Harmonization & Aid Effectiveness in Health:- **********************************

1. Harmonization & Aid Effectiveness in Health:-********************************** Between Health Workers & Communities: The Equity Gauge Zambia Experiences Ms Mary M. Tuba & Dr Thabale Jack Ngulube Centre for Health, Science & Social Research (CHESSORE) P. O. Box 320168, Woodlands Lusaka, Zambia chessore@zamnet.zm

2. The Aid & Harmonization Cascade • Effective aid has the qualities of being: • Harmonized • Predictable • Contributing to overall development • Efficiently used [audits, accountability, enforcement] • Associated with sustainable benefits/ outcomes

3. Health, Health System & Communities • It has been repeatedly observed that to the majority in Zambia, the modern health system is largely perceived to be foreign, and only good for addressing immediate needs • Otherwise before and after their needs are met; the tendency for many is to stay aloof of everyday happenings in health • This trend is further weakened by an uneven distribution of power between health workers and communities served

4. Top-Down Vs Bottom approaches • The current government policy on effective use of available resources lays emphasis on leadership, accountability and partnership, with bottom-up planning and implementation • However, evidence coming from the ground indicates that communities are unable to hold the health system and health workers accountable • Communities are largely powerless • And the bottom-up approach is run along lines of bureaucracy and its procedures; with little harmonization for incorporating community interests • Planning and budgeting is based along an objective criteria for disease burden that is under the sole control of health workers, • For many in the community, the formal health system can be the place of last resort, sometimes used in combination with traditional remedies.

5. A Perception on Current Situation on Harmonization & Aid effectiveness at the Grassroots in Zambia Technocratic Bureaucratic Approaches Planned Change BOTTLE NECK Social Cultural Traditional Contextual Factors Local institutions New Roles / Responsibilities Health competent communities

6. For Aid Effectiveness at the grassroots • The Health system should be perceived to be ‘a local institution’; that addresses local health needs in all it dimensions • Communities need to accept new roles and responsibilities in making this happen, • In order for the above to happen communities require to be empowered and engaged with the health system = Health Competent communities. • This process to achieve this takes time – requiring ‘breaking the ice’, imparting skills, and re-freezing the new arrangements/ procedures that result from the desired positive experience

7. The Equity Gauge Zambia Experience with Effective community participation as a prelude to aid effectiveness on the ground • De-freezing existing practices in order to pave way for new approaches (2001-2005) • Identifying a concept for change – EQUITY policy statement • Appropriate vehicle for change – Applied Research (Equity Gauge concept, along three pillars of advocacy, public participation & measurement) • Through Drama, Poetry, Songs & Sermons

8. EGZ Experiences (II) • Imparting Skills [2001 – Present (2008)] • Defining Equity as social concept (not medical concept) • Research skills • Research on inequities (packaging the local evidence in a participatory manner) • PRA Skills for engagement with communities and the health system • Decision-making practices (DAD, ADD) • Brain-storming • Social mapping • Power and power relations • Computer & Internet training • Management skills (needed but not developed)

9. EGZ Experiences (III) • Re-Freezing [2006 – On-going] • Being fused in, but this will be the next for emphasis in programme implementation, • But the process and requisites for dynamics of planned change are now known – within the Zambian context [Guide being developed] • The next challenges are to take on a health programme and implement the systematized change dynamics (MDRs and SMAGs for maternal health scale-up programmes)

10. THANK YOU chessore@zamnet.zm thabalejackngulube@yahoo.com tuba.mary@gmail.com