PRIMARY HEALTH CARE IN SOUTHERN AFRICA

By Kudzai Makombe Second in a series on health in southern Africa.|
With the World Health Organisation’s (WHO) goal of “Health For All By The Year 2000” only eight years away, enonnous strides have been made in the provision of basic and preventative health care within the southern African region. Yet, a great deal remains to be done, especially in countries where the goal is hampered by war and poor economic progress like Mozambique and Angola.

At a remote commercial farm in Zimbabwe, mothers with infants on their backs and toddlers around them can be found waiting as early as 6 am for the arrival of the mobile health clinic. While the youngsters play and infants either sleep or breastfeed, compliments are passed among the women about how heathy a baby looks or how much he or she has grown. Most of the children look healthy and the mothers are obviously proud.

All the children have cards which arc kept by the mother. They are individually attended to, weighed, examined by the health staff and given the necessary immunizations. Later, a talk followed by a question-and-answer session, is held on nutrition, health and contraceptive use with enthusiastic response from the mothers.

According to one health worker, the mobile health centre is an attempt to reach even the remotest areas where there are no nearby clinics. The facility moves from static points to surrounding areas on a daily basis.

More and more women both in the urban and rural areas are taking the health centres and the provision of free primary health care seriously, seeking better health for their children and themselves.

In sharp contrast to the Zimbabwean situation, the small village of Noburi, in Mozambique’s Zambezia province has one “doctor”, with only two years of nursing training who also serves as the Director of Health in the district. The “hospital”, contains no medicines, only a few vials of assorted vaccines and the patients are mostly malnourished children and their mothers, victims of the rebel Mozambique National Resistance’s (MNR) deliberate policy of destroying health facilities.

Since attaining independence, the countries of the southern African region have sought to improve the health care of their people, previously suffering from colonial inequalities. Soon after independence, most southern African countries adopted the Primary Health Care (PHC) model as the first level of contact individuals have with the health system.

Attainment of adequate food, clean water and sanitation which are considered the most powerful
Preventative medicines in the world by health experts are the essential beginnings of PHC which focuses mainly on children and women of childbearing age.

By 1990, out of 44 sub-Saharan countries that the United Nations Children’s Emergency Fund (UNICEF) surveyed, Zimbabwe ranked 10th with 79 percent of its one-year olds vaccinated against diphtheria {DPT).

In Swaziland, health spending increased sharply in 1989f)O, with the result being an improvement in PHC and access to safe water while Lcso1ho, despite poor sanitation and high malnutrition, sought to improve the quantity and quality of PHC in the rural areas.

The newest SADCC member state, Namibia, launched within its first year of independence, a National Policy on Children, paying particular attention to child immunization.

Despite an under-five mortality rate of 176 out of every 1,000 children and a preventative health care system hampered by former apartheid policies, by the end of 199Q, UNICEF found full immunization coverage of one-year-old Namibians for measles at 14 percent and polio at 52 percent.

While important strides were made by the governments of the individual southern African nations early in the post-independence era, AIDS, economic conditions under economic structural adjustment programmes and the ravaging drought are serious setbacks to the achievements of PHC.

This is particularly the case in Mozambique where the situation has been aggravated by war. At Mozambique’s independence in 1975, health care was nationalized and made free, with services expanded particularly in the rural areas. For the first time rudimentary health care was available to millions of Mozambicans.

Now malnutrition is as serious a problem in Mozambique, as it is in Angola. Thousands of children, particularly in the most war-affected areas, are affected stunted growth.

Along with Angola, Mozambique has the highest infant mortality rate in the world, with three out of five children dying before the age of five. Only 15 percent of the rural population in Angola and nine percent in Mozambique have access to safe water.

Mozambique’s vaccination campaigns have been suspended in the village of Noburi and out of 337 health posts in Zambezia province, 137 are now closed as a result of the war.

Noburi village is not the only case of acute deterioration in primary health care. Many other rural vaccination programmes have also been halted because of the war.

Rates of immunization have fallen and easily preventable diseases are taking their toll on the vulnerable age groups.

However, war has not been the only factor in bringing about the deterioration of what had been achieved in PHC in southern Africa.

As most of the Southern African Development Coordination Conference (SADCC) member states embark on economic reform programmes, it has become evident that the negative effects of the
programme are hitting social services hardest. With massive devaluations of Mozambique’s currency, the effects of the Economic Recovery Programme

(PRE) only serves to aggravate those problems already in existence as a result of the war. The health sector is operating on massive budget cuts in real terms. For example, Marrere district hospital, on the outskirts of Nampula province in northern Mozambique, has a broken down water supply system and acute shortage of drugs.

In Zambia, structural adjustment resulted in an increase in child malnutrition and admissions to hospitals, while in Tanzania, devaluation of the local currency has resulted in much higher costs of medicines. Water systems in Tanzania have deteriorated both in urban and rural areas while 40 to 60 percent of rural children suffer from malnutrition as do 20 to 30 percent of urban children.

Zimbabwe, with a relatively new Economic Structural Adjustment Programme (ESAP), is already feeling the brunt of reform. ”The poor will get less healthy,” says a headline in a local newspaper in protest against the social impacts of the programme.

A document, “Zimbabwe: A Framework for Economic Reform 1991-95,” states that the government will continue to extend basic health and family planning services and to develop further key programmes, such as child and maternal health care.

Despite this, suspicions fuelled by the deterioration of PHC services in neighbouring countries remain. Hospital fees have increased, and many women are unable to afford the high maternity-fee deposit. In recent months, the minimum monthly wage below which people are exempt from medical fees has been raised to ZS400-a-month, the equivalent of US$80.

With the drought and AIDS now facing the entire region, the possibility of a healthy population will remain out of early reach for the countries of the region.

The drought is already causing sharp drops in nutrition levels among children and adults. Zimbabwe’s Matabeleland South province has an under five malnutrition level of 27 percent, while some schools are threatened with closure as a result of a shortage of food and water.

Many schools in the country are reporting that children are fainting in class as a result of hunger. Chances of the spread of water-borne diseases are increasing as the safe water supply situation
Deteriorates. Boreholes are drying up and people are being forced to use unsafe water from streams.

According to Zimbabwe’s health Minister, Dr Timothy Stamps, at least 1.5 million Zimbabwean children under five are malnourished due to drought-related food shortages.

Under such conditions, measures will have to be taken to address the deterioration of PHC, particularly for the low income groups, both in urban and rural areas throughout the region.
It is clear that in the region’s efforts to gain economic development, health is an issue which cannot be ignored. Lack of further development of primary health care will only result in the perpetuation of poverty and poor economic growth. (SARDC)


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