What problems do developing countries face when building and scaling up their health services? The Swiss Tropical Institute, together with the Centre de Support en Sante Internationale, examined the problems faced by Chad, one of the poorest countries in the world. The country's Gross Domestic Product (GDP) is about US$ 200 per person per year.  The population suffers from low life expectancy and high rates of infant and maternal mortality.  Only 15 per cent of the population is able to read. They have little access to health services and nutrition status is poor. In this context, how can health services be strengthened and further developed?

Chad is in the process of recovering from a period of armed conflict.  It is a landlocked country, which has repeatedly suffered from drought. The economy is fragile, dependent on foreign aid, with little tax revenue, and its balance of payments is in deficit.  As with many developing countries, the administration is inefficient and not transparent. The public healthcare system barely functions. Medical staff are poorly trained, and often work short hours in order to run their parallel private practices.  They do not want to work in rural areas where the working conditions are poor.

Health services are poorly used due to cost, distance and low demand.  When people are ill they often try to treat themselves, by buying drugs from street sellers, markets and pharmacies or using traditional healers.  In the Biltine region on the Sudan border the nearest clinic is on average 28km away, more than one day’s journey by donkey.  It is therefore not surprising that pregnant women and children do not attend these clinics.  An additional problem is the lack of trust between communities, such as the nomads, and health providers.  Many people do not consider the state health services to be an effective means of curing disease.

The study found the problems faced by the health sector include:

• Chad is severely short of qualified medical staff. Nearly half of the health sector workforce is unskilled.
• Health services and medical staff are concentrated in urban areas.
• There is a lack of management skills at both the national and the local level.
• Communities are not involved in decision-making, leading to a situation where the planners design services ill-suited to the population.

The report recommends that:

• training personnel must be treated as high a priority as building clinics and hospitals
• new approaches are needed to find out what health services the people actually want. In particular the needs of disadvantaged groups should be targeted
• contracting work out to the private sector may be a way of dealing with the staff shortages, although this would require the private sector to be regulated.

However, putting a few new policies in place is not enough.  The problems are far-reaching.  A project was introduced in Biltine to improve health services.  Results have so far been mixed with the use of services possibly even going down. It is an area without telephone, electricity, good roads, or money to pay for healthcare. Developing the health sector depends on economic development; without this health goals cannot be reached. 

Source(s):
‘Constraints to scaling-up health related interventions:  the case of Chad, Central Africa’, Journal of International Development 15: 87-100, by K. Wyss et al, 2003

Funded by: Swiss Agency for Development and Co-operation; Commission on Macroeconomics and Health; Swiss National Science Foundation

id21 Research Highlight: 2 June 2003

Further Information:
Kaspar Wyss
Swiss Centre for International Health
Swiss Tropical Institute
Socinstr.57
4002 Basel
Switzerland

Tel: +41 61 284 8140
Fax: +41 61 271 8654
Contact the contributor: kaspar.wyss@unibas.ch

Swiss Tropical Institute, Basel, Switzerland

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