NATIONAL HEALTH STRATEGIC PLAN 2006-2010

Republic of Zambia

MINISTRY OF HEALTH

NATIONAL HEALTH STRATEGIC PLAN 2006-2010

“… Towards Attainment of the Millennium Development Goals and National Health Priorities…”

Ministry of Health Ndeke House Haile Selassie Avenue PO Box 30205 Lusaka, ZAMBIA December 2005

Government of the Republic of Zambia MINISTRY OF HEALTH National Health Strategic Plan 2006 - 2010

December 2005

“…equity of access to cost-effective, quality healthcare…”

TABLE OF CONTENTS CONTENTS PAGE

TABLE OF CONTENTS ........................................................................................................................................... 2 FOREWORD .............................................................................................................................................................. I ACKNOWLEDGEMENTS ...................................................................................................................................... II ABBREVIATIONS AND ACRONYMS................................................................................................................... 1 EXECUTIVE SUMMARY ........................................................................................................................................ 4

INTRODUCTION ......................................................................................................................................................... 4 BACKGROUND .......................................................................................................................................................... 4 VISION, MISSION, OVERALL GOAL AND KEY PRINCIPLES ........................................................................................ 5 NATIONAL HEALTH PRIORITY INTERVENTIONS ........................................................................................................ 6 IMPLEMENTATION FRAMEWORK............................................................................................................................... 7

1.0 INTRODUCTION........................................................................................................................................ 9 1.1 CONTEXT.................................................................................................................................................... 9 1.2 PROCESS AND STRUCTURE ......................................................................................................................... 9

2.0 BACKGROUND......................................................................................................................................... 10 2.1 SECTOR ORGANISATION AND MANAGEMENT........................................................................................... 10 2.2 HEALTH SECTOR PERFORMANCE AND DISEASE BURDEN ......................................................................... 13 2.3 PERFORMANCE AGAINST THE MDGS ....................................................................................................... 15 2.4 THE EXTERNAL ENVIRONMENT................................................................................................................ 16

3 VISION, MISSION, OVERALL GOAL, OBJECTIVES AND ASSUMPTIONS .................................... 21 3.1 VISION...................................................................................................................................................... 21 3.2 MISSION STATEMENT ............................................................................................................................... 21 3.3 OVERALL GOAL ....................................................................................................................................... 21 3.4 KEY PRINCIPLES....................................................................................................................................... 21 3.5 NATIONAL HEALTH PRIORITY AREAS ...................................................................................................... 21 3.6 MAIN ASSUMPTIONS ................................................................................................................................ 23

4 HUMAN RESOURCE CRISIS...................................................................................................................... 24 4.1 SITUATION ANALYSIS .............................................................................................................................. 24 4.2 OBJECTIVE ............................................................................................................................................... 27 4.3 STRATEGIES ............................................................................................................................................. 27 4.4 EXPECTED OUTPUTS................................................................................................................................. 27 4.5 KEY INDICATORS...................................................................................................................................... 28

5 THE BASIC HEALTHCARE PACKAGE................................................................................................... 29 5.1 SITUATION ANALYSIS .............................................................................................................................. 29 5.2 OBJECTIVE ............................................................................................................................................... 29 5.3 STRATEGIES ............................................................................................................................................. 29 5.4 EXPECTED OUTPUTS................................................................................................................................. 29 5.5 KEY INDICATORS...................................................................................................................................... 29

6 PUBLIC HEALTH PRIORITY INTERVENTIONS .................................................................................. 30 6.1 CHILD HEALTH......................................................................................................................................... 30 6.2 INTEGRATED REPRODUCTIVE HEALTH ..................................................................................................... 31 6.3 HIV/AIDS & STIS ................................................................................................................................... 33 6.4 TUBERCULOSIS (TB) ................................................................................................................................ 36 6.5 MALARIA ................................................................................................................................................. 37


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6.6 EPIDEMICS CONTROL & PUBLIC HEALTH SURVEILLANCE........................................................................ 40 6.7 ENVIRONMENTAL HEALTH AND FOOD SAFETY ........................................................................................ 42 6.8 OTHER PUBLIC HEALTH INTERVENTIONS................................................................................................. 44

7 CLINICAL CARE AND DIAGNOSTICS SERVICES ............................................................................... 51 7.1 ESSENTIAL DRUGS AND MEDICAL SUPPLIES ............................................................................................ 51 7.2 LABORATORY SUPPORT SERVICES ........................................................................................................... 53 7.3 BLOOD TRANSFUSION SERVICES .............................................................................................................. 54 7.4 MEDICAL IMAGING SERVICES .................................................................................................................. 55

8 INFRASTRUCTURE AND EQUIPMENT .................................................................................................. 57 8.1 INFRASTRUCTURE..................................................................................................................................... 57 8.2 MEDICAL EQUIPMENT AND ACCESSORIES................................................................................................ 59

9 SUPPORT SYSTEMS STRENGTHENING ................................................................................................ 60 9.1 MONITORING AND EVALUATION .............................................................................................................. 60 9.2 HEALTH MANAGEMENT INFORMATION SYSTEM ...................................................................................... 62 9.3 FINANCIAL AND ADMINISTRATION MANAGEMENT SYSTEM (FAMS) ...................................................... 63 9.4 PROCUREMENT MANAGEMENT SYSTEM................................................................................................... 64 9.5 HEALTH SYSTEMS RESEARCH .................................................................................................................. 66

10 HEALTH SYSTEMS GOVERNANCE ........................................................................................................ 67 10.1 POLICY AND LEGISLATION ....................................................................................................................... 67 10.2 ORGANISATION AND MANAGEMENT ........................................................................................................ 68 10.3 GENDER AND HEALTH.............................................................................................................................. 71 10.4 SECTOR WIDE APPROACH (SWAP) .......................................................................................................... 72

11 HEALTHCARE FINANCING ...................................................................................................................... 75 11.1 RESOURCE MOBILISATION ....................................................................................................................... 75 11.2 RESOURCE ALLOCATION .......................................................................................................................... 77

12 COSTING AND FINANCING OF THE STRATEGIC PLAN................................................................... 79 13 IMPLEMENTATION, MONITORING AND EVALUATION OF THE NHSP ...................................... 82

13.1 IMPLEMENTATION .................................................................................................................................... 82 13.2 MONITORING AND EVALUATION .............................................................................................................. 87

14 APPENDICES ................................................................................................................................................. 89


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I

FOREWORD Zambia is a country with a high disease burden, which is compounded by high poverty levels and HIV/AIDS prevalence of HIV/AIDS. Since 1992, the Zambian Government has been implementing significant health sector reforms, aimed at improving health service delivery and the health status of Zambians. The vision of the reforms has been to: “...provide the people of Zambia with equity of access to cost-effective, quality healthcare as close to the family as possible…”. Since the commencement of these reforms, the public health sector in Zambia has taken significant steps towards meeting the objectives of the reforms, particularly in improving access to health care, affordability of health services and health systems strengthening. These achievements have led to some improvements in health service delivery as witnessed by the trends in the main health service delivery indicators. However, these achievements have not resulted into the desired reductions in the disease burden and performance against the Millennium Development Goals (MDGs) has been below the expected levels. The country has therefore remained under significant pressure to reduce the disease burden and improve the health status of Zambians. This plan is therefore an attempt to significantly impact on the disease burden and accelerate the attainment of the MDGs and other national priorities. In line with this approach, the theme of the National Health Strategic Plan (NHSP) is “…Towards the Attainment of the Millennium Development Goals (MDGs) and National Health Priorities…”. This National Health Strategic Plan (NHSP) is the fourth in the series of the strategic plans implemented under these reforms. The plan presents a major departure from the past strategic plans, in that, while it is recognized that all health care interventions are important and should continue to receive the necessary levels of support, prioritization of interventions is of critical importance as the resources and capabilities available are significantly constrained. The plan will therefore focus at achieving the national health priorities, which will include: resolving the human resource crisis; addressing national public health priorities, including the MDGs; and ensuring that priority support systems and services receive the necessary support. The NHSP has been prepared at a time characterised by significant changes and challenges, including: the high disease burden; critical shortages of health personnel; deteriorating health infrastructure; on-going restructuring of the health sector; the new National Decentralisation Policy; a weak economy; and inadequate funding to the health sector. The Ministry of Health (MOH) is committed to reorganize and manage the sector in an efficient, effective and prudent manner that would significantly improve health service delivery. It is my considered view that, with appropriate levels of commitment and support from the Government, Cooperating Partners, health workers and other key stakeholders, this plan would significantly improve the health status of Zambians and significantly contribute to national development. I therefore, urge all the people involved in the implementation of this plan to fully dedicate themselves to this important national assignment. My Ministry will remain committed to ensuring the successful implementation of this plan. Honourable Silvia T. Masebo, MP MINISTER OF HEALTH


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II

ACKNOWLEDGEMENTS This strategic plan has been developed through a participative and consultative process involving significant contributions and support from various individuals and institutions. I therefore wish to extend my sincere appreciation to all those that contributed to the process of developing this plan. While it is recognized that a large number of individuals and institutions contributed to this process, I wish to pay special tribute to the consultants, members of the editorial team, members of the technical review team and members of the technical working groups for their significant inputs and commitment to this process. On behalf of the Ministry of Health, I also wish to acknowledge the financial and technical support rendered to us by our Cooperating Partners, in particular the Health Systems Support Project (HSSP), to support this process. Without the direction and valuable support of our Cooperating Partners, we could not have managed to successfully complete this plan. Finally, I wish to thank all the members of staff of the Ministry of Health, Provincial Health Directors, District Directors of Health, representatives of statutory boards, line ministries, and health NGOs, for their participation, contributions and support to the process of formulating this strategic plan. Dr. S K Miti Permanent Secretary MINISTRY OF HEALTH


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ABBREVIATIONS AND ACRONYMS Abbreviation/ Acronym

Definition

AIDS - Acquired Immune Deficiency Syndrome ACTS - Artemesin Based Combination Therapies ANC - Antenatal Care ARH - Adolescent Reproductive Health ART - Anti Retroviral Therapy ARVs - Anti-Retrovirals BCC - Behaviour Change Communications BHCP - Basic Health Care Package BSc - Bachelor of Science CBoH - Central Board of Health CDC - Centre for Disease Control CHAZ - Churches Health Association of Zambia CIDA - Canadian International Development Agency CPs - Cooperating Partners CSO - Central Statistical Office CPD - Continued Professional Development CTC - Counseling, Testing and Care DANIDA - Danish International Development Agency DALYS - Disability Adjusted Life Years DCI - Development Cooperation Ireland Aid DHBs - District Health Boards DHMT - District Health Management Team DHS - Demographic and Health Survey DILSAT - District Integrated Logistic Self- Assessment Tool DOTS - Directly Observed Treatment Short Course (TB) DPT - Diphtheria Pertusis Tetanus DRF - Drug Supplies Fund DSBL - Drug Supply Budget Line EDL - Essential Drugs List EHTs - Environmental Health Technicians EMOC - Emergency Obstetric Care ESS - Epidemiological Sentinel Surveillance EPI - Expanded Programme of Immunization EU - European Union FAMS - Financial Administrative Management System FDL - Food and Drugs Laboratory FP - Family Planning GDP - Gross Domestic Product GFATM - Global Fund to Fight AIDS, TB, & Malaria GHE - Government Health Expenditure GIS - Geographical Information Systems GRZ - Government of the Republic of Zambia HIPC - Highly Indebted Poor Countries HIV - Human Immunodeficiency Virus HE - Health Expenditure


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HMIS - Health Management Information System HQ - Headquarters HRH - Human Resources for Health HSSP - Health Services and Systems Program ICT - Information Communication Technology IEC - Information, Education and Communication IGAs - Income Generating Activities IMCI - Integrated Management of Childhood Illnesses IMF - International Monetary Fund IMR - Infant Mortality Rate IRS - Indoor Residual Spraying ITNs - Insecticide Treated Nets IP - Infection Prevention IPT - Intermittent Preventive Therapy JICA - Japan International Cooperation Agency M & E - Monitoring & Evaluation MDGs - Millennium Development Goals NDP - National Development Plan MMR - Maternal Mortality Ratio MoFNP - Ministry of Finance and National Planning MOH - Ministry of Health MoU - Memorandum of Understanding MSH - Management Science for Health MSL - Medical Stores Limited MTEF - Medium Term Expenditure Framework NDQCL - National Drug Quality Control Laboratory NFNC - National Food and Nutrition Commission NGOs - Non – Governmental Organisations NHSP - National Health Strategic Plan NMCC - National Malaria Control Centre NORAD - Norwegian Agency for Development ORS - Oral Rehydration Solution ORET - Ontwikkelings Relevant Export Transakie (Development of Relevant

Export Transaction) PAC - Post Abortion Care PEMFAR - Public Expenditure Management Financial Accounting Reform PEPFAR - President’s Emergency Plan for AIDS Relief PLWA - People Living with AIDS PMTC - Prevention of Mother to Child Transmission PSM - Procurement Supplies Management PSU - Procurement Supplies Unit PRA - Pharmaceutical Regulatory Authority PRSP - Poverty Reduction Strategic Paper QA - Quality Assurance RBM - Roll Back Malaria R&D - Research and Development RDU - Rational Drug Use RH - Reproductive Health SADC - Southern African Development Community SP - Sulphadoxine Pyrimenthamine


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SIDA - Swedish International Development Agency STI - Sexually Transmitted Infection STGS - Standard Treatment Guidelines SWAP - Sector Wide Approach SWOT - Strengths, Weakness, Opportunities and Threats TB - Tuberculosis TA - Technical Assistance TGE - Total Government Expenditure THE - Total Health Expenditure ToT - Trainer of Trainers TI - Training Institution TTIs - Transfusion Transmitted Infections TWGs - Technical Working Groups UNICEF - United Nations Children’s Fund UNZA - University of Zambia USAID - United States Agency for International Development VCT - Voluntary Counseling and Testing WHO - World Health Organisation YFHS - Youth Friendly Health Services ZANARA - Zambia Response to HIV / AIDS ZCCM - Zambia Consolidated Copper Mines ZDHS - Zambia Demographic and health Survey ZNBT - Zambia National Blood Transfusion Services ZNF - Zambia National Formulary ZNFC - Zambia National Formulary Committee ZNTB - Zambia National Tender Board ZPCT - Zambia Prevention Care and Treatment ZMK - Zambian Kwacha <5 children - Children under the age of five years.


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EXECUTIVE SUMMARY Introduction Since 1992, Zambia has been implementing significant Health Sector Reforms, whose vision is to “..provide the people of Zambia with equity of access to cost-effective, quality healthcare as close to the family as possible…”. This National Health Strategic Plan (“NHSP” or “plan”) is the fourth in the series of the strategic plans implemented under these reforms. The theme of the NHSP is “…Towards the Attainment of the Millennium Development Goals (MDGs) and National Health Priorities…”. The plan has been prepared at the time when the country and, in particular, the health sector, is facing significant changes and challenges, including the: high disease burden compounded by the HIV/AIDS epidemic; critical shortages of health personnel; deteriorating health infrastructure; significant legal reforms; on-going restructuring of the health sector; a weak economy; and inadequate funding to the health sector. All these factors have significant implications on the organisation and management of the health sector. This situation calls for “prioritisation” of interventions and systems, paying particular attention to areas that would make significant impact on health service delivery to improve the health status of Zambians. This plan therefore places significant emphasis on prioritisation. Background

(i) Health Sector Performance and Disease Burden Over the past five years, the overall performance of the health sector has shown some improvements (Economic Report 2004, MoFNP, 2005). This is reflected in the trends of key basic health care delivery indicators, such as: the health centre outpatient per capita attendance, which improved from 0.42 in 2000, to 0.76 in 2004; first antenatal coverage, from 81% in 2000 to 97% in 2004; fully immunized children under the age of 1 year, from 76% in 2000 to 80% in 2004; and drug kits opened per 1,000 patients, from 0.73 in 2000 to 0.93 in 2004. Despite these improvements, the disease burden has continued to increase, health care delivery has continued to be constrained due to lack of adequate human, material and financial resources, and performance against the Millennium Development Goals (MDGs) has not been satisfactory. The high disease burden in Zambia is compounded by several factors, including the impact of the HIV/AIDS epidemic, high poverty levels and poor macroeconomic situation. Despite discrete and sustained improvements in most indicators, it is unlikely that Zambia will meet most of the MDG targets by 2015.

(ii) The External Environment Implementation of this NHSP will be significantly influenced by many external factors that need to be recognised and taken into consideration. The following will be the major external factors that are expected to impact on the implementation of the plan.


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Political and Legal Factors: The following have been identified as the major political and legal developments that could significantly impact on the implementation of this plan: the recent repeal of the National Health Services Act (NHSA 2005), leading to the dissolution of CBoH, hospital and district management boards; the on-going comprehensive restructuring of the Ministry under the Public Service Reform Programme (PSRP); and the implementation of the new National Decentralisation Policy. These developments will significantly influence the organisation and management systems of the sector. Economic Factors: During the period from 2000 to 2004, the Zambian economy registered positive real growth at an average rate of 4.6% per year (MoFNP, TNDP/2002-05). However, this achievement is considered inadequate as it is estimated that the Zambian economy should consistently grow at 7-8% per annum for at least 10 years, in order to achieve the desired people-level impact. The Government has since made a commitment to progressively increase annual funding for the health sector from the current 11.5% of the budget to 15%. Further, in addition to the support from bilateral and multilateral Cooperating Partners (CPs), new funding from the President’s Emergency Plan for AIDS Relief (PEPFAR) from the U.S.A, the Global Fund Against HIV/AIDS, TB and Malaria and the projected savings from the Highly Indebted Poor Countries (HIPC) initiative offer significant opportunities for increasing the resources available to the health sector. Social and Cultural Factors: Zambia’s population is currently estimated at 11.3 million, comprising of approximately 50% males and 50% females. The country has one of the highest dependency ratios in the world and is also among the most urbanized countries in Sub-Saharan Africa, with approximately 38% of the population living in urban areas. Poverty levels have remained high, estimated at 67% in 2002. As a result of high levels of poverty, preventable and treatable diseases have taken an enormous toll on the poor, increasing pressure on the already constrained health sector. Technological Factors: Significant advances in science and technology in the world present major challenges and opportunities for the health sector in Zambia. These include: Advances in malaria control, presenting new diagnostic tools, more effective chemotherapy and better mosquito control methods; and Anti-Retroviral Therapy (ART) for the management of HIV/AIDS cases. The challenge is to carefully assess and only access the most appropriate, ethical, affordable and sustainable developments in science and technology. Vision, Mission, Overall Goal and Key Principles Vision:

Equity of access to assured quality, cost-effective and affordable health services as close to the family as possible.

Mission Statement:

To provide cost effective, quality health services as close to the family as possible in order to ensure equity of access in health service delivery and contribute to the human and socio-economic development of the nation.

Overall Goal:

To further improve health service delivery in order to significantly contribute to the attainment of the health MDGs and national health priorities.

Key Principles: Equity of access; Affordability; Cost-effectiveness; Accountability; Partnerships; Decentralisation and Leadership.


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National Health Priority Interventions While all health service interventions are considered important and will continue to receive the necessary levels of support, the new NHSP will focus mainly on the following 12 national health priorities. These priority areas include 7 public health interventions and 5 systemic interventions. The systemic interventions represent support services which facilitate the efficient and effective management of the health sector, and without which implementation of the public health priorities would not be possible. These priorities have been selected on the basis of the health related MDGs and other national health priorities, and are presented in Table 1. Table 1: National Health Priorities S/N Intervention/System Objective/Main Targets A. Human Resource Crisis 1. Human Resources: To provide a well motivated, committed and skilled professional

workforce who will deliver cost effective quality health care services as close to the family as possible.

B. Public Health Priorities 2. Integrated Child Health and

Nutrition: To reduce Under-5 MR by 20%, from the current level of 168 per 1,000 live births to 134 by 2010, and significantly improve nutrition.

3. Integrated Reproductive Health: To increase access to integrated reproductive health and family planning services that reduce the Maternal Mortality Ratio (MMR) by one quarter, from 729 per 100,000 live births to 547 by 2010.

4. HIV/AIDS, STIs and Blood Safety:

To halt and begin to reverse the spread of HIV/AIDS and STIs by increasing access to quality HIV/AIDS, STI and blood safety interventions.

4. Tuberculosis (TB): To halt and begin to reverse the spread of TB through effective interventions.

5. Malaria: To halt and reverse the incidence of malaria by 75% and mortality due to malaria in children under five by 20%.

6. Epidemics Control and Public Health Surveillance

To significantly improve public health surveillance and control of epidemics, so as to reduce morbidity and mortality associated with epidemics.

7. Environmental Health and Food Safety:

To promote and improve hygiene and universal access to safe and adequate water, food safety and acceptable sanitation, with the aim of reducing the incidence of water and food borne diseases.

C Support Systems Priorities 9. Essential Drugs and Medical

Supplies: To ensure availability of adequate, quality, efficacious, safe and affordable essential drugs and medical supplies at all levels, through effective procurement management and cooperation with pharmaceutical companies.

10. Infrastructure and Equipment: To significantly improve on the availability, distribution and condition of essential infrastructure and equipment so as to improve equity of access to essential health services.

11. Systems Strengthening: (M&E, HMIS, FAMS, Procurement and R&D)

To strengthen existing operational systems, financing mechanisms and governance arrangements for efficient and effective delivery of health services.

12. Health Systems Governance: (Governance and Health Care Financing)

To provide a comprehensive policy and legal framework and systems for effective coordination, implementation and monitoring of health services.


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Implementation Framework

(i) Implementation The duration of the NHSP is six years, from 1 January 2006 to 31 December 2010. The NHSP is closely linked with the National Development Plan 2006-11 and the Medium Term Expenditure Framework (MTEF). The NHSP will be operationalised through two MTEF plans and a series of annual action plans and budgets. The NHSP will be implemented and coordinated through the existing health sector organisational and management structures at national, provincial and district levels, including public, private, faith based and traditional health institutions and systems involved in providing health care services. Decentralisation will remain as one of the key principles for the organisation and management of the health sector. MOH will aim at making significant progress towards the implementation of the new National Decentralisation Policy. Further, the Sector Wide Approach (SWAp) will play an important role in ensuring efficient and effective mobilization and utilisation of financial resources from the Government and CPs. The existing Memorandum of Understanding (MoU) between MOH and the CPs is being amended to address the new demands and priorities. MOH will ensure that effective and adequate financial and administrative management systems and control procedures are in place to ensure that all GRZ and CP resources are disbursed and accounted for as planned. The Financial and Administrative Management System (FAMS) will continue to form the basis for financial management and control within MOH and its agents. MOH will also establish mechanisms to provide adequate capacity, linked to performance, for successful program implementation, in consultation with the CPs.

(ii) Monitoring and Evaluation Monitoring and evaluation of the implementation of the NHSP will be conducted through appropriate systems, procedures and mechanisms. The Monitoring and Evaluation (M&E) Sub-Committee of SAG will be responsible for providing advice on all matters concerning M&E. The indicators selected for monitoring the implementation of the NHSP 2006-2010 and performance of the health sector are provided in Table 2. The Health Management Information System (HMIS), Financial Administrative Management System (FAMS) and other routine systems will be the major tools for data collection. Depending on the type and relevance of the indicators, routine monitoring will be undertaken, on a monthly, quarterly, bi-annual and annual basis. The SAG, MOH and other agencies will primarily use this data and its analyses for decision making. MOH will produce quarterly activity and financial reports for all levels of the health system for consideration at the Mini-SAG meetings. It will also produce an Annual Performance Review Report every May, on the performance of the sector against annual plans and output targets. MOH will be responsible for sector performance monitoring and review. It will plan and lead the Joint Annual Reviews (JAR) in January-February every year, with appropriate involvement and support of the CP, other Government ministries and other key stakeholders. The findings of the JAR will be presented at the first SAG meeting of each year.


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There will be two evaluations during the duration of this plan. These will consist of a mid-term assessment after the first 3 years of implementation and a comprehensive final evaluation in 2011. All stakeholders will agree on the timing, terms of reference and composition of these two review missions. All costs will be included in the Health Sector Budget. Table 2: Indicators for Monitoring Performance of the NHSP 2006-2010 No. Category Indicator Purpose National

Baseline (Yr. 2005)

National Target (2010)

Source of Data

1 Input Percentage of GRZ budget allocated to health sector

GRZ commitment to health

10% 15% MoFNP

2 Input Total public (GRZ+CPs) allocated to health per capita

Equity of health resources allocation

US$10.5 M (Yr. 2000)

US$16.0 M MoH

3 Input MoH expenditure on PE Equity in health care allocation

66 % (Yr. 2001)

60% MoH

4 Input Percentage of health facilities without any stock-outs of tracer supplies in a month

Proxy to quality of health services provided

82% (Yr. 2004)

100% HMIS

5 Input Percentage of donated blood tested for HIV, Hepatitis B and C, and Syphilis in accordance with National and WHO guidelines


100% (Yr. 2001)

100% HMIS

6 Process Proportion of districts submitting complete HMIS quarterly returns to MoH in time

Management capacity for performance monitoring

95% (Yr. 2004)

100% HMIS

7 Process Health centre staff workload

Staffing levels 17.2 (Yr. 2004)

15.0 HMIS

8 Process Percentage of population within 5 km of a public health facility

Equity in geographical access to health care

75.5% (Yr. 2004)

85% LCMS (CSO)

9 Output Percentage of deliveries supervised by skilled health workers

Maternal health 43% (Yr. 2004)

50% HMIS

10 Output Percentage of fully immunized children under the age of 1yr

Child health 80% (Yr. 2004)

90% HMIS

11 Output ITN coverage (under 5yrs; pregnant women)

Maternal and child health

28% (Yr. 2005)

75% MIS/NMCC

12 Output ART coverage (No. of people accessing ARVs)

Access to HIV/AIDS treatment

40 000 PLWHA

250 000 PLWHA

MoH/NAC

13 Output TB cure rate TB case management

73% (Yr. 2004)

85% MoH

14 Outcome Malaria case fatality rate among children below 5 yrs old

Quality of malaria case management in under fives

33 per 1000 admin

(Yr. 2004)

15 per 1000 admin

HMIS

15 Output Underweight prevalence in children below 5yrs old


15% HMIS

16 Outcome Health centre utilisation by children below 5yrs old

Utilisation of health services

0.76 (Yr. 2004)

3.0 HMIS


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1.0 INTRODUCTION 1.1 Context Since 1992, the Government of the Republic of Zambia (GRZ) has been implementing Health Sector Reforms aimed at improving health service delivery. The reforms, whose vision is to” provide the people of Zambia with equity of access to cost-effective, quality healthcare as close to the family as possible”, were articulated in the National Health Policies and Strategies of 1992 (NHPS/92). The underlying principle of these reforms is decentralisation of health service delivery through the delegation of key management responsibilities from the centre to the district and hospital levels. Decentralisation also aimed at shifting resources from the centre to operational levels, where healthcare delivery services are conducted. The reforms also emphasized the importance of community participation in the management of health services and the need for a well motivated and remunerated work force. Implementation of the reforms has been through a series of National Health Strategic Plans (NHSPs), of which this is the fourth, covering the period from 2006 to 2010. The theme of this strategic plan is “…Towards Attainment of the Millennium Development Goals (MDGs) and National Health Priorities…” The plan has been developed at a time of considerable policy and legal reforms, including the launching of the National Decentralisation Policy of 2003 and the repeal of the National Health Services Act of 1995, leading to the dissolution of the Central Board of Health (CBoH). These developments have significant implications on both the formulation and implementation of this plan. The NHSP has been prepared at the time when the country and, in particular, the health sector, is facing significant challenges and changes, including: launching of the National Decentralisation Policy; repeal of the National Health Services Act of 1995, leading to the de-solution of the Central Board of Health (CBoH), together with the hospital and district health boards; critical shortage of health personnel; on-going restructuring of the sector; high disease burden, compounded by high prevalence levels of HIV/AIDS; deterioration in health infrastructure; weak economy and inadequate funding to the health sector. This situation calls for “prioritisation” of intervention strategies, paying particular attention to areas that would make significant impact on health delivery and improve the health status of Zambians. This plan therefore places significant emphasis on prioritisation. 1.2 Process and Structure The strategic plan has been developed through a participative and consultative process involving all major stakeholders. The approach used included data collection, review of literature, thematic group works, stakeholders’ consensus building workshops, panel reviews and consolidation of the plan.


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2.0 BACKGROUND 2.1 Sector Organisation and Management 2.1.1 Organisation of the Health Sector The main feature of the organisational and institutional restructuring implemented under the health sector reform programme was the decentralisation of health service delivery, through devolution of key management responsibilities and resources to district level. In this respect, two parallel, but complimentary organizational structures were introduced, namely, popular structures for public involvement and participation in the decision-making process, and the technical and management structures, designed to ensure that health services are implemented and managed in a manner that is technically sound and conform with best practices. The popular structures created in this process included: the Central Board of Health (CBoH) board, at national level; Hospital Management Boards (HMBs), at hospital level; District Health Boards (DHBs), at district level; and the Neighbourhood Health Committees and Health Centre Committees, at community level. On the other hand, the technical structures established included: the management teams at MOH and CBoH, at national level; Hospital Management Teams (HMTs), at hospital level; and District Health Management Teams (DHMTs), at district level. Further, the Provincial Medical Offices were reconstituted into Provincial Health Offices. However, the Government has since made a decision to abolish CBoH, together with the hospital and district health management boards. Following this decision, the health sector is undergoing a comprehensive restructuring process through which the functions of MOH and CBoH will be merged and the management and control of all public health facilities and services will directly fall under MOH, through the Provincial Health Offices. In order to ensure continued popular public participation in the management of health services, the hospital and district management boards will be replaced by advisory councils. The challenge for MOH will be to manage the transformation process in a planned and coordinated manner, with minimal disruptions to the existing systems and operations.

2.1.2 Healthcare Providers The main providers of health care services in Zambia include: public health facilities under MOH; facilities under the Ministry of Defence, including clinics and one hospital in Lusaka; clinics under the Ministry of Home Affairs; Mine hospitals and clinics; Mission hospitals and clinics, which are coordinated by the Churches Health Association of Zambia (CHAZ); Private hospitals and clinics; Non-Governmental Organizations (NGOs); and traditional healers. For historical reasons, each of these categories of healthcare providers has concentrated in different parts of urban and rural Zambia. The total number of health facilities including Government, mission and private facilities are as summarized in Table 3, below. Table 3: Summary of Existing Health Facilities in Zambia Type/Level GRZ Mission Private Total Hospitals 53 27 17 97 Health Centres 1,052 61 97 1,210 Health Posts 19 0 1 20 Total 1,124 88 115 1,327 Source: CBoH, Health Institutions in Zambia: A Listing of Health Facilities According to Levels and Locations, 2002

10


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• Health Posts: Intended to cater for populations of 500 households (3,500 people) in rural

areas and 1,000 households (7,000 people) in the urban areas, or to be established within 5Km radius for sparsely populated areas. The target is to have 3,000 health posts but currently only 20 have been commissioned;

• Health Centres: These facilities include Urban Health Centres, which are intended to serve a catchment population of 30,000 to 50,000 people, and Rural Health Centres, servicing a catchment area of 29 Km radius or population of 10,000. The target is 1,385 but currently there are a total of 1,210 health centres (973 Rural, 237 Urban);

• 1st Level Referral Hospitals: These are found in most of the 72 districts and are intended to serve a population of between 80,000 and 200,000 with medical, surgical, obstetric and diagnostic services, including all clinical services to support health centre referrals. Currently, there are 74 1st Level Referral Hospitals;

• General Hospitals: These are 2nd level hospitals at provincial level and are intended to cater for a catchment area of 200,000 to 800,000 people, with services in internal medicine, general surgery, paediatrics, obstetrics and gynaecology, dental, psychiatry and intensive care services. These hospitals are also intended to act as referral centres for the 1st level institutions, including the provision of technical back-up and training functions. Currently there are 19 second level hospitals. Two provinces, namely Southern and Copperbelt, have 5 and 3 second level Hospitals respectively. There is need to rationalize the distribution of these facilities through right-sizing; and

• Central Hospitals: These are for catchment populations of 800,000 and above, and have sub-specializations in internal medicine, surgery, paediatrics, obstetrics, gynaecology, intensive care, psychiatry, training and research. These hospitals also act as referral centres for 2nd level hospitals. Currently there are 5 such facilities in the country, of which 3 are in the Copperbelt Province. Again there is need to rationalize the distribution of these facilities.

Health Sector Reforms introduced in 1992 tended to overlook levels 2 and 3 hospitals. Policy makers and Cooperating Partners (CPs) exclusively focused on primary health care despite the knowledge that healthcare was a continuum of care ranging from primary health to tertiary care. In 1999, there was an attempt to bring the hospitals on board the health reform agenda. A Hospital Sector Reform Steering Committee was established to spearhead hospital sector reforms. The focus of the reforms was on formulation of a hospital policy, systems development in the hospitals such as HMIS and FAMS, development of the Basic Package of Care, quality assurance, leadership and management, and overall improvement of the quality of patient care. In 2003, as part of expanding the district basket funding, a hospital basket was established with plans to later include training institutions. During the same year, a Capacity Assessment Mission (CAMS) was conducted on hospitals, in which management systems and capacities were assessed. Following the CAMS assessments were to be used in providing support to hospitals in strengthening and developing appropriate systems and capacities to qualify for basket funding. However, the CAMS report for hospitals was never finalised, capacity support was not given, and basket funding to hospitals has not been increased above the initial amount agreed upon. MOH has since realised capacity limitations to take this forward and has identified the need to develop technical advisory support to hospitals and training institutions that would improve their efficiencies and effectiveness and help unlock additional basket funding.


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2.1.3 Statutory Boards Statutory boards, both regulatory and service, play an important role in the implementation of the overall Government health policy. In order to provide for efficient and effective coordination of the operations of regulatory boards under the MOH, in 1997 the Government issued a Statutory Instrument, which established the National Public Health Regulatory Authority (NPHRA). NPHRA was mandated to coordinate the activities of regulatory boards, which include the Pharmaceutical Regulatory Authority, Food Safety and Food Quality Control Services Unit, Environmental Health and Epidemiological Trends Unit, Radiation Protection Board, Radiology and Medical Devices Control Unit and Medical Laboratory Regulatory services Unit, Medical Council of Zambia and the General Nursing Council. However, these boards have continued to operate in isolation. The Ministry should ensure that coordination is strengthened, through operationalisation of the provisions of the Statutory Instrument. Similarly, service boards such as, National Food and Nutrition Commission (which is partially regulatory), Zambia National Flying Doctor Services (ZNFDS), Zambia National Blood Transfusion Service (ZNBTS) and the Tropical Disease Research Centre (TDRC) also require more integration into the service delivery activities of the Ministry. 2.1.4 Partnerships Establishing effective partnership is one of the key principles of the Zambian health reforms. The vision is to create strong, sustainable partnerships among all key stakeholders involved in health service delivery in Zambia. Accordingly, partnerships have been established in each district at all levels of service delivery. These partnerships allow key stakeholders to work together to analyse health problems in their respective areas, identify possible solutions, develop joint work plans, implement and evaluate progress of their programmes. Except for the Churches Health Association of Zambia (CHAZ), private sector participation in health service delivery in Zambia has been modest. However, over the past few years, there has been a noticeable steady increase in private sector, resulting into various forms of private/public sector partnerships, which include the sharing of medical technologies, referral of patients, human resources and facilities. The gradual increase in the number of “for profit” and “not for profit” private health service providers presents significant policy implications with regard to their involvement in the delivery of public health services. There is need for the Ministry to provide appropriate standards and guidelines to the private sector on acceptable levels of practice. Lack of such guidelines has resulted into poor case management, irrational drug use, poor prescription methods and unnecessary delays in referring patients to specialized hospitals. Accreditation is another way of increasing private sector participation in health service delivery. However, the existing policy and regulatory environment is weak. In addition, currently there are no incentives from MOH, aimed at attracting the private sector to participate in the implementation of the Basic Health Care Package (BHCP) through the public health care delivery system.


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Many reasons have been given for this state of affairs, including: a) lack of knowledge about the private sector by policy makers in the Ministry; b) limited dialogue between the public and private stakeholders; c) lack of institutionalized policy instruments from MOH for interacting with the private sector especially in financing, regulation and dissemination of information. The establishment of global health funding initiatives and opportunities for specific diseases such as HIV/AIDS, TB and malaria has created further opportunities for enhanced private sector participation in health service delivery. Generally, the Ministry needs to harness the Public/Private sector partnerships in the delivery of public health services, through increased dialogue, development and enforcement of appropriate regulatory framework, improved coordination, monitoring and evaluation. 2.1.5 Gender and Health Zambia still shows some major gender disparities in health outcomes, particularly in terms of morbidity, mortality, under five mortality and nutrition as reflected in the ZDHS 2001-02 report. Overall, the issue of gender differences in access to healthcare and the impact on health outcomes does not seem to have received the attention it deserves. Currently, the participation of men in reproductive and family health is still relatively low, gender policies in the NHSP are not transformed into concrete action plans, there is no collection of gender-disaggregated data within the HMIS, there are fewer women in management positions at all levels of the public health system, and the understanding of gender mainstreaming is still limited. Some of the reasons why little progress has been made to mainstream gender in the health sector are: the lack of conceptual understanding of gender; limited technical expertise and lack of appreciation of linkages between Gender and health. The District Development Coordinating Committees (DDCC) which have been mandated to implement gender and health related issues at the district level are not functional as they also lack capacity in terms of technical expertise, material and financial resources and are not even aware of the National Gender Policy and its Implementation Plan. The challenge for the health sector is to: develop a specific action plan for accelerated gender mainstreaming; address gender balancing in recruitment and human resource development activities; adopt a multi-sectoral approach to strategically mainstream gender; and establish clear monitoring and evaluation indicators, which can show progress on gender mainstreaming. 2.2 Health Sector Performance and Disease Burden The Zambian population is currently estimated at 11.3 million, with an annual average growth rate of 3% and life expectancy at birth of 50 years (CSO, 2004). Over the past five years, the overall performance of the health sector has shown some improvements. This is reflected in the trends of the key basic health care delivery indicators, such as health centre outpatient per capita attendance, first antenatal coverage and fully immunized children under the age of 5 years. Tables 4 presents the trends for selected healthcare delivery and impact indicators.


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Table 4: Selected Healthcare Delivery Indicators, 2000 - 2004 Indicator 2000 2001 2002 2003 2004 Health Centre Outpatient Per Capita Attendance 0.42 0.77 0.73 0.86 0.76 First Antenatal Coverage (%) 81 88 89 95 97 Average Antenatal Visits (Times) 3.6 3.6 3.4 3.3 3.1 Supervised Deliveries (%) 39 44 49 55 61 Fully Immunised Children Under 1 Year (%) 76 86 76 74 80 Underweight Prevalence (% Weight) 23 23 22 21 17 New Family Planning Acceptors Rate per 1000 85 101 111 123 127 Health Centre Staff Load (Patients/Staff) 17 14 16 17 17 Drug Kits Opened Per 1,000 Patients 0.73 0.75 0.69 0.73 0.93 Source: Central Board of Health However, despite these improvements, the disease burden has continued to increase and health care delivery continued to be constrained by lack of sufficient human, material and financial resources. The high disease burden, is compounded by the high prevalence of HIV/AIDS, high poverty levels and poor macroeconomic situation. Presented in Table 5 are summarized statistics on the trends for some of the major diseases in Zambia, for the period from 2000 to 2004.

Table 5: Summary: Some of the Major Diseases in Zambia, 2000-2004 S/N Disease Name Indicator 2000 2002 2004 1 Malaria Incidence/1,000 316 388 383 Cases 3,591,621 4,101,169 4,328,485 Deaths 8,952 9,021 8,289 2 Respiratory Infection: Non-pneumonia Incidence/1,000 119 148 153 Cases 1,340,283 1,565,430 1,726,597 Deaths 1,269 1,057 1,436 3 Diarrhoea: Non-blood Incidence/1,000 65 80 75 Cases 739,055 846,336 843,423 Deaths 2,795 2,996 2,725 4 Respiratory Infection: Pneumonia Incidence/1,000 35 45 44 Cases 402,643 475,389 494,040 Deaths 4,254 4,484 4,186 5 Eye Infections Incidence/1,000 47 43 40 Cases 471,743 451,346 448,280 Deaths 72 8 5 6 Trauma: Accidents, injuries, wounds, burns Incidence/1,000 34 42 46 Cases 390,869 447,278 525,039 Deaths 646 787 833 7 Skin Infections Incidence/1,000 28 37 42 Cases 309,758 393,384 472,746 Deaths 135 126 125 8 Ear/Nose/Throat Infections Incidence/1,000 21 25 23 Cases 238,403 260,058 259,877 Deaths 49 31 34 9 Intestinal Worms Incidence/1,000 20 22 17 Cases 217,142 227,856 197,639 Deaths 49 14 6 10 Anaemia Incidence/1,000 13 16 15 Cases 155,149 166,241 170,846 Deaths 2,761 2,612 2,381

Source: Ministry of Health, HMIS, 2005


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A number of factors have adversely affected the performance of the health sector in Zambia. These include a critical shortage of essential health workers, inadequate funding, poor state of health facilities and equipment, inadequate development of social support systems for fostering health development programmes, insufficient empowerment of communities to improve their health, poor geographical access, especially in rural areas, and inadequate systematic research in alternative and traditional medicines. As a result, health services were not fully appreciated by the public. 2.3 Performance against the MDGs

The sector’s performance against the four relevant MDGs is summarized in Table 6. Table 6: Selected Impact Indicators Indicator Target 1990/2 1996 2002 Infant Mortality Rate per 1,000 36 107 109 95 Under 5 Mortality Rate per 1,000 63 191 197 168 Maternal Mortality Ratio per 100,000 162 * 649 729 HIV Prevalence Rate (ESS) 20 18.6 19.0 HIV Prevalence Rate (ZDHS 2001-2) - - 15.6 TB Cure Rate 85% Detection Rate 70% Malaria Incidence Rate <121 255 388 Source: Zambia Demographic Health Survey 2001/02 As could be observed from Table 3 above, the performance trends against most key MDG targets has been below expectations. Despite discrete and sustained improvements in most indicators Zambia is unlikely to meet most of its MDGs by the target year of 2015. While the causes for the low performance against of the MDGs could be many, the critical shortage of human resources at all levels of the system is no doubt the most important factor, together with the lack or weak inter-sectoral responses to address important cross-cutting health problems such as the deteriorating nutritional status of many Zambians. In order to improve health sector’s general performance and meet millennium development targets, the new NHSP will provide considerable focus on dealing with the human resources crisis, improving the state of infrastructure and fostering multi-sectoral responses in key areas such as nutrition, HIV/AIDS, control of epidemics, health education and increased access to basic environmental health facilities, such as safe water, acceptable basic sanitation, electricity and telecommunications.


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2.4 The External Environment The main external factors that could impact on the performance of the health sector during the duration of this strategic plan include political and legal, economic, social and cultural, and technological factors, as summarized below. 2.4.1 Political and Legal Factors The political climate in Zambia is generally peaceful, stable and conducive for smooth delivery of healthcare services throughout the country. However, the following have been identified as the major political and legal developments that could impact on the implementation of this plan. 2.4.1.1 Public Service Reform Programme In 1993, the Government launched the Public Service Reform Programme (PSRP). The programme aims at increasing efficiency and effectiveness of the public service, through rightsizing, decentralization, development of appropriate performance management systems and capacity building. Under PSRP, the role of the central ministries (head quarters) is considered to be more on policy formulation, resource mobilization and monitoring of sector performance. Pursuant to this programme, MOH was restructured in 2002. However, this was only partially done and concentrated on MOH-HQ, leaving out other units of the public health delivery system. As a result of the partial restructuring, a new organization structure for MOH-HQ was introduced, but was not accompanied with new performance management systems. In view of the foregoing, the Government has identified the need to carryout a comprehensive restructuring of MOH, covering the whole sector. 2.4.1.2 National Decentralisation Policy In 2003, the Government launched the National Decentralisation Policy, which will be implemented over a period of 10 years, starting from 2003. This development has brought in another dimension to the future organization and management of health services in Zambia, with major implications on planning, resource allocation, human resource management and accountability, as the overall decentralization policy calls for channeling and control of resources through the Local Authorities at district level. While the National Decentralisation Policy aims at devolving responsibilities to the district level, the provincial level management will provide the necessary intermediate level of programme management, coordination and supervision of district authorities. Under the existing decentralised health sector, the Provincial Health Director’s Offices play an important role of providing technical support, coordination and supervision to the District Health Boards and Management Teams. The on-going restructuring of the health sector should therefore clearly define the new roles and responsibilities of the provincial level and strengthen management and staffing at this level. The challenge is for MOH to carefully study the implications of the new decentralisation policy and ensure that the achievements already made in this area are harmonized with the requirements of the new policy, while taking full advantage of the opportunities presented by it. Further, MOH should ensure effective collaboration and coordination with the provincial and Local Authorities at district level in respect of healthcare prioritization, planning, coordination and control.


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2.4.1.3 National Health Services Act of 1995 The National Health policies and Strategies of 1992 and the National Health Services Act of 1995 (NHSA/1995) proposed the introduction of a new institutional framework for the health sector in order to address shortcomings in the then existing organizational structure. The new structures created included the Central Board of Health (CBoH) and health management boards. Over the years, there have been noticeable achievements, particularly in health systems strengthening. The Ministry has however faced significant challenges, which include duplication of functions between MOH-HQ and CBoH, failure to implement de-linkage of staff from Public Service to the Health Boards, and an overall bloated and costly central level structure. In view of the foregoing, in August 2004 the Government made a policy decision to restructure the health sector by repealing the NHSA/1995 to facilitate the merger of the MOH-HQ and CBoH functions at the centre and dissolution of the hospital and district management boards, and the introduction of a new organisational structure for the health sector in order to bring the much needed improvements to service delivery. The proposed restructuring of the health sector presents significant challenges, which if not properly managed, could lead to a reversal in the achievements made under the health reforms. The following have been identified as major risks associated with this process: • Possibility of disrupting the technical support services rendered by the CBoH to service units,

which could adversely affect the quality of health service delivery; • Possibility of staff losses due to de-motivation arising from the shift to poor Civil Service

Conditions of Service and uncertainties that may result from the change process. Staff attrition could lead to loss of institutional memory; and

• Possibility of a reduction in donor funding due to concerns that transparency and accountability for donor funds may slacken, with the loss of systems and capacity developed under the CBoH, such as the Health Management Information System (HMIS), Financial and Administrative Management Systems (FAMS), Planning Systems and the Sector-wide Approach (SWAp).

In order to prevent these risks the new NHSP will place considerable emphasis on improving health systems governance, capacity building and addressing the human resources crisis. 2.4.2 Economic Factors 2.4.2.1 Macroeconomic Overview Since 1992, the Government has continued to pursue stringent fiscal and monetary policy measures aimed at stabilizing the macroeconomic environment and achieving sustainable economic growth. During the period from 2000 to 2004, the Zambian economy registered positive real growth at an average rate of 4.6% per year, which is higher than the average rate of 4.4% projected for the period from 2001 to 2005 (MoFNP: TNDP/2002-05). Despite the improvement in GDP growth rate, it is still inadequate to have significant changes on the standard of living and health status of Zambians. It is estimated that the economy must consistently grow at 7-8% per annum for at least 10 years, in order to achieve the desired people-level impact. Table 7 presents selected key macroeconomic indicators for the period from 2000 to 2004.


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Table 7: Selected Key Macroeconomic Indicators, 2000-2004 Indicator Unit 2000 20001 2002 2003 2004 Real GDP Growth % 3.6 4.9 3.3 5.1 5.0 GDP US$ ’Mil. 3,239 3,640 3,776 4,318 5,409 Inflation Rate (Year-end) % 30.1 18.7 26.7 17.2 17.5 Domestic Fiscal Deficit % GDP - - 3.3 5.1 1.9 Exchange Rate K/US$ 3,111 3,608 4,307 4,743 4,772 % GHE to GDP % - 7 6 6 6 Source: Ministry of Finance and National Planning: Macroeconomic Indicators and Economic Reports

Due to the past poor macroeconomic performance, health services are still under-funded to effectively support interventions that would result in significant disease reductions. The WHO Commission on Macro-economics has estimated that a country such as Zambia needs a per capita expenditure on health of US $33 in order to deliver the Basic Health Care Package. In 2000, the total per capita expenditure on health, from GRZ and Cooperating Partners (CPs), was estimated at $10.8 and was projected to increase to $12.0 by 2005. The actual per capita expenditure during the period 2001 to 2004 has however only averaged $10.5. Further, the proportion of Government funding to the health sector has been declining, from 14% of the total budget during the mid to late 1990s to an average of approximately 10% between 2001 and 2004. In US dollar terms, total Government health expenditure increased from US$63 million in 2001 to US$65 million in 2002, but then slightly declined to around US$63 million in 2003, and later rose to US$73 million in 2004. As a percentage of the total national budget, funding to the health sector declined from 8.7% in 2003 to 8.1% in 2004. Similarly, as a percentage of the discretionary budget, funding to the health sector dropped from 12% in 2003 to 11.5% in 2004. Public health expenditure, as a percentage of GDP, has also shown signs of a downward movement, declining from 2.5% around 1995 to 1.5% in 2000, and was estimated at 2.7% in 2003 and 1.7% in 2004. The Government has made a commitment to progressively increase annual funding for the health sector from the current 11.5% of the budget to 15%. Although the longstanding support of bilateral and multilateral CPs plays the most important role in the health sector, large new levels of funding from the American President’s Emergency Plan for AIDS Relief (PEPFAR) and HIPC opportunities will add to the resources. The Global Fund has been providing increased support into efforts targeted at HIV/AIDS, Malaria and TB. Further, the attainment of the HIPC Completion Point early 2005 has potential to unlock significant financial resources, through debt cancellations and increased grants from the international community, especially the G8 countries, International Monetary Fund (IMF) and the World Bank. As at the end of 2004, the total foreign debt stock was US$ 7.1 billion. It is projected that by mid 2006, the total external debt stock would be reduced to US$ 0.5 billion. The savings that would be made from debt cancellations would be targeted to the social sectors, especially the health sector. Given this scenario it is expected that the 15% of budget target for the health sector could be achieved. In 2004, a total of US$ 789.1 million was expected as external aid, out of which US$ 475.6 million was to come as project support and US$ 313.5 million as programme support (MoFNP, Economic Report 2004). However, preliminary data indicated that only US$ 297.9 million or 38% of total funds expected was received. Out of the total received, US$ 64.8 million was programme support and US$ 233.2 million was project financing.


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The data available at the Ministry of Finance and National Planning indicate that the bulk of project financing received in 2004 was earmarked to the social sectors of the economy, especially health and education. The health sector received the largest portion at 42.9% of total project funds and education received 40.6%. 2.4.3 Social/Cultural Factors 2.4.3.1 Demography In 2000, the Zambian population was estimated at 9.9 million (CSO 2000), with an average growth rate of 2.5%. The population for 2005 is estimated at 11.3 million. Out of the total population, approximately 50% are males and 50% females. Zambia is one of the countries with the highest dependency ratios in the world, with 47% of the total population being children under the age of 15 years. It is one of the most urbanized countries in Sub-Saharan Africa, with approximately 38% of the population living in urban areas. Unemployment is high and presents a serious social problem. According to the Living Conditions Monitoring Survey for 2002/2003 (CSO-LCMS III 2003), out of the estimated labour force of 4,055,169, 13.3% were unemployed, 14.7% were employed in the formal sector and the balance in the informal sector. A combination of a high dependency ratio and high unemployment presents a significant challenge for healthcare delivery. 2.4.3.2 Poverty Reduction Poverty levels in Zambia have remained high. In 2002, the overall poverty incidence was estimated at 67%. The link between ill health and poverty has been well established. Poverty leads to ill health and ill health is more likely to lead to further impoverishment among the poor than among the wealthy. As a result of poverty, preventable and treatable diseases have taken an enormous toll on the poorest people in Zambia who do not have access to professional healthcare, health information, safe drinking water and sanitation, education, decent housing and secure employment. Further, evidence from research in Zambia has shown that although the poorest people suffer disproportionately from preventable diseases, they tend to make less use of health services. Table 8 presents statistics on the poverty situation in Zambia. Table 8: Poverty Situation in Zambia, 1996-2002 Indicator Indicator 1996 1998 20021

National Incidence % 78.0 73.0 67.0 Incidence of Extreme Poverty % 66.0 58.0 46.0 Rural Poverty (% of Rural Population) % 89.0 83.0 72.0 Urban Poor (% of Urban Population) % 60.0 56.0 28.0 Income Distribution (Gini Coefficients) - 0.61 0.66 0.57 Source: Ministry of Finance and National Planning – Economic Report 2004 Although some important determinants of inequalities in health may reside in the broader social economic environment, the health sector has an important role to play in improving the health of the poor. Improving the health of the poor will be a major challenge for the MOH. In this respect, the new NHSP will improve the targeting of resources to disadvantaged districts and populations with higher disease burden, poverty and health needs.

1 * The methodology used in 2002 was different from the other years


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2.4.3.3 Literacy Levels The average national literacy rate in 2001-02 was estimated at 65.1% (ZDHS 2001-02). In all the age groups, literacy levels for men were higher than for women. The total literacy level for men was 81.6%, against 60.6% for women. Literacy levels were also higher in urban areas (79% for women and 91% for men) than in rural areas (48% for women and 76% for men). Literacy levels for the 15-24 years age group stood at 59% for females and 71% for males. Poor literacy levels, especially among the females and rural dwellers, has adverse implications on health service delivery as it presents difficulties in communicating health related messages and programmes. 2.4.4 Technological Factors Significant advances in the world of science and technology present major challenges and opportunities for the health sector in Zambia. Currently, there are a number of methodologies and technologies on the market, which could be used in resolving major healthcare problems in a more efficient, effective and economical manner. These include: • Advances in malaria control, representing three important developments: new diagnostic tools,

more effective chemotherapy and better mosquito control methods. The new “dipstick” malaria test reacts to the parasite’s antigens and enzymes and is considered more accurate and effective. Artemisinin based Combination Therapies (ACTs) have now become the treatment of choice and more effective in dealing with resistant strains of malaria. In prevention, the use of insecticide treated nets (ITNs) is proving effective and new long-lasting ITNs would soon be available;

• Anti-Retroviral Therapy (ART) presents major opportunities for the management of HIV/AIDS cases. ART has the ability to extend the lives of HIV-infected individuals;

• Lower costs of computers, improved connectivity, the internet and more user-friendly software packages could improve the abilities of healthcare providers to communicate and share data and contribute to improvements in efficiencies and cost-effectiveness;

• New and improved imaging technologies that have become available. Whilst many new technologies are still beyond affordability in Zambia, digital technologies are likely to offer opportunities for quality improvements in medical imaging. Currently, the Government is constructing a radio therapy centre in Lusaka and there are possibilities of viable public/private partnerships in this area;

• Application of Telemedicine technology, which is currently being considered for implementation by the Ministry; and

• Knowledge of the human biological heritage has now reached a stage where tailor-made diagnostics and, in particular, new treatment methods can be developed. This could, in the foreseeable future, have a positive impact on Zambian health services delivery. On the other hand these technologies will also present significant ethical dilemma, which would require careful consideration.

Whilst it is acknowledged that there are significant advances in the fields of science and technology for health, the need to carefully assess and only access most appropriate, ethical, affordable and sustainable new sciences and technologies is of critical importance. The Ministry will need to develop appropriate policies and approaches for accessing the new developments in science and technology in a planned, coordinated and cost-effective manner. Of critical importance will be the global partnerships and functional links with the private sector.


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3 VISION, MISSION, OVERALL GOAL, OBJECTIVES AND ASSUMPTIONS 3.1 Vision Equity of access to assured quality, cost-effective and affordable health services as close to the family as possible. 3.2 Mission Statement To provide cost effective quality health services as close to the family as possible in order to ensure equity of access in health service delivery and contribute to the human and socio-economic development of the nation. 3.3 Overall Goal To further improve health service delivery in order to significantly contribute to the attainment of the health Millennium Development Goals and national health priorities. 3.4 Key Principles The following principles shall continue to guide the implementation of this Strategic Plan:

1. Equity of access: Equal access to healthcare services for all the people of Zambia, regardless of their location, gender, age, race, social, economic, cultural and political status.

2. Affordability: Affordable healthcare services to all, taking into account the socio-economic status of the people.

3. Cost-effectiveness: Efficient and cost-effective delivery of healthcare services, always ensuring value for resources used.

4. Accountability: Accountability for the resources utilised, services provided and to the communities served at all levels of health service delivery.

5. Partnerships: Partnership with all the stakeholders, taking full advantages of the synergies provided by each stakeholder group.

6. Decentralisation: Devolution of key responsibilities, including planning, organization, coordination and control of healthcare delivery, and resources from the centre to the districts and hospitals, where health services are provided.

7. Leadership: Appropriate, efficient and effective leadership in the implementation of the strategic plan, at all stages of the healthcare delivery system.

3.5 National Health Priority Areas The strategic plan focuses on the attainment of identified National Health Priorities. These priorities are based on the Millennium Development Goals (MDGs) and other national health priorities which are key to the improvement of the health status of Zambians.


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The United Nations (UN) has adopted 8 Millennium Development Goals (MDGs), representing the global human and social development targets for the millennium. These include: 1) To eradicate extreme poverty and hunger; 2) To achieve universal primary education; 3) To promote gender equality and empower women; 4) To reduce child mortality; 5) To improve maternal health; 6) To combat HIV/AIDS, malaria and other diseases; 7) To ensure environmental sustainability; and 8) To develop a global partnership for development. The implementation timeframe for these goals is from 1990 to 2015. Out of these goals, 4, 5, 6 and 8 are directly related to the performance of the health sector. One of the key observations of the Mid-Term Review Report (MTR) of the NHSP 2001-05 was that “…the role of the NHSP as a strategic framework was widely recognised in 2000, but maybe lacked to prioritise its strategies and to translate these strategies into a (costed) implementation plan with targets or milestones…” (MTR 2004). The lesson learnt from this observation is that it is critical for the NHSP to identify and concentrate on a limited number of national health priority areas, rather than attempt to include “everything that needs to be done” in the strategic plan. Failure or lack of prioritization in the NHSP would not provide for the degree of focus and concentration of efforts and resources required to deal with the critical areas requiring such attention. It is acknowledged that all health care interventions are considered important and will be mentioned in this NHSP and continue to receive the necessary levels of support. However, the new NHSP will focus on the following 10 national health priorities. These priority areas can be grouped in four categories, including: Human Resource Crisis, Public Health Priority Interventions, Clinical Care and Diagnostic Services Priorities and priority support systems without which healthcare services can not be delivered in an efficient and effective manner. These priority areas are as follows: A) Human Resources 1. Human Resource crisis: To train, recruit and retain appropriate and adequate staff at all levels. B. Health Service Delivery Priority Interventions 1. Basic Healthcare Package 2. Public Health Priority Interventions

2.1 Child health and Nutrition: To reduce the mortality rate among children under five. 2.2 Integrated Reproductive

Health: To reduce the Maternal Mortality Ratio (MMR).

2.3 HIV/AIDS, TB and STIs: To halt and begin to reduce the spread of HIV, TB and STIs through effective interventions.

2.4 Malaria: To reduce the incidence and mortality due to malaria. 2.5 Epidemics & Public Health

Surveillance and Control: To improve public health surveillance and control of epidemics.

2.6 Environmental health and food safety:

To promote and implement appropriate interventions aimed at improving hygiene, access to basic sanitation, safe water and safe food.

C Clinical Care and Diagnostic Services Priority Interventions 3.1 Essential Drugs and Medical

Supplies: To ensure availability of essential drugs and medical supplies at all levels.

3.2 Infrastructure and Equipment:

To ensure availability of appropriate infrastructure and equipment at all the levels, including the availability of basic services such as water, electricity and telecommunication at all health facilities.

D) Priority Integrated Support Systems 1 Health Research and

Development

2 Systems Strengthening and Health Sector Governance:

To strengthen existing integrated operational systems, financing mechanisms and governance arrangements for effective policy implementation and delivery of health services.


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3.6 Main Assumptions The main assumptions underpinning the successful implementation of this strategic plan include: • Continued peace and political stability in the country; • Availability of adequate numbers of appropriate, well motivated and committed health

workers; • Macroeconomic stability and sustainable economic growth, leading to increased funding to the

sector, improved per capita income and reduction in poverty levels; • Increased Government prioritization and funding to the health sector; • Increased CPs support to SWAp and other programmes within the health sector; and • Timely and appropriate attention to implementation of all health priority areas.


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4 HUMAN RESOURCE CRISIS 4.1 Situation Analysis Availability of appropriate human resources at all the levels of health care is a critical factor in ensuring the delivery of efficient and effective essential health services to all. Currently, the health sector in Zambia is experiencing a human resource crisis, which is significantly undermining its capacity to provide even the basic health care services to the people. The already inadequate health systems in Zambia have suffered further deteriorations due to high staff attrition rates attributed to the migration of health professions and HIV/AIDS related deaths. Consequently, the BHCP is unevenly and barely provided and trends in vital statistics such as life expectancy, maternal, infant and child mortality point to a rapid deterioration in the nation’s health status. In addition, serious HIV/AIDS related opportunistic infections, such as tuberculosis, are on the rise. The extent of the crisis is such that many Rural Health Centres have no staff or are staffed by untrained personnel and new facilities have been opened without additional staff to run them. Hospital wards are grossly understaffed with dozens of patients attended to by one nurse. Several contributing factors have been associated with this crisis, including: • Poor and un-attractive conditions of service; • Emergence of a competitive local, regional and international market for health staff; • Growing reluctance of qualified medical staff to serve in rural locations; • Increased absence from work and high staff deaths attributable to the HIV/AIDS epidemic; • Increasing demands on health staff due to increases in the numbers of HIV/AIDS patients; • Restrictions on new staff recruitments arising from the HIPC completion conditionalities. Table 9 below presents an analysis of staffing levels against the recently recommended staff establishment. The table also presents an analysis of the existing and recommended staff/population ratios. Table 9: Staffing Levels and Staff/Population Ratios

STAFFING LEVELS STAFF/POPULATION RATIOS

Staff Category Existing

Staff

Recommended Establishment

(2005) Variance Existing

Staff

Existing Staff/ Population

Ratios, 1:

Recommended Staff/Population

Ratios, 1: Doctors 646 2,300 1,654 646 17,589 4,940 Nurses 6,096 16,732 10,636 6,096 1,864 679 Mid Wives 2,273 5,600 3,327 2,273 4,999 2,029 Clinical Officers 1,161 4,000 2,839 1,161 9,787 2,841 Pharmacists 24 42 18 24 473,450 270,543 Pharmacy Tech 84 120 36 84 135,271 94,690 Lab. Scientists 25 50 25 25 454,512 227,256 Lab. Technologists 100 210 110 100 113,628 54,109 Lab. Technician 292 1,300 1,008 292 38,914 8,741 EHO 53 120 67 53 214,393 94,690 EH Technologist 32 220 188 32 355,088 51,649 EH Technicians 718 1,300 582 718 15,826 8,741


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Dental Surgeon 14 33 19 14 811,629 344,327 Dental Technologist 40 300 260 40 284,070 37,876 Dental Therapist 2 300 298 2 5,681,402 37,876 Physiotherapist (Degree level) 0 50 50 0

- 227,256

Physiotherapist (Diploma level) 86 250 164 86 132,126 45,451 Radiologists 3 33 30 3 3,787,601 344,327 Radiographers 139 200 61 139 81,747 56,814 Paramedics 320 6,000 5,680 320 35,509 1,894 Nutritionist 65 200 135 65 174,812 56,814 Support Staff 11,003 10,000 -1,003 11,003 1,033 1,136 Total 23,176 49,360 26,184 23,176 490 230 Source: Ministry of Health HRIS database

Based on the above analysis, the current health sector human resource capacity is estimated at about 50% of the recommended establishment. Figure 1: Ratio of professional staff to population by province

Staff/pop ratio

0 200 400 600 800 1000 1200 1400 1600

LusakaCopperbelt

SouthernCentral

North WesternWesternEastern

LuapulaNorthern

Staff/pop ratio

Source: Ministry of Health HRIS Database The World Health Organization (WHO) has recommended the Staff/Population ratios for Africa, of 1:5,000 and 1:700 for doctors and nurses respectively. Based on Table 7 and Diagram 1, it could be observed that the aggregate Staff/Population ratio for Zambia is three times higher than the recommended WHO staff population ratios for doctors and nurses, which means that the Zambian health staff are significantly overworked. An analysis of provincial data shows significant disparities. Although provinces such as Lusaka might have a doctor population ratio of 1:6,247, remote provinces such as the Northern Province have a ratio of 1:65,763. This illustration demonstrates inequities in the delivery of the BHCP in the country. There are significant imbalances in the distribution of staff across provinces, districts and health facilities.

25


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Factors contributing to mal-distribution of health workers include: • Highly qualified staff feel intellectually and socially isolated in rural communities and hence

reluctant to work in rural areas; • Poor standards of accommodation; • Amenities, such as electricity and phones, that staff have been accustomed to elsewhere, are

absent in rural areas; • Transport to maintain contact with family and colleagues is limited; • Professional support and staff development is lacking in rural areas; • Educational facilities for children are below the standards that they are used to; and • The range of professional skills required may not be matched by prior training. The issues raised above, suggest that any programme to strengthen the staffing levels in remote locations requires a broad based, yet integrated approach. The other challenge facing the health sector is in the area of professional education. Professional and continuing education in Zambia are being challenged from several fronts: Firstly, the rate of producing health workers by training institutions is outpaced by demand for these workers especially with the ever-increasing burden of disease brought about by HIV/AIDS, resurgent epidemics and inadequate funding of training institutions; Secondly, training priorities and curricula for nurses and some undergraduate medical professional courses are not consistent with needs and require updating to ensure their relevance to local conditions and demands; and lastly, in-service training is not properly integrated and coordinated, leading to significant numbers of front line staff spending more time attending in-service programmes than providing the service. Several initiatives have been applied at various levels within the health sector, aimed at addressing the human resource crisis. At national level, the initiatives include the on-going restructuring of the Ministry; exemption of the social sectors from the public sector employment freeze; allocation of K32 Billion to the health sector for recruitment and retention of staff, over and above the normal Personal Emoluments budget and the introduction of a loan scheme for public health workers. At district level, the initiatives include provision of transport, group performance incentive schemes, top-up salaries for staff in remote areas, renovation of houses, electrification using solar in remote areas and many more. These initiatives have been implemented in a few districts such as Katete and Sinazongwe. There are also initiatives implemented through support from Cooperating Partners such as: the Zambia Health Workers’ Retention Scheme, currently being piloted amongst medical doctors in rural areas; the recruitment of nin Clinical Care Specialists for the provincial offices, through the Health Systems Support Project (HSSP); programme specific top-up allowances within various district health management teams; the Luapula province renovation and construction of housing for medical staff; the North Western province Zambia Enrolled Midwifery training that has institutional and scholarship support where students are trained within North Western province and bonded for two years. There is need for the Ministry to accelerate the scaling up of these initiatives based on the lessons learnt. Following Government’s decision to merge MOH Headquarters and CBoH, the main challenge in this area will be to carefully manage the transformation in order to ensure that reasonable levels of staff motivation are maintained and critical staff are retained.


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4.2 Objective To provide a well motivated, committed and skilled professional workforce who will deliver cost effective quality health care services as close to the family as possible. 4.3 Strategies 1. Increase the numbers of trained staff and ensure their equitable distribution, by:

• Increasing training output through expansion of the number of training places available; • Increasing the number of applicants for training by widening participation; • Strengthening and improving coordination of the in-service training system; and • Improving the numbers of skilled health workers in post, through deployment and

retention, based on the principle of equity; 2. Increase productivity and performance of health workers, by:

• Improving the quality and cost-effectiveness of pre and in-service training; • Designing appropriate tailor-made courses suited to the national needs; • Improving performance management capacity; and • Improving occupational health and workplace policies;

3. Ensure effective, ongoing and coordinated approach to human resource planning across the sector, through coordination of human resource planning, based on the available data and development of monitoring and evaluation systems to track progress of implementing the HR plan;

4. Strengthen human resource planning, management and development systems at all levels, through: • Reviewing HR functions in the light of the on-going restructuring and decentralisation; • Development of a capacity development plan for improving strategic and operational planning,

management and HRM/D capacity; • Development and implementation of HR planning, management and development systems at all

levels; and • Improvement of recruitment and equitable deployment procedures for HR and management staff;

5. Recruit all graduating students, retiring critical cadres, attract Zambian health workers in the region, foreign interns, old retired expatriate specialist and twining of local with foreign institutions for exchange of expertise in specialized areas in order to fill the human resource gaps in the health sector;

6. Promote the retention of health workers, through the provision of monetary and non-monetary incentives, such as salary supplementation outside the Government’s PE budget and provision of appropriate accommodation; and

7. Strengthen regulatory role of certification and registration of health professionals in order to effectively monitor and control brain drain.

4.4 Expected Outputs 1. 100 medical doctors annually; 2. 500 nurses produced annually; 3. 250 graduates produced through direct entry midwifery; 4. 3 training institutions renovated annually; 5. 100 Zambian doctors recruited through a retainer package annually; 6. 300 Zambian nurses recruited through a retainer package annually; 7. 100 CO recruited through a retainer package annually;


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8. 400 interns recruited under bilateral agreements; 9. 50 old retired specialists recruited under bilateral agreements; 10. 100 other retired health workers recruited under bilateral agreements; 11. 9 second level hospitals twinned with foreign health institutions; 12. Motivation and retention package for other medical staff implemented by 2010; 13. Human Resource Management Systems re-engineered at all levels; 14. Mandatory rural posting for all graduates implemented by December 2006; and 15. Information on Zambian health workers abroad compiled and published annually. 4.5 Key Indicators 1. % of establishment filled; 2. Staff/Population Ratio; 3. Number of graduates produced (Doctors, Nurses, Mid-wives and other paramedics); 4. Number of staff recruited; and 5. Staff Attrition Ratios.


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5 THE BASIC HEALTHCARE PACKAGE 5.1 Situation Analysis Introduction of a basic package of essential healthcare services is a central principle of the health reforms. The Government is committed to providing basic health care to all Zambians, through the implementation of the Basic Health Care Package (BHCP). The elements of the BHCP are selected on the basis of an epidemiological analysis of those diseases and conditions that cause the highest burden of disease and death. Currently, eleven priority areas for health services have been identified for inclusion into the BHCP: child health; nutrition; environmental health; control and management of communicable diseases, including malaria, tuberculosis, STIs, and HIV/AIDS; mental health; control and management of non-communicable diseases; epidemic and disaster prevention, preparedness and response; school health; and Oral health. These essential healthcare services are offered at five standard types of health facilities: Health Post; Health Centre; and the 1st, 2nd and 3rd Level Referral Hospitals. BHCP packages for the secondary and tertiary levels of the hospitals have already been defined, but not yet finalized. The challenge is that though the BHCP has been defined and implemented at certain levels, little progress has been made in using the packages for actual decision making in the allocation of resources to priority areas. Further, work is needed at the policy and planning level to refine the packages and use them in the manner for which they were intended. 5.2 Objective To provide efficient and cost-effective quality basic health care services for common illnesses as close to the family as possible, through the implementation of a BHCP concept at all levels. 5.3 Strategies 1. Finalize and implement the BHCP at all levels of the health delivery system; 2. Develop the capacity of health providers through pre-service and in-service training of health

workers in essential clinical services in order to provide quality essential clinical care; 3. Develop and distribute standard guidelines, logistics and supplies for implementation and

coordination of essential clinical services; and 4. To strengthen the referral system in order to support the implementation of the BHCP. 5.4 Expected Outputs 1. BHCP finalised, costed and approved for all levels of health care by 2009; 2. Logistics to support the implementation of the BHCP strengthened by 2007; 3. Treatment guidelines for priority diseases developed and implemented by 2008; and 4. Accessibility of the population to appropriate essential clinical care increased. 5.5 Key Indicators 1. Number of health facilities providing care according to BHCP guidelines; 2. Number of pre-service training institutions that have incorporated the BHCP concept in their

curriculum; and 3. Morbidity and mortality rates for the top 10 diseases.


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6 PUBLIC HEALTH PRIORITY INTERVENTIONS 6.1 Child Health 6.1.1 Situation Analysis Zambia has an Under-five Mortality Rate (U-5 MR) of 168 per 1,000 live births, an Infant Mortality Rate (IMR) of 95 and Neo-natal Death Rate (NNDR) of 37 per 1,000 live births (ZDHS 2001-2002). The major causes of child mortality are malaria, respiratory infection, diarrhoea, malnutrition and anemia. HIV/AIDS is increasingly contributing to morbidity and mortality in children. Malnutrition has been on an increase, which is attributed to the worsening poverty levels and increase in food insecurity as well as suboptimal infant and young child feeding practices. According to available statistics, 70% of the population are food insecure, 47% of the children are stunted, 28% are underweight, while 5% are wasted (ZDHS 2001-20). These rates are among the highest in the region. There is also a general critical deficiency of micro-nutrients (iodine, iron and Vitamin A) among both children and expecting mothers. Under the 2001-2005 NHSP, various child health interventions/strategies were implemented. These included promotion and support for nutrition, immunization and management of common childhood illnesses. Immunization coverage in Zambia is higher than in most Sub-Saharan African countries, with coverage rates for measles, DPT3 and polio in the range of 80-85% and BCG at above 90% of the eligible populations. Full immunization coverage in 2004 stood at 80% (Health Statistical Bulletin 2004). Although child mortality rates were decreasing from 1955 to 1980, a progressive increase was noted between 1980 and 1999. However, there is an indication of a slight decrease between 1996 and 2002. During the period from 1992 to 2002, the U-5 MR declined by 12%, from 191 per 1,000 live births to 168, while IMR declined by 11% from 107 per 1,000 live births to 95 (ZDHS 2001/2). Despite these decreases, the current child mortality rates, are still unacceptably high. In this respect, Zambia is committed to reducing child mortality by two thirds (to 63/1000 live births) in 2015, from the 1990 figures as per the MDGs. Even though improvements have been noted in child health the constraints in achieving high impact include the inadequate coverage of effective child health interventions and the poor quality of services provided. The major reasons for this include the critical shortage of skilled staff, weak infrastructure and inadequate funding for child health interventions. It is envisaged that during the life of this strategic plan, child health will be a key agenda item both globally and nationally. The challenge for the health sector is to accelerate implementation of effective child survival interventions in the country, targeting areas of most need. Programs and strategies for child health need to be significantly scaled-up, including, immunization, management of childhood infections, management of the new born, nutrition promotion and strengthening of school health programmes. 6.1.2 Objective To reduce Under-5 MR by 20%, from the current level of 168 per 1,000 live births to 134 by 2010.


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6.1.3 Strategies 1. Scale up and strengthen community and facility based Integrated Management of Child

Illnesses (IMCI) strategy in all districts; 2. Improve care for severely sick children at all district hospitals; 3. Strengthen the Expanded Programme for Immunisation (EPI) in all districts; 4. Strengthen the care of new born babies in communities and all health facilities; 5. Promote and strengthen the involvement of the private sector in child survival programs; 6. Strengthen mechanisms for regulation and coordination of nutrition; 7. Promote appropriate diets and lifestyles, including appropriate exclusive breast feeding,

dietary diversification, supplementation and expansion of micro-nutrient fortification of major food commodities; and

8. Facilitate the strengthening and expansion of the school health program in the country. 6.1.4 Expected Outputs 1. At least 3 district staff trained as trainers in IMCI for all district during the first three years of

the planning period; 2. 80% of health centre staff trained in Integrated Management of Childhood Illness (IMCI) case

management; 3. At least 3 Provincial health staff trained in planning and implementation of C-IMCI; 4. 80% of health centers managing children according to IMCI guidelines; 5. 80% of district hospitals able to provide appropriate Emergency, Triage and Treatment of sick

children; 6. 80% of districts promoting at least six priority practices in community IMCI; 7. Full immunisation coverage of at least 80% in all districts; and 8. 50% of health workers in Maternal and Child Health units at all levels trained in Essential

Newborn care. 6.1.5 Key Indicators 1. Under-5 Mortality Rate; 2. Infant Mortality Rate; 3. Neo-natal Mortality Rate; 4. % of children less than six months who are on exclusive breast feeding; 5. % of children aged 6-59 months receiving vitamin A supplementation 6. % of children aged 12 months who are fully immunized; 7. Proportion of IMCI trained health centre staff; 8. Cases of malaria, pneumonia and diarrhoea presented to health facilities; and 9. Proportion of Maternal and Child health workers trained in Essential newborn care. 6.2 Integrated Reproductive Health 6.2.1 Situation Analysis Zambia has one of the highest Maternal Mortality Ratios (MMR) in the world and safe motherhood is far from being assured. The MDG for Zambia is to reduce Maternal Mortality Ratio (MMR) by three quarters, i.e. to 162 deaths per 100,000 live births by 2015. However, the country is unlikely to achieve this goal in the remaining 10 years.


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Despite high antenatal attendance, currently estimated at 80% for urban and 68% for rural areas, MMR has increased from 649 per 100,000 live births in 1996 to 729 in 2002 (ZDHS-2001/02). It is estimated that approximately 50% of maternal mortality is directly attributed to postpartum hemorrhage, sepsis, obstructed labour, post-abortion complications and eclampsia. Indirect causes of maternal mortality include malaria, anemia and HIV/AIDS related conditions. Other contributing factors include delays in accessing healthcare at community and health center levels. Although 90% of all pregnant women receive some kind of antenatal care, only 43% deliver in health facilities. The Total Fertility Rate (TFR) has been decreasing slowly but still remains high. Access to family planning services is a key determinant for TFR. In this respect, the use of modern contraceptives accessed through the public health sector increased from 56% in 1992 to 61% in 2001/02 (ZDHS 2001-02). The level of awareness of ART has improved, with about 500 women receiving counseling each month countrywide. Several interventions were implemented in this area including, the strengthening of reproductive health services through stronger referral systems, purchase of 86 ambulances for distribution to all the districts, integration of PMTCT in Reproductive Health, improvements in adolescent health, promotion of positive male involvement, improved co-ordination and collaboration between actors, and procurement of equipment and drug supplies for essential obstetric care in all the 72 districts. The Post Abortion Task Force was formed in 2000, whose main role is to integrate management of abortions with prevention infection techniques and family planning counseling and provision. Further, within the framework of the RH sub-committee and other smaller sub-committees, such as safe motherhood and standardisation, effective partnerships were established among CBoH, UN agencies, CPs and NGOs. All these efforts contributed to the increase in the number of supervised deliveries from 44% in 2001 to 55% in 2003 (these figures include deliveries supervised by TBAs). The national antenatal coverage also increased from 86% in 2001 to 95% in 2003, though the quality of antenatal services still remained below expected standards. The main constraints affecting IRH include: the slow pace in developing policies, which limits implementation of some interventions; shortage of appropriate personnel; poor transport and communication facilities; social-cultural factors, such as the belief that seeking care early in labour is a sign of weakness; delays in reaching facilities due to long distances; inadequate infrastructure such as space, lighting, lack of privacy in some facilities; and inadequacy of drugs and other essential equipment. These factors contribute to delays in providing care at the facilities and consequently contribute to problems of unsupervised deliveries. The challenge for the Ministry is to scale up the delivery of services and the demand for key services among the population within the limited resources that are currently available. There is an acute shortages of human resources and transport at both primary and referral levels, which adversely affects emergency obstetrics. Efforts are needed to change health seeking behaviour, including socio-cultural factors which lead to delays in seeking health care. The quality of services also needs to improve: constant delays in the provision of care leads to low use of health facilities and results in an increase of unsupervised deliveries and in poor quality of ANC. 6.2.2 Objective To increase access to integrated reproductive health and family planning services that reduce the Maternal Mortality Ratio (MMR) by one quarter, from 729 per 100,000 live births to 547 by 2010.


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6.2.3 Strategies 1. Strengthen the quality and expand coverage of essential obstetrics, including ANC, delivery

and post-natal services; 2. Provision of emergency obstetric care as per national guidelines for different levels of care; 3. Strengthen family planning and contraceptive choice programmes, with a special focus on

rural districts; 4. Accelerate midwifery training, ensure equitable distribution and retention of midwives; 5. Promote continuum of care from traditional birth attendants to referral centres through

provision of appropriate training, tools, logistical support and incentives; and 6. Strengthen programmes for health education, screening, treatment and care of cervical, breast

and prostate cancers. 6.2.4 Expected Outputs 1. Focused - ANC increased from 70% to 80%; 2. Increase in facility deliveries from 30% to 50% for rural and from 70% to 80% for urban

areas; 3. Increase in the number of mid-wives at health centres from the existing 2,273 to 2,700 by

2010; 4. Modern contraceptive prevalence rate increased from 23% to 35%; and 5. 20% of the women of reproductive age screened at least once for cervical cancer (PAP smear).

6.2.5 Key Indicators 1. ANC Coverage; 2. Antenatal visits per client; 3. Births assisted by skilled health personnel; 4. Maternal Case Fatality Rate; 5. Caesarian Section Rate; 6. Contraception Prevalence Rate; 7. Maternal Mortality Ratio; 8. Proportion of Teenage Pregnancies; and 9. Proportion of health centres providing screening services for cervical cancer. 6.3 HIV/AIDS & STIs 6.3.1 Situation Analysis HIV prevalence in the general population is high, with 16% of the population aged 15-49 years being HIV positive (ZDHS, 2001-2002). Prevalence rates are higher in urban than rural populations, estimated at 23% and 11% respectively. Prevalence rates also vary among geographical areas, the highest at 22% was Lusaka and the lowest at 8% was the Northern Province. Women were more vulnerable than men, with prevalence rates of 18% and 13% respectively, which calls for gender sensitive interventions. About 8% of boys and 17% of girls aged 15-24 are living with HIV and approximately 39.5% of babies born to HIV positive mothers are infected with the virus. Over 10% of the reported outpatient attendance to clinics is due to STIs (CBoH Syndromic Guidelines). The 2001-2002 ZDHS shows that 7 % of women and 8% of men in the 15-49 age group have Syphilis.


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During the duration of the NHSP 2001-05, the Government took major steps towards the strengthening of the policy framework for fighting the HIV/AIDS epidemic. This included the following: all government line ministries, including the Ministry of Health, developed action plans on the implementation of HIV/AIDS at the work place; in 2002, a National Action Plan for the implementation of AIDS-related activities was adopted; the HIV/AIDS Policy was finalised and adopted by Cabinet; and in 2003, the National HIV/AIDS and Infection Prevention Committee was established by CBOH. Generally, the awareness and mitigation of HIV/AIDS at work places has improved and the fight against the evils of stigma and discrimination at work places has been intensified. Within the National HIV/AIDS, TB and STI Policy and Strategic Framework, the health sector has been implementing several interventions. The Counseling Testing and Care (CTC) programme was strengthened and expanded to 420 centres country-wide. Similarly, the Prevention of Mother to Child Transmission (PMTCT) programme was strengthened and expanded to 220 centres. CTC is the entry point for PMTCT. In 2004, over 80, 000 women were tested at these centres and 95% of those who tested HIV positive were put on Nevirapine. According to the available statistics, in 2004, at least 12% of the expected number of pregnant women in the country were tested for HIV through the PMTCT programme. HIV prevalence at PMTCT sites is estimated at 23%, which is higher than the 19% prevalence recorded at sentinel surveillance sites. Anti-Retroviral Therapy (ART) activities were also scaled up. In this respect, a total of 700 medical personnel were trained in the administration of ART and management of opportunistic infections. The number of centres providing ART increased from 2 in 2003 to 84 in 2005. As a result of all these efforts, the level of ART awareness improved significantly leading to an increase in the number of eligible patients accessing ART from 4,000 patients in 2003 to about 32,144 by August 2005. The national target has been to have 100,000 eligible HIV patients on ART by end of 2005 (50% of each year’s demand). Home Based Care (HBC) activities were scaled up to all 72 districts and a total of 305 trainers were trained to establish and strengthen palliative care in the communities. The HBC program has been primarily implemented through NGOs and Faith Based Organisations mainly along the line of rail. There is therefore a need for the District Health Management Teams to own and coordinate the delivery of this programme by these organisations. In the area of STIs, 3, 600 health workers were trained in Syndromic Management. Youth Friendly Health Services were established in 50 districts and require expansion to cover all the health centres. STI treatment protocols and guidelines were revised and are being used as reference materials by health facilities. HIV/AIDS will continue to present significant challenges to the health sector. Currently, multi-sectoral coordination at provincial and district levels is still limited, and there is lack of capacity to scale up programmes using best practices. Shortages of HIV test kits and specialized testing equipment still exist. Although VCT services have expanded, in most districts, especially those in remote areas, only a few health facilities offer these services. There is also need to further strengthen blood safety through rationalisation of blood banks involved in collecting and screening of blood. Even though substantial funds were received from the Global Fund (GF) and the President’s Emergency Plan for AIDS Relief (PEPFAR), the need to mainstream these activities into national and district level action plans remains a major challenge.


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6.3.2 Objective To halt and begin to reduce the spread of HIV/AIDS and STIs by increasing access to quality HIV/AIDS and STI interventions. 6.3.3 Strategies Within the National HIV/AIDS, TB and STIs Policy and Strategic Framework, the following strategies will be implemented: 1. Scale-up prevention activities through increased promotion and support to ABC programmes

and culturally sensitive IEC; 2. Increase access to HIV counseling and testing, in health facilities and at community level; 3. Strengthen PMTCT activities through integration with Reproductive and Child Health and

routine HIV testing in antenatal clinics; 4. Develop and implement HIV/AIDS work place policies at the provincial and district levels; 5. Expand access to ART for eligible adults and children; 6. Strengthen and scale up HBC activities; 7. Expand access to STI interventions; 8. Further strengthen the national blood transfusion services so as to ensure equitable and

affordable access to adequate safe blood and blood products; and 9. Facilitate the strengthening of the multi-sectoral response to HIV/AIDS; 6.3.4 Expected Outputs 1. Number of CTC centres in health facilities and at community level increased from 420 to 840

by 2010; 2. Increased number of Health Centre catchment areas with a functional HBC program from

current 300 to 750 by 2010; 3. HIV/AIDS at work place programmes implemented in all districts; 4. Increased number of AIDS patients on ART from current 40,000 to 210,000 by 2010; 5. Increased % of the adult population using VCT from current 13% (cumulative) to 30% by

2010; 6. Increased the number of AIDS patients treated for OIs from 50% of AIDS patients to 80%; 7. The number of HIV positive pregnant mothers accessible to PMTCT increased from current

22500 HIV pregnancies (25%) to 61600 (70%); 8. Increased number of AIDS patients accessible to HBC from current 57,000 to 200,000 by

2010; 9. Increase the coverage of STI treatment from current 50% to 80% by 2010 (prevelance = 8% of

adult pop); and 10. Increase the number of blood units collected from 63,000 per year to 80,000 units, and ensure

that all units of blood are adequately screened for HIV in accordance with national and WHO guidelines and standards.

6.3.5 Key Indicators 1. HIV and STIs incidence and prevalence rates by age, sex and geographical area; 2. Number of people counseled, tested and received results; 3. Number of CTC centres;


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4. % of pregnant women testing positive for HIV; 5. % of babies testing positive for HIV at 18 months; 6. Number of centres with HIV/AIDS at work place programmes at provincial and district levels; 7. Number of people on ART treatment, by geographical area, facility, sex and age; 8. Number of chronically ill patients registered with HBC programmes 9. % of blood collected that has been screened in accordance with WHO guidelines. 6.4 Tuberculosis (TB) 6.4.1 Situation Analysis TB is one of the major non-pneumonia respiratory infections in Zambia. Since 1985, the TB notification rate has increased from 105 per 100,000 population to 545 in 2002. The increase was largely associated with the HIV/AIDS epidemic. It is currently estimated that 70% of patients with TB are HIV positive. The peak age group for TB is 20-35 years and the annual risk of infection in Zambia is estimated to be around 2.5%. The target for the national cure rate and treatment success rate is 85% by end of 2005. Even though these targets have not yet been reached, significant progress is being made in the fight against TB. In the recent years, cure rates have improved from 58% in 2001 to 64% in 2002 and 73% in 2003. Similarly, the treatment success rate improved from 77% in 2002 to 79% in 2003. These improvements were largely attributed to the successful implementation of a number of interventions, including: the expansion of the Directly Observed Treatment Scheme (DOTS) to all districts; improved drug compliance; improved supply of TB drugs; cascade training of provincial and district staff in laboratory diagnosis and TB management; renovation of the Chest Diseases Laboratory (TB Reference Laboratory) in Lusaka; procurement of adequate microscopes; procurement of transport (vehicles, motor bikes, water motor boat engines and bicycles) for TB activities at all levels; and increased community involvement. The main constraints faced in implementing TB control & treatment programs include: the lean managerial structure at central level and lack of clear reporting structures at lower levels; inadequate diagnostic centers at district level; poor quality of diagnosis; inadequate laboratory supplies and equipment; shortage of appropriate laboratory personnel at district level; inadequate supervision of TB activities at district level; inadequate of TB integration with other interrelated diseases; lack of coordination between the public and private sectors; and high poverty levels leading to poor nutritional status among TB patients and consequently poor treatment compliance. The challenge for MOH is to develop strategies that would effectively deal with these constraints and provide for improved services throughout the country. 6.4.2 Objective To halt and begin to reduce the spread of TB through effective interventions. 6.4.3 Strategies 1. Review the organisation and management structures and relationships to ensure effective

coordination of the TB programme, through the on-going sector-wide restructuring; 2. Support and strengthen health systems for TB control at all levels; 3. Expand and strengthen the TB DOTS/DOTS plus programmes in all districts;


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4. Scale-up and strengthen diagnostic centres in all districts; 5. Introduce and strengthen TB/HIV collaborative activities in all districts; 6. Develop and implement a BCC strategy for TB and TB/HIV activities; 7. Improve the nutritional and social economic status of TB patients and caregivers; 8. Scale up public/private partnerships in TB/HIV programmes; 9. Increase advocacy, awareness, prevention and management of TB; and 10. Develop an operational research agenda to ensure continuous quality for the TB control

programme. 6.4.4 Expected Outputs 1. TB Central Unit staff increased from 2 to 5, and a position for one TB Officer included in the

establishments at provincial and district levels by 2008 for improved support to all levels; 2. Regular support and supervision provided at all levels by 2008. 3. 100% of population covered by DOTS activities by 2008; 4. Smear microscopy centers providing quality assured TB diagnostic services established in all

72 districts by 2008 5. Quality DOTS and TB/HIV collaborative activities implemented by the private

sector/communities at least in 3 high burden provinces by 2010; 6. BCC strategy for TB/HIV implemented in all districts by 2008; 7. All eligible TB patients to have access to nutrition supplementation by 2010; 8. All treatment supporters to have access to Income Generating Activities (IGAs) by 2010; and 9. 50% of the districts to include a plan for operational research in their work plans by 2010. 10. IEC materials for increased TB awareness levels produced 6.4.5 Key Indicators 1. TB Case detection rate (Number of patients tested for TB); 2. TB prevalence rates; 3. TB Cure rates; 4. % population covered by DOTS; 5. % of TB patients tested for HIV; 6. % of HIV patients screened for TB; 7. Number and % of private clinics receiving free TB drugs from the public sector; 8. % of eligible TB/HIV patients accessing ARVs; 9. % of staff in the private sector trained in TB/HIV, TB/DOTS; 10. % of eligible patients who access food supplements; 11. % of eligible patients and care givers who have access to IGAs; 12. % of districts including operational research in their plans; and 13. Number of regular support and supervisory visits conducted. 6.5 Malaria 6.5.1 Situation Analysis Malaria is a major public health problem in Zambia. It is the leading cause of morbidity and mortality, accounting for 45% of all hospitalizations and outpatient attendances and 50% of cases among children under-five years of age (HMIS 2004).


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The National Malaria Control Centre (NMCC) estimates that malaria is responsible for nearly 4.3 million clinical cases and over 50,000 deaths per year, including up to 20% of maternal mortality. The National Health Strategic Plan of 2001-2005 set the target to reduce malaria incidence rate to 300 per 1,000 population by the year 2005. However, this target is yet to be achieved, as malaria incidence in 2004 was 383 per 1,000 population. Over the past three decades, malaria incidence rates in Zambia tripled, from 121 per 1,000 population in 1976 to 383 in 2004. Statistics also indicate that over the past three years, the national malaria incidence rate has been fluctuating, increasing from 388 in 2002 to 425 in 2003 and then dropping to 383 in 2004. In 2004, the malaria case fatality rate (in hospitals only) remained high at 43 per 1,000 admissions for children under the age of five years, 65 for the over five and 33 as overall for all age groups. Factors which have contributed to this increase in malaria incidences include the spread of drug resistance, reduced vector control efforts, and decreased access to health care, HIV and high poverty levels. Within the framework of the Roll Back Malaria (RBM) initiative, the Ministry of Health has been implementing a number of malaria control interventions through the National Malaria Control Centre. Over the past five years, Zambia has made significant efforts towards the development of an appropriate policy framework and infrastructure capacity required to accelerate malaria control. The major achievements include: change in the malaria treatment policy to Artemisinin combination therapy (ACT) as the standard for care countrywide to address the emergence of chloroquine-resistant strains; decentralized programming leading to capacity development at district level; introduction of Intermittent Presumptive Treatment (IPT) for pregnant women; in-door residual spraying (IRS) in 8 selected districts; improvements in methods of diagnosis for malaria; promotion of the use of Insecticide Treated Nets (ITN); staff training; improvements in data and information capturing and management; strengthened public/private partnerships in malaria control; and increased resource mobilisation efforts. The Global Fund against HIV/AIDS, TB and Malaria has awarded Zambia a total of US$ 82.77 million over a period of 5 years under 1st and 4th Rounds. The country has already made significant achievements in the process of developing the necessary policy framework and in enhancing the technical, administrative and financial capacities for scaling up the fight against malaria. A five year strategic plan aimed at rapidly scaling up the malaria control interventions has already been developed and several key strategies have since been ratified by the Roll Back Malaria (RBM) partners and the Government. Significant financial resources have also been committed to the fight against malaria. Major challenges for the next six years would include: the need to continue sourcing adequate resources for scaling up to meet the demand for ITNs; inability by most poor people in rural areas to purchase ITNs; the need to scale up the in-door residual spraying programme to from the 8 selected pilot districts to all IRS eligible districts; need to strengthen partnerships with the NGOs involved in malaria prevention and control; staff retention and training staff; shortage of personnel at most health centres; and need to provide adequate and appropriate diagnostic equipment for detection of malaria. 6.5.2 Objective To halt and reduce the incidence of malaria by 75% and mortality due to malaria in children under five by 20%.


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6.5.3 Strategies Within the framework of the National Malaria Programme, the following will be the main strategies during the duration of this plan: 1. Rapid scale up of malaria prevention, through integrated vector management interventions,

including the access and usage of ITNs and In-door Residual Spraying (IRS); 2. Scale up prevention of malaria during pregnancy, through increased access to IPT, ITN and

anemia reduction by expectant mothers; 3. Improve laboratory diagnosis for malaria, by progressively extending the use of microscopy

method of diagnosis to all health facilities, while in the interim Rapid Diagnostic Test Kits (RDTs) are used;

4. Ensure prompt and effective malaria case management by scale up the use of ACT (Coartem) as the treatment of choice by extending its use to the private sector and community health workers, strengthen the malaria component of c-IMCI and strengthening referral systems;

5. Strengthen national, provincial and district health systems’ capacity to effectively and efficiently plan, implement and manage malaria control efforts;

6. Develop an efficient and effective system for procurement and supplies management of malaria specific commodities;

7. Strengthen and expand strategic private/public, multi-sectoral and community partnerships for delivery of high impact malaria prevention and control efforts at all levels of the health system;

8. Develop and implement an effective information, education and communication system in order to impart knowledge and skills to families and communities for effective prevention and control of malaria;

9. Strengthen technical and administrative systems including M&E, financial management and operations research for efficient use of available resources; and

10. Ensure sustainable financing of the malaria programme. 6.5.4 Expected Outputs 1. At least 80% of people in eligible ITN areas of every district sleep under ITNs by December

2008; 2. At least 85% of people in eligible IRS areas of every district (15 out of 72 districts) sleep in

sprayed structures by December 2008; 3. At least 80% of women have access to a full-three course of IPT and an ITN to reduce the

burden of malaria in pregnant women by December 2008; 4. At least 80% of pregnant women have access to iron supplement (anemia reduction) by December

2008 5. At least 80% of suspected malaria patients are correctly diagnosed annually by December

2008; 6. At least 80% of malaria patients in all districts receive prompt and effective treatment

according to the current drug policy, within 24 hours of onset of malaria symptoms, by December 2008;

7. Joint planning and implementation mechanisms between all partners developed by 2010; 8. Malaria data management harmonized by all partners by 2010; and 9. Malaria reporting and feedback improved in at least 90% of health facilities by 2010.


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6.5.5 Key Indicators 1. Malaria incidence rate; 2. Malaria case fatality rate; 3. Number of new ITNs distributed to households; 4. Number of ITNs retreated; 5. Number of ITNs replaced; 6. Number of households sprayed following the appropriate standards and guidelines; 7. Number of functional FANC points; 8. % of pregnant women receiving all doses of IPT in antenatal clinic per pregnancy; 9. % of health facilities using microscopes for malaria testing; 10. Number of health facilities providing ACT according to the Malaria Treatment Policy; 11. % of the private partners participating in joint planning and implementation; and 12. % health facilities correctly reporting and obtaining feedback on malaria. 6.6 Epidemics Control & Public Health Surveillance 6.6.1 Situation Analysis Zambia has for many decades been prone to outbreaks of epidemics including cholera, measles and polio, leading to significant public health concerns. In order to improve the detection and management of epidemics, in 2000, the country adopted the Integrated Disease Surveillance and Response Strategy (IDSR). This strategy aims at improving capacity at district levels to detect and respond to disease/condition outbreaks, in order to reduce levels of morbidity and mortality. Through the use of a selected set of IDSR indicators (e.g. the proportion of epidemics reported within 48 hours), the health system seems to be steadily improving its capacity to detect and manage outbreaks of epidemics including: timely reporting of summary data, reporting of priority diseases using case based information, notification of suspected outbreaks of epidemic prone diseases, routine analysis of data, investigation of outbreaks reported through case based data, presence of functional laboratory network, appropriate response to confirmed cases of epidemic diseases, and quality of case management. Main achievements in IDSR implementation during the first two and half years include adaptation and adoption of the WHO generic IDSR technical guidelines; adaptation and adoption of the WHO IDSR training modules, a set of user-friendly modules for training health workers at district and health centre levels in surveillance; participatory approach, with involvement of selected health care workers at all levels of the health system and training experts from health training institutions; development of a three-year strategic training plan; adoption of “Cascade type” training for health personnel, in IDSR; and incorporation of staff from medical laboratories into the surveillance teams at the central, provincial and district levels. There has been continuous acceleration in active polio surveillance activities and in maintaining certification level surveillance through heightened active surveillance at the district level. With the successful completion of the national measles immunisation campaign for children aged 6 months to 15 years (95% verified coverage) in June 2003, case-based surveillance for measles was started to monitor the impact of the campaign. This was preceded by measles targeted surveillance training across the country.


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The quality of AFP surveillance showed improvement between 2000 and 2003. This has been in both Non-AFP case detection rate and stool adequacy. As at July 2002, the annualised Non-polio AFP rate for Zambia stood at 2.6/100,000 population aged 15 years and below.(Vaccine Preventable Diseases Bulletin, 2002).The target is = >1/100,000 population below 15 years. In the control of epidemic prone diseases, surveillance activities also seem to have improved during the last two years. Cholera cases, however, continue to occur sporadically in the northern part of the country where the abundant existence of water bodies makes it difficult to implement hygiene and sanitation interventions. The cases however, are often quickly detected, confirmed by the laboratory, and appropriate responses commenced by the affected District Health Management Team. What is still of concern is the high case fatality rate (CFR) of around 4.0% observed in these outbreaks. During the past 3 years the timeliness of reporting on notifiable priority diseases has improved from 60-65% to 85% and above. Completeness of reporting has followed a similar trend.

The major constraint in scaling up the IDSR strategy has been financial resources to support the training of health workers in the integrated disease surveillance concept and practice. The challenge for the Ministry is to source adequate funding to scale up IDSR in all the districts. 6.6.2 Objective To significantly improve public health surveillance and control of epidemics, so as to reduce morbidity and mortality associated with epidemics. 6.6.3 Strategies 1. Strengthen the country’s capacity to conduct effective surveillance for both communicable and

non-communicable diseases; 2. Strengthen laboratory capacity and involvement in confirming pathogens and monitoring of

drug sensitivity; and 3. Review HMIS in the context of IDSR to include integrated data collection, and strengthen its

capacity to monitor the burden of NCDs. 6.6.4 Expected Outputs 1. Formal surveillance structures established at all levels by 2007; 2. Staff trained and oriented to public surveillance starting from 2006; 3. All laboratories equipped with basic equipment to support public surveillance by 2007; and 4. Review and strengthening of HMIS in the context of surveillance completed by 2008. 6.6.5 Key Indicators 1. Number of staff trained in public health surveillance; and 2. % of designated surveillance laboratories with basic equipment for supporting public health

surveillance activities.


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6.7 Environmental Health and Food Safety 6.7.1 Situation Analysis Poor environmental sanitation is a major source of public health problems and epidemics in Zambia. Currently, over 80% of the health conditions presented at health institutions in Zambia are diseases related to poor environmental sanitation i.e. water and food borne diseases such as cholera, dysentery and typhoid, with significant adverse impact on the poor. The aim of environmental health services in Zambia is to attain universal access to safe, wholesome, adequate water supply, acceptable sanitation and safe food as close to the family as possible. In Zambia, over the past 20 years, access to safe drinking water among the population has improvement. In 1985, safe drinking water was only available to 40% of the population, the figure increased to 48% in 1992 and to 51% in 2002. On the other hand, access to adequate sanitation has declined from 23% of the population in 1985, to 17% in 1990 and 15% in 2000 (ZHDS 2001-02). During the period from 2000 to 2004, significant work was done in the area of environmental health and food safety. A National Environmental Health Policy was formulated. The Food and Drugs Regulations (2001) were reviewed and updated, to take into account the changed market place in a liberalised economy, particularly in the area of food safety. Advocacy for introduction of a local BSc degree course at the University of Zambia was successfully concluded. Many Environmental Health Officers were taken up into managerial positions in District Health Management Teams (DHMTs). The Participatory Hygiene and Sanitation Transformation (PHAST) training materials for urban and rural settings were developed. A total of 22 out of the 72 districts were trained in PHAST, a community-based methodology aimed at scaling up hygiene and sanitation programmes where they are most needed, and ensuring sustainability. CBoH developed a health care waste management plan, and three pilot sites in Livingstone, Ndola and Lusaka embarked on a solid waste management project. A manual on food safety to help in the enforcement of the law on fortification of sugar with Vit A and salt with iodine was developed and put in use. Environmental health and food safety is a multi-sectoral problem, involving the Ministry of Health, Ministry of Energy and Water Development, and Ministry of Local Government and Housing. In order for the country to achieve the desired goals in this area, multi-sectoral collaboration will be of critical importance. In this respect, CBoH provided technical and financial support to two local authorities, Ndola and Livingstone city councils, to carry out key environmental health programmes. These included a focus on promotion of the Hazard Analysis Critical Point (HACCP) tool for food inspection. This is another intervention, which requires quick scaling out in order to have impact. Even though significant work was done, the measures still fall short in addressing some of the problems related to environmental health at the operational levels. The main constraints hampering progress in environmental health work seems to be the need to have the discipline mainstreamed into the Ministry of Health planning and operational structures, shortage of personnel with expertise in public health law enforcement, and lack of appropriate equipment for use in food inspection.


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Main challenge for environmental health include the need to review some of the provisions of the Public Health Act to meet the present day emerging issues, to strengthen multi-sectoral approach to environmental health, need for MOH to scale up and strengthen PHAST in all the districts, and scale out the pilot projects on solid waste management from 2 to all the big towns and cities in Zambia. 6.7.2 Objective To promote and improve hygiene and universal access to safe and adequate water, food safety and acceptable sanitation, with the aim of reducing the incidence of water and food borne diseases. 6.7.3 Strategies Within the context of a multi-sectoral approach, the following strategies will be implemented: 1. Strengthen capacity in enforcement of environment health policies and legislation; 2. Promote the establishment of new and strengthening of existing Water, Sanitation and Hygiene

Education (WASHE) Committees at national, provincial, district and sub-district levels; 3. Promote the provision of appropriate and suitable water and sanitation facilities in peri-urban

and rural areas; 4. Strengthen national health care waste management at all levels of care; 5. Introduce and institutionalise Food Safety Protocols of Hazard Analysis and Critical Control

Point System (HACCP); 6. Strengthen training and capacity building in environmental health; and 7. Strengthen coordination and management of environmental health at all levels of care. 6.7.4 Expected Outputs 1. Public Health Act and the Food and Drugs Act reviewed and amended by 2007; 2. National Environmental Health Policy developed by 2007; 3. WASHE Committees established and functional in all priority areas identified to be highly

prone to incidences of environmental related diseases by 2010; 4. At least 50 environmental health specialists with Bsc. Degrees produced every year by the

University of Zambia starting from 2008; 5. One hundred environmental health personnel trained in public health prosecution at the

National Institute of Public Administration (NIPA) by 2010; 6. HCWM system strengthened in all health facilities in Zambia by end 2008; 7. HACCP system introduced by 2008; 8. Waste disposal facilities for all hospital in the country assured by 2007; 9. PHAST activities implemented at district level; and 10. Health services at all ports improved in Zambia. 6.7.5 Key Indicators 1. % of districts with functional WASHE Committees; 2. % of communities accessing safe drinking water within 500 metres; 3. % of public water supplies within residual chlorine levels ( >0.2mg/litre); 4. % of water sources sampled complying with WHO Safe Drinking Water Guidelines and

Regulations;


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5. % of communities with adequate and suitable sanitation facilities; 6. Number of environmental health graduates recruited into the system; 7. % of General dealer premises complying with Public Health Statutory Notices; 8. % of food establishments complying with Public Health Standards; and 9. % of health care facilities at district level with functional incinerators. 6.8 Other Public Health Interventions 6.8.1 Objective To significantly strengthen the delivery of other relevant interventions in communicable and non-communicable diseases. 6.8.2 Nutrition Adequate nutrition is essential to the achievement of the following six MDGs: Eradicating hunger and poverty; achieving universal primary education; promoting gender equality; reducing child mortality; improving maternal health and helping to combat HIV/AIDS. Nutrition and health are interrelated. High prevalence of malnutrition is attributed to morbidity and mortality. Malnutrition, long recognized as a serious public health problem in Zambia has now worsened. Latest figures on Protein Energy Malnutrition (PEM) indicate that 47% of Zambian children are stunted, 28% are underweight while 5% are wasted. (ZDHS 2001/2). These rates are among the highest in the sub-region. In the case of breastfeeding, only 40% of infants under 6 months were exclusively breastfed and the median duration of exclusive breastfeeding was found to be 2 months (ZDHS 2001/2). Feeding is very critical in infants and young children. According to the LCMS, 2002/3 findings, growth for children aged 4 to 36 months was found to be faltering reaching the peak between 12 to 24 months. This is an indication of poor weaning and feeding practices, and the need for maternal education and behavioural change communication. The high prevalence of HIV/AIDS in Zambia has had negative influence on breast-feeding. Like other countries, exclusive breastfeeding until six months of age has become less of an automatic choice. It is possible that an infected woman can pass the AIDS virus to her child in pregnancy, labour, delivery and during breast feeding. There is need for reducing the risk of HIV transmission to infants while minimising the risk of other causes of morbidity or mortality. This is being done through appropriate infant and young child feeding practices. In relation to HIV/AIDS there has been improved access to ARVs and palliative care. However the nutrition care and support of people living with HIV/AIDS requires strengthening. Micronutrient deficiencies continue to be of public health concern. Vitamin A deficiency continues to be a public health problem, resulting in lowered immunity and increased morbidity and mortality. A survey to determine vitamin A deficiency (VAD) using serum retinol concentrations were carried out in children 6 – 59 months in 2003. Results indicated that 5.0 % had severe VAD, 49.1 % had moderate VAD, while 45.9 % had normal VAD. Though a significant improvement from the 1997 survey, both levels still indicate a severe health problem. The 1998 national baseline study showed that Iron deficiency anaemia was found in 50 % of women attending ante-natal clinics and 15% of children under the age of 15 years. The same report indicated that 65% of the children, 39% of the women and 23% men were anaemic.


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The recent study done by the National Food and Nutrition Commission in 2003 to determine the prevalence of anaemia in children aged 6- 59 months indicated that 52.9 % of the children were found to be anaemic. Progress has been made in the distribution of Vitamin A capsules and de-worming during the bi-annual Child Health Week and the routine distribution at health facilities. One critical aspect that needs to be looked at is the dietetic management of inpatients and referrals for non-communicable diseases. Emphasis has been made on the public health interventions but a strategic approach of improving dietetic care in hospitals will be major area of focus for improvement. Focus on adolescent and maternal nutrition has been very weak in most health programmes and yet it plays a very cardinal role in the life cycle. Poor nutrition in women contributes significantly to the growing rate of maternal deaths and is directly related to faltering nutritional status and growth retardation in children. Unfortunately, there is limited data on maternal and adolescent nutrition in Zambia. Zambia has had its share of short and long-term emergency episodes ranging from disease outbreaks to unfavorable weather conditions. This has continued to exacerbate malnutrition in the country. Food Aid has played a major role as a direct nutrition resource for nutrition improvement for the vulnerable population. However, not much has been done to ensure appropriate quality and quantity in terms of rations reaching the intended beneficiaries at the appropriate time. The absence of planning and implementation guidelines for each programme and the inadequate staffing and capacity at national and provincial level to provide support to districts has contributed to poor implementation of nutrition programmes. 6.8.2.1 Strategies 1. Strengthen National Food & Nutrition Commission for optimal coordination of nutrition

programs of all sectors; 2. Strengthen the nutrition service delivery in HIV/AIDS programmes and activities; 3. Promotion of optimal feeding practices for infants and children in order to improve their

nutritional status, growth development and survival chances; 4. Promotion of maternal nutrition in pregnancy and during lactation; 5. Provide support to the micronutrient deficiency prevention and control (supplementation); 6. Provide quality dietary including food aid management services and information to in and

out patients; 7. Develop nutrition planning and implementation guidelines; 8. Develop human resource capacity to effectively implement nutrition programmes; 9. Capacity building in Nutrition Advocacy and technical support and supervision; 10. Strengthen implementation of Infant and young child feeding programme; and 11. Strengthen use of Growth Monitoring and Promotion to improve nutrition interventions. 6.8.2.2 Expected Outputs 1. Nutrition implementation guidelines developed; 2. Number of children exclusively breastfed for the first six months of life increased from 40%

to 60%; 3. Increased number of districts implementing community based growth monitoring and

promotion from current 40 to 72; 4. Increased coverage of vitamin A supplementation of children aged 6 – 59 months from

68% to 90%;


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5. Increased coverage of vitamin A supplement for lactating women postnatally (within 8

weeks of delivery) from 39% to 80% 6. Increased proportion of health facilities providing nutritional care and support from 10% to

60% 7. Increased proportion of AIDS patients with nutrition supplement and support from current

20% to 60%; 8. Increased number of health facilities providing dietetic support in to patients with

communicable and non-communicable diseases from current 8% to 60%; 9. BSc programme in nutrition introduced at UNZA in 2008, which enrolls 20 students each

year; and 10. Increased proportion of paediatric medical staff trained in severe malnutrition management

from current 20% to 80%. 6.8.2.3 Key Indicators 1. % of underweight children below the age of five years; 2. % of children exclusively breast fed for the first six months of life; 3. % case fatality among moderate and severely malnourished children; 4. Number of trained nutritionists placed at all levels of health care system; 5. Number of health facilities providing dietetic support to patients with non-communicable

diseases; 6. Coverage for Vitamin A supplementation in children aged 6 – 59 months and women post-

natally (within 8 weeks); 7. Proportion of people living with HIV and AIDS accessing nutritional care and support 8. Number of Growth Monitoring & Promotion manuals distributed; 9. Number of Guidelines & IEC materials distributed; 10. Decreased case fatality rate in severely malnourished children; and 11. Proportion stunting children below the age of 5 years. 6.8.3 Mental Health 6.8.3.1 Situation Analysis Mental disorders and mental ill-health, including alcohol and substance abuse constitute a significant proportion of the overall burden of disease in Zambia. Currently, the burden of mental ill health in Zambia in terms of incidence and prevalence, health care expenditure and loss of productive years of life can not be quantified. However, it is estimated that over 12.5% of the global burden of disease is caused by mental disorders. Coordination of mental health services in Zambia, at national level, will be carried out by the Mental Health unit, through consultations and collaboration with other main stakeholders such as the Mental Health Association of Zambia (MHAZ) and Mental Health Users Network of Zambia (MHUNZA). Planning, co-ordination, and effective supervision of mental health services will be undertaken at each level namely: national, provincial, district and community levels. A multi-sectoral and professional approach shall be adopted, with emphasis on preventive and promotion services. The main challenges in mental health include the lack of an appropriate policy and legal framework, lack of appropriate guidelines and standards for the management of mental illnesses, poor public awareness and attitude towards mental illnesses, weak partnerships, and lack of coordination for multi-sectoral responses to mental health.


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6.8.3.2 Strategies 1. Strengthen the policy and legal framework for mental health; 2. Develop standards and guidelines for management of mental health services; 3. Strengthen partnerships in mental health; 4. Promote public awareness and education on mental health, especially prevention of mental

illnesses; 5. Promote the integration of mental health patients into their families and communities; 6. Promote the integration of mental health in all relevant community based programmes; 7. Facilitate inter-sectoral co-ordination, to bring together workers from other sectors; and 8. Strengthen coordination, management, monitoring and evaluation of mental health

programmes. 6.8.3.3 Expected Outputs 1. Mental Disorders Act of 1951 Cap. 535 repealed and replaced with the new Mental Health Act

by March 2006; 2. Operational guidelines and standards for management of mental health problems developed by

end 2006; 3. Public awareness strategy for mental health services developed by March 2006; and 4. Mental Health Coordinating Committee established by January 2006. 6.8.3.4 Key Indicators 1. Number of policies and legislation approved; 2. Number of districts using operational guidelines for mental health management; 3. Number public awareness programmes conducted; 4. Number of partnerships established; and 5. Incidence of mental illnesses. 6.8.4 Oral Health 6.8.4.1 Situation Analysis The role of oral health has increased significantly with the advent of HIV/AIDS and its oral manifestation. Major activities carried out in oral health included: the development of guidelines on oral manifestations of HIV/AIDS; pamphlets on Cancrum Oris (noma); review of Oral Health Guidelines for levels 2 and 3; strengthening of School Oral Health Programmes in 30 districts; capacity building for dental therapists in the use of lower technologies, such as Atraumatic Restorative Technique; and the introduction of a dentist degree programme at the University of Zambia. 6.8.4.2 Strategies 1. Strengthen the policy framework for Oral Health; 2. Scale up oral health services to all districts; 3. Promote oral health awareness and education; 4. Integrate oral health in child health and HIV/AIDS programmes; and 5. Strengthen oral health training.


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6.8.4.3 Expected Outputs 1. Oral Health Policy approved by Dec 2006; 2. All first level referral facilities provided with at least one dentist or dental therapist by 2010; 3. Oral health promotion and education strategy designed by 2008; 4. Oral health integrated in child health and HIV/AIDS programmes by 2007; and 5. School of Dentistry at the University of Zambia opened by 2008. 6.8.4.4 Key Indicators 1. Proportion of health facilities with physical space and equipment for basic oral health care; 2. % of districts with at least one dentist or dental therapist; 3. % of children with noma identified during IMCI; and 4. Incidences of oral diseases. 6.8.5 Bilharzia and other parasitic infections 6.8.5.1 Situation Analysis Schistosomiasis (bilharzias) is prevalent in rural districts especially those close to the Lakes and rivers. It is estimated that close to 2 million people in Zambia are infected with bilharzia. The prevalence is as high as 90% in some communities. Children are often heavily infected, and then suffer serious morbidity several years later when as adults their liver, bladder and kidneys become affected by trapped eggs. Infections with intestinal helminths, (hooZMKorm, Ascaris and whip worm) are also very common and found throughout the country. Heavy infections cause anaemia in children and pregnant females. Schistosomiasis and intestinal worms are best treated during school aged years when annual treatments can prevent morbidity in later life. It is recommended that schistosomiasis treatment be made available at all primary schools in endemic areas, and annual mass treatment be offered where blood in urine is a common symptom. De-worming treatment (albendazole or mebendazole) should be made available at all primary schools in Zambia annually, delivered in conjunction with other campaigns (EPI, measles and vitamin A)for pre-school children, and to pregnant females as part of ante natal care. 6.8.5.2 Strategies 1. To promote the use of Chemotherapy through the School Health Programme; 2. Health education; 3. Support for provision of safe water and adequate sanitation standards; and 4. Vector control. 6.8.5.3 Expected Outputs 1. Communities at high risk of schistosomiasis and soil transmitted helminths morbidity

identified; 2. Treatment of high risk groups undertaken; 3. Teachers and community health workers trained in administering de-worming drugs; 4. Information education and communication (IEC) activities in all schools and communities

undertaken; 5. Improved sanitation standards in communities; and 6. Strengthened partnerships with all stakeholders at all levels.


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6.8.5.4 Key Indicators 1. Number of eligible persons treated; 2. Number of surveys carried out to monitor effect of treatment; 3. Percentage of population with adequate KAP on Bilharzias & soil helminthes; 4. Number of communities at high risk identified; 5. Number of persons treated; and 6. Number of Teachers and Community Health workers trained in drug administration.

6.8.6 Other Non-Communicable Diseases 6.8.6.1 Situation Analysis Due to changes in lifestyles, diseases such as diabetes, hypertension, renal failure, tumors, and substance and alcohol abuse are becoming more prevalent. Even though there is no data on Non-Communicable Diseases (NCDs) in this country, the projections are that if not addressed appropriately, morbidity and mortality rates could rise to 60 and 65% respectively, by 2020. 6.8.6.2 Strategies 1. Develop appropriate policy and legal framework for NCDs; 2. Improve capacity of the health system to respond to NCDs; 3. Develop NCD communication and public awareness strategy; 4. Promote prevention of NCDs through advocacy of healthy lifestyles; and 5. Integrate NCDs into IDSR. 6.8.6.3 Expected Outputs 1. Disease specific policies on NCDs developed and implemented by 2008; 2. Basic equipment, tools, drugs and other supplies for management of NCDs available at all

levels of care by 2007; 3. NCD communication strategy developed and implemented by 2008; 4. Health care workers trained in NCDs annually from 2006; and 5. IDSR strengthened by 2007. 6.8.6.4 Key Indicators 1. % of health facilities with physical space and equipment to provide basic care on NCDs; 2. % of population with specific health care seeking behaviour related to NCDs; 3. Number of health care workers trained in NCDs; and 4. Incidence of NCDs.


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6.8.7 Health Education and Promotion a) Objective To facilitate effective and efficient health education and promotion programmes that will empower individuals, families and communities to develop healthy lifestyles. b) Strategies 1. Strengthen the health education unit to provide technical coordination of all health promotion

activities; 2. Build central, provincial district health center and community focal point capacity and

capability to plan and manage health communication; 3. Establish collaborative systems with partners, stakeholders and allies to support health

communication programmes; 4. Advocate for public policies that support health; 5. Promote the role of the lay community to participate and be involved in participatory health

communication programmes; 6. Develop social support systems to foster health development programmes; 7. Initiate, develop and disseminate appropriate health learning materials; 8. Provide technical and ethical professional guidelines in health education and promotion; and 9. Strengthen coordination and management of health education and promotion. c) Expected Outputs 1. Health education specialists trained and retained at all levels of service delivery; 2. Alliances, partnerships and coalitions established with all key stakeholders; 3. Advocacy programmes initiated to support public health policies that enhance and promote

health; 4. Participatory health promotion programmes initiated and sustained by the health education

systems in communities; 5. Health learning materials produced and disseminated; and 6. Technical guidelines developed and distributed to all health personnel.


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7 CLINICAL CARE AND DIAGNOSTICS SERVICES 7.1 Essential Drugs and Medical Supplies 7.1.1 Situation Analysis The quality, efficiency and effectiveness of health service delivery are, to a large extent, determined by the availability of appropriate staff, infrastructure and equipment, and essential drugs and medical supplies. It is therefore critical that essential drugs and medical supplies are always in stock at any given health facility. In this respect, in 1999, the Ministry developed and adopted a National Drug Policy (NDP), which is based on the requirements of the BHCP. The vision of the NDP is to provide equity of access for all Zambians to good quality, safe and efficacious medicines which are affordable and rationally used as close to the family as possible. The 2001-2005 National Health Strategic Plan projected the availability of essential drugs at 85% by the year 2005. Over the past 4 years the bulk supply of essential drugs and medical supplies was erratic, with more than 50% of essential drugs out of stock. However, the availability of rural health centre kits was fairly steady. Health Centre stocks, on average, improved from 73% in 2002 t0 76% in 2004. A number of activities were undertaken in the area of essential drugs and medical supplies, which included: • A three year procurement plan for the period from 2005 to 2007 was developed; • The “Essential Drugs” list were developed, intended to help in the monitoring of stocks and

management of procurement for critical drugs and supplies; • In order to facilitate enforcement of the quality assurance legislation, in 2003 the National

Drug Policy Steering Committee (NDP-SC) carried out a review of the Food and Drug Act and laboratory to establish their capacity to effectively enforce quality control on medicines. The review identified a number of weaknesses and the Government is yet to implement the recommendations; In order to improve on the quality of donated drugs and medical supplies, in 2004 the Pharmacy and Poisons Board, in collaboration with various stakeholders, produced Guidelines on Donation of Drugs and Medical Supplies. However, the same have not yet been disseminated and applied.

• Process for establishment of a Zambian Logistics Management Information System (LMIS) continued with the establishment of the Zambian tracer drugs/medical supplies list;

• Under the newly established Pharmaceutical Regulatory Authority (PRA) structure, activities to operationalise/establish the Pharmacovigilance Unit (NPVU) have been initiated. The Unit will be responsible for introducing the concept of Pharmacovigilance in Zambia, including training and training in Adverse Drug Reaction/Events (ADR/Es) detection and its reporting systems; and

• Due to limited experience with the operational use of antiretroviral drugs in developing country settings, a draft national framework for HIV drug resistance (HDR) monitoring was developed. This is to ensure that measures are taken not only to guarantee the quality, safety and efficacy of the products, but also to ensure proper monitoring of ARV drug resistance. This will fall under the NPVU.

Shortages and inappropriate clinical usage of drugs and medical supplies still remains a major problem. Efforts need to be enhanced in the dissemination and enforcement of compliance with recognized/recommended treatment guidelines and prescriptions.


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7.1.2 Objective To ensure availability of adequate, quality, efficacious, safe and affordable essential drugs and medical supplies at all levels, through effective procurement management and cooperation with pharmaceutical companies. 7.1.3 Strategies 1. Integrate the use of the “Essential Drugs” and “Tracer Drugs” lists in procurement and stock

planning, management and control; 2. Undertake periodic Baseline surveys on the use of drugs and medical supplies; 3. Prepare and implement 3 year rolling procurement plans; 4. Ensure efficient, cost-effective and ethical procurement, storage and distribution of essential

drugs and medical supplies. Parallel importation by the Government will only be an option, if necessary, to drive down prices of locally based suppliers;

5. Ensure adequate and timely financing of the procurement of essential drugs and medical supplies;

6. Encourage the establishment of a strong local pharmaceutical and chemical industry to lower the costs of drugs;

7. Strengthen and support Pharmacy and Therapeutics Committees at all levels to promote rational use of drugs and medical supplies; and

8. Ensure the appropriate and rational use of drugs and medical supplies at all levels, through provision and enforcement of treatment guidelines and procedures.

9. Establish a national Logistics Management Information System (LMIS) to facilitate effective monitoring of the national supply chain;

10. Ensure the timely establishment of the organizational structure for the National Pharmacovigilance Unit (NPVU) under the Pharmaceutical Authority (PRA); and

11. Establish and strengthen reporting systems for ADR/Es and HIV/Malaria/TB drug resistance monitoring at all levels

7.1.4 Expected Outputs/Indicators 1. Lists of Essential incorporated in the procurement plans, from 2006; 2. Pharmaceutical Logistics Management Information System (LMIS), established by 2008 3. Appropriate procurement regulations and guidelines developed and enforced for all levels, in

accordance with FAMS and Zambia National Tender Board (ZNTB) guidelines, in 2006; 4. Promotion of rational drug use through dissemination and implementation of therapeutical protocols

and standards by 2007 5. Establishment of the Drug Supply Fund finalised and operationalised, and the Drug Supply

Budget Line (DBSL) established by end 2006; 6. Operationalisation of the Pharmaceutical Regulatory Authority by end 2006; 7. Establishment of the National Pharmaco-Vigilance Unit under the Pharmaceutical Regulatory

Authority in 06/07; 8. NPVU established and operational by end 2007; and 9. Adverse Drug Reaction (ADR) and HDR monitoring reporting systems operationalised by end

of 2008.


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7.2 Laboratory Support Services 7.2.1 Situation Analysis Appropriate laboratory support is a critical factor in the diagnosis and delivery of quality health care services. Laboratory requirements for health posts, health centres and 1st level hospitals have been identified, while work on the identification of requirements for the 2nd and 3rd Level referral hospitals is still going on. Currently, the importance of laboratory support has taken an even higher profile, mainly due to the scaling-up of ART, which demands certain laboratory tests for monitoring patient response to ART. Laboratory baseline data and follow up data is cardinal for the management of HIV/AIDS patients with ARVs. In Zambia, currently there are only about 75 health centres with laboratory facilities in the periphery. Main challenges as far as provision of appropriate and essential laboratory support include: the need to upgrade laboratory infrastructure; need to improve service delivery through the provision of laboratory equipment, reagents and supplies; the need to enhance management and quality assurance systems at all levels of care; development and dissemination of policy guidelines and initiatives to support the Basic Health Care Package; and the need to ensure safety and ethics for laboratories at all levels of care. 7.2.2 Objective To provide appropriate, efficient, cost-effective and affordable laboratory support services at health centre and hospital levels throughout the country. 7.2.3 Strategies 1. Review and maintain appropriate policy and legal framework for laboratory support; 2. Review and develop laboratory protocols and standard operating procedures; 3. Ensure adherence to laboratory protocols and standards by implementing effective quality

assurance systems; 4. Ensure that laboratory infrastructure and equipment are maintained in good order; 5. Strengthen existing systems for stores management of laboratory reagents and supplies; 6. Strengthen training and capacity building for bio-medical scientists and laboratory staff; and 7. Strengthen coordination and management of laboratory services. 7.2.4 Expected Outputs/Key Indicators 1. National Medical Laboratory Policy reviewed and updated by 2007; 2. Laboratory protocols and standard operating procedures updated by 2008; 3. Quality assurance guidelines developed and implemented by 2007; 4. Number of trained bio-medical technologists and scientists increased by 50% by 2010; 5. Planned preventative maintenance system developed and implemented by 2007; 6. Laboratory monitoring and evaluation system developed and implemented by 2007; 7. Guidelines on ethics and minimum standards of safety developed by 2007; and 8. Procurement plan for essential lab equipment and consumables developed by 2007.


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7.3 Blood Transfusion Services

7.3.1 Situation Analysis The Zambia National Blood Transfusion Service (ZNBTS) is mandated to ensure nationwide, equitable and affordable access to blood and blood products, ethically collected and rationally used, for purposes of preventing transfusion related transmission of HIV and other blood borne infections, and saving of lives of patients requiring blood transfusion. ZNBTS is a government unit, under the Ministry of Health, and responsible for collection, laboratory screening, processing and distribution of blood to all hospitals in Zambia. The main achievements of ZNBTS include: the increase in the number of blood collections per year from 40,000 units in 2003 to 62,000 units in 2005; the reduction of the HIV prevalence rate in donated blood from 25% in the late 1980s to about 5% in 2005; the imposition of mandatory laboratory screening of all blood for HIV, Hepatitis B/C, and syphilis in accordance with the national and WHO guidelines; the establishment of standard operating procedures (SOPs) inclusive of all the stages of blood transfusion value chain; the significant improvements to infrastructure, equipment and transport at the head office and at all provincial centers; and mobilization of technical and financial support from the international cooperating partners. 7.3.2 Objectives To rapidly scale up the blood safety programme and ensure nationwide, equitable and affordable access to safe blood and blood products, ethically collected and rationally used. 7.3.3 Strategies 1. Recruitment and retention of regular, voluntary non-remunerated blood donors from low-risk

groups; 2. Mandatory screening of blood for HIV, Hepatitis and Syphilis; 3. Promotion of appropriate clinical use of blood and blood products; and 4. Continuous improvements in the organization, coordination and management of blood

transfusion services. 7.3.4 Expected outputs 1. Blood transfusion system streamlined, through designation of provincial centres as the only

facilities authorized to collect and test blood for distribution to transfusion outlets/ hospitals; 2. Lusaka Blood Bank building renovated and up-graded, and new Kabwe Blood Bank building

constructed in 2008. Other provincial blood banks renovated and upgraded by end of 2008; 3. Adequate transport for mobile outreach blood collections and appropriate equipment for bulk

testing, storage and distribution of blood procured for all the 9 provincial centres by end 2006; 4. National Blood Transfusion Services legislation and regulations developed and enforced by

2007; 5. Guidelines on appropriate use of blood and blood products reviewed, updated and

disseminated by end 2008; 6. Staff training and public awareness in blood safety enhanced, throughout the duration of the

plan;


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7. Blood collections increased from 62,000 units per year as at 2005, to 100,000 units per year by

2010; and 8. Total discards due to infectious markers reduced from 19% as at 2005, to less than 3% by

2008.

7.3.5 Key indicators

1. Number of blood units collected; 2. National Blood Transfusion legislation and regulations developed; 3. % of blood collected that has been screened in accordance with national and WHO guidelines; 4. % of blood units discarded due to disease markers; and 5. % of blood units discarded due to HIV. 7.4 Medical Imaging Services

7.4.1 Situation Analysis Medical Imaging as a science involves the application of controlled amounts of radiation on a patient’s body for diagnostic or therapeutic purposes. The major components of radiography include, General Radiography, Ultrasound, Nuclear Medicine, Computerized Tomography, Magnetic Resonance Imaging and Radiotherapy. Radiology in Zambia was introduced in the early 1930s with conventional x-ray facilities being provided. Over the years other forms of imaging services such as Ultrasound, Nuclear Medicine and later Computerized Tomography have gradually been introduced in the country. Medical Imaging is important in the provision of the Basic Health Package (BHCP) as it provides necessary diagnostic data for clinical decisions and policy guidelines at national and international level. Approximately 70% of cases in a hospital are referred to the Radiology Department at some stage of management. Imaging services are now found at a) 1st, level hospitals where basic radiological services such as simple chest and ultrasound scans are conducted b) 2nd Level Hospitals where few specialized examinations such Barium studies, ultrasound are conducted c) 3rd level hospitals where all specialized examinations are conducted including Radiotherapy services d) Imaging services are also found at the Urban Health Centres especially in the Lusaka Province. The Zambian Government and its Cooperating Partners have been instrumental in devising, implementing and promoting Medical Imaging services. Some of the efforts undertaken are already showing positive results, e.g. Under the ORET Project, 71 hospitals will be equipped with new x-ray and ultrasound equipment, and Training will be conducted in ultrasound, radiographic application and maintenance. Further, a BSc. Degree Programme will be introduced, the Cancer Diseases Hospital has been constructed in Lusaka and will be in use by January 2006, and Tele-radiology services will be introduced at all levels of care. However, a number of constraints have been identified in the area of Medical Imaging. The major constraints include shortage of appropriate human resources, obsolete equipment, poor infrastructure, and lack of consumables to run the departments effectively, no clear policy and standard operating procedures, lack of educational facilities for advancement in education, poor public awareness on hazards of radiation.


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7.4.2 Objectives To provide the health care delivery system with high quality, cost effective and safe medical imaging and radiation therapy support at various levels of health care.

7.4.3 Strategies 1. Scale up on Continued Professional Development in various imaging modalities and

radiography training so as to significantly improve the technical skills of staff; 2. Develop and ensure effective dissemination of the Medical Imaging and Radiation Therapy

Policy; 3. Develop Protocols and Standard Operating Procedures for management of medical imaging

and radiation therapy services; 4. Develop and implement a plan for procurement, installation and maintenance of equipment; 5. Strengthen the existing logistics management systems for consumables (Developers, Fixers,

chemicals etc.); and 6. Promote public awareness on the hazards of Radiation

7.4.4 Expected Outputs 1. Medical Imaging and Therapy Policy Developed by 2007; 2. Medical Imaging Protocols and Standard Operating Procedures developed and disseminated to

all imaging departments by end of 2006; 3. Procurement plan for essential equipment and consumables developed as part of the

procurement planning process by 2007; 4. 60% of the radiographers in hospitals trained in ultrasound, radiographic application and

maintenance by the year 2010; 5. 30% of doctors needed for specialized units in oncology, radiology, nuclear medicine trained

through training institutions by 2010; 6. Basic Equipment, consumables and other accessories available at all levels of care in the

imaging departments by the year 2009; 7. Planned preventive maintenance system developed and implemented by 2008; and 8. Public Awareness strategy on hazards of radiation developed by February 2006. 7.4.5 Key Indicators 1. Percentage of x-ray departments at district, general and tertiary hospitals with functional

imaging equipment; 2. Percentage of Radiographers Established in x-ray departments filled; 3. Number of radiological graduates recruited into the system; 4. Percentage of districts, general and tertiary x-ray department functional; 5. Percentage of imaging departments receiving adequate consumables; and 6. Number of public awareness programmes conducted.


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8 INFRASTRUCTURE AND EQUIPMENT 8.1 Infrastructure 8.1.1 Situation Analysis Currently, the deterioration of health infrastructure and equipment has reached a stage where urgent repairs and replacements are required in order for health facilities to function effectively. Various reasons have contributed to this state of affairs, including: the lack of financial resources, little use of existing capital-funding programmes; an emphasis on an expansion of the network rather than on the rehabilitation of the existing facilities; inadequate mobilisation of community resources; lack of a preventive maintenance policy (and guidelines); and lack of skilled staff for preventive and corrective maintenance. Analysis of the Joint Investment Plan 2001-5 clearly shows that there is inadequate investment going to infrastructure from both GRZ and Co-operating Partners. For instance, during the period from 2001 to 2004, only USD 1,885,000 was available for infrastructure. In October 2004, the Ministry of Health and its Co-operating Partners agreed to allocate funds from the Expanded Basket to a capital basket at a monthly allocation of USD$200,000. It was also agreed that what would trigger the release of these funds to beneficiary institutions was a clearly articulated capital investment plan which outlined priority districts and interventions to be undertaken under infrastructure development. In order to provide information which would feed into the development of a prioritised capital plan, the Ministry commissioned a health facility census in the fourth quarter of 2004. While data collection for the districts has been finalised, there are concerns with delayed finalisation of the health facility census report. It is imperative for the Ministry to embark on a speedy finalisation of the health facility census database from which various infrastructure databanks could be generated which would be used to develop infrastructure development plans. Such plans should strategically prioritise in terms of rehabilitation versus new construction, at what level of the health care delivery system interventions are being applied and the geographic location of such interventions. The focus of health reform interventions has been the district. It is the policy of the Government to make available at least one level 1 hospital which would operate as a referral hospital to a satellite of health centres in every district. Although there are currently 74 level 1 hospitals, there are currently 19 districts without a level one referral hospital. During the implementation of this plan, more emphasis should be placed on constructing one level 1 hospital in each of the remaining districts. Planning of health infrastructure needs to be embedded in the overall strategy for the development of the health sector. In Zambia, the need for rightsizing the health facilities is widely acknowledged, and commendable efforts have been made so far. However, there is need to speed up the process, and importantly, to develop a general, well-phased master plan which will provide guidance on issues such as, which level II Hospitals will be reclassified to Level I, which Level 1 Hospitals will be reclassified to a Health Centre and which Health Centre should become a Health Post. In practice, current planning for infrastructure ignores recurrent cost implications. Districts, hospitals and MOH are keen to use funds for capital investment, but do not have a methodology to make provisions for recurrent cost and replacement at the time of planning. The recurrent cost coefficients of building a Health Post, a Rural Health Centre, an Urban Health Centre or a Level 1 Hospital etc are not known, but could easily be determined.


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It may be wise to calculate these coefficients, apply them to the proposed construction works, assess the total resources required and compare the result with the resource envelope before final investment decisions are made. The availability and condition of infrastructure and medical equipment to support health service delivery are of critical concern for Zambia. The main challenges in this area include: the need to complete the health facility infrastructure development plan in order to ease the allocation of resources as well as prioritisation of capital projects in under-served areas; finalisation of the health facilities (infrastructure) databank to serve as a source of information for formulation of development and procurement plans for capital/infrastructure programmes; finalisation of infrastructure standards and guidelines, which will form the basis for implementation of programmes; approval of the draft maintenance policy, which will provide guidelines on how to manage repairs and maintenance of infrastructure; need to increase Government’s and CPs commitment towards capital investment programmes; and the need for capacity building at district level to interpret and implement infrastructure activities. 8.1.2 Objective To significantly improve on the availability, distribution and condition of appropriate essential infrastructure so as to improve equity of access to essential health services. 8.1.3 Strategies 1. Establish a health infrastructure database system that would provide essential information on

the status of each health facility, at all levels of care; 2. Review the infrastructure standards and define the appropriate sizes and types of health

facilities for the different levels of care; 3. Develop and implement a Health Infrastructure Development Plan, consistent with the overall

national health needs, priorities and BHCP, paying particular attention to under-served areas. The development of this plan will be based on the principle of “prioritization”;

4. Establish a capital basket for financing infrastructure development and maintenance, including an appropriate criteria for prioritization and selection of capital projects for this basket;

5. Promote private sector participation and public/private sector partnerships in infrastructure development;

6. Ensure effective dissemination and compliance with the approved infrastructure maintenance policy and guidelines; and

7. Build appropriate capacities in the effective development and preventive maintenance of infrastructure at district level.

8.1.4 Expected Outputs/Key Indicators 1. Census of health infrastructure completed by June 2006; 2. Infrastructure database system established and operational by end of 2006; 3. Health Infrastructure Development Plan completed and launched by end 2007 and

implemented from the beginning of 2008; 4. Capital basket fund established and operational by 2007; 5. Capacity-buildings needs determined. Appropriate programmes developed and implemented

by January 2007; and 6. Increased number of private and public/private health facilities.


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8.2 Medical Equipment and Accessories 8.2.1 Situation Analysis Efficient and effective delivery of clinical care is highly dependent on the availability of appropriate equipment and accessories, in good functioning order. Such equipment and accessories should always be properly maintained and calibrated, so as to ensure accurate diagnosis and/or performance. The list of essential equipment and accessories has already been defined for the health post, health centre and level 1 referral hospitals. However, work has continued on the development of lists for the level 2 and 3 referral hospitals. The main challenges as far as essential medical equipment and accessories are concerned include, the need to: develop standard equipment lists for all levels of service delivery; develop appropriate equipment management plans whose objective would be to restock clinical centres with the right quantities of appropriate equipment; develop criteria to determine human resource needs for equipment management and maintenance; develop appropriate maintenance facilities, with appropriate tools and equipment; and allocate adequate budget funds for maintenance activities at all levels of service delivery. 8.2.2 Objective To significantly improve on the availability and condition of essential medical equipment and accessories so as to ensure effective delivery of key health services. 8.2.3 Strategies 1. Develop standard checklists for essential equipment and accessories for the remaining levels,

i.e. hospitals, training and statutory institutions; 2. Establish and maintain an equipment database system which will provide information on the

status and adequacy of equipment at all levels of the health care delivery system; 3. Develop and implement appropriate equipment development plans so as to ensure a planned

and coordinated approach to equipment management; 4. Ensure continuous dissemination and compliance with the established maintenance policy and

guidelines at all levels; and 5. Enhance capacities for management and maintenance of equipment at all levels, through

training in appropriate usage, maintenance and repairs of equipment.

8.2.4 Expected Outputs/ Key Indicators 1. Standard equipment checklists for all levels completed by December 2006; 2. Equipment database established by June 2007; 3. Equipment development plan developed and implementation commenced by January 2008; 4. Guidelines on the monitoring of compliance with maintenance policy and guidelines

developed and implementation commenced by January 2007; and 5. Capacity building programme in equipment maintenance, developed and implementation

commenced by January 2007.


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9 SUPPORT SYSTEMS STRENGTHENING The Central Board of Health (CBoH) has been acting as the main link between the central level structures and District and Hospital Boards, through the Provincial Health Offices (PHOs) and has been facilitating the provision of integrated technical support to the Hospital and District Health Management Boards. In this respect, CBoH has been co-coordinating the development of standards and guidelines for health care, work plans and budgets, systems and strategies for effective management of contracts, human resources and physical health infrastructures. CBoH has also been responsible for monitoring and evaluation of health service delivery at all levels, so as to ensure quality, efficient and effective public health services. Performance assessment tools to facilitate the monitoring of Provinces, Health Boards and Training Institutions have been developed and used regularly during technical support visits conducted to PHOs and health boards. During the period under review, CBoH also provided technical support in planning and the review of the planning processes. A number of challenges were experienced in the provision of technical support services, including: development of management guidelines for hospitals and training institutions was not completed and as a result these institutions continued to operate without management guidelines; development of a tool to monitor community activities was not completed, which deprived the system of the much-needed information for monitoring community activities; and implementation of activities at the PHO level was also constrained by the shortage of key staff. The main central integrated support systems and services provided to all the levels of health service delivery include: Human Resource Management Systems (HRM), Health Management Information Systems (HMIS), Financial Administrative Management Systems (FAMS), Quality Control Systems, Internal Audit; and Monitoring and Evaluation Systems. During the duration of this plan, these systems will be further strengthened, taking into account the on-going restructuring of the health sector and the national decentralisation policy. 9.1 Monitoring and Evaluation 9.1.1 Situation Analysis The health sector in Zambia has had a functioning Monitoring and Evaluation (M&E) system for many years now though not always adequate. Its evolution has depended on the needs and advancement in technology of the time. Various attempts have been made to strengthen M&E in the sector. The 1996 setting up of the Health Management Information System (HMIS) and Financial and Administration Management System (FAMS) marked a major milestone in the development of health sector performance monitoring under health reforms. Currently the HMIS is functional at all levels though not in all aspects. Performance Appraisals are regularly done by Provincial Health Offices, Integrated Disease Surveillance Response (IDSR) is well developed for polio, measles and tetanus. Coordination of sector M&E through Sector Wide Approach (SWAp) is relatively strong centrally. Population based surveys to feed policy and planning are regularly and consistently done. Despite these positive aspects the M&E function in the sector still has gaps. The HMIS is not fully developed and is not flexible enough to accommodate the needs of all programmes leading to development of parallel systems. This has made the coordination of M&E very difficult for the Ministry of Health.


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Some components such as IDSR and FAMS are not fully functional at all levels. Although a lot of data is collected at all levels there is poor utilization. The central level demand for reports determining fund release has also contributed to poor information utilization by the districts. The other challenge is the inter play of HIV/AIDS, brain drain and staff shortage in the sector. Some recent developments, however, bring hope for the future. Several partners have come on board to assist government in re-aligning the M&E function. The three ones principle too is an opportunity for the government (MoH) to fully take charge and to channel resources in the areas where the sector M&E is still weak. On the other hand, research work has been conducted in the sector but has faced a challenge of poor coordination in both legal and implementation frameworks. The national health research agenda, an effort towards strengthening research prioritization and coordination, has also lacked substantial legal and implementation backing. To a large extent the contribution of research to overall sector performance monitoring has not been mainstreamed enough to provide timely evidence for policy and action. 9.1.2 Objectives To strengthen overall M&E system of the health sector in order to provide evidence for policy and action. 9.1.3 Strategies 1. Strengthening of the routine health care information systems building on the current HMIS

assessment; 2. Development of mechanisms for conducting regular annual joint health sector reviews; 3. Strengthening population based health surveys such as Zambia Demographic Health survey

(ZDHS) and sentinel surveys, and ensure devolution of ZDHS implementation in order to account for performance needs of the lower service delivery levels;

4. Strengthening mechanisms for coordination and harmonization of various health sector performance monitoring and evaluation systems;

5. Strengthening research for policy and action; 6. Development of a core indicator set that accounts for the direct health sector contribution to

NDP and MDGs; 7. Strengthening of partnerships for health sector M&E at provincial and district levels including

the private sector; 8. Strengthening research regulatory mechanisms and dissemination of findings for policy and

action; 9. Strengthening and build capacities for M&E at all levels of the health sector; 10. Defining performance standards for service delivery at every level of care; and 11. Development of a result-based performance rewarding system at every level of service

delivery. 9.1.4 Outputs/Indicators 1. Functional HMIS at district level by 2008; 2. Functional Hospital MIS at every level of care by 2008; 3. Functional M&E department in the MOH by 2007; 4. Nation health research agenda for 2006-2010 developed by 2006;


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5. Core indicator set for the NHSP revised by 2007; 6. Functional M&E mini-Sector Advisory Group (SAG) at provincial and district level by 2008; 7. Health research regulatory framework (legal and implementation) developed and implemented

by 2010; 8. Functional M&E system at all levels of the health service delivery by 2010; 9. Health service delivery Performance standards defined at every level of health care by 2009; and 10. Result-based performance rewarding system developed by 2009. 9.2 Health Management Information System 9.2.1 Situation Analysis The Health Management Information System (HMIS) is a comprehensive system which is used for capturing and processing data within the health sector. HMIS aims at providing efficient and effective support to the planning, coordination and monitoring and evaluation of health care services, by ensuring availability of relevant, accurate, timely and accessible health care data at all levels of health care delivery. A comprehensive assessment of the HMIS was conducted in July/August 2005 by the Euro Health Group, commissioned by the European Union. This assessment concluded that the Zambian HMIS is well established and functional at all levels of the health delivery system, and that it compares favourably with HMIS’ in other Africa countries. The assessment further stated that there is a defined set of indicators and data is regularly collected and analysed. Data collection and reporting tools are in place at all health facilities and district offices, and the flow of information has been clearly setout using the “one channel” principle. Routine data is regularly analysed, on a quarterly basis, with reasonably good coverage for indicators of underweight children, measles immunization, supervised deliveries, malaria and TB incidence and TB DOTS coverage. However, despite the above positive conclusions, the assessment observed that the Zambian HMIS still has a number of weaknesses including: the lack of indicators to monitor all MDGs; poor integration of vertical programmes and administrative information into the routine HMIS; the quality of data is not checked and the system of vital registration is weak; most staff are not adequately trained in HMIS procedures and there is not much faith in the results coming out of the HMIS. The European Union has committed significant financial and technical support to strengthen HMIS and ensure that it operates smoothly, by implementing the following strategies. 9.2.2 Strategies 1. Strengthen the HMIS capacity to monitor health sector performance in Zambia,

particularly at district level, through intensive skills development, upgrading of manuals and study of best practice sites;

2. Return to the 1996 HMIS principles of decentralisation, action oriented, responsive and transparent HMIS, and introduction of the information pyramid;

3. ICT strengthening, through making the database more flexible and strengthening of decentralized information centres that are linked by internet to a central data warehouse;

4. Effective use of information through integration of vertical systems, with improved central coordination between stakeholders and sectors so that the information from HMIS is used to assess out-put-oriented performance;


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5. Improved action research capacity to improve feedback and dissemination and reduce overlap

and duplication; and 6. HMIS staff retention, particularly district information officers, by improving skills and status

and ensuring sustainability of systems, procedures and staff. 9.2.3 Expected Outputs/Key Indicators 1. 50% of the HMIS staff trained; 2. 50% of the managers and policy makers to be trained in data usage for decision- and policy-making 3. Districts and Hospital databases connected to the central data warehouse through the internet 4. Dissemination meetings for the HMIS Annual Statistical Bulletin held 9.3 Financial and Administration Management System (FAMS) 9.3.1 Situation Analysis Apart from the routine HMIS, a number of other administrative and management systems have been established at all the levels of health service delivery. One such system is the Administrative Management System (FAMS) whose objective is to provide a simple, comprehensive, accountable and transparent financial and administration management system at all levels of the health delivery system, that adequately meet the financial management and reporting requirements of all stakeholders. FAMS was introduced at district level in 1991, however, computerized accounting procedures using Navision Financial were only introduced by CBoH in 1997. Currently, all districts are using manual FAMS, with a cash book, a system of ledgers, forms and procedures as provided for in the Financial Management Procedures Manual. FAMS is not a complicated system, is adequately documented and fully complies with the local and internationally accepted accounting principles. There are approved plans to introduce computerized FAMS in all provinces and districts though a number of issued require careful consideration. It is important to determine how far down Navision should be used and what the practical implications of introducing it at such levels are. FAMS based on Navision Accounting Software is considered expensive and it is imperative to do a cost benefit analysis of scaling it out to the various levels of health service delivery. Technical skills to maintain Navision software are not available within the Ministry and consideration should be made on how this would be handled and there is need for intensive training and capacity building at all levels to support FAMS implementation. The other major challenges are that CBoH and MOH headquarters will soon merge into one central body. This will entail merging the accounting departments currently und CBoH and MOH. While the computerised FAMS has been implemented at CBoH, it is not the case at MOH, where most of the accounting staff do not have the necessary knowledge and experience in FAMS and would require significant training and capacity building. Further, FAMS and other administrative and management systems, are not integrated with HMIS. The implication of this state of affairs is that the indicators from these systems are not consolidated.


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9.3.2 Strategies 1. Scale-up implementation of FAMS to all levels of the health delivery system, provincial,

hospital and district levels. This process should be based on a careful analysis of technical and financial implications;

2. Ensure compatibility of FAMS modules at all levels; 3. Integrate HMIS, FAMS and other information systems into a single reporting system at all

levels; 4. Strengthen performance and financial audits at all levels; 5. Integrate FAMS indicators in performance audits, supportive supervision and accreditation

activities at provincial, hospital and district levels; and 6. Strengthen coordination and management of FAMS. 9.3.3 Expected Outputs/Key Indicators 1. FAMS implemented and strengthened at all levels by end 2007; 2. Compatibility of FAMS modules at all levels achieved by 2007; 3. Integration of FAMS and HMIS attained by 2007; 4. Financial and performance audit systems strengthened at all levels; 5. FAMS indicators incorporated in performance audits and accreditation process; 6. At least 570 management staff trained in FAMS; and 7. FAMS accounting software implemented in 56 health institutions. 9.4 Procurement Management System 9.4.1 Situation Analysis The purpose of the procurement management system is to provide well-coordinated, efficient, cost-effective, transparent and accountable procurement support services to all levels of service delivery. Prior to 2000, the MOH Procurement Unit undertook all central level procurement functions. In 2001, following the establishment of the CBoH procurement unit, there was a split in procurement functions between MOH and CBoH. The Ministry assumed the responsibility of policy formulation and provision of procurement guidelines to all procurement units in the health sector, in accordance with the Zambia National Tender Board (ZNTB) Act, while the CBoH procurement unit assumed responsibility for procurement of all public health sector goods financed by GRZ and the Co-operating Partners. The CBoH procurement unit has acquired significant experience in managing procurements financed by GRZ and Co-operating Partners. This has been demonstrated by the high value procurements successfully completed by the unit, such as the procurement of motor vehicles for all district health boards and the procurement of ARVs and drug kits. In order to improve planning and transparency in procurement management, the Ministry started preparing procurement plans in 2004, in consultation and agreement with the Co-operating Partners. A draft procurement procedures manual was developed although it is yet to be operationalised. It has also been recommended that MOH should collaborate with ZNTB to prepare a more comprehensive manual, which would include procurement planning, contract management and a manual for a procurement filing system and checklist.


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To facilitate the co-ordination of all procurement efforts between the Co-operating Partners and the Ministry, in 2002, a Procurement Technical Working Group was established. The Procurement Technical Working Group also acts as an overseer of all procurement processes undertaken in the health sector. Essential drugs and medical supplies constitute the bulk of the procurements undertaken using Co-operating Partners and GRZ resources. In order to efficiently procure drugs and medical supplies, a decision was made to pool the Ministry of Health and Co-operating Partners resources into a Drug Supply Fund (DSF), which would facilitate undertaking of bulk buying of drugs. Bulk buying of drugs would attract large discounts in prices and could lead to price stability, especially where flexible long-term framework contracts are used. Conditional to the establishment of the DSF was the undertaking of an external assessment of the Central Level Procurement Unit. Results of this external assessment, which was carried out in December 2004 by the World Bank, indicated an overall Average Risk rating for the Ministry. It was observed that substantial risks remained as a result of poor selection and quantification of requirements, inadequate procurement planning and monitoring, poor procurement records management, insufficient contract management and because of the Ministry’s previous record of not implementing agreed actions. The assessment report further recommended actions to be undertaken by the Ministry in order to strengthen the Central Level Procurement Unit which included the contracting of a long term Technical Assistant to build capacity in the identified weaker areas, preparation of a procurement plan for a minimum of 24 month period, establishing record management systems, launching the prequalification exercise for the procurement of a 2 year drug supply (with staggered) delivery, modifying the system for registering suppliers and service providers and establishing a system for procurement monitoring. It is important for the Ministry to aggressively implement this recommendation during the duration of this strategic plan. 9.4.2 Strategies 1. Develop and maintain a well coordinated, reliable and transparent procurement and supply

system that is acceptable to all stakeholders; 2. Develop and enforce procurement management regulations and guidelines at all levels, based

on the Zambia National Tender Board and FAMS regulations and guidelines; 3. Develop and implement a long-term strategy for Medical Stores Limited, with performance

indicators and clear targets; 4. Provide training and capacity building in procurement and supplies management at all levels; 5. Ensure that the Drug Supply Budget Line (DSBL) is established for funding drugs and medical

supplies; and 6. Facilitate the integration of procurement functions in MOH and CBoH into one central level

procurement unit. 9.4.3 Expected Outputs/Key Indicators 1. A well-coordinated procurement system established by end of 2006; 2. Appropriate procurement regulations and guidelines developed in accordance with FAMS and

(ZNTB) guidelines in 2007 3. Long-term strategy for Medical Stores Limited developed by end 2006;


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4. Procurement and supplies staff training programme commenced by 2006 (50 for each year) 5. MOH and CBoH procurement units fully integrated by end of 2006. 9.5 Health Systems Research 9.5.1 Situational Analysis The current MoH structure does not provide for a Health Research Unit. Reliable National Research Priorities and recommendations for action must emerge from the Provincial and District level to be effective. Currently, the capacity at both Province and District levels to analyze, interpret and utilize data is limited. Integration and institutionalisation of research as an integral routine component of the health policy development and program implementation process is of critical importance. Institutionalisation of the use of research outcomes for health planning, policy and decision making and program implementation at program level, as well as, the Central and Provincial levels of MoH is currently unsatisfactory. Mobilization of resources for conducting relevant health research is therefore important. The development of effective mechanisms and systems in setting out MoH and national program health research priorities is almost non-existent. Therefore, it is important to develop and strengthen existing health research systems at all levels that define priorities for health research, influence national, regional and global health agendas and lobby for a more equitable allocation of resources. 9.5.2 Strategies The proposed research strategies involve building capacities, infrastructures, competences in the relevant MoH Directorates, participation at research conferences, undertaking research and tackling policy issues and will include: 1. Strengthening of the research capacity in MoH and mandate for National Health Research

Advisory Committee in an effort to institutionalise health research at the various levels of health care;

2. Provision of assistance and building on existing structures, efforts, research networks, and experiences to link research to policies for improving the quality and extending the coverage of Malaria, MCH, RH and HIV/AIDS services. Facilitate dissemination of research results to all relevant stakeholders, including PHOs in order to maximize utilization of research outcomes; and

3. Strengthening capacity to conduct applied health research in the academia, and other statutory health bodies.

9.5.3 Expected Outputs / Key Indicators 1. Finalisation of the National Health Research Policy for framework implementation; 2. Implementation of the National Health Research Policy monitored; 3. Link between health research, health policy and programmes strengthened; 4. National Health Research Agenda priorities identified and regularly updated; and 5. Research institutionalised at all levels of health care. 6. Grants/contracts for health system research annually provided


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10 HEALTH SYSTEMS GOVERNANCE 10.1 Policy and Legislation 10.1.1 Situation Analysis The National Health Policies and Strategies of 1992 provide the overall policy framework within which health services are provided. They further articulate areas where new policies and legislation should be developed and/or revised in order to create an enabling policy and legal framework for health reforms implementation. After more than ten years of implementing the National Health Policies and Strategies, there still remain gaps in the policy and legislative framework. Out of the total of 14 pieces of legislation that were set for review during the period 2001-05, only the Pharmacy Legislation has been reviewed and approved at Cabinet level. During the same period, about ten areas were identified as requiring new legislation. However, up to 2004 the Ministry only managed to promulgate the National HIV/AIDS/STI/TB Act of 2002. The challenge is for the Ministry to enhance capacities for policy analysis and formulation, as well as develop appropriate mechanisms to support policy implementation. 10.1.2 Objective To provide a comprehensive policy and legal framework for effective coordination, implementation and monitoring of health services. 10.1.2.1 Strategies 1. Review and harmonize the existing policies and legislation and, where gaps exist, formulate

new legislation in order to provide a legal framework that effectively supports the on-going health sector reforms;

2. Develop policies aimed at promoting interventions that are cost-effective, pro-poor and address key health priorities;

3. Disseminate all legislation and policies applicable to the health sector to all levels of the health service delivery system, community representatives and other stakeholders;

4. Develop a system for coordinating and monitoring implementation of health sector policies and legislation; and

5. Strengthen capacity at MOH for health sector policy formulation, analysis and advocacy in order to ensure that better policies that address the health needs of the Zambian population are developed.

10.1.3 Expected Outputs 1. Existing policies and legislation reviewed and harmonized and new ones developed by 2007; 2. Appropriate new policies and legislation developed and updated on a continuous basis; 3. Existing health sector policies and legislation disseminated to all levels of health service

delivery on a continuous basis; 4. Mechanisms for coordination and monitoring enforcement of policies and legislation

developed by 2007; and 5. Capacity in policy formulation, analysis and advocacy strengthened at MOH through staffing,

technical support and training.


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10.1.4 Key Indicators 1. Checklist on status of the existing/required policies and legislation produced during 2006; 2. Number of policies and legislation reviewed or/and developed against the checklist; 3. Number of policies legislation disseminated and number of centres/institutions reached; 4. Guidelines for monitoring and evaluation of policy and legal implementation; and 5. Staffing levels and number of people who received appropriate training in policy formulation

and analysis.

10.2 Organisation and Management 10.2.1 Situation Analysis The main feature of the organisational and institutional restructuring implemented under the health sector reform programme was the decentralisation of health service delivery, through devolution of key management responsibilities and resources to district level. In this respect, two parallel, but complimentary organisational structures were introduced, namely, popular structures for public involvement and participation in the decision-making process (the District and Hospital Boards, and the Central Board of Health) and the technical and management structures (District and Hospital Management Teams), designed to ensure that health services are implemented and managed in a manner that is technically sound and conform with best practices. However, the Government has since decided to abolish CBoH and has repealed the National Health Services Act of 1995 to pave way for these changes. By so doing, the Government is confident that the problem of duplication of duties between MOH and CBoH, as well as the bloated central level structures, would be resolved. The decision to repeal the National Health services Act has also affected the hospital and district health management boards which derived their mandate from the Act. Following this decision, the health sector is already undergoing a comprehensive restructuring process through which the functions of MOH and CBoH will be merged and the management and control of all public health facilities and services will directly fall under MOH. In order to ensure continued popular participation, the hospital and district management boards will be replaced by advisory councils. The Health Sector Reforms introduced in 1992 tended to overlook levels 2 and 3 hospitals. Policy makers and CPs exclusively focused on primary health care despite the knowledge that healthcare was a continuum of care ranging from primary health to tertiary care. In 1999, there was an attempt to bring the hospitals on board the health reform agenda. A Hospital Sector Reform Steering Committee was established to spearhead hospital sector reforms. The focus of the reforms was on formulation of a hospital policy, systems development in the hospitals such as HMIS and FAMS, development of the Basic Package of Care, quality assurance, leadership and management, and overall improvement of the quality of patient care. In 2003, as part of expanding the district basket funding, a hospital basket was established with plans to later include training institutions. During the same year, a Capacity Assessment Mission (CAMS) was conducted on hospitals, in which management systems and capacities were assessed. Following the CAMS assessments, the intention was to then provide support to hospitals in strengthening and developing appropriate systems and capacities to qualify for basket funding. Unfortunately, the CAMS report for hospitals was never finalised, capacity support was not given, and basket funding to hospitals has not been increased above the initial amount agreed.


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MOH has since realised its capacity limitations to take this forward and has identified the need to develop Technical Advisory support to hospitals and training institutions with the help of outside expertise. This programme of would aim to increase efficiency and effectiveness of the hospitals and unlock additional basket funding. The coming of the National Decentralisation Policy has brought about new challenges to the organization and management of the sector. Under the National Decentralisation Policy, all the ministries will be expected to gradually, over a period of 10 years commencing in 2003, devolve their management responsibilities to the Local Authorities. Considering that MOH has over the years made significant progress in the decentralization of health service delivery, there is a danger that if not properly implemented, the Ministry could lose most of the gains achieved in this area. The challenge for the Ministry is to proactively participate in the National Decentralisation process in order to ensure that structures and systems created under the health reforms are harmonised with the scope and direction of National Decentralisation Policy, particularly at the district level and provincial levels. Establishment of effective partnerships in the delivery of health services is one of the key principles of the Zambian health reforms. The vision has been to create strong, sustainable partnerships among all key stakeholders involved in health service delivery in Zambia. Accordingly, partnerships have been established in each district at all levels of service delivery. These partnerships allow key stakeholders to work together to analyse health problems in their respective areas, identify possible solutions, develop joint work plans, implement and evaluate progress of their programmes. The National Health Policies and Strategies also articulated policies aimed at enhancing the public private partnerships in health service delivery. Except for the Churches Health Association of Zambia (CHAZ), private sector participation in health service delivery in Zambia has however been modest. The main contributing factor is that currently there are no incentives from MOH, aimed at attracting the private sector to participate in the implementation of the Basic Health Care Package (BHCP) through the public health care delivery system. Many reasons have been given for this state of affairs, including: a) lack of knowledge about the private sector by policy makers in the Ministry; b) limited dialogue between the public and private stakeholders; c) lack of institutionalized policy instruments from MOH for interacting with the private sector especially in financing, regulation and dissemination of information. There is also need for the Ministry to strengthen accreditation of private sector health providers as another way of increasing private sector participation in health service delivery. However, the existing policy and regulatory environment is weak. The challenge for the Ministry is to harness the Public/Private sector partnerships in the delivery of public health services, through increased dialogue, development and enforcement of appropriate regulatory framework, improved coordination, monitoring and evaluation. 10.2.2 Objective To ensure efficient and effective organization and management of health service delivery at all levels, providing clearly defined role and responsibilities and appropriate authority to contribute to the improved delivery of cost-effective and quality health services.


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10.2.3 Strategies 1. Reorganise and restructure the MOH/Health sector, in order to facilitate the establishment of a

health system that is equitable, efficient, well integrated, cohesive and accountable to all stakeholders, in line with the National Decentralisation Policy;

2. Strengthen and harmonize the health sector decentralisation system in line with the new National Decentralisation Policy of 2003 and its implementation framework;

3. Clarify roles, responsibilities and organisational linkages between the popular structures and technical structures at different levels of health service delivery in the light of the new National Decentralisation Policy;

4. Strengthen institutional capacity at all levels, in particular at national and provincial health office levels, so as to improve organisation and management of health services;

5. Promote and strengthen partnerships between health centre committees and various communities/villages and resident NGOs within the catchment areas, aiming at identifying health problems and finding solutions, developing community-based work plans and sharing implementation of the planned activities;

6. Develop and implement a system for collecting accurate information about the capabilities of private health care providers and their activities, in order to assess and channel their contribution to national health priorities;

7. Develop and implement mechanisms for on going communication between government officials involved in policy design and implementation and private health care providers so as to develop better policies, taking into account the likely perspective and reactions;

8. Develop systems for enhancing the contribution of existing private providers by enhancing the effectiveness of health service regulation including price regulation; capacity regulation (i.e. volume and distribution of services); market entry and level of service; quality of care; health audits; practice guidelines and clinical protocols;

9. Promote multi-sectoral collaboration in addressing public health priorities; 10. Intensify the pace of the hospital reforms; 11. Strengthen and harmonize operations of statutory boards/bodies, service units and other

institutions under the Ministry of Health; and 12. Strengthen health services contracting and commissioning in the light of the new

Decentralisation Policy, in order to achieve equitable, efficient and cost-effective service delivery in national priority areas.

10.2.4 Expected Outputs/Key Indicators 1. Restructuring of the sector completed by 2006; 2. Capacity strengthening needs identified by 2007 and thereafter addressed; 3. Guidelines on the harmonization of the implementation of the NHSP and new Decentralisation

Policy developed in 2006; 4. Hospital reforms reinvigorated and commencement of implementation by mid 2006; 5. Capacity building in hospitals completed by 2010 6. Guidelines for coordination/monitoring/evaluation of Statutory Boards developed by 2007; 7. Guidelines for coordination, monitoring and evaluation of the private sector involved in

delivering the BHCP through the public health sector developed by 2007; 8. Existing mechanisms for health services commissioning in a decentralised environment

replicated to Local Authorities; 9. A framework for regulating the private sector involved in delivering the BHCP through the

public health system developed and implemented by 2010;


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10. Capacity strengthening needs identified by 2007 and thereafter addressed; 11. Guidelines on the harmonization of the implementation of the NHSP and new

Decentralisation Policy developed in 2006; 12. Hospital reforms reinvigorated and commencement of implementation by mid 2006; 13. Guidelines for coordination/monitoring/evaluation of Statutory Boards developed by 2007; 14. Guidelines for coordination, monitoring and evaluation of the private sector involved in

delivering the BHCP through the public health sector developed by 2007; 15. Existing mechanisms for health services commissioning in a decentralised environment

replicated to Local Authorities; and 16. A framework for regulating the private sector involved in delivering the BHCP through the

public health system developed and implemented by 2010.

10.3 Gender and Health

10.3.1 Situation Analysis On gender mainstreaming, Zambia still shows some major gender disparities in health outcomes, particularly in terms of morbidity and mortality. Overall, the issue of gender differences in access to healthcare and the impact on health outcomes does not seem to have received the attention it deserves. Currently, the participation of men in reproductive and family health is still relatively low, gender policies in the NHSP are not transformed into concrete action plans, there is no collection of gender-disaggregated data within the HMIS, there are fewer women in management positions at all levels of the public health system, and the understanding of gender mainstreaming is still limited. The challenge for the Ministry is to: develop a specific action plan for accelerated gender mainstreaming; address gender balancing in recruitment and human resource development activities; adopt a multi-sectoral approach to strategically mainstream gender; and establish clear monitoring and evaluation indicators, which can show progress on gender mainstreaming. 10.3.2 Objective To ensure that the different situations and requirements of men and women are catered for, both in service delivery and human resource management of health staff so as to enable gender sensitivity and equity in delivery of and access to health services. Also, to accord high priority to meeting the special reproductive health requirements of women. 10.3.3 Strategies 1. In line with the National Gender Policy, develop guidelines for mainstreaming gender issues in

health sector planning; 2. Development of methodologies, tools and training activities to assist integration of gender

concerns into delivery of the health care package at all levels; 3. Carry out gender training of health staff using the new methodologies and monitor their

performance; 4. Establish a data bank and carry out reviews to provide gender relevant information for

planning, decision-making and balancing of sex representations in the health boards; 5. Selection and train gender focal persons in the DHBs;


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6. Review sex balance of the composition of DHB and take steps to redress imbalance, if any;

and 7. Make all currently female focused health services including participation in family health,

more make (user) friendly. 10.3.4 Expected Outputs/Key Indicators 1. Guidelines for mainstreaming gender issues in planning developed and used in training; 2. Methodologies, tools and training activities development for enhanced gender relevant

delivery of health services; 3. Health staff practicing the gender relevant skills acquired; 4. Desegregated gender data available for planning and gender perspective action plans; 5. Review of sex balance composition of the health boards completed; 6. Gender focal persons selected by DHBs and trained in all districts; 7. Increased number of women involved in DHBs; and 8. Increased male participation in family health.

10.4 Sector Wide Approach (SWAp) 10.4.1 Situation Analysis In the context of the Zambia Health Reforms, the Sector Wide Approach (SWAp) is a long-term commitment to developing the capacity to manage the health sector, which recognizes the mandates and agenda on all parties involved. It is an agreement to a minimum sector wide programme of action with clearly defined roles, including joint planning, monitoring and implementation by Government and the CPs. The main achievement of the SWAp component of health reforms has been the pooling of MOH and donor funds for the creation of the district basket of funds. This has paved the way for harnessing internal and external resources and targeting them towards commonly shared priority interventions at the district level, resulting in improved equity and efficiency. Basket funding has also increased over the years, which has resulted in the percentage of district allocations increasing in absolute terms. SWAP management tools and structures have been developed and strengthened. This has resulted in improved policy dialogue between the Ministry and CPs. In 2001 a policy decision was made to expand the district basket into a Health Sector Basket (Health Services Fund), which would include capital, human resources, drugs and laboratory supplies, and service delivery recurrent support to all levels of the health system. The Ministry’s vision is to attain a full SWAp by end of 2005, which would entail the Ministry and CPs shifting from district basket funding to direct sector budget support, adopting common planning, monitoring and evaluation systems for managing the sector, discontinuing discreet project support, and a shift from a culture of dominance to that of partnership, mutual trust and interest. Implementation of this policy commenced in 2002, however, with the exception of the Hospital Basket, none of the above funds have been operationalised due to the following reasons: the decision to expand the basket was not accompanied with an increase in the resources; donors have kept on changing conditionalities for expanding the basket; systems, which were agreed upon to trigger the flow of funds, were not established in the proposed beneficiary institutions under the expanded basket; there is also a problem of capacity to manage the process at the center; the process of nurturing of trust between the Ministry and the CPs has been slow;


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the unavailability of a comprehensive and generally accepted resource allocation criteria that covers all levels and budget lines; some CPs still prefer direct project funding; and some donors are still not in support of the concept, for fear that there would be more emphasis on secondary and tertiary health care at the expense of primary health care. Integration of health programmes is one of the cornerstones of health reforms and significant efforts have been made in this area. However, one of the major challenges to the SWAp approach is the increasing trend for earmarked resources, especially for HIV, TB and malaria, which if not systematically addressed could increase the risk of programme fragmentation and verticalisation. MOH shall therefore engage into dialogue with the CPs to facilitate integration of earmarked vertical funding to support generic systems development and other related service delivery interventions in order to enhance synergies, minimise duplication of efforts and maximise resource utilisation. The other major challenge is the increasing Government’s emphasis on shifting from the SWAp to the Direct Budget Support (DBS) system of financing. It is envisaged that, within the duration of the NHSP, the Government will replace the SWAp with DBS, through the national treasury, as the preferred route for financing the sectors. As the numbers of CPs providing DBS increases, some form of “ring fencing” for the health sector ought to be worked out. In this respect, MOH will engage into constructive dialog with the Ministry of Finance and National Planning (MoFNP) and the relevant CPs supporting the health sector to explore various options and agree on an appropriate way of ensuring that the health sector is not disadvantaged by this change in the method of financing. (This whole section must move to the SWAp section under governance) In order to improve coordination and rational use of resources, the Ministry should integrate efforts and support in implementing health service programmes. The Ministry should also continue its efforts to strengthen the SWAp Secretariat and to expand the basket funding to other levels of the system. 10.4.2 Objective To strengthen SWAP management and coordinating mechanisms in order to improve health sector performance. 10.4.3 Strategies 1. Expand the existing common basket funding mechanism to include all levels of health service

delivery, training institutions and statutory boards; 2. Develop and transform the common basket funding into the Health Sector Budget Support

mechanism; 3. Review, develop and harmonise systems and procedures for the management of the common

basket funds; 4. Develop a common and objective framework for the release of funds by the donors, based on

agreed health sector performance benchmarks; 5. Review and strengthen the resource allocation criteria under SWAp; 6. Advocate for more funding to SWAp from the Government and CPs; 7. Review and strengthen financial reporting, transparency, accountability, monitoring and

evaluation of SWAp programmes and activities; and 8. Strengthen the SWAp Secretariat, through capacity building and training.


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10.4.4 Expected Outputs/Key Indicators 1. Existing common basket funding mechanism expanded to include all levels of health service

delivery, training institutions and statutory boards, by 2007; 2. Common basket funding transformed into the Health Sector Budget Support mechanism; 3. Systems and procedures for the management of the common basket funds harmonized by end

2006; 4. A common and objective framework for the release of funds by the donors, based on agreed

health sector performance benchmarks, developed by end 2006; 5. Existing resource allocation criteria under SWAp, reviewed and strengthened by 2007; 6. Financial reporting, monitoring and evaluation of SWAp programmes improved; and 7. Strengthened SWAp Secretariat staff, through capacity building and training.


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11 HEALTHCARE FINANCING 11.1 Resource Mobilisation 11.1.1 Situation Analysis In Zambia, the Basic Health Care Package (BHCP) for the first and second levels of care is estimated to cost around US$12.00 per capita, out of which US$10.5 is intended to be spent at the district level and US$1.5 at the secondary level. Out of the total cost for the first level health services, 38% percent is assumed to be spent at the health centre level for curative care, 36% at the district hospital for curative care, 25% for preventive programs and about 1% percent is estimated to cover operating costs at the District Health Office. If an estimate of US$2.0 is used for the cost of tertiary care, the total per capita for delivering the BHCP would be US$14.0. On this basis, Zambia would require US$14.0 x 11.6 million population = US$162.4 million per year to offer quality basic health services. It should be noted that this cost of BHCP excludes the following: • The cost of sending patients for specialized treatment abroad; • The Cost of ART and extensive use of nevirapine to control mother-to-child transmission of

HIV/AIDS, estimated to cost US$36 Million per year; • The cost implications of the recent policy change to adopt Coartem as the first line of

treatment for malaria, estimated to cost US$ 5 Million per year; • The re-introduction of residual indoor spraying for malaria; • The introduction of DPT+ Hib vaccine in January 2004, with a view to switching to

pentavalent vaccine in 2005, estimated to cost around US$6 Million per year; and • The cost of the human resource complement needed to carry out the approved Global Fund

proposals, PEPFAR and related activities. If these costs are factored in, the total resource requirements would reach approximately US$209.0 million or in per-capita terms US$18.0. In order to view the Zambian BHCP cost estimates in perspective, it would be useful to compare it with similar per-capita costing standards. The Commission on Macroeconomics and Health estimates that a typical low income country needs US$33.0 per capita to offer quality health services to its citizens. The World Bank's "Better Health for Africa," set a figure of US$12 per capita for services excluding tertiary care. In the case of Malawi, the essential health package is costed at US$12.60 per capita, excluding tertiary care, for the terminal year of the Program of Work.

The financing of health care has over the years ranged between 5.4% – 6.6% of the Gross Domestic Product (GDP). Total health care expenditure has averaged US$115 million per year during the period from 2000 to 2005, from both Government and CPs. Donor funds account for over 50 percent of health sector funds. As a percentage of the National budget, the health sector currently receive 10.5% of the central government discretionary budget.


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Table 10: Overall Health Sector Resource Envelope, 2001-2005 (US$) Source 2001 2002 2003 2004 2005

GRZ

63,034,389

65,094,432

62,673,381

92,012,654

109,194,237

Co-operating Partners

94,097,998

100,596,205

123,322,621

143,221,095

149,119,568

Households+Other

52,377,462

55,230,212

61,998,667

78,411,250

86,104,602

Total Health Expenditure(THE)

209,509,849

220,920,849

247,994,669

313,644,999

344,418,407

Per Capita Health Expenditure

22

22

24

23

21

Total Health Expenditure as % GDP

7

6

6

6

6

Change in THE over previous year (%)

5

12

26

10

CP/(CP+GRZ) (%)

60

61

66

61

58 Table 11: Public Health Sector Resource Envelope, 2001-2005 (US$) Source 2001 2002 2003 2004 2005GRZ 63,034,389 65,094,432

62,673,381 92,012,654 109,194,237

Co-operating Partners

40,957,354

42,690,917

52,048,120

68,350,550 110,032,246

Households+Other

43,329,893

44,910,562

47,800,626

59,728,501

95,186,070

Total Public Health Expenditure(THE)

147,321,636

152,695,911

162,522,127

220,091,705

314,412,553 Per Capita Health Expenditure 10.1 10.17 10.55 10.23 10.75

GRZ Budget as % GDP 1.70 1.60 1.90 1.69 1.91PHE as % GRZ Budget 13.1 10 10 11.7 11.9

Change in PHE over previous year (%)

3.65

6.44

24.95

59.36

CP/(CP+GRZ) (%)

39.39

39.61

45.37

42.62

50.19 In Zambia, the main sources of financing public healthcare services include: 1. Allocations from the Central Government; 2. Support from International Cooperating Partners (CPs); 3. The general public, through user fees and insurance schemes; 4. Contributions from employers in form of health insurance payments or direct support to their

employees; and 5. Other miscellaneous receipts, including donations in kind. In 2003, the Government started receiving significant financial support from the Global Fund for the Fight Against HIV/AIDS (Global Fund). In this respect, a total of US$1.6 million was received in 2004 for various anti-HIV/AIDS programmes. Other significant contributions to the fight against HIV/AIDS are being received from the World Bank, under the Zambia National Response to AIDS (ZANARA) Project, and the USA President’s Emergency Plan for AIDS Relief in Africa and the Caribbean (PEPFAR). It is important to note here that this international financial


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and technical support is being channeled through the Government, religious based institutions, non-governmental organizations and other projects at various levels of intervention. 11.1.2 Objective To mobilise resources through efficient and sustainable means, and to ensure efficient use of those resources in order to promote equity of access to cost effective, quality health care as close to the family as possible. 11.1.2.1 Strategies 1. Develop and implement an appropriate Healthcare Financing Policy; 2. Develop and implement appropriate healthcare financing operational guidelines; 3. Broaden the resource base through the implementation of various financing options, including

social insurance, community financing schemes, and earmarked taxes on alcohol and cigarettes;

4. Improve the targeting of exemptions on cost sharing; 5. Expand the basket funding mechanism to cover other levels of healthcare and statutory

institutions; 6. Strengthen Public/Private Sector Partnerships in healthcare financing; 7. Further develop and use the National Health Accounts as a tool for planning and resource

allocations; and 8. Harmonize and strengthen the links between the district and hospital budgets on one hand and

the sector budget and national strategic plan on the other hand. 11.1.3 Expected Outputs/Key Indicators 2. Healthcare Financing Policy approved and implemented by end 2006; 3. Various healthcare financing options identified and developed by 2008; 4. Basket funding expanded to include other levels by end 2006; 5. Public/Private Sector partnerships strengthened; and 6. A system of National Health Accounts Institutionalised and operationalised. 11.2 Resource Allocation 11.2.1 Situation Analysis The major challenge is how to manage limited health resources in an equitable and effective manner so as to ensure the delivery of quality health services. In this respect resource allocation criteria have been developed. In 1994, district resource allocation criteria applied district population multiplied by the agreed per capita, weighted for population density and presence of a second or third level hospital. In 1995, more parameters were added to account for an index of fuel prices as a proxy for cost differentials. Other parameters included proneness to cholera or dysentery and proximity to a bank and a service station. In 2004, the resource allocation criteria for the districts was further revised to include the Material Deprivation Index to take into account the poverty issues in resource allocation. While the agreed criteria were applied to the portion of the budget earmarked for districts, the rest of the budget allocation process was not clear with regard to determining appropriate proportions of funding that should go to districts in relation to other levels of the health care system. The allocation criteria has been criticised for not being flexible enough to address the utilisation of inputs such as human resources, number of health


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facilities and disease burden. Further, there are problems in “small districts” where administrative costs are high relative to the population. 11.2.2 Objective To allocate resources equitably and efficiently and ensure the effective utilization of those resources for the provision of healthcare services. 11.2.3 Strategies 1. Strengthen existing resource allocation criteria so as to take better cognisance of different

health service needs of various population groups and geographical location, including the need for appropriate incentives for healthcare providers;

2. Prioritise primary healthcare in the resource allocation process; 3. Promote the retention and use of locally generated resources; 4. Develop mechanisms for enhancing co-ordination of domestic and external health resources

and commodities with a view to promoting higher efficiency levels; 5. Allocate more resources to the development of specialized health facilities as a way of

reducing expenditure on treatment abroad; and 6. Develop new tools for costing and budgeting in order to improve allocation and utilization of

resources in second and third level hospitals. 11.2.4 Expected Outputs 1. Resource allocation criteria for equitable distribution of resources to both primary health care

and hospitals revised by 2006; 2. Guidelines for intra district resource allocation developed by end 2007; 3. Mechanisms for enhancing coordination of local and external resources developed by end of

2007; and 4. New tools for costing and budgeting developed for second and third level hospitals by end

2007.


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12 COSTING AND FINANCING OF THE STRATEGIC PLAN This Strategic Plan, unlike the previous one is costed. The addition of a section on cost and financing of the NHSP in the plan is expected to significantly enhance the financial sustainability of the plan by ensuring sufficient financing for planned programmes. The costing and financing plan covers a period of 5 years starting with 2006 to 2010, which is in line with the NDP duration and allows for implementation through two three-year term rolling MTEF plans. The cost and financing study for the NHSP used approaches of rapid assessment, which utilizes secondary data generated from various cost studies (such as on human resource, HIV/AIDS, Malaria, and TB) and key informant opinions and makes assumptions based on investigators experiences in arriving at estimates on both financing need and gaps. In the detailed costing and financing report in annex III, the cost is divided into baseline costs and incremental costs. The rationale for using this principle is that the focus of NHSP 2006-2010 is on what need to be done, in addition to what we have been doing. The cost for additional activities or outputs is defined as incremental cost, and the cost for maintaining regular activities is defined as baseline cost. The sum of these two is the total financing need for the NHSP. The estimation of the financing need is based on outputs, rather than activities since only the objectives, strategies and the outputs are specified in the NHSP. It was assumed that the costs for achieving the objectives, for implementing the proposed strategies and for producing the defined outputs are equal. Given the fact that outputs were more costable than either objectives or strategies, the costing study adopted an output-based costing approach. Table 12 above shows the total financing need by strategic area for the period 2006 to 2010. The total financing need for implementing the 5-year NHSP is 8.45 trillion ZMK, rising at a compounded annual rate of 22% from ZMK 1.1 billion in 2006 to ZMK 2.4 billion in 2010. The strategic areas that make up the major portion of the total financing need are: human resources (30%), HIV/AIDS (23%), essential drugs and medical supplies (12%), and for infrastructure and equipment (11%). Financing for malaria and TB account for 7% and 5% respectively while the financing need for reproductive health is 4%. These 7 strategic areas occupy 90% of the total 5-year financing need of the NHSP. The growth in the total financing need is bound to be influenced by the performance of the economy at macro level vis-à-vis monetary exchange rate fluctuations; inflation; debt servicing; employment; population growth; huge disease burden (current and emerging diseases – seasonal and climatic); cost of new interventions (introduction of new Vaccines and provision of expensive HIV/AIDS, Malarial and TB drugs); implementation of the Human Resources Strategic Plan (training, recruitment and retention of health workers); and implementation of the User fees removal policy. Appendix III provides a detailed analysis of the incremental, baseline and total financing need by strategic area for the period 2006 to 2010.


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Table 12: Total financing need by strategic area and by year (ZMK 000)

AREA 2006 2007 2008 2009 2010 Total

Human resource 385,133,957 411,692,837 438,712,457 616,718,543 663,247,680 2,515,505,475

HIV/AIDS, STIs and blood safety 138,206,770 253,939,512 375,617,424 515,914,456 672,954,581 1,956,632,742

Essential drugs and medical supplies 150,250,617 175,432,531 202,367,820 233,042,377 260,601,978 1,021,695,324

Infrastructure and equipment 122,023,298 167,550,970 179,268,176 206,158,402 236,999,085 911,999,931

Malaria 70,699,454 95,042,157 116,943,754 124,165,012 142,854,118 549,704,494

Tuberculosis (TB) 61,664,750 71,370,245 88,698,994 95,722,481 110,080,853 427,537,323

Integrated reproductive health 37,883,000 47,104,645 58,019,928 71,447,597 86,265,579 300,720,749

Clinical care support services 35,313,532 41,589,707 53,917,658 63,331,638 73,721,803 267,874,338

Child health 36,471,660 39,594,863 45,368,283 52,192,360 60,040,523 233,667,690

Nutrition 6,535,168 11,339,564 17,639,926 25,628,542 35,555,559 96,698,757

Environmental health and food safety 9,373,809 10,841,650 12,426,220 12,846,201 14,688,279 60,176,160

System strengthening 5,948,000 6,766,370 7,532,696 8,312,190 6,910,324 35,469,579

Other public health interventions 4,734,351 6,013,925 5,814,314 5,658,349 6,507,102 28,728,041

Epidemics control and public health surveillance 3,965,546 4,560,378 5,112,185 5,780,155 6,647,179 26,065,443

Health systems governance 2,056,000 2,358,880 1,867,899 1,779,424 2,046,337 10,108,540

Health care financing 1,164,400 2,178,560 2,187,944 2,219,565 2,250,901 10,001,370

Total 1,071,424,314 1,347,376,793 1,611,495,676 2,040,917,292 2,381,371,879 8,452,585,955

Financing of the plan will be based on the commitments made by both the Government and the CPs, projected inflows from other sources including the Global Fund, PEPFAR, World Bank/ZANARA project and direct project funding from various donors, and income generating opportunities. A Memorandum of Understanding between the MOH and the CPs covering the duration of this plan is being drafted, which will form the basis for future financial and technical support from the CPs. Table 13 below presents the total financing need, available resources, and financing gap of the national health strategic plan 2006-2010 Table 13: Total financing need, available resources, and financing gap of the national health

strategic plan 2006-2010 (ZMK 000)

2006 2007 2008 2009 2010 Total

Total Financing Need 1,071,424,314 1,347,376,793 1,611,495,676 2,040,917,292 2,381,371,879 8,452,585,955 Total Financing Available (High Level Scenario) 895,234,054 1,186,471,263 1,397,967,867 1,584,005,782 1,951,618,481 7,015,297,446

Total Financing Available (Low Level Scenario) 895,234,054 902,927,210 919,369,571 945,652,315 984,396,308 4,647,579,457

Financing Gap (Better Scenario) 176,190,260 160,905,530 213,527,810 456,911,511 429,753,399 1,437,288,509

Financing Gap (Worse Scenario) 176,190,260 444,449,583 692,126,105 1,095,264,978 1,396,975,571 3,805,006,498


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The total 5-year available financing ranges from 7.01 trillion ZMK with better scenario and 4.6 trillion ZMK with worse scenario. The total 5-year financing gap in the better situation, which considers high level financing scenario for both the GRZ and donors, is 1.4 trillion ZMK; and in the worse situation, which considers low level financing scenario for both the GRZ and donors, the 5-year financing gap will be 3.8 trillion ZMK. The financing gap under better scenario in 2006 is 176 billion ZMK, falling short about 16% of the estimated financing need (see table 7 and figure 5). For the later years and in the better situation, the financing gap increase at an annual rate of 25%, and the gap reaches 429 billion in 2010. In the worse situation, the financing gap will increase from 176 billion ZMK in 2006 to 1.4 trillion in 2010, is close to 8 times of increase by the end of the planning period. There is need to mention that resources from global initiatives such as the global funds and the President’s emergency fund are available but have not been adequately captured because of the difficulties associated with predicting resource flows from these sources and the fact that a sizeable proportion of these resources are targeted towards community based programs not directly related to health. The data presented in Table 13 above is further depicted in Figure 2. Figure 2: Total financing need, available financing, and financing gap of the National Health

Strategic Plan 2006-2010 in ZMK ‘000

0

500,000,000

1,000,000,000

1,500,000,000

2,000,000,000

2,500,000,000

3,000,000,000

2006 2007 2008 2009 2010

Year

(1,0

00 K

w)

Total financing needTotal financing available (high level senario)Total financing available (low level senario)

The financing gap of the NHSP will be filled by employing a combination of the following four strategies: (1) improving the efficiency of current health system through better allocation of resources, performance-oriented and need-based training, appropriate use of incentive and motivation strategies, and harmonized program activities; (2) resource mobilization from donors via improved political commitment of the GRZ, showing results from the resource inputs, improved accountability and transparency, and better communication strategies; (3) increasing government financial commitment; and (4) increased private financing via various prepayment schemes especially high cost services.

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13 IMPLEMENTATION, MONITORING AND EVALUATION OF THE NHSP 13.1 Implementation 13.1.1 Implementation Timeframe The NHSP covers duration of six years, commencing 1 January 2006 to 31 December 2010. This timeframe is in line with the duration of the National Development Plan (NDP). 13.1.2 Link to National Development Plan and MTEF The NHSP is closely linked to the National Development Plan 2006-10 (NDP). The NDP presents a summarised version of national priorities, strategies and implementation framework for the whole national economy. In this respect, the NDP chapter on health presents a summary of the health sector strategy. On the other hand, the NHSP is an expanded version of the NDP chapter on health, and presents a more detailed analysis of the existing situation, sector priorities, proposed strategies and expected outputs, and will serve as an important tool for implementing the NDP. The NHSP is also linked to the Medium-Term Expenditure Framework (MTEF). MTEF plans are three-year rolling plans based on the NHSP priorities and strategies, and are considered as important tools for implementing the NHSP. The NHSP will be operationalised through a series of MTEF and annual action plans and budgets. MTEF plans will translate the NHSP priorities and strategies into costed activities for implementation over three-year durations. The NHSP will provide the framework and requisite parameters for the development of MTEF and annual action plans for all relevant planning entities at all levels, including the centre, provincial health offices, districts, hospitals and statutory boards under MOH. To this effect, MOH will prepare and disseminate specific guidelines on how to operationalise the NHSP into MTEF and annual action plans. 13.1.3 Decentralisation: Centre –District Linkage In 2003, the Government launched the National Decentralisation Policy, which aims at providing the citizenry with an opportunity to exercise control over its local affairs and foster development. The National Decentralisation Policy spells out various measures aimed at, among other things, devolving specified functions and authority with matching resources to local authorities at district level. Under this environment, the role of the centre will be to provide policy, strategic guidelines, overall coordination, monitoring and evaluation. Implementation and supervision of the programmes will be through the local authorities. This policy will implemented gradually over a period of 10 years, starting from the time it was launched in 2003. The full-scale devolution will therefore not be achieved during the 6-year duration of this NHSP. However, MOH will aim at making significant progress towards the implementation of this policy by developing and implementing appropriate measures aimed at empowering the local authorities to start actively participating in the planning and management of health services.


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These measures will include: • Ensuring that the process of developing district health plans includes inputs from other non-

health sectors such as agriculture, community development, education, child and youth departments at district level, and reviews by the District Health Advisory Committees (DHAC) before submission to the DDCC for approval;

• Build appropriate capacities for local authorities, especially the District Development Coordinating Committees (DDCC) in health planning and programme oversight. In this respect, the procedure for approving district health plans will be changed to allow the DDCC to review and approve these plans at local level, before they are submitted to PHOs/MOH; and

• Increasingly integrate district health planning into the overall District Development Plans and long-term vision.

13.1.4 Link to the Sector Wide Approach (SWAp) The NHSP will have a direct influence on resource requirements, mobilisation and allocation for the health sector. Both resource mobilisation and resource allocation will be directed towards addressing the health sector priority interventions to achieve the vision and goal for the NHSP. Over the past 5 years, the Ministry has made reasonable progress in strengthening the SWAP mechanism as an important tool for mobilizing and allocating funds for the health sector. In this respect, appropriate SWAP management tools and structures have been developed and strengthened, which has improved policy dialogue between the Ministry and the CPs. The Ministry is committed to further strengthen the SWAp and will encourage all the CPs and other stakeholders supporting the NHSP to channel their financial contributions through the SWAp mechanism. In this respect, all the main stakeholders, including the Government and CPs are required to commit themselves to support this plan. To facilitate this process, the existing Memorandum of Understanding (MoU) between MOH and the CPs will have to be amended to address the new demands and priorities presented in the NHSP. In order to ensure that all the relevant areas receive appropriate support through the SWAP, MOH will build on the successes of the existing basket funding arrangement and, together with the CPs, take appropriate measures to expanded the health sector basket, both vertically and horizontally, so as to include all the levels and areas that are critical to efficient and effective health service delivery. However, the sustenance and expansion of the health sector basket is contingent upon MOH meeting a number of benchmarks in respect of levels of income and expenditure, mainstreaming of gender, procurement management, planning and budgeting, monitoring and evaluation, and reporting at all levels. MOH will undertake to fulfil these milestones and take advantage of the good will and support from CPs to mobilise adequate resources for effective implementation of the NHSP. 13.1.5 Implementation Structures The NHSP will be implemented and coordinated through the existing health sector organisational and management structures, which will include: the Health Sector Advisory Group (SAG) and MOH Headquarters at national level; Provincial Health Offices (PHOs) at provincial level; District Health Advisory Boards (DHABs) and District Health Management Teams (DHMTs) at district level; Hospital Management Advisory Boards (HMABs) and


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Hospital Management Teams (HMTs) at hospital level; Statutory Boards, both regulatory and service boards; the Churches Health Association of Zambia (CHAZ) and faith based health institutions; private health institutions and hospitals; traditional healers and their registered associations; and non-governmental institutions involved in the health sector. Each of these structures will have specific coordination and implementation functions for the NHSP. Health Sector Advisory Group (SAG) The Health Sector Advisory Group (SAG) is a high level forum bringing together the Ministry, CPs and the Civil Society, to provide advice to the Ministry on aspects of health sector governance. As part of its mandate, SAG will be responsible for overall steering of the implementation process. SAG members will meet every after six months (biannually) to review progress, recommend solutions to identified bottlenecks and build consensus on the overall strategic direction of the NHSP. Ministry of Health The MOH Headquarters will be responsible for policy and legal framework formulation, strategic decision-making, standards setting and enforcement, and the overall coordination of the implementation of this plan. In this respect, the Ministry of Health will coordinate the policy formulation and legislative changes aimed at supporting of the implementation of the NHSP. The Directorate of Planning and Development of the Ministry o Health will be responsible for the overall functional and technical coordination of the implementation of the NHSP. Explicit activities for plan coordination will therefore be an integral component of the directorate’s annual action plan. Concurrent to the policy formulation and coordination function, the other MOH directorates and units will be responsible for the implementation of specific aspects of the NHSP in line with their defined roles and responsibilities. Statutory Boards Currently, there are two types of Statutory Boards under the MOH structures, regulatory and service statutory boards. The role of the regulatory statutory boards in the implementation of the NHSP will be to ensure that the relevant laws and regulations are developed and enforced to ensure high standards of ethics and professionalism in the health sector. On the other hand, the role of the service statutory boards in the implementation of the NHSP will be to provide their respective services in support to the core health services. All statutory boards will be required to develop and implement three year MTEF plans and annual action plans in respect of their mandates, and in line with the strategic direction provided by the NHSP. MOH and SAG will facilitate the approval, implementation, monitoring and evaluation of the implementation of these plans. Provincial Health Offices PHOs will continue serving as intermediaries for operationalisation of the NHSP. They are the MOH’s functional link with the lower level structures, training institutions and the civil society. PHOs will specifically ensure that the priorities and scope of the hospital and district MTEF and action plans are informed by the parameters provided through this NHSP. The PHOs will continue to be responsible for coordinating and supervising the implementation of the NHSP and health service delivery in general for their respective territories and provide the necessary technical support to all health service institutions.


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Districts and Hospitals Districts health management structures and hospitals will serve as the major implementing agencies for this plan. This will include public and faith based hospitals and clinics spread all over the country. Harmonization of the district and hospital plans to match the aspirations of the NHSP will therefore be crucial for successful implementation. Other Implementation Structures The other structures, including private health institutions, NGOs and traditional health practitioners. These institutions will be expected to significantly contribute to the implementation of this plan by effectively playing there respective roles. MOH is committed to strengthening partnerships with all these stakeholder groups and ensure synergies, through improved coordination and collaboration. In this regard, the District and Hospital Management Teams will translate the strategies provided in this plan into three year MTEF and annual action plans. In order to ensure that plans at this level of the health care delivery system reflect the provisions of the NHSP, the MOH shall prepare and disseminate annual planning guidelines, which will spell out areas of strategic focus by District and Hospital Management Teams as they prepare their MTEF and annual action plans. 13.1.6 Health Sector Management Every year, MOH will organise two SAG meetings, which will involve the participation of all NHSP stakeholders, in particular, GRZ, CPs and the civil society. These meetings will be arranged as follows: • The first SAG meeting will be held in March every year and will review the work undertaken

to implement the NHSP during the previous year. Its purpose will be to review overall progress in the sector, reaffirm/revise policies and strategies, agree on priorities, and the overall resource allocation for the next annual action plan. This comprehensive review will be informed by a technical and financial progress report for the previous year, together with the findings of the external Joint Annual Review (JAR) mission, which will be undertaken in January-February each year.

• The second SAG annual meeting will be held in September and will discuss the draft annual action plan and the draft budget for the next financial year. The annual action plan includes the plans of the various sub-committees, the technical working groups and the sector investment plan (SIP). In addition, the financial audit report for the previous year will be presented and discussed during the second SAG meeting.

In November each year, an Annual Consultative Meeting (ACM) will be held at which the Minister of Health and the Heads of Missions of the CPs will discuss the next year action plan and budget and present their financial commitments of support to the health sector. MOH will notify the CPs at least 21 days in advance about date, time, venue and agenda of the ACM and the two SAG meetings. In addition to the SAG, ACM and mini-SAG meetings, there are monthly MOH-CP Policy Coordination Meetings (every last Thursday of the month), which are chaired by either the Permanent Secretary of MOH or his/her delegated authority. These monthly policy meetings address general SWAp related issues. MOH will be responsible for establishing any additional mechanisms for consultation on a needs basis, e.g. specialist ad hoc technical working groups, and consultation processes with other stakeholders and constituencies, including the civil society, boards, private sector and NGOs.


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MOH and CPs will ensure that appraisal, supervision, monitoring, auditing and evaluation missions are carried out jointly to the extent possible. CPs will endeavour to reduce bilateral missions to a minimum, consistent with their own organizations’ requirements, and to align any such missions to the extent possible with the Joint Annual Review (JAR) mission. Finally, the MOH will be responsible for ensuring relevant and appropriate inter-ministerial coordination in health sector policy dialogue and service delivery, including participation at key fora as appropriate. 13.1.7 Planning and Budgeting Systems In addition to the Health Sector Budget for the six year period of the NHSP, MOH will prepare an Annual Action Plans with budgets that will include all the resources (GRZ and CP) available for the implementation of the annual plan. In principle, all health sector resources2 will be captured in the MOH resource envelope and the MTEF. MOH will ensure that the proportion of the overall GRZ budgetary allocation to the health sector is maintained at 11% (2005) or increased over the period of the NHSP to 12% in 2006 and 15% by 2010. Further, GRZ/MOH will ensure that all plans, budgets and expenditures are in line with national policy and the requirements of the NDP, the NHSP and MTEF. The planning and budgeting framework and process will follow the MTEF requirements and guidelines. Each level of the health system will formulate its own plan, priorities and budget requirements in line with the budget ceilings allocated to them by MoFNP and the annual planning and budgeting guidelines issued by the MOH. Increasingly, Rolling Work Plans will replace the current annual action plans to improve the quality of planning and reduce transaction costs. MOH will develop sector work plans with expenditure proposals as part of the MTEF and the annual budget cycle in consultation with the CPs. Proposed expenditures on all health activities, however financed, should be included in the budget, as required by GRZ financial regulations and procedures. The CPs will be requested to support the health sector by aligning and – to the extent possible – by synchronising their interventions with the MOH priorities and timelines as specified in the NHSP. To support this process, the CPs will be expected to provide information on their disbursements to the MOH by the end of each February, for financing Quarter 2+3, and at the end of each August, for financing Quarter 4 and Quarter 1 of the next year. Wherever possible and appropriate, consultations on health issues will be undertaken collectively through meetings with the members of the SAG, rather than through bilateral meetings of MOH with individual CPs.

2 Financial resources for the health sector (next to GRZ resources) include: (i) the expanded basket, (ii) the district basket, (iii) various earmarked pooled funding arrangements (like those for training institutions, hospital reforms, pharmaceuticals and MOH, and (iv) specific programme/project support.


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13.1.8 Capacity Development MOH will establish mechanisms to provide adequate capacity, linked to performance, for successful program implementation. Programmes supported by CPs will work through the structures designated by the MOH, in order to build capacity, improve sustainability, and ensure maximum integration with the MOH policies and programmes. No new project implementation units, financial management agencies, or similar parallel structures will be created for the specific purpose of managing external assistance projects. Notwithstanding this position, MOH may choose to use external agents for implementation tasks in circumstances where it is cost-effective and sustainable to do so. Such arrangements are likely to occur as exceptions, and there should be a clear rationale and strong case made for this approach. CPs will work towards establishing a pooled funding arrangement for externally funded technical assistance to MOH to improve coordination and avoid duplication. Technical Assistance programs should rely on Zambian resources whenever possible. Expatriate assistance (when required) should be complementary to and develop national and regional consultancy expertise. MOH, in consultation with the CPs, will be responsible for preparing an annual Capacity Development Plan, which identifies programme implementation priorities and associated financing needs. This plan will include broad capacity development priorities such as technical assistance, institutional strengthening, training, research, pilots and studies for supporting the planning and implementation of the NHSP. In this respect, the CPs will ensure that their current and proposed support to capacity development is aligned with the plan. A contingency provision to fund urgent tasks that were not anticipated will be included. Allocation of these funds will be approved through the second annual SAG meetings. 13.2 Monitoring and Evaluation Monitoring and evaluation of the implementation of the NHSP will be conducted through appropriate existing and new systems, procedures and mechanisms. The Monitoring and Evaluation Sub-Committee of SAG will be responsible for providing advice on all matters concerning monitoring and evaluation. The following describe the main tools and approaches that will be applied in the monitoring and evaluation of the implementation of the NHSP. 13.2.1 NHSP Indicators The indicators to be used in monitoring and evaluating this NHSP are presented at Appendix I. They cover 14 major thrusts: Child health, reproductive health, malaria, TB, HIV/AIDS and blood safety, critical service delivery areas, infrastructure and equipment, essential drugs and medical supplies, health education, gender and equity, human resources, surveillance and information systems, financing and procurement. The goals/objectives and indicators were guided by the following sources: • Millennium Development Goals and indicators; • Indicators covered in the previous NHSPs that are still deemed relevant;


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• Goals, indicators and targets of national programmes and international

declarations/commitments (PRSP, Roll Back Malaria, Stop TB Programme, Abuja Declaration, etc); and

• Other emerging high priority areas for the health sector in Zambia.

MOH and the CPs will harmonise sector performance indicators (as specified in the MTR/NHSP), and use these as the basis for the joint reviews. Indicators will include: sector performance benchmarks and triggers for sector budget support, output and process indicators to assess service delivery (quality, access, efficiency) and indicators of health status (impact). They will be derived as far as possible from routine monitoring systems (HMIS) and build on those required for the monitoring and evaluation of the NDP/PRSP and the MTEF in order to avoid duplication of effort. 13.2.2 Monitoring Depending on the type and relevance of the indicators, routine monitoring will be undertaken, on a monthly, quarterly, bi-annual and annual basis. The HMIS, FAMS and other routine systems will be the major tools for data collection. The SAG, MOH and other agencies will primarily use this data and its analyses for decision making. MOH will produce quarterly activity and financial reports for all levels of the health system for consideration at the Mini-SAG meetings. It will also produce an Annual Performance Review Report every May, on the performance of the sector against annual plans and output targets. MOH will be responsible for sector performance monitoring and review. It will plan and lead the Joint Annual Reviews (JAR) in January-February every year, together with appropriate involvement and support of the CP, other Government ministries and other key stakeholders. The findings of the JAR will be presented at the first SAG meeting of each year, in March. CPs and other key stakeholders will actively and fully participate in the JAR and will accept the JAR as satisfying their own review requirements. To the extent possible, they will not undertake separate monitoring or review missions, without the approval of the M&E Sub Committee of the SAG. 13.2.3 Evaluation

There will be two evaluations during the duration of this plan. These will consist of a mid-term assessment after the first 3 years of implementation and a comprehensive final evaluation in 2010. MOH will organise a joint mid-term review (MTR) before the end of the third year of NHSP. An independent external evaluation will be undertaken in the final year of NHSP. All stakeholders will agree on the timing, terms of reference and composition of these two review missions. All costs will be included in the Health Sector Budget. Where appropriate/possible, the MTR and the final NHSP evaluations will be combined with the JAR for that year. The mid-term assessment will focus on progress made in plan implementation and assess the appropriateness of the overall strategic direction. It will therefore be designed to inform the remaining period of the plan and recommend adjustments where need be. The final evaluation will focus on impact/outcome of the NHSP and assist in providing the contextual framework for the subsequent planning period.


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14 APPENDICES Number Description Appendix I Matrix of Monitoring & Evaluation Indicators and Targets Appendix II Health Sector Planning Circle Appendix III Costing and Financing Report


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82 “…equity of access to cost-effective, quality healthcare…”

Appendix I Matrix of Monitoring & Evaluation Indicators and Targets No. Category Indicator Purpose National

Baseline (Yr. 2005)

National Target (2010)

Source of Data

1 Input Percentage of GRZ budget allocated to health sector

GRZ commitment to health

10% 15% MoFNP

2 Input Total public (GRZ+CPs) allocated to health per capita

Equity of health resources allocation

US$10.5 M (Yr. 2000)

US$16.0 M MoH

3 Input MoH expenditure on PE Equity in health care allocation

66 % (Yr. 2001)

60% MoH

4 Input Percentage of health facilities without any stock-outs of tracer supplies in a month


82% (Yr. 2004)

100% HMIS

5 Input Percentage of donated blood tested for HIV, Hepatitis B and C, and Syphilis in accordance with National and WHO guidelines


100% (Yr. 2001)

100% HMIS

6 Process Proportion of districts submitting complete HMIS quarterly returns to MoH in time

Management capacity for performance monitoring

95% (Yr. 2004)

100% HMIS

7 Process Health centre staff workload

Staffing levels 17.2 (Yr. 2004)

15.0 HMIS

8 Process Percentage of population within 5 km of a public health facility

Equity in geographical access to health care

75.5% (Yr. 2004)

85% LCMS (CSO)

9 Output Percentage of deliveries supervised by skilled health workers

Maternal health 43% (Yr. 2004)

50% HMIS

10 Output Percentage of fully immunized children under the age of 1yr


90% HMIS

11 Output ITN coverage (under 5yrs; pregnant women)

Maternal and child health

28% (Yr. 2005)

75% MIS/NMCC

12 Output ART coverage (No. of people accessing ARVs)

Access to HIV/AIDS treatment

40 000 PLWHA

250 000 PLWHA

MoH/NAC

13 Output TB cure rate TB case management

73% (Yr. 2004)

85% MoH

14 Outcome Malaria case fatality rate among children below 5 yrs old

Quality of malaria case management in under fives

33 per 1000 admin

(Yr. 2004)

15 per 1000 admin

HMIS

15 Output Underweight prevalence in children below 5yrs old


15% HMIS

16 Outcome Health centre utilisation by children below 5yrs old

Utilisation of health services

0.76 (Yr. 2004)

3.0 HMIS


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, quality healthcare…”05 83 “…equity of access to cost-effective

Appendix II Health Sector Planning CircleHealth Sector Planning Circle

National Level Consultations


Programme Strategic Plans


Directorate/Units Strategic Plans

Institutional Strategic Plans

National Development Plan

National Health Strategic Plan

District level consultations

District Level consultations

District Level consultations


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Appendix III Costing and Financing Report

Table A1. Baseline and incremental financing need for human resource by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total

100 medical doctors produced annually 3,087,500 7,101,250 12,249,656 18,782,806 27,000,284 68,221,496

500 nurses produced annually 8,312,500 19,118,750 32,979,844 37,926,820 43,615,843 141,953,757250 graduates produced through direct entry midwifery annually 4,156,250 9,559,375 10,993,281 12,642,273 14,538,614 51,889,794

3 training institutions renovated annually 8,809,532 10,130,962 11,650,606 13,398,197 15,407,927 59,397,224100 Zambian doctors recruited through a retainer package annually 4,771,726 5,058,029 5,361,511 11,366,403 12,048,387 38,606,056

300 Zambian nurses recruited through a retainer package annually 5,388,372 5,711,674 6,054,375 6,417,637 6,802,696 30,374,754

100 CO recruited through a retainer package annually 1,796,124 1,903,891 2,018,125 2,139,212 2,267,565 10,124,918400 interns recruited under bilateral agreements in planning years 5,984,761 6,343,847 6,724,477 7,127,946 7,555,623 33,736,654

50 old retired specialists recruited under bilateral agreements 954,345 1,011,606 1,072,302 1,136,640 1,204,839 5,379,732

100 other retired health workers recruited under bilateral agreements 359,225 380,778 403,625 427,842 453,513 2,024,984

Motivation and retention package for other medical staff implemented by 2010 0 0 0 152,087,500 174,900,625 326,988,125

Human Resource Management Systems re-engineered at all levels 2,475,825 2,847,199 3,274,279 3,765,420 4,330,233 16,692,956

Mandatory rural posting for all graduates implemented by December 2006 495,000 569,250 654,638 752,833 865,758 3,337,479

Information on Zambian health workers abroad compiled and published annually 200,000 230,000 132,250 152,088 174,901 889,238

Total incremental cost 46,791,160 69,966,611 93,568,969 268,123,620 311,166,808 789,617,168

Baseline cost 338,342,798 341,726,226 345,143,488 348,594,923 352,080,872 1725888306

Total financing need 385,133,957 411,692,837 438,712,457 616,718,543 663,247,680 2515505474


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Table A2. Baseline and incremental financing need for child health by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total At least 3 district staff trained as trainers in IMCI for all district during the first three years of the planning period 172,800 198,720 228,528 0 0 600,048

Facilitation of health centers managing children according to IMCI guidelines; 100,000 115,000 132,250 152,088 174,901 674,238

80% of district hospitals able to provide appropriate Emergency, Triage and Treatment of sick children; 100,000 115,000 132,250 152,088 174,901 674,238

80% of districts promoting at least six priority practices in community IMCI 2,700,000 483,000 238,050 273,758 0 3,694,808

Full immunizations coverage of at least 80% in all districts; 5,433,600 6,448,574 7,653,149 9,082,763 10,779,307 39,397,393

1000 health workers trained in Essential Newborn care; 480,000 552,000 634,800 730,020 839,523 3,236,343Provincial health management teams trained in planning and implementation of C-IMCI (3 per province) 0 74,520 0 0 0 74,520


Baseline cost 27,485,260 31,608,049 36,349,256 41,801,645 48,071,892 185,316,102

Total financing need 36,471,660 39,594,863 45,368,283 52,192,360 60,040,523 233,667,690


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Table A3. Baseline and incremental financing need for nutrition by year (ZMK 000)


Number of children exclusively breastfed for the first six months of life increased from 40% to 60% 150,000 172,500 198,375 228,131 262,351 1,011,357

Vitamin A supplementation for children increased from 68% to 90% 1,118,332 2,572,164 4,436,982 6,803,373 9,779,848 24,710,699

Iimplementation of nutrition guidelines 200,000 230,000 264,500 304,175 349,801 1,348,476Increased number of districts implementing community based growth monitoring and promotion from current 40 to 72

210,000 241,500 277,725 372,614 428,507 1,530,346

Increased coverage of vitamin A supplement for lactating women postnatally (within 8 weeks of delivery) from 39% to 80%

479,490 1,102,827 1,902,385 2,916,990 4,193,173 10,594,864

Increased proportion of health facilities providing nutritional care and support from 10% to 60% 810,000 931,500 1,071,225 1,231,909 1,416,695 5,461,329

Increased proportioin of AIDS patients with nutrition supplement and support from current 20% to 60% 3,000,000 5,390,625 8,430,938 12,262,055 17,052,811 46,136,428

Increased proportion of hospitals providing dietetic support to patients from current 8% to 60% 400 460 529 669 770 2,828

BSc programme in nutrition introduced at UNZA in 2008, which enrolls 20 students each year 0 0 254,581 585,537 1,010,051 1,850,169

Increased proportion of paediatric medical staff trained in severe malnutrition management from current 20% to 80% 0 46,000 52,900 60,835 69,960 229,695


Baseline cost 566,946 651,988 749,786 862,254 991,592 3,822,566



December 2005


Table A4. Baseline and incremental financing need for integrated reproductive health by year (ZMK 000)


Focused - ANC increased from 70% to 80% 3,753,800 4,529,013 5,460,103 6,664,351 8,121,853 28,529,120Increase in facility deliveries from 43% in 2005 to 50% 22,522,800 27,648,046 33,872,543 41,423,238 49,581,079 175,047,707

Modern contraceptive prevalence rate increased from 23% to 35% 5,630,700 7,846,651 10,319,445 13,456,520 16,871,955 54,125,271

20% of the women of reproductive age screened at least once for cervical cancer (PAP smear) 5,630,700 6,684,184 7,911,574 9,378,787 11,087,285 40,692,530

Total incremental cost 37,538,000 46,707,895 57,563,666 70,922,896 85,662,172 298,394,628Baseline cost 345,000 396,750 456,263 524,702 603,407 2,326,122Total financing need 37,883,000 47,104,645 58,019,928 71,447,597 86,265,579 300,720,749


December 2005


Table A5. Baseline and incremental financing need for HIV/AIDS, STIs and blood safety by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Number of CTC centres in health facilities and at community level increased from 420 to 840 by 2010 126,000 144,900 166,635 191,630 220,375 849,540

Increased number of Health Centre catchment areas with a functional HBC program from currnent 300 to 750 by 2010 180,000 207,000 238,050 273,758 314,821 1,213,629

HIV/AIDS at work place programmes implemented in all districts 7,000 8,050 9,258 11,407 13,118 48,832

Increased number of AIDS patients on ART from current 40,000 to 210,000 by 2010 68,000,000 140,250,000 212,500,000 284,750,000 357,000,000 1062500000

Increased % of the adult population using VCT from current 13% (accumulative) to 30% by 2010 3,580,710 4,117,817 4,735,489 5,445,812 6,262,684 24,142,512

Increased the number of AIDS patients treated for OIs from 50% of AIDS patients to 80% 17,000,000 42,032,500 74,192,250 115,054,194 166,505,395 414,784,339

The number of HIV positive pregnant mothers accessible to PMTCT increased from current 22500 HIV pregancies (25%) to 61600 (70%)

382,500 630,976 945,389 1,339,929 1,831,559 5,130,354

Increased number of AIDS patients accessible to HBC from current 57,000 to 200,000 by 2010 14,250,000 26,665,625 42,485,313 62,450,930 87,450,313 233,302,180

The coverage of STI treatment increased from current 50% to 80% by 2010 (prevelance = 8% of adult pop) 2,527,560 2,906,694 3,342,698 3,844,103 4,420,718 17,041,773

All additional units of blood screened 153,000 175,950 202,343 232,694 267,598 1,031,584

Total incremental cost 106,206,770 217,139,512 338,817,424 473,594,456 624,286,581 760044741

Baseline cost 32,000,000 36,800,000 36,800,000 42,320,000 48,668,000 196,588,000



December 2005


Table A6. Baseline and incremental financing need for tuberculosis (TB) by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Regular support and supervision provided at all levels by 2008 4,720,100 5,428,115 12,484,665 14,357,364 16,510,969 53,501,212

100% of population covered by DOTS activities by 2008 9,201,600 10,581,840 12,169,116 13,994,483 16,093,656 62,040,695Smear microscopy centers providing quality assured TB diagnostic services established in all 72 districts by 2008 3,200,000 3,680,000 4,232,000 0 0 11,112,000

Quality DOTS and TB/HIV collaborative activities implemented by the private sector/communities at least in 3 high burden provinces by 2010

813,430 935,445 1,075,762 0 0 2,824,637

BCC strategy for TB/HIV implemented in all districts by 2008; 225,000 258,750 297,563 0 0 781,313

All eligible TB patients to have access to nutrition supplementation by 2010; 576,000 993,600 1,523,520 1,752,048 2,014,855 6,860,023

50% of the districts to include a plan for operational research in their work plans by 2010. 649,997 872,079 1,002,891 1,318,085 1,515,798 5,358,850

IEC for TB awareness increase 200,000 230,000 264,500 304,175 349,801 1,348,476


Baseline cost 42,078,623 48,390,416 55,648,979 63,996,325 73,595,774 283,710,117



December 2005


Table A7. Baseline and incremental financing need for malaria by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total At least 80% of people in eligible ITN areas of every district sleep under ITNs by December 2008 6,827,200 7,851,280 9,028,972 0 0 23,707,452

At least 85% of people in eligible IRS areas (15 out of 72 districts) sleep in sprayed structures by December 2008; 472,260 1,086,198 1,873,692 2,154,745 2,477,957 8,064,852

At least 80% of pregnant women have access to full-three course of Intermittent Preventive Therapy by December 2008

221,630 260,443 305,250 358,141 419,117 1,564,581

At least 80% of Pregnant women have access to iron supplement (anemia reduction) by December 2008 1,744,309 2,049,782 2,402,430 2,818,704 3,298,609 12,313,834

At least 80% of suspected malaria patients are correctly diagnosed annually by December 2008; 11,430,687 26,290,579 45,351,249 52,153,937 59,977,027 195,203,479

At least 80% of malaria patients receive prompt and effective treatment according to the current drug policy, within 24 hours of onset of malaria symptoms, by December 2008;

1,323,620 1,522,163 1,750,487 2,013,061 2,315,020 8,924,351

Joint planning and implementation mechanisms between all partners developed by 2010; 200,000 230,000 264,500 304,175 349,801 1,348,476

Malaria data management harmonized by all partners by 2010; 352,000 404,800 465,520 535,348 615,650 2,373,318

Malaria reporting and feedback/M&E improved in at least 90% of health facilities by 2010. 352,000 404,800 465,520 535,348 615,650 2,373,318

Improved operational research on Malaria control 545,054 626,812 720,834 828,959 953,303 3,674,962


Baseline cost 47,230,695 54,315,299 54,315,299 62,462,594 71,831,983 290,155,871



December 2005


Table A8. Baseline and incremental financing need for Epi control and public health surveilance by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Formal surveillance structures established at all levels by 2007 100,000 115,000 0 0 0 215,000

Staff trained and oriented to public health surveillance starting from 2006; 172,800 198,720 228,528 262,807 302,228 1,165,083

All laboratories equipped with basic equipment to support public surveillance by 2007; 490,000 563,500 648,025 798,459 918,228 3,418,213

Reviewing and strengthening of HMIS in the context of surveillance completed by 2008. 100,000 115,000 132,250 0 0 347,250

Total incremental cost 862,800 992,220 1,008,803 1,061,267 1,220,457 5,145,546

Baseline cost 3,102,746 3,568,158 4,103,382 4,718,889 5,426,722 20,919,896



December 2005


Appendix

Table A9. Baseline and incremental financing need for environmental health and food safety by year (ZMK 000) Incremental cost 2006 2007 2008 2009 2010 Total Public Health Act and the Food and Drugs Act reviewed and amended by 2007; 0 57,500 66,125 76,044 0 199,669

National Environmental Health Policy developed by 2007; 31,514 36,241 0 0 0 67,755WASHE Committees established and functional in all priority areas identified to be highly prone to incidences of environmental related diseases by 2010;

471,250 541,938 623,228 358,356 412,110 2,406,881

At least 50 environmental health specialists with Bsc. Degrees produced every year by the University of Zambia starting from 2008;

500,000 575,000 661,250 760,438 874,503 3,371,191

100 environmental health personnel trained in public health prosecution at the National Institute of Public Administration (NIPA) by 2010;

200,000 230,000 264,500 304,175 349,801 1,348,476

HCWM system strengthened in all health facilities in Zambia by end 2008; 713,797 820,867 943,997 0 0 2,478,660

HACCP system introduced by 2008; 164,591 189,280 217,672 250,322 287,871 1,109,735Waste disposal facilities for all hospital in the country assured by 2007. 5,000,000 5,750,000 6,612,500 7,604,375 8,745,031 33,711,906

PHAST activities implemented at district level 7,425 12,809 14,730 16,939 22,078 73,981


Baseline cost 2,202,345 2,532,697 2,912,601 3,349,491 3,851,915 14,849,050



December 2005


Table A10. Baseline and incremental financing need for other public health interventions by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Mental health 1,514,351 728,525 837,804 963,474 1,107,995 5,152,150Mental Disorders Act of 1951 Cap. 535 repealed and replaced with the new Mental Health Act by March 2006; 102,451 0 0 0 0 102,451

Operational guidelines and standards for management of mental health problems developed by end 2006; 402,000 0 0 0 0 402,000

Operational guidelines and standards for management of mental health problems developed by end 2006; 376,400 0 0 0 0 376,400

Public awareness strategy for mental health services developed by March 2006; 372,000 427,800 491,970 565,766 650,630 2,508,166

Formation and maintenance of Mental Health Coordinating Committee ; 261,500 300,725 345,834 397,709 457,365 1,763,133

Oral Health 810,000 1,391,500 1,520,875 1,749,006 2,011,357 7,482,738

Strengthen the policy framework for Oral Health; 60,000 69,000 0 0 0 129,000

Scale up oral health services to all districts; 0 460,000 529,000 608,350 699,603 2,296,953

Promote oral health awareness and education; 200,000 230,000 264,500 304,175 349,801 1,348,476Integrate oral health in child health and HIV/AIDS programmes 150,000 172,500 198,375 228,131 262,351 1,011,357

Strengthen oral health training. 400,000 460,000 529,000 608,350 699,603 2,696,953

Other infectious diseases 1,350,000 2,329,900 2,679,385 2,509,444 2,885,860 11,754,589

Communities at high risk of schistosomiasis and soil transmitted helminths morbidity identified 100,000 115,000 132,250 152,088 174,901 674,238

Treatment of high risk groups undertaken 0 345,000 396,750 456,263 524,702 1,722,714

Teachers and community health workers trained in administering de-worming drugs 400,000 460,000 529,000 608,350 699,603 2,696,953

Information education and communication (IEC) activities in all schools and communities undertaken 0 432,400 497,260 0 0 929,660


December 2005


Improved sanitation standards in communities. 500,000 575,000 661,250 760,438 874,503 3,371,191

Strengthened partnerships with all stakeholders at all levels 350,000 402,500 462,875 532,306 612,152 2,359,833

Non-communicable diseases 960,000 1,449,000 661,250 304,175 349,801 3,724,226Disease specific policies on NCDs developed and implemented by 2008; 80,000 92,000 0 0 0 172,000

Basic equipment, tools, drugs and other supplies for management of NCDs available at all levels of care by 2007;

600,000 690,000 0 0 0 1,290,000

NCD communication strategy developed and implemented by 2008; 0 345,000 396,750 0 0 741,750

Health care workers trained in NCDs annually from 2006; 200,000 230,000 264,500 304,175 349,801 1,348,476

IDSR strengthened by 2007 80,000 92,000 0 0 0 172,000


Baseline cost 100,000 115,000 115,000 132,250 152,088 614,338



December 2005


Table A11. Baseline and incremental financing need for clinical care support services by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Laboratory support services 10,404,345 12,732,470 19,548,924 22,309,229 25,655,613 90,650,581National Medical Laboratory Policy reviewed and updated by 2007. 24,750 47,438 21,821 0 0 94,009

Laboratory protocols and standard operating procedures updated by 2008; 72,461 83,331 127,774 0 0 283,566

Quality assurance guidelines developed and implemented by 2007; 87,411 100,523 0 0 0 187,935

Number of trained bio-medical technologists and scientists increased by 50% by 2010; 0 0 0 0 0 0

Planned preventative maintenance system developed and implemented by 2007; and 75,000 86,250 0 0 0 161,250

Laboratory equipment procured and serviced regularly for all levels of care 2,603,472 3,742,491 8,607,729 9,898,889 11,383,722 36,236,304

Guidelines on ethics and minimum standards of safety developed by 2007 41,250 47,438 872,850 1,003,778 1,154,344 3,119,659

Lab reagents and supplies procured and distributed to all levels of care 7,500,000 8,625,000 9,918,750 11,406,563 13,117,547 50,567,859

Medical imagining services 11,240,538 12,552,825 14,326,643 16,425,450 18,889,268 73,434,723

Medical Imaging and Therapy Policy Developed by 2007 41,250 47,438 0 0 0 88,688Medical Imaging Protocols and SOPs developed and disseminated by 2006; 241,538 0 0 0 0 241,538

Procurement plan for essential equipment and consumables developed by 2007; 41,250 47,438 0 0 0 88,688

60% of the radiographers trained in ultrasound, radiographic application and maintenance by 2010 0 0 0 0 0 0

30% of doctors in specialized units (oncology, radiology, nuclear medicine) trained by 2010 0 0 0 0 0 0


December 2005


Basic Equipment, consumables and other accessories available at all levels of care in the imaging departments by the year 2009;

10,800,000 12,420,000 14,283,000 16,425,450 18,889,268 72,817,718

Planned preventive maintenance system developed and implemented by 2008 16,500 37,950 43,643 0 0 98,093

Public Awareness strategy on hazards of radiation developed by 2006. 100,000 0 0 0 0 100,000

National blood transfusion services 7,168,650 8,829,412 11,445,841 14,711,272 17,808,382 59,963,556Blood collections increased from 70,000 units per year to 100,000 units by 2010, discards reduced to less than 3% by the end of 2006

5,134,500 6,326,438 8,245,457 10,597,837 12,828,961 43,133,192

Mandatory adherence to WHO guidelines on blood safety attained. 0 0 0 0 0 0

All provincial centres equipped with adequate blood storage facilities 1,992,900 2,455,538 3,200,384 4,113,435 4,979,421 16,741,677

Guidelines on appropriate use of blood reviewed and disseminated 41,250 47,437 0 0 0 88,686


Baseline cost 6,500,000 7,475,000 8,596,250 9,885,688 11,368,541 43,825,478



December 2005


Table A12. Baseline and incremental financing need for essential drugs and medical supplies by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total List of essential drugs incorporated into the procurement plan in 2006 100,000 0 0 0 0 100,000

Strengthening of logistics management system at all levels 1,500,000 1,725,000 1,983,750 2,281,313 2,623,509 10,113,572Pharmaceutical logistic management information system established at all levels in 06/07 400,000 460,000 0 0 0 860,000

Promotion of rational drug use through dissemination and implementation of therapeutical protocols and standards by 2007

72,352 416,026 239,215 275,097 632,724 1,635,415

All levels trained in adverse drug reactions/events detection and reporting systems by 2009 840,000 3,622,500 5,554,500 6,707,059 0 16,724,059

Establishment of the Drug Supply Fund finalise and operationalise, and the DSBL established by end 2006 66,083,780 75,996,347 87,395,799 100,505,169 115,580,944 445,562,038

Establishment of a fully functional Pharmaceutical Regulatory Authority according to the legislation in 2006 100,000 0 0 0 0 100,000

Establishment of the National Pharmaco-Vigilance Unit under the Pharmaceutical Regulatory Authority in 06/07 100,000 0 0 0 0 100,000

National drug policy implemented during the planning period 1,054,485 1,212,658 1,394,556 1,603,740 1,844,301 7,109,740


Baseline cost 80,000,000 92,000,000 105,800,000 121,670,000 139,920,500 539,390,500



December 2005


Table A13. Baseline and incremental financing need for infrastructure and equipment by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Infrastructure 105,525,000 120,894,900 125,804,135 144,674,755 166,375,969 663,274,759

Census of health infrastructure completed by June 2006; 337,000 0 0 0 0 337,000Infrastructure database system established and operational by end of 2006; 62,000 0 0 0 0 62,000

Health Infrastructure Development Plan completed and implemented by 2008 95,126,000 109,394,900 125,804,135 144,674,755 166,375,969 641,375,759

Capital basket fund established and operational by 2007; 10,000,000 11,500,000 0 0 0 21,500,000

Equipment 16,458,798 46,610,645 53,411,802 61,423,572 70,554,030 248,458,848Standard equipment checklists for all levels completed by December 2006 100,000 0 0 0 0 100,000

Equipment database established by June 2007; 62,000 71,300 0 0 0 133,300

Equipment development plan developed and implementation commenced by January 2008; 16,089,798 46,258,170 53,196,896 61,176,430 70,352,895 247,074,189

Guidelines on the monitoring of compliance with maintenance policy developed and implemented 2007 82,000 94,300 0 0 0 176,300

Capacity building programme in equipment maintenance developed and implemented by 2007. 125,000 186,875 214,906 247,142 201,136 975,059


Baseline cost 39,500 45,425 52,239 60,075 69,086 266,324



December 2005


Table A14. Baseline and incremental financing need for systems strengthening by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Monitoring and evaluation 1,029,000 1,183,350 1,360,853 1,564,980 1,799,727 6,937,910

Functional HMIS at district level by 2008; 250,000 287,500 330,625 380,219 437,252 1,685,595

Functional Hospital MIS at every level of care by 2008; 100,000 115,000 132,250 152,088 174,901 674,238

Functional M&E department in the MOH by 2007; 85,000 97,750 112,413 129,274 148,666 573,102

Nation health research agenda for 2006-2010 developed; 82,500 94,875 109,106 125,472 144,293 556,246

Core indicator set for the NHSP revised by 2007; 75,000 86,250 99,188 114,066 131,175 505,679Functional M&E mini-Sector Advisory Group (SAG) at provincial and district level by 2008; 82,500 94,875 109,106 125,472 144,293 556,246

Health research regulatory framework (legal and implementation) developed and implemented by 2010; 92,000 105,800 121,670 139,921 160,909 620,299

Functional M&E system at all levels of the health service delivery by 2010; 150,000 172,500 198,375 228,131 262,351 1,011,357

Performance standards defined at every level of health care by 2009; and 54,000 62,100 71,415 82,127 94,446 364,089

Result-based performance rewarding system developed by 2009. 58,000 66,700 76,705 88,211 101,442 391,058

Health management information system (HMIS) 814,000 1,466,020 1,685,923 1,588,402 1,822,465 7,376,809

Number of HMIS staff trained 0 529,920 0 350,410 0 880,330

Number of managers and policy makers to be trained in data usage for decision- and policy-making 0 0 609,408 0 398,773 1,008,181

Number of Districts and Hospitals supported with software and internet connectivity 679,000 780,850 897,978 1,032,674 1,187,575 4,578,077

Number of dissemination meetings for the HMIS Annual Statistical Bulletin held 135,000 155,250 178,538 205,318 236,116 910,221

Financial and Administration Management System (FAMS) 3,463,000 3,522,450 4,019,078 4,621,939 2,670,733 18,297,199

Number of institutions implementing and strengthening 340,000 391,000 1,079,160 1,241,034 1,427,189 4,478,383


December 2005


FAMS

Number of meetings held to discuss compatibility of FAMS modules at all levels 30,000 34,500 39,675 45,626 52,470 202,271

Integration of FAMS and HMIS attained by 2007; 33,500 38,525 44,304 50,949 58,592 225,870Financial and performance audit systems strengthened at all levels; 350,000 402,500 462,875 532,306 612,152 2,359,833

FAMS indicators incorporated in performance audits and accreditation process; and 33,500 38,525 44,304 50,949 58,592 225,870

Number of staff trained in FAMS 276,000 317,400 365,010 419,762 461,738 1,839,909

Number of institutions implementing FAMS software 2,400,000 2,300,000 1,983,750 2,281,313 0 8,965,063

Procurement Management System 329,000 326,600 158,700 182,505 209,881 1,206,686A well-coordinated procurement system established by end of 2006; 165,000 0 0 0 0 165,000

Procurement regulations and guidelines developed for all levels by 2007 82,000 94,300 0 0 0 176,300

Long-term strategy for Medical Stores Limited developed by end 2007; 82,000 94,300 0 0 0 176,300

200 Procurement and supplies staff training programme commenced by 2006; 0 138,000 158,700 182,505 209,881 689,086

Number of institutions implementing FAMS software 0 0 0 0 0 0

Health systems research 263,000 210,450 242,018 278,320 320,068 1,313,856Implementation of the National Health Research Policy monitored; 120,000 138,000 158,700 182,505 209,881 809,086

Link between health research, health policy and programmes strengthened; 80,000 0 0 0 0 80,000

Research institutionalised at all levels of health care. 63,000 72,450 83,318 95,815 110,187 424,770


Baseline cost 50,000 57,500 66,125 76,044 87,450 337,119



De

“…equity of access to cost-effective, quality healthcare…”cember 2005 101

Table A15. Baseline and incremental financing need for health systems governance by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Health policy and legislation 92,000 177,100 121,670 121,670 139,921 652,361Existing policies and legislation reviewed and harmonized and new ones developed by 2007; 0 57,500 0 0 0 57,500

Appropriate new policies and legislation developed and updated on a continuous basis; 60,000 69,000 79,350 91,253 104,940 404,543

Existing health sector policies and legislation disseminated to all levels of health service delivery on a continuous basis;

20,000 23,000 26,450 30,418 34,980 134,848

Mechanisms for coordination and monitoring enforcement of policies and legislation developed by 2007; and 0 0 0 0 0 0

Capacity in policy formulation, analysis and advocacy strengthened at MOH through staffing, technical support and training.

12,000 27,600 15,870 0 0 55,470

Organization and management 439,200 364,320 0 0 0 803,520Capacity strengthening needs identified by 2007 and thereafter addressed; 60,000 0 0 0 0 60,000

Guidelines on the harmonization of the implementation of the NHSP and new Decentralisation Policy developed in 2006;

0 94,300 0 0 0 94,300

Hospital reforms reinvigorated and commencement of implementation by mid 2006; 90,000 69,000 0 0 0 159,000

Guidelines for coordination/monitoring/evaluation of Statutory Boards developed by 2007; 49,200 37,720 0 0 0 86,920

Guidelines for coordination, monitoring and evaluation of the private sector involved in delivering the BHCP through the public health sector developed by 2007;

0 94,300 0 0 0 94,300

Existing mechanisms for health services commissioning in a decentralised environment replicated to Local Authorities; and

150,000 0 0 0 0 150,000

A framework for regulating the private sector involved in delivering the BHCP through the public health system 90,000 69,000 0 0 0 159,000


December 2005


developed and implemented by 2010.

Gender and health 464,800 517,960 450,179 167,296 192,391 1,792,626Guidelines for mainstreaming gender issues in planning developed and used in training; 120,000 0 0 0 0 120,000

Methodologies, tools and training activities development for enhanced gender relevant delivery of health services; 90,000 69,000 0 0 0 159,000

Desegregated gender data available for planning and gender perspective action plans; 82,000 0 0 0 0 82,000

Review of sex balance composition of the health boards completed; 0 69,000 79,350 91,253 104,940 344,543

Gender focal persons selected by DHBs and trained in all districts; 172,800 264,960 304,704 0 0 742,464

Increased number of women involved in DHBs; and 0 115,000 66,125 76,044 87,450 344,619

Increased male participation in family health. 0 0 0 0 0 0

Sector Wide Approach 560,000 724,500 634,800 730,020 839,523 3,488,843Existing common basket funding mechanism expanded to include all levels of health service delivery, training institutions and statutory boards, by 2007;

0 0 0 0 0 0

Common basket funding transformed into the Health Sector Budget Support mechanism; 80,000 0 0 0 0 80,000

Systems and procedures for the management of the common basket funds harmonized by end 2006; 480,000 552,000 634,800 730,020 839,523 3,236,343

A common and objective framework for the release of funds by the donors, based on agreed health sector performance benchmarks, developed by end 2006;

0 172,500 0 0 0 172,500

Existing resource allocation criteria under SWAp, reviewed and strengthened by 2007; 0 0 0 0 0 0

Financial reporting, monitoring and evaluation of SWAp programmes improved; and 0 0 0 0 0 0

SWAp Secretariat staff, through capacity building and training. 0 0 0 0 0 0


Baseline cost 500,000 575,000 661,250 760,438 874,503 3,371,191



December 2005


Table A16. Baseline and incremental financing need for health care financing by year (ZMK 000)

Incremental cost 2006 2007 2008 2009 2010 Total Basic health care package 0 51,750 198,375 159,692 0 409,817

BHCP costed for all levels of health care by 2009; 0 51,750 99,188 45,626 0 196,564Treatment guidelines for priority diseases developed and implemented by 2008; and 0 0 99,188 114,066 0 213,253

Resource mobilization 762,400 1,578,260 1,616,624 1,859,118 2,020,032 7,836,434Healthcare Financing Policy approved and implemented by end 2006; 150,000 172,500 0 0 0 322,500

National Health Insurance Designed and implemented by end 2010 112,400 129,260 148,649 170,946 78,635 639,891

Basket funding expanded to include other levels by end 2006; 0 701,500 806,725 927,734 1,066,894 3,502,853

A system of National Health Accounts Institutionalised and operationalised. 500,000 575,000 661,250 760,438 874,503 3,371,191

Resource allocation 352,000 491,050 306,820 124,712 143,419 1,418,000Resource allocation criteria for equitable Distribution of resources through SWAP to primary health care and hospitals revised by 2007;

0 86,250 99,188 0 0 185,438

Guidelines for intra district resource allocation developed by end 2007 120,000 138,000 0 0 0 258,000

Mechanisms for enhancing coordination of local and external resources developed by end of 2007; and 82,000 94,300 108,445 124,712 143,419 552,875

New tools for costing and budgeting developed for districts and hospitals by end 2007. 150,000 172,500 99,188 0 0 421,688


Baseline cost 50,000 57,500 66,125 76,044 87,450 337,119


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NATIONAL HEALTH STRATEGIC PLAN 2006-2010

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