Zambia's National Health Plans: Decentralizing Services for Better Health Equity

1. Understanding Zambia’s National Health Plans Collins Chansa Chief Planner – Development Cooperation Directorate of Policy and Planning, Ministry of Health - Zambia

2. Presentation Outline • Part One: Background • Part Two: Current NHSP 2006-2010 • Challenges • Way Forward • Take Home Messages • Q&A

4. Background to the Health Reforms • 80’s and early 90’s Zambia’s 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

5. 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

6. 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

7. 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

8. 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

9. Rationale:Why Focus on the Poor Where So Many Are Poor?

10. WHY?: TWO REASONS • Existence of Large Economic and Health Disparities • Possibility that Faster Progress toward the Health MDGs Might Not Significantly Benefit the Poor

11. 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

12. 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

13. 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 13

14. The OBJECTIVES of Zambia’sHealth Plan • The Plan’s Vision :“Equity of access to assured quality, cost-effective and affordable health services as close to the family as possible” • The Plan’s Key Principles start with: “Equity of access...”

15. Three Illustrative OPERATIONAL TARGETS of Zambia’s 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

16. Zambia’s 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

17. Zambia’s 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.”

18. Zambia’s 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)

19. 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)

20. Performance: Malaria Indicators (1)

21. Performance: Malaria Indicators (2)

22. 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)

23. 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.

24. 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

25. NHSP Financing Gap 2009-2010

26. 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

27. 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

28. Isn’t Donor Collaboration Wonderful? WHO INT NGO CIDA 3/5 UNAIDS GTZ RNE UNICEF Norad WB Sida USAID UNFPA MOF UNTG PMO CF DAC GFCCP PRSP PEPFAR HSSP GFATM MOEC MOH SWAP CCM NCTP CTU CCAIDS NACP LOCALGVT CIVIL SOCIETY PRIVATE SECTOR Source: WHO: Mbewe

29. Verticalization of Aid leads to Fragmentation and Poor Results: Child Health Nutrition Malaria 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

30. 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

31. 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

32. PROGRESS TOWARDS THE ATTANIMENT OF THE HEALTH MDGs

33. Expanded Outputs- Tutors- Clinical Instructors- Books, Computers, Models- Infrastructure & Equipment- Operational Grant HRH IS KEY

34. END of Presentation I Thank You