Improving Equity in the Provision of Primary Health Care: Lessons from Decentralized Planning and Management in Namibia
Bell, Ruth, Ithindi, Taathi, Low, Anne, Bulletin of the World Health Organization
Voir page 680 le resume en francais. En la pagina 680 figura un resumen en espanol.
Health sector reform in developing countries, including the decentralization of management and the provision of primary health care, is expected to produce changes in the pattern of health service delivery and improvements in the equity of provision (1-4). In particular, first-level services may require strengthening in order to improve local access to basic primary health care. This requires that local health management teams develop the skills to assess the adequacy of provision and to identify and implement ways of improving services.
This paper describes how the Khomas Regional Health Management Team undertook a review of primary health care services in urban Windhoek, Namibia, in order to obtain evidence that would underpin local planning decisions. The review led to changes in resource allocation and enabled the team to influence central planning decisions.
Health sector reform in Namibia
When Namibia gained its independence in 1990 it inherited a state health system typical of colonial Africa: centrally planned, largely based on hospitals and in urban areas, and fragmented on ethnic lines (5-7). Subsequently, the Ministry of Health and Social Services adopted the primary health care approach (8). Thirteen regional health management teams were created in 1994 to decentralize responsibility for the planning and management of local primary health care services from four directorates, which were being phased out in 1997-98 when the work described in this paper was being carried out. The role of regional health management teams was to support and supervise district health management teams in their role of operationalizing the primary health care strategy at the local level. There were between one and three districts per region. During the transitional period, assistance with finance and training was provided from programmes funded by donors. This help included the provision of technical advisers who were involved in the development of management and planning capacity in the regional and district health management teams.
At the time of this work, key decision-making on resource allocation had not been decentralized to regional health management teams. The directorates retained responsibility for setting official staff establishments for all primary health care facilities, while decisions on capital developments, such as the extension of clinics and the construction of new facilities, were taken centrally by planners in the Ministry of Health and Social Services.
Windhoek: population and primary health care services
Before Namibia attained independence from South Africa in 1990, Windhoek was racially segregated: the areas of Katutura and Khomasdal were designated for the Black and Coloured populations, respectively, while the rest of the urban area was designated for the White population. In 1995, urban Windhoek had an estimated population of 181 000 and an annual population growth rate of about 5.4%, resulting mainly from migration from rural areas (9). The urban area expanded to accommodate the migrant population, largely in informal settlements of shacks spreading outwards from Katutura. Such communities suffer high levels of poverty and ill-health (10). In 1995 a survey revealed wide geographical variations in the levels of poverty in the urban area of Windhoek (Table 1) (9).
For the purposes of primary health care management, urban Windhoek is covered by a region and a district, both of which have the same boundaries. The overall planning and management of primary health care services are undertaken by the regional health management team, while district staff are responsible for delivering services in the clinics.
There are seven clinics in the urban area. At the time of the review, four were staffed by nurses only and three had doctors on site (Table 2). …