The concept of primary health care in Zaire predated the 1978 Alma-Ata
conference. In 1975 a national seminar organized by the churches, and with
full MOH participation, adopted the principles of integrated medicine and
proposed the establishment of geographically defined health zones. Based
on those principles, a few pilot health zones developed between 1975-1980
as models for the management of decentralized health zones.
The Alma-Ata conference in 1978 firmly established the eight essential
components of primary health care and regenerated interest in moving forward
with a national strategy for the systems development of health zones in
Zaire. Since USAID had been receiving numerous requests from church hospitals
for assistance, it was decided to create the Basic Rural Health Project
(which became better known as SANRU ) as a "project of projects"
to assist 50 rural hospitals in establishing sustainable PHC systems. At
the same time, the MOH officially adopted PHC as the national strategy,
and announced a five year national health plan to create 300 decentralized
health zones.
The SANRU project was initially conceived by USAID as a project to promote
primarily family planning. However, a survey of rural hospitals conducted
by USAID during the project design phase determined that the need and desire
was for a broader project which could provide resources to develop the
entire health zone, i.e. a need for systems strengthening assistance. USAID
(in particular Richard Thornton who was the health officer at that time)
is to be commended for designing the SANRU Basic Rural Health project to
emphasize comprehensive rural health programs and health zones. The fact
that SANRU was designed shortly after Alma-Ata, but before
A.I.D. adopted Child Survival as its selective primary health care approach,
provided a "window of opportunity" to experiment with a systems
strengthening approach.
The SANRU Basic Rural Health project also became well known as an example
of bilateral cooperation (USA and Zaire) which was managed by an umbrella
Non-Governmental Organization (the Protestant Church of Zaire). The Protestant
Church of Zaire (ECZ) was chosen as the implementing agency because of
the strength of their existing medical infrastructure throughout rural
Zaire, and because of their pioneering efforts in developing decentralized
health districts.
Between 1982 and 1987 the number of functional health zones in Zaire increased dramatically from fewer than ten to over 200 (of the 306 proposed). Access to primary health care services in SANRU-assisted health zones increased from 10% to almost 50%. The creation of autonomously managed health zones not only provided the momentum for implementation of PHC in Zaire, but also made other significant contributions to systems development (see Box 1).(1)
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Box 1 HEALTH ZONES AND SYSTEMS
DEVELOPMENT IN ZAIRE The health zone is the organizational unit for primary
health care in Zaire. A health zone is a well defined geographical area
of around 100,000 inhabitants comprising a referral hospital, some 20 satellite
health centers and 200 communities (see
below for Health Zone Components). The MOH's systems development approach
coupled with the resources of the SANRU and PEV (Expanded Program of Immunizations)
projects were key elements in the rapid development of health zones. The
systems development of health zones also:
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However, the worsening economic situation, the AIDS epidemic of the
late 1980s, and the increasing political instability of the 1990s, robbed
the health system of most of the gains that it was achieving. The August
1991 SANRU evaluation aptly summarizes a best case scenario for the future
of health zones in Zaire:
SANRU's raison d'etre is the initiation and strengthening of the
health zones' ability to render primary health care to rural populations.
SANRU has been dramatically successful in initiating or extending primary
health care activities...
The concept of the health zone is a strong building block for the
future development of the Zairian health system. By keeping this concept
viable, SANRU can offer to a future, more development-minded GOZ a model,
based on the health zone concept, on which to build a sustainable, effective,
and efficient national health system.
In light of current and projected shortfalls in financial assistance,
including the GOZ, SANRU should immediately develop a "survival"
strategy that continues assistance to the current health zones at levels
sufficient to maintain operations as long as possible.(2)
Despite some noble efforts, and numerous survival strategies scenarios, USAID failed to establish an "offshore" funding mechanism for the SANRU project which could continue assistance during the inflationary and political turmoil which culminated in the riots and mass evacuation of September 1991. However, of the 175 health zones which were functional in 1975, some of the NGO-assisted health zones are still considered operational. This, in itself, demonstrates the advantage of a decentralized systems strengthening approach. Keeping the concept of health zone viable in Zaire might be an important contribution of a regional project, and could also serve as a teaching ground for other countries to capture the vision and potential of decentralized health districts.
1. Baer, F.C. SANRU: Lessons Learned (1981-1991), Harrisonburg, VA:BaerTracks. :86 pages, 1992.
2. Tomaro,J. et al. Mid-Term Evaluation of the SANRU Basic Rural Health Project, 1991.
