International policy and health: lessons from Zambia
Von Chris Simms
Obama’s “tough love” message in Ghana that a political era in Africa “must start from the simple premise that Africa’s future is up to Africans” was meant to underscore Africa’s governance issues. But the chief beneficiaries of biased migration policies and unfair intellectual property regimes are rich countries, writes Christopher Simms* with a glance on the situation in Zambia.
In the run-up to President Obama’s first visit to Africa, a myriad of competing interests lobbied the new administration, some warned of ballooning budgets and local priorities while others sought delivery on key campaign promises: to double U.S. foreign assistance in support of the Millennium Development Goals (MDGs), to tackle access barriers to needed medicines created by Trade Related Aspects of Intellectual Property Rights (TRIPS) and, reauthorize and enhance the President's Emergency Plan for AIDS Relief (PEPFAR). (1) One such group was the Health Worker Migration Global Policy Advisory Council, chaired by Mary Robinson, former President of Ireland, which asked Obama to address the practice of rich countries poaching health workers from poor countries. (2) As it turned out, Obama speech to Ghanaian Parliament did address the linkage between “incentives created by donor nations, the migration of health workers and the resulting gaps created in primary care and basic prevention in Africa”. (3)
Missionary health facilities and government austerity measures
The negative influence of inadequate resources such as health workers, essential drugs and aid flow minimums on outcomes that plagues Africa has been poignantly illustrated by Zambia over the last 30 years. During the period 1980-91, the proportion of Zambian children dying before reaching five years of age increased from under 15 to 19 percent. This rise in mortality was not explained by poverty or malnutrition but rather reduced access to effective health care. Economic crisis and structural adjustment operations implemented without steps to protect the poor, led to a 44% cut in real public health expenditure, the collapse of essential healthcare and a doubling of case fatality rates (CFRs) for diarrhoeal disease, malaria and malnutrition. (4)
Yet this was not the case in all parts of Zambia. In districts where missionary health facilities were the predominant health provider, access to effective services was largely maintained. Missionary organizations typically had some access to external resources, mainly from Europe, which helped cushioned the effect of government austerity measures. Thus, despite being more geographical remote from the line of rail, more vulnerable to drought, having a larger percentage of female-headed households, higher levels of poverty and childhood malnutrition, health outcomes were better in these district than those where government was the main provider. CFRs for childhood disease and malnutrition remained stable and, the per capita number of women receiving delivery assistance at birth (reflective of the supply of essential services and the public perception of their quality) remained unchanged and, by the end of the 1980s was 75% greater than government districts, a statistically significant difference. (4) In the 1990s a multitude of shocks hit the Zambian population including drought, loss of food subsidies, HIV and health sector reform which reduced demand for health care through user fees and privatization. There was another small rise in under five mortality but again, missions managed to protect their populations (5).
Several analyses show that mission facilities, although financially stressed, were able to maintain access to drugs and supplies, expatriate physicians and sometimes modest overseas funds (4-6). Partcipatory Rural Assessments carried out in 10 Zambian health institutions show that unlike government facilities where underpaid local health workers diverted energy to secondary jobs and alternative sources of income, “the mission hospitals were better supplied with motivated and qualified health personnel and they managed to have access to drugs, equipment and transport” (6). Furthermore, “mission facilities went out of their way to make things happen the way they should. For example, they ensured that drugs were available, by arranging to barter drugs with other institutions, and/or making arrangements with other agencies to provide grassroots health personnel with transport”. Lower level health workers in mission facilities were imbued with these attitudes (6).
Under-paid health workers
Over the last 10 years there has been “stagnant progress in health indicators” under the Zambia Poverty Reduction Strategy which the World Bank reports is the result of two key factors - “the current human resources crisis in the health sector” and “the availability of essential drugs and medical supplies”. (7) Zambia’s health workforce crisis is one of the worst in SSA: with a standing workforce of about 9000 nurses, 3,444 filled out the paper work needed to work abroad between 1993 and 2005, the United States and United Kingdom being their primary destinations. (8) Under-paid, poorly equipped and motivated workers, overburdened by HIV/AIDS are easily drawn to the private sector and wealthier countries – and the medical and professional schools has limited capacity to produce additional workers (9, 10).
Obama’s “tough love” message in Ghana that a political era in Africa “must start from the simple premise that Africa’s future is up to Africans” was meant to underscore Africa’s governance issues. At least for the 2.1 million children that the World Bank predicts will die as the result of today’s economic crisis and the 100s of million impoverished by last year’s food and fuel crisis, the future was determined by other forces. Furthermore, insofar as the chief beneficiaries of biased migration policies and unfair intellectual property regimes (as well as trade practices and lopsided use of natural resources) are rich countries, the bulk of governance issues and the power to determine future directions in poor countries rest mainly with them. If countries like Zambia are to realize improvements in outcome, Africa’s best bet is that Obama will keep his promise that “America will be with you every step of the way, as a partner, as a friend” (3). His acknowledgement of the linkage between donor countries incentives, loss of health workers and decline in essential healthcare ought to be taken a positive sign.
*Dr. Chris Simms is assistant professor at the School of Health Administration, Dalhousie University, in Halifax. He has spent most of the last 20 years living and working in Africa and Asia. His areas of interest include the influence of reform and globalization on access to effective health care particularly by the poorest quintile, aid effectiveness, the policy process, and the HIV pandemic. Chris is on the Board of Directors of the Canadian Society for International Health, and editorial board member of the International Journal of Clinical Practice. Contact: ch638828@DAL.CA
- (2) http://www.aspeninstitute.org/publications/health-worker-migration-initiative-global-policy-advisory-council-recommendations-repor
- (3) http://www.america.gov/st/texttrans-english/2009/July/20090711110050abretnuh0.1079783.html
- (4) Chris Simms, John Milimo and Gerry Bloom: “The Reasons for the Rise in Under-five Mortality in Zambia in the 1980s” Institute of Development Studies (IDS), IDS Working Paper Series, No 76, 1998
- (5). Chris Simms: “Donor Response to Zambia’s Childhood Mortality Crisis” Institute of Development Studies (IDS), IDS Working Paper Series, No 121, 2000
- (6) Milimo, J.: 1997, PRA Study of the Rising Childhood Mortality in Zambia, Participatory Assessment Group, Lusaka.
- (7) The World Bank 2008: Country Assistance Strategy for the Republic of Zambia (2008-2012), Report No. 43352-ZM, Washington D.C Click here
- (8) C. Swinburne “Zambia’s Nursing Brain-Drain, BBC African Perspective, September 3, 2006 http://news.bbc.co.uk/2/low/africa/5362958.stm
- (9) G. Kombe et al Human Resources Crisis in the Zambian Health System: A call for Urgent Action, Partners for Health Reformplus 2005 Abt Associates, Maryland USA.
- (10) USAID:, “The health sector Human resources Crisis in Africa: An Issues Paper” Bureau for Africa, Office of Sustainable Development February, Washington D.C. 2003.