Rhetoric-implementation gap in health policy and health services delivery for a rural population in a developing country

Sot'. Sci. & Med., Vol. 13A, pp. 577 to 583 © Pergamon Press Ltd. 1979. Printed in Great Britain

R H E T O R I C - I M P L E M E N T A T I O N G A P IN H E A L T H POLICY A N D H E A L T H SERVICES DELIVERY FOR A R U R A L P O P U L A T I O N IN A D E V E L O P I N G C O U N T R Y * F. M. MBURU Department of Community Health, Faculty of Medicine, University of Nairobi, P.O. Box 30588, Nairobi, Kenya

Abstract--Health development in developing countries invariably involve the improvement of existing health structures, the development of new strategies to cope with new demands in situations of scarce resources, and the implementation of programmes which could reach the majority of the populaiion. Most of the population in developing countries is rural. In some cases, people are scattered and are difficult to reach. This is the situation in Kenya. The country's population is about 90% rural. Rural health programmes designed to provide services for that proportion of the population include a hierarchical system beginning with mobile clinics, dispensaries, sub-health centres and health centres. This paper discusses the system available to the rural population, how it is implemented and goes on to show that the Kenyan health development programme stresses the improvement of hospitals in urban areas rather than the improvement of rural health services. The rhetoric in health planning is not consistent with actual health programmes.

INTRODUCTION

The determinants of the amount of health care available to people include partly the health policy and the prevailing socioeconomic conditions and partly the accessibility of the services. The structure of the health system will influence the pattern of utilization. The prevailing health status of the population should be to a certain extent an indication of the level of effectiveness of the health policy and its implementation• A multiplicity of individuals and institutions determine the pattern and direction of changes in the socioeconomic system. They determine the type and the distribution of health services provided to the needy areas• Admittedly, consensus of planning goals are hard to come by. In most countries curative health services are considered to be a priority, even though they may not be necessary for changing the health status of a community. The provision of public health services, rather than curative services, may be a reflection of the importance of community-wide health care as a rational investment. This is certainly the case in the poor third world countries [1]. In some of those countries, however, lip service to community health needs is not followed with meaningful allocations. Most of the health budget goes to create and maintain expensive hospital complexes serving urban areas where not more than 10% of the total population is found. Hospitals are preferred because they are often visible symbols of achievement and government in action. During times of budgetary squeeze, public health sectors become more susceptible to cuts. Consequently the rural population is deprived of the benefits of an otherwise effective health programme [2, 3]. The rhetoric associated with an effective rural health system in developing countries is quite fre* This is an additional paper, which will be presented at the Conference. 577

quently incompatible with the reality of the health care system [-4]. In Kenya the forcefulness of the rhetoric blurs the actual policy and implementation which are mainly directed towards hospital care. This paper reviews the health policy and its implementation in Kenya. After presenting an overview of the 1964-1978 health development policy and health system structure, development constraints are discussed. The paper focuses on two questions: since the health policy stresses rural public health, especially preventive and prornotive care, i s health planning consistent with the objective? Secondly health development programmes are questioned as to their impact on the Kenyan rural population. The discussion therefore identifies political rhetoric from actual policy implementation•

HEALTH D E V E L O P M E N T P O L I C Y 1964-1978

The first health development plan, 1964-1970, was formulated "in order to provide adequate health services to all". Its major components included the construction and staffing of health facilities, renovation and improvement of existing facilities, training of medical personnel at all levels and increased emphasis on preventive and promotive health services. The objectives were adopted to facilitate the accessibility to promotive, preventive and curative services in the large rural populations with little or no health services. The expansion of existing health services was speeded up to cope with a runaway population growth rate estimated to be in excess of 3.0% a year. The second health development plan, 1970-1974, was formulated to achieve the same objectives as its predecessor. It was formulated in the face of major constraints including the galloping fertility, urbanization at the rate of 6% a year, inequitable distribution of health services among and within the provinces and districts, a critical scarcity of medical and admin-

578

F.M.

istrative and financial resources and a dire lack of vital data. The third plan, 1974-1978, included new dimensions like the prevention of communicable diseases, the control of deficiency conditions, environmental problems and the promotion of maternal and child health. It was explicitly stated that the emphasis of the new health policy was preventive and Oromotive health for rural areas. The problems of the 1964-1970 era and the constraints of the 1970-1974 period were still prominent, however. S T R U C T U R E O F T H E H E A L T H SYSTEM

At the inception of modern (or Western) system of health care in Kenya, as in Tanzania and Uganda, there were three medical institutions hierarchically for Africans, Asians and Europeans, in an ascending order of sociopolitical status. Generally the Africar~ modern medical institutions were mainly designed to keep the needed African labourers in acceptably good •health for the purpose of increasing their productivity in the small urban industries. The structure of the Kenyan health system includes: (i) The Public or Government run health service; (ii) The Missionary health services with an emphasis on hospital and dispensary-based curative medical practice. Payment for services is required. During the colonial period the Missionary outreach centres served the isolated communities not served by the public service; (iii) The Private Sector Services with complex metropolitan hospital systems operated on service-for-fees. These hospitals were, and still are, to be found in the major cities. Before independence, they mainly catered for Europeans and Asians. Inadvertently, today they cater also for the needs of the elite including an urban corps of privileged Africans; (iv) A host of private clinics of various sizes operated by one or more doctors specializing in curative medicine again mainly in urban communities. Charges for services are high and only a few can afford; (v) Small section of industrial health and services for occupational groups, also in urban areas; and (vi) a non-integrated traditional health system providing inexpensive care to many people in urban and rural areas. The system was generally loathed and explicitly curbed from the pulpits and politico administrative structures. Only recently has the impact of traditional medicine been officially acknowledged. Research on the system is promised in the 1979-1983 Health Development Plan. M A J O R CONSTRAINTS IN H E A L T H PLANNING

Kenya, like most developing countries, is lacking in reliable demographic, economic, health and other data, all necessary for effective planning and implementation processes. Data are vital especially for determining the relative emphases to be attached to preventive vis-a-vis curative care. Without reliable information, most decisions may seem to be based on hunches, political and bureaucratic expediencies. Under such circumstances, effective and efficient health planning is difficult, if not impossible I-5]. Admittedly, inputs into the health care system are

Mr~uRu

often well known and quantifiable. The outputs in the equation are not tangible, let alone quantifiable. Increased health expenditure requirements, however, may be difficult to justify unless an improved health status can be shown to be achievable. That is not demonstrable without the gathering and processing of reliable information. Results of public health activities are often long term, unlike outcomes from curative health activities. However, wide coverage of immunization, maternal and child health, environmental hygiene, among others could rapidly change infant mortality rate, life expectancy, and, indeed crude death rate. From a relatively short term viewpoint, and for political expediency, investment in curative health may become a more persuasive proposition. That is not peculiar to Kenya. Not surprisingly, hospitals, as centres of relatively highly specialized care, take precedence over community health and its preventive component. Over sixty percent of the health budget is reserved for curative services compared to twenty one percent reserved for both rural health and public health programmes (see Table 5). Overall, it can rightly be said that inadequate planning and resource constraints greatly compromise effective comprehensive planning. It is often beyond reach. In Kenya, lack of qualified health planners in the Ministry of Health must be considered to be another obviously major drawback in plan formulation and execution. Perhaps the physicians who are responsible for planning are still biased in favour of hospital-based care, a legacy of the British colonial times. MAJOR HEALTH DEVELOPMENT PROBLEMS 1964-1978

Even prior to independence it had become clear that the health services available to the population, especially in the rural areas, were inadequate and illequipped to cope with the escalating demand for them. Three closely related constraints had hindered effective health improvement. First, the growth of the population at about 3.4% a year (see Table 1) far exceeds the growth of the economy [6]. There has been, and will continue to be, an increasing Youth dependency ratio, greater demand for maternal and child health services and greater requirement for curative services (see Table 2). Inevitably, these needs tend to call for the maintenance of the existing structure of health system. Unfortunately, the system is skewed in favour of hospital-based curative services. In spite of recognized fertility problems, Kenya did not adopt a family planning policy until 1967. The second limiting factor has been the immense disparity of health services from one region to another, and an immensely disproportionate distribution of services between urban areas on the one hand, and rural areas on the other (see Table 3). This is not peculiar to Kenya, however. But in some cases the disparity is disquieting. For instance, since 1960s the city of Nairobi has had nearly six hospital beds per 1000 people whereas rural areas have one bed per 1000-2500 [7-9] people. Although the per capita expenditure on health has increased considerably over the years from KShs. 4/92 in 1964 to 19/00 in 1973,

Populations in a developing country

579

Table 1. Kenya population: structure in 1970 and projected structure in 2000 Year 1970

2000 Projection 1 (AGR: 3.78)* No. ('000) (%)

No.

Age groups

('000)

Total Population Pre-school age (0-5) Primary school age (6-12) High school age (13-16) Productive age (15-59) Potential labor force Children (0-14) Persons 60 years or more Dependency ratio

(~)

11,247 100 2556 22.7 2235 19.9 1040 9.2 5445 48.4 3818 33.9 5239 46.6 473 4.2 105.0

34,286 8192 7067 3210 16,011 11,215 16,962 1313 114.1

100 23.9 10.6 9.4 46.7 32.7 49.5 3.8

Projection 2 (AGR: 3.10) No. ('000) (%) 28,131 4947 5134 2661 15,379 10,771 11,439 1131 82.8

100 17.6 18.3 9.5 54.7 38.3 40.7 4.6

Source: Kenya Development Plan, 1974-1978 1-15]. * AGR = Annual Growth Rate (percent), 1970-2000. Table 2. Percentage distribution of the population, Kenya 1969-1984 Age Group

1969

1974

1979

1984

0-4 5-14 15-49 Female 15-49 Male 50+ Total Rural (%) Total Urban (~o)

20.9 30.4 20.6 18.7 9.5 90 10

20.9 30.6 20.4 18.8 9.3 89.5 10.5

20.9 30.6 20.3 18.7 9.5 88 12

21.4 30.4 20.2 18.6 9.4 86 14

Total (in '000)

10,951

13,057 15,620 18,786

most likely a disproportionate share is spent on urban populations. SHORTAGE AND-MALDISTRIBUT1ON OF PERSONNEL

Finally, the shortage of competent health and medical personnel at all levels has compounded an already desperate problem. The 70-80 doctors graduating from the University of Nairobi are absorbed mainly by the existing network of hospitals, others soon join the fast-growing market of private practice. The distribution of physicians, nurses, midwives, medical

assistants, among others, has been inequitable, partly because they follow the pattern of health facilities, partly because of the prevailing socioeconomic conditions, and partly because of the favourable working conditions in urban hospitals. Further senior nurses and midwives tend to follow the doctors. It is generally believed that paramedicals, who are quicker and cheaper to train, are capable of providing health care services to the rural populations more effectively and efficiently than physicians [10,t 1]. Indeed all rural areas are served by medical assistants at health centres. Since 1970,-82~0 of all the medical assistants were serving the rural populations. But the number o f medical assistants are few in relation to their demand. In 1972 they were 643, in 1974, 1976 and 1978, they numbered 821, 976, 1030, respectively. They are expected to be 1209 in 1980 and 1497 in 1984, with 82~o serving rural populations [9]. Among other ranks of paramedicals, except health assistants, rural areas have not and are not expected to get their proportionate share. For instance, less than 13~o of all the registered n u r s e s a n d midwives have been assigned to rural populations since 1970. The same proportion is expected to be rural-based in 1984. Less than 50 of all the enrolled nurses have been and will be serving rural areas, less than 30~o of the enrolled midwives and about 5 5 ~ of the health inspectors. It would appear that all these ranks of

Table 3. Distribution of medical institutions and hospitals by province and providing agencies, Kenya, 1970 Non-Government (church, private)

Government Province Nairobi Coast Central Rift Valley Eastern Western Nyanza North Eastern Total o~, Distribution Source: Ref. [93.

Population in millions 0.54 1.00 1.78 2.35 2.02 1.41 2.25 0.26 11.61

Institutions 1 12 10 21 10 3 5 3 65 36~0

Beds 1856 7152 1171 1770 1008 447 840 106 8359 58~

Institutions 19 9 20 26 15 9 18 -117 64%

Total

Beds

Institutions

1269 451 1075 1103 989 645 634 -6166 42%

20 21 30 47 26 12 23 3 182

Approximate population Beds per bed 3134 1603 2246 2873 1997 1092 ! 474 106 14,525

172 624 793 818 1012 129 t 1526 2453 799

580

F. M. MBURU

paramedicals including the newly started group called community nurses, are trained to serve urban areas rather than the needy rural areas for which they are supposedly trained to serve. For many years past and many more to come the bulk of Kenya's population--85-90%--has been and will be rural. It can be seen that 87% of the registered nurses and midwives, 53% of the enrolled nurses, 70% of the enfblled midwives and 45% of the health inspectors serve 10-25% of the population. Clearly, the rhetoric, meant to be heard and the policy implementation, meant to be achieved, are different. Perhaps the failure of the policy makers to plan ahead and appreciate the needs of the people quite inevitably leads to the formulation of policies which may not alter the basic problems [-12-14]. Not surprisingly, the first health development plan 1964-1970 was designed not to make radical changes in the existing inequitable health system, but to improve, and therefore entrench the structure of that system. Perhaps that has been the thorn in the side. It has been shown, however, that when the cost of a particular policy is deemed to be high, regulatory policies are preferred [15, 16]. Only when the cost of policy programs is perceived to be low are distributive structural policies acceptable. -The paucity of resources is not a sufficient condition for the continuation of an otherwise inequitable system. On the contrary, lack of resources should enhance the formulation and implementation of policies which could maximize the performance and output of the few available resources. H E A L T H P R I O R I T Y - - R E L A T I V E L Y LOW

health care services are available to a minority of privileged urban people. The paucity of resources does not sufficiently explain this inequitable system [23, 24]. If services are to be appro.priately used, they should be accessible to those who need them. Distance to the service facility may reduce utilization of needed services. One study has shown that users of maternal and child health (MCH) services travel an average of 7.5 miles. Utilization of MCH tapers off as distance increases [25, 26]. A similar trend has been observed in the utilization of general outpatient services [27]. Other factors affecting accessibility include travel time, cost of travel and time spent waiting to be served. In large parts of Kenya are found dispersed populations, some of whom are nomadic. It is impossible to provide easily accessible hospital services to such poor populations, and often lacking modern means of travel. Still, Kenya emphasizes hospital development rather than small-scale rural health units (see Table 5). Finally, services provided should be structured in a manner acceptable to the prospective clients. The perceived quality, personnel behaviour and the existing norms governing the interaction between providers of services and recipients are significant determinants of acceptability. They affect the pattern and adequacy of utilization. A health development programme that fails to consider these criteria is likely to be ineffective. It could easily lead to an inefficient use of health resources [28-33]. That appears to be already happening in Kenya. VIABLE AND EFFECTIVE H E A L T H

Admittedly rural health care development is conPROGRAMMING strained by a variety of problems, some political and Clearly, it is one thing to formulate a health policy others economic, although not necessarily mutually exclusive. A rural health system is among many other and quite another thing to implement the policy as stated. The viability and effectiveness of policy ideals priorities within a very tight development package. Food supply, modernization of agriculture, education, depend partly on political acceptability and adminiscapital investment and an infrastructural base on trative structure to run the programme, partly on a which most of the services depend vie for attention clear understanding of the goals to be achieved and [17, 18]. Investment in these sectors may have the partly on the availability of adequate resources and upper hand in priority setting. effective strategies of the policy activity [34] (see National priorities are created in the framework F i g . 1). Even government has so much resources of political activity. Unless the sociopolitical leaders available at any time. The viability of a policy may recognize the value of community based care, such be weak and of questionable consequence unless the a need may never materialize as a priority. Policies objectives and means to achieve them are feasible and are not likely to be implemented unless they are per- meaningful [35]. ceived to have some local or national political Since 1965 there have been free outpatient services. payoffs. Visibility is an important factor in politics. Inpatient services were also made cheaper. But the Unfortunately, most rural health needs lack political shortage of services in most rural areas is so gross visibility and hence their low relative value. as to make the ideals of inexpensive or free care meaningless. Many health centres opened up since CRITERIA FOR RURAL H E A L T H 1964 are still inadequate to maintain the standards PROGRAMME existing in the 1960's, partly because the population To provide adequate health services for a fast grow- growth rate has been as high as 3.5% a year [36]. ing rural population three conditions of health devel- Further, the proportion of the recurrent expenditure opment should be fulfilled. The conditions pertain to for health centres and dispensaries has remained availability, accessibility and acceptability of health about 15% of the health budget. At present the rural services [19-21]. population per health centre varies from 45,000 to 122,000 in remote areas. The availability of health services is a necessary condition, though not sufficient for adequacy. Service In spite of the obvious inadequacy of health facilities should be erected and maintained among centres, most of the allocations have been directed populations which need them [22]. Table 3 shows toward the construction of hospitals at the expense that this ideal has yet to be realized. Most of the of the more viable and effective programme (Table 4).

Populations in a developing country actlvit y : J policy J~-

l

581

= [ Admimstretion Jcapocity 1

Socioeconomic conditions, health developement and maintenance. Resources: finonce, staff, facilities, equipment and supplies1 etc.

] I

I~ J

roductivity Target: I rural 1 popuatJon [

use

Rural health ._ services p r e v e n t i v e , ~ promotive, curetve

t

Effective services provided to achieve desired health objective

Effectiveness of resources to reach target population; efficient use of services

Fig. I. The weakness in the pursuit of hospitals and their services is the tendency to spend increasingly more resources to control diseases which might have been prevented at much less cost [-37]. Conceivably effective preventive and promotive care could greatly reduce overcrowding common in hospitals, at least for some diseases [38]. It is possible that the health planners in Kenya are unaware of the fact that the

greater mvestment made in hospital-based care, the more expensive the care becomes. For instance, the ratio of capital investment to recurrent expenditure will be about 1:3 between 1978/79 to 1982/83 fiscal years (see Table 5). In an environment where infectious diseases are numerous and infant mortality exceeds 140 per 1000 births disease control should be a priority." The con-

Table 4. Kenya: health development budget, 1974-1978 programme and sector allocations, percentage distribution by programme and sector

Programme

Plan budget in (K '000)

~o Health budget in programme and sector

4015 2472 6487

14.08 8.67 (22.75)

2872 1973 4845

10.07 6.92 (16.99)

742 251 242 536 35 1806

2.60 0.88 0.85 1.88 0.12 (6.33)

A Rural health services: Expanded programme Family planning programme Programme total = B Health training: Regular programmes Family planning programme Programme total = C Public Health: Environmental sanitation Communicable disease control* Health education Family planning programme Other (not specified) Programme Total = D Hospital development: New district hospitals Extensions, improvement Staff housing Provincial hospitals Kenyatta nat. hospital Programme Total = E Medical stores F Grants-in-aid (Municipalities) G Research Total Health Budget * Includes Vector-Borne Disease Control. A-G are programmes, sectors fall under them.

3285 2904 1526 2541 4524 14,780 210 100 283 28,511

11.52 10.19 5.35 8.91 15.87 (51.84) 0.74 0.35 0.99 100.00

582

F. M. MBURU Table 5. Distribution of per capita health budget 1978-1983 (Kenya Shillings) Total Health Per Capital Recurrent Capital Curative programme Rural health facilities Preventive and promotive programme Health manpower development Total expenditure (in K£ '000)

1978/79

1979/80

1980/81

1981/82

1982/83

60.00 43.00 17 ~ 36.00 8.70

66.60 46.60 20.00 40.80 9.95

69.50 48.50 21.00 40.80 9.85

69.90 50.50 19.40 40.40 10.20

65.50 51.00 14.50 37.80 10.35

4.00 6.10

6.20 5.15

6.35 6.60

6.65 7.95

6.10 6.90

42,038

46,737

49,850

52,443

52,466

Source: Computed from second draft of Health Development Plan 1978/79-1982/83, Ministry of Health, Nairobi, Kenya. trol of communicable diseases and childhood diseases cannot be accomplished adequately and efficiently at the hospital level. Such a preventive activity usually does not require highly qualified personnel [37, Chap. 3]. It would appear that the health centre is not vigorously pursued because of its comparatively minor sociopolitical visibility vis-h-vis a hospital that may be partially or poorly staffed and organized. In addition, people tend to favor large hospitals--the larger, the better!--for sickness. For preventive and M C H purposes, people in Kenya prefer health centres. Under the present socioeconomic conditions, the health centre has the potential to save resources, to increase efficiency in their utilization and to provide some degree of equity in the distribution of rural health services. CONCLUSIONS

Specific policy objectives should bear some close relationship to the available socioeconomic resources. Ideally more than one set of strategies are planned and carefully weighed as escape routes in case one set fails to achieve the intended objectives. These options should not just appear in policy statements, they should be options at the actual implementation stage. It is no longer fashionable to invest in hospital complexes which cater for the few. Ironically, the size of Kenyatta National Hospital, with an intended bed capacity of over 2000, complete with a cardiac unit and facilities for private patients, is viewed as a national pride. How much the hospital will cost to run and how much of other resources, like personnel and equipment it will absorb to the detriment of the rest of Kenya does not appear to be relevant. Equitable distribution of the available services will take time. Attempts must be made to shorten that time especially because resources are far too inadequate. The available resources, then, must be shared in terms of relative needs. Realistic planning should identify the problems involved, recognize the condition of scarcity of the needed resources, the multiplicity and interrelationships of the needs of the people before finally determining how the national cake should he shared. There is no evidence to indicate that the training of doctors, at the usually very high costs, in a poor country like Kenya, will dramatically improve health

status among rural population [39, 40]. All levels of paramedicals, at much less cost, would appear to hold promising potential [41, 42]. The better educated and trained nurses follow the physicians and few serve rural populations. Whether the available health services are equitably distributed throughout the country is a relevant question to ask in Kenya. But it requires a political answer. Those who could provide the answer do not ask the question [43]. And that is the problem for the rural health care development in Kenya. REFERENCES

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