A Study of Fiscal Recovery in Toamasina (Madagascar), or the Hospital as Arena.

Claire Mestre,

Doctor and anthropologist.

The main hospital of Toamasina, Madagascar's principal port and capital city of the betsimisaraka region, was chosen first place for initiating a restructuring, as a process for fiscal recovery. The project was started in 1995, under the aegis of the non-military arm of French Cooperation national service.

This economic project is the product of international politics, sponsored by the World Health Organization as the "Bamako Initiative." It aims to compensate for the enormous lack of health funding in developing countries by making populations themselves participate in the financing of their own care. The initiative's effect on access to healthcare, particularly among the poorest, remains controversial, however.

In Madagascar, the budget devoted to health care has decreased, comprising less than 3% of the national budget in 1994. This relatively low number is better understood if placed within a more global context of the Ratsiraka regime, under which the country's debt increased. As a result, conditions imposed by international organizations such as the International Monetary Fund (IMF) and Programs for Structural Adjustment (PSA) have only exacerbated an already weakened economy with drastic consequences for public health and social life and conditions. The resurgence, in big cities, of illnesses like the plague are the most emblematic of these changes.

The Malgache population is poor, with the gap between rich and poor only widening; the consequences of such poverty ever more present: morbidity, infantile malnutrition, illiteracy... Parallel to this, what money is allocated to improve social conditions is very low, making public works and any form of social security nonexistent. Family budgets are stretched to the limit due to the high cost of food, as is the budget for child education and health, absent for the most impoverished.

The Minister of Health who is at the origin of the project, by his own admission has had to hustle to defend a program of sanitation bridging small rural and large urban centers as public funding in other areas is increasingly cut, bringing disastrous consequences, chiefly lack of medicine, too few and under-paid medical staff, and generalized corruption. In 1991, at the time of the change of government, and under the impetus of the violent revolution which forced Ratsiraka to leave(1), France and Madagascar had reached a bilateral agreement. Toamasina, a hospital with approximately 480 beds, was chosen as the main hospital center for a number of reasons: The President and Minister of Health had made this political decision; the hospital facility was to be renovated; and finally, the choice was made more personally by the French Cooperation project manager.

The project thus came into being within a political and economic context, specific to Toamasina, with political instability and socio-economic hardship as a backdrop. Its application has also brought into sharp focus the social and ethnic tensions governing relations between decision-makers, medical professionals and the population at large. In the meantime, use of the hospital by patients deemed "fourth category/terminal" , i.e. the poorest, has radically dropped. This fact alone, I would argue, is a consequence of the cost recovery project, suggesting that communities were not informed that such changes would initially occur, and further, that reform would only burden the already high cost users are accustomed to paying. Indeed, exemptions to fees allowing free access and care have long ceased to exist. One must already pay for crucial medicine that is in short supply ; one must also pay the hospital staff attached to the doctor, stretcher bearers, the cost of transportation to the hospital, the cost of food for the patient and his companion, let alone compensating for the loss of daily salary.

The success of this French Cooperation reform would depend in part, albeit narrowly, on the support possible between Malgachen administrative teams and medico-surgical teams, and would include a change in their practices and processes. Each professional would have to discover for him/herself an interest in reform. And yet, the will of French Cooperation must have had to hurl itself violently against the interests of doctors already on the ground and in place.

Before analyzing the conflict which shook up the hospital and engaged its methods of conflict resolution, I would like to take up, initially, the administrative logic of the cost recovery project as well as the strategies it put into place.

Implementation of cost recovery applied to consultations, radiology and laboratory exams as well as hospitalization was part of a vaster project initiated as early as 1991, and which comprised an equal apportionment for the following: computerization of medico-surgical acts, administrative and medical training, the management of receipts for supply purchases, their redistribution to medical personnel, and renovation of pediatric and pneumo-phtisiology units. According to the argument of its international promoters (Dumoulin and Kaddar, 1993), a systemic increase in resources allocated for health services would allow for higher quality of care as well as more equitable access.

Payment by users for part of this care presumes their ability to pay, a fact which Malgache and French Cooperation administrations never publicly questioned. If certain poor couldn't pay, exemptions would be made. One would think the ensuing regular decrease in use of health care services and surgery by the poorest must have given officials reason to question their policies, but the most convenient explanation on the part of French Cooperation officials was that Malgache doctors were conducting " misinformation " campaigns and that city doctors were " withholding clients ". As for Malgache administrators, they believed patients were putting up " resistances " to the changes.

The un-nuanced assertion that populations would be able to pay obscures a number of questions and problems, as much economic as anthropological, that I will only touch upon: Can the notion of care enter brutally into a logic of commerce ? Does the family budget include expenses for health care? Can such money be counted upon to be immediately available at all times?

Obviously, the collapse of hospital use by the poorest posed no particular problem for decision-makers since revenues were still coming in, foregoing the more social dimension/dynamic of the hospital's function. And yet, the notion of equity and fairness was not absent from the mission of French Cooperation: patients deemed first category would pay 12,000 Fmg per day; second category patients, 9,000 Fmg; third category, 7,500 Fmg, and finally fourth category, 6,000 Fmg for 12 days(2). Two obstacles would surface straightaway: Barring the fact that a number of users would not be able to pay, a critical and complexly reasoned lack of medicine would further prevent a valorization of such a system. More importantly, reform would require the abolition of a systemic and informal bribery scheme by users to hospital personnel, which the latter refused to renounce.

Issues and objectives of quality of care were also not absent from the French Cooperation project, as seen convincingly through amelioration of physical locales and patient services, rehabilitation and modernization techniques, organizational restructuring, adjustments made to work methods, and training of personnel. Still, the reform was at a loss to solve problems linked to patient "racketing ", a generalized fraud in all areas, as well as passive/aggressive opposition by doctors, in short, problems falling under the category of "behavior and attitude".

The conflict would thus inevitably explode between French Cooperation, itself opposed to management logic and clear economy- further defended by a handshake of an authoritative ruler, and medical nursing teams. These divisions would transform the hospital into an "arena," in the sense of a centralized space for confrontation (Olivier de Sardan, 1995).

Indeed, the application of cost recovery would lose pertinence if populations continued to be solicited for the purchase of medicine and equipment, and by the financial demands of all personnel, from stretcher-bearer to physician, which large informational entrance signs couldn't prevent. Thus, insured that each and every Cooperation service person become an agent of repression in terms of power, and that exchanges between Malgache and French were riddled with suspicion. The situation took a dramatic turn at the place where the economic stakes were highest, i.e. in the operating room. French Cooperation servicemen would in turn pressure hospital staff through threats of sanction, surveillance, and tactical encouragement of nursing staff to respect the laws.

Exchanges between physicians quickly became critical. French Cooperation put into place a system of "profit sharing", a reform whereby "shares" issued from receipts of cost recovery would be reinvested on behalf of surgeons. According to French Cooperation, they felt themselves "obliged to instill new methods of working, new behaviors, with special emphasis on respect of work hours/schedules and appearance."

In accord with the proposed contract, certain professionals would become key players: the operating room nurse, also a French Cooperation service person, would be in charge of training other nurses and cooperation majors in surgery, and as such would be in direct contact with surgeons and a witness to their practices. The majors in surgery were caught between the logic of French Cooperation and that of the surgeon/clients, who would continue to charge patients high fees for procedures, sometimes under threat.

The conflict would be played out, through an explicit bias of ethnic and social stakes, between French Cooperation, Merina physicians and the Betsimisaraka staff, who, in fact were behind a confrontation between French project leaders and Malgache surgeons. I will now retrace the arguments of the protagonists, according to the terms of their "leader" and key players.

A Cooperation major and surgeon found himself on the frontlines of the conflict. A warm person, his comments were prudent and unambiguous, adopting in front of surgeons an attitude of competent firmness in light of making the Cooperation project "their" project, that is, a project in keeping with his profession. His intention was to "sensitize" colleagues and to "moralize" the profession through the use of "disciplinary sanctions for those who don't show up to work, or show up drunk, or gauge patients financially." His actions were justified through the idealizing mission of bringing the best to the region. He was from Betsimisaraka, knew the region well, and was a teacher and militant Christian. He saw French Cooperation as an ally who would help build a new team that would share a sense of solidarity. For him, it was clear that surgeons were using the political instability of the moment to discredit reforms and lead an anti-project resistance by bribing nurses. The major received the support of the patients. Another major, a woman, shared his commitment without mincing words. A pro-regional engagement was inseparable from that of the hospital. Her vigilance focused on the sick and poor, whose stories of bribery were collected as proof against responsible authorities. Her particular adversary was clearly drawn out: Merina surgeons were intent on undermining all progress in the region. It is no surprise then, that the defense tactic adopted by these majors aimed to re-valorize their profession through participation in the newly-created leadership committee and further encouraged through reward and profit-sharing schemes to the most disciplined. They were convinced of their mission, and thus vulnerable in the face of surgeons who were openly scornful of the new initiatives brought about by French Cooperation. Their logic, including ethnic arguments, would support a line of defense in the region against surgeons who were part of the Merina elite(3), and who were accused of preventing change and of siphoning funds for themselves. These arguments fully echo the discourse of those now referred to as federalists, and which my interlocutors didn't say they were a part of. This movement, born before Ratsiraka's departure, foments resentment between ethnic groups by sustaining confusion between inhabitants of the capital, Antananarivo, and the Merina, as well as through a contrived rift rendering the Betsimisaraka region ethnically homogeneous in order to better claim political power and control of resources. (Delval, 1994, Rakotondrable, 1993).

The director of the hospital was a surgeon/physician of Merina origin. This man, distant and courteous, didn't hesitate to denounce the authoritarian attitude of the French Cooperation leadership and its disconnectedness from the more concrete concerns of medical staff. According to him, the standard of living and low hospital salaries would make it extremely difficult to subsist. As for the systemic paying of surgeons by patients, this incursion was small in comparison to French Cooperation salaries, set in some cases as much as thirty times higher than their own.

The acerbic criticisms of the chief of the project were seen as offensive, forcing Malgaches to lose face. These criticisms were an offense to the respect usually given to Madagascar men in positions of responsibility, whose influence and council extends well beyond the limits of family and its immediate circle. Hence the idea that French Cooperation personnel were "tolerated", nothing more. As to conflicts between Merina and Côtiers factions, their origins are historic, resting on deep-running misunderstandings. Many bankers, doctors and men in positions of authority/responsibility are Merina, and political leaders exploit this fact.

Surgeons would construct their defense on two axes, pitting French Cooperation against Malgache-Merina. This opposition can only be understood by looking more deeply at the colonial past of Madagascar: The French Cooperation member, who is accused of ostentatiously dumping riches without respecting the code of speech in practice, most often behaves, inadmissibly, like a conqueror.

Ethnic arguments and the rift between Merina and Côtiers factions were exploited by at least part of French Cooperation forces, reinforcing the old idea that members of French Cooperation are suspect, and follow in the tradition of colonialist, only sharpening hostilities in order to favor the Côtiers over the supposed privileges of the Merina, considered exorbitant. These arguments served implicitly to justify the success of the project. Hostility on the part of Merina doctors would only continue to surface as decisions/initiatives were deemed inadequate to the most socially influential members of Malagache society.

Hence, using ethnic and regional arguments in their defense, the majors tended to make their demands more explicit, as well as question their lack of authority in attempting to modify, symbolically, relationships of power. Their hope was to take advantage of the positive effects, both material and symbolic, of French Cooperation. They could have reversed, in part, the wealth and power of surgeons, or at least questioned the power and privileges of a medical system deemed scandalous, and up until now, immutable. Such demands were heard with interest by a member of the French Cooperation who was skeptical about defending a project in the Indian Ocean smacking of " window dressing ", and of having to shake up an organized body of physicians opposed to such a venture. Still, ethnic arguments proved to be explosive.

At the hospital, the conflict reached its climax during a strike, whose banner delivered the following slogan: "Cooperation, yes, dictatorship, no ", or " French Cooperation = Bob Denard !*" The strike would cause trouble: The voice of the most powerful would mask those of the weak, legitimizing its defense against the menace of an external power against which no Malgache could extricate himself. But the conflict would not end here, taking a decisive turn through the expulsion of one of a number of French Cooperation members, chiefly the operating room nurse, and a witness to surgery practice. The expulsion was not officially explained, yet would continue to play out through rumor accusing the nurse of " trafficking and stealing bones". Several months later, and after an investigation by Malgache police, the Malgache Minister of Health extended a public apology to French Cooperation forces. The nurse in question had already been forced to leave the country, taking into account the impact of such discrediting in the eyes of the Malgaches. In reality, however, his departure appeased everyone: The French Cooperation project would be able to continue, affirming, on paper at least, that it "works" and could thus be considered a model pilot program for the rest of the country. On the Malgache side, and despite the embarrassment felt during the course of the minister's public apology, the client-based and commercial structure of the surgical establishment would remain intact.

Resolution of the conflict in favorable terms to the interests of the dominant and most powerful, set into motion a form of systemic regulation through networking, against which the Malgache state would have no recourse. Social relations were mobilized in order to affect the departure of one French Cooperation member, even if officially cleared, and would constitute a system of networks: Networks of power and rumor, whose combined effects would be very successful. The first would bring together, according to my argument, various Malgaches officials linked through old alliances and who shared common economic interests. These informal groups were quite legitimate and capable of "exercising power where it had not yet been stabilized by a group of organized institutions." (Hannerz, 1983, pp 249).

The other network, that of gossip and rumor, would also allow for social control and the defense of individual interests. It would extend itself even further to serve and protect the interests of individuals who looked unfavorably upon the changes proposed by French Cooperation. This group of interests would be hypothetically unified by the commercial and client-centered system at work in the hospital. This rumor(4) was even more effective since it was based on sacred representations of Malgache culture: the bones of the deceased, which guarantee the continuation of life, and which are the central focus of descendents. In this particular example, the rumor plays out intersecting representations: that of the foreigner, and that of the Malgache vazaha, who is suspected of doing terrible things to the organs of Malgaches(5).

On the side of the French, representations of Malgaches were equally ripe with fear and use of the occult. Hence the tripartite collusion of undesirable foreigner/native/rumor acts as efficiently as the tripartite victim/collectivity/sorcerer, which Levi-Strauss analyzes (1974, pp.183-203), the two systems depending on collective consensus.

Thus the rumor was to act as a powerful mechanism of regulation of a conflict pitting French and Malgache forces. The power of the surgeons, however victorious, is only strengthened. Their function and social status would confer upon them a place and power to collectively manage public health care, beyond the power of the state. This is why the project of cost recovery initiated by French Cooperation would fail to defend the right of access to health care for all, which it had claimed to do. As to populations themselves, excluded from the debates, they can only continue to suffer passively the violence of institutional silence.

Notes :

1- Ratsiraka returned to power since then, elected by popular vote (universal suffrage) in 1997.

2- 750 Fmg equals around 20 U.S. cents at the time of this study. The equivalent of a minimum salary was around 120 000 Fmg.

3- The Merina-Betsimisaraka opposition, which extends to Merina-Côtiers, has its roots in the colonial history of Madagascar. The Merina people represent the dominant and hegemonic ethnic group, and this antagonism was reinforced under colonization along the lines of "divide and conquer". Even today, it is tangibly alive and resurfaces during times of economic, political and social conflicts.

*- Translator's note : A French mercenary who lead the nearby Comoreans to independence.

4- The rumeur extends throughout the island, and rests in part on facts duely observed : graves are vandalized and tombs disappear.

5- Ancient representations of the foreigner include that of mpaka-fo (taker of the heart), and mpaka-ra (blood sucker), studied by Molet (1979).

Bibliography :

- Balandier G. , 1986, (1971), Sens et puissance, Paris, PUF.

- Baré J.F., 1997, « L'anthropologie et les politiques de développement. Quelques orientations », in Terrain, 28, mars 1997, pp.139-152.

- Benoist J., 1992, « Les communautés, l'argent et la santé en Afrique », in Argent et santé, expériences de financement communautaire, Actes du séminaire international 24-27 septembre 1991, CIE, Coopération française, UNICEF, OMS, pp.47-60.

- Delval R., 1994, « Le Fédéralisme, forme nouvelle de l'ethnicité », in Madagascar 1991-94 dans l'oil du cyclone (1994), Paris, L'Harmattan, pp.41-66.

- Dumoulin J., Kaddar M., 1993, « Le paiement des soins par les usagers dans les pays d'Afrique sub-sahérienne : rationnalité économique et autres questions subséquentes », Sciences Sociales et Santé, Vol XI, n°2, Juin, pp.81-119.

- Hannerz U. , 1983, (1980), Explorer la ville, éléments d'anthropologie urbaine, Editions de minuit.

- Levi-Strauss C., 1974, (1958), Anthropologie structurale, Paris, Plon.

- Mangalaza E., 1994, La poule de Dieu, Essai d'anthropologie philosophique chez les Betsimisaraka (Madagascar), Bordeaux, Université de Bordeaux 2, Mémoires des Cahiers Ethnologiques n°4.

- Mestre C., 1999, « Un hôpital à Madagascar. Analyse anthropologique de la confrontation des pouvoirs, des savoirs et des représentations à l'hôpital de Toamasina », Thèse option anthropologie sociale et culturelle, Université de Bordeaux 2.

- Molet L., 1979, La conception malgache du monde du surnaturel et de l'homme en Imerina, tome 1 et 2, Paris, L'Harmattan.

- Olivier de Sardan J.P., 1995, Anthropologie et développement, Essai en socio-anthropologie du changement social, Paris, APAD, Karthala.

- Rakotondrabe D.T., 1993, « Essai sur les non-dits du discours fédéraliste », Politique africaine, décembre, n°52, pp. 50-57.