FUDGING SOCIAL POLICY

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

University of Zambia, Lusaka, 1988 

 

In Zambia, as in any other system of political rule, governments want to stay in power. In practical terms, this entails the enactment of public policies in such a way as to selectively suppress all threats of opposition to public authority or to force opposite tendencies into a state of repressed dynamism. The constitution of social policy publics amenable to political domination must necessarily draw attention not only to the broader structural relations in society which underlie state political power such as the prevailing forms of economic organization but also to the techniques and mechanisms of policy practice. In effect we need, continuously and critically, to examine the ways in which public support is mobilized behind particular public policies and programmes, and how resistance is organized and/or overcome in pursuing such projects.

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

The areas of social policy in which there has been increased effort to reconstruct public policy realities in Zambia are the health and education sectors. While there have always been calls by some politicians for charges to be levied against users of social services at various times in Zambia’s post colonial history they pale in comparison to the force of the current advocacy for cost recovery by  academic policy scientists. In this respect, two Zambian policy analysts, one an educationist, Professor Michael Kelly, and the other an economist, Dr. Situmbeko Musokotwane, have argued more forcefully than their political

counterparts for sweeping reform in the financing of health and education services . Their conclusions are that new user-based cost recovery measures should be re-introduced.

 In order to inform our readers, and avoid the critical practice of creating straw men, we shall review their accounts comprehensively as part of our attempt to challenge the validity of the solutions proposed to the problems they seek to resolve. In undertaking this work, we hold the position that we are in fact not simply engaged in the formulation of logical structures but rather in different forms of political practice. We shall suggest therefore, that these two accounts are not simply the result of the authors seeing the world wrong, but that rather of objective limits of the analysts upon knowing and hence upon their forms of practice. We shall argue that the analysts only apprehended aspects of the reality of health and education through official/state accounts and that Musokotwane and Kelly were forced to recommend the reforms they advocated in their capacity as state policy scientists. More substantively, we shall point out that the advocacy for cost recovery measures in Zambia reflects a general rather than a specific view about the problems of financing social services in the country.

The general understanding of the problem of financing health and education services as well as the solutions suggested are supplied to Zambian officials and academic state policy scientists by that giant machinery of international money lending machines: the IMF and the World Bank. In other words, they are devoid of any originality.

A. MUSOKOTWANE’S COST-RECOVERY MEASURES IN HEALTH: THE POLITICS OF POLICY REVERSALS

Examining the health sector, Situmbeko Musokotwane’s study, commissioned by the Fredrick-Ebert Foundation, was apparently prepared in response to a specific request by the Zambian Ministry of Finance. Its objectives were: (a) to analyse the financing of health services in Zambia with a view to recommending how best, if at all, user fees for health should be imposed, and (b) to make relevant recommendations about the best forms of financing health services (p3). By its tone, the paper seeks to provide an economic appraisal of the health care delivery. We shall argue that Musokotwane’s contribution fails to define the nature of the problem of health care financing in Zambia. Further, we are going to show that this limitation means that his proposed solutions have no basis in fact and cannot satisfy the real interests which underlie and even undermine public budgets. In addition, we will show that, on its own terms as a rationalist economic discourse, the account is largely incoherent and that therefore, its implicit critique of political discourses in health financing as ideological cannot be sustained on any other grounds other than the political/ideological.

Musokotwane starts by observing that the government’s budget deficit is running in magnitudes that may not be in the economic interest of the country and, on this account, government wishes to achieve greater economic stability as part of its New Economic Recovery Programme (NERP). But, Musokotwane points out, that for stabilisation in the economy to have a chance of success it is necessary that the government, among other things, follows a cautious monetary policy, for example by reducing its deficits and with it reduce the need for increased money creation to fund the deficit. This in turn calls for a review of all government expenditures with a view to reducing wastage and promoting financial efficiency (p.1). We understand Musokotwane as attempting to address both a concern for clear monetary policy and, prudent fiscal policy whose authorities may not always coincide.

According to Musokotwane there is consensus on this definition of the problem of budget deficit between apparently two significant actors: official and academic economists. The question that needs to be raised therefore, is whether “ health services be provided free of charge to all citizens or should they pay for it” (p1)? The question of cost burdens, according to Musokotwane, must be linked to two economic principles of “excludability and rivalry” (p2). These principles relate to the resolution of the public/private good question.  On the basis of these two principles, Musokotwane sees health services as in the main, a private good. He however, excludes preventive services as falling outside a strict criterion of being both exclusive and competitive. In assigning preventive health to the status of a public good, Musokotwane does not intend to be charitable. He is aware that the concept of prevention in health care assumes as a pre-requisite, increased individual responsibility (Lalonde, 1976). In other words, Musokotwane is saying that the magnitude of public involvement in health should be greatly curtailed. Musokotwane’s project in this respect is justified on the basis of his rejection of what he sees as generally irrational political reasons for abolishing fees in public health services. He observes: “the main reason health [services were] made free to the consumer was that 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).

Having largely de-linked health from its public purpose in Zambian society, Musokotwane then proceeds to point out that the task of cost-saving proposals ought to be how to “ reduce costs substantially (without being) too painful for the majority of the people” (p3).  Implicit in this project of humanizing cost recovery measures is a real concern with the question of social implementation of policies. An important aspect of implementation in Musokotwane’s account is the need to provide a reasoned justification for actions. And, in this case, Musokotwane seeks to provide socially acceptable rationality for medical fees. Musokotwane’s analysis considers various components of the health sector: a) supply of health services including facilities and financial inflows, and state of health care facilities, b) demand of services, examining types of ailments, demand on facilities, c) financing practices both present and “alternatives”. Using various canons of argument and particularly, a multitude of tables (about 12), Musokotwane concludes that the public health sector is under-funded and inefficient.  He attempts to illustrate these observations by, among other things, pointing to an apparent influx of people to private clinics. He asserts: “By all accounts, private clinics appear to be getting popular as complaints about deterioration of the services provided in government hospitals become more frequent and louder” (p.6)

On financial flows, Musokotwane observes that the average of 5.6 % of total expenditure that Zambia spends on health services: “does not appear to be very much. On the other hand, it is doubtful, given the many competing interests on the Treasury whether in fact the government can afford to commit a higher portion of its resources for health services.”  Musokotwane then proceeds to review various options of financing health services other than through the public budget arguing that there is no scope for financing the health sector through government expenditures. This means for Musokotwane, finding new ways to recover costs and save. The objective of such an exercise is to consider cost saving with a human face. In considering various “alternative models of financing health services” (p28), Musokotwane identifies four interventions: a flat health service tax; fees imposed on the basis of the nature of medical service rendered; medical insurance scheme; and institutional reform. On the first option, a medical tax would be imposed on every individual and there would be few exceptions based on” real need”. According to Musokotwane “ children would be paid for by the parents at a reduced cost” (p.28). The levy should not be too high so as to be affordable by many people. The size of contributions would offset pressures on its budget. He suggests either a levy structure tied to income or to health centre visit. He points out that this strategy has weaknesses including the fact that as a “ fixed sum it does not contribute anything towards the process of economic restructuring” (p.30). On the basis of data (whose source is not stated save that it was a ‘quick survey’) about medical fees in Lusaka’s private clinics,
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).

Medical insurance schemes according to Musokotwane could be introduced through insurance companies or could be community-based. As a community-based scheme it operates on the same principles as a cooperative. Preference for private hospitals by insured members would encourage the construction of private hospitals. However, Musokotwane points to the potential for abuse through demand for treatment “even in frivolous cases”. (p34). This is what in monetarist policy discourses is called the “moral hazard” Finally, Musokotwane proposes potential institutional reforms which include: permitting the re-introduction of private fee-paying hospitals and nursing homes; encouraging missionaries to open up more medical centres; and allowing hospitals to own investments. From these “options”, Musokotwane concludes by making a series of concrete recommendations. The first is that a medical insurance scheme be introduced for all those who want and can afford. In general, this recommendation applies largely to “ all people in mid and upper level management positions ‘ (p.38).  The second recommendation is “for the rest of the population...each individual be levied a medical fee”   (p38). Musokotwane recommends, “children up to five years of age, the elderly (over 60 years), the physically and mentally sick would be exempted” (p.39). However, according to Musokotwane, the unemployed would not be exempted. This measure, which “appears to be a socially unjust proposition”, is justified by Musokotwane because: “the token medical fee would go towards making people realise that medical services, like other basic necessities like shelter and food, are by and large individual responsibilities for which each should struggle to obtain resources to meet such requirements” (p.39).

Musokotwane further recommends the re-introduction of private hospitals and nursing homes because “ the reasons for their abolishment were not very convincing in the first place”.  And a final recommendation that he offers is for the government to return back to the missionaries, hospitals that the government took over.

In our ensuing critique of Musokotwane’s politics, we are going begin by questioning the underlying premise in these recommendations that an adequate case has been made which would satisfy any inquiring mind as to why we need this policy reversal now.  We are going to show that Musokotwane fails to provide a clear definition of the problem of health sector financing; that he fails to sustain his implicit claim to provide a rationalist/factual account which would overcome the limits of political justifications of governmental expenditures; and lastly that, without a clear understanding of the specific problem of health financing in Zambia, his recommendations cannot be fruitfully evaluated.

MUSOKOTWANE’S ELUSIVE PROBLEM OF HEALTH FINANCING

Musokotwane’s paper is unclear about the nature of the problem of financing and about how this difficulty should be analysed. At one level, the problem is presented as a general crisis of public health budgets in Zambia.  Stated in this manner, the question one expects to be posed is whether the Zambian government can “increase” investments in health or “reduce” services altogether. To answer such a question requires evidence showing a decline in health sector investments and from this evidence one can make projections of future resource requirements and availability. Musokotwane does neither. He writes, for example, “The quality of health care is believed to have declined because of inadequate funding”. While Musokotwane claims that funding declined, information given in his paper suggests the opposite. In his Table 2 (p.9) data indicate that in fact, in “nominal” terms, there was a progressive increase in governmental health expenditures.  The share of official health expenditure as a proportion of total government spending increased from 5 per cent in 1965 to about 8 per cent in 1984. Musokotwane fails to demonstrate what he claims to be the situation on the basis of his own evidence.

Further, had he chosen to deflate by a price index for gross domestic expenditure and measured in terms of, say, 1981 Kwacha, it would have been apparent that total MoH expenditures, in  “real” terms, fell from K91.4 million in 1970 to K76.3 million in 1981 or a decline of 16%.  The decline is especially reamarkable when measured in per capita terms. Thus, in the period from 1970 to 1981 real expenditures per head fell from K21.9 to K 13 or 41%.

Musokotwane does not attempt even such basic levels of analysis. Moreover, if such a case about declining funding was made, the more vexing question remaining to contend with is that of the adequacy of the existing levels of investment. Taking the increases in nominal expenditures between 1982-4, Zambia compares very favourably with other “average middle income countries” according to the World Bank’s (1984) World Development Report. For these countries, health sector expenditures averaged 1.2% of GDP and 4.9% of total government expenditures compared to Zambia’s 2.5% and about 5.6% respectively.

The question to ask then becomes, why this high proportion of resources devoted to health seems to have only a small payoff in terms of reduced morbidity and mortality?  To address this question requires a careful reading of epidemiological data, and a re-examination of the efficiency of resource allocation and planning. Musokotwane does not address such a question. If the question is not that the Zambian government spends less, relative to levels in other countries (not comparing apples and oranges which Musokotwane frequently does when he uses developed vs. less developed in related examples), then the problem of emphasis of the paper shifts from how to raise more money to how to increase efficiency. When an attempt is made to define efficiency as the main difficulty of health financing, Musokotwane gives no evidence on this nor does he suggest appropriate indicators. The problem is introduced “ex nihilo”. Implicit in the paper is the thesis that there is wastage particularly in governmental facilities. We are
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.

On a more generous interpretation of the “essence” of Musokotwane’s concern, a point may be conceded.  We could infer (nay, “read into” the account!), a “general” understanding. That is the author is really saying: we need alternative forms of funding because “ the government’s financial position has deteriorated very badly compared to the [situation in the] years shortly after independence”. The problem then is that of a  “general” budget deficit not strictly that of a decline in government health
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.

Like others who have done a great deal of planning, I have been at times, somewhat cast down when many hours of work and thought have served no more useful purpose than to swell the bulk of a file called Health              Department: Future Development.  Like others too, I have smiled sadly when turning the yellowing pages of an ancient file recording the plans of a predecessor which, after a full, careful and hopeful period of gestation either failed of delivery and died in utero or succumbed soon after birth to the east wind of financial stringency  (Dr. J.F.C. Haslam, Director of Medical Services, HD 1945:3)

Even when there were stints of “relative adequacy” of financial resources, those responsible for health services were constantly reminded of the tenuous situation. Hence, a successor to Dr.Haslam observed in 1951: “Those of us who have seen the expansion of services since 1926 are at times confused by these figures. It has been made possible by the development of the great copper
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.

 During the period of the Transitional Plan to the FNDP, planners did not plan assuming a “very healthy financial position” but rather on the assumption that money would be short which dictated that the share of health sector expenditures remain within 2 % of GDP. The budgetary crisis suggested by the author lacks any appreciation of historical evidence. Moreover, Musokotwane does not succeed in showing that there was anything new or unique about the case he documents.

MUSOKOTWANE’S POLITICS

           

The problem addressed by Musokotwane appears to be the ideological concern of justifying public expenditures on “private goods”, health being presumed to be one such good. The concern is not simply with whether or not there are difficulties in the current sources and uses of resources; rather, whether any public expenditure on health is justified at all is the major one. Even on this score, Musokotwane’s argument is poorly articulated and documented. The private/public good definition he provides and then applies to the health sector is a very spent argument.

Briefly, the author is oblivious to questions that make the
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)

The author fails to realize that he is making a political rather than a purely economic argument. His, is a two-sided question that raises the issue of the scope of state intervention in health care. He participates in an ideological struggle about whether social policy goals would be better achieved through the private market or through state intervention.  Like in all such cases, sentiments on both sides are quite strong and the arguments are often convincing. Why governments choose one side or the other, involves more than the logic of supply-side economics. Musokotwane’s neo- conservative monetarist argument conforms to a more general thrust now popular among World Bank advocates. As viewed by writers such as de Ferranti (1985:x), the problems of health budgets have reached critical levels in most developing countries. He views the difficulties to have emanated from the pursuit of government health policies supporting political rather than the economic goals for the provision of free medical services. According to de Ferranti (1985), such policies are inefficient and tend to encourage inappropriate economic relations among health service providers and consumers.

Inefficiencies, in this case are created by ‘weak management’ within state allocative structures arising from heavy reliance upon distortionary tax policies, which in turn, hinder the productivity of other sectors of society. Secondly, governmental participation in the provision of health services exacerbates inequity by reinforcing tendencies, which favour the urban, advantaged populations. Thirdly, official health policies are over-ambitious, creating gaps between policy goals and funding capacity. Thus, financing “crises’ are chronic and cost-recovery measures, entailing increased household responsibility for generating resources are advocated as the necessary response.  User fees or some forms of health insurance coverage are considered more effective methods of generating funds for health than government taxes. These arguments have been particularly identified with the supply-side economists’ critiques of welfare programs in industrialized countries. 

The policy implications of what monetarists say is that a society can allocate benefits more equitably through increasing the amount of benefits, reducing the population, or diluting the level of benefits. And that a society can distribute costs more evenly by decreasing the sum of the total cost burden, or increasing the relevant population in order to spread the costs broadly, or raising the cost level that the members of society are willing to accept (Nagel, 1986). Ironically, these analysts do not take account of the political conditions necessary to implement a policy that is both efficient and equitable. To implement the sort of social service programme advocated requires a strong rather than a weak administration. In effect, their prescriptions would tend to increase the total government budget. The supply-side monetarists like Musokotwane, therefore, “misread” the conditions necessary for the realization of their project.

Musokotwane makes an incorrect judgement of the rationale behind the abolition of fee-paying health services. He asserts that: “the main reason health [services were] made free to the consumer was that
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.

Further, Musokotwane makes a wrong assessment of the structure of health financing in Zambia. Central to the whole paper is the idea that health care in Zambia was provided “ free” and that the abolition of user charges eliminated all cost burdens for the consumption of health services.  Not even ardent advocates of user charges like de Ferranti (1985) would support such an assertion. As we shall see from a review of Kelly’s paper, there is no empirical basis for such a claim.  In assessing the health sector, de Ferranti (1985:82) points out that the production cost of health services can be borne through a variety of means including community and individual labour. In addition, Kasonde and Martin (1983) reported that of all rural health centres in Zambia 30 % were built out of self-help labour. This is a major saving in capital cost that would otherwise have been borne by the central government!  De Ferranti (1985:9) also provides some data, bearing on this point, which ranks Zambia (at 50%) among the highest in terms “private as a percent of total health expenditure”. The World Bank (1984) shows that over a period of 10 years  (1970-1981), of all total health sector resources contributed,  private sources averaged 27%, government’s 45%, while others, including ZCCM, mission, and foreign donors contributed the rest. From this premise Musokotwane cannot convincingly argue that people have been over-dependent on government for financing the health sector (p27). There is a piece of empirical evidence, which among others makes it possible to dismiss Musokotwane’s two major hypotheses that a) people are encouraged to misuse health services if they are not charged and b) that they are free riders. Evidence from community studies in Zambia (Freund and Kalumba, 1985) and from other African countries (Kroeger, 1983) reveals that one remarkable feature of health systems is under-utilization. In Zambia, 40% of illnesses that occur in households are not taken either to modern health centres or traditional healers but either ignored or treated within the household. This practice, sometimes contributes to complications in treatment when such cases have to be finally taken to a health centre. It is important to note that this figure excludes maternal deliveries that in rural areas are dealt with by traditional birth attendants. Typically, these would have to be attended by hospitals or clinics in countries such as Canada. What this suggests is the fact that even when services are available, there are many people who would otherwise be entitled to use public health services who, due to a variety of reasons, do not actually do so.

MUSOKOTWANE’S METHODOLOGY

           

On the question of efficiency, Musokotwane uses general opinion to indict the “state of health facilities”. He writes, “the general opinion in the country, however, is that the quality of health services had declined substantially since independence” (p. 16). He ignores studies that would support his claim among which are included the well-known impact studies of Freund and Kalumba (1985; 1986; 1988), Bygren (1982) and WHO/UNICEF/MoH (1984; 1982). This body of work gives sufficient information, better than “general opinion”, for making generalized statements. Instead, Musokotwane lists ‘quality’ indicators, which are poorly conceptualised and are made to assume empirical status merely by their being listed.

When the question is posed as that of the relative efficiency of
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.

Musokotwane commits the error or mistake of comparing statistically unlike entities (p17). It would have been more informative had he compared the Infant Mortality Rate (IMR) and life expectancy for countries with   similar characteristics than simply cramming the reader with a list of countries. The broad comparison of less developed and advanced countries cast little light on what has or has not been achieved in Zambia. The conclusions drawn by Musokotwane could have been made without
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?

Even when Musokotwane has the indicators to use to present his case, he does not interpret them. Take table 10, for example, nothing is said about rural/urban distribution of facilities (p24) in this table. The observation made about in-patient admissions being less than outpatient is banal or trite.  The indicators that would clarify the issues of efficiency and cost structure are beds per 1000 population and in-patient days per capita (Heller, 1975) respectively. Had Musokotwane used a measure such as in-patient days per capita it would have been noticed that a rate of 0.9 per year nationally is relatively efficient in comparison to other countries with a large rural population. Musokotwane found that duration of stay for in-patients tended to be highest for mission-run hospitals (p25); does this mean mission Hospitals are more efficient than other, facilities? His interpretation of this information shows that he knows the solution before understanding the problem. Knowledge of the literature (e.g. Scrivens, 1979) would have shown that another interpretation was possible. By lowering the quality of service in terms of recurrent expenditures, a hospital can be turned into a hospice, a place where patients go to feel good. In addition, reducing admission can increase duration of in-patient stay. This may well be due to improved outpatient treatments or, again, to referral of other admissible cases to non-mission facilities. The actual situation is unknown.

Musokotwane ignores the literature on medical service organization and medical dominance. The definitions of problems presented by the medical profession are accepted as the societal definition.

1.      THE SCIENCE OF MUSOKOTWANE’S POLICY MODELS

In part, the weakness of Musokotwane’s account of health financing stems from his politics. His writing reflects the flaws of a state policy science. He is engaged in an official discourse while claiming independence of thought as an “academic economist” (p.1). From that point of view, it is little wonder he fails to see the substantive and socially relevant issues of user-fees. Ample evidence is available from many countries suggesting the social, political and economic complexity of user-fees in health care (Badgley and Smith, 1978; Gilson, 1988; Stinson, 1982; Lasker, 1981).  Dr. Musokotwane’s models of health care financing in Zambia are self-defeating. The questions posed are: what kinds of user charges are necessary to overcome a perceived scarcity of governmental resources and, at the same time, are socially acceptable to the majority who need health services but are unable (and not simply unwilling) to afford them? The need for additional financing through user charges is given while ability and willingness to pay are considered “logistical” problems. This is the approach by which Musokotwane dismisses summarily, the efficacy of government financing as an unthinkable (p27). Assumed in his model is that government resources are scarce while resources of households are abundant. Concealed is the fact that the bulk of official finance comes from the same household product upon which new, and not “alternative” but “additional”, ‘cost-recovery’ pressures will be put. In sum, Musokotwane’s paper has found a ready audience within the Zambian policy community; a reception that has little to do with its scientific merits. It has been shown that in the main, Musokotwane does not attempt to deal with the prior and substantive question: why do we need to start thinking about user charges in health care?  The position is simply justified by its politics as part of a new official discourse replacing the earlier pre-independence, UNIP idealism about a humanitarian social democratic society.

B.     KELLY’S COST-RECOVERY MEASURES IN EDUCATION:  A PROBLEM WITHOUT A SOLUTION

The subject of Kelly’s (1988) seminar paper is the public financing of formal education in Zambia. Limiting the scope of the paper to the formal school system administered by the central government ministries of education, Kelly examines mainly the financing of primary, secondary and university education.  The major part of the paper analyses the sources and disposition of funds over the seventeen-year period from 1970 to 1986 from which the principal problems of Zambian educational financing are identified. Further, an assessment is made of the official policies taken or contemplated in response to the difficulties delineated and the conclusion indicates the prospects for the future financing of education in Zambia. Kelly’s work, then, consists of a review of the role, problems and policies of central government in the financing of the Zambian state school system.

Kelly finds that the Zambian school system was funded inadequately by the central government in the period reviewed. He shows that school enrolments doubled while official expenditures on education decreased (p.21) and argues that the problems of
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).

 It may be observed that Kelly’s paper suggests that, the key to the Zambian central government’s management of educational financing is structural reform of the school system. He argues that for as long as the structure of the school system remains unchanged, the problems of educational financing will be unremitting. According to Kelly, three main classes of difficulties faced the financing of Zambian education. These were under-funding, poor allocation of resources within the education sector, and poor budgeting. He finds that even though central government spending on education did not vary substantially over the seventeen-year period reviewed, there was a decline since 1977. More importantly, the decrease in official educational expenditures was not steep since the education sector as a whole maintained the same share of the total public budget. The implication drawn from this was that available resources were stretched more thinly over ever-increasing numbers with the result that the quality of education suffered: “overcrowded classrooms, inadequate furnishing, wholesale extension of double and triple session teaching, reduction in the availability of teaching materials and textbooks, inadequate support and supervision from the centre, impoverishment of teachers through the devaluation of their salaries (resulting in some pressure on teachers to undertake private commercial activities to supplement their incomes), lack of maintenance of school facilities, and mechanical utilisation of an examination system of dubious worth (p. 33)”. In short, it is suggested that the quality of education declined considerably as a result of inadequate funding by the central government.

The official response to under-funding of the school system was that government encouraged other ‘participants’ to increase their contribution to education in order to supplement public sources. The minor contributors to educational finance that were considered were mainly of four types: parents, educational institutions, private schools, and local government. Kelly’s opinion is that central government lacks clear awareness of the limited extent to which these non-traditional sources could provide additional finances. He shows that funding by educational establishments through the productive activities of their staff and students are quite small in comparison to the running costs of institutions. Through such activities, the University of Zambia obtained less than .01% of its operating costs while production activities in schools raised, in 1984, 0.5% to 1% of the running expenses of primary and secondary schools (p.8). It is also asserted that the contribution of private schools in terms of enrolments is small (p. 9).

 The contribution by levels of the administration below the central government was indicated to be that provincial governments administered funds provided by central government for primary schools and that a major change had been proposed to empower district governments, in future, to levy local educational taxes to support primary schools. Although this was the direction of policy since 1980, it was reported that the necessary legislation to implement this decision has not been enacted (p.3). On the potential contribution of private households, Kelly reports that a 1985 survey found that some direct and indirect educational costs were already borne by the parents (and families) of school-going children. This was especially the case for students in primary and secondary schools. Direct educational costs so borne by families included payments for educational supplies, examination fees and school funds, while indirect educational costs covered payments for school uniforms, transport to and from school, food and boarding. A finding of the 1985 survey was that indirect educational costs were high and substantial. In addition, families have carried a portion of the boarding costs for students in primary and secondary schools since 1986 (p.6). The implication drawn from all these factors is that private households are unlikely to contribute the additional amounts required by central government. He asserts that: “It is probably no exaggeration to say that a combination of poverty and large families has brought many families close to the limits of what they could pay for educational services. Hence any expectation that they would be able to bail out the system by paying much more than they are doing at present may either be dashed or be responded to by a withdrawal from the system” (p. 34). By Kelly’s reckoning, then, there are severe limitations to the amount of additional funds, which can be secured from non-traditional sources.

Turning to the second class of difficulties, Kelly suggests that imbalances in the allocation of educational finances are five. To begin with, distribution of resources was biased in favour of higher education. Kelly observes that, over the period reviewed, the share of resources allocated to primary and secondary education decreased while the share allocated to university education increased (p.18). Secondly, there is unbalanced allocation in favour of personal services and the welfare of students. These being in the terms, which draws attention to the dominance of teachers’ salaries and payments in (and for the) support of students within the educational budget. Indeed, transfer payments and the salary component are argued to be the two aspects of educational spending most deserving of special consideration (p28). Thirdly, allocation of public resources is said to favour those (students and their families) who are already privileged. By which finding is meant that the beneficiaries of the less costly post-secondary education (less costly, that is, in comparison to primary and secondary education) are themselves mainly the progeny of parents who received advanced education. Kelly’s concern about the scale of transfer payments involved in this is for two reasons: that the increasing size of these outlays cripple the educational budget and pre-empt the productive use of funds elsewhere within the education sector; and that it involves a transfer of resources from the poor to the rich which is inequitable (p30). For these reasons, and given that upon completion of their studies university students can expect a lifetime of relatively high earnings, payments made to this group of students could well be made in a reimbursable form such as by a scheme of student loans or graduate taxes (p. 30). Fourthly, maintenance and expansion of the operation of schools was promoted without any consideration for the impact of these policies on the effectiveness of schools. Finally, allocation favoured quantitative expansion at the expense of quality performance. In effect, Kelly argues that the problems of the Zambian central government and the financial administration of schools go beyond the matter of inadequate funding. It also touches upon issues of inefficient and inequitable allocation of those resources that are available to education. Chief among these failings is the tendency among officials to allocate a disproportionate share to post-secondary education and to ‘subsidize’ the education of those students taking these (rather than the more ‘populous’) levels of education. All of which failings are related to the third class of problems of Zambian educational financing centred on the budgetary process.  Kelly contends that the budget process cannot be used as an instrument for policy implementation and that  “budget proposals are initially prepared at a reasonably low level of the administration and for the greater part are dealt with thereafter by a finance and not by a policy section” (p.35). In consequence, he argues, the process by which the Zambian education budget is derived is incremental and lacking in control and direction (p.31). In addition, there is the difficulty of knowing in advance the amount that will actually be made available for education that hinders (rather than aids) the planning process. In other words, the budgetary process neither allows the central government to use the educational budget as an instrument for policy implementation nor does it aid the process of educational planning.

Turning to the policy responses to these problems, Kelly groups these remedies into three categories. First are those policies comprising of remedial measures already taken and six of these are discussed. There is, to begin with, the promotion of community participation (through “self-help” labour) in the construction of primary and basic schools. The second involves the promotion of community-based maintenance of primary schools. Thirdly, there is the question of transfer to parents of the costs of writing materials and textbooks for primary and secondary schools. Fourthly, the ‘restitution’ of responsibility for boarding fees at primary and secondary schools to parents. Fifthly, there is the problem of establishment of each educational institution as a ‘production unit’. Finally, there is the question of policy to encourage the establishment of private schools. The second category of policy responses analysed comprises of remedial measures considered to be forthcoming. The paper
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).

 At first glance Kelly’s arguments appear non-committal to almost suggest that they cannot be classified within, what we are here calling a monetarist discourse. Upon closer examination however, the goal of Kelly’s paper is to reduce on fiscal expenditures by shifting public tasks to private or quasi-public organizations.

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.

Kelly correctly says the users of post-secondary education are the persons of higher socio-economic status and that, on this account; they ought to pay for the educational services they have received freely so far. What Kelly does not address is the question:  to what extent are these categories of persons able to obstruct regulations disadvantageous to them? These social groups are able to claim benefits from public provisions, based on their capacity to block the administrative implementation of programmes, which they do not favour (Offe, 1984). If we are unaware of the political
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.

 

USER FEES: A RECONSTRUCTION OF A MONETARIST POLICY DISCOURSE

The current argument on user charges is valid to the extent that it points out that there are problems in government financing of social services. However, the monetarist argument fails as a basis for addressing what is wrong because it is essentially incomplete. The valid point the monetarists make is that there is a problem in the government financing of social services; where this argument is incomplete is that they assume that financing exhausts all government responsibility in the field of social services.

To specify a social service system we must describe both the mode of financing as well as the method of regulation.   It is through the regulatory system that the duties and obligations of users and providers of services are structured. Unless both aspects of the system of social services are adequately addressed, our prescriptions for system reform are bound to go awry.  What is wrong with current proposals for change is that while they make prescriptions for the supply of social services they say nothing about regulation. It is possible to conceive of taxonomy of social service systems classified according to the method of provision and the method of regulation.

There are four ideal types, which could characterize the extremes of this classificatory scheme. The first of which commits the government to total/high provision as well as to total/high regulation of social services (we call this a Government system of social service provision). The second commits the administration to high provision and low regulation of services (we shall call this model of services a Government-Aided system). A third type entails high regulation by the state of services provided with little or no public financing (we have called this a Privately provided system). The final type commits the government to minimal provision as well as minimal regulation of social services (we have called this the “Informal Sector” arrangement). 

The first ideal-type involves social services provided through government service organization and administered as part of the state bureaucracy. In this case, the government not only finances the system but also administers the services through personnel who are public servants. In the second extreme, the administration regulates through the system of financing such as grants.  What we have here is a method of social services delivery through a quasi-official network of non-governmental organizations that are nonetheless dependent on state-provided financing for the operation of services but yet exercising administrative autonomy. This in effect amounts to a state-supervised service in which overall policy direction by the state is exercised through the allocation of public money. By this device the state maintains a public presence without incurring responsibilities for the administration and operation of services. An illustration of the relation between the state and the producers of services can be gained from remarks made by the Director of Medical Services, to Mission’s in 1946 when he chided them that their administrative practices ‘seriously’ threatened ‘both the quality and quantity’ of services they were expected to provide “for appreciable financial assistance from the Health Department’s allocation of public money” (HD, 1946:22). In the third ideal-type, the government sets “the rules of the game” and acts as a referee between providers and users. In this case while the cost burden of social services is borne by private households, the state maintains an active presence.  This derives from the larger question of the right of the state to intervene in all forms of “public life” falling within the realm of the nation-state under its jurisdiction. John Keane, (1984) aptly asks whether there is any autonomous sphere of public life in the modern state. In the final extreme, governments are inadequate to provide and/or inadequate to control and yet limit their role to surveillance. We consider two variants of this ideal-type. The first case may include attempts at registration or accreditation of independent producers of services. The administration seeks a minimal level of regulation without responsibility for financing of such services. In effect saying, “I will not bother you as long as you organize yourselves and are not a danger to the public”. The state assumes a social/public hygiene function in such a system of social service provision.  In the second case, the government may simply “turn a blind eye” to the activities of such a sector.

The system of social services provision in any given society does not consist entirely of a single or pure form of ideal-type; in most cases it consists of a mix of two or more ideal-types. At any given moment in time, we describe a system of social services by the dominant mode of providing and regulating such services.  Nonetheless, to say one of a mix of ideal-types is dominant is not to say that all others are absent. Moreover, of crucial relevance here is the process by which one mode becomes dominant over others. The rise of one ideal-type over others as the dominant mode of organization involves a political process. In other words, the advocacy of a particular mode of providing social services is always a political choice. Therefore, to propose one form of organization over another has less to do with the technical merits of the organizational form and more to do with political muscle. What we are saying is that there is more to the contemporary policy issue of user charges than the question of rational technical organization of social services. The question is fundamentally political! It is the changing balance of political forces that influence the mix of ideal-types making up the delivery system and what becomes the dominant mode.

The advocates of current proposals to reform the structure of social services financing are saying that once you shift the burden of social service provision from government to private households you thereby remove the constraints of government-provided services.   Once this has been done, the problem of what is wrong with the present system by which social services are provided will have been solved. So the policy options being considered in this respect are designed to promote a privately provided system of social services, underwritten by the state, and in which government-aided services are provided as an important (auxiliary) component. What the monetarist argument has done is to structure the field of viable options of social services organization to three modes of delivery: publicly provided; private and publicly aided; and “informal sector”.  The desired organizational form being advocated in these reform proposals is a combination of the private and publicly aided system.

There are two questions that need to be answered. First, for what political forces is this a desirable outcome? Secondly, to what extent is this coalition of political forces likely to implement this project in the circumstances of deteriorating economic conditions? Our own assessment is that the system of social service provision is being altered fundamentally and that we shall indeed break away from a situation in which government-provided services dominate.  The replacement, however, will not be the sort of system being espoused in current proposals.  The most likely outcome, in our view, is a system of social services provision through the “informal sector” organization or arrangement. The question of what makes this the most likely outcome and, “if so, so what?” must be seen in the overall context of the current structure of political responses to what is, evidently, a deteriorating economic situation.   Is it possible to plan social services in an economic system in which producers are free to price the services they provide while incomes of users are controlled by legal and statutory means?

References