HOLISTIC AND DECENTRALISED APPROACHES CRITICAL TO EFFICIENCY AND EQUITY IN HEALTH SERVICES

9 May 2003

Holistic and decentralized rather than sectoral and centralised approaches are key to effective and equitable delivery of health services in Zambia, observes the Jesuit Centre for Theological Reflection (JCTR).  This is the message of a major study released by JCTR on 09 May 2003.

The study, entitled “Health Status and Health Equity: A Case Study of Zambian Households in Selected Areas,” was commissioned by JCTR and conducted by Prof. V. Seshamani and Dr. C. Mwikisa of the Economics Department of the University of Zambia.  One of its prominent findings is that centrality has a consequence of the inequity that emerges in terms of the distribution of health facilities and services as well as overall development.  For example, Chongwe district, despite being in the best fairing province of Lusaka, has a higher incidence of mortality and illness compared to Mongu, the capital of the most deprived province.

Moreover, the study established that people do not see much benefit from the health facilities that are not adequately equipped with competent medical personnel and supplies.  They were concerned, in particular, with the continued lack of drugs at health facilities. This forced them to use drugs whose quality they were not sure of. The situation also means that they obtained drugs from relatives and friends or purchased from chemist shops. They are also not aware of the right dosages of the drugs resulting often in over-consumption and consequent resistance to drugs over a period of time.

The JCTR study also notes that if there are many sick members in a household or members who are chronically ill, even if they are receiving treatment for which households are spending money, it does not imply that households can afford such expenditures. Often, this expenditure may be incurred by cutting back on food and children’s education. A household may consume less food or pull children out of school so that the resultant savings may be used to treat sick members.  This is a very dangerous situation arising out of the inadequate household incomes characteristic of most households in Zambia.

“This fact is critically important,” says Muweme Muweme, Coordinator of the Social Conditions Research Project of the JCTR “and is one of the reasons the JCTR has been advocating for policies that enhance living conditions through ensuring that households earn adequate incomes.”  The just-released April 2003 Basic Needs Basket report -- though confined to Lusaka but certainly giving an idea of what is obtaining elsewhere in the country in terms of cost of living -- continues to show high cost of living for a family of six.  Currently the cost of food for a family of six in Lusaka is K383,650.  This continues to be high, despite some reduction in the price of mealie meal because of the start of the harvest of the current maize crop.  The total Basic Needs Basket, which includes non-food items such as housing and charcoal, was K1,030,850 for April 2003.

Sadly, the worst affected households are those headed by females, says Muweme.  The study established that gender inequity exists in respect of health status and affordability of health care. This study serves to reinforce the broader findings from numerous researches that gender differentials constitute a serious development issue that needs to be addressed.  Furthermore, the growing impoverishment of households and the incidence of orphanhood caused by death of parents from disease, largely due to AIDS, have been generating growing numbers of children dependent on other households to take care of them. This in turn leads to deterioration in the living conditions of these latter households.  The burden of supporting additional children seems to be a widespread phenomenon in both rural and urban households.

RECOMMENDATIONS OF THE STUDY

Based on some the major findings highlighted above, the JCTR study on Health Equity makes the following recommendations:

• First, poverty reduction and development programmes should not be concentrated only  in the vicinity of major towns, cities and capitals. This results in an “out of sight, out of mind” approach to development! Programmes need to be evenly spread over the entire country. Indeed, given the higher levels of deprivation already obtaining in the more remote areas in the country as a whole as well as within each province and district, there is need to focus development efforts more on these areas than on those that are already empowered to some extent in respect of various dimensions of development such as social services, employment, infrastructure, etc.

• Second, the problem of health has to be addressed from a holistic perspective because of the inter-linkage of health with other elements such as food, nutrition, education, etc. Spending to cure the illness of the sick members of the household by reducing food and nutritional intake of other healthy members, for example, would increase the probability of the latter also falling ill and thereby warrant further future spending on curative health. Thus the affordability of health services must be gauged not simply by the actual spending by households on the services but in relation to the overall basic needs of the households.

• Third, as has been suggested in other major studies cited in the JCTR report, targeting beneficiary groups in poverty reduction programmes should use, for greater effectiveness, “Poverty + Health, notably HIV/AIDS” as the formula to assure more effective coverage.

• Fourth, in working out exemption mechanisms (e.g., doing away with cost-sharing in health services), account should be taken of other variables other than monetary ones only. Given the scarcity of resources, use of broader variables, like the ones used in this study to construct socio-economic indices, will ensure that only the needy benefit from the well intended exemption mechanisms.

• Fifth, health programmes and more broadly poverty reduction and development programmes must target female-headed households.  The gender element is critical to overall effective development efforts in Zambia.