Infrastructure and equipment problems

Existing health facilities in many African countries have deteriorated in recent years. A study in Tanzania found that only 660 out of 1,800 rural government dispensaries were in good condition, while 810 were in fair and 330 were in bad condition. A 1990-91 survey of fifteen hospitals operated by the Kenya Ministry of Health found that 40 percent of the buildings were in poor or unsatisfactory condition (Porter 1992). Some hospitals, such as the Tres de Agosto Hospital in Guinea-Bissau, have crumbled beyond the point of repair. Equatorial Guinea has an extensive network of health facilities in most cities and small towns, but they will need major repairs to make. them usable. And in countries such as Angola. Mozambique, Somalia, and Sudan, numerous health structures have been severely damaged by civil war.

Health equipment has also fallen into disrepair. In Nigeria, for example, one study (Erinosho 1991) found that close to one-third of the equipment in a series of health care institutions was not being used. In general, the more sophisticated the health care facility, the more equipment was out of use, and the longer it was out of service (Table 7-1). Studies of secondary hospitals in Nigeria carried out in 1992 suggest that equipment worth around $47 million (out of a total of $150 million) would require repairs, and that another $35 million is needed for reinvestment in essential items (Porter 1992). Studies of thirteen Ministry of Health hospitals in Kenya found 40 percent of all their equipment out of order and 40 percent of operating room equipment in need of repair (Porter 1992). A 1987 survey of seventeen hospitals in Uganda found that only 20 percent of inventoried equipment was in working order, while only about a third of the remaining 80 percent w as worth repairing (Porter 1992).

The use of vehicles in the health sector has been greatly restricted by short-ages of fuel, lack of maintenance, and repairs. A 1987 inventory of 660 Ministry of Health vehicles in Ghana found that 167 were roadworthy, 230 needed extensive repair, and 263 were worthless. In Guinea-Bissau, 42 percent of the Ministry of Health's vehicles were inoperable in 1990. This was not unexpected, since the ministry's vehicle maintenance program had ended in 1986.

Table 7- 1 Health Care Equipment Not In Service in Nigeria, 1987 (percent)

Not available
Source: Erinosho 1991.

Africa's tertiary hospitals have not escaped decline either. A report on Queen Elizabeth Hospital in Lesotho found that its buildings were in poor physical condition and that it had other problems, including shortages of basic equipment, lack of maintenance capability, uneven distribution of work loads, weak planning, little staff development and supervision, and poor financial management

Underfinancing of maintenance and repairs-virtually universal among African health facilities-is particularly apparent in public sector facilities. A study in one of Nigeria's states found that public hospitals and maternity clinics spent only 5 to 8 percent of their budgets on non personnel items, such as maintenance, transport, and supplies, compared with private sector spending of-17 to 18 percent on such items, in Dar es Salaam, Tanzania, the budget for preventive maintenance of health facilities in the late 1980s was less than 1 percent of what should have been spent In Guinea-Bissau, the total Ministry of Health budget allocation for preventive and routine maintenance in 1989 was a mere $5,000. A study of six district hospitals in Malawi found that an average of only 1.5 percent of recurrent expenditures was devoted to building maintenance and 0.2 percent to equipment maintenance in 1987-88 (Mills 1991). The maintenance problem is frequently complicated by division of responsibility because building maintenance is often the responsibility of other ministries.

The low priority given to training people in maintenance and repair further exacerbates the deterioration of physical infrastructure. In Senegal, civil service personnel assigned to maintenance do not perform adequately because suitable skills and appropriate supervision are lacking. In Zimbabwe, equipment maintenance personnel are in desperately short supply, and of all categories of workers employed by the Ministry of health, the highest vacancy rate in 1990 was for medical equipment technicians. The same factors that have caused poor maintenance have made it difficult. for African countries to expand the health sector infrastructure. Assuming that one health center serves about 5,000 people, for example, Mali will need to increase the number of its health centers by 242 in the 1990s. This is nearly five times the actual increase of fifty-two during the 1980s (Table 7-2). Other countries face similar challenges. In Tanzania, population growth has led to a gradual decrease in health coverage.

Some countries, however, have strongly promoted expansion of health facilities at levels below the national level:

· Botswana has given special attention to improving its infrastructure at the lowest levels. The number of clinics grew from 40 in 1974 to 150 in 1986, while health posts grew from 22 in 1974 to 227 in 1986. Over the same period in Botswana, the number of district hospitals increased by less than 10 percent

· In mainland Tanzania, the number of dispensaries rose from 1,847 in 1976 to 2,600 in 1980 and 2,935 in 1988

· In Mozambique, the number of "primary facilities" (the equivalent of health centers) rose from 326 in 1975 to 1,195 in 1985. Similarly, the number of district hospitals rose from 120 in 1975 to 221 in 1985.

Table 7-2. The Growth of Health Centers in Selected African Countries and the Challenge Ahead number of centers)

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. São Tomé and 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

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.