General country health policies
Public policies in the health sector, together with those in other sectors, have a huge potential to secure the health of communities. They represent an important complement to universal coverage and service delivery reforms. Unfortunately, in most societies, this potential is largely untapped and failure to effectively engage other sectors is widespread. Looking ahead at the diverse range of challenges associated with the growing importance of ageing, urbanization and the social determinants of health, there is, without question, a need for a greater capacity to seize this potential. That is why a drive for better public policies forms a third pillar supporting the move towards primary health care, along with universal coverage and primary care (see figure).
The following policies must be in place:
- Systems policies – the arrangements that are needed across health systems’ building blocks to support universal coverage and effective service delivery. These are the health systems policies (related to essential drugs, technology, quality control, human resources, accreditation, etc.) on which primary care and universal coverage reforms depend.
- Public health policies – the specific actions needed to address priority health problems through cross-cutting prevention and health promotion. Without effective public health policies that address priority health problems, primary care and universal coverage reforms would be hindered. These encompass the technical policies and programmes that provide guidance to primary care teams on how to deal with priority health problems. They also encompass the classical public health interventions from public hygiene and disease prevention to health promotion.
- Policies in other sectors – contributions to health that can be made through intersectoral collaboration. These policies, which are of critical concern, are known as “health in all policies”, based on the recognition that a population's health can be improved through policies that are mainly controlled by sectors other than health. The health content of school curricula, industry’s policy towards gender equality, or the safety of food and consumer goods are all issues that can profoundly influence or even determine the health of entire communities and that can cut across national boundaries. It is not possible to address such issues without intensive intersectoral collaboration that gives due weight to health in all policies.
This section on General country health policies is structured as follows:
Over the past years, the Government of Zambia has taken a number of actions and strategies in various sectors, aimed at reducing inequities and improving health and living conditions. The concept of "equity of access to assure quality, cost-effective and affordable health services, as close to the family as possible" is at the heart of the 1992 National Health Policies and Strategies which is guiding policy reforms since it enactment.
Overview of major policy reforms
Over the years, the health sector has under-gone major policy reforms, which are still on-going. These reforms have been guided by the National Health Policies and Strategies of 1992, which has provided the strategic direction to the reforms, based on the following vision, goal and principles:
- Vision: Equity of access to assured quality, cost-effective and affordable health services, as close to the family as possible.
- 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.
- Principles: Equity, cost-effectiveness, affordability, accountability, partnerships, decentralisation and leadership.
In practice, these policy reforms materialized into a major restructuring of the health sector which conducted to the enactment of the National Health Services Act (attach doc) of 1995. This led the same year to the first model of decentralization of responsibilities of priority setting, planning and health service delivery to the districts and local communities. Yet, the model opted for was hardly sustainable in practice and the second version developed in 2005 somewhat resulted in re-centralization of decision-taking at central level, as discussed in Decentralization of the system
Also in 2005, the Government of Zambia has launched a new long-term vision, called “Vision 2030” (attach doc), which aims at transforming the country into a “middle-income prosperous nation by 2030”. During the same year, the Fifth National Development Plan (FNDP) (attach doc), the National Health Strategic Plan 2006-2010 and the Human Resources for Health Strategic Plan 2006-2010, all covering a period of 5 years from 2006 to 2010, were launched, and are still being implemented. The FNDP is broad-based and focused at achieving accelerated, meaningful and sustainable development across the sectors. In this respect, it is largely influenced by local and international priorities, particularly the Millennium Development Goals (MDGs). Through this plan and the respective sector strategies, all the 8 MDGs have been appropriately domesticated and incorporated.
A summary of the evolution of the major health sector policy reforms implemented since 1992 is provided Table 7.1 below.
Public health policies
By design, the existing health policies are modelled along the national health vision of “equity of access to assured, cost-effective and affordable health services, as close to the family as possible”.
In this respect, key policies and accompanying strategies implicitly comprise an objective of ensuring equitable access to primary health care services for all the population, regardless of the social, economic and geographical status, and comply with most recommendations of the WHO Commission on Social Determinants for Health.
The Zambian policy formulation process, is articulated around broad consultations at all the levels of the health system, which provide additional guarantee on their compliance with international standards and concepts (as the WHO PHC renewal). The process is also significantly influenced by global health initiatives, through the SWAp arrangement and also through various global initiatives and disease-centered approaches.
However, in practice, the health system faces a number of challenges which contribute to inequities in various areas, such as: inadequate funding and imperfect coordination arrangements regarding Global Initiatives; critical shortages of health workers and sub-optimal distribution of available health workers, to the disadvantage of rural communities; weaknesses in the supply of drugs and other medical items; inappropriateness of some infrastructures and equipment, and maintenance issues.
The above factors largely affect health service delivery, particularly for rural communities and disadvantaged vulnerable population groups, such as women, children, and physically challenged groups. These matters are discussed in addressed in a number of reports and assessments. It creates various forms of iniquities:
- Iniquities between the urban and rural areas in several areas, including the distribution of facilities, human resources and drugs and other medical supplies.
- Iniquities between provinces with a significant differential in the distribution of resources between A and D provinces (see among others the section on HR stock and distribution). These iniquities actually extends to differences in socio-economic development and access to other essential public services (education, transports, etc.).
Efforts made towards primary health care policies are also somewhat undercut by the importance taken by priority health programmes in the Zambian health system. These mainly include: HIV&AIDS programmes, including the National HIV/AIDS/STI/TB Council (NAC); the National Malaria Control programme; National TB and Leprosy Control Programme; the Child Health and Nutrition Programme; and the Maternal Health Programme.
These programmes undoubtedly play an important role in the implementation of various health policies, which they spearhead at all the levels. Nevertheless the vertical nature of their activities may undermine PHC services, mainly through creation of imbalances in the financing and support to critical activities throughout the health system and through inadequate coordination and integration within the SWAp institutional arrangements.
Health system policies
Zambia’s health system offers an interesting set of policies, which have clearly been influenced by principles as decentralization, community participation, patient centeredness and equity.
Yet, reforming a health system takes time. For various reasons, there are still gaps between the principles (“bringing health services as close to the family as possible”) and actual implementation.
In this section, we briefly discuss, building block per building block, to what extent health system reforms comply with the primary health care (PHC) objectives and the key options conveyed by the Commission on Social Determinants for Health.
- Leadership and governance (see Chapter 1)
- The 1995 decentralization policy was a clear attempt to strengthen community participation, distribution of power, and the responsiveness of the health system to the patients’ demand. However, the actual outcomes are now being questioned with the latest 2005 restructuring, which appears to have re-concentrated decision-making power back to the MOH.
- The long-lasting SWAp governance system is a strong Zambian asset to stimulate the participation of main stakeholders of the sector, including other sectors, cooperating partners. Yet, these are mainly the big players. An important (identified) challenge is now to see how it can be extended to the civil society and under-represented groups, as NGOs and civil society organizations.
- Service Delivery (see Chapter 2)
- A policy on Basic Heath Care Packages (BHCP) is under discussion since 2004, and should guarantee citizens with access to a full range of essential and affordable health services at the different levels of the health system. However it is not yet implemented and the current organization of services does not full comply with PHC requirements.
- The Government has consented important efforts for improving geographical coverage with the agreement made with the (faith-based) Churches Health Association of Zambia health facilities, including provision of subsidized health staff. The opportunity to conduct similar arrangements with the private for-profit sector is a pending question.
- Vertical programmes are contributing significantly to health services delivery at primary level, including in underserved areas. To a certain extent, they may also interfere with PHC performance. As an illustration, it is estimated that approximately US$200 millions, from the USG alone, are absorbed by HIV/AIDS activities country-wide
- The MOH acknowledges failures in the provision of PHC services and attempts to provide alternative solution through e.g. innovative targeting initiatives as the Child Health Weeks (CHW) (provision of a comprehensive set of preventive and curative services to children during specified weeks).
- Health Workforce (see Chapter 3)
- The MOH is struggling for years to provide solutions to the critical shortages and imbalanced in the distribution of health workers throughout the country. The policies currently under discussion include:
- The retention programme is aimed at motivating quality health workers to settle in underserved areas. It was successfully introduced in 2008 and is now getting expanded to include other medical cadre, in addition to medical doctors
- Since the 1990s, bonding of students agreements aim at improving the distribution of health workers, particularly for rural areas, by requiring students to work for specified institutions and for a specified minimum period upon completing the course.
- A contracting strategy is being considered since the mid 2000s to fight the brain drain. It would encourage the recruitment on short-term renewable contracts of health professionals that are either returning from abroad or have been retired. The results are mild so far, with some partial success regarding retired professionals but no real results as relates to attracting Zambians from abroad.
- Staff development: in-service training programme targeted at continuous capacity-strengthening. In 2008, a comprehensive in-service development plan was developed and is under implementation. This initiative is intended to provide for continuous upgrading of skills for the health workers, inorder for them to favourably cope with the changing health needs and environments;
- Vertical programmes attract significant portion of skilled workforce due to the attractive conditions they offer. It impacts on the availability of health workers to the public sector, and particularly at primary level. Poor coordination of activities with the public sector may also negatively impact on PHC activities.
- Medical products and infrastructures (see Chapter 4)
- At present time, the distribution of health infrastructures and equipment is inequitable and favours urban areas, and the Lusaka and Copperbelt provinces. Efforts are being undertaken to correct geographic inequalities. The first comprehensive Health Facilities Census (HFC) has been conducted in 2006, together with a health facility database, which are now both used by the government and SWAp partners to orientate decisions and funds allocation.
- Drug supply still suffers from shortages and erratic distribution, particularly in poor underserved areas. Since 2007, the issue of drugs procurement has been separated from other procurement arrangment, specific accompanying measures and budget lines were introduced. Also reforms of the drug information system were recently introduced together with other reforms of the Health Information System (e.g. reform of the HMIS). It led to significant improvements discussed during the latest Joint Annual Review.
- Health financing (see Chapter 5)
- There is surprisingly no formal Health Financing Policy at present time (2009). Discussions are ongoing since the mid-2000s and should soon lead to the production of a formal strategy and policy.
- Results Based Financing (RBF) approaches have been piloted in 2008 with a aim to improve staff allocation throughout the country (with increased satisfaction and motivation), as well as the quality of services and their responsiveness to the population's expectations. The policy is to be extended in the coming months.
- Financing options contributing to universal coverage are are still at an early stage in Zambia. Two main options are being considered for the time being: (1) a user fee removal policy which was implemented in health centres and district hospitals in rural areas in early 2006, and later extended to cover facilities in peri-urban areas in mid-2007 and (2) a forthcoming social health insurance for the formal sector (targeting a better-off population), which will probably be piloted in late 2009 / early 2010 (see the 2008 SHI Actuarial Report). It seems that the insurance / risk pooling option would be the preferred approach for future development towards universal coverage, yet this will still have to be confirmed in the forthcoming health financing policy.
- The coordination of financial resources and alignement of strategies are quite satisfying in Zambia due to the long-lasting history of SWAp and basket funding arrangements. Still, only an estimated 25% of all donor funding transits through basket funding. There are also fears that specific global initiatives budget lines and some unaligned cooperating partners could jeopardize further coordination of partners and funds.
- Health Management Information System (see Chapter 6)
- Zambia benefits from a comprehensive set of data sources, which is constantly being improved, and can provide the information needed for conducting efficient primary health care reforms. SWAp arrangements and, to a lesser extent, decentralization policies, favour their concerted utilization in policy orientations and decision-making process.
- The restructuring of the HMIS in 2008 is considered as a success. The new system has improved capabilities and features for data capturing, analysis and reporting, with additional capacity to provide refined information by gender, age, geographic area and other level of details.
Policies in other sectors and intersectoral policies
In Zambia there are quite a number of policies and actions in various sectors which have a clear impact on health status and health inequities. Some of them include:
- Nutrition : scaling up of activities, particularly in schools and vulnerable groups in rural areas, through a multi-sectoral approach (attach doc);
- “Keep Zambia clean” campaign, a Presidential initiative aimed at improving general hygiene in public places, currently being implemented in all the districts (attach doc);
- HIV/AIDS awareness campaign is placed under the leadership of the central governments and aims at ensuring that all sectors develop a HIV/AIDS component, in order to use every public opportunity to inform and educate the public (attach doc);
- The Road safety initiatives under the leadership of the Road Safety Agency (RTA) is made of various actions related to inappropriate driving behaviour (drinking, cell phone, no helmet protection...). It strongly collaborates with the Police Service and led to increased road patrols, licensing rules and speed controls, with significant impacts on road safety (attach doc).
These health-related initiatives are merely the result of a strong leadership taken by the central Government on public health issues, rather than a direct influence of the MOH on other sectors' agenda.
It does not mean that the MOH's influence must be neglected. The National Health Strategic Plan 2006-2010 sets partnership as one of the leading principles underpinning the health sector reforms. It applies to the main stakeholders of the health sector, but also to stakeholders from other sectors, whose policies and actions may have an impact on the general health status of the population and on health inequities.
In this regard, stakeholders from a variety of sectors are invited as active voting members of the Sector Advisory Group (SAG), and represented at the lower levels of the SAG (Technical Working Groups, sub-committees etc.). It provides them with opportunities to influence and get a better ownership on public health issues discussed in the SAG. Reversely, the MOH to influence other ministries' policies by partcipating to their SAG.
Yet, results are mild so far. Except regarding HIV/AIDS, only a few sectors have a specific health programme on their agenda. Similarly other ministries do not specifically attempt to measure the positive or negative externalities of their policies on the general health status of the population and on health inequities. Yet, the indicators produced by all ministries are consolidated and used to evaluate the implementation of the national development plan (NDP) (attach doc). Putting essential primary health care indicators higher on the NDP requirements to other ministries could possibly be an option to improve knowledge on progresses made regarding “Health in All” policies.
Priorities and ways forward
Endnotes: References, sources, methods, abbreviations, etc.
- ↑ Systems thinking for health systems strengthening (pdf 1.54Mb). Geneva, World Health Organization, 2009
- ↑ It includes: the Global Alliance for Vaccines and Immunization (GAVI); the Global Fund to Fight AIDS, TB and Malaria (GFTATM); the USG Presidential Emergency Plan for AIDS Relief (PEPFAR) and the Presidential Malaria Programme; and several other initiatives under the UN Group
- ↑ These reports and assessment comprise among others the Joint Annual Reviews (JARs), Mid-Term Reviews (MTRs), Zambia Demographic and Health Survey (ZDHS), the Health Sector Public Expenditure Review (PER), the National Human Resources for Health Strategic Plan (NHRHSP) and other studies
- ↑ An evaluation has been performed with the support of the London School of Hygiene and Tropical Medicine. A first draft report has been communicated in August 2009 but is not yet ready for publication.
- ↑ The only ones who do have some kind of health-related policy (most often with a long-lasting collaboration with the MOH) include: Ministry of Local Government and Housing, Ministry of Education, Ministry of Labour and Social Services, Ministry of Agriculture, Food and Fisheries and Ministry of Defence and Home Affairs.