FUDGING SOCIAL POLICY: THE PROBLEM OF MONETARIST DISCOURSES IN HEALTH CARE AND EDUCATION SERVICES IN ZAMBIA
Katele Kalumba PhD (Public Health) and Chitalu Lumbwe PhD (Education Administration)
Paper presented to the Economic Association of Zambia, Pamodzi Hotel
In this paper, we examine current policy discourses and suggest that an important ideological struggle is taking place. This conflict is typified by increasing calls for cost recovery measures in the provision of social services. Our reading of this particular debate is that it reflects a fundamental questioning of whether social policy goals would be better achieved through private, market intervention or through direct state actions. The object of this paper is to analyse the ideological underpinnings of this increased advocacy for cost recovery in state programmes and to question the extent to which suggested measures provide enduring solutions to the practical policy problems of the UNIP government in the fields of education and health care.
THE CURRENT ADVOCACY OF USER CHARGES FOR SOCIAL SERVICES IN ZAMBIA
Musokotwane argues that the poor: “were prepared to pay higher fees because of gross dissatisfaction with the government hospitals. Contrary to the long held government views that medical service is a public good that must be provided free of charge, there appears to be evidence suggesting that the public consider medical service as a private good that may be purchased with individual funds” (p.30). The benefit of option 2, according to Musokotwane, is that each person pays according to the benefits. He notes that government subsidies in this case would not be a problem because, “ people would still understand the value of medical services more as compared to when they are paying nothing” (p.32). The major disadvantage of this option as Musokotwane sees it, is ideological. He argues, “if one holds the view that health is a basic human right then imposing user fees on them is unjust because it disregards need” (p.33).
given neither evidence nor the basis for this assertion. Elsewhere in the same paper, Musokotwane claims that, “ Although no scientific concrete evidence exists to the effect” [can scientific evidence be non-concrete?], ‘the general opinion’ in the country seems to be that the best run health facilities are the mission and mine hospital while those owned and managed by the government are trailing behind” (p.7). The caveat, not withstanding, it is clear the author believes the “general opinion” that government services are “trailing behind” the managerial posterior of excellent mission and mine services. Lacking any concrete evidence to prove inefficiency, Musokotwane argues that the fact that government has sought to reform the health sector was itself evidence of inefficiency. This argument, not fully articulated is implied in the manner in which he juxtaposes his acceptance of the “general opinion” on inefficiency of governmental services and efforts by the government towards reform. By this device, the fact of governmental reforms assumes the status of empirical evidence of inefficiency. Clearly, reforms are introduced for a variety of reasons, least of which is a clear commitment to overcoming administrative inefficiency. A historical study of health sector reform proposals backs the argument that reform measures have been recycled as an instrument of political penetration rather than serving purely administratively productive aims (Kalumba, 1988). In other words, as far as we can tell, the problem is neither here nor there.
expenditures or inefficiency (p.2). A serious study of the field would indicate that this crisis theory of government budgets is not new. A colonial Director of Medical Services commented in 1945 thus: “Sitting down, at the age of fifty-seven, to write the memorandum on development of health services in Northern Rhodesia, I am reminded of Captain Hook in Peter Pan saying: Something moves me to make me dying speech, for it seems certain that I shall never carry out the plans, dearly as I should like to do so.
industry … a state of affairs, which cannot be contemplated with complete complacency (HD, 1950: 1). Fifteen years later the post-colonial Director of Medical Services noted the same “crisis” in 1965 that is, if the author would have read the Transition Development Plan (1965/6). There was a crisis of finance then, as there appears to be now.
public/private good distinction in health care overspent. Consider the simplified case of a “free rider”, that person who has been eliminated from the roster of consumers of our now private good after introducing user-fees. He contracts a non-infectious, curable disease from which he dies. Is his death a public or private affair? The ‘free-rider’s death is a public stressor especially in our African, and more specifically Zambian, context. Funerals have unpredictable emotional consequences. The relevant point here is: where do you draw the line between a purely preventive and a totally curative medical service? We are suggesting that it is not quite easy to draw such a distinction between preventive or curative care. Had the relevant literature been reviewed, the author would have not adopted the simplistic position he took and it would have been obvious that the public/private distinction revolved around other issues. (Evans et al, 1981: McLachlan & Maynard, 1982; Townsend and Davidson, 1982: Maynard, 1981; Zschock, 1978; Abel-Smith, 1978)
President Kaunda held very strong views about the fact that nobody should ever be denied health care just because they could not afford to pay for it” (p.2). A fuller examination of the situation would show that, rather user-fees were abolished as a consequence of a long colonial nationalist struggle, which had both racial and socio-economic elements. Under the Rhodesian Federation, services to Africans were “free” and only beds reserved for whites were fee-paying. In the colonial medical context therefore, fee-paying defined the racial and with it, class division of society. The qualitative differences between fee and non-fee paying services were such that Africans received mediocre health care. It was prudent politics for the UNIP-government to take the measures they did in order to avoid racial conflicts after independence.
various health sectors, Musokotwane’s argument is also hard to sustain. Accepting Bygren’s (1982) finding that governmental subsidies to the missions was about 59% of the total recurrent costs of their services, the real status of mission-provided care is more complicated as is the definition of the comparative efficiency between government and mission services. There has not been an independent evaluation of the efficiency of mine hospitals compared to the government health sector. One statistic that would be interesting to examine is the relationship between total investment, population served and health status indicators. Our suspicion is that at roughly 20% of total health sector investments, the mines medical services (which are primarily curative) may be getting a lesser return in health improvements than government relative to the catchment populations served. This hypothesis requires careful thought and may be, in fact, difficult to establish largely on account of finding acceptable health indicators.
relying upon any kind of comparison; Zambia has always lagged behind developed countries! Musokotwane presents morbidity and mortality data in tables 9a and 9b to suggest that curative services should be excluded from being publicly funded. However, these tables are, in our view, meaningless. The benchmark years selected, 1975 and 1984, have no epidemiological significance. It is well known that annual fluctuations in morbidity are not particularly eye opening unless they are shown to be statistically significant. Only time-trend analysis over a relatively longer period of time can support the kind of conclusions Musokotwane seeks to draw from tables 9a and 9b about the major causes of mortality. Besides, mortality data in Zambia are generally problematic. Without comprehensive registration system, hospital and health centre deaths alone are not representative of the community at large (Freund and Kalumba, 1986; Bygren, 1982). More information would be obtained from analysing health status by paying attention to institutional specific differences. Thus, disaggregated data by level of treatment, geographical distribution, gender, age etc, would be more instructive. For economic analysis these, if well handled, are important indicators. But again, Musokotwane does not use data that are important for his analysis. When he attends to detail, such as observing Freund’s (1985) result about women (p19), he fails to take account of the qualification that the result relates only to institutionally attended health problems. Very little is known about male health-seeking behaviours and the low level of representation of males in health statistics reflects less a state of good health and perhaps more about utilization patterns. Relevant here are implications for cost recovery of a morbidity and mortality structure in which children are over-represented. Is the health of children sufficiently important to command continued public expenditure? It is debatable, is it not?
Zambian educational financing are both economic and demographic. The economic aspect is that about the same proportion of resources were devoted to education out of total government expenditures whose value (in constant prices) declined over time (table 1). The demographic context is that a rapid rate of population growth led to increasing numbers of school-age children. In this situation, Kelly asserts, the two methods by which the government sought additional funds for education were by intergovernmental assistance from abroad and from private sources at home (p.37). This set of sources, in his view, contributed less than was needed for the adequate funding of the school system. He advocates that fresh initiatives be taken to reform educational practice: “A declining economy and an expanding population are on widely diverting tracks. Tapping additional sources within the public, semi-state, private or foreign sectors cannot span the gaps. What is needed is something that Zambia has not yet thought out, a new method of making educational provision that will make a much smaller demand on resources than the traditional hierarchic institutional modality that few have dared to question (p.41-42).
presents and discusses two such remedies. The first is the proposal to transfer some of the costs of higher education to ‘beneficiaries’. The second consists of the policy proposal to institute educational taxes through provincial and district governments. Kelly’s assessment of the likely impact of these policies as indicated earlier, is that they are unlikely to yield sufficient resources to bail out the Zambian government of its present difficulties with educational financing. The third group of policy responses discussed consist of those remedial measures, which were under consideration. Four such policy proposals are detailed. First was the proposal to rationalize the use of the services of teacher recruitment such that government was not committed to hiring all graduates of teacher training institutions. Secondly, the policy to reduce the number of support staff in schools and colleges. Finally, there is the question of the proposal to encourage the university to assume responsibility for generating its operating funds. Nonetheless, even for these prospective policy choices, Kelly’s view is that “the prospects for the adequate financing of education in future are very dim” (p. 40).
The suggestion that social policy functions should be financed through special taxes and charges on participants is simply a mechanism by which monetarists seek to contain the potential for structural conflict. This rationalization has been termed “ the scientization of politics” (Offe, 1984). Kelly’s scientization of the defects of the Zambian state’s social policy is ambivalent thereby opening the possibility of differing interpretations of his account which, in practice, serves to justify “any and all” measures. Kelly’s implied preference seems to be the proposal to shift the burden of cost to users at the post-secondary, particularly University, level. This position conforms to the argument of the World Bank for user-fees to be charged for health and education.
conditions for the implementation of any policy output, our understanding of the limits of policy proposals for financing is gravely undermined. Kelly avoids political commitment and his monetarist liberalism is presented as an exercise in the scientization of policy.