Health reformers' response to Zambia's childhood mortality crisis.
This study examines the reasons for the rise in Zambian under-five mortality during the 1990s, paying particular attention to the relevance and effectiveness of health sector reform strategies and their impact on ordinary Zambians. In the 1980s, economic crisis and structural adjustment led to reduced public health spending in real terms so that by the early 1990s, Zambia's health care delivery system was characterised by a low-supply, low utilisation paradigm, typical of most of SSA. Health reform was designed to improve these trends by the integration and decentralisation of services, district capacity building and addressing issues of sustainability and financing. While large investments were made by the donors in the development of financial and health information systems, they did not actually improve the delivery of basic services. On the contrary, reform measures taken by government and donors appear to have further reduced access especially among the vulnerable populations through the implementation of user charges, and failed attempts to decentralise and integrate services. Although a variety of shocks are contributing to the rise in under-five mortality, particularly the HIV epidemic, there is strong evidence that a key factor explaining the rise over the last 20 years is that vulnerable populations have not received adequate protection from restructuring operations. Government and donors had little or no motivation to see that the poor had access to effective health care, were protected from the worst drought in 50 years, food subsidy withdrawal, falling living standards and rising prices. Poverty interest groups have never participated in the policy process and agencies which ought to have represented the poor have been a disappointment. As a consequence, health restructuring as social policy has been far removed from the reality of ordinary Zambians. An alternative set of reform strategies might have provided better protection for the poor by incorporating a livelihoods perspective, by being more flexible, attentive and responsive to changing needs in a turbulent environment. (author's)