Journal of Social Development in Africa (1989) 4,1, 69-83 Rural-Urban Health Care Service Imbalances in Zambia — Forces and Outcomes LENGWE-KATEMBULA MWANSA+ ABSTRACT The central argument of this paper is that health care delivery systems, like any other social institution, are shaped by various forces relating to their respective societal context. Essentially, therefore, imbalances can be explained through historical, cultural, social, economic and political forces. In this paper only historical circumstances, prevailing ideology, power and income distribution are considered. These forces vary from country to country in terms of their nature and impact on the health care system. The discussion assumes that rural-urban disparities in the modern health care services in Zambia occur as a logical outcome of a historical process in relation to die forces referred to. A consideration of the introduction of allopathic medicine in Zambia by missionaries, and the impact of the mining industry and the government on the distribution of health care services, is, therefore, of critical importance. Introduction The purpose of diis paper will be to document and examine the health care delivery system in Zambia in terms of the forces and outcomes diat have led to distributional differences, and die extent of the imbalances between rural and urban areas. According to Gil (1981) the allocation of resources is based upon certain choices. Gil further explains that the generation and distribution of provision among humans living in groups always involves socially structured and sanctioned processes. It is therefore important to understand what the dominant interests are, in relation to prevailing power relations and ideology, widi respect to rural-urban resource allocation, particularly health care services. Ideology, here, refers to die political beliefs and concepts diat govern socio-political choices. By implication, then, ideology serves (consciously and unconsciously) die dominant interests. Dixon and Navarro (1984) suggest that the rules and priorities pertaining to die distribution of resources among competing needs are dominated by the ideology widiin a +Social Development Studies, University of Zambia, P O Box 32379, Lusaka, Zambia. 70 Lengwe-Katembula Mwansa given political framework. It should be acknowledged here that those with power define and impose their own choices as regards the distribution of resources, eg the type of health care system in a given society. The lop-sided development experience of health care services in Zambia, like elsewhere, be explained with reference to colonial ideological bias, and economic d religious interests. Chagula and Tarimo (1975), Gish (1973), Hampson 982), Ramasubban, Doyal and Pennel (1979), and Macpherson (1982), monstrate the existence of similar patterns of biased health development Tanzania, Zimbabwe, India, East Africa and Papua New Guinea spectively. They have unanimously argued that the essential objective of ilonial health policy was to provide a safer environment for the Europeans, maintain a healthy labour force engaged in industrial and commercial tivities, and for conversion of the natives to Christianity in the colonial ritories. In other words, health care was provided only in so far is it could ld economic or other special advantages for the colonialists, international pitalists and religious bodies. Furthermore, available evidence shows that alth care provision according to colonial policies and practices was strictly lour-segregated. Consequendy, Zambia's population was divided into ropeans, Asians (who came into the country as traders and shop-owners) d coloureds (off-spring of black and white unions), and Africans, in that der of importance (Northern Rhodesia, 1946). It should also be noted that, from die time of colonisation until shortly :er independence, copper (essential to die country's economy), and other nerals like zinc and cobalt, have been privately owned, exploited and trolled by foreign mining companies (Fortman, 1969). For die country it :ant mat the private foreign investors held die power to control and direct 'ings, consumption, investment and, above all, the allocation of ources. In other words, die decision making process in relation to die tribution of economic resources was foreign, ie in the hands of ernational capitalists. With the prospects of quick profits and capital :umulation as the reason for investment, foreign investors naturally ght to aid only those areas in which they could expect rapid returns on investments. deology and power are therefore of considerable importance in setting orities and achieveing an equitable healdi care system. The questions of ere, how much, and what amounts of resources are to be used for health, I who die beneficiaries should be, are all ideologically and economically 'tivated. Those nations diat have succeeded in providing relatively anced health care services have not asked "how many people can die :em provide health for?" but rather "given the resources we have how >uld they be applied to provide health care to all?", esides ideology and power, imbalances in health are affected by the type economy in a country. Gray (1982) makes an attempt to distinguish Rural-Urban Health Care Services 71 between capitalist and socialist economies and how they may affect the distribution of resources and, ultimately, equity. In general terms, socialist economies such as China and Cuba advocate government ownership and control of the means of production, the redistribution of resources and the promotion of individual as well as general welfare. This includes the provision of health care services for all, based on the assumption of egalitarianism and that health is a right for all. In such economies healdi care services are available and and accessible to a large part of the population, eidier as a free service or heavily subsidised and therefore available at a low cost (Elling, 1980). This contrasts with the free-market enterprise system such as that of die United States of America. Wealdi and resources in such an economy are largely privately owned and this has led to sharp inequalities when contrasted with socialist economies. Healdi is seen as a commodity to be purchased. Public support for health care services is relatively less. Private payment plays a greater role, in the form of insurance, in diese economies. Consequently, a smaller share of the Gross National Product is devoted to health services in the United States than in China (Lindblom, 1977). The basic argument, here, is that the availability of more resources alone will not achieve an equitable distribution of healdi care services. As noted by Turshen (1984), a distinction needs to be made between (a) die ability to generate or mobilise resources and (b) the actual will to distribute die same resources among individuals, communities and regions equitably, especially between rural and urban areas. It is therefore suggested mat die availability of financial resources does not mean that healdi care services in both rural and urban areas will receive equitable provision. This can be seen particularly in the Zambian Health Care Service where the urban areas, as will be demonstrated, have received and continue to receive, more resources dian the rural areas. Historically, modern health care services were introduced into Zambia during the late 19di century widi die advent of the missionaries (Gann, 1964). David Livingstone and other European missionaries came to die area with die first mission being established by Francois CoUard in 1855 at Sesheke in Barotseland, now the Western Province of Zambia. Initially health service were provided on a very small scale and often limited to converts or potential converts. Medical services were employed as a means to convert the 'African pagan masses'. This view is supported by Rotberg (1972) when he indicates diat "Africans were dius attracted to dieir station — if only to enhance die appeal of a worldly web". But gradually die health care services, which were curative in nature, became one of the major secular contributions of the missionaries. They knew how to bandage wounds, to drain sores, to set bones and to nurse patients. They alleviated pain and healed die sick. However, it should be mentioned that diese missionary activities,were only found in few parts of the country leaving many odier 72 Lengwe-Kattmbvla Mwansa parts of the country without services. But, by and large, missionaries have and continue to offer health services in rural areas. In 1899 die Northern-Western Council proclaimed the territory north of the Zambezi river to be direcdy under British Colonial Administration. Later in 1924, die British South African Company (BSAC) completely handed over the administration of Northern Rhodesia to the British Government Colonial Office, while retaining full rights over minerals in the country. Administrative centres were established with modern heakh care services to cater for the expatriate colonial officers. The indigenous workers at diese centres also received, separately, die services from die white expatriates, to create a buffer zone in disease transmission. Again, diese administrative centres, which existed at district and provincial levels, did not adequately cover die country. In fact they were dotted, for administrative convenience, diroughout die country. However, die coming of die railway line in 1902 and die introduction of die mining industry on the Copperbrlt in 1906 (Republic of Zambia, 1980) had created a new dimension to the provision of health care services. It is being argued here diat die essential objective of providing heakh services in colonial Zambia was to provide a safer environment for die white expatriate population, and to maintain a healdiy labour force for die industrial and commercial activities in die colony. It seems diat services like education were also extended only to local workers where they could yield economic, political or odier special benefits for die colonial power or odier international' capitalists. For example, Fry (1979) writes diat: "the mining industries in Zambia realised that die efficiency of African labour could be increased substantially by improving heakh condition services of die workers by means of innoculations, good sanitation, clean water, good housing, nutrition and environment." One could, dierefore, suggest that, since die rural areas did not offer lucrative, easily exploitable economic benefits to investors as well as die colonial government, diey did not have any great incentive to provide adequate health care services in diese areas. Instead die investors, togedier with die colonial government, invested more in die Copperbelt and along die railway line. It is not an accident, dierefore, diat the most developed areas in Zambia to-day are die metal-producing areas centred on die old railroad. As a consequence, rural areas have been comparatively neglected. Also, during diis stage of development, the newly introduced money economy created new needs and wants which could only be met widi cash. However, economic investment was skewed towards die urban areas, and so migratory wage labour became even more necessary as a way to meet diese new needs. But more importandy, this development created disparities in die incomes of households in rural and urban areas. Several studies have Rural-Urban Health Care Services 73 suggested that rural household incomes are much lower than the incomes of households in urban areas. It seems clear, therefore, that two major factors tend to emerge as being largely responsible for imbalances in the provision of health services. These are: (a) a pattern of skewed urban investment and (b) lack of adequate government intervention to equitably allocate resources. This gap between rural and urban areas continues to grow ever wider. The extent of the imbalance (1964-1984) Experts on health care provision in developing countries appear unanimous in suggesting that the major problem facing these countries, including Zambia, is not merely inadequate numbers of health personnel or facilities in relation to the population, but the great disparities between rural and urban areas. To examine the extent of this .imbalance in Zambia, the following discussion will focus on resource allocation in the health sector in relation to rural and urban areas. This will be done by using official data on health resource distribution in Zambia. Resource inputs will be looked at in terms of the allocation of expenditure and the distribution of personnel and health provision in rural and urban areas. If, as is being argued here, resources are inequitably distributed between rural and urban areas, then services, and the results of measures of availability, accessibility and outcomes will be unequal between rural and urban areas. However, because of the difficulty of measuring health outputs, or outcomes that are a direct result of these resource inputs, quantitive distributions of inputs, as the best available indicators of health output, will be looked at. (The reader is reminded that it is extremely difficult to state entirely accurately how much any particular country spends on health provision.) In the post independence era, the government sought to redefine the basic values which would lead to a national health care system that is accessible, universal and affordable. These values were determined by the philosophy of'humanism'. Although Humanism in Zambia has been used as a guide to policy implementation, many observers doubt its effectiveness or impact on health care and other sectors of life in the country. However, Humanism is used here to aid the reader appreciate the principles that govern the allocation and distribution of resources in Zambia. Health care provision was seen as important as the physical well-being of individuals is seen to be a critical influence on their capacity to contribute to and benefit from socio-economic development. This spirit is reflected in all National Development Plans and is summarised in the overall objectives of the National Health Policy (Govt of the Republic of Zambia, 1979): "To improve and expand health services; cover all areas in the Republic and in doing so, continue to make the health service efficient and readily available to all people." 74 Lmgwe-Katembula Mwansa The government has continued to expand health care services in the country. Substantial investments (Ministry of Health, Zambia, 1981) have been made since independence to make health care available to all, as can be seen in Table 1. Table 1 Health Care Facilities (1964 and 1978) Facility 1964 1978 % Increase [ospitals 70,8 82 90,6 ieds and Cots 14 700 120,9 48 7 710 306 otal Health Centres 676 Source: Country Health Profile, 1981, p. 16 "he idea was to provide as many modern health institutions as possible, "hese were to be equipped with high technology and supported by highly rained staff even at health centres. According to the Family Health Care leport (1979) the government's expenditure on health (recurrent and apital) rose from US$44,4 million to US$65,5 million (47,8 percent) or rom US$10,9 to US$12,73 (16,7 percent) per capita between 1972 and 976. Total health expenditure, including recurrent and capital, for ;overnment, missions and mines, however, rose by only 5,7 percent from JS$87,5 million to US$92,5 million during the same period. However, lese improvements in the health expenditure of Zambia are largely eflected in improvements in urban areas. The rural population appears to ontinue to be by-passed and their health status largely remains unaffected, 'he crucial question that needs to be investigated, therefore, is how the ealth care investment has been disbursed across the nation. In the FNDP, as presented in Table 2, government's health expenditure iuggested a bias in favour of urban areas. The government spent C10 499 000 or 58 per cent on one third of the population living in urban ireas. This contrasts with K7 624 000 or 42 per cent for the remaining rural- >ased two-thirds of the inhabitants. In the Second National Development 'Ian (SNDP) this bias in spending favourable to urban areas did not seem to hange, as Tables 3, 4 and 5 reveal. Based on this evidence it may not be •resumptuous to indicate that the presence of the three large hospitals in the bree largest towns is no accident, but a deliberate decision by those in lower against the alternative decision to build smaller hospitals throughout the country. In addition to making health care available and accessible to the majority of people through smaller hospitals, mis approach would not only correct the imbalances but decentralise the country's health care system. This inability to alter the imbalance is said to have been caused by the influence of the political and bureaucratic elite and organised urban labour. These groups control the decision-making process and exert pressure on the government (ILO, 1977). It is also argued that these groups control both political and economic power, and dierefore have the decision-making power over the distribution of resources. Conversely,rural people tend to lack both political and economic power, and dierefore one cannot control and decide upon the allocation of resources. Unlike die urban population, rural people, despite having common problems, remain unorganised and fragmented and thus without an effective voice. They are not seen as posing any danger to the system. Observers such as Bates (1970) and Rothchild (1972) view this power imbalance as one of the major contributors to die rural-urban gap. National Summary of Government Capital Investment by Province on Health — 1966 Province Copperbelt Central Southern Total (Urban) Northern Eastern Western Luapula North-Western Total (Rural) Grand total Source: First National Development Plan (FNDP) 1966-1970: p 81. Rural-Urban Health Care Services 75 Table 2 (in Kwacha) Percentage Amount 23,3 4 214,8 25,8 4 677,7 8,9 1 607,4 58,0 10 499,9 14,8 2 674,0 1 737,4 1016,6 1 707,4 9,6 5,6 9,4 2,7 488,8 42,1 7 624,2 100,0 18 124,1 INSTITUTION 1. Province 2. UTH 3. Ndola Central Hospital 4. Kitwe Central Hospital 5. Headquarters 6. Other Total. Health Budget Total All Zambia Budget Source: Adapted from Republic of Zambia, Ministry of Health, Country Health Profile 1978, Planning Unit, Ministry of Health, Lusaka, p 32. 1 Percentage in relation to the Total Health Budget of Zambia. Table 3 Recurrent and Capital Budgets (Approved Estimates for some Institutions) (in Kwacha) 1974 Capital Recurrent % %' 1 521 031 87,5 18,1 7,1 18 564 — 26 580 43,8 992 052 28,5 0,5 — 916 852 26,4 0,8 100 25,2 6,3 100 11856 642 5 735 995 2 253 307 1 899 280 6,0 8 011893 2 001215 31 758 322 440 928 314 3 475 079 158 271620 1978 % % Capital Recurrent 200 000 — 485 000 1 668 000 49,5 1019 000 30,2 5,9 — 14,4 — 100 20 758 650 41,1 8 734 750 17,3 7,8 6,3 20,7 6,8 100 3 935 710 3 167 950 10 481 151 3477 110 50 555.321 652 782 747 3 372 000 139 996 900 1979 Capital % % Recurrent 21 256 700 4 418 310 3 805 480 827 000 485 000 195 000 — 755 000 — 3 660 080 36,6 21,4 8,6 — 33,4 — 2 262 000 100 123 906 000 38,4 10 182 330 18,4 8,0 5,9 12 595 751 22,7 6,6 55 418 651 100 725 508 616 Rural-Urban Healtfi Care Services 77 The actual expenditures cited in Table 3 are not sufficiently specific to render an easy rural-urban comparison. But it is evident that the three central hospitals, viz UTH, Ndola and Kitwe (all urban-based), out of thirtynine (39) hospitals in the country, spent K9 888 582 or 31,1 per cent of recurrent expenditure and K1010616or29 per cent of capital expenditure in 1974. Similarly in 1978, the same three hospitals, now out of forty-two (42) in the country, spent K15 838 410 or 31,3 per cent of the recurrent expenditure and Kl 219 000 or 36,2 per cent of the capital expenditure. Likewise, K17 906 120 or 32,3 per cent of the recurrent and K680 000 or SO per cent of total capital health expenditure was spent on the three hospitals in 1979. It is apparent therefore that the three urban hospitals account for a larger .proportion of the total health budget. Notably, the UTH had the largest share of the total budget during the period under consideration. This share is expected to grow even bigger as a newly built children's wing (donated by Japan) has been opened. Provinces represent provincial and district hospitals and health centres in both rural and urban areas. But more and larger hospitals are found in the urban areas. It is interesting to note that of the total recurrent budget in 1974 only 37,3 per cent was allocated for the activities in the provinces, districts and rural areas. Similarly in 1978 with 41,1 per cent and in 1979 with 38,4 per cent. Capital expenditure figures are not significantly different to this. For example, in 197 8 while the UTH alone was allocated 30,2 per cent of the total health capital expenditure, provinces were allocated only 49,5 per cent. This allocation of health funds to rural and urban services could be both the cause and effect of structural health imbalances, perpetuating and reinforcing the existing disparities. Availability of health facilities In the data presented in Table 4 both personnel and facilities appear to be concentrated in urban areas. For example, King (in Family Health Care Reports, 1979) contends that in Kenya the overall doctor-patient ratio is 1:10 000 but in rural areas the ratio rises as high as 1:50 000. He goes on to say that the situation is said to be even worse in Nigeria where although the overall doctor-population ratio is 1:33 000 the ratio in the Northern rural part of the country was been reported as being as high as 1:140 000. Similarly in Zambia, while the overall doctor—population ratio in 1978 (Table 5) was approximately 1:8 700 that of urban areas was 1:4 000 widi rural areas at 1:38 000. A cursory examination of Tables 4 and 5 reveal considerable imbalances in the availability of health facilities and personnel between rural and urban areas in Zambia. Both Tables 4 and 5 demonstrate that there are far more health facilities and personnel in urban areas than in rural areas. According to the ILO Report (1981:104): 78 Lengwe-Katembula Mzoansa "In 1972 about one-fourth of the total population did not have access to any type of health facilities within 15 kms; in some worse-off provinces, predominantly rural areas, the proportion was one-third." On the other hand, the Report continues, coverage in the Copperbelt was more than 90 per cent. This has since improved, but the gap does not seem to have significantly narrowed over time, as can be observed in Tables 4 and 5. In 1977, 59 per cent of the population lived within a 30 km radius of existing hospitals and 41 per cent outside it (see Table 4). This situation, as seen in the table, is comparatively worse in the predominantly rural provinces such as the Northern Province where 70 per cent of the Province Central Copperbelt Lusaka Southern Eastern Luapula Northern North-Western Western National Average Source: International Labour Office, Zambia, Basic Needs in an Economy Under Pressure, Jobs and Skills Programme for Africa, Addis Ababa, 1981, p 104. Note: (a) including Lusaka 'Excludes Army hospitals and private surgeries. Table 4 Availability of Health Facilities* in 1977 Beds and Cots per Population per doctor 100 people (thousand) Percentage Population within 30 Kms radius of existing hospitals 2,9 15,2 66,8a 97,6 3,0 . — 5,8 3,0 3,5 3,0 51,4 14,5 2,4 2,2 1,9 4,4 2,7 29,6 23,6 24,8 15,5 20,4 43,2 34,9 29,1 50,6 46,0 2,3 59,0 8,9 Percentage of Rural Population 12 Kms from existing health centres 59a 83 — 75 84 78 52 65 53 68 Rural-Urban Health Care Services 79 population live outside the 30 km radius. This is in contrast to 2,4 per cent of the population in the Copperbelt Province who live outside of the 30 km radius. Differences also exist in the distribution of beds and cots between rural and urban areas. The data indicates that while the number of beds and cots is above the national average in urban areas, some provinces (such as Northern) are well below the national average. It would seem dear dien that the rural population has less access to health facilities than the urban population. The distance patients have to cover to reach a health facility is a major factor in defining the accessibility and availability of health care. This situation is further compounded by the under development of communication systems in rural areas. In Zambia, as in many less industrialised countries, problems of transportation in getting to and from hospitals or health centres are often worse in rural areas than in urban areas. Even the use of mobile clinics is not always feasible, especially during the rainy season when tropical rains sometimes wash away roads making them impassable, because of problems of maintenance and fuel. For example, in 1980, out of the total of 576 Ministry of Health vehicles only 23 vehicles or 21 per cent were in running condition. Three hundred and eighty vehicles or 66 per cent, were out of service and needed repair, and 73 vehicles or 13 per cent were beyond repair (Family Health Care Report, 1979). Simply stated, apart from the flying-doctor service which operates only in certain areas, an ambulance service in predominandy rural areas does not exist. It is not uncommon therefore for patients to be brought to hospital or health centres on bicycles, blankets or on relatives' backs. Even if bus services were frequendy available, a majority of die rural population would still be unable to reach health services. They lack adequate disposable income for transportation (Ollawa, 1979). In brief, in terms of both expenditure and the provision of heakh facilities, the urban areas (widi one-diird of die population) have enjoyed far more resources dian die rural areas (with two-diirds of die population). The UNICEF Report (1979) states diat "diere has been dramatic growth in cosmopolitan healdi facilities since independence. The numbers of government urban clinics excluding mine clinics have risen by more than 202 per cent". Distribution of health personnel The imbalances in medical services between rural and urban areas is compounded by a lack of adequate and suitable personnel in rural areas. The data presented in Table 5 suggests that, except for medical assistants, there are more health personnel in predominandy urban than rural areas. The Medical Assistants' figures must be interpreted with caution and widiin a historical context. This cadre of medical workers were established, during Province Central Copperbelt Lusaka Southern Total Urban Ratio Urban Percentage of the Total Eastern Luapula Northern North-Western Western Total Rural Ratio Rural Percentage of the Total All Zambia: National Ratio 53 992 1:5 516 Source: Republic of Zambia, Ministry of Health, Country Health Profile, 1982 and 1978 Population Estimates, Population Census 1980. 'Excludes private and Army and traditional health personnel. It also excludes other non-medical and paramedical workers in Zambia. "This category includes matrons and sisters. Although these are supervisory staff, they are considered to possess similar qualifications and skills and perform the same functions. Table 5 Health Personnel* in Zambia — 1978 (Government, Missions and Mines) Dentists Doctors 1 14 8 3 26 1:82 807 41 219 244 87 541 1:3 979 86 23 12 21 11 21 88 1:37 715 90 1 — 1 — 1 3 1:1 106 333 14 629 1:8 699 10 29 1 188 689 Registered/** Registered Mid- Wives Nurses 77 632 351 95 1 155 1:1 864 78 53 48 83 79 64 327 1:10 149 22 1482 1:3 692 Zambia Enrolled Nurses/Zambia Enrolled Midwives Nurses 214 1 406 436 , 315 2 371 1:908 78 134 107 167 120 124 652 1:5 090 22 S023 1:1 810 s Medical Assistants 73 220 76 94 463 1:4 650 47 153 91 105 90 90 529 1:6 274 Rural-Urban Health Care Services 81 the colonial era, primarily for rural areas. They were trained to run rural clinics. At that time it was not usual to find doctors, other dian missionaries, in rural areas. So the tendency was to send the medical assistants to rural areas after training. The marked service imbalance for other categories of personnel is sometimes attributed to an unwillingness on the part of most medical personnel to work in remote areas where the need is greatest. Theorists, such as Lipton (1977), point to the lack of incentives and the unattractive social conditions in rural areas. The general tendency even among Zambian-trained health personnel, including doctors, is to work in urban centres. These are places where conditions of life are relatively attractive. Analysis of Table 5 reveals that Zambia-enrolled nurses (ZENs) together with Zambia-enrolled midwives (ZEMs) form the largest health personnel contingent (2 023) nationally). This is the lowest level of formally trained medical personnel in Zambia. They usually work under the supervision of medical assistants. Candidates in this group must hold a form three (Junior High) or Junior Secondary School Certificate or its equivalent. They un4ergo a two-year medical training with further training for the midwives. This group, in the author's opinion, currently form the backbone of the primary health care services with other personnel in lower cadres of social services in Zambia, especially in rural areas. However, despite their critical and essential nature, there are not enough of them in rural areas. While the national population ratio stands at 1:1 810, the urban ratio stands at 1:908 and in rural areas 1:5 090 respectively. Provision of more ZENs/ZEMs in rural areas could reduce imbalances in this category of service between rural and urban areas, their services could make a difference to the overall health status in Zambia. It should also be mentioned that Zambia will shortly introduce medical fees. The change from non-fee to fee-paying medical services has been prompted by rising medical costs in die production and distribution of health care services and to the sagging economy. However, due to a lack of data on the criteria for payments, it is hard to say anything meaningful about the forthcoming system. It remains to be seen how the new system will either exacerbate or reduce the rural-urban disparities that already exist. Conclusion From the data presented in this paper, it is evident that there exist imbalances in health services between rural and urban areas in Zambia. These imbalances are skewed towards urban areas, where only a third of the population live, and these imbalances continue to grow. They are reflected in the distribution of health expenditure, personnel and facilities. These imbalances have come about, and are perpetuated by, the pattern of deliberately investing more resources in urban than rural areas. Health 82 Lmgwe-Katembula Mwansa care services have been provided, in large measure, where they yield economic, political or other benefits for the sponsors. 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