ofosu-Amaah, D. Peters, G. Pham-Kanter. D. Porter, W. Rosebery, R P. Shaw, J. Silverman, D. Vaillancourt. W. Van Lerberghe, M. Venkatraman, and Z7 Yusuf. S. Kim, A. Bohon, H. Dao, K Dugbatey, G. McGrory, A. NDiaye, and C. Stomberg assisted in the research; J. Shafer, A. Bohon, EC Goodwin, M. Thurston-Greenwalt.1 D. Jaekel, A. Kamau, D. McGreevy, M. Verbeeck, M.-C. Verlaeten, J. Watlington, and C Yee provided administrative support; M. Vu and A. Sy prepared the statistical appendix; and P. Sawickli edited the manuscriptforpublication. L Ajayi, . Bitran, K. Subbarao, and H. Wassef helped in the initial framing of the study. L. Boya, E. Brown. M. Dia, K Dugbatey. M. Kirmani. M. Malonga, A. Nyamnete, 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, and A. Tinker helped on women and health; J. Doyen, D. Gray, J. Leitman, and L. Obeng, on the environment and health: D. Porter, on health equipment; M. Lechat, on technology and health; G. Dukes, on pharnaceuticals; S. Ofosu-Anaah, on human resources for health; G. Pham-Kanter. on health service outputs; A. Tchicaya and G. McGrory, on external assistance for health; J. Silverman, on management capacity and decentralization; and E. Heneveld and M. Zymelrman, on education and health. Commentators from outside the World Bank included S. Adjei, F.S. Antezana, F. Bacr, P, Bail; K Bezanson, G. Bloom, C. Cosmas, J. Davis, G. Dahlgren, J. Decaillet, J. Desmazieres, S. Duale, L Erinosho, M. Fargier, R. Feacham, C. Forsberg, S. Foster, H. Gilles, H. Gorgen, J. P. Grant, A. Hamer, R. Heyward, D. Hopkins, RP 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, 221 222 B.ETT ER H E ALT H I N A FR I CA 0. Ransome-Kuti, T. Rothermel, J, Roy, F. Sai, J. -Seaman, D. Shepard. M. Skold, H. Sukin, A. Tchicaya, H. Van Balen, A. Vernon, G. Walt, J. Wolgin, and D. Yach. Commentators from inside the World Bank were M. Ainsworth, J. Armstrong, M. Azefor, J. Baudouy, D. Berk, J.-L. Bobadilla, E. Boostrom, E. Boohene, L. Boya, E. Brown, N. Burnett, A. Colliou, H. Denton, L. Domingo, M. Fardi, F. Colladay, R1. Heaver, E. Heneveld, A. 1Hill, 1. Z. Husain, D. Jamison, E. Johnson, S. Jorgenson, J. Kutzin, P. Landell-Mills, D. Mahar, W. McGreevey. A.R. Measham, P. Musgrove, 0. Pannenborg, D. Peters, M. Pierre-Louis, M. Plessis-Fraissard, D. Radel, J. Salop, H. Saxenian,,K. Subbarao,J.-P.Tan,andR.Vaurs. The study benefited greatly from earlier work undertaken by F. Golladay with the assistance of T. Asefa; from worksbops facilitated by P. Gittinger with the assistance ofi.l Dejong, held with African colleagues in Abidjan, Accra, Bujumbura, and Lilongwe; and from an internal World Bank staff workshop. Aside from the background papers and. other sources mentioned below, the stidy also drew on World Bank population, health, and nutrition sector and project appraisal reports. Background Papers Abosede, Olayinka, and Judith S. McGuire- 1991. 'Improving Women's and Children's Nutrition in Sub-Sahar Africa.' Working Paper 723. World Bank, Population and Human Resources Department, Washington, D.C. Arnadi, Regina. 1992. "Cultural Dimensions in Better Health in Africa." World Bank, ; Africa Technical Department, Population, Health and Nutrition Division, Washington, D.C. Brunet-Jailly, J. 1991. "Health Financing in the Poor Countries Cost Recovery or Cost Reduction?" PRE Working Paper 692. World Bank, Population and Human Resources Departnent, Washington, D.C. Dejong, Jocelyn. 1991. 'Nongovernmental Organizations and Health Delivery in Sub- Saharan Africa." PIlE Working Paper 708. World Bank, Population and Human Resources Department, Washington, D.C. 1991. "iTraditional Medicine in Sub-Saharan Africa.' Working Paper 735. World.Bank,Population andHumanResourcesDepartment,Washington,D.C. Diop, Francois, Kenneth Hill, and Ismail Sirageldin. 1991. "Economic Crisis, Structural Adjustment, and Health -in Africa"' Working Paper 766. World Bank, Population and Human Resources Department. Washington, D.C. Eldund, Peter, and Knut Stavem. 1990. "Prepaid Financing of Primary Health Care in Guinea-Bissau." Working Paper 488. World Bank, Population and Human Resources Department, Washington, D.C. Foster, S.D. 1990. -Improving the Supply and Use of Essential Drugs in Sub-Saharan Africa." Working Paper 456. World Bank, Population and Human Resources Department, Washington, D.C., Liese, Bernard H., Bruce Benton, and Douglas Mart 1991. "The Onchocerciasis Control Program in West Africa." Working Paper740. World Bank, Population and Human Resources Department. Washington, D.C. Mwabu, Gennano. 1989. "Financing Health Services in Africa: An Assessment of Altemative Approaches.'t Working Paper457. World Bank, Population and Human Resources Department, Washington, D.C. B I B L I O G R A P H Y 223 Tchicaya, Anastase J.R. 1992. 'L'Aide Exterieure h la Sante dans les Pays d'Afrique au Sud du Sahara." Africa Technical Department. World Bank, Population, Health and Nutrition Division, Washington, D.C. Vaughan, Patrick. 1992. "Health Personnel Development in Sub-Saharan Africa." Workling Paper 914. World Bank, Populadon and Human Resources Department, Washington, D.C. Vogel, Ronald J. 1989. "Trends in Health Expenditures and Revenue Sources in Sub- Saharan Africa." World Bank, Population and Human Resources Department, Washington, D.C. 1990. "Health Insurance in Sub-Saharan Africa." Working Paper 476. World Bank, Population and Human Resources Department, Washington, D.C. World Bank. 1993. "A Framework and Indicative Cost Analysis for Better Health in Africa." Technical Workling Paper 8. World Bank, Africa Technical Department, Human Resources and Poverty Division, Washington, D.C. Yusuf, Zia. 1993. "A Framework and Indicative Cost Analysis for Better Health in Zimbabwe." Africa Technical Department, Human Resources and Poverty Division, Washingtont D.C. Bibliography Abeill, Bernard, and others. 1991. "Etude Sectorielle: Pratiques de Construction des Infrastructures Sociates dans les Pays du Sahel.' Volume IV, Fiches d'Enquete. World Bank, Washington, D.C. Also in English as Abeilld, Bernard, and Jean- Marie Lanun. 1993. Social Infrastructure Construction in tire Sahel: Optionsfor Improving CtrrentPractices. World BankDiscussionPaper200. Washington, D.C. Abosede, Olayinka, and Judith S. McGuire. 1991. -Improving Women s and Children's Nutrition in Sub-Saharan Africa." Working Paper 723. World Bank, Population and Human Resources Department, Washington, D.C: Adjei Samuel. 1993. Personal communication, July. African Population Advisory Committee. 1993a. -Reliability of Population Estimates and Sources of Demographic Data for Africa." World Bank, APAC Secretariat, Washington, D.C. - 1993b. "African Population Programs: Status Report." World Bank, APAC Secretariat, Washington, D.C. 1993. "Report on the African Population- Agenda." World Bank, APAC Secretariat, Washington. D.C. 1993c. "The Impact of HIVIAIDS on Population Growth in Africa." World Bank, APAC Secretariat, Washington, D.C. Ageyi, William K A., and Elsbeth J. Epema. 1992. "Sexual Behavior and Contraceptive Use Among 15-24 Year Olds in Uganda." International Family Planning Perspecrives 18 (March):13-17. Ainsworth, Marha, and Mead Over. 1992. "The Economic Impact of AIDS: Shocks, Responses, Outcomes." Technical Working Paper 1. World Bank, Africa Technical Department, Human Resources and Poverty Division, Washington, D.C. Akoto, Eliwo, and Dominique Tabutin. 1989. "Les in6galitds socioeconomiques et culturelles devant la mort" Mortalizet et Socieit en Afrique. Institut National d'Etudes Demographique, et Presses Universitaires de France, Paris. 224 BETTER H E A LTH I N A:FRICA Aleta, 1. R. 1992. "Health Research in the WHoAfrican Region: Situational Analysis and Prospects for Developmentt" wHO/AFRo, Brazzaville. Alihonou, E., L. Miller, R. Knippenberg, and T. Gandaho. 1986. "L'Utilisation du Mdicament Essentiel comme Base du Financement Communautaire." Paper presented at the International Symposium on Essential Drugs in Developing Countries. Paris. Alihonou, E., and others. 1988. "I'interface des soins de santE de base et des soins primaires." Pahou, Health Development Project, Benin. Amadi, Regina. 1992. "Cultural Dimensions in Better Health in Africa." World Bank, Africa Technical Dep. flment, Population, Health and Nutrition Division, Washington, D.C. Amonoo-Lartsen, R. 1990. "Experiences of Cooperation for Health." Unpublished report. World Bank, Population and Human Resources Department, Washington, D.C. Barnum, Howard, and Joseph Kutzin. 1993. Public Hospitals in Developing Countries: E Resource Use, Cost, Financing. Baltimore, Md.: Johns Hopkins University Press fortheWorldBank. Behnnan, Jere R. 1990. "A Survey of Economic Development, Structural Adjustment and Child Health and Mortality in Developing Countries." Child Survival Programs: Issuesforthe990Os. Baltimore, Md.: Johns Hopkins UniversityPress. Bentley, Chris. 1989. "Primary Health Care in Northwestern Somalia: A Case Study." Social Science andMedicine 28(lO):1019-30 .. Berman, P., C. Kendall, and K. Bhattacharyya. 1989. "The Household Production of Health: Putting People at the Center of Health Improvement" In I. Sirageldin and others, eds. Towards More Efficacy in Child Survival Strategies. Baltimore, Md.: Johns Hopkins University School of Hygiene and Public Health. Bertrand, William E. 1992. Letter dated December 15, 1992, to Dr. Seth Berkley, Rockefe1lerFoundation. TulaneUniversity. * Beza, B., and others. 1987. "Introduction of a Local Health Informnation System in Kinshasa Zaire." Annales de La Sociitd Belge de Midecine Tropicale 66 (3). BP 4832. Kinshasa Gombe, Republique duZaire . Bhargava, Alok, and Jian Yu. 1992. "A Longitudinal Analysis of Infant and Child Mortality Rates in African and Non-African Developing Countries." Unpublished technical paper. World Bank, Africa Technical Department, Human Resources and Poverty Division, Washington, D.C. Bitran, R, M. Mpese, and others. 1986. "Zaire: Health Zones Financing Study.- United States Agency for International Development, Washington, D.C. Blakney, R B., J. I. Litvaclc, and J D. Quick. 1989. "Financing Primary Health Care: Experiences in Pharmaceutical Cost Recovery." Report by the Pritech Committee. Management Sciences for Health, Boston. Bloom, G., M .Sega]L and C. Thube. 1986. "Expenditure and Financing of the Health Sector in Kcnya." World Bank, Department of Population, Health and Nutrition, Washington,D.C. Bloom, Gerald, and Caroline Temple-Bird. 1988. "Medical Equipment in Sub-Saharan Africa A Framework forPolicy Formulation." Research Report 19. Institute for DevelopmentStudies, University of Sussex, Brighton, England. B I B L I O G R A P H Y 225 Boateng, E Oti, Kodwo Ewusi, Ravi Kanbur, and Andrew McCay. 1989. A Poverty Profile for Ghana, 1987-88. SDA Working Paper Series 5. World Bank. Washington. D.C. Bocar, DIem. 1989. "Integration-de l'h6pital de Labe dans le systeme sanitaire du district." Term paper for the International Course in Health Development. Institute of Tropical Medicine,Antwerp. Boermna, J. Ties, A. Elisabeth Sornmerfelt, and Shea 0. Rutstein. 1991. Childhlood Morbidityand TreatmentPatnerns. Demographicand Health Surveys, Comparative Studies no. 4. Columbia Md.: Institute for Resource Development/Macro International, Inc. -Bradley, A. K. 1976. "Effects of Onchocerciasis on Settlement in the Middle Hawal Valley, Nigeria." Transactions of the Royal Society of Tropical Medicine and Hygiene 70(3):225-29. Bradley,- David John, and others. 1992. A Review of Environmental Heathi Impacts in Developing Country Cities. Urban Management Program, Paper 6. World Bank, Washington, D.C. Brieger, Witlliam, Jayashrec Rarnakrishna, and Joshua D. Adeniyi. 1986. "Self-- Treatment in Rural Nigeria: A Community Education Diagnosis." International Journal of Health Education (Hygie), 5:2 (June). Brinkman, Uwe, and Brinkman, A. 1991. Malaria and Health in Africa: The Present Situation and Epidemiological Trends." Tropical Medicine and Parasiiology 42(3)204-13. Brudon-Jakobowicz, P 1987. "Evaluation et Monitoring dans le contexte du Programme d'action pour les Medicaments et Vaccins Essentiels." In: Le Midicament Essential dons les Pays en Developpement. Comnptes Rendus du Symposium International, Paris; 19-20 Mai, 1987. Paris: Minisere de la Coop6ration. Brunet-Jailly, J. 1991. -Health Financing in the Poor Countries: Cost Recovery or Cost Reduction?" PRE Working Paper Series 692. World Bank, Population and Human Resources Department. Washington, D.C. Bulataot R. A., and Patience W. Stephens. 1992. "Global Estimates and Projections of Mortality by Cause, 1970-2015." Working Paper Series 1007. World Bank, Population, Health, and Nutrition Department Washington, D.C. Caldwell. John, and others, eds. 1989. "'What WMe Know about Health Transition: The Cultural, Social and Behavioural Determinants of Health." Health Transiton Senes No. 2, Vol. L Proceedings of an Inteonational Workshop, Canberra, May 1989. Health Transition Centre, The Austalian National University. Cassels, Andrew, and Katja Janovsky. 1991. "Strengthening Health Management in Districts and Provinces: Handbook for Facilitators." World Health Organization Document WHO/sHs/Dis/91.3. Geneva. Castro, E. B., and K M. Mokate. 1988. "Malaria and its Socioeconomic Meanings: The Study rf Cunday in Colombia." In A. N. Herrin and P.L. Rosenfield, eds. Economics, Healthr and Tropical Diseases. Manila: School of Economics, University of the Philippines. Chambers, R. 1982. "Health, Agriculture, and Rural Poverty: Why Seasons Matter." Journal ofDevelopment Studies 18(2):217-38. 226 B EBTT E R HEALTH IN A FR I C A Chen, Lincoln C., Arthur Kleinman, and NormaC Ware, eds. 1992.Advancing Health in Developitng Countries: The Role of Social Researchf. New York: Aubum House. Chen, Shaohua, Gaurav Datt, and Martin Ravallion. 1993. "Is Poverty Increasing in the Developing World?" Policy Research Working Paper 1146. World Bank, Policy Research Department, Washington, D.C. Chin, James. 1991. "The Epidemiology and Projected Mortality of AIDS." In Richard G. Feachem and Dean T. Jamison, eds., Disease and Mortality in Sub-Sa/aran Africa., -iew York: Oxford University Press. Cleaver, Kevin, and G6tz Schreiber..1993. 'The Population, Agriculture and Environment Nexus in Sub-Saharan Africa." Agricultural and Rural Development Series 9. World Bank, Africa Technical Department, Washington, D.C. Forthcoming as Reversing the Spiral: The Population, Agriculture, -and Environment NexusinSub-SalMranAfrica.WorldBankWashington, D.C. Commission on Health Research for DevelopmenL 1990. Health Researchi: Essential Link to Equirt in Development. New York: Oxford University Press. Conly, G. N. 1975. "The Impact of Malaria on Economic Development: A Case Study." Scientific Publication 297. Pan American Health Organization, Washington, D.C. Conyers, Diana, Andrew Cassels, and Katja Janovsky. 1992. "Decentralization and. Health Systems Change." November. Unpublished manuscript. Cook, Rebecca, and Deborah Maine. 1987. "Spousal Veto over Family Planning Services." American Joumal of Public Healthi 77(3):L339-44. Corbett,Jl 1988. "Famine and Household Coping Strategies." World Development 16(9):1099-1122. Cornea, A. G., Richard Jolly, and Frances StewarL 1987. Adjustment with a Human * f XFace. Oxford: Clarendon Press. Cosrmaas, Cheka. 1994. Contribution to Report No. 12577-Afr."Better Health in Africa." Personal communication. Cross, P. N., M. A. Huff, J. D. Quick, and J. A. Bates. 1986. "Revolving Drug Funds:, Conducting Business in the Public Sector." Social Science and-Medicine 22(3):335%43. Dabis F., A. Roisin, J. G. Breman, and others. 1988. "Improper Practices for Diarrhoea Treatrnent in Africa.' Transactions of the Royal Society of Medicine and Hygiene 89Z935-36. Daniels, D. L, S. N. Cousens, L. N. Makoae, and R. G. Feachem. 1990. "A Case-Control Study of the Impact of Improved Sanitation on Diarrhoea Morbidity in Lesotho.' Bulletinofthe wHo68(4):455-63. Dejong, Jocelyn. 1991. "Nongovernmental Organizations and Health Delivery in Sub- Saharan Africa." Policy Research Working Paper708. World.Bank Population and Human Resources Department, Washington, D.C. .1991. "Traditional Medicine in Sub-Saharan Africa." Policy Research Working Paper 735. World Bank, Population and Human Resources Department, Washington, D.C. Demery, Lionel, Marco Ferroni and Christiaan Grootaert, with Jorge Wong-Valle, eds. 1993. Understanding the Social Effects of Policy Reform. Washington, D.C.: World Bank. B I B-L I O G R A P H Y 227 DeSweemer, C., and others. 1982. "Critical Factors in Obtaining- Data Relevant to Health Programmes." In MethoJdologies for Hnmart Population Studies in uwitririon, Related to Health 82-2462:59-8 1. De Vries, T. 1992. "Experimental Application of the Groningen Prescribing Programme in 15 Universities." Unpublished status report. University of Groningen. Diop, Francis. 1991. "Economic Determinants of Child Health and Utilization of Health. Services in Sub-Saharan Africa: The Case of Ivory Coast." Ph.D. dissertation. Johns Hopk-ins University, Baltimore, Md. Diop, Francois, Kenneth Hill, and Ismail Sirageldin. 1991. "Economic Crisis, Structural Adjustment, and Health in Africa" Policy Research Working Paper :766. World Bank, Populadon and Human Resources Department, Washington, D.C. Dissevelt, Anthony Gerardus. 1978. Integrated Maternal and C/did Healtdt Services: A Study at a Rural Health Centre in Kenya. Meppel, Netherlands: Krips Repro. District Health Development Study Core Group. 1991. "Review of District Health System Developrnent in Ethiopia." August. Unpublished manruscript.. Dunlop, D. W., and A. Mead Over. 1988. Determinants of Drug Imports to Poor - Countries. Greenwich, Conn- JAI Press. Edungbola, L., and others. 1988. "The Impact of a UNICEr-Assisted Rural WaterProject .on the Prevalence of Guinea Worm Disease in Asa Kwara State, Nigeria." American Journal ofTropical Medicine andHygiene 39(1):79-85. Ek-lund, Peter, and Knut Stavem. 1990. "Prepaid Financing of Primary Health Care in Guinea-Bissau." PRE Working Paper 488. World Bank. Population and Human Resources Department, Washington, D.C. Elbadawi, Ibrahim A., Dhaneshwar Chura, and Gilbert Uwujaren. 1992. "World Bank AdjustmentLending and Economic Performance." In "Sub-Saharan African in the 1980s." Policy Research Working Paper 1000. World Bank, Country E:conomics Department, Washington, D.C. Elmendorf, A. Edward. 1993. "Structural Adjustment and Health in Africa in the 1980s." Paper prepared and presented at the American Public Health Association Conference, San Francisco, October. Engelkes, Elly. 1993a. "Process Evaluation in Colombian Primary Health Care Progamme." Health Policy andPlanning 5 (December):327-35. 1993b. "What Are the Lessons from Evaluating PHC Projects? A Personal View." Health Policyand Planning 8(1):72-77. Erinosho, Olayiwola A. 1991. "Health Care and Medical Technology in Nigeria." InternationalJournal of TechnologyAssessm ent in Healtht Care 7(4):545-52. Esrey, S. A, J. B. Potash, L. Roberts, and C. Schiff. 1991. "Effects of hnproved Water Supply and Sanitation (Excreta Disposal) on Ascaris, Diarrhoea, Dracunculosis. Hookworm, Schistosomiasis and Trachoma." Bulletin of the lWorld Health Organization 69(5):602-21. Evans, T. 1989. "The Impact of Permanent Disability on Small Households: Evidence from Endemic Areas of River Blindness in Guinea." Institute for Development Studies Bulletin 20:41-48. FAO (Food and Agriculture Organization). 1991. FAO Yearbook. Rome. Feachem, Richard G., and Dean T. Jamison, eds. 1991. Disease and Mortality in Sub- Saharan Africa. New York: Oxford University Press. 228 B.3 E T T E R H E ALT H I N A F R I C A Feachem, Richard G., Tord Kjellstrom, and Christopher I. L. Munray, eds. 1992. 717w Health ofAdults in the Developing World. New York: Oxford University Press. Fendall, N. R. E. 1963. "Health Cuaters: A Basis for Rural Healdt Service." Journal of TropicalMedicine and fySiene 66:219. Ferster, G., P. H. van Kessel, Y. Abu-Bohene, and F. R. Mwambaghi. 1991. Strategic Framework for the Cost Shlaring System for tize Malawfi Government Health Services, 1. Main Report, Government of Malawi, PHC Sector Credit Report Nurnber 9036-MAI, May. Foster, S. D. 1990. "Improving the Supply and Use of Essential Drugs in Sub-Saharan Africa.", PRE Working Paper 456. World Bank, Population and Human Resources Departrnent, Washington, D.C. Free, Michael 3. 1992. "Health Technologies for the Developing World." International Journal ofTechnotogyAssessment in Health Care 8(4):623-34.. Galland, B. 1990. "Systbmes d'autofinancement alternatifs au paiement & l'act-etude de cas au Rwanda." Unpublished report. World Bank, Central Africa and Indian Ocean Department, Wasfhington, D.C. Gbedonou, P.-J. M. Ndiaye, D. Levy-Bruhl, R. Josse, and M. Yarou. 1991. "Enlarged program of vaccination and commnunity participation in Benin. Bureau UNICEF, Cotonou. Bulletin Soc. Pathol ExoL France. G:erder, Paul, and Jacques van der Gaag. 1990. 77ie Willingness to PayforMedical Care:- Evidence from Two Developing Countries. Baltimore, Md.: Johns Hopkins University Press. Global Coalition for Africa. 1993. African Social and Economic Trends:. First Annual Report-Washington, D.C.. Golladay, FredrickL 1980. Healthi.WorldBankSector Policy Paper. d ed Washington, D.C. Govindasamy, Pavalavalli, and others. 1993. High-risk Births and Maternity. Demographic and Health Surveys, Comparative Studies no. 8. Columbia, Md.:.- Macro InternationaL - Griffin, C. C. 1988. User Charges for Health Care in Principle and Practice. EDi Seminar Paper 37. World Bank, Washington, D.C. .1992. 'Cost Recovery.". Health Financing and Sustainability, Technical Theme Papers. Year Two. Health Financing and Sustainability Project. Washington, D.C.: Agency forInternational DevelopmenL - Grimaud, Denise. 1992. Evaluation de la Participation des Beneficiaries a ia Gestion des Programmes de Sante. Rapport Preliminaire sur l'Enquete. R6publique du. Benin: Banque Mondiale. Grootaert, Christiaan. 1993. "The Evolutior, of Welfare and Poverty under Structural Change and Economic Recession in Cote d'Lvoire, 1985-88." Policy Research WorkingPaperl1078. WorldBank,Washington, D.C. Gwatkin, Davidson R. 1991. "The Distributional Implications of Alternative Strategic Responses to the Demographic-Epidemiological Transition." Paper Prepared for the National Academy of Sciences Workshop on the Policy and Planning Implications ofthe Epidemiological Transitions in LDCs. Washington, D.C- Hall, Budd. 1978. "Man is Health: Mtu ny Afya." Clearinghouse on Development, Communication Academy forEducational Developnent, Washington, D.C. B I B LI 0 G R AP l Y 229 Hall, David, and Gwen Malesha. 1991. Healthi and Family Planning Services in Lesotho: Thie People's Choice. Unpublished report. World Bank, Southern Africa Dcpartment, Washington, D.C. Halstend, Scott B., Julia A. Walsh, and Kenneth S. Warren. 1985. Good Healtht at Low Cost. Conference Report. New York: The Rockefeller Foundation. 1Hamel, L, and P. W. Janssen. 1988. "'On the Average: The Rural Hospital in Sub- Saharan Africa." Tropical Doctor 18. Harnmeijer, J. W. 1990. "The Issue of Recurrent Costs: Implementing PHC in Zambia." In Pieter Streefland and Jarl Chabot, eds., Implementing Primary Heallth Care: Experiences sinceAlma-Ata. Amsterdam: Royal Tropical Institute. Hartnett, Teresa. and Ward Heneveld. 1993. "Statistical Indicators of Female Participation in Education in Sub-Saharan Africa." Technical Note 7. World Bank, Africa Technical Departmnent, Human Resources and Poverty Division. Washington, D.C. Haynes, R. B., and others. 1986. "Improvement of Medication Compliance in Uncontrolled Hypertension." Lancet 1(7972):1265-68.- Hecht. Robert, Catherine Overholt, and Hopkins Holmberg. 1992. "Improving the Implementation of Cost Recovery forHealth: Lessons from Zimbabwe." Technical Working Paper 2. World Bank, Africa Technical Department, Population, Health and Nutrition Division, Washington, D.C' Heller, Peter S. 1978. "Issues in the Allocation of Resources in the Medical Sector of Developing Countries: The Tunisian Case." Economic Development and Cultual Change27(1):121-44. Hicks, Norrnan. 1991. "Expenditure Reductions in Developing Countries Revisited." JournalofinternauionalDevelopment3 (January):29-37. HilL, Kenneth, and Abdo Yazbeck. "Trends in Child Mortality, 1960-1990: Estimates for 84 Developing Countries." Background paper prepared for W/orld Development Report 1993. World Bank. World Development Report office, Washington, D.C. Ho, Teresa. 1985. "Managing Health and Family Planning Delivery through a Management Information System:` World Bank, Population, Health and Nutrition Department, Washington,D.C.- Hodes, R.M., and FL Kloos. 1988. "Health and Medical Care in Ethiopia." NewEngland JournalofMedicine319:918-24. Hogerzeil H. V., and P. J. N. Lamnberts. 1984. "Supply of Essential Drugs for Church Hospitals in Ghana." Tmopical Doctor 14:9-13. Hogerzeil H. V., and G. D. Moore. 1987. "Essential Drugs for Church-Related Rural Health Care." World Health Forum 9:472-73. Huff-Rousselle. 1990. "The Regional Pharmaceuticals Management Project and the F-astern Caribbean Drug Service." Paper prepared for the 17th National Council for International Health Conference. Washington, D.C. Hunter, John M. 1966. "River Blindness in Nangodi, Northem Ghana: A Hypothesis of Cyclical Advance and RetreaL" Geographical Review56:409-10. Imboden, N. 1980. Managing Infoirmationfor Rural Development Projects. Paris: OECD. International Labour Office. 1989. WoridLaborReport,1989. Brighton, England. 230 B E T T E R H E ALT H IN A F R IC A Isenalumhe, A. E. and, 0. Ovbiawe. 1988. "Polypharmacy: Its Cost Burden and Baniers to Medical Care in a Drug-Orientated Health Care System." International Jouernal of Health Services 18(2):335-42. Jacobson. 1989. "Tenwek Program in Kenya." Social Science and Medicine. Special issue on community-based health care in East Africa. Jagdish, Vulimiri. 1985. "A Rapid Assessment Methodology for the Collection of Health Information in Developing Countries Using Existing Information." Doctoral thesis. Johns Hopkins School of Hygiene and Public Health, Baltimore, * 0 Md. Jamison, Dean T., W. Henry Mosely, Anthony R. Measham, and Jos6 Luis Bobadilla. 1993. Disease Control Priorities in Developing Coountries. New York: Oxford - JUniversity Press for the-World Bank. Jancloes, M., and others. 1985. "Financing Urban Primary Health Care Services." Tropical Doctor 15:98-104. Jarrett, Stephen W.+ and Samuel Ofosu-Amaah. 1992. "Strengthening Health Services * Xfor MCH in Africa: the First Four Years of the 'Bamako Initiative'." Health Policy and Planning 7(2):176.4:7 Johnson, K. E., W. K. Kisubi, J. K. Mbugua, D. Lackey, P. Stanfield, and B. Osuga. 1989.. "'Community-Based Health Care in Kibwezi, Kenya 10 Years in Retrospect." Social Science andAMedicine 28(10):1039-51. * Johnston, Tony, and Aart de Zeeuw. 1990. The Status of Development Support - . bCommunication in Eastern and Southern Africa. Monograph Series 1. New York: -UnitedNations Population Fund. - Joseph, Andre J., Peter N. Kessler, and Elizabeth S.M. Quamina. 1992. Program Assessment and Future Development of tihe wwo Program on Strengritening District Health Systems Based on Prinary Health Care. New York: United NationsX Development Programme. Kamarek, Andrew M., and World Bank. 1976. The Tropics and Economic Development. A Provocative Inquiry into tde Poverty of Nations. Baltimore, Md.:. Johns Hopkins University Press. Kaseje, Danny, and others. 1989. "Saradidi Project in Kenya." Social Science and Medicine. Special issue on commnunity-based health care in East Africa. Kasongo Project Team. 1982. "The Impact of Primary and Secondary Health Care Levels on Tuberculosis Control Activities in Kasongo (Zaire)." Bulletin, of International Union against Tuberculosis 57(2). 1984. "Primary Health Care for Less than a Dollar a Year." World Health Forum5:211-15. King, Elizabeth, and Yan Wang. 1993. "The Economic Burden of Illness: Evidence from Developing Countries." iWorld Bank, Population, Health and Nutrition Departnent, Washington, D.C. King, Cole S. 1984. Information Systems, Monitoring. Evaluation, and Research. New York: UNICEF. King, M. 1966. Medical Care in Developing Countries: A Primer on the Medicine of Poverty and a Symposiumfrom Makerere. Nairobi: Oxford University Press. Kirby, Jon P. 1993. "The Islamic Dialogue with African Traditional Religion: Divination andHealthCare." SocialScienceandMedicine36(3):237-47. BI B L I 0 G R A P HY 231 Kleczkowski, B. M., and R. Pipbouleau, eds. 1983. Apprmaches to Planning anfd Design of Health Care Facilities in Developing Areas, 4. Geneva: World Health Organization. Kloos, Helmut. 1990. "Utilization of Selected Hospitals, Health Centers, and Health Stations, in Central, Southern and Western Ethiopia." Social Scienice antd Medicine 31(2):101-14. Knippenberg, R., and others. 1990. "The Bamako Initiative: Experiences in Primary Health Care from Benin and Guinea." C'/ildrer. in t/he Tropics, no. 184/185. Intemational Children's Center, Paris. - . and others. Forthcoming. "Strengthening African Health Systems through the Bamako Initiative: Opemtions Research Issues." UNICEr, WCARO. Knippenberg, R., S. Ofosu-Amaah, and David Parker. 1990. "Strengthening PHC Services in Africa: An Operation Research Agenda." Draft. UNICEF, New York. Korte, R., and others. 1992. "Financing Health Services in Sub-Saharan Africa: Options for Decision Makers during Adjustment." Social Science andMedicine 34(1):1-9. Lamboray, J. L., and C. Laing. 1984. "Partners for Better Health." World Hea/l: Forum 5:30-34. World Health Organization, Geneva. Landell-Mills, Pierre. 1992. "Governance, Civil Society and Empowerment in Sub- Saharan Africa." Presentation to the Society for the Advancement of Socio- Economics. May 5. Leitmann, Josef. 1992. "Environmental Management and Urban Development in the Third World: A Tale of Health, Wealth and the Pursuit of Pollution from Four Cities in Africa, Asia, Eastem Europe, and Latin America." Ph.D. thesis. University of California, Berkeley. Leneman, Leah, and G. Fowkes. 1986. Health Centers in Developing Countrnes: An Annotated Bibliography, 1970-1985. Geneva: WHO. Leslie, Joanne. 1987. "lime Costs and Time Savings to Women of the Child Survival Revolution." Paper presented to the Rockefeller Foundationr/RDc Workshop on Issues Concerning Gender, Technology, and Developmient in the Third-World. February 25-26. New York. iese, Bernard H., Bruce Benton, and Douglas Marr. 1991. "The Onchocerciasis Control Program in WestAfrica." Working Paper 740. World Bank, Population and Human Resources Department, Washington, D.C. Utvack, Jennie-I. 1992. "The Effects of User Fees and Improved Quality on Health Facility Utilization and.Household Expenditure: A Field Experiment in the Adamaoua Province in Cameroon." Ph.D. dissertation. Fletcher School, Tufts University, Medford, Mass. London School of HygieneandTropical Medicine. 1989.AnEvaluatio6nof wHzo Action Programme on Essential Drugs. London School of Hygiene and Tropical Medicine and Koninklijk Instituut voor de Tropen. Lucas, Adetokunbo 0. 1992. "Public Access to Health Information as a Human Right.'" In Centers for Disease Control,"Proceedings of the International Symposium on Public Health Surveillance." Morbidity and Mortality Weekly Report 41 (December, Supplement):77-78. - Malkin, J. E., D. Carppentier, and C.J Lefaix. 1987.' "Evaluation des besoins en ;mddicaments en zone rurale africaine." In Le Midicament Essential dans les Pays 232 B E TT ER H E A LT H. IN A FR I-C A en Developpenieni, Comptes Rendus du Symposium International, Paris, 19-20 Mai, 1987. Paris: Ministzre de la Coopdration. Management Sciences for Health, 1984, Improving the Availability of Piarniaceuticals in t/he PublicSector, Boston, Mass. Marzagao, C., and M, Segall. 1983. "Drug Selection: Mozambique." World Developient 11(3):205-16. Matomora, M. K. S. 1989. "Mvumi Project in Tanzania." Social Science atnd Medicine. Special issue on community-based health care in East Africa, Mburu, F. M., and J. T. Boerma. 1989. "Community-Based Health Care 10 Years Post Alma-Ata."SocialScienceandMedicine 28(10). Mburu F. M.$ H. C. Spencer, and D. C, 0. Kascje. 19874 "Changes in Sourccs of Treatment after Inception of a Community-Based Malaria Control Programme in Saraddidi, Kenya." Ann. Trop. Med. Parasit. 8l(Supplement 1):105-10. McGrory, Glenn. 1993. "Extemal Assistance for Health in Africa," Unpublished report. World Bank, Africa Technical Department, Human Resources and Poverty Division, Washington, D.C. McGuire, J. S., and J, E. Austin. 1986. Beyond Survival: Children Growth for National Development. Cambridge, Mass.: James E. Austin Associates. McNamara, Robert S. 1992. A Global Population Policy to Advance Humtan Development in the Twenty-First Century, with Particular Reference to Sub- SaharanAfrica. Kampala, Uganda: Global Coalition forAfrica. McPake, Barbara, and others.. 1992. Experience to Date of Implementing lite Bamako Initiative: A Review and Five Country Case Studies. Health Economics and Financing Program, London School of, Hygiene and Tropical Medicine. Mebrahtu, Sabra. 1991. "Women, Work and Nutrition in Nigeria." In Meredeth Turshen, ed., Women and Healsh in Africa. Trenton, N.J.: Africa World Press. Miller, L. 1987. Les Possibilircs d'Autonomie Financi&re de la Zone de Sante uu Zaire. Report of a UNICEF Mission, Kinshasa. Mills,- Ann, and Lucy Gilson. 1988. Health Econonoics for Developing Countries. Evaluation and Planning Centre for Health Care, London School of Hygiene and Tropical Medicine. Mills, A. J. 1991. "The Cost of die District Hospital-A Case Study for Malawi." Working Paper Series 742. World Bank, Population and Human Resources Department, Washington, D.C. Minist&e de la SantE Publique et des Affaires Sociales, Guinea. 1990. "Evaluation des Systemes de Gestion des Services de Sante en Ve REgion." Direction Nationale de ia Planification et de la Formation Sanitaire et Soc iale, Conakry. Minist&re de la Santd Publique. Rdpublique de B6nin. 1990. Rapport de Supervision du = Pi ggramme PEv/sse. Minis.tre de la SantE Publique et des Affaires Sociales du Mali. 1990. Evaluation des Syst&mes de Gestion des Services de Santi. Direction Nationale de la Planification et de laFormation Sanitaire et Sociale. Bamako. Ministry of Health, Kenya. 1984. Evaluation-Management of Drug Supplies to Rural Health Facilities in Kenya. Nairobi. B I B L IO G R AP HY 233 Monekosso, G. L 1989a. Accelerating theAchievement of HealtdiforAllAf icans: -The Thtree-Phtase Health Developament Scenario. WHO Regional Office for Africa, Brazzaville, Congo. . 1989b. Implemenation of tie African Heak/az Development Scenario. WHO Regional Office for Africa, Brazzaville, Congo. 1 .991. Meeting the Chiallenge of Africa's Health Crisis in tIhe Decade of the Nineties. WHO Regional Office forAfrica, Brazzaville, Congo. - 1992a. Global Changes and HealthforAll: An AgendaforAction. WHO/AFRO, Brazzaville, Congo. * 1992b. Workingfor Better HealIth in Africa: Experiences in tis e Management of Change. ewHOAFRO Brazzaville, Congo. 1 1993. "Statement at the WHO/AFRO Regional Coz mittee Meeting.". September7. Gaborone, Botswana. Mosley, W. Henry, and Peter Cowley. 1991. "The Challenge of World Health." Population Bulletin 46 (December). Mujinja. P. G. M., and R. Mabala. 1992. C/aurging for Services in Non-Governmental Health Facilities in Tanzania. Technical Report Series no. 7. VNICEF, Bamako Initiative Unit, New York. Mwabu, Germano. 1984. "A Model of Household Choice Among Medical Treatment Alternatives in Rural Kenya." Ph.D. dissertation. Boston University, Boston, Mass. 1989. "Referral Systems and Health Care Seeking Be'.avior of Parents: An Econonic Analysis." World Development 17(1):85-92. 1 1990. "Financing Health Scrvices in Africa: An Assessment of Altemative Approaches." PRE Working Paper 457. World Bank, Population and Human Resources Department, Washington, D.C. Nicholas, David D., James R. Heiby, and Theresa A. Hatzell. 1991. "'The Quality Assurance Project: Introducing Quality Improvement to Primary Health Care in Less Developed Countries.t QualityAssurance in Health Care 3(3):147-65.; Niimi, Reiko. 1991. "Back-to-Office Report, Zaire." Office mernorandum, World Bank mission. Washington, D.C. North, W. Haven. 1992. "Addressing Management and Institutional Capacity Issues in the Health and Nutrition Sector." World Bank, Population and Human Resources Department, Washington, D.C.-: Nur, El Takir M., and Hotim A. Mahram. 1986. "The Effects of Health on Agricultural LaborSupply: ATheoretical andEmpirical Investigation. InAlandro N.Harnn and Patricia Rosenfield, eds., Economics, Health, and Tropical Diseases. Manila: UniversityofthePhilippines, SchoolofEconomics. OECD. 1989. Development Co-operation in the1990s. Paris. Ofosu-Amaah, SamueL and others. 1978. Health Needs and Health Services in Rural Ghana, 1. Institute of Development Studies, Sussex. England. Ojo, K 0. 1990. "International Migration of Health Manpower in Sub-Sahaian Africa". Social Science andMedicine 31(61):631-37. Over, Mead, Randall P. Ellis, Joyce H. Huber, and Orville Solon. 1991. "The Consequences of Ill-Health." In Richard G. Feachem, Tord Kjellstrom, and 234 B E T T E R H E A L T H I N A F R I C A Christopher J. L. Murray, eds., The Heathi of Adults in the Developing World. World Bank, Population and Human Resources Department, Washington, D.C. Over, Mead, and Peter Piot. 1991. "HWV Infection and Sexually Transmitted Diseases." In Dean T. Jamison, W. Henry Mosely, Anthony R. Measham, and Jos6 Luis Bobadilla. 1993. Disease Control Priorities in Developing Countries. New York: Oxford University Press for the World Bank. Owuor.Omondi, L. 1988. "The Development of Health Systems Research as a Toot for District-Level Health Planning and Management: The Case of Botswana." In World Health Organization, Thze Challaenge of Implementation: District Hlea kit Systemsfor Primary Health Care. WHO Document WHtOISHS/DHsIBB.1lRev.1. Geneva. Pangu, K. A. 1988. "La santd pour tous d'ici lPan 2000: c'est possible. Experience de planification et d'implantation des centers de santd dans la zone de Kasongo au Zaire." Thesis dissertation. Universite LibredeBruxelles, Brussels. Pangu, K- A., and W. Van Lerberghe. 198R. "Financement et autofinancement des soins tde aantE en Afrique." In Sante en Afrique, Perspectives et Srrategies de' Cooperation. Sonderpublikation dercrz N 218:6388. Eschborn, Germany. Parker, D., and R. Knippenberg. 1991. Community Cost-Sharing art4 Participation: A R- eview of the Issues. Technical Report Series no. 9. UNICEF, Bamaklo Initiative Unit. Population Reference Bureau. 1992. Adolescent Women in Sub-Salzaran Africa. Washington, D.C. Porter, David. 1992. Personal communication, fax of November 20. Scottish Overseas Health Support. - Preston, Samuel H. 1980. "Causes and Consequences of Mortality Declines L, Less Developed Countries during the Twentieth Century." In R. A. Easterlin,g ed. - Population and Economic C/tange in Developing Countnes. Chicago: University of Chicago Press. : 1983. Mortality and Development Revisited. Philadelphita: University of Pennsylvania. .1986. 'Review of Richard Jolly and Giovanni Andrea Cornia, eds., The Impact of World Recession on Children." Journal of Development Economics 21 (May):374-76. Raikes, Alanagh. 1990. Pregnancy, Birtking and Family Planning in Kenya, Changing Patterns of Behavior: A Health Utilization Study in KLsi District. Copenhagen: Center for Development Research.. Ransome-Kud, O., and others. 1990. "'Strengthening Primary Health Care at Local Government Level: The Nigeria Experience," Presentation at Abuja International Conference on PHc. Abuja, Nigeria. Rasmuson, Mark. 1985. "Report on the 1982 'Happy Baby Lottery.'" Field Notes, Communication for Child Survival Project, Academy for Educational Development. Washington, D.C. Republic of Uganda, Ministry of Health. 1991. National Healtdi Personnel Study.. Kampala. Republique du Tchad. 1992. Annuaire snatistique. Minist?.re de la SantE et des Affaires Sociales. Novembre 1992 supplementto 1991 version. N'Djamena. ., 0 ' | . X,' - ' ' . , : ' ' =' 0 ' A:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-, B l B L I O G R A P H Y 235 Reynders, D., R. Tonglet, E. Mahangaiko Lambo, and others. 1992. "Les agents de santi sont capables de determiner avec prdcision la population-cible des programmes de sanl4." Annalesde Sociezet Beige de Midecine Tropicale 72:145-54. Roemer, M. 1. 1972. Evaluation of Conmnunity Healthi Centers. Genevw: WHO. Rogo, K. 0. 1991. "Induced Abortion in Sub-Saharan Africa." Unpublished manuscript. Saadah, P. 1991. 'Socio-economic Determinants of Child Survival in Ghana: Evidence from the Living Standards Measurement Survey, 1987-88." Unpublished dissertation. Johns Hopkins University,.Baltimore, Md. Sahn, David E. 1992. "Public Expenditures in Sub-Sahamn Africa During a Period of Economic Refonns." World Development 20 (May)-673-93. Sambe, Duale, ahd Franklin C. Baer. n.d. "Church-State Partnerships-Can They Really Work?" SANRu Basic Rural Health Project, Kinshasa, Zaire. Sauerborn, R., A. Nougtara, and H. J. Diesfeld. 1989. 'Low Utilization of Community Health Workers: Results from a Household Interview Survey in Burkina Faso." Social Science andMedicIne 29(10):1163-74. Schulz, T. Paul, 1989. Return to Women 'sEducation. PHRWD Background Paper98/001. World Bank, Washington, D.C. Senderowitz, Judith. 1993. Adolescent Fer ility Health, and N/utrition: Issues and - - - Strategies. Prepared for the World Bank. Revised draft. Serageldin, I., A. E. Elmendorf, and E. El-Tigani. Forthcoming. "Structural Adjustment and Health in Africa in the 1980s." World Bank. Washington, D.C. Shaw, RI Paul, and Martha Ainsworth, eds. Forthcoming. Financing Healthi Services through User Fees and Insurance: Lessonsfrom Sub-Saharan Africa. World Bank Discussion Paper. Washington, D.C. - Shepard, Donald S., Taryn Vian, and Eckhard F. Kleinau. 1990. "Health Insurance in Zaire." PRe Working Paper 489. World Bank, Population and Human Resources - Department, Washington, D.C. Shepard, Donald S., M. B. Ettling, U. Brinkman, and R. Sauerborn. 1991. "The - Economic Cost of Malaria in Africa." Tropicat Medicine and Parasitology 42(3):199-203. Sheppard, James D. 1986. Capacity Building for the Healtth Sector in Africa. Washington, D.C.: U.S. Agency forInternational Development, Bureau forAfrica. Silverman, Jerry M. 1992 PublicSectorDecentralization: Economic Policy and Sector Investment Programs. Technical Paper 188. World Bank, Africa Technical, Department Series; Washington, D.C.. - Simukonda, H. P. M. 1992. "Creating a National NGO Council for Strengthening Social Welfare Services in Africa: Some Organizational and Technical Problems Experienced in Malawi." PublicAdnainistration and Development 12:417-31. - - Sirageldin, I., A. Wouters, and F. Diop. 1992. "The Role of Government Policy for Health: Equity versus Efficiency or Poverty versus Vulnerability." Unpublished manuscript. Johns Hopkins University, Baltimore, Md. Slobin, Kathleen 0. 1991.. "Family Mediation of Health Care in an African Community (Mali)." Ph.D. dissertation, University of North Dakota. Available from UMt Dissertation Information Service, Ann Arbor, Mich. .236 B ETT ER H E ALT H I N A F R I CA Smith, T. D., and J. H-. Bryant. 1988. "Building the Infrastructure for Primary Health Care: An Overview of Venical and Integrated Approaches." Social Science anrd Medicine 26(9):909-17. Soeters- Robert. and Wilbert Bannenberg. 1988. "Computerized Calculation of Essential Drugs Requirements." Socia Science and Medicine 27(9):955-70. South Commission and Julius K. Nyerere. 1987. Statement by Jutius K. Nyerere, ChairmanoftheSoLthnCommission.27thJuly.DaresSalaam. Stamps, limothy. 1993. "Communication to the WHO Regional Committee for Africa." Gobarane, Botswana. September 2. Steenstrup, J. E. 1984. "The Kenyan Management System of Drug Supplies to Rural Health Facilities." Unpublished manuscripi World Bank, Washington, D.C. Stein, C. M., N. P. Gora, and B. M. Macheka. 1988. "Self-Medication with Chloroquine for Malaria Prophylaxis in Urban and Rural Zimbabweans." Tropical and GeagraplhicalMedicine 40:264-68.: Stinson, Wayne, and Marty Pipp. 1987.: Commnxunity Financing of Ptrniary Health Care: the PRICOR Experience: A Comparative Analysis. University Research Corp., Center for Human Services, Bethesda. Md.; U.S. Agency for International - Development. Bureau for Science and Technology, Office of Health. Washington, D.C. Stomberg, Claudia, and Christopher Stomberg. 1992. Regression Results: Infant Mortality in Africa" Unpublished report. World Bank, Africa Technical Department. Population, Health and Nutrition Division, Washington, D.C. Tanahashi, T. 1978. "Health Services Coverage and Its Evaluation." Bulletin of WHO 56(2):295-303. Tchicaya, Anastase J.R. 1992. "L'Aide Ext6rieure h la Santd dans les Pays d'Afrique au Sud du Sahara." Africa Technical Departnent World Bank, Population, Health- and Nutition Division, Washington, D.C. Temple-Bird, C.L. 1991. "Training for Maintenance in Zambian Mine Hospitals." Unpublished paper prepared for the International Labour Office. Brighton, England. - Turwine, James. 1993. Issues in Healthj and Developmentfrom 0xfams Gross Roots Experience. Oxford: oxFAm.i- Unger, J.-P. 1991. "Can Intensive Campaigns Dynamize Front Line Health Services?: The Evaluation of an Immunization Campaign in Thies Health District, Senegal." Social Science and Medicine 32(3):249-59. UNICEF. 1987. Guinea Worm Controt as a Major Contributor to Self-SuciencyinRice - Production in Nigeria. urccEF-Nigeria. .1990a "Country Program Recommendation, Botswanaand Cape Verde." 1990b. The WorldSummitfor Children. New York. .1990c. The State of twe. Worldcl Ch2ildren 1990. New York. - - - .1991. The State ofthe World-s Chiildren 1991. New York. 1992a. "Achieving the Health Goals in Africa." Paper prepared for the International Conference on Assistance to African Children, Dakar, Senegal, ; November. ;- -. 1992b.Africa's Children, Afica Future. New York. B I B L I 0 G R A P N Y 237 1 1992c. Jhe Bawnako Initiative: Progress Report. UNICEF Executive Board 1992 Session. New York. - 1992d. Thje Stare of tlie World s ChiEldren 1992. New York. . 1993. Tte Stare oftli e World v Clhildren 1993. New York. .1994. TheSlateof tite World Chlildren 1994. New York. United Nations. 1991 Denmographlic Yearbook New York. *1992. Demographic Yearbook. New York. - 1992. Cltild Mortalitysince ti/e 1960s. New York. - 1993. Worid Populationt Prospects. 1992 revision. New York. United Nations Development Programme and World Bank. 1992. African Development hndicators. Washington, D.C. lUpanda, G., J. Yudkin, and G. V. Brown. 1983. Guidelines to Dnrg Usage. London: Macmillan Press. U.S. Agency for International Development. 1993. Nutrition of Infants and Young. Chzildren in Nigeria. Africa Nutrition Chartbooks. Macro Intemational, Inc., forthe IMPACa Project of the US. Agency for International Development, Washington, D.C. - VaillancourL Denise, Janet Nassim, and Stacye Brown. 1992. *'Population, Health and Nutrition: Fiscal 1991 Sector Review." PRE Working Paper 890. World Bank, Population and Human Resources Department Washington, D.C. van der Geest, Sjaak. 19822. "The Efficiency of Inefficiency:- Medicine Distribution in South Cameroon." Social Science and Medicine 25 (3):293-305. and Susan Reynolds Whyte. 1988. nTe ConJtext of Medicines in Developing Countries: Srudies in Plharmaceutical Anthropology. Dordrecht, Netherlands, and Boston, Mass.: Kluwer Academic Publishers. Van Lerberghe, W., and Y. Lafort. 1990. The, Role of the Hospital in thze District: Delivering or Supporting Primary Healthj Care? Institute for Tropical Medicine. WHOISHS/CC/90.2. Wn Lerberghe, W, and K. A. Pangu. 1988. "Comprehensive Can Be Effective: The Influence of Coverage with a Health Center Network on the Hospitalization Patterns in the Rural Area of Kasongo, Zaire." Social Science and Medicine 26(9):949-55. Van Lerberghe, W., K A. Pangu, and N. Vandenbroek. 1988.- "Obstetrical Interventions and Health Center Coverage: Spatial Analysis as a Routine Evaluation Tool." Health Policyand Planning 3:4. Van Lerberghe, W., H. Van Balen, and G. Kegels. 1989. Disirkil and First Referral Hospitals in Sub-Sazaran Africa: An Empirical Typology Based on a Mail Suney. Antwerp: Medicus Mundi International, Institute forTropical Medicine. Vaughan, Patrick, A. Mills, and D. Smith. 1984. District Health Planning and Managemenr: Developments Required to Support Primary Health Care. EPC Publication 2. Autumn. London School of Hygiene and Tropical Medicine.- Vaughan, Patrick. 1992. "Health Personnel Development in Sub-Saharan Africa." Policy Research Working Paper 914. World Bank, Population and Human Resources Department, Washington, D.C. 238 BETTER HEALTH I N AAFR I C A Vogel, Ronald J. 1987. "Health Cost Recovery in Mali: Preliminary: Report after Mission." World Bank, Population, Health and Nutrition Department, Washington. D.C. 1988. Cost Recovery i thte Health Care Sector: Selected Cotutry Studies in WestAfrica. Technical Paper 82. World Bank, Washington, D.C. 1 1989. "Trends in Health Expendilures and Revenue Sources in Sub-Saharan Africa." Unpublished report. World Bank, Population and Human Resources Department, Washington, D.C. 1990. "Health Insurance in Sub-Saharan Africa." PRE Worlking Paper 476. World Bank, Population and Human Resources Department, Washington, D.C. Vogel, Ronald I., and B. Stephens. 1989. "Availability of Pharmaceuticals in Sub- Sahamn Africa: Roles of the Public, Private and Church Mission Sectors." Social Science and Mediciie 29(4):479-86. Walsh, 1. A., and K. S. Warren. 1979. "Selective Primay Health Care: an Interim Strategy for Disease Control in Developing Countries," New England Journal of Medicine 301(18):967-74. XValt, G. 1988. "Community Health Worklers: Are National Programs in Crisis?" Heatlr-- Policyand Planning3(a):1-21.- Walt, G., M. Perera, and K. Heggenhougen. 1989. "Are Large-Scale.Volunteer Community Health Worker Programs Feasible? The Case of Sri Lanka." Social Science andMedicine 2%(5):599-608. Wasserheit, J. 1989. "The Significance and Scope of Reproductive Tract Infections Among Third World Women." International Journal of GQwecological Obstetnics (supplement 3):145-68.. Weaver, Marica, Kadi Handou, and Zeynabou Mohamed.- 1990. Patient Surveys a: Niamey National Hospital: Results and Implicationsfor Reform of Hospital Fees. - Prepared underUSAID Project683-0254.AbtAssociates, Inc. Wells, Stuart, and Steven flees. 1980. Heaflt Econonucs and Development. New York: Praeger. wHo. 1986. "Rapportde Voyage en Republique Islamique deMaurtanie." Unpublished manuscriptAction Programme on Essential Drugs. Geneva. 198 a. The Challenge of Implementation: District Heatth Systems for Primary Health2 Care. Document WHOISHS/DHS/88.1/Relv.1 Geneva. -. : 1988b. Estimating Drug Requirements: A Practical ManuaL Action Programme on Essential Drugs. Geneva. 1988c. Financing Essential Drugs: Report of a wzeo Workshop, wHo/ DAP188.10. March 14-18. Harare . 1988d. The World Drug Situation. Geneva. - . - - 1988e. WorldHealtt StatisticsAnnual. Geneva. -. 1990. "Programme for Control of Diarrhoeal Diseases.4 Interim Programme. Report 1990. Geneva. .- 1991a. The Evaluarion of Recent Changes in the Fmancing of Healtk Services. Geneva. 1991b. "The Relationship of Hiv/AtDs and Tuberculosis in the African Region." Plenary presentation during the wHo/GPA/NAcP manager's meeting. Saly Mbour, Senegal. B ItB L I O G R A P H Y 239 1 .991c. Maternjal Mortalio?. A Global Facibook Geneva. 1 l992a. "Human Resources database." Geneva. 1 1992b. Thre Hospital in Rural and Urbyan Districts. WHO Technical Report Series 819. Geneva. *1992c. "Health for All data base. Geneva. 1 1992d. Global Health Situation and Projections. Geneva. WHOIAFRO. 1990. Maternal and Child Healtit. Brazzaville. - 1991. Th7e Wo rk of wvuo in tle African Reg ion, 1989-1990. AFRJRC4I/3. Biennial Report of the Regional Director to the Regional Conimituce for Africa I January. Brazzaville. * 1993a. Regional Comnittee Meeting. 43rdSession. Statements by delegates. - 1993b. The Work- of vWio in tie AfricanfRegion, 1991-1992. AFRIRc43/3. Biennial Report of the Regional Director to the Regional Committee for Africa. Jmrazzaville. WHo, Netherlands Ministry for Development Cooperation. and Royal Tropical Institute. 1992. Healtlh Systems Researchi: Does It Make a Difference? Joint HSR Project in the Southem African Region. wHo/sHs/HsRJ9 2.2. wi o Information System. "Summary fortheWHo Africa Region." WHO/EPI/CEis/93.1 AF. Whyte, S. R. 1990. "The Consumers' Use of Pharmaceuticals: A Case from Uganda" Paperpresented to the World Bank/DANIDA Seminar on the Economics and Policy Choices of Pharmaceuticals in Developing Countries. Copenhagen, July 2-13. World Bank. 1985. -Pharmaceutical Strategy Paper Consumption, Production, World Trade, and Industry Structure." D-59e. World Bank, Industry Department, Washington, D.C. * 1987. Financing Health Services in Developing Countries: An Agenda for Reform. World Bank, Washington, D.C. 1990. World DevelopmentReportI990. New York: Oxford University Press. 199-.l "Tanzania: AIDS Assessment and Planning Study." World Bank, Southern Africa Department, Population and Human Resources Division, Washington, D.C. 1991b. WorldDevelopmentReportl99J. New York: Oxford University Press. 1992a. "Etude Sectorielle Regionale: Pratiques de Construction des Infrastructures Sociales dans les Pays du Sahel." Report 10294-AFR. Vol. IlL Washington, D.C. 1992b. "FY92 Africa Region ARtS." Annual Report on Inplementation and Supervision. Main Report Washington, D.C. . 1992c. "Pharmaceutical Expenditures and Cost Recovery Schemes in Sub- Saharan Africa." Technical Working Paper 4. Africa Technical Department, Population, Health, and Nutrition Division. Washington, D.C. * 1992d. "'The Public/Private Mix atthe DistrictLevel." Unpublished manuscript prepared at the consultation on district health systems for World Development Report 1993. November. M'Bour, Senegal. 1992e. World Development Report 1992: Devetopment and the Environment. New Yorkc Oxford University Press forthe World Bank 240D BETTER HEALTH IN A F R:I C A 1993a. "A Framework and Indicative Cost Analysis for Better Health in Africa." Technical Working Paper 8. Africa Technical Department, Human Resources and Poverty Division4 Washington, D.C. 1 1993b. CGestion du secteur de la sante: approches. mEthodes& et outils pour la gestion des proaznmes sectoriels dans les pays francophones ouest-africains." Report. 11953. Occidental and Central Africa Department, Population and Human Resources Operations Division, Washington, D.C. - 1993c. "Objectives and Evalution of District Performance: Are the Districts Really Useful?" Proceedings of consultations in support of World Development Report 1993, November 24-27, 1992. Institute of Health and Development, UniversityofDakar, Senegal. - 1993d. srrs 1993. Data files. Washingtont D.C. 1993e World Development Report 1993. Investing in Healrh. New York: Oxford University Press. . 1994. Adjustment in Afriac Refornm Resulrsf, and the Road Ahead. A World Bank Policy Research ReporL New Yorka- Oxford University Press. Yudkin, John. 1980. "The Economics of Pharmaceutical Supply in Tanzania." InternationalJournal ofHealth Services 1O(3):455-77. Yusuf, Zia. 1993. "A Framework and Indicative Cost Analysis for Better Health in Zimbabwe." World Bank, Africa Technical Deparment, Human Resources and Poverty Division, Washington, D.C. ~ THE WORLD.BANK - - v~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I Better Health in Africa sets forth a vision of health improvement that challenges African countries and their external partners to rethink current health strategies. The report stresses positive experiences in Sub-Saharan Africa and concludes that far greater progress m im- proving health is possible than has been achieved in the past-even within existing resource constraints. On the basis of experiences with well-functioning health care systems in a number of countries, the report proposes tat a basic set of health services can be provided in low-income Africa at an annual cost of around $13 per person. At present, the amount spent per person averages about $14-from $10 per person in some countries to more than $100 per person in others. Yet in many countries more than 50 percent of the population lacks regular access to quality health services. Keys to providing basic health services to larger numbers of people include minimizing current high levels of waste - a,id inefficiency, reallocating funds from expensive services that benefit the few to more cost-effective services that benefit many, and mobilizing additional domestic and foreign revenues, especially for the poorest African countries or for the poorest groups witbin countries. This report illustrates the costs and benefits involved, casting new light on the advantages of health reform. Many governments and their partners in Africa-including private voluntary providers, private-for-profit providers, and donors-are already taking important strides to implement the recommendations in this report. Their experiences figure prominently here and are testimony to the importance of health as a critical foundation of sustainable economic development. Others have yet to move as decisively in directions deemed essential. The current high level of unnecessary suffering and the waste of human lives and potential underscore the urgency of the task. Better Health in Africa was written by staff of the World Bank Africa Technical Department in dose cooperation with the World Health Organization and UNICEF. The book is documented by a compre- hensive statistical appendix, as well as by nulmerous tables, figures, and boxed essays in the text. (!n,nar r1aerrin bv Arnuroa C Watonn