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Health system outcomes

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Health systems have multiple goals.[1] The world health report 2000[2]defined overall health system outcomes or goals as improving health and health equity in ways that are:

  • responsive
  • financially fair
  • make the best, or most efficient, use of available resources.

There are also important intermediate goals: the route from inputs to health outcomes is through achieving greater access to, and coverage for, effective health interventions without compromising efforts to ensure provider quality and safety.

The health systems access framework[3]

Countries try to protect the health of their citizens. They may be more or less successful, and more or less committed, but the tendency is one of trying to make progress, in three dimensions:

  • First, countries try to broaden the range of benefits (programmes, interventions, goods, services) to which their citizens are entitled.
  • Second, they extend access to these health goods and services to wider population groups and ultimately to all citizens: the notion of universal access to these benefits.
  • Finally, they try to provide citizens with social protection against untoward financial and social consequences of taking up health care. Of particular interest is protection against catastrophic expenditure and poverty.

In health policy and public health literature, the shorthand for these entitlements of universal access to a specified package of health benefits and social protection is universal coverage.

This section on Health system outcomes is structured as follows:


Analytical summary

The health status of the Zambian people has been improving over the past 18 years.

Since the commencement of major health sector reforms in 1991, Zambia’s efforts have been directed towards improving the standards of living, particularly health, of the population throughout the country. This is being done through a combination of strategies and approaches, which include health specific strategies and those intended to influence the performance of other determinants of health, including education, poverty reduction, and access to good sanitation and safe water.

These efforts have manifested through the implementation of the Millennium Development Goals and the development and implementation of the vision 2030, the national development plan, national health strategic plans (see the latest National Health Strategic Plan 2006-2010) and other relevant sector strategies.

General overview and systemic outcomes

Overall health system status

Since the commencement of major health sector reforms in 1991, Zambia’s efforts have been directed towards improving the standards of living, particularly health, of the population throughout the country. This is being done through a combination of strategies and approaches, which include health specific strategies and those intended to influence the performance of other determinants of health, including education, poverty reduction, and access to good sanitation and safe water. These efforts have manifested through the implementation of the Millennium Development Goals (MDGs) and the development and implementation of the vision 2030, the national development plan, national health strategic plans (see the latest National Health Strategic Plan 2006-2010) and other relevant sector strategies.

Table 10.1 shows that the health status of the Zambian people has been improving over the past 18 years. This observation is supported by the performance trends of almost all the MDG health impact indicators and the conclusions of the Mid-Term Review 2008(see section 2.1). Improvements have also been reported in have been reported in the 2007 Zambia Demographic and Health Survey, the HMIS report for 2008 (insert doc) and the malaria indicator survey of 2008 (insert doc). Though some of these indicators are still below the targeted levels, the general trends are improving.

Zambia Table 10.1.jpg

Still, Zambia remains a high disease burdened country. The disease burden has continued to be high, causing significant pressure on the national health system. The situation is further compounded by the high levels of unemployment and poverty, the devastating impact of malaria, HIV&AID and other epidemics, and critical shortages and uneven distribution of health workers, which have continued to significantly impact on the standards of health of the population. In 2008, the top 10 main causes of morbidity and mortality in Zambia were malaria, HIV/AIDS, respiratory infections (non-pneumonia), diarrhoea (non-blood), trauma (accidents, injuries, wounds and burns), eye infections, skin infections, respiratory infections (pneumonia), ear, nose and throat infections, intestinal worms and anaemia. Table 10.2 presents the top 10 major causes of morbidity and mortality for all ages for the period from 2006 to 2008, whilst Table 10.3 presents data on the major causes of morbidity and morality in children under the age of 5 years.

Zambia Table 10.2.jpg

Zambia Table 10.3.jpg

Malaria is the leading cause of morbidity and mortality in the country. An effective national malaria control programme has been set up in recent years, which is making considerable progress in the implementation of major malaria prevention and treatment strategies throughout the country. As a result of the consented efforts that are being made, recent trends in key malaria indicators are showing significant progress in the fight against malaria. Over the past 3 years, malaria incidence per 1,000 population is reported to have reduced from 412 cases in 2006 to 358 cases in 2007 and 252 cases in 2008 (MOH, HMIS 2008).

Currently, HIV&AIDS is the biggest epidemic in Zambia, with significant impact on morbidity and mortality levels throughout the country, cutting across all ages, gender and social status. HIV&AIDS has placed a major social and economic burden on the country and has continued to significantly undermine the country’s capacities and efforts towards socio-economic development. It is currently estimated that approximately xxxx adults and xxx children (provide figures or preferably percentage on the total population) are living with HIV. However, significant efforts are being made, through a multi-sectoral response to control HIV/AIDS and mitigate its impact. As a result of these efforts, major achievements have been made at all the levels of interventions, including prevention, treatment and care for HIV infected persons. The Zambia Demographic and Health Survey 2007 has also revealed that over the past 5 years, HIV prevalence in the adult population aged between 15 and 49 years has reduced from 16.1% in 2002 to 14.3% in 2007 (ZDHS 2007).

Tuberculosis (TB) is one of the main non-pneumonia respiratory infections and among the major causes of morbidity and mortality in Zambia. The situation is further complicated by the emergence of drug resistant TB and also the TB/HIV core infections. It is estimated that approximately 70% of confirmed TB patients are also HIV positive. In this respect, current efforts are aimed at ensuring collaborative efforts in the diagnosis and treatment of TB/HIV. Even though significant progress has been made in the fight against TB, more still needs to be done in order to achieve the national and MDGs targets on TB. More discussion of malaria, HIV&AIDS, TB and other major health problems is provided in the section below on communicable diseases.

Achievement of the stated objectives of the health system

The objectives of the health system are articulated in the National Health Strategic Plan 2006-2010 as follows:

  • Vision: To ensure 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 Millennium Development Goals and national health priorities.
  • The following principles guide the implementation of this Strategic Plan: (1) equity of access; (2) affordability; (3) cost-effectiveness; (4) partnerships; (5) accountability; (6) decentralisation; and (7) leadership.

Achievement of the stated objectives of the Zambian health system is assessed by reviewing the sector’s performance in respect of the 7 stated key principles that underpin the National Health Strategic Plan 2006-2010. This assessment significantly draws from the previous recent assessments, including the Mid-Term Review 2008, the Demographic and Health Survey2007 and the Joint Annual Reviews (see for example the Joint Annual Review 2008).

(1) Equity of access

At the time of preparing the National Health Strategic Plan 2006-2010, in 2005, the major issues affecting equity of access to health care included: inadequate and irrational distribution of health facilities; critical shortages and inequitable distribution of health workers, particularly for rural areas; poor transport and communication; payment of user fees to access the services; shortages and erratic supply of essential medicines and other medical supplies; and the deteriorating standards of quality of care.

The National Health Strategic Plan 2006-2010 proposed a number of strategies targeted at ensuring “equity of access” as close to the family as possible". Over the past three years, MOH has implemented a number of these strategies which have contributed to the improvement of “equity of access”. Major decisions implemented include:

  • The policy on the removal of user fees in 54 rural districts in 2006 (see the sections on Health financing for the most vulnerable and on Health financing strategy towards universal coverage) is believed to have significantly increased service utilisation in the affected districts. Yet, a recent study[4] also showed that “the abolition of user fees had a very different impact in each of the health centers and hospitals visited (…). In some places the policy change was said to have greatly benefited the poorest, without negatively affecting the quality of services provided. In others, no impact on utilization could be detected but loss of income has seriously challenged service provision, or drug availability was compromised". Also, user fees still present a financial barrier for urban districts, where it still applies;
  • Scaling up of infrastructure development, including construction of new facilities, renovation of old infrastructure and expansion of existing facilities across the country (see the section on Infrastructure and equipment). A comprehensive infrastructure development plan is in place and being implemented. Procurement of medical equipment has also been scaled up, with support from partners such as the ORET project (what does this acronym mean?), the Global Fund to Fight AIDS, TB and Malaria (GFATA), the USG PEPFAR program and the World Bank funded ZANARA (idem) project;
  • Efforts aimed at improving the availability and rational distribution of health workers, which include the development and on-going implementation of a comprehensive National Human Resources for Health Strategic Plan 2006-2010, restructuring of the health sector, the introduction and expansion of the health workers’ staff retention scheme, task shifting strategies and strengthening of community health partnerships (see the chapter on Health workforce);
  • Improvements in the procurement, supply and distribution of essential drugs and medical supplies, through the introduction of the drug supply budget line system and improved funding from the treasury and the cooperating partners, particularly the GFATM and USG PEPFAR (see the section on Medical products); and
  • The resource allocation criteria used for distribution of financial resources to the districts is based on the material-depreviation index and is aimed at ensuring equitable distribution of resources (see the section on Health expenditures patterns, trends and funding flows).

As a result of these measures, significant improvements in equity of access have been observed, a fact that is also acknowledged in Section 5.1 of the Mid-Term Review 2008. In this respect, per capita annual utilisation of primary health care facilities has gradually increased, from 1.2 in 2006 to 1.3 in 2007 and 1.6 in 2008.

However, it should be noted that, even though these achievements are acknowledged, the scale of implementation of the above interventions point to the fact that there are still significant challenges/barriers, which need to be addressed in order to achieve the desired vision of “equity of access”. Universal free services would improve access for the urban poor, who make up about 50% of the Zambian population.

See also the chapter on Universal coverage for further details.

(2) Affordability

still to be completed

(3) Cost-effectiveness

still to be completed

(4) Partnerships

Partnership is one of the key principles that guide the implementation of the National Health Strategic Plan 2006-2010. The underlying assumption is that MOH will establish efficient and effective partnerships with all the stakeholders of the health sector in Zambia and that these partnerships will benefit from the synergies provided by each stakeholder group. In this respect, over the past years, Zambia has been significantly successful in establishing strong partnerships with the communities through enhanced decentralisation and increased participation of communities in the management of health services, other line ministries implementing various health-related programmes, the faith-based health sector under Churches Health Association of Zambia, international cooperating partners, civil society and the private sector. These partnerships have led to significant technical and financial support to the health sector, coming in form of direct sector support through the sector basket under the SWAPs, direct budget support, through the central treasury, earmarked funding for specific activities and project support. Partnerships with the other line ministries, CHAZ group, private sector and civil society have been mainly through their direct participation in the delivery of health care services.

Whilst it is acknowledged that the partnerships have led to significant increases in technical and financial support from the cooperating partners and that the health sector SWAp is significantly developed, there is still the problem of coordination and harmonisation of the efforts and resources. This leads to significant amounts of support being provided outside the SWAps, without proper coordination and prioritisation. Zambia is a signatory to the IHP+ Global Compact and efforts have commenced towards alignment of partnerships to the IHP+, so as to provide for enhanced prioritisation, coordination, harmonisation and scaling up of resources towards achievement of the MDGs. Already, the introduction of Joint Annual Reviews (JARs) in 2006 (insert doc) has gone a long way towards this aim.

Further, partnerships with the private sector need further strengthening. To this effect, efforts are currently undertaken towards developing appropriate policy and institutional frameworks for strengthening health services contracting and also towards expanding the coverage of the monitoring and evaluation systems to cover the private sector and civil society programmes and activities, which currently is a major weakness.

See also the section on Partnership for health and coordination mechanisms for further details.

(5) Accountability

The principle of accountability aims at ensuring that all the resources are utilized for the intended purposes in a professional and transparent manner. It also aims at ensuring that the ministry is accountable for the actions taken. To achieve this aim, appropriate fiduciary management systems have been developed to guide and control the: planning, procurement and financial management for the health sector. These systems are grounded into the national fiduciary management policies and systems, and include:

  • Policy and regulatory frameworks;
  • Institutional/implementation framework; and
  • Monitoring and evaluation framework.

Generally, it can be observed that the Ministry of Health (MOH) has made significant achievements in establishing a strong system for ensuring both financial and operational accountability. In July 2008 an assessment of Public Expenditure and Financial Accountability (PEFA) for the Government (insert doc) was undertaken to update the previous assessment carried out in 2005. The conclusion was that overall the system was operating at an average level and in some areas above average. There had been some clear improvements since the 2005 assessment.

In order to further strengthen accountability within the public sector, the Government has embarked on the implementation of the PEMFA programme (what does this acronym means?). This programme includes an improved and consistent legal framework for public expenditure management; introduction of an Integrated Financial Management Information System (IFMIS); strengthening of internal and external audit; and improvements in public procurement, debt management and external financing arrangements.

Though these accountability systems exist, they are also undermined by limitations in system and institutional capacities, particularly the continued shortages of financial management professionals. The situation calls for further capacity building.

Further, the accountability systems were put to test in the course of 2009 by the government’s revelation of possible fraudulent dealings and misappropriation of funds by some public health workers. This in a way could be considered to be an indication that the system is working. It also sets the basis for the need for continuous reviews and strengthening of the systems.

(6) Decentralization

The Zambian health sector has since 1995 embraced decentralization as an important tool for organizing the sector in a manner that allows for broader participation in health service delivery. The organizational model implemented between 1995 and 2005, aimed at greater decentralization of the functions of planning, management of service delivery and prioritization of resources from the centre to the districts, with stronger participation of the community (see the section on Decentralization of the system). Initially, these reforms were guided by the National Health Policies and strategies of 1991 (insert doc if available) and the National health Services Act of 1995 (insert doc if available), as there was no national policy on decentralization. However, since 2002, the Government has put in place the National Decentralization Policy, which is currently under implementation. The National Decentralization Policy (2002) (insert doc) was intended to follow that policy ‘towards empowering the people’. A comprehensive Decentralization Implementation Plan (DIP) followed (insert doc), that produced a roadmap 2006-2010 to guide the implementation of the policy by the various stakeholders.

The health sector has made significant achievements towards decentralization and is far ahead of the other sectors. However, decentralization of the sector is currently challenged by the need to appropriately align the health sector decentralization to the national decentralization policy, and ensure that this process does not reverse the achievements and lessons learnt. Further, it remains to be assessed, to what extent the recent restructuring of the sector, which resulted into the abolition of the semi-autonomous Central Board of Health and the district and hospital management boards, has impacted on the level of decentralization and community participation. The successful implementation of the National Decentralization Policy (attach doc) will to a large extent depend on the capacities of the local authorities to establish appropriate governance and institutional capacities to efficiently and effectively carry out this mandate. Currently, these capacities appear to be inadequate.

(7) Leadership

The principle of leadership recognizes MOH as the institution responsible for providing focus and coordination of all the programs and actors in the health sector. In this respect, the National Health Strategic Plan 2006-2010 identified leadership as one of the key principles to guide its successful implementation. This is also emphasized in the Memorandum of Understanding (MOU) between MOH and the Cooperating Partners (attach doc), which states that “the MOH will be fully accountable and responsible for the implementation of the NHSP and that it will provide overall leadership in planning and budgeting, implementation, monitoring and evaluation of the NHSP and the health component of the Fifth national development Plan (FNDP)”(attach doc).

It can be concluded that MOH has to a large extent been successful in providing overall leadership to the health sector, in all the key areas. Since 1992, Zambia has been implementing comprehensive reforms aimed at transforming the health sector into a responsive, efficient and effective sector. MOH has provided the necessary leadership to this process by developing and implementing the National Health Policies and Strategies of 1992 and the National Health Services Act of 1995 (NHSA 1995) (attach doc), which facilitated major policy, legal and organizational reforms within the sector. It has also continued to provide leadership, through the development and implementation of various sector policies, legislation and strategies, including the recent major restructuring of the health sector.

However, the ministry has also faced significant constraints and challenges in the process of exercising its leadership role. Major factors include:

  • The failure by MOH and the Zambian Government to successfully influence the global community into supporting efforts aimed at broader harmonization of the various forms of support to the sector, in line with international initiatives, such as the Paris Declarations and the IHP+;
  • Lost opportunity to control the prioritization of all the financial resources available to the sector, due to the proliferation of various forms of parallel and earmarked funding mechanisms, particularly the Global Fund and other Global Health Initiatives;
  • Inadequate technical capacity, attributed to shortages of planning and finance staff; and
  • Limited capacity by civil society organizations to make meaningful contributions to the planning process, and advocacy.

The distribution of health system's costs and benefits across the population

Currently, the health system in Zambia combines public, faith-based, private and civil society owned health services. Except for the private for-profit facilities, the other facilities are inclined towards provision of free and subsidised health services aimed at increasing access to these services. Within the public and faith-based health sectors, three main systems apply, namely: the free health care services, particularly for the rural areas and selected categories of the population, such as children, the aged and the defence and security personnel; flat user fee paying system, which are significantly subsidised; and full cost recovery basis, charged to patients asking for specialised services that are outside the prescribed basic packages of health care for the respective levels, and to patients opting for high cost services within the public and faith-based health facilities.

Whilst the general inclination of the public and faith-based health facilities and civil society services is towards expansion of free and highly subsidised health services, such services can not entirely be claimed as being an equitable health financing system, largely due to additional unmet costs which are more difficult to support for the poorest than for the rich (see the recent London School evaluation[5]). According to NHA data, approximately 30% of Zambia’s total health expenditures are incurred through inefficient out-of-pocket purchases of drugs and health services.

Such a system, inclined towards free health services, has a potential to contribute to reduce “catastrophic health care expenditures” (health expenditures that drive one into poverty, very often due to the sale of essential asset, such as productive land, cattle and other means of survival). Yet it also has several weaknesses, including the following:

  • It is not progressive (vertical equity). The poor is given the same advantage as the rich, and the rich does not contribute more than the poor to funding the health system;
  • There is no redistribution of resources, i.e. there is no transfer of resources from the rich to the poor, and from richer provinces to poorer provinces; and
  • Its sustainability can be questioned, due to financial and capacity limitations. Currently, the Government provides approximately 64% of the health sector budget, while the balance of 36% comes from cooperating partners. With the global economic crisis and shifts in global policies, sustained global financial support may not be guaranteed. Further, due to economic constraints and competing priorities, the government may not have the necessary financial muscle to sustain such a system and at the same time improve the standards of health services.

The system is also challenged by a number of factors, including:

  • Personnel and facilities: The current distribution of facilities and health workers is not equitable and largely favours urban areas. Rural areas are usually disadvantaged as health workers find it difficult to cope with the underdevelopment and lack of basic facilities; and

Future prospects might change the picture. Currently the government is working on the development and implementation of a health insurance mechanism, which is envisioned as a possible option for extension of the population coverage under the forthcoming health insurance policy. This could, in theory, meet principles of progressivity, redistribution and protection against catastrophic health care expenditures. The Mid-Term Review 2008 recommended the following 3 approaches as worth pursuing:

  • Social health insurance (SHI) scheme for formal sector employees should be implemented as soon as feasible. The actuarial analysis for the SHI is completed. Key decisions should be made on the results of the analysis in terms of the affordable benefit package and the government’s contribution, as employer of civil servants, to the proposed scheme. The SHI provides a risk-pooling platform for the current substantial expenditures of households that are often made out-of-pocket and (inefficiently) at the point of need;
  • Private investments in the country’s health sector should be encouraged through PPP arrangements. The design-finance-build-operate-transfer scheme for the replacement of Lesotho’s Queen Elizabeth II Hospital provides a practical example of how a fixed amount of government budget could leverage private resources to provide wider coverage and better quality health services; and
  • Work-based health and HIV/AIDS prevention and treatment programs should be encouraged among employers. Studies show that if employers could be assisted by government to negotiate better ARV prices, they would be willing to shoulder all or part of the ARV costs themselves. The Debswana scheme in Botswana and Anglo American scheme in Namibia are a good example for the mining sector.

Efficiency of resource allocation in health care

The National Health Policies and Strategies of 1992 (attach doc) and the policy, legislative and institutional reforms that followed aimed at achieving equity of access to quality health care. To achieve this aim, a number of important policy, strategies and systems have been implemented that aim at ensuring efficiency in the allocation and utilisation of resources available to the health sector. The major ones include:

  • The decentralisation of planning and service delivery functions to the districts, including enhanced participation of the communities and other stakeholders;
  • Development and implementation of the Basic Health Care Package (BHCP), which defines the packages of health care services to be provided at the different levels of health service delivery;
  • Development of a resource allocation formula that aims at promoting equitable distribution of resources to all the levels of health care across the country. Since 2004, MOH has adopted a resource allocation criteria for district level services, which is based on Material Deprivation Index (MDI). This formula allocated resources to districts on the basis of the population, giving more weighting for resource allocation to the most deprived districts;
  • Establishment of appropriate institutional frameworks for efficient and effective management of the sector, including a strong SWAp governance system, allowing active participation of all the key health partners, in the management of the health sector, and the continuous review and realignment of the health system structures;
  • Development of fiduciary systems for ensuring transparency and accountability in the allocation and utilisation of the resources available to the sector. The sector system falls within and is aligned with the national level fiduciary policies, legislation and systems; and
  • Monitoring and evaluation frameworks that are broad based, involving active participation of all the key health sector partners, including the cooperating partners and civil society, through the established SWAp coordination and governance structures.

The intention of this approach is clear, “to ensure effective allocation and utilisation of the available resources within the health sector”. However, there are a number of constraints and challenges that are adversely affecting these efforts. The major ones, as observed in the Mid-Term Review 2008 include:

  • Inadequate coordination and harmonisation of financing to the sector from the government and its partners, particularly the global health initiative and some cooperating partners. The increasingly fragmented financing is leading to large inefficiencies as reflected in the increasing proportion of total health expenditures going to administration and consequently, reduced finances available to service delivery). The Zambia National Health Accounts exercises (attach the most recent NHA) show clearly that when off-budget expenditures of CPs increased, total health expenditures going to administration more than doubled from 14.8 percent in 2001 to as high as 30.8 percent in 2004, and this trend seems to have persisted. Aside from the actual cost of administration, the cost of coordinating these off-budget activities also involves hidden costs of managerial and staff time of both government and donor partners.
  • Systemic inefficiencies persist, with incalculable costs to the health system. The current system of facility construction and renovation involving the Ministry of Works and Supply (MOWS) provides many bureaucratic obstacles that preclude timely, efficient, and “within-budget” completion of infrastructure projects. Alternative arrangements including PPP should be explored to circumvent these difficulties. Further, it is not always that construction of facilities is matched with the availability of the critical inputs, such as human resources. Though disbursement of grants to the districts has significantly improved over the past 2 years, it still remains a major challenge to sustain. Drug procurement and distribution, though much improved, still experiences many inefficiencies. The availability, distribution and management of human resources for health still experiences significant challenges and leaves significant room for improvement (See Public Expenditure Tracking Survey report (attach doc)). Staff available is currently at approximately 52% of the needs and distribution is not equitable. Poor staff morale also significantly reduces staff productivity, with as much as 44 percent dissatisfaction rate among staff;
  • Current clinical practices sometimes produce inefficiencies that are often undetected; and
  • Weaknesses in the existing financial management systems, which at times leads to leakages, misappropriations and inefficient allocation and utilisation of resources, as highlighted in the Auditor General’s reports.

A number of measures are underway, aimed at addressing the identified weaknesses. These include: full implementation of the restructuring recommendations, so as to strengthen institutional capacities; increased harmonisation and coordination of financial resources available to the sector, through implementation of the Paris Declarations on aid effectiveness and the IHP+; implementation of the National Human Resources for Health Strategic Plan (attach doc) and the expanded health workers retention scheme (attach doc); further strengthening of the procurement and distribution system for drugs and medical supplies, through the Drug Supply Budgetline (DSBL); and continuous review and strengthening of the fiduciary management systems.

Technical efficiency in the production of health care

In the Zambian health system, the efficacy of most health products is already determined. The strategies to improve the effectiveness of services are largely a function of the means of delivery used. At the adoption stage, the selection of the most effective approach to delivery services has largely been guided by availability of resources (human, financial, infrastructure), plus the political and economic environment. These variables have informed the approaches used to deliver most of the new interventions introduced so far in the National Health Strategic Plan 2006-2010, such as the use of Artemesin-based Combination Therapies (ACTs) and Insecticide Treated Nets (ITNs) for malaria prevention and control, Bilharzia prevention amongst others. Three key ingredients however have not been extensively utilized, namely:

  • The systematic use of evidence to guide choice on effective interventions. Not all the health programmes have developed evidence bases to inform policy and decisions;
  • The involvement of health service delivery managers in the design of the mode of delivery of services, despite the very participative policy development process in place in Zambia thanks to the long-lasting partners’ coordination set up. Involvement of the service delivery managers is essential and could ensure that greater integration and benefits are derived from the limited resources that are available to delivery of all services; and
  • The involvement of users. Appropriate involvement of users enables delivery to be better tuned to their needs and expectations, and in this way increasing likelihood of use and satisfaction.

It is acknowledged that the Zambian health sector has developed appropriate packages of basic health care services to be provided at different levels. These packages are clearly defined and disseminated to all the levels of health care. In this respect, the levels of compliance with these packages could indicate the efficiency of the service delivery. Whilst the facilities, by-and-large have continued to observe and try to consistently apply these packages, there are significant challenges, which mainly relate to the availability and conditions of infrastructures and equipments, availability of critical inputs such as human resources, essential drugs and medical supplies, and financial resources. These factors act as hindrances to effective delivery of the recommended packages of health care.

Quality of care

The standards of quality of care largely depend on the availability and consistent compliance to appropriate policy, legal and regulatory frameworks, systems and procedures, established to set and regulate the standards of performance of the various aspects of care. In the Zambian situation, the Government has established the necessary building blocks for ensuring quality of health care, including :

  • A system of appropriate health policies and legislation for guiding and regulating health service delivery. The government has also established appropriate institutional framework for effective enforcement of these policies and legislation, which includes the various health statutory boards responsible for specific pieces of policies and legislation. These are discused in the section of the Specific regulatory framework of Service delivery.
  • Service delivery systems and procedures, which include: health facilities; defined packages of basic health care; standard guidelines and operating protocols for various aspects of service delivery, including the lists of essential and tracer drugs, guidelines on appropriate drug use, treatment and laboratory guidelines. In addition, quality assurance systems and procedures are in place.
  • Monitoring and evaluation frameworks have been established for purposes of obtaining feedback on the implementation and compliance to the set standard procedures. The institutional framework for such a system includes the directorate of technical support services at the central level, provincial health offices and district health services, which are responsible for reviewing technical performance and provision of appropriate technical support. The tools used for monitoring quality/compliance include, routine data management and reporting systems, including HMIS, provincial performance assessments, and special surveys and reviews, such as the Demographic and Health Surveys (see for example the 2007 Demographic and Health Survey), joint annual reviews (see the Joint Annual Review 2008), mid-term reviews and malaria indicator surveys.

The quality of healthcare in Zambia is partly compromised by the shortages of appropriate facilities, shortages and inequitable distribution of health workers, difficulties in ensuring steady adequate supplies of drugs and medical supplies. It is also affected by the observed weaknesses in the existing policy and regulatory frameworks, standard operating procedures and the need for further institutional strengthening within the technical support services, provincial and district offices. More about the quality of heath care is discussed in the section on Quality of health services.

Contribution of the health system to health improvement

Health is the outcome of various social determinants (the so-called Social Determinants for Health (SDH)) rather than of the efforts of the health system alone (see the specific section on Social Determinants for Health). However, the health sector has the overall responsibility to identify potential areas for influencing SDHs to improve health, both within the health sector and in other sectors, and suggesting appropriate policy recommendations and strategies in various sectors aimed at exploring such potential to achieve good health for the population. The contribution of the health system to health improvement in Zambia could be viewed as a function of two variables, namely the direct contributions to health service delivery and the aspect of influencing and supporting the implementation of various policy interventions in other sectors, which influence the performance of the SDHs.

In this respect, the health system in Zambia significantly contributes to health improvements. Some of the major areas of contribution in this regard, include:

  • Direct participation in health service delivery. The MOH is the leading provider of public health services, controlling over xxx% (complement) of the total number of primary level facilities and xx% (complement) of the secondary and tertiary level facilities throughout the country. It also controls 11 specific disease based programmes, which focus on coordinating appropriate responses for the particular disease. MOH is also responsible for coordinating the contribution of the whole health system, including the faith-based, private sector and health sector civil society organisations.
  • Influencing and supporting implementation of health related programmes and SDHs in the other sectors. The ministry is overall responsible for identifying and recommending and/or influencing policies that are relevant to health across the sectors. In this respect it is also responsible for coordinating the national health agenda, including provision of technical backup to all the sectors implementing health related programmes. The other sectors also have an important role to play in influencing the performance of the specific SDH. Major contributions are in form of:
  • Poverty reduction, through employment creation, nutrition and economic empowerment;
  • Environmental issues, including ensuring safe and healthy environments, and environmental protection;
  • Access to safe and clean water and sanitation; and
  • Prevention and mitigation of disasters, as well as prevention of accidents, which could lead to ill health.

Even though it is clear that the health system is the main contributor to health improvements, in the absence of empirical evidence, it is difficult to suggest the percentage of such contribution.

Priorities and ways forward


A key interest of links is that they can be included directly in the text as the following Zambia: Joint Annual Review Report 2008 which is a key policy document in Zambia

Zambia: National Health Strategic Plan 2006-10

The issue of decentralisation of the health system is addressed in section 1.2.3 which is part of the leadership and governance chapter.

Endnotes: sources, methods, abbreviations, etc.

  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. The world health report 2000. Health systems: improving performance (pdf 1.65Mb). Geneva, World Health Organization, 2000
  3. The world medicines situation (pdf 1.03Mb). Geneva, World Health Organization, 2004
  4. The study was conducted with the support of the London School of Hygiene and Tropical Medicine. A first draft has been delivered in mid-2009 but is not yet ready for dissemination.
  5. The study was conducted with the support of the London School of Hygiene and Tropical Medicine. A first draft has been delivered in mid-2009 but is not yet ready for dissemination.