Politics, Personnel and Infrastructure
This section gives a summary of the infrastructure, people and equipment available in the health sector. It also gives an overview of the political situation regarding health and the level of public information. The constitution of São Tomé e Príncipe declares that health is a right of all citizens and the government is committed to improving the health of the community. However, since the late 1980s the situation facing the health sector in São Tomé e Príncipe has been somewhat bleak, economic problems of the country have ssen some factors become visibly worse.
Health Resources
A large part of health resources come from international organisations and/or NGOs, due to the pressures of the Structural Adjustment Programme on the governments own budget. In 1994 85% of health expenditure was externally funded, and by 1996 this had risen to 90%.
Organisation of the Health System
The health system oerates on two levels. The central level and the periphery/district level. At the central level, management is headed by the Ministry of Health. Below this are two alternate strands. The first is the administration and management of the health system. The government manages the direction, financing, planning and external co-operation of the health system. The other is the orchestration of programmes to tackle national health problems. Examples of these are programmes to combat malaria, tuberculosis, AIDS and epidemics and work to improve the level of vaccination coverage and mental health care. The National Centre for Epidemics is responsible for initiatives relating to malaria and other diseases, as well as investigating different areas of health.
At the district level, district hospitals head the infrastructure, and are followed by health posts and then community level health systems. Health delegates (doctors), health teams (doctors, nurses, laboratory technicians pharmacists, statisticians etc.) work within this structure. The health posts are staffed by trained nurses, and at the community level Community Health Agents (ASC) and Traditional Midwives (PT) operate largely on a voluntary basis. Thus there are often times when such workers are inactive, depending on their financial situation. They are capable of providing a basic level of care, focussing more on preventative measures.
Health Infrastructure
The country is divided into 7 districts, as part of the Health for All Programme, and in an attempt to introduce primary health care. There are two branches of the central hospital and 4 district hospitals covering the country then various health centres and posts. Resources vary, most people live within reach of some form of health centre. The ratio of population per health centre/post on a national level has risen significantly over the last decade and a half, from 2,400 in 1983 to 4,474 in 1998. The ratio of population to hospital beds has also risen from 155 in 1983 to 291 in 1998 demonstrating the difficulties the government has faced in trying to keep the colonial plantations’ (roças) hospitals running. Under the colonial regime each roça had some form of health care for its workers, but independence saw a dramatic decline in cocoa prices and such a level of infrastructure proved unsustainable.
Human ResourcesDevelopment
Immediately after independence the majority of the qualified personnel, mainly Portuguese, left the country. Even in 1983 46 of the 49 practising doctors were expatriates. Since then a concerted effort has been made to train doctors and medical staff from within the country. By 1998 there were 60 doctors practising of whom 47 were Santomeans. There remain shortcomings in health management, and the distribution of the human resources is weighted towards hospitals, and even then heavily weighted to the branches of the Central Hospital.
A problem that remains is the level of wages. Low pay demotivates those working in the field and encourages others to go for better paid jobs. It is estimated that there are 50 Santomean doctors living abroad.
Education institutions
Whilst doctors were trained abroad, there is a national institution, the Escola de Fomação de Quadros de Saude (EFQS), for training nurses, midwives, laboratory technicians and nutritionists. The school does not teach issues of health management - the most serious shortcoming in health. It is the aim of the WHO, up until the year 1999, to improve the School’s facilities and train teaching staff.
Public information and education is governed by the National Centre for Health Education (CNES).
Medical Provisions
Medical provisions are imported to São Tomé e Príncipe, as is the case with most small island states. This of course leads to certain problems: time delays in receiving supplies, the need for a clear understanding of future needs and, of course, slightly inflated costs. In such a situation it is necessary to have effective management of the health service, to ensure that future needs are quickly and precisely predicted and budgetted for accordingly. This problem falls back to the shortfall in personnel skilled in the field of management, as well as the more general problem of financing an effective health service.
A body called Fundo Nacional de Medicamentos is the government organ in charge of medical provisions.
National Health Politics
A fundamenntal problem for São Tomé e Príncipe is that no document has been written pulling together political objectives in the area of health. This is a major stumbling bloc for much of the health work in the country, although the main government priorities can be identified as:
to reinforce institutions
In order to reinforce the health institutions it is recognised that it is necessary for the government to provide health legislation, and to encourage a better quality of management, especially at the district level. Also it is of crucial importance that a way be found to increase the motivation of the personnel. The backdrop for these changes is one of creating a more open system of information and care, whereby community members and government officials alike can work on providing Primary Health Care for all. The work towards decentralisation is therefore being continued and supported, by all aspects of the political machinery. On the one hand hospitals need to be given the capacity for their own management and administration, and on the other traditional medicines should be promoted.
National Health Plan
This is a brief summary of the actual Health Plan for 1995-8.
In a situation where so much of the budget is supported by different agencies it is essential for the government to propose a clear plan, allowing the combined efforts to work in the same direction. Within this plan the rights of the communities themselves to predict their health needs is sacred and work including their participation is a general aim in the development of the health sector.
The programmes of priority will be:
All of these are to be carried out in the new system of decentralised management.
country situation 1998-1999 programmes who's who documents home headquarters correspondence
