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close this bookBetter Health in Africa: Experience and Lessons Learned (WB, 1994, 260 p.)
close this folderChapter 4 - Revitalizing national systems of health care
View the document(introduction...)
View the documentAfrican health care systems today
View the documentA brief history of primary health care strategies in Africa
View the documentHealth care system realities
View the documentUnderpinnings of a cost-effective approach

Underpinnings of a cost-effective approach

Well-functioning health centers, working in conjunction With first-referral hospitals, have the capacity to manage more than 90 percent of health care demands. Experience in a number of African countries shows that the most fundamental clement of such an approach is a limited and flexible, cost-effective package of basic services that can be delivered at the community level. The first clement of the package is a basic set of health care inputs. The second is a battery of supporting services that aim to ensure that households make the most effective use of such inputs. The third consists of multisectoral inputs to better health.

The basic services emphasized in this report are those needed largely in countries that have not yet passed through the "health transition." This means a shift in the demographic and epidemiological makeup of a country, and associated social conditions and attitudes, from an environment dominated by high fertility, high mortality, infectious disease, and malnutrition to a low-mortality, low-fertility environment with a disease profile increasingly weighted toward noncommunicable conditions of adults and the elderly. Although some population groups within individual African countries, particularly among the elite, have entered or passed the health transition, the package concept still applies to all countries and populations. Both the content and the cost of a basic package


Box 4-2 continued less than $25 and often between $50 and $150 Activities in this category include immunizations; school-based health services; information and selected services for family planning; programs to reduce tobacco and alcohol consumption; regulatory action, information, and limited public investments to improve the household environment; and AIDS prevention. Although the cost-effectiveness of clinical services will vary from country to country; depending on local health needs and the level of income, five groups of interventions are highly cost effective and address very large disease burdens) These include services to ensure pregnancy-related care (prenatal, childbirth, and postpartum); family planning services; control of sexually transmitted diseases; tuberculosis control; and care for the common serious illnesses of children - diarrheal disease, acute respiratory infection, measles, malaria, and acute malnutrition. These interventions form the core of the package of health care services recommended in this study. Provided by well-functioning health centers and first-referral hospitals, they have the capacity to (a) manage more than 90 percent of health care demands and (b) reduce the national burden of disease by up to 30 percent. Source: World Bank 1993e.

The cost - effectiveness of many of the health recommended in this study has been substantiated in the World Bank's World Development Report 1993: Investing in Health. Given a common currency for measuring cost and a unit for measuring health effects, the World Development Report compares the costs required for different interventions to achieve one additional year of healthy life. Outcomes are expressed in terms of disability-adjusted life years (DALYS). The ratio of cost and effect, or the unit cost of a DALY, is called the cost effectiveness of the intervention. The lower the unit cost to gain one DALY, the greater the value for money offered by the intervention. Only a small number of the thousands of known medical procedures have been assessed using the cost-effectiveness criteria described above, but the approximately fifty studied would be able to deal with more than half the world's disease burden. Just implementing the twenty most cost-effective interventions could eliminate more than 40 percent of the total burden and fully three-quarters of the health loss among children. Several public health activities stand out as being particularly cost-effective: the cost of gaining one DALY can be remarkably low—sometimes will vary according to a country's epidemiological profile. social priorities, and income levels. A number of public health interventions have been documented to be particularly cost-effective, and include health and nutritional education aimed at personal behavior change. control of environmental hazards, immunization, and screening and referral for selected infectious diseases and high risk pregnancies. A review of disease control priorities in developing countries includes the following among the most cost-effective interventions: breastfeeding promotion, DPT plus polio immunization; measles immunization; smoking prevention; antibiotic treatment of acute respiratory infection in children; and supporting therapy, including vitamin A (Box 4-2). . Health facilities may be publicly operated; private, for-profit; or private voluntary organizations, such as mission facilities. When they function well. they respond to local health and economic conditions by "bundling" services into basic care packages. Packages may change over time to. adapt to evolving epidemiology or changing resource availability. For example, oral rehydration therapy (ORT) has been strongly promoted in well-functioning health centers as a low-cost technology to manage cases of diarrhea. As the incidence of diarrhea decreases, more people learn to use ORT at home, or clean drinking water becomes more accessible, health workers will spend less time on treatment and more on prevention. As coverage rates for immunization increase-through sustained understanding and demand by the population-vaccinations will continue to be important, but their place in the health worker's daily caseload will be reduced. To combat frequently occurring illnesses and health conditions, such as malaria, hypertension, diarrhea, respiratory infections-, measles. polio, STDS. and malnutrition, a regular supply of essential drugs is also needed. Making drugs, contraceptives, and vaccines more available to the community is not enough, however. It is also important to ensure that clients' ills are diagnosed correctly, that providers prescribe or apply the right services, and that clients use the drug or service correctly. While these caveats may sound obvious, problems of diagnosis, drug prescription, and client use of drugs or other treatment regimens are sufficiently prevalent in Africa that the effectiveness of potentially good solutions can be reduced by up to 50 percent (Box 4-3). Bringing these services together in well-functioning health facilities can benefit households in a number of important ways:


Most health problems, ranging from common illness to measles, malnutrition tuberculosis, or sexually transmitted diseases, can be treated with the technology and competence available to well-functioning health centers. And in 80 to 90 percent of preventive work and for most curative cases, the health, center car' outperform hospitals in terms of continuity, comprehensiveness, integration, and cost of care. The small scale of the health center also favors integration of various programs. Major gains in vaccination coverage or family planning can be made when the health center staff consults a sick child's growth monitoring chart and vaccination record. Conversely, at a hospital, outpatient care is a service separate from vaccination, growth monitoring, or family planning. Overprescription is also less common in health centers than in hospitals. in Ghana. for example, a study found that the average cost of drugs per person, per episode was $.20 at hospitals compared with $.07 at health centers, with the lower costs explained by less sophisticated prescription and better management of drug stocks (Hogerzeil and Lamberts 1984).The health center's comparative advantage lies in its accessibility and potential for communication with the community. Its scale of operations permits nurses to become acquainted with the households and their social environment, thus preventing dropout and facilitating reestablishment of contact if the patient stops treatment The small scale of the health center cannot guarantee greater interpersonal communication and empathy toward clients, but it makes it possible.

· Comprehensive care. This means that the health care provider deals not only with the immediate illness but also its underlying causes. For example a battered child will receive more than a painkiller or a cast for a broken leg. His family situation will become a matter of concern to the health care provider as well. For a child suffering from micronutrient deficiencies, the health care provider will not only provide vitamin supplements but also look into the child's daily diet.

· Continuity of care. This means that a specific health care provider will interact with household members as long as such interaction is necessary to have a longlasting impact on health. A tuberculosis patient, for example, will not only receive a drug prescription but will be asked to discuss her work and family situation so that an appropriate long-term treatment program can be established for her. If-she stops, treatment prematurely, the health service will try to reestablish contact by visiting her home or contacting other members of the household. Continuity of care also implies that community health workers and health care providers will make sure that cost-effective preventive and primary care services are made available at opportune times. For example, children less than one year old are identified during home visits, a practice in well- functioning health facilities in Ghana (Ofosu-Anlaah and others 1978), Zaire (Niimi 1991), Benin (Alihonou and others 1988), and Nigeria (Ransome-Kuti and others 1990).

· Integrated care. By moving from project-based to program-based approaches, the health care provider is able to perform several tasks concurrently, cognizant of the household's time constraints and cultural background. The provider may link preventive and curative care so that a pregnant woman who arrives at a health center to be treated for malaria will have a prenatal consultation before going home- And her children's immunization records will be checked so that vaccination can be given if necessary. In Kenya, integrated care resulted in increased use of clinics, fewer consultations, a more balanced use of health staff, a reduction in unmet demand, and a striking increase in immunization rates (Dissevelt 1978).

The Role o the Health Center

The concept of the health center as a necessary part of health care was well articulated in the 1960s (Fendall 1963; Gng 1966; Roemer 1972). During the 1970s and 1980s, health centers with community outreach began to appear in Africa, launched with donor assistance in Danfa (Ghana), Pahou (Benin), Machakos (Kenya), Pikine (Senegal), Kasongo (Zaire), Kinshasa, and Lapos. To make health centers more effective, planners have developed ways to tackle the problems of accessibility (Van Lerberghe, Pangu, and Vandenbroek 1988), acceptability, intensity of use and compliance with medical instructions, quality of care (Kasongo Project Team 1982), recurrent costs (Paiigu and Van Ler 1988), and community ownership (Jacobson 1989-, Kaseje and others 1989; Matomora, 1989). In many African countries, the health center (sometimes known as health post or dispensary) is a physical entity at the hub of community life and is the first level of contact with the formal health care system. Community participation, and especially the participation of women, in deciding the location and operation of health centers is critical to their success. By serving communities of 5,000 to 15,000 people, health centers justify the employment of a critical mass of personnel and services, thus providing a strong underpinning for cost-effective health care. Health centers have also gained attention because they have performed more effectively and at less cost than hospitals in providing primary care.


Demographic profile of community served

Total population


Children <1 year (4 percent of the population)


Women ages 15-49 years (20 percent of the population)


Children <15 years (50 percent of the population)


Package of care and services provided

Maternal services

Predelivery care, delivery care and postdelivery care

Breastfeeding IEC

Micronutrient supplements (iodine for pregnant women)

Supplementary feeding (pregnant and lactating women)

Well-baby services

Expanded Programme of Immunizaton (EPI)

Micronutrient supplements (iron, iodine, and vitamin A)

Nutritional rehabilitation (children ages 0-5)

Supplementary feeding programs (children ages 0-2)

School health

Antihelminthic treatment (children ages 5-14)

Vitamin A plus iodine, as required

Curative care (especially children 0-5)

Basic trauma



Other local infections limited chronic care

Tuberculosis treatment


STD testing, treatment, and IEC

AIDS prevention (provision of condoms and IEC for high-risk groups)

Family planning

Family planning IEC

Provision of contraceptives

Staff profile

Doctor on visiting basis from District Health Management Team

One registered nurse; two assistant nurse/midwives, one community service (FP/nutrition) assistant; one clerk

Infrastructure profile

One building (approximately 125M2; includes sanitation facilities); one housing unit for staff

Two bicycles, one refrigerator, and other medical and office equipment

Note: IEC includes ongoing dialogue during consultation and outreach visits to villages and groups served by the health center. Source: Adapted from World Bank 1993a.

An essential precondition for well-functioning health centers is that the communities they serve be well-defined. For example, when a given health center serves about 10,000 people in an area with a high fertility rate, the staff can safely estimate that about 400 babies are likely to be born in the community each year (Box 4-4), To meet the objective of universal immunization, EPI planning can therefore be based on serving roughly thirty-rive new children a month. When district-based health systems are in place, health centers can obtain information useful for patient management. Though largely ignored for such purposes by national health systems, household files can be used by health center nurses to contact individual households, to make a profile of the community to be served, and to measure the impact of health care within the district. Nutrition services targeted toward malnourished children and feeding programs for preschool children, pregnant women, and lactating mothers can also be organized effectively at the district level. Information available to this study suggests that nutritional services of this kind can be provided for about $1.30 per capita a year (World Bank 1993a). Health centers are also in a position to generate their own information on community coverage and use. When combined with in-house assessments of staff work load and costs, a balance can be established to ensure reliability, accuracy, and affordability of services (Imboden 1980; DeSweemer and others 1982; Jagdish 1985; King 1984). For example, a low-cost health management information system (MIS) in Zaire has been developed to trigger timely management decisions and actions by health centers and communities (Beza and others 1987). In Guinea and Benin, the entire m is was revamped and simplified so that health center staff could use it to integrate and manage their own services. Forms, files, and registers were redesigned first to serve supervisors' and local monitoring needs (including feedback to communities) and second for reporting to agencies at the provincial and national level (Knippenberg and others 1990). Although registering information and performing periodic analysis are time-consuming tasks, most health center staff consider them an important responsibility and do not suggest a reduction in the quantity of forms and files (Ministère de la Santé Publique [MSP], Benin 1990; Ministère de la Santé Publique et des Affaires Sociales [MSPAS], Guinea 1990).

Any attempt to generalize about the characteristics of well-functioning health centers must. of course, take into account different conditions, resources, and needs among and within countries. At the same time, however, it is helpful to visualize what may be involved. A prototypical health center is depicted in Box 4-4 in terms of demographics of the community serviced, care and services provided, staff profile, and infrastructure.

The Role the First-Referral Hospital

The first level of referral for problems beyond the scope of a health center is typically a district hospital. Health care systems with these two tiers have demonstrated the capacity to provide comprehensive and effective care (WHO 1992b; Hamel and Janssen 1988; Van Lerberghe, Van Balen, and Kegels 1989; Barnum and Kutzin 1993; Mifls 1991, Van Lerberghe and Lafort 1991). In Kasongo (Zaire), for example, the network that provides comprehensive primary care clearly reduces hospitalization rates, Rural dwellers' hospital admission rates were 50 percent lower in areas with health centers than in areas without. Treatment for illnesses targeted in the past by selective programs, such as measles, tetanus, and diarrhea, dropped by 86 percent when health centers provided vaccinations, oral rehydration therapy, and chloroquine as well as general out-patient care for amoebiasis, skin diseases, and accidents. Conversely, patients who needed hospitalization benefited from easier access to hospital care (Van Lerberghe and Pangu 1988).

Judging from the performance number of rural hospitals in central Africa, a staff composed of three physicians, perhaps one surgeon, and a support staff of about fifteen can provide the following services at an affordable cost and with reasonably good results.

Outpatient care treatment of emergency cases and patients referred firm health centers. A nurse may provide primary care equivalent to what can be obtained at a district health center, but such care would carry a high consultation fee to discourage patients from bypassing the health center.


Demographic profile of community to be served
Inhabitants served by the 15 health centers 150,000
Children <1 year (4 percent of the population) 61000
Women ages 15-49 (20 percent of the population) 30,000
Children <15 years (50 percent of the population) 75,000
Package of care and services offered

Inpatient care

Obstetrics and Gynecology


Medicine: infectious diseases

Medicine: limited surgery

Outpatient care


Referred patients

Other services

Basic laboratory

Blood bank

Staff profile

Three medical doctors; ten registered nurses; twenty-five assistant nurses; three medical technicians

Two management staff (including accountant)

Fifteen support staff (including driver); two clerks

Infrastructure profile

One building(approximately 4,000m²; 140beds)

Three vehicles (including two ambulances)

Colds to rage facilities

Medical equipment

Other equipment(including beds, furniture, and soon)

Source: Adapted from World Bank 1993a.

Inpatient cure: wards for pediatric patients, patients with standard serious diseases surgery gynecological cases, and delivery of babies. Laboratory services: blood microscopy, direct examination of cerebrospinal fluids, urine and faeces tests, vaginal smears and blood groping. The hospital produces its own intravenous fluids, has a blood bank, and performs blood transfusions. Also importune is microscopy. primarily for the detection of tuberculosis. Radiography and fluoroscopy of extremities, skull, chest, stomach, and bowel. There is, of course great variation in district size, infrastructure, and personnel, within and among countries. Based on the median of two surveys-of eighty-nine and forty hospitals, and average figures From official sources, "typical" rural district hospital serves 110,000 to 160,000 inhabitants and has 140 beds, 3 physicians, and IS health centers in its district. It conducts about 1.000 deliveries and hospitalizes 4,000 to 5,000 patients a year on average. Size vanes from as little as thirty to forty beds in Mozambique, for example, and catchment areas of tens of thousands, as in Lesotho, to hundreds of thousands. as in Ethiopia or Tanzania (Van Lerberghe, Van Balen, and Kegels 1989; Harnel and Janssen 1988). More important than the number of buds or staff size is that the first-referral hospital functions at full capacity and is neither underused (bypassed) nor overcrowded (because it competes for patients with health centers). A prototypical first-referral hospital is depicted in Box 4-5, again with the caveat that its community profile, services, staffing, and infrastructure are at best indicative. Well-functioning health care centers and first-referral hospitals will also make it easier for African health care systems to cope with the otherwise unmanageable task of responding to the HIV epidemic (Box 4-6).The Role of the Large Central Hospital Central-level hospitals in urban areas would be expected to provide technical backup and support by training health personnel for service in district-based facilities and to perform relatively rare interventions, such as cataract operations. One such hospital might also be developed as a center of excellence", as was done in Mozambique. The challenge is to enlist central hospitals as partners in providing more efficient and equitable health care in Africa instead of enabling them to act as competitors with lower-level facilities. Their consumption of resources then jeopardizes the provision of basic care to the entire population. Since central hospitals have benefited from elitism in national systems of health care, their actual contribution should be reexamined so that their links with the rest of the system can be better articulated. Instead of being treated as special institutions qualifying for disproportionate shares of resources, central hospitals should be scrutinized to determine whether those who need specialized procedures are actually benefiting from them, and the costs at which these services are provided. Despite a dearth of studies on the subject, few administrators of large hospitals in Africa would deny that much of their staff's time is devoted to providing primary and first-referral care.

Governments need to consider ways to enforce the use of the referral System. One option is to issue bills for charges incurred by those who deliberately bypass the referral system, assuming that well-functioning health centers and first-referral hospitals are in place. All African governments also need to consider imposing substantial user fees at central hospitals, or else-at least in part-privatizing them, to shift additional public resources to the primary health interventions that are most cost-effective, One hundred percent cost recovery at central hospitals would not be an unreasonable goal. A possible first step would be to freeze existing budget


The burden of AIDS underscores the importance of reforming African health core systems. Despite the incurable character of the disease, AIDS patients have begun to overwhelm hospitals in number of African capital cities, in" eluding Bujumbura, Harare, Kampala, Kigati, Kinshasa, and Lusaka. These patients displace others who can be cured, further reducing the effectiveness of the health care system. The development and introduction of guidelines for treatment and care of AIDS patients for use by health care personnel are critical. WHO'S Global Program on AIDS has done important work on this subject to help developing countries. An appropriate public policy response by African governments to the public outcry to combat HlV infection starts with prevention. The top priority Is to use available public financial and human resources for carefully targeted public education and condom promotion campaigns, and for the protection and treatment of other sexually transmitted diseases. For those affected by the opportunistic infections associated with AIDS, the first point of contact in a well-functioning health care system will be health centers for drugs, counseling, and relief of suffering. As the afflicted develop full-blown AIDS, they may need referral to a hospital. In the final stages, they tend to become bedridden at home and are best served at the community level by family members and outreach from health centers. Making the health care system function as it should can be expected to reduce what would other wise become an unbearable burden of AIDS patients on African hospitals.

Levels for tertiary care, instead of increasing them in parallel with population growth and inflation. Prospects and methods of Cost recovery are taken up in Chapter 10, and it will suffice to say here that cost recovery from patients for care .it central hospitals is quite defensible, given that (i) patients are generally willing to pay for hospital care for acute problems, (ii) the demand for such care tends to be price inelastic, meaning that higher prices do not deflate demand, (iii) the clients of tertiary-level hospitals tend to be from the middle- and upper- income echelons or society, and (iv) hospitals are more likely than health centers to have the administrative capacity to assess and collect fees.


Far greater headway is likely to be made in resolving Sub-Saharan Africa's health crisis if systems of health care feature cost-effective packages of basic services, well-functioning health centers and first-referral hospitals at the district level, and community participation. Emphasis on basic health care services is precisely what is needed given the demographic and epidemiological profile of African societies. Development of well-functioning health centers and first- referral hospitals is compatible with the goal of promoting equity by extending services to underserved households in rural and periurban communities. By improving efficiency of health care services at the first level of contact and getting the referral system working well, prospects of bringing down skyrocketing hospital costs improve. A distinctly community focus helps to overcome weaknesses in capacity at the national level and offers the opportunity of deter a locally relevant health care package, enhancing accountability between providers and clients of health care, and mobilizing resources for intersectoral inputs to health. Finally, support from public health services can play a critical role in building more effective communication between health care providers and consumers with regard to health legislation and-regulation affecting facilities and services, and thus ensure provision of health information to the public.