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Saturday, September 14, 2013

WHEN HEALTH DIES



 

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 na├»ve 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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