Resisting reforms. A Resource-based perspective of collective action in the
distribution of agricultural input and primary health services in the Couffo region,
Benin
Dedehouanou, H.
Publication date 2002
Link to publication
Citation for published version (APA):
Dedehouanou, H. (2002). Resisting reforms. A Resource-based perspective of collective action in the distribution of agricultural input and primary health services in the Couffo region, Benin.
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Thee present chapter will discuss the background of the health- sector reforms of the 1990s in Benin.. It will address more specifically the primary health services in the Couffo region.
Itt should be stressed from the outset that the primary health services under study are assessedd from a government intervention perspective. Recall that the government sector has reservedd a monopoly right on the distribution of health services during the 1960s and even the 1970s.. Although it committed to grant more participation in the decision-making process to the beneficiariess during the 1990s, the formulation and implementation of the reforms have remainedd its responsibility. From such a perspective, the success or failure of the reforms will primarilyy be evaluated with respect to the willingness of the public-sector organisations to relinquishh former privileges. More importantly, the assessment of the liberalisation processes underwayy in the health sector must encompass the global strategy of government intervention andd the various mechanisms for ensuring success.
Thee primary health services (PHSs) mainly concern the segment of the health sector orientedd towards promotional health activities, preventive care and first-aid care. Consequently, promotionall activities such as community health education and out-post visits, and preventive caree activities like vaccination and some first-aid care are central to the reforms. Then, the reformss suggest that not only curative care matters, but also other health activities are important. Thee rationale for the neglect of those health activities and an over-emphasis on curative care will thenn be documented. It is believed that a good understanding of the mechanisms underlying the reformss of the PHSs will enlighten the way in which these may be expanded to other sectors for rurall development purposes. For instance, the distribution of PHSs hinges on the local health-seekingg behaviour, the expenditure structure of various groups of households, people's purchasingg power, and the cost of drugs. Although these issues are not assumed endogenous to thee PHSs, they have not been integrated to the reforms in a systematic way. It appears that reformss address more organisational shortcomings, while the existing government organisations (thee Ministry of health, the regional direction of health and other related organisations) are expectedd to carry out their institutional goals. An overview of those issues and their relation to thee PHSs will then provide some explanatory underpinnings for the performance of the reforms.
Thee present chapter will provide the background for understanding the conditions under whichh health reforms are implemented in Benin. In order to attain this objective, this chapter is organisedd into six sections. The first one will give an overview of people and health-care practicess in the Mono-Couffo region. The second section will give a brief description of the existingg health-care system. The third one will present an account of health performance through people'ss utilisation of the PHSs in the Mono-Couffo region. The fourth section will address resource-performancee relationships in the health sector, while the fifth section will focus on healthh policy sequencing. The last section will then draw some conclusions.
6.11 People and health-care practices in the Mono-Couffo region
Policyy discourse on health care in the Mono-Couffo region draws from the alleged large size of thee so-called parallel channel of modern health care, and the traditional medicine. In the presencee of endemic poverty and a shortage of public health services, a growing parallel
channelchannel is hardly avoidable. In fact, the Mono-Couffo region used to score very low for the
ratioss population/health personnel compared to the national level. Its relative importance within thee national health-care system will be presented below. The intra-regional differential is
strikinglyy equivocal as well. Therefore, the present public health-care system hardly keeps pace withh the ever-growing demand for health care in some remote villages.
Unlikee the agricultural sector, there hardly is a delineation of health zones in the Mono-Couffoo region. However, similarities with the agro-ecological zones may be inferred from some generall features at the sub-prefecture level, such as the population gradients (cf. chapter 3, map 3.1),, the spatial distribution of health facilities (cf. map 6.1), the degree of involvement in government-sponsoredd agricultural projects and, more specifically, in cotton promotion, etc. Bearingg in mind the population density and other geographical characteristics, statistics on healthh care will be presented following the administrative jurisdictions, the sub-prefectures. Wheneverr possible, aggregation may be carried out in order to portray some more general geographicall features than do the administrative territories.
PeoplePeople and health zones in the Mono-Couffo region
Inn order to illustrate the low profile of the Mono-Couffo region among the other six regions of Benin,, the case of maternity care is appealing (see table 6.1). Next to children, this group constitutess a second vulnerable segment of the PHS users. The first row of the table indicates the ratee of respondents who received at least one out-post visit from a community health worker. At thee national level, the relative importance of out-post visits is higher in rural (59 per cent) than in urbann areas (32 per cent). This is justified because out-post visits are mainly destined to alleviate distancee travel for users. For instance, 61 per cent against 27 per cent of women are within a 1 Kmm range from the nearest maternity outlet in urban and rural areas, respectively. More revealingg is that 87 per cent of urban women, against only 47 per cent of rural women are within thee range of 5 Km. This shows the urban-rural differentials. The inter-regional situation portrays aa low profile for the Mono-Couffo region compared to its counterparts. For the importance of out-postt visits, the region scores just above Atlantique, which is a highly urbanised region (cf. rowss numbers 2 and 3 in table 6.1). In addition, the Mono-Couffo region has the worse score comparedd to the other regions for facilities within the range of 1 Km. Furthermore, 4 per cent of womenn lack maternity care within the range of 30 Km and beyond. However, this region seems betterr endowed within the 5 Km range compared to at least two other regions, Atacora and
Borgou. Borgou.
Tablee 6.1: Distribution (%) of married women according to the distance from the nearest maternity centre
Out-postt visits Distancee (km) <1 1 1-4 4 5-9 9 10-14 4 15-29 9 300 and more Noo health centre
Total l Numberr of respondents s Living g Urban n 31.5 5 61.4 4 25.8 8 5.9 9 4.2 2 2.0 0 0.0 0 0.7 7 100.0 0 1459 9 location n Rural l 59.2 2 27.3 3 19.7 7 28.5 5 10.5 5 10.7 7 2.4 4 0.9 9 100.0 0 2739 9 Regions s Atacora a 85.7 7 24.7 7 7.7 7 21.1 1 26.6 6 15.3 3 4.6 6 0.0 0 100.0 0 706 6 Atlantique e 18.1 1 58.5 5 22.1 1 10.1 1 3.6 6 5.7 7 0.0 0 0.0 0 100.0 0 740 0 Borgou u 73.8 8 40.1 1 12.2 2 26.2 2 12.9 9 8.5 5 0.0 0 0.0 0 100.0 0 853 3 Mono o 29.0 0 16.5 5 41.9 9 34.7 7 0.0 0 2.8 8 0.0 0 4.0 0 100.0 0 606 6 Ouémé é 52.8 8 37.1 1 29.9 9 22.4 4 3.8 8 4.3 3 2.6 6 0.0 0 100.0 0 638 8 Zou u 30.6 6 54.7 7 22.7 7 10.2 2 0.0 0 8.6 6 2.4 4 1.4 4 100.0 0 656 6 AU U 49.6 6 39.2 2 21.8 8 20.7 7 8.3 3 7.7 7 1.5 5 .8 8 100.0 0 4198 8
1 1
Source:: INSAE-MPREPE 1997S S
S S
1400 0
Mapp 6.1: The Existing Formal Primary Health Services and Referrall Hospitals in the Couffo Region
District capital centre
Village or Commune capital centre
Village QQ Referral hospital SII Primary health service
Markett place Majorr road Minorr road
Boundaryy of district territory
Concerningg health personnel, their spatial distribution in the Couffo-Mono region is at the core off the skewed supply of health care referred to above. Table 6.1 is very illustrative in this respect.. Recall, however, that the records of health personnel hardly follow a rigorous methodologyy over the years. Therefore, care must be taken not to compare figures from one yearr to another, but rather to derive insights from the relative weight of the Mono-Couffo regionn on a yearly basis. For instance, figures for 1996 are strikingly high compared to those forr other years. This is explained by the fact that records encompass all health personnel, from thee public to the private sector, expatriate personnel included.
Thee overall figures also point at market failure in the distribution of health personnel, whichh the government sector is expected to correct in the Mono-Couffo region. As will be shownn below and in the chapters ahead, government failure also applies with even greater extentt to the distribution of the public-sector health personnel. Although medical doctors are thee scarcest human resources in the health sector, the shares of the Couffo region over the yearss are low compared to those of population figures, which are around 13.75 per cent of the nationall total (cf. INSAE-MPAE 1994). A similar picture can be derived following the figures off medical assistants. But, the shares of the Mono-Couffo region are relatively adjusted to the risesrises for all three types of health personnel. The case of midwives is at midway between medicall doctors and health assistants. The figures for 1996 are strikingly low for both medical doctorss and midwives. However, those figures have been on the rise already from 1997 onward.. It should be acknowledged here that the skewed distribution of health personnel is moree related to issues of incentives than to availability.
Tablee 6.2: Health personnel in Benin and in the Mono-Couffo region over 1985-1997 Personnel l Years s 1985 5 1986 6 1987 7 1988 8 1989 9 1990 0 1991 1 1992 2 1993 3 1994 4 1995 5 1996* * 1997 7 Medicall Doctors Béninn M o n o % Bénin 2966 16 5.4 3044 16 5.2 2833 16 5.7 2722 18 6.6 2766 15 5.4 1755 16 9.1 1755 17 9.7 2700 12 4.4 2888 18 6.3 3188 25 7.9 2766 23 8.3 7155 26 3.6 5499 39 7.1 Medicall Assistants Béninn Mono % Bénin
14433 130 9.0 15033 136 9.0 14266 136 9.5 13666 133 9.7 12788 126 9.9 10522 117 11.1 10522 118 11.2 12099 107 8.9 12233 110 9.0 12477 125 10.0 16866 196 11.6 19022 206 10.8 15799 153 9.7 Midwives s
Béninn Mono % Bénin 4155 26 6.3 4644 33 7.1 4544 29 6.4 4388 30 6.8 4300 34 7.9 4277 34 8.0 4277 45 10.5 4133 37 9.0 4677 40 8.6 4099 43 10.5 4333 42 9.7 7033 43 6.1 5766 56 9.7
Source:: Extracted from MS (1986 through 1993) MSPSCF (1994 through 1998).
Note:: records of health personnel for 1996 exceptionally comprise both the public and the private sector,
expatriatee personnel included.
6.22 The existing health-care system in the Mono-Couffo region
Thiss section will define the concepts of health-care system and health system, followed by a thoroughh presentation of the existing health-care system in the Mono-Couffo region.
Accordingg to Frenk (1994), quoted in Zwi and Mills (1995), the health-care system comprisess a range of strategies and means aimed at supplying services following some standard ruless for efficiency purposes. The health system, on the other hand, concerns equity issues and institutionall linkages. Although efficiency concerns are stressed in the health sector, equity goals
mustt not be underrated This is not to assert that efficiency and equity goals are necessarily incompatiblee in the health sector. The extent of the conflicts between the two goals is, however, commensuratee with the balance of power among the various actors. Too much consent might twistt the health outcome either efficiency-wise or equity-wise. Too many conflicts, on the other hand,, might tear health goals apart. The underlying mechanisms will be discussed later on. 6.2.16.2.1 The existing health-care system in the Mono-Couffo region
Thee Mono-Couffo region used to be one of the least endowed with social infrastructures, just in frontt of the Atacora region. Most of the villages had no school and some communes did not havee a health post. In addition to these commonly shared general features, locality-wise differentiationn was striking. However, this region has some great, yet untapped potentials comparedd to the other regions in Benin, like the existence of development-oriented grassroots organisationss operating in the margins of the health services. More importantly, there is a high ratee of women involvement in these organisations as well as in agricultural activities. The extent too which these grassroots organisations are entrusted with health goals is yet to be untangled. Policyy bias applies with force in the health sector. The question whether people resourcefully adjustt to the prevailing health conditions, i.e. they are captured by the means of the existing health-carehealth-care and health systems, will be pursued.
Itt was claimed earlier that PHSs lapse in certain villages. In addition to the formal modern healthh sector, traditional systems of various sorts coexist and serve the majority of people. This iss known as medical pluralism (cf. Phillips 1990). It is also assumed that most health care is eitherr from traditional sources or by self-treatment. The extent to which people resort to either traditionall sources or self-treatment will also be pursued.
AA full-fledged description of the existing health-care system cannot be carried out without ann overview of the national and regional organisations in charge of public health care. The latter organisations,, however, will be described at length later on. For now, the emphasis will be on thee distribution of health facilities within the Mono-Couffo region.
Thee provision of health facilities in the region could be summarised within a two-fold framework,, one implying a central unit deciding upon where and how to locate health facilities, andd the other one depending on the local communities and their ability to initiate the constructionn either from their own or from external resources. The latter option becomes more prominentt nowadays because of a partial withdrawal of the government sector following the economicc crises of the 1980s and, thereafter, the implementation of the structural adjustment reforms. .
Itt may be equally instructive to stress that government withdrawal applies with greater forcee to the provision of health facilities. From the 1970s onward, most of the facilities for healthh purpose are essentially financed either by donors, or by a joint effort of donors and the locall population. There are also cases where people's participation in the provision of health infrastructuress is completely driven by local resources. Arguably, the propensity to involve donorss and beneficiaries in the decision leading to the choice of a location has important implicationss for the provision. It is unlikely that the government sector in charge of health care hass successfully co-ordinated between local initiatives and donors' aid to improve the distributionn of health services. The list of criteria to be satisfied before the provision notwithstanding,, location aspects seem much less relevant to explain the existing pattern of healthh facilities (cf. Dèdèhouanou 1993). As also will become clear below, the mode of provisionn of health facilities has direct bearings on the qualifications and size of the health personnel. .
6.2.26.2.2 Centrally planned health facilities in the Couffo region
Mostt of the centrally planned facilities are located in a few key centres, former colonial economicc centres, capital centres of the present sub-prefectures or districts (not recorded in table 6.33 because of their status as referral health centres for the rural PHSs operating at the commune level),, villages with a past politically glorious history, etc. (cf. map 6.1). Following table 6.3, onlyy four locations are recorded for the period up to the late 1960s in addition to the second-orderr referral health facilities in the centres of the five sub-prefectures. The locations of these facilitiess were characterised either by their economic dynamism during the colonial period or by theirr political dynamism during the post-independence era. Therefore, the decision to locate a healthh facility mainly stems from the ability of the local communities to meet some expected requirements. .
Tablee 63: Rural primary health services and their status (year of creation - source of finance - construction
material)) in five sub-prefectures of the Mono-Couffo region (1996-97)
Aplahoué é Djakotomey y Dogbo o Klouékanmè è Toviklin n Atomey y Lagbave(Depko) ) Godohou u Lonkli i Adjintimey y Gohomey y Houégamey y Kpoba a Ayomi i Deve e Madjre e Adjahonmè è Djotto o Tchikpe e Adjido o Houédogli i Yearr of creation n 1980 0 1988 8 1992 2 Colonial l 1985 5 1995 5 1960+ + 1995 5 1969 9 1985 5 1985 5 1960+ + 1992? ? 1988 8 1995 5 1984 4 Sourcee of Finance Government t X X X X X X X X X X Donors s X X X X X X X X X X X X X X X X Communities s X X X X X X X X X X X X X X X X X X X X X X X X X X X X Construction n Material l C C C C C C C C C C C C CL L C C C C C C C C C C C C L L C C CL L
Source:: adapted from Dèdèhouanou (1993) and health facility survey 1996-97.
Note:: X is used to mark the source of finance (for colonial facilities, no mark is added since the source of finance
iss implicit) - C stands for concrete, L stands for local material.
6.2.36.2.3 Locallyplannedhealth facilities in the Couffo region
Twelvee facilities may be categorised as locally planned, which of five are totally financed by the rurall communities while the other seven are co-financed with either the central government or donorss (cf. map 6.1). For the latter facilities, the motives for their location have varied throughoutt the communist era (1972-1989) to the democratic period of the 1990s. Initially, the beneficiaryy villages must initiate a co-operative movement and rank among the best in the implementationn of government-acknowledged slogans. In this respect, hard facts were needed:
thee number of agricultural co-operative groups (the necessity to pull together all production factors,, service facilities, agricultural processing equipment, etc.). the level of attainment of otherr social services (water wells, schools, facilities for community education, warehouses, etc.), productionn activities achieved, and the level of innovation (cash-crops of which cotton is one, food-cropss and the like). The provision of health facilities was based on the philosophy of self-reliance,, with the aim of ensuring the sustainability of the service. During the democratic period, healthh reforms have from the beginning mainly stressed the involvement of the beneficiaries, but withh much less stringent criteria than during the communist period. A further elaboration of the ensuingg participatory scheme will be pursued later on.
Drawingg from both the locations of health facilities and the skewed distribution of health personnell described earlier, the comparative distribution of married women according to the distancee from the nearest maternity centre can be inferred (cf. table 1). Indeed, the bias is more pronouncedd in rural areas than in the vicinity of the sub-prefecture centre. The supply system mayy seriously undermine people's willingness to avail themselves of the PHSs.
6.2.46.2.4 Parallel channel for the distribution of health services in the Couffo region
AA new class of health-care peddlers increasingly compete with the existing public health services,, even in very remote villages.1 It then appears that these new practitioners intervene forr outpatient health care. They are hardly identifiable in terms of infrastructures and location. Apartt from this group, there are non-certified established clinics operating at fixed locations, yett they are more disguised than are the health-care peddlers. Between those two categories of healthh practitioners, there are a large number of practitioners who never attended any medical school.. This certainly questions the quality and trustworthiness of the medical practices deliveredd to the patients.
Thiss surge of non-professionals in the health system is of great concern to the health authoritiess in Benin, and those in the Couffo region in particular. There is then a strong basis for statingg that the supply of the formal PHSs could be improved by a substantial reorganisation. As too what the health policy reforms aim at, among other things. These reforms also attempt to offsett the emptiness left over for the parallel channel.
6.2.56.2.5 Traditional medicine in the Couffo region
Traditionall medicine is mainly guided by people's health-seeking behaviour. In Benin, for example,, Heywood (1991) found that home treatment is first and foremost relied on after the firstfirst symptoms of an illness appear. Then, when symptoms persist, the family clairvoyant is consultedd At this stage, three possibilities for healing are offered, depending on the clairvoyant's perceptionss of the origin of the health problem: a spiritual medium, herbalists, or the health centre.. In the same vein, Vodouhê (1996: p. 22) illustrated a similar health model within the Couffoo region. Indeed, such a health model gives prominence to self-medication in the first place.. Then, mystical worship follows, while traditional medicine ranks third. More often, traditionall medicine will be assimilated to traditional practices in this study.
Whenn rural people do seek modern health care as the last resort, it is quite unlikely that the villagee or the nearest PHS is the adequate health centre. As Phillips (1990) rightly claimed, the referrall system in a developing country's hierarchy will often be ignored and may only exist in theory.. The nearest health centre with any form of outpatient or accident and emergency status mayy well be used for general consultations and primary health care, regardless of its specialisation,, It seems likely that the ensuing cumulative grievances and frustrations against the modemm health sector are some of the reasons why rural people's health-seeking behaviour barely changess over time. Consequently, the extent to which the current health reforms transform this modell and improve rural health status will also be explored.
6.33 Utilisation of the PHSs in the Mono-Couffo region
Drawingg from secondary-source data, attendance figures are on the rise within the Couffo region.. Table 6.4 depicts a steady increasee for all five sub-prefectures between 1993 and 1997. However,, the degree of discrepancy is so high that three categories of sub-prefectures are consideredd below. The first category is that with higher attendance figures, for which the case off Aplahoué is illustrative. The second category is that with average attendance figures and comprisess the sub-prefecture of Djakotomey. The third and last category is that with low attendancee figures, comprising three sub-prefectures, Dogbo, Klouékanmè and ToviUin.
Tablee 6.4: Attendance figures for the primary health services in five sub-prefectures of the Mono-Couffo region,
1993-97. . Aplahoué é Djakotomey y Dogbo o Klouékanmè è Toviklin n Couffoo region 1993 3 18529 9 8067 7 8833 3 5875 5 5302 2 46606 6 1994 4 25882 2 12617 7 16291 1 11298 8 7299 9 73387 7 1995 5 27494 4 12367 7 15113 3 11062 2 7574 4 73610 0 1996 6 27246 6 16557 7 13014 4 10585 5 9649 9 77051 1 1997 7 32239 9 21184 4 11687 7 11212 2 13565 5 89887 7 Source:: DDS-Mono (Statistical office)
Thee attendance figures for Djakotomey are on the rise, while those for Dogbo declined from 19933 to 1997. Many reasons, such as the vicinity of an important confessional hospital and the degradationn of the health facilities in Dogbo, may explain people's disaffection. The other two sub-prefecturess lack good transport links from one place to the other. This suggests that peoplee from distant villages hardly attend the existing health centres.
Overalll trends indicate a decline following the devaluation of the CFA franc in 1994. At leastt three prefectures out of five depict such trends. However, in only two sub-prefecturess did this perverse trend continue to 1996. The third sub-prefecture, ToviUin, renewedd with an increase in attendance in 1996, after the creation of a new health outlet at Adjido,Adjido, one of its six rural communes (cf. table 6.3). The sub-prefecture of Aplahoué, on the otherr hand, has a sustained increasing performance in attendance figures. From the health personnell point of view, this may suggest some strategies that encourage rather than discouragee people's health-care seeking behaviour, regardless of the growing health costs. As willl be shown later, people's own characteristics and other external factors may justify such a steadyy increase.
Ann increase in the demand for health care may also be due to demographic pressure and otherr factors, among which the growing awareness of modern health practices among rural people.. Although financial access remains a nagging issue, physical access has improved a great deall lately. Infonnation on health care is also widely spread through the channels of the local healthh management committees (LHMCs). The rationale for the creation of such an organisation willl be pursued in the chapters ahead. In addition to the LHMCs, it should be stressed that some grassrootss organisations are also entrusted with the same institutional goals towards health care. Thiss is not to the point in this chapter. For now, the emphasis will be on the utilisation of both curativee and preventive health care within the Mono-Couffo region.
6.3.16.3.1 Curative health care in the Mono-Couffo region
Tablee 6.5 shows the order of demand for the ten main diseases. Malaria is foremost the diseasee with the largest expressed demand. It is a disease common in hot countries, passed by
thee bite of mosquitoes, and causing alternating attacks of fever and coldness. The demand for malariaa treatment has increased in three sub-prefectures from 1995 to 1997, Aplahoué, Djakotomeyy and Toviklin, and decreased in Dogbo. Stagnation of the demand has been observedd in Klouékanmè. Although the relative weight of the demand is proportionate to the populationn weight of each sub-prefecture, there is a great deal of inter-sub-prefecture movementss of patients, as mentioned earlier. This theme will be extensively explored later on. Thiss is to assert that the figures in table 6.5 are not indicative of the per capita demand expressedd in each sub-prefecture.
Diseasess of the low respiratory system, the lungs and the tubes leading to them, score secondd in the Couffo region. As with malaria, demand figures have increased in almost all sub-prefecturess except Dogbo from 1995 to 1997. The number of patients suffering from the third-orderr diseases concerned with the traumatic injuries have increased in three sub-prefecturess and decreased in two during the same period. Because of high prevalence among agriculturall workers, the figures for traumatic injuries may follow the degree of people's involvementt in agriculture. Therefore, the figures in table 6.5 probably express a high intensityy of agricultural work in Djakotomey compared to Aplahoué. This may be justified on thee ground that Aplahoué is located in the Lorikly Savannah zone, while Djakotomey is on the PlateauPlateau zone, where vegetation, among other things, is more aggressive than in the latter zone.. The nature of the cultivable land is also very characteristic of heavy soils and light soils,
respectively,, in the Plateau and the Lonkly Savannah zones. More importantly, while the first zonee is characterised by two distinct rainy seasons, hence two growing periods, the second zonee is increasingly identified to only one rainy season as soon as one moves to the north.
Tablee 6.5: Evolution of attendance statistics for the ten main current diseases in five sub-prefectures of the
Mono-Couffoo region, 1995-97. 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 0 Sub-prefectures s Aplahoué é 1995 5 9333 3 5225 5 766 6 570 0 677 7 639 9 376 6 196 6 312 2 98 8 1996 6 7724 4 3066 6 828 8 721 1 857 7 819 9 562 2 206 6 499 9 53 3 1997 7 14426 6 5527 7 834 4 917 7 661 1 790 0 342 2 551 1 264 4 105 5 Djakotomey y 1995 5 4728 8 2379 9 681 1 519 9 250 0 117 7 174 4 141 1 26 6 111 1 1996 6 6250 0 2463 3 1232 2 737 7 575 5 247 7 304 4 147 7 47 7 93 3 1997 7 8718 8 3240 0 1418 8 990 0 555 5 190 0 321 1 325 5 51 1 216 6 Dogbo o 1995 5 6764 4 1920 0 797 7 550 0 557 7 161 1 73 3 137 7 112 2 9 9 1996 6 5582 2 1416 6 676 6 411 1 564 4 260 0 84 4 87 7 151 1 20 0 1997 7 4003 3 1085 5 757 7 364 4 552 2 316 6 137 7 226 6 171 1 42 2 Klouékanmè è 1995 5 4720 0 1062 2 644 4 934 4 183 3 80 0 76 6 202 2 45 5 26 6 1996 6 3946 6 1093 3 532 2 684 4 86 6 222 2 109 9 170 0 56 6 38 8 1997 7 4837 7 1261 1 486 6 674 4 158 8 178 8 179 9 100 0 62 2 154 4 Toviklin n 1995 5 2953 3 945 5 430 0 319 9 345 5 74 4 71 1 78 8 17 7 76 6 19966 1997 40833 5546 9722 1875 5900 554 3833 488 3800 542 1233 132 744 119 955 109 366 73 1866 201
Source:: DDS-Mono (Statistical office)
Legendd for diseases: 1 Malaria; 2 Respiratory diseases (lung diseases); 3 Traumatic injuries; 4 Respiratory
diseasess (ORL); 5 Skin diseases; 6 Conjunctivitis; 7 Cardio-vascular diseases; 8 Baccilli dysentery; 9 Sexually transmittedd diseases; 10 Neuro-malaria.
Diseasess of the high respiratory system (the pharynx, the larynx and the tubes connecting them)) score fourth in the Mono-Couffo region. Similar to the traumatic injuries, the number of patientss has increased in three sub-prefectures and decreased in two during the period under consideration.. The number of patients suffering from the fifth-order diseases, on the other hand,, has increased in only two sub-prefectures and decreased in three. As to skin diseases, thee sub-prefecture of Aplahoué maintains the highest figures, compared to the first four diseases.. Dogbo scores second for the whole period from 1995 to 1997 (cf. table 6.5). It
shouldd be noted that both sub-piefectures demonstrated some stationary trends over this period.. For the sixth-order disease, conjunctivitis, which is a painful disease of the eye, with rednesss and swelling, the number of patients is on the rise in all five sub-prefectures. Once more,, Aplahoué and Dogbo carry the highest figures.
Inn connection to the cardio-vascular diseases, which represent the seventh most importantt disease as to prevalence, the number of cases is on the rise in four out of five sub-prefectures.. The sub-prefecture of Aplahoué is characterised by rise and fall trends, similar to thosee observed for the skin diseases. It should be stressed here that cardio-vascular diseases constitutee a very peculiar case of illness, which is often referred to traditional healers because off the feelings that symptoms are man-made rather than naturally contracted. Therefore, officiall figures truly underscore the prevalence figures of this illness, which is among the first importantt causes of death among the elderly class of rural people.
Dysenteryy caused by bacilli, on the other hand, is more prevalent with youngsters. The numberr of registered cases, which relative importance is shown by the eighth place among the tenn main diseases, is on the rise in four out of five sub-prefectures. Klouékanmè is the only sub-prefecturee with decreasing trends for the figures presented over the period 1995-1997. For sexuallyy transmitted diseases (STD), ranking at the ninth position, the number of patients is on thee rise in four sub-prefectures while Aplahoué is characterised by rise and fall trends. The tenthh disease in the table, neuro-malaria, which mainly concerns the nerves, has become more prevalentt between 1995 and 1997 in all five sub-prefectures of the Couffo region. Figures of registeredd cases are strikingly higher in Toviklin and Djakotomey compared to the other three sub-prefectures. .
Thee interpretation of the figures in this table should be hedged with caveats, because of aa number of insufficiencies, which will be underlined below. The sub-prefecture of Aplahoué, forr instance, has the most performing referral health centre among all five sub-prefectures, in additionn to its large share of population figures. The sub-prefecture of Klouékanmè has a healthh facility similar to that of Aplahoué, but does not host the same specialised curative healthh services as the latter. It should be noted that the referral health centres in the other three sub-prefecturess lack adequate health facilities. This may partially explain the shaky trends observedd for health statistics in Dogbo. It should also be added that Dogbo has performed withoutt a medical doctor during the same period. Lately though, figures for both maternity andd curative care have been on the rise, following some renovation works carried out on the healthh facilities and the availability of two medical doctors. The health centres in Djakotomey andd Toviklin, on the other hand, have performed better compared to that in Dogbo, in spite of thee shortcomings linked to the physical infrastructure. The rationale for such an unexpected performancee may find its roots in the lack of alternative health facilities within a reasonable physicall reach. More importantly, the high population density in the vicinity of those health centress may justify such a performance. Organisational factors, such as the quality of health care,, and easy contacts with health personnel, may also explain the celebrated achievements. 6.3.26.3.2 Preventive health care in the Mono-Coujfo region
Itt should be stressed here that table 6.6 gives aggregate figures of vaccination regardless of the diseases.. Vaccination figures entail a more than double counting of patients, implying some cautionn in the subsequent interpretation. Indeed, for most vaccinations, such as those against diphtheria,, typhoid fever, poliomyeHtis, tetanus, etc., repeated doses of vaccine are given. For onlyy a few kinds of vaccinations, such as those against meningitis, smallpox and tuberculosis, aa unique dose of vaccine is given to the patients. Children under 11 months constitute the targett population for most vaccinations. Adult women are also concerned within the frameworkk of the maternity-care service. In this respect, vaccinations against tetanus are more
appliedd to women over 15 years old than to men. Other age groups are also vaccinated, though inn very small proportions compared to children and pregnant women. Therefore, the statistics presentedd in table 6.6 express the performance of health personnel in terms of workload rather thann population coverage. For vaccinations against tetanus, for instance, the same woman may bee represented two or three times during the period of one year. The rationale for considering thee performance in workload here derives from the non-triviality of patients lending themselvess to the required number of repeated doses of the same vaccine.
Tablee 6.6: Evolution of vaccination figures in five sub-prefectures of the Mono-Couffo region, 1992-97
Sub-prefectures s Aplahoué é Djakotomey y Dogbo o Klouékanmè è Toviklin n 1992 2 89180 0 72818 8 29400 0 38138 8 31337 7 1993 3 88250 0 51136 6 30633 3 46939 9 29877 7 1994 4 102240 0 43228 8 39799 9 42616 6 28933 3 1995 5 101367 7 58120 0 42583 3 45794 4 33977 7 1996 6 95348 8 52599 9 39958 8 46957 7 25388 8 1997 7 90485 5 63123 3 34738 8 47978 8 29030 0
Source:: DDS-Mono (Statistical office)
Recalll that foreseen vaccination coverage is calculated for each targeted age- or sex-groupp from the population figures. The latter figures help health personnel set out quantitative goalss for each type of vaccination. The monitoring system is therefore directed towards adjustingg the empirical results to the set goals. It should be stressed that results in any given sub-prefecturee may outstrip goals when patients from other jurisdictions are vaccinated there. Thiss happens very often and may explain the abnormally high figures in certain sub-prefecturess and the low figures in other sub-prefectures. For instance, the sub-prefecture of
AplahouéAplahoué carries the largest figures for all vaccinations, followed by Djakotomey, Klouékanmè,Klouékanmè, Dogbo and Toviklin, respectively. If the results are very much illustrative of the populationn weight of each sub-prefecture and, more secondarily, to the availability and quality
off the health facilities, it should be noted that out-post strategies are needed in order to cover thee targeted population. Therefore, skilled health personnel, road links and transport means aree very relevant in explaining the results achieved within each jurisdiction.
Figuress for vaccinations against tetanus are the largest compared to those registered for otherr types of immunisation in all five sub-prefectures. This is justified on the ground that the onlyy two groups of people who seem to be concerned with the preventive health care are womenn and children under 11 months old. From this perspective, it is logically correct that the figuress for vaccinations against other diseases are lower than for those against tetanus, for severall reasons. The first reason of interest derives from the fact that vaccinations against tetanuss are part of the maternity-care package within the health-care system. In fact, the participationn of people other than pregnant women in the vaccination campaign of 1993 rangess from less than 1 per cent in most sub-prefectures to not more than 19 per cent in
AplahouéAplahoué (DDS-Mono 1994). In addition, it should be stressed that most children born from womenn initially involved in immunisation are no longer vaccinated against tetanus. The
secondd reason of interest is linked to infant mortality, which stays high in Benin in general (94 perr thousands) and in the Couffo region in particular (cf. de Souza et Zomahoun 1997). However,, figures for women vaccinations are sometimes lower than those for children in four sub-prefectures,, with the exception of Aplahoué. This may be explained by the large range of healthh services available and the high discrepancies between the attendance figures within the latterr sub-prefecture as compared to the other four. The quality of health infrastructures and thee subsequent services, among other factors, explain such discrepancies.
Figuress for vaccinations against the primary infant diseases then follow. The smallest
figuresfigures of vaccination concern poliomyelitis administered to children of one day old in all five sub-prefectures.. For other vaccinations, figures must be corrected for the rise because of the
sharee of various age groups who seek vaccination.
Thee figures observed for both curative and preventive health care are very illustrative of thee health resource endowment of each sub-prefecture. Logically, Aplahoué, which is the most endowedd sub-prefecture, has the best profile for any type of health care. Then, the sub-prefecture off Djakotomey follows. Toviklin, which is the least endowed, has the worst profile for any type off health care. This suggests a high correlation between health facilities, health personnel and the performancee of the PHSs.
6.44 Resource-performance relationships in the health sector
Thiss section will address resource performance and policy issues in the primary health servicess (PHSs). Recall that aspects related to the conditions for access and utilisation of the PHSss have been discussed earlier. This section will then discuss resource performance and policyy issues from various perspectives, including technical and economic perspectives. Then, thee extent to which knowledge influences resource performance and how knowledge might be integratedd into policy concerns will be documented.
6.4.16.4.1 Resource performance and policy issues in the health sector
Healthh policy as substantiated in table 1 in annexe F invokes organisational issues related to resource-performancee relationships. In fact, different stages of policy measures address solutionss to the improvement of these relationships. More importantly, the shift operated in policyy approaches, from the curative to the preventive health care, constitutes a strategic responsee to the nature of those relationships. During the 1960s, the pressure on health services wass so great and achievements so meagre that most developing countries came to some resolutionss based on preventive care. This approach to health care is believed to release the strainss on curative care and to help reduce to a great extent the provision costs. At the same time,time, prevention is believed to save valuable time lost by long illness and, henceforth, to contributee both quantitatively and qualitatively to the availability of the rural labour force for productionn purposes. Therefore, by adopting the preventive strategy for health care most governmentss of the developing countries, and that of Benin in particular, have set out to achievee resource-performance goals beyond the health sector. Indeed, development goals in generall are assumed more attainable if those of the preventive health care are fulfilled.
Theree appear to be reciprocal relationship between health care and development goals (Phillipss 1990). However, the debate on whether changes in public health might or might not bee associated with changes in certain economic indicators, such as per capita income or gross nationall product (GNP), or whether investments in health might be justified in economic terms,, is obsolete. To date, it is widely recognised that those relationships are not as simple as impliedd earlier. Development itself affects health both favourably and unfavourably. The balancee of advantages and disadvantages lies respectively with developed and Third World countries.. That is why Seers's (1977) well-known distinction between growth and development,, and his views on the obsession of many economists with quantifiable economic characteristicss are, very critical to the understanding of resource performance in the context of health.. Some practical issues have been emerging, for instance, those concerning the people served,, the services provided, the coverage, and the sponsorship of health programmes. Relationshipss must therefore be sought from different perspectives. Setting new goals and definitionss might be a first step in the formulation of a health strategy.
Thee PHSs are valuable components of the strategy based on preventive health care. As such,, it entails both the health-care system and the health systems (Zwi and Mills 1995). Appropriatee conceptual delineation and underlying rationale will be discussed later. For now, itt is of interest to mention that the health-care system addresses issues directly related to the organisedd social response to the health conditions of the population, while the health system concernss the various actors involved in the process. The latter actors are health care
providers,providers, the population, the state, the organisations that generate resources and the other sectorssectors that produce services, which impact upon health (Ibid p. 301).
Exampless from table 1 in annexe F help understand how efficiency and effectiveness mightt be reconciled in the sector. The strategic restructuring of the health sector is meant to addresss the cost component of health care, the efficiency dimension. This option, derived from thee preventive strategy, also entails taking health services to users. This justifies the planning andd establishment of dispersed health outlets for physical accessibility purposes. In this respect,respect, transport costs are reduced, driving down health costs for users. In addition, the adoptionn of the cost-recovery approach for health delivery may participate in lowering health
costs.. The cost-recovery scheme deals with charging user-fees so as to compensate all recurrentt health costs.
Thee institutional restructuring of the health sector, on the other hand, is geared to ensure thee extent to which goals are achieved, the effectiveness of health care. As stated earlier in the firstt section of this chapter, the involvement of self-help groups and the private sector in the provisionn of the PHSs is subsequent to government failure to sustain the strategic change at a significantt scale. Building new health outlets as prescribed in the policy document, equipping themm with adequate materials, staffing them with skilled personnel, maintaining the premises andd ensuring affordability for an effective health attendance are no longer within the reach of thee public sector. Identifying new health providers, such as confessional and private initiators, co-operativess of beneficiaries and the like, willl contribute to such an endeavour.
Regardingg both efficiency and effectiveness dimensions of health care, an assessment of resource-performancee relationships proves very problematic. The complexity of each of the twoo dimensions is to be mutually reconciled. The strategic option of the preventive care, as contrastedd with the curative care, strikes the debate on the type of the distribution, let alone thee type and nature of the health facilities. Large hospitals with adequate services are more convenientt for curative care than are scattered small outlets. The latter, in turn, seem to be moree relevant in the case of preventive care than are large hospitals. It should be stressed here thatt the search for the most convenient distribution channels is not as easy to unfold as was thoughtt earlier. More importantly, the debate at the territorial level on which health services mayy be cost effective is up to date. In Benin, for instance, the PHSs have been established at thee communal level for about two decades. But, most evaluation reports conclude to the necessityy of establishing District Health Services, departing from the present first-order referralreferral health services and encompassing larger territorial units than the present sub-prefecturess (MSP/CE 1999).
Thee difficulty of reconciling efficiency and effectiveness goals is illustrated by drawing fromm the present distribution of health outlets. Although a few communes are still lacking theirr own PHSs, this distribution is effective as far as the vaccination goal is concerned. However,, the efficiency goal is not attainable because most PHSs run idle capacity. One way off reconciling both goals is to consider vaccinations and other preventive health treatments as outpatientt health activities, while curative health care must be viewed as in-patient activities. Inn this respect, the proposed District Health Services will be not just effective, as proponents acknowledge,, but they will also be more efficient than the present organisation of health outlets.. It is suggested that most in-patient health care be referred to this level, while seasonal
vaccinationn activities may be prepared and carried out at lower territorial levels, for instance, att the existing PHSs (Ibid.).
Thee time dimension is very relevant in the appreciation of resource performance dependingg on the strategic choice between curative and preventive health care. If the results of curativee care can be seen straightforward, those of the preventive care may only become perceptiblee in the long run. For instance, while an appendectomy is a surgical immediate treatmentt for appendicitis, vaccinations against poliomyelitis may prove successful only after childrenn have passed childhood. More importantly, the importance of vaccination against poliomyelitiss may only be appraised in the development process when a great number of invalidd adults (people, who might have reached the adult stage) have been avoided. Furthermore,, if the deficiency of different vitamins proves to be at the core of several diseases thatt may cause illness and serious invalidity among the labour force, education on a balanced diett (preventive care) is very costly and its impact is not readily perceptible as compared to curativee health care. Therefore, resource performance implies a value judgement as to whether curativee care is more valuable than preventive care. It also implies a belief about the future, as too whether the likelihood of securing the population against some hypothetical health hazards mayy be valued better than saving on the present scarce financial resources for alternative developmentt uses.
Inn case that both policy approaches are carried out concomitantly within the same health-caree system, as is the case in Benin, the nagging issue remains the right mix of these servicess to be considered from a budget-allocation point of view. This issue apparently parallelss that discussed in game theory, the zero-sum or cum-sum games. In the absence of an educationn programme for a balanced diet, for instance, there are children who resist deficiency-relatedd diseases such as kwashiorkor, beriberi and the like. Other children resist andd survive widespread health tragedies, such as yellow fever, meningitis, and cholera in the absencee of vaccinations. A mix of both curative and preventive health care would then take accountt of the risks and success involved in each option of the choice-set.
Thiss discussion, which is a catalyst for the justification of the reasons underlying governmentt intervention, is very useful in the health sector. In fact, some activities are best assimilatedd to merit goods. People may not be willing to engage into preventive care, for instance.. This is decisive for the nature of preventive health providers, prompting the governmentt sector to step into the process until a general awareness among the beneficiaries is secured. .
Regardingg the state of resource-performance as handled by health practitioners, an implicitt effect of preventive care is derived from the number of children vaccinated and the numberr of people who attend a health-education programme. If the vaccination case proves to bee reliable, that of the health-education programme must not be readily assumed. In fact, a numberr of intrinsic characteristics of the population play their part in explaining health outcomes.. Policy intervention and the way in which this is articulated with people's characteristicss are other valuable determinants. For the vaccination case it should be acknowledgedd from the outset that resource performance might not be assessed in the same wayy as for the health-education programmes. All vaccines used to protect people against diseasess are formally certified, with a clearly specified rate of success. This success may probablyy depend on the prevailing conditions, such as safe handling and adequate conservation.. Similar to the health-education programmes, the relative participation of people inn various vaccination programmes hinges on the awareness and belief of the beneficiaries. Therefore,, participation itself is a performance criterion in the healthh sector.
Ann analysis of the policy issues that influence resource performance in the health sector supposess the relaxation of assumptions, many of which have been reviewed above. Yet, a
greatt number of other assumptions remain unaccounted for. Bearing in mind the limitations forr not proceeding with a full-fledged account of resource performance in the health sector, thiss review certainly provides some clues about government health policies in this respect and theirr translation into village-level health practices.
6.4.26.4.2 Relevance of knowledge to resource-performance in the health sector
Inn the health sector, knowledge of policy measures is relevant to the provision of health facilities,, equipment and personnel. Following table 1 in annexe F, each policy stage correspondss to a different mode of provision. Regarding health facilities, for instance, people'ss participation hinges among other things on their knowledge of health issues that influencee their behaviour. The 1960s were very characteristic of government provision, while fromfrom the 1970s onward people's involvement has become increasingly effective. Knowledge off health concerns and of the means by which cures might be sought justifies to some extent thee degree of people's involvement. Where awareness is high, the chances of people engaging intoo collective action for health purposes are greater than otherwise. For this to happen at any significantt scale, the relationships between the various actors of the health system must be improved. .
Itt should be stressed that knowledge has both compound and threshold effects in resourcee performance. Compound effects derive from that the role of knowledge in more than onee sector, agriculture, education and health, for instance, improves health performance. This justifiess the rationale underlying the proposed membership in the local health management committeess (LHMCs). All economic as well as social sectors are represented in these committees.. Agglomeration economies may result where compound effects are achieved. Indeed,, a better performance in the health sector may arise from knowledge interlocked with education,, agriculture and the like. This view will be pursued later.
Ass to threshold effects, on the other hand, these relate to the minimal knowledge requiredd for health initiatives to take off. A critical number of people and adequate leadership aree at the heart of the erection of a new health centre. Knowledge diffusion is critical for a successfull local lobby of a PHS. Therefore, scale economies arise when threshold effects are obtained.. In this sector, minimal knowledge is required in order to reconcile efficiency and equityy goals. This suggests interwoven linkages between health strategies and institutional development.. This theme will also be turned to later.
Concerningg health equipment and personnel, their provision is mainly guided by health policyy goals. Indeed, if this provision used to be concomitant to that of health facilities during thee 196X»s, this is hardly the case nowadays. There are redundant facilities in villages where peoplee unsuccessfully lobby for local PHSs after procuring the hardware themselves. Sometimes,, it takes years to have the health post upgraded to the level of a PHS. Somehow, as inn the case of the agricultural input market, alternative solutions to the public health sector are locallyy sought. Although still in its infancy to date, the parallel distribution of modern health caree persisted, in spite of the government monopoly and the private-sector deprived policy measuress of the last two decades. The traditional medicine has also evolved over time. More andd more people are inclined to take recourse to traditional practices in the face of rising costs forr modern health care.
Knowledgee about the various alternatives and their relevance is somewhat lacking for thee achievement of the health goals in the Couffo region. The different health-policy measures advocatedd through people's participation in the LHMCs hardly improve the situation. In this respect,, the underlying mechanisms which bar the diffusion of knowledge to spread to all beneficiariess are very relevant to the objectives pursued in this study.
6.55 Health policy sequencing in Benin
Governmentt interventions have been subject to financial constraints in the health sector over time.. These entail the construction of health facilities, the recruitment and staffing with skilled personnel,, the equipment in materials and drugs, the design and structuring of the public-sector organisationn in charge of health care, the shift of emphasis from a curative to a preventive care system,, etc. (cf. Dèdèhouanou 1993).
Dynamicss in the health sector will be assessed following the main features of government healthh policies over the last four decades. For an overview, see table 1 in annexe F. Overall, threee major stages will be considered. During the first stage, the policy of free provision of healthh care to the people wherever they live, is revealing of the level of expectation and the politicall motive in the wake of the independence. The last two stages, by contrast, correspond respectivelyy to the initiation and enhancement of people's participation in the health sector in generall and primary health services in particular. Yet, government health interventions may be organisedd into two main periods. The first period, from the 1960s to the 1970s, corresponds to thee free provision of health services. The second period, from the late 1970s onward, correspondss to the incubation, maturation and implementation of the reforms.
Inn the first section, an overview of the first period is presented. Then, the second sub-sectionn provides a description of health-policy reforms, focusing on the incubation, maturation andd implementation of health reforms by government-sponsored organisations.
6.5.16.5.1 Health policy from the 1960s to the 1970s: failure to achieve full coverage
Inn the wake of the independence, the widespread development slogans included, among other things,, the provision of social services to the people wherever they live, in urban as well as in rurall areas. Not surprisingly, the Republic of Benin (former Dahomey) inherited all the social infrastructuress established by the colonial administration. In addition, new infrastructures have beenn developed, in line with the norms and standards set within each social sector.
Withh respect to the health sector, the organisational setting for the service provision has beenn centralised, reflecting the political structure of the post-independence era. The decision and thee means for planning health centres used to come from the central government, leaving the populationn with no alternative choice in the design and the implementation of government policy.. The main drawback has been that such a planning process could last as long as the availablee resources were sufficient to sustain the policy objectives expressed in terms of targets andd standards.
Inn the Couffo region, at least eleven dispensaries could be recorded during the late 1960s (cf.. table 6.3). Most of the time, a political motive was behind each centre restored or built. For instance,, the inauguration held at Ayomi for its dispensary was effectively presided by the presidentt of the country in 1969.2 The enthusiasm raised during the early 1960s, however, turned intoo disillusion when political leaders found out that the provision of social services in general andd health services in particular was no longer feasible, given the strains on the limited resources available.. This is to assert that, from this very moment on, a drastic change was observed in the planningg of health services, and targets and standards were increasingly shelved in favour of people'ss participation.
Thee Republic of Benin was not unique in this situation. Other developing countries have experiencedd disillusion as well. The resulting social crisis, namely the worsening of the health statuss of the great majority of the people, has led to the Alma Ata conference in 1978.
6.5.26.5.2 Health-policy reforms from the late 1970s onward: community involvement and the cost-recoveryrecovery scheme
Inn the Republic of Benin, the second period of health-policy measures started during the late 1970s,, but was marked by a formal milestone following the implementation of the structural adjustmentt programmes in 1991. It should be stressed trom the outset that health reforms are merelyy oriented towards a deliberate government discharge of health costs, or so the implementationn of the health policy suggested (cf. table 1, annexe F). Policy measures were sustainedd through innovating a decentralised primary health system in 1972, which had been successfull during the first years. However, by the end of the 1970s and in the early 1980s, the healthh system collapsed. The Alma Ata declarations on primary health care then inspired new reformss during the 1980s. Before continuing with these reforms, it is instructive to grasp the organisationall setting for public health services in Benin.
OrganisationOrganisation of public health services in Benin
Inn most Third World countries, Benin alike, the public health-care system is based on a pyramidall hierarchy, for both administration and facilities (cf. Phillips 1990: 63). It is divided intoo five levels, together forming a hierarchy of services and orientation: the National and
UniversityUniversity Hospital Centre or Centre National Hospitalier et Universitaire (CNHU), 6 regional hospitals,, 83 sub-prefecture health centres, 244 so-called Primary Health Services (PHSs) at the
communee level, and 292 village health posts (cf. figure 1, annexe F). Although the figures for PHSss and village health posts might be revised upward, this would hardly change the general resultss in terms of physical, financial and socio-cultural access.
Thee health service is thus organised according to the administrative structure of the country.. Each administrative layer corresponds with a certain level of health service. However, thiss is not neatly arranged in every part of the country, because of a lack of equipment and skilled
person-power.person-power. The national-level hospital is an integrated complex with the faculty of medical studies,, and located in the economic capital of the country, Cotonou. The regional level is the
mainn referral health centre of tertiary order. As an illustration of the low profile of the Couffo regionn with respect to the provision of health services, a full-fledged regional referral hospital onlyy started operating in 1997 at Lokossa, the capital city of the Mono-Couffo region. The second-- order referral health service is located at the prefecture level. All twelve sub-prefecturess in the Mono-Couffo region are endowed with this level of health service, although onlyy one doctor is often in charge of the whole sub-prefecture centre. The PHS, which is of the firstfirst order and which is the main concern of this research, is found at the level of the communes. Nott all of the communes in a region have their own health centre. For instance, in the five sub-prefecturess covered by the research area, only twenty-one PHSs are located out of the thirty-nine communess in 1997. The situation has evolved since then. A few village-level health posts are alsoo dispersed in this region.
Primaryy health-care packages and Health for All in the Year 2000
Thee concept of primary health care derived from the Alma Ata conference and the Bamako
Initiative,Initiative, endorsed by African leaders in 1987. This initiative refers to a variety of models for communityy financing of essential drugs for raimary health care (Hubert 1994; Lennart et al.
1996).. If, for the primary health care, Health for all in the Year 2000 constitutes the ultimate goal,, the Bamako Initiative remains the underlying strategy. A subsequent definition of the minimumm health-care package for Health for All in the Year 2000 is in line with the policy reforms.. This package is organised into health activities, following a strategy to ensure success.. The first aspect of the minimum health-care package to be dealt with is the activities
involved.. The latter are arranged into three main categories (OMS-BRA 1993; Omyale and Aguessyy 1994).
Onee category of the package concerns the curative health care that addresses the need to reducee infant as well as maternal mortality rates. Above all, it aims at prolonging a productive andd healthy life. A second category concerns the preventive component of health care that consistss of vaccination coverage, family planning and the availability of basic drugs at the leastt costs. A third and last category deals with health-related activities, including functional literacy,, food security, safe drinking water and a healthy environment.
Accordingly,, the statement from WHO stressed the following points:
EducationEducation concerning prevailing health problems and the methods of preventing and controlling them;them; promotion of food supply and proper nutrition; an adequate supply of safe water and
basicbasic sanitation; maternal and child health care, including family planning, immunization againstagainst the major infectious diseases; prevention and control of locally endemic diseases;
appropriateappropriate treatment of common diseases and injuries; and provision of essential drugs (1984, p.. 6).
Att first glance, it seems that the set of definite services and activities that should be carried outt concerns the necessity of inter-sector co-ordination and the additional skills required to communicatee with the beneficiaries. Health-care planners and decision-makers may not be awaree of those requirements; this is certainly not the case for health personnel. The latter are directlyy confronted with such practical issues in the field.
Thee minimum health package is backed with a strategy that should ensure efficiency and effectivenesss of the new institutional health goal. In terms of goals, the three components of thee first category are easily turned into the specific objectives to be aimed at. The health reformss aim at improving the health status of the communities through the reduction of both infantt and maternal mortality rates and the increase in the number of productive and healthy years.. In order to achieve such objectives, a strategy is devised, in the sense of a better resourcee mobilisation for achieving improved health coverage at the least costs. Such a strategyy is based on the cost-recovery scheme and on people's effective participation. These twoo themes will be developed at length in the coming chapters.
People'sPeople's purchasing power and other constraints on the access to the PHSs
Purchasingg power and wealth are crucial constraints that impede the access to health services. Fromm the cost-free supply to people's participation through the LHMCs, financial access has progressivelyy tightened, probably discriminating against those beneficiaries with lower purchasingg power (MSP/CE 1999). It should be stressed, however, that the concepts of wealth andd purchasing power are very complex to investigate in the rural context. Some related flaws aree turned to below.
Itt should be pointed out from the outset that people's ability to avail themselves of socio-economicc services hinges on the nature of wealth. In most rural villages, where wealth iss expressed in kind, financial access in cash becomes problematic, regardless of the level of accumulation.. For instance, Czesnik et al. (1992) found no difference between various income groupss in their utilisation of primary health services in Benin. As the authors rightly point out, measuringg people's material wealth is misleading for two reasons. The first is that reliability dependss on respondents' good will not to conceal information. The second is that the valuationn method involving the translation of material resources into quantifiable cash may provee problematic. Therefore, the low-income elasticity for utilising the existing PHSs, as impliedd in Czesnik et al's report, is no evidence to the contrary. However, the latter results are consistentt with those from other studies. Agossa et al. (1997), drawing from three different studiess carried out by INSAE (1994), PNUD/MDR (1996) and INSAE/PNUD (1996), found
