WHEN HEALTH DIES: GOVERNANCE OF HEALTH CARE IN ZAMBIA IN THE 1990S.
Dr
Katele Kalumba
If by account of mental infirmity, loatheness or delusion, we deprive
ourselves today of something so naturally occurring as the human experience and
power to dream; if it will be said that our endeavours, if any at all,
bequeathed for our children and their generations thereafter, a future devoid
of possibilities for quality leisure time, sterile family lives, idiocy of the
mind for lack of a zest for learning, and many poverties of unproductive work,
I am afraid then that our time and our politics were nothing but echoes. And
let it be stated that he who echoes, deceives (Kalumba, 1997:1 Chienge Notes)
I. INTRODUCTION
The World Health Report (WHR)
for 1998 produced by the World Health Organisation (WHO) presented an
optimistic picture of health in the new millennium. It argued that the 21st
century will hold the prospects for both prolonged life and superior quality of
life with less disability and disease. However, the Report also cautioned that
while “humanity has many good reasons for hope in the future… such an
optimistic view must be tempered by recognition of some harsh realities” (WHR , 1998:1). One such harsh reality
identified in the WHR, is poverty. In countries such as Zambia, it is often
stated in official and unofficial statistics, that over 70% of the population
live under conditions of abject poverty (CSO, 1997). In order to address the
problems of poverty, Zambia like other developing countries are involved in
macroeconomic structural adjustment programmes under the guidance of the
International Monetary Fund (IMF) and the World Bank.
It can be argued that
structural reorganisation and economic growth are important considerations to
guarantee both lasting health reforms initiatives and poverty reduction
(Jorgensen,1995). Yet, attempts at addressing poverty issues in the
context of health requires an understanding of the complexity of macroeconomic
performance and health outcomes. ( Genberg, 1992: 47; Behrman,1992 ; Jolly,
1988; Pinstrup-Andersen, 1987 ). There are serious limits in studies that seek
to establish linkages between the macroeconomy and health outcomes,
particularly at the household level (Berhman,
1988).
Surface complexity arising out of deep
simplicity is a perfect definition of turbulence,
totally ordered here and pretty much random over there. The movement of health and macroeconomic
performance in the general population has characteristics of non-linear systems
like ecosystems. In the non-linear world, many components interact in complex
ways, leading to notorious unpredictability. Small inputs can lead to
dramatically large consequences characterised by the “butterfly effect”. The
next time around very slight differences in initial conditions produce very
different outcomes (Lewin, 1993). Movements in health and macroeconomic
performance have disturbingly similar characteristics of turbulence.
While global health
trends reported by the WHR (1998) may appear promising, movements of
macroeconomic factors at country level may have, qualitatively and
quantitatively, uncertain prospects for households and individuals in the 21st
century. Invariably, as Behrman (1992) has pointed out, the state of the
macro-economy, including its current and expected rate of growth, affects
health determination through affecting the actual and the expected values of
variables that determine health in reduced-form demand relations or in the
marginal benefit-marginal cost relations. And because these relations operate
within the whole economy, with lags and feedback, and given the large magnitude
of behavioural responses, it is not possible to predict precise impacts of
macro-economy on health but instead, a range of possibilities. In other words,
from the point of view of economic theory, almost anything can happen (Behrman,
1992:34).
Moreover, the general
public and the educated elite in most countries mainly judge the government’s
health policy management by their own health situations. Consequently,
individual health evaluation is invariably subjective. In this order of things,
the public cannot be expected to consider whether things would still be worse
in the absence of specific policy
reforms adopted either in the macroeconomy or health, let alone to separate the
snarled interactions of announced policies, actual government actions, and
factors beyond government control such as the impact of El Nino weather
patterns. A country study gives us an
opportunity to closely examine these issues and pose the question in the
negative: by what process does a country’s vision of a healthy society die?
HEALTH REFORMS IN THE 1990S
After seven decades of
evolution, Zambia’s modern health care system at the beginning of the 1990s,
appeared to be totally inadequate to respond to the many health needs of its
population or to tackle the underlying causes of ill-health. Health care
resources –infrastructure and
manpower—were in scarce supply and mal-distributed between the urban and rural
areas and between peri-urban and affluent parts of urban areas . And following
the collapse of the seventeen year old One-Party, pseudo-Socialist State
Administration of the Kenneth Kaunda
regime with its health policy dilemmas
(Kalumba and Freund, 1989), a new
pluralist government led by a former
Trade Unionist, Frederick Chiluba, nd imbued with the idealism of democratic reform introduced a comprehensive
health sector reform programme alongside liberal market policy reforms in the
economy which reflected much of the cutting-edge knowledge of the 1990s.
However, ten years in
the reform programme both the promised benefits of macro- economic adjustment
and of effective health sector reform have remained largely elusive
institutional objectives for countries
such as Zambia. It was argued during the 1990s that good governance characterized by decentralisation of financial
control, public sector reform, meaning largely improved and down-sized
personnel and health programming and management leads to improvements in
efficiency and effectiveness of health care system and improved health status (Streefland et al ,1995:16-17). Yet, we shall
show that Sub-Saharan African countries like Zambia, face a loss of
popular confidence in government’s ability to manage national health
situations. The idealism of a new cost-effective and equitable health order
which has inspired the international health movement for over two decades seems
to have dissipated in countries such as Zambia.
Much of the literature
sponsored by Donor AID agencies and governments during the 1990s stressed that
during health sector management reforms, government strategies in African
countries, including in the SADC region must change the relations between ‘civil society’ and public service institutions. Health
sector reforms had translated into an ideology of good governance.
Correspondingly, it appeared that reform efforts were being challenged in the
process by various interests (most of which were sponsored by donor agencies
themselves) seeking to transform technical questions of medical and health care
into issues of political representation and of power. What processes were set
in motion by this paradigm shift and with what consequences for health?
Because Zambia’s health sector reform efforts
appeared to have led the way within the Southern African Development Community
(SADC) region countries in the 1990s, and granted that popular press in Zambia
has already passed judgement that health sector reforms have failed, an
informed understanding of what really happened in Zambia would be instructive
to the region, if not to Africa generally.
The first question we pose for a country such as Zambia is: by what process does the vision of public
health erode?
METHODOLOGY
The study is in four
parts. First, we describe the nature of health sector reforms which have been
advocated in the last three decades and those that are still being proposed for
the next millennium. We point to the many technical design issues they raise.
Second, we examine
issues of democratic and market-type governance of health sector reforms as a
particular case of the “technical” governance problem that health sector reform
policy design and action entail. The
current global movement towards what Saltman (1995) and Moore (1996) refer to
as “New Public Management” or market-type health sector reforms presuppose
specific forms of the institutional allocation of resources to various social
segments of society. What these forms of allocation actually become in the
process of policy implementation, is unpredictable in their social consequences
for any government. Third, we examine
Zambia’s health sector reforms during the 1990s and reveal the reform political
problem of “orthodox paradox” (Nelson,
1989).
And finally, we attempt to draw some lessons
learned in particular, regarding the role of “transformational leadership”
(Heifetz, 1996) and implications for future reform efforts in the health sector
in developing countries like Zambia.
A. HEALTH SECTOR REFORMS: The governance problem
In Zambia as in many
developing countries, “health sector reform” has become part of the broad range of state public sector reform
interventions that go with the need to restructure economies that are severely
distorted (Kalumba and Freund, 1989). The decades of the 1970s through into the
1990s in particular, have seen concerted and varied innovations in the quest to
address the structural problems assumed to exist in the performance of national
health systems. These efforts have not been limited to developing countries
alone. Above all, it is naïve to assume that
the issues they address have been unique to our era of “structural
adjustment”. Witness the efforts at
reform in the British National Health Service (NHS) since 1948 culminating into
various attempts at “reforming “ the NHS in the1980s. Prime Minister Margaret Thatcher’s government
efforts at introducing “internal markets” have had considerable intellectual
currency among public sector service reformers. However, Tony Blair’s Labour
government elected in 1997 promised to get rid of “internal markets” in the NHS
and revert to the 1948 principle of health care on the basis of “clinical need”
and not on the “ability to pay” (Langlands, 1998:viii-xv).
That health systems
are assumed to be under particular stress today is remarkably clear in various
developed countries’ reform attempts. President Clinton’s Health Security Plan
in the USA, and its collapse; the crisis in the Canadian Health Insurance
–based health system that Prime Minister Jean Chretien’s Health Forum addressed
in 1996; reform efforts in the Swedish
health system during the 1990s, (Reich, 1995; Anell, 1994) all testify to a
global movement that suggests a continuing problem in the way governments
govern health care.
The focus of Zambia’s
health sector reforms during the 1990s was, like in many developing countries,
double-pronged. On one hand, it emphasized on a social crusade of empowerment driven by values of equity and
social justice. And, on the other hand, it stressed on the need for a strong
public management philosophy of cost-effectiveness, driven as it were by changes
in the macroeconomy (Kalumba and Freund, 1989; Jamison, 1993; Cassels, 1995;
1997; Saltman, 1995; Diderichsen, 1995;,
Kalumba, 1997, Paul , Walt, 1994,
Berman 1995). The idea that health care is a right has been a dominant
ideology for many health reformers since the Primary Health Care (PHC) Declaration of Alma Ata in 1978. The
notion has been that citizens can be placed back at the centre of the health
care system, where they may play the role of decision maker, consumer and even
perhaps, financier if market forces are properly aligned. Defining the nature
of this right, let alone enforcing it, has been both a legal and health policy
challenge. Above all, increasing popular disaffection by those populations for
which reforms in health are intended to benefit, often referred to in
literature as “stakeholders” or “partnerships” (Cassels, 1997;….. ) suggests some fundamental
mis-apprehension, about the central
issues and processes involved in reforms.
It is clear therefore
that, from the vantage point of health policymaking, it is a pretty rough road
into the twenty first century. We draw upon a thesis developed by Bates
(1981:4) in a study of agricultural markets and state intervention in Africa
for a general proposition that may guide us in a critical analysis of
macroeconomy, governance and health policymaking in Zambia. Bates argues that
while we can acknowledge the importance of public purposes and reasons of State
in public policy, we have to recognize as equally important, that more personal
motives and capacities, animate political choices and we can add, political
judgements. Governments in Zambia, like governments anywhere, want to stay in
power. They must therefore appease those powerful interests who underwrite
their ascendance to, and sustain them in power. Bates further points out that
people turn to political action to secure special advantages. What forms of
political action are available to the people for this purpose? And in addition,
there is the role of leadership and its manifestation in those policy makers
who assume responsibility for the health sector.
A. HEALTH SECTOR REFORM DEFINED
If we had to sum
up the gamut of reasons why reform in the health sector are justified, we would
share Knowles and Leighton’s (1997) definition of what health sector reform is:
a broad range of health system
interventions with varied objectives. They write, “Health sector reform is a process that seeks major changes in
national policies, programs, and practices through changes in health sector
priorities, laws, regulations, organizational and management structure, and
financing arrangements. The central goals are most often to improve access,
equity, quality, efficiency, and /or sustainability. ( Knowles & Leighton,
1997:2) . Below we attempt to show just how challenging this definition is in
practice.
B. REFORM PROCESSES ARE COMPLEX
If any lessons have
been learnt about health sector policy formation and performance during the
twentieth century, one might be forced to conclude that, government intervention anywhere is self‑evidently partial, incoherent,
and provisional in nature. This is
the case because in the first place, the government of health policy formation
and implementation is influenced by the various forms of institutional and organisational
arrangements. And secondly, state action
in the health sector, when analysed as political practice, reveals the heavy influence of the pressures exerted by
various social interests in their individual and collective identities. It is precisely because of the fact that
neither institutional reforms in health care itself nor the social pressures
that make such reforms necessary have clear origins, consistent and rational
managerial or social objectives that the processes involved in, and consequences
of government intervention are always problematic. This is what we have defined
as conditions of “policy turbulence”
The history of reform in health care systems leads to one
conclusion that the process of improving the health of a country is slow
and complex; that profound changes in social systems including values and
attitudes that are necessary are the result of a long-term commitment to build
a multi-faceted and broad-based process of social and economic change; and that
many of the challenges to health that countries face anywhere in the world, are
interrelated and require a holistic and continuous intervention to address
them.
There are complex issues related to the governance of the
structure of provision of health care. Even in countries where the public
sector is considered to be the primary provider of health care services, health
care reform must consider the potential role of other providers, whether family
members, indigenous healers or private allopathic providers. Governments in the
process of reform will reconsider what health care services should be provided,
how care should be organized and inputs should be used; as well as how the
provision of care will be financed. To
maximize the efficiency of the system, government planners often program the
use of limited public sector resources in a way likely to complement other
sources of financing. Consideration of
the entire system is necessary in order for planners to anticipate how the
different components can complement one another to ensure the development of an
effective and affordable system. Yet,
this may appear to be such a daunting exercise, that few will attempt it,
preferring instead to address specific components of the system (e.g., primary
health care) or specific issues (e.g., the public/private mix).
C. OBJECTIVES ARE MANY AND SOMETIMES CONTRADICTORY
Most health systems
analysts would agree with the characterization by Knowles and Leighton (1997)
as to why and how countries embark on health sector reform. In many analyses of
health sector performance problems that countries are addressing, the following
are common issues: 1) the efficiency
with which resources are used (cost-effectiveness); 2) access constraints (the equity problem), 3)
the unsatisfactory nature of services themselves ( the quality issue); 4) the financing difficulties both for the
government and people (the resource availability ) (Cassels, 1993; World Bank,
1993; Diderichsen,1995). Cassels’ (1993) refers to these measures as addressing
themselves to the institutional imperatives of structuring health service
delivery.
Cost-effectiveness has
particularly attracted the attention of
many reformers during the 1990s. The World Bank’s World Development Report (WDR)
of 1993, stressed the importance of cost-effectiveness in the governance of
health care. It observed:
The need for health sector reform is
virtually global. Developed and
developing countries, centrally planned and market oriented health systems, successful
and flawed health institutions all seem to share two basic attitudes: a
profound dissatisfaction with the present organization and financing mechanisms
of health care delivery, and a conviction that there are ways to obtain better
results with the available resources. To
be effective, health sector reformers will need to review existing services and
adapt them to provide the most cost-effective interventions available.[1]
However, Tugwell et. al. contend that effectiveness cannot be
maximized without improving provider and patient compliance, diagnostic
accuracy and coverage. Provider
compliance is the extent to which the provider adheres to standards for care;
patient compliance, the extent to which the client follows treatment regimens;
diagnostic accuracy, the extent to which the provider distinguishes clients who
could benefit from care; and coverage, the extent to which clients who could
potentially benefit from care actually receive it[2]. Although the model is used to describe the
effectiveness of an intervention, system effectiveness is similarly
determined. Concerns about equity might
be more accurately defined as equity of access, or coverage. If the system cannot reach everyone who could
benefit from its services, then it cannot maximize its effectiveness, where
maximum effectiveness is defined by efficacy (the potential impact which the
system could achieve under ideal circumstances). The potential impact of health care services
upon helath status is limited, as other factors such as social and economic
ones will also affect health, the potential impact of the system might be
considered its efficacy, or potential effectiveness.
Achieving effectiveness will require that the household and
community as well as the health care facility meet specified standards for
compliance, accuracy and coverage. It
must be recognized that each of these levels of the system will incur costs in
their effort to meet established standards, and that standards which are unaffordable
will not be achieved or maintained.
Given the limited resources available for health care, all available
sources of financing will need to be used efficiently in order to maximize
effectiveness. The objective of health
care reform might be described as an effort to maximize the cost-effectiveness
of the system.
Contributions to the process of planning reform have focussed
on defining a) cost-effective interventions for health care; and b) alternative
mechanisms for financing health care.
In recent years, making a full range of
services available to the total population has relied primarily on the
development of financing mechanisms.[3]
Yet, changing what interventions are provided, or the way
that care is financed will not be sufficient.
A combination of cost-effective interventions will not necessarily
result in a cost-effective system, nor will new approaches to financing
automatically produce a more efficient system.
The planning of effective health care reform will need to envision all
the aspects of the kind of system which will best enable the achievement of
national goals given the resources available.
The World Development
Report (World Bank, 1997) which is
dedicated to the understanding of the State institutional capability and forms
of intervention in a changing world market, point to various state
institutional mechanisms of service delivery that touch upon the efficiency
with which health sector performance may be achieved. These mechanisms refer to
problems of “exit options”, “voice” and “compliance and loyalty”. (WDR,
1997:87) But it is equally critical to
observe that these institutional ‘problems’ have different social consequences
for various social interests in any country.
Another major theme
posed throughout this study therefore is :
how should governmental performance in health sector reform be judged when the
conditions and process of effecting such reform appear contumaciously turbulent
at every turn? The case of Zambia’s experience, attempts to show that
popular acquiescence to continued health sector reforms in the twenty first
century will depend on the implementation of a series of transformational
management strategies applied to seemingly diverse health policy problems and
yet yielding small but demonstrably incremental benefits to some significant
population. This process is qualitatively different from what policy analysts
call “disjointed incrementalism” (Kahn,
). It is on the contrary, “transformational incrementalism” as it forces
allocative structures of health policy to progressively concede to pressures to
account for equitable distribution of health benefits. Apparently, it so
appears that for the general population, health will die as the health sector
becomes a centre of contestation for various stakeholders seeking political
representation and policy makers manifest their specific and peculiar
understanding of the management of the health sector and their political
agenda.
D. A SPECIFIC PARADIGM OF HEALTH IS ASSUMED
Inherent in the
various objectives of health sector reforms is a health paradigm which has been
assumed for many decades and regurgitated in profound speeches of Health
Ministers during the annual “ health
carnival ” of the World Health Assembly convened by the World Health
Organization (WHO). A typical Head of
delegation speech to the World Health Assembly would, besides the wish list of
donor AID (if a developing country) or self-praise about their country’s
achievements, pronounce a variety of what they perceive as fundamental concepts
health and health care. Health policy
makers see people’s health as a resource for everyday life. People wish to be healthy in order to lead
rich and fulfilling lives, and to attain their maximum potential. In this context, health is more than just
physical health—but national efforts in health service provision are also
challenged by the need to pay attention to mental and social well-being. Invariably, this is understood as the
standard objective of health change as enshrined in the WHO constitution. This
reads: “Health is a state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity” (WHO 1946:1). Having paid tribute to the
founding fathers of 20th century health thinking , the delegate would further state that their
country recognises that the level of
health of their communities is a reflection of the quality of such communities
and that health for all must be an imperative of national health policy goals. Their country aspires to providing the
basic prerequisites for health for all. They will tell the Assembly that theirs
is a sophisticated understanding of health, one which illuminates the complex
interactions and the holistic nature of the determinants of health.
In the characteristic nature of the assumed paradigm, there
is always the acknowledgement that national health situations are in “crisis”
spurred by financing problems, institutional modalities etc. A careful analysis
of literature would reveal that the stress on the role of markets and
privatization, incentives, and disincentives, cost control and cost benefit
analysis, deductibles and co-payments, various budgeting and organizational
schemes , public\private mix, centralization
vs decentralization span a long history of health systems development thinking.
What the health sector reform literature and in particular, the World Health
Organization policy scientists ( Yach, 1996) do not provide us with is their
assessment of the adequacy of all the various national responses to the
"health crisis". One would wish to ask, given this history, have all
health reform responses been enough ? Even more cryptically, the question,
enough for what? Is it not the case that
national and global responses by international health institutions such as
WHO have focussed primarily upon the issues related to the means of medicine
and health care and not, upon their goals and ends? The intensity of debates on
health reforms globally has obscured the poverty of discussion about the
purpose and direction of medicine and health care and hence upon the national
health goals and purposes. Shouldn't we be considering as one major issue, the
point that the ends of medicine and health care and not only the means for them
are at the core of the definition of the problem of health sector reforms? Too
often, it is taken for granted that the goals of medicine and of its service
technology of health care are all well understood and self-evident, needing
only sensible implementation.
In the movement of
state policy formation and implementation in the health sector, the definition
of what constitutes “benefits” is a work of deconstruction. It involves a study
of the practice of how health sector reform objectives are represented and
accounted for by health policy
stakeholders including State agents such as health workers. To be adequate,
analysis of health sector reforms must examine the specific scientific
construction of strategies of public policy rationalisation. Health care
strategies and their official accounting of health outcomes are forms of
scientific practice in which a constitutive power is granted to ordinary
language by a group that uses that language with its invested authority. The
language of health sector reform strategies at any particular moment, imposes
what it states, tacitly laying down the dividing line between the thinkable and
the unthinkable in health policy accounting. It is completely besides the point
to seek to characterise health sector reform strategies as either scientific or
pre-scientific. It matters however, if we are to understand the science of
health sector reforms, first to recognise the primary profit of the practice of
health sector reforms and second, to identify “second-order strategies” which
are used to engender intellectual conformity to particular prescriptions of
what constitutes acceptable reform strategies. Therefore we need to ask as a
specific theme this question: How is a new reform “idea” regularised into
“scientific thinking” within health policy formation and implementation such
that it would give the group that practice it the satisfaction of enlightened
self-interest and the advantage of ethical impeccability?
E. MULTIPLE HEALTH SYSTEMS VALUES
A content analysis of
World Assembly speeches from the official records of WHO between 1992-1996 from
15 English-speaking country delegates randomly selected yielded the following
“articles of faith” in public health values:
·
Promotion of health and prevention
of disease is better than cure.
·
Social interventions to enhance
the common health of the community are appropriate and may take precedence over
individual concerns.
·
Inequalities in health must be
reduced and their roots in social inequities must be addressed.
·
A healthy sustainable
environment is essential to health development of communities
·
Communities must be
human-centred , caring, sharing, co-operative and supportive particularly for
the most vulnerable.
·
Each individual in society
needs a meaningful role and the ability and the opportunity to participate
actively in the community and in the decisions affecting their health.
·
Access to health care is a
human rights issue.
These are some of the
many values that have informed the promise of “health for all by the year
2000”, now restated to be timeless (WHO, 1998). Values like promises are not
solutions. Getting policies right and saying all the right things does not
bring about positive health. The promised land of Health for All is not
consumable or credible in the absence of tangible evidence that real
investments to improve those health services that touch upon the everyday
health experiences of ordinary people have been committed and are being
judiciously spent.
F. CHANGES TO MANAGEMENT STRUCTURES PROBLEMATIC
Andrew Cassels (1993)
points out that health sector reforms are concerned with changing health
policies and the institutions through which policies are implemented. He
stresses that redefining policy objectives alone is not enough. Institutional
reform is a priority because existing institutions, organizational structures
and management systems generally fail to deal adequately with empirical
problems of health sector performance.
The critical question here is: for which social categories are currently
observed empirical failures of institutional performance problematic?
G. HEALTH SECTOR REFORM AS DONOR DISCOURSE
Many critics of health
sector reforms in developing countries stress the point that they are
donor-driven. Donor support for such reforms are bound to have varied
objectives least of which may be public health. Donor agencies have attempted
to articulate what their expectation of health sector reforms are. We attempt a
very brief overview (Cassels, 1995, 1997)
The World Development Report (WDR) by the World Bank (1993)
was a very sophisticated epidemiological discourse which told us that there is
life in the breath of governments. That the ‘quality’ of government health
policies really matter in terms of better levels of health. The WDR
told governments that there are three ingredients of quality health
policies. These are fostering an environment that enables households to improve
health; Improving government spending on health; promoting diversity and
competition.
In 1994, the British
Conservative Party government’s Overseas Development Administration’s (ODA)
approach under the strong arm of Barronness Lynda Chalker stipulated that
foreign aid in general must be based upon ‘good governance’. In health sector
support , ODA advanced what appeared as a strictly economic analysis: The
British wanted developing countries : to
promote economic liberalisation; enhance productive capacity; encourage good
government; help implement poverty reduction strategies; promote human
development; improve status of women, and help tackle potential environmental
problems. Therefore British ODA recommended reform in the health sectors
through what was termed as an ‘efficient management of scarce resources and appropriate organisational structures, and
financing systems’. This was to be coupled by the need to have children by choice and better
reproductive health; control of malaria, tuberculosis and HIV and, alertness in
managing health under emergency situations (ODA, 1994).
The World Health
Organization, has in the last five years been
re-defining the New Global Health Policy. Governments
are being asked to pay attention to equity,
solidarity and health and make health a fundamental human right and worldwide
goal. A study group has been established
under the auspices of the of WHO to examine the concept of good governance in
health care. In various attempts at defining this “politicality” in health, WHO
has urged governments that they must: initiate political action for health;
focus on health protection and
promotion; pay attention to health system development, reform and
management; and combat ill-health.
During the 50th World Health Assembly, an attempt was made to pass a
resolution on “preventive health diplomacy” . The Indian delegation found the
initiative murky and poorly defined and in committee stage, successfully
negotiated its exclusion.
Clarity of policy
concepts is central to their operationalization. But clarity appears to elude
the concept of health sector reforms in
health policy governance. Anders Anell
(1995) has described Sweden’s long history of reforms in the health
sector. During the conservative government in the 1990s , particularly between
1992-1994, major reforms were attempted to address structural problems in the
way in which county councils provided services. The new reforms emphasised:
patient choice, purchaser\provider split; performance based provider payments;
and increased competition in service provision.
The jury is still out about the success or failure of these reforms.
More significant however is the observation that when the Social Democrats went
back to power in 1994, major policy reversals which introduced ‘market’
concepts such as a national system to allow for competition among general
practitioners, and opportunities for specialists to set up private practices
with funding from county councils , were
reversed. For developing countries, the period of conservative government rule
in Sweden during the 1990s increased unpredictability in Swedish funding to its
AID agency SiDA. There were attempts whose effects still remain, to put
emphasis on result-oriented programme planning or “ ROPPS”, a unique system of
programme performance appraisal which even officers within the Swedish
bureaucracy often found difficult to explain to recipient countries like
Zambia.
In Michael Reich’s
(1996) Policy Maker , A computer-assisted political analysis, there is
an underlying theory of political practice in which the political actors with
various interests, manouvre out through
positions by way of systematically designed strategies that each player is
capable of constructing for the sole purpose of winning his or her group’s
specific demands by overcoming those of others. It is an interesting exercise.
What is not clear and needs additional explanation is how it is that the system
of political institutions is sufficiently positioned to be responsive and
reactive to become aware of any particular group’s demands as to accord them
the status of political issues or as Reich puts it, be on the ‘agenda’. Moreover , why is it not so responsive and
reactive that any individual group’s ‘issues’ or ‘ policy contents’ might be
significantly registered and dealt with in ways that are not necessarily the
preferred outcomes of the group in question?
In other words, Reich’s approach does not tell us anything about the
“intelligence” of the state institutions through which needs, interests and
demands are articulated and the process of the conversion of ‘demands’ and ‘
policies’ into agenda issues worthy of substantive treatment. The form and
manner of practice of state policy institutions is missing somehow in Policy
Maker.
The decisions made during the planning of health care reform
will be examined by the many stakeholders in the existing system of care:
clients, public and private providers, government leaders, and donors. Even when the general objectives for reform
are agreed upon, if the decision-making process for designing the new system is
not appreciated by all involved, the plan will not receive the support critical
for implementation. Methods which will
facilitate a systematic approach to the comprehensive planning of a cost-effective
health care system can assist planners in guiding a viable process of reform
which will have external credibility.
The process must be transparent and where possible based upon analytical
techniques which enable more objective decision-making.
Another perspective on
examining health reforms is to consider them as instruments through which by
altering public forms of organisation of health care agents and restructuring markets or ‘publics’ within
which various health skills are employed and demands are made, reconstruct
political subjectivity. The practice of
health reforms involves the state political management of the whole field of
the production and consumption of medicine as a social service. We are arguing here for analyses which point
out that the constitutive power of
health policies lie not with the
policies themselves but with the group which authorises it and invests its
authority. State health policy,
particularly the system of concepts by means of which agents of the state
provide themselves with a representation of official state and public relations in any policy field including
health, sanctions and imposes what it states, tacitly laying down the dividing
line between the thinkable and the unthinkable, thereby contributing towards
the maintenance of the political order from which it draws its authority.
A hard-nosed analysis
of health futures for countries such as Zambia is necessary therefore, to
inform policy decisions. One dictum is correct in the WHR (1998) analysis:
Public health is the art of applying science in the context of politics so as
to reduce inequalities in health while ensuring the best for the greatest
number (ibid: 14). This process of
“sciencing out” public health (Kalumba, 1995:6) recognises the
complexity of interactions between on the one hand, health outcomes and on the
other, political democracy, social and cultural development, and economic
efficiency. It is evidently, a turbulent process.
A
comprehensive view of the health care system recognizes that it is comprised of
households, communities, and public and private health care institutions. "Because of its complexity and the
existence of numerous subsystems,
health care is, in fact, disorganized, creating problems in the distribution
and quality of health care and the inefficient use of the services that
exist"[4].
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