Understanding Zambia

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Understanding Zambias National Health Plans

• Collins Chansa
• Chief Planner Development Cooperation
• Directorate of Policy and Planning, Ministry of
  Health - Zambia

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Presentation Outline

• Part One Background
• Part Two Current NHSP 2006-2010
• Challenges
• Way Forward
• Take Home Messages
• QA

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(No Transcript)
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Background to the Health Reforms

• 80s and early 90s Zambias health sector -
  centralized planning decision making
• Service delivery not linked to the needs of the
  communities
• Inadequate GRZ leadership, and inopportune
  partnerships with local external stakeholders

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Background to the Health Reforms

• Several fragmented donor projects and Project
  Implementation Units
• Project support tended to undermine national
  efforts to develop the health sector in an
  holistic and comprehensive manner

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Zambian Health SWAp

• Health reforms commenced in 1991/2 with a renewed
  vision, decentralisation of health services,
  Sector Wide Approach (SWAp)
• Through the SWAp, GRZ perceived a need to
  integrate all the vertical programmes into a
  sectoral framework that would meet common
  national goals and objectives
• In 1993, Zambia was the first country in Africa
  to implement a health SWAp

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Why was the SWAp Adopted?

• Increases predictability of funding
• Improve the financing base since priorities are
  identified in advance
• Reduce transaction costs and duplication
• Apply interventions equitably and to reduce
  geographic disparities
• Leadership Stewardship. Place government in
  charge leading to institutional financial
  sustainability
• Improved efficiency in resource allocation use

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Enabling Policy Environment in the Health Sector

• Four (4) Sector Strategic Plans covering the
  periods 1995-1998 1998-2000 2001-2005 and
  2006-2010
• Fifth (5th) Plan to cover the period 2011-2015
• Link Policy, Planning, Budgeting
• Capacity and willingness to reprioritize and
  reallocate scarce resources
• Affordability
• Cost, Cost-effectiveness, expected results
• Monitoring Evaluation

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• Rationale Why Focus on the Poor Where So Many
  Are Poor?

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WHY? TWO REASONS

• Existence of Large Economic and Health
  Disparities
• Possibility that Faster Progress toward the
  Health MDGs Might Not Significantly Benefit the
  Poor

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ECONOMIC DISPARITIES The Top 20 of the
Population is over 10 Times Well Off as compared
to the Bottom 20
of Total National Consumption
Economic Quintile of the Population
Economic Decile of the Population
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PROGRESS TOWARD THE MDGs Achieving the MDGs
would Benefit the Poor Significantly IF the Gains
Are Evenly Distributed Across Economic Groups.
In this case, Under-5 Mortality among the Poor
would Decline by 2/3
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NEED TO FOCUS BETTER

• Human Resources for Health (HRH)
• Health Systems Strengthening
• Health Service Delivery
• Maternal, Neo-natal and Child Health (MNCH)
• Essential Drugs and other Medical Supplies
• Governance and Leadership
• Better Financing

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The OBJECTIVES of ZambiasHealth Plan

• The Plans Vision Equity of access to assured
  quality, cost-effective and affordable health
  services as close to the family as possible
• The Plans Key Principles start with Equity of
  access...

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Three Illustrative OPERATIONAL TARGETS of
Zambias Health Strategic Plan 2006-10

• Under-5 Mortality Reduce National Average from
  168 to 134 (20 Reduction)
• Supervised Deliveries Increase National
  Average from 43 to 50 (16 Increase)
• Fully-Immunized Children Increase National
  Average from 80 to 90 (12 Increase)
• New NHSP 2011-15 targets to attain the MDGs

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Zambias Human Resources for Health Strategic
Plan 2006-10
Two Parts, Divided into Five Sections

• First Part is Analytical Sections on Situation
  Analysis, and on Objectives
• Second Part is Operational Sections on
  Strategies, on Expected Outputs, and on Key
  Indicators

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Zambias Human Resources for Health Strategic
Plan 2006-10
The Opening Two, Analytical Sections Are Strongly
Oriented toward Poverty

• Section One - Situation Analysis Extensive
  Discussion of Mal-distribution and Initiatives
  Designed to Deal with them
• Section Two - Objective Emphasis on Health
  Workforce as Close to the Family as Possible.

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Zambias Human Resources for Health Strategic
Plan 2006-10
Expected Results - Geographical inequities in the
distribution of staff
Sections Three and Four - Strategies, Expected
Outputs with references to Correcting
Mal-distribution Section Five - Key Indicators
expressed in Population Terms (e.g. National
Staff/Population Ratios)
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Key Health Indicators

• Population 12.2 (2007 proj.)
• Under-5 mortality rate 119 per 1,000 live births
• Infant Mortality Rate 70 per 1,000 live births
• Maternal Mortality 591 per 100,000
• HIV/AIDS Prevalence 14.3 (15-49 Age Group)
• Poverty incidence 64 percent
• Extreme poverty 46
• Gini-coefficient 0.57
• Formal sector employment 416,228 out of 4 million
  eligible to work (2004)

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Performance Malaria Indicators (1)
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Performance Malaria Indicators (2)
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Financing Sources (I)

• As a of the total GRZ Discretionary Budget, the
  health sector currently receives 11.5
• The major sources of funding for Public health
  services are GRZ (45), Donors (55) though SWAp,
  Direct Sector Support, Projects
• As a of Total Health Exp. Donors 42,
  Households 27, GRZ 25, Employers 5, Others 1
  (NHA 2006)
• As a of GDP, Total Health Exp. Represents -
  6.3 which translate to approximately USD 58 per
  capita (NHA 2006)

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Financing Sources (II)

• Other sources include
• User fees which until the scrapping in rural
  areas represented about 4. User fees still
  remain an important source of financing for major
  hospitals like the UTH.
• Medical levy (1 tax on interest earnings) which
  contributes about K8 billion annually.

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Financing Sources (III)

• Since 2003, Zambia has been receiving significant
  resources from various GHIs
• But Issues with Vertical Funding
• Focus only on a few priority areas Between 2005
  and 2010, over 60 funding is expected to be on
  HIV/AIDS alone. This grows to 77 when malaria is
  added.
• Focus on selected cost items mainly drugs and
  medical supplies. Human resources and
  infrastructure for increased accessibility
  neglected
• High transaction costs duplication in planning
  monitoring

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NHSP Financing Gap 2009-2010
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CHALLENGES

• Continued shortage of health workers Sector
  operating at less than 50 of the HRH
  establishment
• High disease burden mainly due to HIV/AIDS, TB,
  Malaria, other preventable diseases and NCDs
• Poor transport and obsolete equipment
• Persistent high poverty levels amidst high
  sustained economic growth (6) and macroeconomic
  stability over the past 5 years
• Poor performance of the Agric, Energy,
  Infrastructure Sectors

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CHALLENGES

• Overall level of funding to the health sector is
  still low. 33 per capita is required to
  implement the Basic Health Care Package but only
  18 per Capita available through the public
  health system
• Several donors still outside the SWAp and use
  parallel systems
• Several Donors providing support along
  programmatic lines and not addressing health
  system

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Isnt Donor Collaboration Wonderful?
INT NGO
WHO
CIDA
3/5
UNAIDS
GTZ
RNE
UNICEF
Norad
WB
Sida
MOF
USAID
UNFPA
UNTG
PMO
CF
DAC
GFCCP
PRSP
PEPFAR
HSSP
GFATM
MOEC
MOH
SWAP
CCM
NCTP
CTU
CCAIDS
NACP
PRIVATE SECTOR
CIVIL SOCIETY
LOCALGVT
Source WHO Mbewe
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Verticalization of Aid leads to Fragmentation and
Poor Results Child Health
Case management
Community Management
Skilled birth attendance
Drug Use
HIV/AIDS
New born care
PMTCT
Safe and Supportive Environment
Health system
Maternal health
Source WHO Mbewe
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WAY FORWARD

• SWAp and its funding modality Basket works but
  there is need for further harmonization
  alignment of donor procedures
• Need to create opportunities for all donors to
  participate taking cognizance of their
  constraints
• An optimal mix of various funding modalities is
  not bad
• Further strengthening of government systems for
  management and accountability

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TAKE HOME MESSAGES

• There is need to build on the lessons learnt in
  the NHSP
• 2006-10 as we prepare implement the NHSP
  2011-15
• But we have an Environment of
• Increasing disease burden
• Constrained human, financial and material
  resources
• Poor infrastructure and equipment
• Need for a strategic focus on Service Delivery
• Human Resources
• Improve the state of infrastructure and equipment
• Improve Health financing
• Strengthen Health Systems and Governance
• Fostering multi-sectoral approaches in key areas

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PROGRESS TOWARDS THE ATTANIMENT OF THE HEALTH MDGs
INDICATOR ZDHS 1990 ZDHS 1996 ZDHS 2002 ZDHS 2007 NHSP TARGET (2010) MDG TARGET (2015)
Infant Mortality Rate per 1000 107 109 95 70 NS 36
Under Five Mortality Rate per 1000 191 197 168 119 134 63
Maternal Mortality Ratio per100,000 649 729 591 547 162
New Malaria cases per 1,000 373 (HMIS 05) 412 (HMIS 06) 358 (HMIS 07) 252 (HMIS 08) 94/1000 lt121/1000
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Expanded Outputs- Tutors- Clinical
Instructors- Books, Computers, Models-
Infrastructure Equipment- Operational Grant
HRH IS KEY
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END of Presentation

• I Thank You