National health policies: sub-Saharan African case studies (1980–1990)

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Abstract

Four countries, Botswana, Cote d'Ivoire, Ghana and Zimbabwe, were chosen as cases to study the impact of national health policies on national health status in sub-Saharan Africa. Through a conceptual framework that covers health problem identification, policy formulation and implementation procedures, the study examined national translations of Primary Health Care (PHC) and Health for All by the Year 2000 (HFA/2000) strategies. A series of government measures, taken between 1980–1986 for health policy development and implementation in these countries, were treated as policy determinants of national health outcomes for the period ending 1990. The impact of these determinants on national health status was then analyzed through a comparative description and documentation of observable patterns and trends in infant mortality rates (IMR), under-5 mortality rates (U5MR) and life expectancy. Policy guidelines from PHC and HFA/2000 were used in conjunction with the respective per capita Gross National Products to categorize the four cases. Based on these guidelines, Botswana was ranked high, both in terms of policy development and the level of economic development, while Zimbabwe ranked high in terms of policy development but relatively low in economic terms. Cote d'Ivoire ranked high on economic development but low with regard to its policy framework. Ghana was at the other end of the spectrum, ranking low both in terms of its policy development and its economic performance. The comparative analysis revealed that Botswana and Zimbabwe performed better than Cote d'Ivoire and Ghana on the three outcome indicators. Despite Cote d'Ivoire's superior level of economic development, its health status fell behind that of Zimbabwe and even Ghana. The study concluded that policies formulated and implemented in accordance with key PHC principles could account for improvements in national health status. Since the end of the study period (1990), there have been significant political changes in the sub-Saharan African region as a whole and in some of the case countries in particular. Political leadership has changed in Ghana and Cote d'Ivoire with some course corrections in Ghana's health plans. Health sector financing in the region has become more dependent on external donors. The World Bank leads the external donor community in promoting policy-based lending. The complexity of a number of health problems has changed while the problems themselves remain the same as before. Essentially, building viable public health infrastructures to address basic public health needs must still be high on the agenda of action for most governments in the region. Thus, notwithstanding some course corrections and reasonable shifts in priorities, all the PHC principles are still applicable, indeed, much needed in the sub-Saharan African region. This study's findings, underscoring the fact that significant improvements in health are possible even where financial resources are limited, still hold true.

Introduction

Throughout the twentieth century, significant improvements in life expectancy have been strongly associated at the national level with income growth, particularly for the poor (with per capita incomes less than $3000). This is because these people are then able to pay for more food, better housing and more health care (World Bank, 1994). Furthermore, such income gains for the poor also affect the use of modern medical technologies and can lead to increased schooling. On the other hand, public policies which affect health systems enable various inputs to act together to produce the desired changes in national health status. Public policies influence the introduction of public health measures such as the supply of clean water, good sanitation and regulations that safeguard food. As Feacham and Preker pointed out in connection with the role of national policies affecting health care, efficiency and quality of care are lower in centrally planned and supply-driven health sectors in Central and Eastern Europe (Feacham and Preker, 1994). Thus, although the contribution of economic performance cannot be underrated, policies that are well formulated and implemented do have important roles to play. The situation in sub-Saharan Africa provides a unique opportunity for examining policy effects because of the universal adoption of Primary Health Care (PHC) for health sector and national development in the region.

By the year 1978, all independent African nations had declared their respective commitments to developing national health policies to institutionalize PHC (UNICEF and WHO, 1978). In support of this PHC ideal, the World Bank started investing in health sector development in 1985 (World Bank, 1991b). At the time of this study, 45 countries in the region had received some form of assistance or were being assisted by the World Bank in restructuring their health systems to make them more responsive to mounting health and development needs.

According to the 1991 `Human Development Report' by the United Nations Development Program (UNDP), sub-Saharan Africa has made important human development gains in recent decades. “Since 1960, infant mortality rates have fallen by 37% and life expectancy has increased from 40 to 52 years.” “Despite these improvements, under-5 mortality still stands at 178 deaths per 1000 life births, which compares to 57 per 1000 for Southeast Asia and 72 per 1000 for Latin America and the Caribbean.” In contrast to the situation in Southeast Asia and Latin America, national health policies in sub-Saharan African countries have been more symbolic than real (UNDP, 1991, pp. 29–30). Inadequacies in the translation of policies into implementable activities are believed to have contributed to, if not produced, poor national health status across sub-Saharan Africa.

When one examines national development strategies aimed at improving national health status along with the corresponding health outcomes, wide variations are noticeable amongst countries in the sub-Saharan African region. Only a few nations have encouraging records. For instance, by 1989/1990, Botswana had achieved a sustained human development profile (UNDP, 1990). Zimbabwe, on the other hand, had reportedly achieved a high record of health development, but had had some disruptions in its human development program in subsequent years. The situation in some other countries was less satisfactory.

This study was conducted in an attempt to examine the impact of national health policies, where they exist, on the health status of the respective nation. It started as part of a background paper for a World Bank resource book which was published in 1994 as an enabling health sector reform instrument, `Better Health in Africa' (BHA) (World Bank, 1994). Though some ideas from this study have already made their way into BHA, publishing the specific results through this article at this time is designed to further contribute to an on-going regional and sub-regional discourse on appropriate health system reform measures1.

Through a conceptual framework that covers the identification of health problems, policy formulation and implementation procedures, it examined national translations of the PHC and the Health for All by the Year 2000 (HFA/2000) strategies. Four countries were used as illustrative cases to analyze policy steps that had been taken to promote PHC as the process for achieving HFA/2000. A series of government actions related to health sector development, taken between 1980 and 1986 in these countries, that is, procedures for health policy implementation and administrative rules established by responsible agencies, were treated as policy determinants of national health status. The impact of these determinants on national health status was then analyzed through a comparative description and documentation of observable patterns and trends in infant mortality rates (IMR), under-5 mortality rates (U5MR) and life expectancy.

Section snippets

Conceptual framework

In the Alma-Ata declaration of 1978, Primary Health Care (PHC) was defined as `essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community…. It forms an integral part of both the country's health system of which it is the central function and main focus of the overall social and economic development of the community' (Basch, 1990). The African Health Development Scenario of

Design and methodology

This research evolved from the proposition that, in developing nations, national health policies have a claim to improvements in life expectancy and mortality rates. A multiple-case study design is used to analyze policy formulation and implementation procedures together with socioeconomic and demographic data. The study was based on secondary data analysis; an analysis of diverse national policy statements and strategies crafted within the framework of Primary Health Care to bring about

Database

The following types of policy documents were used for the analysis:

  • 1.

    National health policy documents that are available in the form of primary government statements that delineate the various dimensions of policy formulation and management, parts of development plans, reports or reviews by third parties (commonly by the World Bank in its sector or staff appraisal reports) and in the form of budget statements or public expenditure reviews from the International Monetary Fund (IMF).

  • 2.

    World Health

Case selection

The single most important inclusion criterion is the documentation and availability of a national health policy statement. That is, selected cases must have documented national health policy statement(s), preferably from more than one source and including an original national source. Among the 47 countries in sub-Saharan Africa, South Africa and Namibia, until 1989, had not had any development agendas with any of these United Nations sister organizations. By 1992, two other countries (Sudan and

The four cases

Botswana (BOT), Cote d'Ivoire (IVC), Ghana (GHA) and Zimbabwe (ZIM) are the four cases selected, following a sequence of exclusion based on the conditions stated above. In an attempt to develop a basis for comparison, a scale of zero to three was used to rank the policy statements. Zero indicates the least and three the most inclusive and detailed statement. According to this scale, Nigeria's policy statement discussed policy dimensions substantially with respect to content and specificity. By

Operationalized policy dimensions and processes

The Alma-Ata Declaration describes PHC as “essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation and at a cost that the community and country can afford” (Basch, 1990, p.204). This approach to health services delivery emphasizes the district health unit as the key locus of operations. Hence, a logistically and administratively self-reliant district health unit is the central symbol for a

Analytic plan

The analytic plan is twofold. First a descriptive analysis of each of the countries is presented in the form of verbatim quotes and paraphrases, with respect to the type and content of the national health policy. This gives an overview of how each country handled the key policy dimensions included in the WHO model.

The other part of the assessment is done through a ranking system based on perceived appropriateness of, or fit between, the respective policies and formally instituted programs. This

Section A: Descriptive analysis of national health policies and their implementation

This section specifically examined how policy statements treated the following issues:

  • Problem definition

  • Setting goals and objectives

  • Decentralization of the health care system with corresponding institutional development

  • Resource allocation patterns reflecting political commitments

  • Extent of community participation in the policy process

  • Manifest multisectoral perspective in planning and executing programs towards achieving the set goals and objectives.

Case summaries: The fit or misfit of policies

This section provides a resumé of the assembled evidence on the four cases with respect to policy thrust as related to health outcomes. It is presented in the form of case-by-case summaries followed by a synthesis of all the observations. A simple classification of the four countries based on how they addressed the two levels of the analytic model in their respective national health policy statements together with an assessment of health outcomes is presented in Table 8. This ranking of the

Discussion

The unit of analysis in this study is the national health policy. It has content as well as process dimensions. Much richer information on both of these policy aspects could have come from a combination of both secondary and primary data sources. However, for this study, a pragmatic choice was made to use documentary evidence, that is, archival records and summary reports exclusively. Thus, the convergence of information from multiple sources is limited and construct validity is undermined to a

Conclusion: Health outcomes as policy effects

Within the context of the Alma-Ata declaration of 1978 and the African Health Development Scenario (1985), most sub-Saharan African countries have been trying to reform their health systems in response to economic and social realities of the time. As national resources decline, most of these countries have become progressively dependent on external funding to meet their recurrent costs (Okuonzi and Macrae, 1995). Propelled by this general reform imperative and influenced by external donor

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