Understanding Zambias National Health Plans Collins Chansa Chief Planner – Development Cooperation Directorate of Policy and Planning, Ministry of Health - Zambia

Presentation Outline Part One: Background Part Two: Current NHSP Challenges Way Forward Take Home Messages Q&A

Background to the Health Reforms 80s and early 90s Zambias 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 ; ; and Fifth (5 th ) Plan to cover the period 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% % of Total National Consumption Economic Quintile of the Population 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

13 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 11/9/

The OBJECTIVES of Zambias Health Plan The Plans Vision : Equity of access to assured quality, cost- effective and affordable health services as close to the family as possible The Plans Key Principles start with: Equity of access...

Three Illustrative OPERATIONAL TARGETS of Zambias Health Strategic Plan 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 targets to attain the MDGs

Zambias Human Resources for Health Strategic Plan 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

Zambias Human Resources for Health Strategic Plan … 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.

Zambias Human Resources for Health Strategic Plan … 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 Financing Gap

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 Sida WB UNICEF UNAIDS WHO CF GFATM USAID NCTP HSSP GFCCP DAC CCM UNFPA 3/5 SWAP UNTG PRSP Isnt Donor Collaboration Wonderful? Source: WHO: Mbewe

Verticalization of Aid leads to Fragmentation and Poor Results: Child Health Verticalization of Aid leads to Fragmentation and 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 as we prepare & implement the NHSP 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 31

PROGRESS TOWARDS THE ATTANIMENT OF THE HEALTH MDGs 32 INDICATOR ZDHS 1990 ZDHS 1996 ZDHS 2002 ZDHS 2007 NHSP TARGET (2010) MDG TARGET (2015) Infant Mortality Rate per NS 36 Under Five Mortality Rate per Maternal Mortality Ratio per100, New Malaria cases per 1, (HMIS 05) 412 (HMIS 06) 358 (HMIS 07) 252 (HMIS 08) 94/1000 <121/1000

33 Expanded Outputs - Tutors - Clinical Instructors - Books, Computers, Models - Infrastructure & Equipment - Operational Grant HRH IS KEY

I Thank You END of Presentation