4. Field Case Studies of Nine Districts 57
health workers who continued to provide the best possible services did so because of professional ethics
and increased control on decisions. In one district, the board was said to have provided moral support to
the DHMT. Quality appeared to be threatened by the lack of diagnostic equipment. Respondents reported
that equipment was not replaced as needed; for example, weighing scales in health centers were said to be
missing. This may be part of the reason why immunization coverage declined in some districts. In
districts with hospitals, a main concern was the infrastructure and equipment of the hospital. Drug
supplies were said to be a major element of quality, and they were recently found to be deficient in many
districts. This complaint was, however, much more common among board members, health centers, and
community representatives than DHMT members.
In terms of equity in financial access, one district team clearly stated problems with favoritism on the
side of health workers. But there was no clear assessment as to whether financial access was lower after
the reform, probably because user fees and decentralization were implemented jointly. In several districts,
a failure to raise user fees due to popular discontent was reported (for example, Siavonga in 1998). In
Petauke, a bypass fee to prevent first use of hospital outpatient services could not be applied for the same
reason. These instances of popular participation suggest that fees cannot be raised beyond users’ ability to
pay. When interviewed about geographical access, DHMT members mentioned existing outreach and
community programs, new health centers, and plans for health posts, but there was no clear assessment of
a change in performance over time. Three districts in the sample appeared to have inherited community
programs developed prior to 1995 (Mongu, Kaoma, and Isoka). For the remaining districts, such
programs were likely to have developed around 1995. It is difficult to assess whether such decisions
reflected district initiatives or developments induced by districts’ assets and donors, and these would have
been observed even in the absence of decentralization. The sole element of comparison of equity changes
associated with the decentralization reform lies in central allocations to districts. These allocations were
seen as being fairer than the prior provincial system where districts funds were said to be disbursed on a
first come, first-served basis.
In terms of efficiency in the mix of inputs, all DHMTs mentioned difficulties in allocating personnel,
especially female nurses to rural health centers. Efficiency in service delivery may be discussed in light of
districts’ strategies for service delivery. The quantitative data discussed above suggest that districts with
community-based services achieved greater results in basic primary health care services (with perhaps the
exception of immunization) for a comparable level of funding in these services (Katete versus Mongu).
Again, the role of decentralization and local choice in developing such services is difficult to isolate from
the effects of the districts’ assets and central influences. In terms of other aspects of efficiency gains for
finances, drug management, and services organization, districts related numerous decisions regarding the
management of resources in line with improved efficiency. Reduced bureaucratic delays were not among
the major achievements except in the case of controlling outbreaks. Districts explained that all their
decisions had to be justified through lengthy reporting procedures. Even in the case of outbreaks, the
districts’ rapid responses were followed by a load of “red tape” to justify unplanned expenditures.
Lengthy bureaucratic responses were also noticed with respect to central approval for fee increases and
inquiries regarding DHBs.
In terms of financial soundness, most districts had some debts and argued that debt payment was a
priority. This may not always be the case, however, as some districts continue to hire staff and pay their
salaries through advances drawn from grant funds rather than use the funds to clear their debts. (Details of
this situation are discussed in the section on human resources). Some district teams acknowledged that
user fee revenues are borrowed to make up for delays and cuts in grant payments.
In most cases, DHBs were seen as legitimate to the extent that they contributed to district income
through fund-raising activities. Such activities were successful in a couple of districts whereas in others,
the views were inconsistent or negative.