FROM CHRONIC EMERGENCY TO DEVELOPMENT: AN ANALYSIS OF THE HEALTH OF THE URBAN POOR IN LUANDA, ANGOLA Najmi Kanji and Trudy Harpham There is a dearth of published literature on health care systems in Angola. Like many sub-Saharan African countries, Angola is experiencing rapid urbanization. The authors provide an analysis of the health status, environmental health conditions, and health-related behavior of the urban poor in Luanda, Angola. Although data are patchy and rarely disaggregated to reveal severe conditions in the shanty towns, a grave picture emerges. An average infant mortality rate of 104/1,000, with malaria and intestinal infections the main causes of death in children under 1 year old, reflects the poor environmental conditions, which are worsening as urbanization continues at a rapid rate. Use of health services is limited; for example, 50 percent of women give birth at home, mainly unassisted, and only 28 percent of children are covered by measles immunization (as validated by card). A discussion of existing health strategies, programs, and their constraints is set in the context of the future possibilities of the ending of the 15-year war and the introduction of structural adjustment policies.
Urbanization has become an important issue in the developing world. Over the last 30 to 40 years, the growth of some cities in developing countries has doubled their population within 10 to 15 years. Although the rates of migration to many cities in developing countries have in general stabilized and urbanization is now more a function of natural increase, the chronic war situation in Angola means that migration to the cities is still a major factor in the country’s urbanization. An unprecedented and unplanned-for population increase in Luanda, the capital city, has put enormous burdens on the social infrastructure of the city, and there is now a growing interest in the issues of urban health care amongst government and international agencies. The documentation of the health situation in Luanda can therefore be a useful tool in helping policy makers in government and international agencies develop urban health programs. After almost 15 years of continuous war in Angola, there are signs that the conflict may soon be over and that health policy and planning that have long been determined by the chronic emergency may soon be able to develop within a broader context. We hope that this article can contribute to the debate within that future development. Also suggested here are actions and processes that may influence health, especially in the context of limited resources. This may be of particular interest to both government and international agencies, neither of which has the necessary capital to make large-scale International Journal of Health Services, Volume 22, Number 2, Pages 349-363, 1992 0 1992, Baywocd Publishing Co., Inc.
349
doi: 10.2190/DXVL-GKX4-RNXB-8C0J http://baywood.com
350 / Kanji and Harpham investments in water, sanitation, and housing, which are necessary to allow rapid improvement in the health of Luanda’s poor. Finally, we believe that this article provides a useful addition to the extremely few English-language publications on health in Angola. A MEDLINE search covering the last six years failed to find even one such article on health care in Angola-rural or urban.
THE WAR AND THE ECONOMIC SITUATION Angola won its independence in 1975 after 14 years of armed struggle against Portuguese colonialism. However, open warfare has continued as South Africa, both directly through full-scale invasions and indirectly through its support for UNITA (Union for the Total Independence of Angola) with U.S. backing, has attempted to militarily and economically destabilize the country. Thus, Angola has been in a situation of war for almost 30 years, with the last 10 to 15 years characterized by some of the largest conventional battles since World War 11. The prevailing war conditions have resulted in enormous economic and social costs. The Angolan government and the United Nations estimate that between 1975 and 1985, physical damage alone caused by the war cost an estimated $17 billion (all amounts in U S . dollars). Defense and security continue to account for a major proportion of total expenditure, doubling between 1982 and 1985 to $1.15 billion (37.9 percent of total government expenditure and 50 percent of all imports) (1). Since independence, the output of all sectors, with the main exception of the oil industry, has fallen. Sabotage of the diamond industry and of the power plants and transmission lines has resulted in losses estimated at $60 million annually. Food production is extremely low, and the country is becoming increasingly dependent on food aid. Total foreign debt at the end of 1988 was $3.9 billion, increasing by 43 percent since the fall in oil prices in 1986, and debt repayment increased from $25 million in 1986 to $432 million in 1988 (2). The situation has been further aggravated by natural calamities, with periodic droughts affecting large areas of the country. In early 1989, an estimated 1.0 million people in six of the country’s 18 provinces were seriously affected by drought. The interrelated effects of the war and the destruction of the economy have given rise to some of the worst health indicators in the world. The infant mortality rate (IMR) in 1987 was estimated at 169/1,000 and the childhood mortality rate (CMR) at 288/1,000 (3).Almost 21 percent of babies born in health institutions weighed 2.5 kilograms or less (4). The dramatic reduction in agricultural production has seriously affected the ability of millions of people to feed themselves and the urban population. This direct attack on people’s health status has been exacerbated by the bombing and destruction of rural health clinics, the murder and intimidation of health workers, and the sabotage and breakdown of water supplies. In 1985, there was a 30 perccnt dccline in the use of health services, and in that same year, at least 20 vaccination posts and an equal number of food distribution centers were destroyed by the rebels. By March 1989, of a total population of about 9.5 million, 1.5 million were directly affected by the war (447,000 urban destitutes, 648,000 displaced, and 406,000 rural destitutes) (5). Although the share of the health budget has generally remained at around 6 percent of the total government budget, the decline in the absolute value of the total budget plus the
Health and the Urban Poor in Luanda, Angola / 351 towering rate of inflation has resulted in a significant fall in the real health budget. Moreover, the foreign currency assigned to the health sector fell from approximately $78 million in 1981 to a low of $9 million in 1986, rising to $23 million in 1988 (6). Between 1980 and 1985, the war and its related effects (famine) caused at least 100,OOO deaths. In 1985, at least 10,000 people had limbs amputated as a result of sustaining war injuries. UNICEF estimates that 45 percent of annual infant and child deaths in Angola (about 1,000 children every week) can be directly attributed to war, making this the chief cause of death in children in Angola (3). LUANDA: DEMOGRAPHIC BACKGROUND The partial 1983 census of Luanda suggested that for the period 1985-95, a 174 percent increase in population was likely and that the city’s population would be about 2 million in 1995. Current estimates indicate that the population of Luanda may already be around the 2 million mark, suggesting that the earlier forecast had underestimated not only the rural-urban migration rates but perhaps more importantly, the natural increase rates. Luanda’s infrastructure and public utility systems were geared to benefiting a small colonial elite. This infrastructure has been severely strained by the increase in the urban population. The overall decline in the country’s food production, the high prices charged for basic commodities, the overcrowding in houses that badly need refurbishment and maintenance, and the inadequate maintenance of the limited water supply, sewerage, and refuse collection systems-all are negatively affecting people’s health. While data are limited, indications are that recently migrated people make up the most vulnerable groups. Many of these households are female-headed with a large number of dependents. They are almost totally dependent on the informal market for their survival. They have limited education and marketable skills and have poor access to health, education, water, and other essential social services (5). Luanda Province occupies an area of about 2,000 square kilometers divided into nine municipios and 28 comunas. Approximately 98 percent of the population is concentrated in the urban and periurban areas. Evidence suggests that the high rate of natural increase combined with the unquantified rate of migration has led to a doubling of the population in less than ten years. The 1983 partial census indicated that 50.6 percent of the population was under 15 years of age and that in the 18 to 25 age group, there were substantially fewer males than females. This anomaly is probably due to the demands of conscription on young men and the higher proportion of female migration into Luanda. Underreporting by young men avoiding the draft is also likely. Approximately 70 percent of Luanda’s population lives in musseque settlements. The word was initially used to designate sandy areas and later applied to clusters of huts built on these areas by individuals expelled from the city during colonial times. Currently, the term means much the same as shanty towns in other urban areas in the world. These areas consist of improvised and extremely high-density housing. In addition to the musseques, there are a few bairrospopulares or “native townships” established toward the end of the colonial era, and endowed with a planned network of serviced streets. Following the deterioration of basic urban services, conditions in these buirros are now similar to those in the musseques.
352 / Kanji and Harpham ENVIRONMENTAL HEALTH According to a variety of documents, 87 percent of Luanda’s population is supplied with water, 20 percent having water connections and 67 percent having access to public fountains. The source of this information has been difficult to trace. The documents also suggest that the figure of 67 percent should be heavily qualified, as a large proportion of the public fountains in the musseque communities are out of order because of damage or lack of maintenance, or because the supply has been turned off to avoid excessive water losses due to burst pipes. Frequent failures in the working of the public fountains are thought to be due to insufficient pressure resulting from clandestine connections made to supply private households. The lack of maintenance and of essential spare parts means that only 50 to 60 percent of Luanda’s potential capacity of 200,000 cubic meters per day is actually supplied. In practice the distribution system operates for about eight hours a day. Water pressure is insufficient to raise it past the first floor of many multistory buildings in the capital. A recent (as yet unpublished) household survey has found that 76 percent of households are dependent on fountains or vendors for their water supply. The disaggregation of these results by bairro, however, shows a range of 20 to 100 percent. Information on the quantity of the water used by the poor, the time spent on water collection, the direct and indirect costs associated with collection, and the quality of water is unavailable. The endemic characteristics of cholera in Luanda do not suggest an acceptable level of quality. In the 1950s Luanda’s sewage and sanitation services were characterized as inadequate and the situation as serious. A master plan to reconstruct and extend the services was drawn up by the colonial authorities during the 1960s, but was only partially implemented. In any case, this plan covered only the “white” cement city. Since then there has been a continuous decline in the already deficient system. Estimates suggest that only 13 percent of Luanda’s population has sewerage connections and 16 percent has septic tanks, concentrated in the cement city. For the 70 percent of the population residing in the musseques, sanitary conditions are often primitive (shallow pits) and sewerage channels are uncovered and close to dwellings. Services for the collection and treatment of refuse appear to be deficient, especially in the musseques. Recently, however, as a result of proposals made by the Ministry of Health, the existing fleet of rubbish collection trucks has been significantly strengthened. Rubbish collection containers have been placed all around the city, but whereas the situation in the city has been almost resolved, it has only slightly improved in the periurban areas. At the beginning of 1989, the unsuitable open disposal site was closed and a new in-fill site was opened, with plans to set up a small treatment plant. NUTRITIONAL STATUS Data related to nutritional status are usually collected from children up to 5 years of age; this indicator not only can provide a reasonable idea of the nutritional status of the whole family, but when interpreted with other variables and caution, it may also provide an indication of poverty levels. Unfortunately, only a limited number of nutritional surveys have been carried out and the understanding of the situation is limited. A recent
Health and the Urban Poor in Luanda, Angola / 353 Table 1 Prevalence of malnutrition in Luanda Province, 1988 and 1989" Area Calumbo Calumbo Calumbo Calumbo Luanda city
Indicator* Wt./age < 80% Wt./ht. < 90% MUAC < 13.5 cm MUAC < 13.5 cm MUAC < 13.5 cm
Year
Sample size
Age, yr.
1988 1988 1988 1988 1989
210 210 170 44 209
Urbanization has become an important issue in the developing world. Over the last 30 to 40 years, the growth of some cities in developing countries has doubled their population within 10 to 15 years. Although the rates of migration to many cities in developing countries have in general stabilized and urbanization is now more a function of natural increase, the chronic war situation in Angola means that migration to the cities is still a major factor in the country’s urbanization. An unprecedented and unplanned-for population increase in Luanda, the capital city, has put enormous burdens on the social infrastructure of the city, and there is now a growing interest in the issues of urban health care amongst government and international agencies. The documentation of the health situation in Luanda can therefore be a useful tool in helping policy makers in government and international agencies develop urban health programs. After almost 15 years of continuous war in Angola, there are signs that the conflict may soon be over and that health policy and planning that have long been determined by the chronic emergency may soon be able to develop within a broader context. We hope that this article can contribute to the debate within that future development. Also suggested here are actions and processes that may influence health, especially in the context of limited resources. This may be of particular interest to both government and international agencies, neither of which has the necessary capital to make large-scale International Journal of Health Services, Volume 22, Number 2, Pages 349-363, 1992 0 1992, Baywocd Publishing Co., Inc.
349
doi: 10.2190/DXVL-GKX4-RNXB-8C0J http://baywood.com
350 / Kanji and Harpham investments in water, sanitation, and housing, which are necessary to allow rapid improvement in the health of Luanda’s poor. Finally, we believe that this article provides a useful addition to the extremely few English-language publications on health in Angola. A MEDLINE search covering the last six years failed to find even one such article on health care in Angola-rural or urban.
THE WAR AND THE ECONOMIC SITUATION Angola won its independence in 1975 after 14 years of armed struggle against Portuguese colonialism. However, open warfare has continued as South Africa, both directly through full-scale invasions and indirectly through its support for UNITA (Union for the Total Independence of Angola) with U.S. backing, has attempted to militarily and economically destabilize the country. Thus, Angola has been in a situation of war for almost 30 years, with the last 10 to 15 years characterized by some of the largest conventional battles since World War 11. The prevailing war conditions have resulted in enormous economic and social costs. The Angolan government and the United Nations estimate that between 1975 and 1985, physical damage alone caused by the war cost an estimated $17 billion (all amounts in U S . dollars). Defense and security continue to account for a major proportion of total expenditure, doubling between 1982 and 1985 to $1.15 billion (37.9 percent of total government expenditure and 50 percent of all imports) (1). Since independence, the output of all sectors, with the main exception of the oil industry, has fallen. Sabotage of the diamond industry and of the power plants and transmission lines has resulted in losses estimated at $60 million annually. Food production is extremely low, and the country is becoming increasingly dependent on food aid. Total foreign debt at the end of 1988 was $3.9 billion, increasing by 43 percent since the fall in oil prices in 1986, and debt repayment increased from $25 million in 1986 to $432 million in 1988 (2). The situation has been further aggravated by natural calamities, with periodic droughts affecting large areas of the country. In early 1989, an estimated 1.0 million people in six of the country’s 18 provinces were seriously affected by drought. The interrelated effects of the war and the destruction of the economy have given rise to some of the worst health indicators in the world. The infant mortality rate (IMR) in 1987 was estimated at 169/1,000 and the childhood mortality rate (CMR) at 288/1,000 (3).Almost 21 percent of babies born in health institutions weighed 2.5 kilograms or less (4). The dramatic reduction in agricultural production has seriously affected the ability of millions of people to feed themselves and the urban population. This direct attack on people’s health status has been exacerbated by the bombing and destruction of rural health clinics, the murder and intimidation of health workers, and the sabotage and breakdown of water supplies. In 1985, there was a 30 perccnt dccline in the use of health services, and in that same year, at least 20 vaccination posts and an equal number of food distribution centers were destroyed by the rebels. By March 1989, of a total population of about 9.5 million, 1.5 million were directly affected by the war (447,000 urban destitutes, 648,000 displaced, and 406,000 rural destitutes) (5). Although the share of the health budget has generally remained at around 6 percent of the total government budget, the decline in the absolute value of the total budget plus the
Health and the Urban Poor in Luanda, Angola / 351 towering rate of inflation has resulted in a significant fall in the real health budget. Moreover, the foreign currency assigned to the health sector fell from approximately $78 million in 1981 to a low of $9 million in 1986, rising to $23 million in 1988 (6). Between 1980 and 1985, the war and its related effects (famine) caused at least 100,OOO deaths. In 1985, at least 10,000 people had limbs amputated as a result of sustaining war injuries. UNICEF estimates that 45 percent of annual infant and child deaths in Angola (about 1,000 children every week) can be directly attributed to war, making this the chief cause of death in children in Angola (3). LUANDA: DEMOGRAPHIC BACKGROUND The partial 1983 census of Luanda suggested that for the period 1985-95, a 174 percent increase in population was likely and that the city’s population would be about 2 million in 1995. Current estimates indicate that the population of Luanda may already be around the 2 million mark, suggesting that the earlier forecast had underestimated not only the rural-urban migration rates but perhaps more importantly, the natural increase rates. Luanda’s infrastructure and public utility systems were geared to benefiting a small colonial elite. This infrastructure has been severely strained by the increase in the urban population. The overall decline in the country’s food production, the high prices charged for basic commodities, the overcrowding in houses that badly need refurbishment and maintenance, and the inadequate maintenance of the limited water supply, sewerage, and refuse collection systems-all are negatively affecting people’s health. While data are limited, indications are that recently migrated people make up the most vulnerable groups. Many of these households are female-headed with a large number of dependents. They are almost totally dependent on the informal market for their survival. They have limited education and marketable skills and have poor access to health, education, water, and other essential social services (5). Luanda Province occupies an area of about 2,000 square kilometers divided into nine municipios and 28 comunas. Approximately 98 percent of the population is concentrated in the urban and periurban areas. Evidence suggests that the high rate of natural increase combined with the unquantified rate of migration has led to a doubling of the population in less than ten years. The 1983 partial census indicated that 50.6 percent of the population was under 15 years of age and that in the 18 to 25 age group, there were substantially fewer males than females. This anomaly is probably due to the demands of conscription on young men and the higher proportion of female migration into Luanda. Underreporting by young men avoiding the draft is also likely. Approximately 70 percent of Luanda’s population lives in musseque settlements. The word was initially used to designate sandy areas and later applied to clusters of huts built on these areas by individuals expelled from the city during colonial times. Currently, the term means much the same as shanty towns in other urban areas in the world. These areas consist of improvised and extremely high-density housing. In addition to the musseques, there are a few bairrospopulares or “native townships” established toward the end of the colonial era, and endowed with a planned network of serviced streets. Following the deterioration of basic urban services, conditions in these buirros are now similar to those in the musseques.
352 / Kanji and Harpham ENVIRONMENTAL HEALTH According to a variety of documents, 87 percent of Luanda’s population is supplied with water, 20 percent having water connections and 67 percent having access to public fountains. The source of this information has been difficult to trace. The documents also suggest that the figure of 67 percent should be heavily qualified, as a large proportion of the public fountains in the musseque communities are out of order because of damage or lack of maintenance, or because the supply has been turned off to avoid excessive water losses due to burst pipes. Frequent failures in the working of the public fountains are thought to be due to insufficient pressure resulting from clandestine connections made to supply private households. The lack of maintenance and of essential spare parts means that only 50 to 60 percent of Luanda’s potential capacity of 200,000 cubic meters per day is actually supplied. In practice the distribution system operates for about eight hours a day. Water pressure is insufficient to raise it past the first floor of many multistory buildings in the capital. A recent (as yet unpublished) household survey has found that 76 percent of households are dependent on fountains or vendors for their water supply. The disaggregation of these results by bairro, however, shows a range of 20 to 100 percent. Information on the quantity of the water used by the poor, the time spent on water collection, the direct and indirect costs associated with collection, and the quality of water is unavailable. The endemic characteristics of cholera in Luanda do not suggest an acceptable level of quality. In the 1950s Luanda’s sewage and sanitation services were characterized as inadequate and the situation as serious. A master plan to reconstruct and extend the services was drawn up by the colonial authorities during the 1960s, but was only partially implemented. In any case, this plan covered only the “white” cement city. Since then there has been a continuous decline in the already deficient system. Estimates suggest that only 13 percent of Luanda’s population has sewerage connections and 16 percent has septic tanks, concentrated in the cement city. For the 70 percent of the population residing in the musseques, sanitary conditions are often primitive (shallow pits) and sewerage channels are uncovered and close to dwellings. Services for the collection and treatment of refuse appear to be deficient, especially in the musseques. Recently, however, as a result of proposals made by the Ministry of Health, the existing fleet of rubbish collection trucks has been significantly strengthened. Rubbish collection containers have been placed all around the city, but whereas the situation in the city has been almost resolved, it has only slightly improved in the periurban areas. At the beginning of 1989, the unsuitable open disposal site was closed and a new in-fill site was opened, with plans to set up a small treatment plant. NUTRITIONAL STATUS Data related to nutritional status are usually collected from children up to 5 years of age; this indicator not only can provide a reasonable idea of the nutritional status of the whole family, but when interpreted with other variables and caution, it may also provide an indication of poverty levels. Unfortunately, only a limited number of nutritional surveys have been carried out and the understanding of the situation is limited. A recent
Health and the Urban Poor in Luanda, Angola / 353 Table 1 Prevalence of malnutrition in Luanda Province, 1988 and 1989" Area Calumbo Calumbo Calumbo Calumbo Luanda city
Indicator* Wt./age < 80% Wt./ht. < 90% MUAC < 13.5 cm MUAC < 13.5 cm MUAC < 13.5 cm
Year
Sample size
Age, yr.
1988 1988 1988 1988 1989
210 210 170 44 209
