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Universal coverage

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People expect their health systems to be equitable. The roots of health inequities lie in social conditions outside the health system’s direct control. These root causes have to be tackled through intersectoral and cross-government action. At the same time, the health sector can take significant action to advance health equity internally. The basis for this is the set of reforms that aims at moving towards universal coverage, i.e. towards universal access to health services with social health protection. Health inequities also find their roots in the way health systems exclude people, such as inequities in availability, access, quality and burden of payment, and even in the way clinical practice is conducted.

Three ways of moving towards universal coverage

The fundamental step a country can take to promote health equity is to move towards universal coverage: universal access to the full range of personal and non-personal health services required, with social health protection. The technical challenge of moving towards universal coverage is to expand coverage in three ways (see figure).:

  • The breadth of coverage – the proportion of the population that enjoys social health protection – must expand progressively to encompass the uninsured, i.e. the population groups that lack access to services and/or social protection against the financial consequences of taking up health care.
  • The depth of coverage must also grow, expanding the range of essential services that is necessary to address people’s health needs effectively, taking into account demand and expectations, and the resources society is willing and able to allocate to health. The determination of the corresponding “essential package” of benefits can play a key role here, provided the process is conducted appropriately.
  • The height of coverage, i.e. the portion of health care costs covered through pooling and prepayment mechanisms, must also rise, diminishing reliance on out-of-pocket copayment at the point of service delivery. Prepayment and pooling institutionalizes solidarity between the rich and the less well-off, and between the healthy and the sick. It lifts barriers to the uptake of services and reduces the risk that people will incur catastrophic expenses when they are sick. Finally, it provides the means to reinvest in the availability, range and quality of services.

This section on Universal coverage is structured as follows:


Analytical summary

Access by the population to quality social and health services has been an area of concern for successful Zambian Governance since ninepence in 1964. Public health infrastructures have been progressively brought closer to the population, while decentralization policies were aimed at giving them ownership on their health services. Different health financing systems have been tested, resulting today in an increasing tendency towards the provision of free or highly subsidized health services.

Organizational framework of universal coverage

Overview of main actors and arrangements related to universal coverage

Coverage of the health and other social needs of the population has been a driving force in successive Zambian political orientations since the independence.

As from 1964, Zambia set out on a mission to expand access to health care services, education and other social services and reduce social inequities. The main focus at that time was to promote employment and to facilitate the expansion of health services, education and other social services on a free of charge basis. This Socialist-oriented held the power power from 1964 to 1991. Major successes were achieved, particularly in infrastructure development at all the levels, including primary level, health, educational and transport and communication infrastructure, thanks to maintained political will and a strong economy boasted by high international copper prices

However, the situation deteriorated during the 1970s and 1980s, mainly due to major economic crisis precipitated by the drop in copper prices, the mainstay of the economy. This led to reduced investments at all levels of health services, especially primary level, and deteriorations in standards of living of the general population.

In 1991, multi-party politics were reintroduced and the economy turned towards a free market system. Since then, Zambia has been implementing major socio-economic reforms. By that time, significant deterioration in health services had been observed, with resource allocation to the health sector dropping from US$26 per capita in the 1970s to US$6 in the 1990s. The main focus of the health sector has been on equity of access to health care services, as close to the family as possible.

The major policy reforms passed since 1991 in relation to the concept of universal health coverage in Zambia include:

  • 1995 – National Health Services Act passed. Willingness to raise the voice of the population in the management of health services through the decentralization of health services;
  • 1995 - User fees introduced in the health sector following Alma Ata and Bamako declarations. Also introduced in other social sectors, such as education. Exemption of some categories of the population from paying for health services, including children, the aged and military personnel;
  • 2005 – Second phase of major restructuring of health sector. Reduction in the decentralisation of powers, through the dissolution of health management boards;
  • 200X - Basic education services are decreed free, before health services. Extended in 2009;
  • 2006 - Removal of user fees for health centres and district hospitals in rural areas, extended to peri-urban areas in 2007;
  • 2008-2009 - Draft Health care Financing Policy and Social Health Insurance (SHI) scheme developed. Finalisation planned for late 2009 or early 2010;

Nowadays, universal coverage issues are discussed (together with other health system issues) in the existing coordination forums at national and decentralized level. The long-lasting coordination with partners and SWAp arrangements has certainly contributed to set the issues of universal coverage and equity high on the Zambian agenda. Progresses in the field of equity are also being made within these institutions to allow the voice of a diversity of actors in the governance on health issues. For example, SWAp bodies are progressively getting extended to include previously excluded players, such as the NGOs and grassroot organization.

There are also a number of other mechanisms to make the demands of the population heard regarding inequities and coverage failures: (1) the planning cycle developed through the reforms provides a decent opportunity to decentralized level, including the population, to raise their voice in the national policy debate; (2) traditional leaders are becoming more and more active in claiming the rights to social services for their populations, due partly to the decisive influence they may have on local votes in national elections; (3) churches also play an important role in passing on the communities’ complaints to the related authorities (the Catholic Commission for Justice and Peace is one such important church institutions in advocating and promoting peace and social justice); (4) finally, a number of Non-Governmental Organisations (NGOs) and Community Based Organisations (CBOs) are also specialized in advocacy for health-related and other social problems and are having increasing influence in the course of liberalization of Zambia.

Zambia benefits from a significant set of information sources to measure inequities and coverage failures. As discussed in the chapter on Health Information System, recent reforms in the HMIS allow for detailed socio-economic analyses by age, gender, socio-economic status, etc. In addition, a number of reports and surveys (DHS, ZSBS, MIS, LCMS) provide additional information. Institutional arrangements within the MOH and with partners at central level allow for optimal use of this information in decision-making and policy formulation processes, including universal coverage issues.

Health mapping and geographical coverage

The total population of Zambia is estimated at approximately 12 million people, comprising of 40% urban and 60% rural populations. According to the xxxxx survey, approximately xxx% of the total population have access to decent health care, representing xxx% of the urban and xxx% of the rural populations. As a result of this failure in achieving the desirable levels in universal coverage, some people resort to seeking health services from sub-standard unauthorised providers, which endangers their lives.

The country face a number of issues regarding geographical coverage. The overall problem relies in an uneven repartition of health infrastructures, personnel and other inputs between urban and rural areas, and between provinces (Lusaka and Copperbelt being significantly advantaged).

More particularly, the poor state of transport and communication infrastructure, especially for rural areas, presents a major challenge. Even though the government has already mapped and defined the types and numbers of health facilities needed for each district, the available facilities are inadequate. Further, some facilities are considered as inappropriate by the patients (e.g. mothers delivering at home due to the absence of mothers’ waiting shelters that meet their standards). The country has also continued to face a critical shortage of qualified health workers, with only about 52% of the total number of health workers needed. The rural areas are worst affected, due to inequitable distribution of the available health workers. Though the Joint Annual Review 2008 observed that there were significant improvements in the availability and distribution of essential drugs and other pharmaceuticals, it also pointed out that there were still shortages being experienced in some parts. This again, is more prevalent in rural areas.

The government has undertaken several measures and developed strategies aimed at dealing with these challenges to geographical coverage. These include:

  • Scaling up of infrastructure development in health, transport and communication, and education;
  • Strengthening of partnership with the faith-based health sector under the Churches Health Association of Zambia (CHAZ) (now accounting for approximately 30% of total national health services and approximately 60% in rural areas);
  • Promotion of outreach operations, conducted by health facilities, the Zambia Flying Doctor Service and specific disease based programmes, as a strategy to compensate the gap of primary health care services.
  • Strengthening of the community health worker strategy for provision of basic health care services, including maternal health in communities; and
  • Continuous efforts to develop primary health care services at all level of the health system.

Health financing strategy towards universal coverage

At present time (2009), there is no formal Health Care Financing policy. A draft had been prepared in 2003, updated in 2008, but not amended yet.

In these conditions, one cannot draw with certainty the vision defended by the MOH and its partners regarding health financing options towards universal coverage, and its implication in terms of extension of the target population, package of services and social protection (see the following subheadings).

Officially, user fees are still in application in the health sector. Yet, the population benefits from so many subsidy mechanisms from the government and partners that user fees tend to narrow down to some lump sum payments in urban health facilities. There are actually a variety of exemption options:

  • Some important groups of the population (under five, elderly) benefits from free services for years;
  • The entire population gets a selection of services for free or at nominal fees under the Basic Health Care Package policy[1];
  • Health services are free in health centres and district hospital located in rural and peri-urban areas (representing about xxx% of the population), since the two successive waves of user free removal in 2006 and 2007. The early results of this strategy have been the subject of an evaluation in late 2008 utilized during the Joint Annual Review[2].
  • Some additional forms of characteristic free services come in addition (for the militaries, etc.).
  • All other services are subject to partial subsidy and only invoiced through a lump sum mechanism.

A strategy of Social Health Insurance is currently being discussed, and is supposed to be finalized by late 2009 and soon piloted (see the 2008 SHI Actuarial Report).

In line with the stated vision of the MOH to bring health services “as close to the family as possible” it is very likely that the government will adopt some form of strategy towards universal coverage at a certain stage. Yet, in the absence of health financing policy, what this strategy will be is still to be defined.

It seems, according to early works around the Health care financing policy under preparation, that insurance mechanisms would be the preferred option with extension of the forthcoming SHI for the formally-employed workers and development of community-based health insurance for the rest of the population.

As a matter of fact, in the current situation, citizens can only claim for a partial social protection for health. For instance, none of them is protected against the high out-of-pocket expenditures to be encurred at provincial or national hospital level.

In that respect, the option to progressively launch and extend insurance mechanisms, first to formal employees, and then to communities, could make sense as long as it provides a quite comprehensive protection (as Zambian citizens already enjoy some protection).

But risk pooling mechanisms are complicate process in which Zambia has virtually no experience. Beside, there might also be arguments in favour of extension of the package of already existing free services.

The subject requires further reflexion and technical guidance. In practice, the two options will imply making a choice between focusing on, strengthening and reforming two different funding sources: (1) either demand-side financing for SHI (2) or tax-based financing + donor financing for free health care services.

Breadth - extending the target population

In the absence of clear health financing policy[3], the strategy to extend the coverage of the population in Zambia is still to be defined.

See the discussion on possible options in the generic section on Health financing strategy towards universal coverage for further information.

Depth - expanding the package of services

In the absence of clear health financing policy[3], the strategy to extend the coverage of the population in Zambia is still to be defined.

See the discussion on possible options in the generic section on Health financing strategy towards universal coverage for further information.

Height - reinforcing protection against financial risk

In the absence of clear health financing policy[3], the strategy to extend the coverage of the population in Zambia is still to be defined.

See the discussion on possible options in the generic section on Health financing strategy towards universal coverage for further information.

Other initiatives towards universal coverage

Equity and universal coverage are for long high on the Zambian policy agenda, as demonstrated in the cross-sectoral National Population Policy since 1989 as discussed under specific regulatory framework, or efforts and reflexion made for more than 15 years around decentralization of decision and priority setting to the local population and health workers (see the section on decentralization of the health system)

It led to the development of actions and strategies taken in various sectors, aimed at reducing inequities and improving health and living conditions (see Social determinants for Health).

Universal coverage also means favouring cross-sector interventions. For instance, in order to counter the challenges associated with long distances and communication barriers, the Government now invest on infrastructure development plan; improvement of road conditions along the ministry of works and supply policy, and communication infrastructure with the ministry of communication and the private sector. The general policy context favouring similar interventions is discussed in the section on Policies in other sectors and intersectoral policies.

Barriers on access to health services

There are no recent specific study giving an appropriate picture of the barriers faced by patients when trying to access health services. Yet the barriers issue is acknowledged and addressed in a number of recent policy decision taken by the MOH in coordination with partners (e.g. inclusion of socioeconomic indicators in the revised HMIS, development of retentions schemes and bonding systems...)

  • The distribution of health facilities is inequitable with the country. The government has classified districts in A to D zones, C & D zones being the districts suffering from the poorest level of investment. Patients in these zones are believed to face additional barriers in accessing health facilities due to poorer health mapping, allocation of health staff, equipment, maintenance level, road conditions, etc.
  • The Zambian health financing system is characterized by a combination of specific free health care policies at lower levels (see the section on health financing in this chapter). The financial barrier to access public services is then reduced, and most out-of-pocket expenditures actually relate to paying private health services[4]. Nevertheless, user fees are applied in the public secondary and tertiary level, where services are more expensive, and could lead to catastrophic health care expenditures. This is partly compensated by a general policy of subsidized lump sum payment per episode of illness. Still, in the absence of risk- and cost-pooling mechanism, the poor undoubtedly face financial barrier in accessing hospital services, and one can not talk about any form of vertical and horizontal equity[5]. Social Insurance mechanisms are envisionned as a possible option, but early pilots (in late 2009 / early 2010) will remain focused on formally employed workers, who are less confronted to financial barriers.
  • Equity in the distribution of human resources is a key concern in Zambia. Only 50% of planned posts are covered, and poorest areas (C & D) suffer the most. Yet, since 2005, the MOH and its partners have launched a comprehensive set of measures (retention schemes, incentive schemes, bonding system, invesment on training institutions) in line with the Human Resources for Health Strategic Plan 2006-2010 (see the chapter on health workforce).
  • It seems that most health facilities manage in reasonnably covering their package of activities as defined under the Basic Health Care Package. Main failures are related to investment and budgetary issues as: (1) drug stock-outs, which is a recurrent issue related among others to insufficient government grant; (2) lack for equipment or of human resources to cover specific aspects of the package (e.g. maternal care). Problems related to the "human factor" as absenteism, under-the-table payments and other shadow practices seem to be less prevalent than in numbers of low and middle income countries.

Only few information is available about the barriers on access to health services which may be related to the patient's profile. Are some sections of the population discriminated, what are the main cultural and social barriers, does the chronic patient represent a social load for his family? It remains unclear. The 2007 Demographic and Health Survey tends to show that women have a say in household expenditures decision, which is a positive sign. Also one may guess that the population from C & D zones faces additional barriers due to poorer living conditions (and then discrimination), poor education (and then a less informed decision-making process) etc. But more research is needed on this question.

Endnotes: References, sources, methods, abbreviations, etc.

  1. The elements of the Basic Health Care Package are selected on the basis of an epidemiological analysis of those diseases and conditions that cause the highest burden of disease and death.
  2. 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.
  3. 3.0 3.1 3.2 The health financing policy is under discussion since the mid-2000s and should hopefully lead to an amended policy and strategy in 2010
  4. The 2008 Public Expenditure Review has shown that 71% of patients out-of-pocket expenditures were merely allocated to private health services.
  5. The rich pays the same as the poor while he could contribute more; the ill pays more than the healthy while he is not responsible for being ill.