Source: World Bank 1992a.

For the most part, however, governments have made the funding of tertiary and other inpatient facilities their leading infrastructural priority. In Ethiopia the number of people per hospital bed fell from 3,500 in 1970 to 3,400 in 1980, and in Rwanda from nearly 800 in 1970 to (450 in 1980. STomnd Principe enjoys one of the highest ratios of hospital beds to population in the developing world. In 1990 that small African country had roughly one hospital bed for every 190 people, which was twice as in Nigeria and nearly three times as high as in Colombia. These accomplishments have come at a high price, tend to be concentrated in urban areas (Table 7-3), and provide disproportionate benefits to relatively well-to-do households.

Poor infrastructure planning is evident in the location of health facilities, in uncoordinated community initiatives for facility expansion and in weaknesses m project design and execution. In Guinea-Bissau, for example, one region has more than five times the number of hospital beds per person found in another, more populated region. In Burundi, the population served by health, centers varies from 870 to more than 17,000, with a mean of around 2,500. Even in Tanzania, where a special effort has been made to achieve equity in the health sector, a sample of primary cam facilities in 1984 revealed that some dispensaries served only about 1,500 people, compared with the target of 6,500, while others were expected to serve populations many times larger than the target figure.

Table 7-3. Percentage of Population with Access to Health Care Facilities, Selected African Countries, Late 1980s

Country	Urban	Rural
Botswana	90	85
Burkina Faso	5 1	48
Congo	97	70
Gabon	97	70
Ghana	92	.45
Kenya	80	53
Liberia	50	30
Mauritius	99.	99
Nigeria	87	62
Rwanda	60	25.
Somalia	50	15
Tanzania	94	73
Togo	60	60
Zaire	40	17
Zimbabwe	90	so

Source: Statistical appendix in this volume

Poor planning is particularly apparent in imbalances between urban and rural areas. A study of rural health stations in Ethiopia in 1985-86 found that they served only sixteen patients per day, many fewer than the ninety to 100 anticipated, and concluded that improper location of the facilities was responsible. Another study (Kloos 1990) found that more optimal location of maternal and child health facilities in rural Nigeria would have increased coverage by 20 percent In the fifteen African countries -for which data on the matter are available, six are countries where less than 50 percent of the rural population has access to health care facilities. In seven of the countries, however, 90 percent or more of the urban population had access to health facilities in the same, period (Table 7-3).

Lack of coordination between the public sector and nongovernment providers has complicated matters because decisions on the location of public sector facilities need to take into account the planning of the nongovernment providers. In Uganda, church missions have built clinics to meet the needs of the population in rural areas. Governments ran build on, or complement, such networks.

Lack of coordination between government officials and community leaders is another manifestation of weak planning. In a number of African countries, health centers have been built by communities with the understanding that public authorities would operate them, but adequate resources have seldom been set aside for that purpose. In Mauritania, where community participation was encouraged by the government, health posts were built at random locations by local communities. In some regions, the proliferation of health posts has resulted in shortages of personnel and material resources. Financial and other constraints have frequently prevented the government from assuming responsibility for operations at health centers and have made local communities, cynical about the national government.

Poor project design and execution are another. Manifestation of weak infrastructure planning. A wide range of construction standards and methodologies, combined with a lack of norms, has led to oversized facilities, substandard construction, and high unit costs. Unit construction costs for almost identical health centers in Mali in the late 1980s, for example, varied by a factor of four (World Bank 1992a). Construction costs in the Sahel countries range from $750 to $1,200 per square meter for primary care facilities, compared with $350 to $450 per square meter in other African countries (Porter 1992). In the absence of norms for designing catchment areas, national officials responsible for planning health sector construction have often been unable to identify the type and size of infrastructure needed to provide-health services to local communities. Renewing Health Sector Infrastructure and Equipment Physical proximity to health care facilities is only the be inning of effective health care coverage. A facility that is near people's homes will have little value if it lacks basic equipment In many African. countries this problem has arisen partly because plans were made to construct new facilities before determining whether the money was available to operate them. Some of these problems can be resolved by charging fees and making improvements in the quality of care, at lower level facilities. What remains critical, however, is to improve infrastructure planning, selection of equipment, and equipment maintenance.

Cost-effective allocations of financial resources for infrastructure and equipment tend to be those that give priority to rehabilitation over new investment, and to health centers and district hospitals instead of tertiary facilities, as discussed in Chapter 4.

Rehabilitation needs are widespread, but effective rehabilitation requires careful analysis of existing investments and a clear ranking of priorities compatible with a commitment to preventive and primary health care and to cost-effective-interventions. Mali, for example, has begun to establish a foundation for this kind of analysis through the creation of a data. bank on existing infrastructure, equipment, and associated health care services that will be available to local health administrators.

Norms, skills, and procedures for determining where to build health facilities and for the maintenance of buildings, equipment, and vehicles also need to be established and carefully monitored. The norms should cover actual maintenance work- as well as its Financing, and should apply to nongovernment as well as public sector facilities. As a general rule, African countries should expect to spend between 2 and 3 percent of the replacement cost of health centers and hospital buildings on maintenance annually. A detailed study of Kenya, for example, led to an estimate of 2.6 percent (Porter 1992). Specific standards on spending for equipment maintenance, repair, and replacement are also needed. It has been suggested as a rule of thumb that a sum equivalent to 20 percent of the value of existing stock should be allocated annually to maintenance, repair, and replacement (Bloom and Temple-Bird 1988). Another way to look at the issue is in terms of the recurrent expenditures of operations. As a general rule, around 10 to 15 percent of recurrent costs will be required to maintain a first-referral hospital (Barnum and Kutzin 1993).

Standardized lists of the equipment used in the various types of health care facilities are also needed, along with norms for maintenance and repair. WHO has prepared such norms in a number of related areas, such as the estimated annual cost of maintaining specific types of medical equipment as a percentage of their capital cost (Kleczkowski and Pipbouleau 1983) Ghana is planning to set up a hospital equipment maintenance service with workshops, equipment and tools, vehicles, spare parts, and training programs. Mozambique is establishing a national network of health facility and equipment maintenance centers. The experience of nongovernment partners is often relevant (Box 7-1).

When health center facilities and equipment are well managed, local communities tend to be involved. The basic principle underlying this arrangement is that facilities planned without the active participation of beneficiaries will, at best, be viewed with indifference. If appropriately planned, partnerships constitute a powerful instrument for promoting local initiatives and strengthening management through a sense of ownership. As part of a World Bank-financed health and population project in Mali, for example, a cost-sharing formula (50 percent government and 50 percent local communities) is supporting construction and planned maintenance of 120 community health centers during a five-year period.

The special problem of tertiary care facilities

The management of tertiary-level health facilities (meaning mostly major urban hospitals) merits special attention. Improving efficiency at such facilities without increasing their budget allocations in real, or even nominal, terms would be highly desirable. Management audits can lead to the establishment of specific targets for efficiency gains. At the Kenyatta National Hospital in Nairobi, for example, the performance targets include reducing the average length of an inpatient's period of hospitalization from 8.6 days in 1989-90 to 7.1 days in 1995-96, a reduction in staff from 5.4 to 4.0 per 1,000 patient days, and an increase in the ratio of maintenance to total recurrent expenditures from 2.2 percent to 6.0 percent. Malawi has prepared five-year efficiency plans for its three major hospitals that include reductions in funding for transport and utility systems, other items, and improved accounting and expenditure control.

Assessing technology choice

In many African countries, modem technology is often not used properly, even in leading hospitals and medical schools (Free 1992). It is complex technology that requires every component to interact at the right place and the right time, but the more complex the technology. the greater the risk that a link in the chain will break down. The introduction of oily technology should therefore include the introduction of all the things needed to make the technology work: equipment, training, maintenance, quality control, and the capacity to translate the results of quality control analyses into corrective actions.

BOX 7-1. MAINTENANCE IN HOSPITALS OF ZAMBIA'S MINING CORPORATION

The public sector In Zambia is facing great difficulties in providing and sustaining medical equipment services. In public hospitals, about 20 percent of medical equipment is working poorly and 40 percent is completely out of operation. Zambia Consolidated Copper Mines (ZCCM) has established a health care system of its own, separate from the public sector, that consists of eleven hospitals and fifty-eight health centers. It has developed a good maintenance system for its medical equipment, which is about the same-age as that in the public sector) Its ability to do this has been due to the following factors:

- It has established an autonomous body, the Medical and Educational Trust, to operate all health care facilities and train health care and operational personnel)

- It has established work practices that encourage good staff performance, combined with strong supervision and incentives. It offers better service conditions than the public sector and has higher staff retention rates.

- ZCCM has recognized the importance of maintenance in its operations and health care activities. Mine hospitals are financed significantly better than their public sector counterparts and therefore receive adequate maintenance budgets and foreign exchange.

- It has separated medical equipment maintenance and safety policies from its operational activities and wisely applied technical and human resources, maintenance, and management expertise from industrial instrumentation to medical applications.

- Initial training in management and maintenance for health care specialists has been conducted by mine operational staff. Some operational maintenance staff have been seconded to mine hospitals.

Source: Templ + Bird 1991.

New technologies have expanded the potential scope of the health system; some examples follow.

- Computerized systems make it possible to store and retrieve the large amounts of vital statistics and other data needed to assess risks and to plan, implement, and evaluate health programs. Pharmaceutical supplies can be managed more efficiently through computerized updating of inventories, thus preventing waste and reducing costs. Computers are only helpful, however, to the extent that they support a management information system With adequate software and maintenance.

- Radio communication has proven essential in mobilizing the resources. needed to deal with epidemics and natural disasters, Health activities in rural areas can be better integrated into district health care through the use of two- way radios, particularly if transport is available to evacuate patients when necessary. Supervisory consultation by radio improves the efficacy of services and. reduces the cost of referral.

- New diagnostic tests, such as "dipsticks" to diagnose HIV and other sexually transmitted diseases, or tests using saliva, may give community health centers diagnostic powers that were previously restricted to specialized urban laboratories.

- Noninvasive diagnostic tools with high sensitivity and high specificity,. such as uItrasound machines, may sharply improve diagnosis at the district level. Less invasive treatment “keyhole" surgery, for example-can minimize patient trauma and reduce the length of hospital stays. A shift to one-day surgery with improved technologies and care practices, as is now being done in many industrial countries, could help to contain the growing demand for hospital beds and other health facilities (Porter 1992).

- The development of powerful drugs that can be effective when administered in a single oral dose has drastically modified the therapeutic approach to such diseases as helminthiasis and amoebiasis. Similarly, thermostable vaccines that can be given in a single oral dose have increased the prospects for controlling common children's diseases, such as measles and polio. Drug kits and blister packs fall in the same category.

The greatest obstacle to improving medical technology in Africa may be "technology philanthropy" - the uncoordinated donation of equipment to African countries by foreign agencies and charities. Given their. often precarious finances, developing countries find it hard to refuse such gifts, even when they are unsuited to the-country's immediate needs. One solution would be to devise "donation protocols," whereby the kinds of equipment to be donated would follow a model-paralleling, for example, the selection of drugs by using essential drugs lists (Porter 1992).

BOX 7-2. ACQUIRING NEW TECHNOLOGIES

There is generally no established mechanism in African countries for planning the acquisition of new health technologies. Awareness of technologies is not a problem, because there is a sufficient pool of knowledge at universities, among staff returning from abroad, and among consultants and donors. It is the process of technology transfer that is problematic, since it is usually made on an ad hoc basis according to vested interests, pressures, and prejudices. When there is some form of planning, the acquisition of new technologies is to a large extent controlled-by physicians and, more likely than not, by clinicians trained abroad. They are generally not the best persons to perform this task While the medical profession can readily pinpoint a problem, it generally has little idea of the complexity and extent of the engineering problems or the level of training associated with the technologies needed to solve them. Rather, a team is needed, including public and nongovernment health care providers, engineers, planners, and social scientists—to ensure that the broader cultural, social, and economic dimensions are considered) Public, private voluntary, and private commercial perspectives are all useful to this end. Because the choice of health technologies determines the allocation of human and financial resources in health care, African governments need to support operationally oriented research that will facilitate decisions about whether to introduce new tests, treatments, and their associated technologies into their countries' health care systems. Factors to be considered include the appropriateness and cost-effectiveness of the intervention, its links to the basic package of health services, its impact on health equity, the ease of its use and maintenance, its training requirements, and its life-time cost. A cautious attitude toward uncontrolled diffusion of medical technology is emerging in the industrial countries, and African policymakers would do well to exercise prudence in the face of quite understandable pressures for investment Selection of appropriate equipment, and arrangements-to ensure its maintenance, are appropriate ministry of health roles.

Much of the work of technology assessment will require intercountry cooperation, because the costs of undertaking assessments and preparing appropriate recommendations are likely to exceed the capacity of most individual African countries. Some support for such work exists at the international level, including a joint Technology Introduction Panel inaugurated by UNICEF in 1988 in cooperation with WHO and other international agencies (Box 7-2) (Free 1992).

Conclusion

Strengthening the management of infrastructure and equipment is one of the several health system reforms needed to achieve health goals in Africa. One concrete step would be for governments to assign responsibility for decisions about health facilities, equipment, and technology to a senior ministry of health official. Another would be to establish norms for health facilities at different levels in the system and to support operational research on the most cost- effective technologies available. Budgetary standards and provisions for maintenance and operating costs need to be established, particularly in public sector, health facilities. Since the financial resources required to provide basic health services are frequently depleted by cost overruns and-inefficiencies at the tertiary level, more efficient use of technologies, equipment, and facilities in large urban hospitals should L-e a priority. African ministries of health might take a look at the global -action plan devised by WHO for the management, maintenance, and repair of health care equipment.