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Primary Health Care: Beyond policies: Is Africa delivering?

FOCUS - UNGA SPECIAL REPORT

Primary Health Care: Beyond policies: Is Africa delivering?

Post-independence Africa is still grappling with the enormous task of delivering sufficient health services. While some efforts are being made to achieve the goal, progress is slow and much more needs to be done. Reginald Ntomba reports from Northern Zambia.

In most, if not all of their official speeches, African leaders and health officials acknowledge the importance of investing in the health of their citizens as the cornerstone for sustained economic development. Globally, Goal 3 of the Sustainable Development Goals enjoins governments to ensure the good health and wellbeing of their citizens. The development blueprint of the African Union’s Agenda 2063: The Africa We Want envisages a fully healthy and prosperous continent in less than 50 years’ time.

It is the duty of those elected into office to invest in health, ensure universal health coverage and reduce health inequalities for people of all ages. And to that effect, many African governments have translated global and continental visions into national development plans, strategies, frameworks and policies. But it is the gulf between what documents say and what is on the ground that continues to deny citizens access to even the most basic health care.

For example, under its ‘Vision 2030’, Zambia – a mineral-rich country with a population of 17m – aims to transform “into a nation of healthy and productive people”. Its National Health Strategic Plan (NHSP, 2017-2021) seeks to deliver quality universal health coverage by providing services “as close to the family as possible”, ensuring there is a health facility within a 5km distance.

However, in reality, there is a huge gap as well as inequality in the provision of health services in Zambia. While urban dwellers can access health services easily and even afford to pay for the highly expensive private medical care, the bigger problem is in rural areas where patients can travel for kilometres to access the nearest, at times even basic health centre.

 

Welcome Kaputa

On a tour of northern Zambia last month, this writer saw first-hand the dearth of health services in one of the remotest parts of the country. Located over 1,000km from the nation’s capital Lusaka and bordering the Democratic Republic of Congo, Kaputa District is one of the places where the government’s NHSP vision is just a mirage, due to inadequate social services, including health provision.

With a baby strapped on her back and just returning from an under-five baby clinic, 29-year-old Musenge Chabu may never know about the existence of Sustainable Development Goals (SDGs) as a global development blueprint, but she certainly knows the importance of having well-equipped health facilities within easy reach.

“It’s not easy,” she says, while breastfeeding two-year-old baby Mwewa at her roadside makeshift store. “As women we have a lot of chores. Apart from cooking, fetching water, and going to the grinding mill, we also have to queue at the clinic [health centre] after walking a long distance.” 

The long distances that the rural folk have to cover are exacerbated by poor road infrastructure, and the long distances between districts. For instance, the furthest settlement in Kaputa is over 100km from the town centre.

But distance is not the only problem. The unforgiving terrain impedes travelling around the region further. And even after patients have made it to the health centres, they are met with other problems.

Zambia suffers from a desperate shortage of health personnel. The World Health Organisation recommends a doctor-patient ratio of 1: 1000, but Zambia has a runaway ratio of 1: 5000. To make the situation worse, many qualified health workers find rural areas unattractive, and unqualified personnel routinely fill the gap, to the detriment of thousands. And even where health services run okay, long queues and delays to see a qualified doctor and access proper help, sometimes lead to preventable deaths.

“There is a substantial shortage of medical doctors across Zambia in government-run health institutions. However, the people in rural areas are more affected by this situation. This is because urban areas do have private clinics and hospitals, which are usually well staffed with qualified medical personnel and doctors,” notes a 2014 study published in the International Journal of Innovative Science, Engineering & Technology.

The study, ‘Addressing the Shortage of Medical Doctors in Zambia: Medical Diagnosis Expert System as a Solution’, notes that the causes of staff shortages include early retirement of health personnel; limited places in training institutions for them; migration of health workers to other countries for greener pastures; the direct impact of HIV and Aids and change of careers by some staff, who join other domains which offer a greater financial reward.

But it is not all gloom for Zambia’s health sector as the government is making visible efforts to improve service provision. In the 2019 national budget, the government has allocated 9.3% of its national budget to health (still falling short of the 15% governments are mandated to do in the Abuja Declaration of 2003). The budget also revealed that between 2016 and 2018, the Zambian government has recruited over 15,000 health workers, half its target of 30,000 by 2021.

However, a huge chunk of Zambia’s health budget is financed by western donors. US Ambassador to Zambia, Daniel Foote, says his government has contributed almost $4bn towards controlling HIV in Zambia over the past 16 years and plans to contribute $421m by 2020. The US government’s President’s Emergency Programme for AIDS Relief (PEPFAR) has also been crucial in supporting the provision of lifesaving antiretroviral drugs to Zambians living with HIV. In August 2019, Japan gave Zambia a grant of $3m for the purchase of essential drugs, most of which will go to rural areas, according to Finance Minister Dr Bwalya Ng’andu, who signed the grant.

However, there are genuine fears about what would happen to the country’s health sector and its aspirations to meet SDG3 and its own national commitments if donors reduced or withdrew budget support for health. As such, there are growing calls from various stakeholders and the civil society, for government to increase domestic resource allocation in health, including in training and the retention of health professionals.

 

Dismal performance

According to 2018’s The State of Health in the WHO African Region: An Analysis of the Status of Health, Health Services and Health Systems in the Context of the Sustainable Development Goals, Malawi, Namibia, Mozambique, South Africa, Tanzania, Zambia and Zimbabwe all have a “health status too low for the attainment of the SDGs”.  In fact, most of the 47 countries in the WHO African Region performed dismally.

Algeria, Cabo Verde, Mauritius and Seychelles were the few bright spots. The WHO says the purpose of its report is “to act as a compass to guide progress towards health in the SDGs.”

If this compass is anything to go by, it is safe to say Africa needs to change course if it is to achieve SDGs and deliver on the many promises to improve provision of health services to its people. 

And this clarion call from leading health care experts and activists when they adopted the 2016 Shanghai Declaration on Promoting Health in the 2030 Agenda for Sustainable Development, could serve as a guide: “…health is a political choice, a universal right, an essential resource for everyday living, a shared social goal and a political priority for all countries…policies for health and social justice benefit the whole of society and failures in governance are too often detrimental to actions on promoting health.” 

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