Understanding Zambia’s National Health Plans

Collins ChansaChief Planner – Development Cooperation

Directorate of Policy and Planning, Ministry of Health - Zambia

Presentation Outline

Part One: Background

Part Two: Current NHSP 2006-2010

Challenges

Way Forward

Take Home Messages

Q&A

Background to the Health Reforms

80’s and early 90’s Zambia’s health sector - centralized planning & decision making

Service delivery not linked to the needs of the communities

Inadequate GRZ leadership, and inopportune partnerships with local & external stakeholders

Background to the Health Reforms …

Several fragmented donor projects and Project Implementation Units

Project support tended to undermine national efforts to develop the health sector in an holistic and comprehensive manner

Zambian Health SWAp

Health reforms commenced in 1991/2 with a renewed vision, decentralisation of health services, Sector Wide Approach (SWAp)

Through the SWAp, GRZ perceived a need to integrate all the vertical programmes into a sectoral framework that would meet common national goals and objectives

In 1993, Zambia was the first country in Africa to implement a health SWAp

Why was the SWAp Adopted? Increases predictability of funding

Improve the financing base since priorities are identified in advance

Reduce transaction costs and duplication

Apply interventions equitably and to reduce geographic disparities

Leadership & Stewardship. Place government in charge leading to institutional & financial sustainability

Improved efficiency in resource allocation & use

Enabling Policy Environment in the Health Sector

Four (4) Sector Strategic Plans covering the periods 1995-1998; 1998-2000; 2001-2005 and 2006-2010

Fifth (5th) Plan to cover the period 2011-2015 Link Policy, Planning, Budgeting Capacity and willingness to reprioritize and

reallocate scarce resources Affordability Cost, Cost-effectiveness, expected results Monitoring & Evaluation

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

WHY?: TWO REASONS

Existence of Large Economic and Health Disparities

Possibility that Faster Progress toward the Health MDGs Might Not Significantly Benefit the Poor

ECONOMIC DISPARITIES: The Top 20% of the Population is over 10 Times Well Off as compared to the Bottom 20%

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Economic Quintile of the Population

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Bottom 10% Top 10%

Economic Decile of the Population

PROGRESS TOWARD THE MDGs: Achieving the MDGs would Benefit the Poor Significantly IF the Gains Are Evenly Distributed Across Economic Groups. In this case, Under-5 Mortality among the Poor would Decline by 2/3

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Early 2000s Upon MDG Attainment with Equally-Distributed Gains

Bottom 20% Average Top 20%

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NEED TO FOCUS BETTER …

Human Resources for Health (HRH)

Health Systems Strengthening

Health Service Delivery Maternal, Neo-natal and Child

Health (MNCH)

Essential Drugs and other Medical Supplies

Governance and Leadership

Better Financing 04/10/23

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The OBJECTIVES of Zambia’sHealth Plan

The Plan’s Vision : “Equity of access to assured quality, cost-effective and affordable health services as close to the family as possible”

The Plan’s Key Principles start with: “Equity of access...”

Three Illustrative OPERATIONAL TARGETS of Zambia’s Health Strategic Plan 2006-10

Under-5 Mortality: Reduce National Average from 168 to 134 (20% Reduction)

Supervised Deliveries: Increase National Average from 43% to 50% (16% Increase)

Fully-Immunized Children: Increase National Average from 80% to 90% (12% Increase)

New NHSP 2011-15 targets to attain the MDGs

Zambia’s Human Resources for Health Strategic Plan 2006-10

Two Parts, Divided into Five Sections

• First Part is Analytical: Sections on Situation Analysis, and on Objectives

• Second Part is Operational: Sections on Strategies, on Expected Outputs,

and on Key Indicators

Zambia’s Human Resources for Health Strategic Plan 2006-10 …

The Opening Two, Analytical Sections Are Strongly Oriented toward Poverty:

• Section One - Situation Analysis: Extensive Discussion of Mal-distribution and Initiatives Designed to Deal with them

• Section Two - Objective: Emphasis on Health Workforce “… as Close to the Family as Possible.”

Zambia’s Human Resources for Health Strategic Plan 2006-10 …

Expected Results - Geographical inequities in the distribution of staff

Sections Three and Four - Strategies, Expected Outputs with references to Correcting Mal-distribution

Section Five - Key Indicators expressed in Population Terms (e.g. National Staff/Population Ratios)

Key Health Indicators

Population: 12.2 (2007 proj.) Under-5 mortality rate: 119 per 1,000 live births Infant Mortality Rate 70 per 1,000 live births Maternal Mortality: 591 per 100,000 HIV/AIDS Prevalence: 14.3% (15-49 Age

Group) Poverty incidence; 64 percent Extreme poverty; 46% Gini-coefficient; 0.57 Formal sector employment 416,228 out of 4

million eligible to work (2004)

Performance: Malaria Indicators (1)

Performance: Malaria Indicators (2)

Financing Sources (I)

As a % of the total GRZ Discretionary Budget, the health sector currently receives 11.5%

The major sources of funding for Public health services are GRZ (45%), Donors (55%) though SWAp, Direct Sector Support, Projects

As a % of Total Health Exp. Donors 42%, Households 27%, GRZ 25%, Employers 5%, Others 1% (NHA 2006)

As a % of GDP, Total Health Exp. Represents - 6.3% which translate to approximately USD$ 58 per capita (NHA 2006)

Financing Sources (II)

Other sources include User fees which until the scrapping in

rural areas represented about 4%. User fees still remain an important source of financing for major hospitals like the UTH.

Medical levy (1% tax on interest earnings) which contributes about K8 billion annually.

Financing Sources (III)

Since 2003, Zambia has been receiving significant resources from various GHIs

But Issues with Vertical Funding Focus only on a few priority areas: Between 2005 and

2010, over 60% funding is expected to be on HIV/AIDS alone. This grows to 77% when malaria is added.

Focus on selected cost items mainly drugs and medical supplies. Human resources and infrastructure for increased accessibility neglected

High transaction costs: duplication in planning & monitoring

NHSP estimated financing gap 2009-2010

93.86 154.65

756.18

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Scenario 1 Scenario 2 Scenario 3

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GRZ SWAp Project Financing gap

NHSP Financing Gap 2009-2010

CHALLENGES

Continued shortage of health workers: Sector operating at less than 50% of the HRH establishment

High disease burden mainly due to HIV/AIDS, TB, Malaria, other preventable diseases and NCDs

Poor transport and obsolete equipment

Persistent high poverty levels amidst high & sustained economic growth (6%) and macroeconomic stability over the past 5 years

Poor performance of the Agric, Energy, Infrastructure Sectors

CHALLENGES …

Overall level of funding to the health sector is still low. $33 per capita is required to implement the Basic Health Care Package but only $18 per Capita available through the public health system

Several donors still outside the SWAp and use parallel systems

Several Donors providing support along programmatic lines and not addressing health system

MOH MOEC

MOF

PMO

PRIVATE SECTORCIVIL SOCIETYLOCALGVT

NACP

CTU

CCAIDS

INT NGO

PEPFAR

Norad

CIDA

RNE

GTZ

SidaWB

UNICEF

UNAIDSWHO

CF

GFATM

USAID

NCTP

NCTP

HSSP

HSSP

GFCCPGFCCPDAC

CCM

UNFPA

3/5

SWAPSWAP

UNTG

PRSP PRSP

Isn’t Donor Collaboration Wonderful?Isn’t Donor Collaboration Wonderful?

Source: WHO: Mbewe

Verticalization of Aid leads to Fragmentation Verticalization of Aid leads to Fragmentation and Poor Results: Child Healthand Poor Results: Child Health

Drug Use

Malaria

Nutrition HIV/AIDS

Health system

PMTCT

Maternal health

New born care

Safe and Supportive

Environment

Skilled birth attendance

Case management

Community

Management

Source: WHO: Mbewe

WAY FORWARD SWAp and its funding modality ‘Basket’ works but

there is need for further harmonization & alignment of donor procedures

Need to create opportunities for all donors to participate taking cognizance of their constraints

An optimal mix of various funding modalities is not bad

Further strengthening of government systems for management and accountability

TAKE HOME MESSAGES

There is need to build on the lessons learnt in the NHSP 2006-10 as we prepare & implement the NHSP 2011-15

But we have an Environment of Increasing disease burden Constrained human, financial and material resources Poor infrastructure and equipment

Need for a strategic focus on Service Delivery Human Resources Improve the state of infrastructure and equipment Improve Health financing Strengthen Health Systems and Governance Fostering multi-sectoral approaches in key areas

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PROGRESS TOWARDS THE ATTANIMENT OF THE HEALTH MDGs

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INDICATOR ZDHS 1990

ZDHS 1996

ZDHS 2002

ZDHS 2007

NHSP TARGET

(2010)

MDG TARGET

(2015)Infant Mortality Rate per 1000

107 109 95 70 NS 36

Under Five Mortality Rate per 1000

191 197 168 119 134 63

Maternal Mortality Ratio per100,000

649 729 591 547 162

New Malaria cases per 1,000

373 (HMIS 05)

412(HMIS 06)

358(HMIS 07)

252 (HMIS 08)

94/1000 <121/1000

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Expanded Outputs- Tutors- Clinical Instructors- Books, Computers, Models- Infrastructure & Equipment- Operational Grant

HRH IS KEY

I Thank You

END of Presentation