TOSHIBA

CRITICAL EVALUATIONHEALTH SYSTEM OF ZAMBIA

CHIMAROKE OBINYA

11/1/2010

The Black nation of Zambia has an impressive health system in comparism with several other African countries worth preserving. This is a critical look at the areas that need attention.

INTRODUCTION:

The Zambian health system is predominantly Government run with 85% of the health institutions publicly owned, 9% in the private sector mainly based in the urban areas and 6% owned by the mission (Chankova et al. 2006). It has the ministry of health, MOH, at the center coordinating formulation of policy, employment of staff and distribution of resources. Health care is financed by every able-bodied citizen with an income (International Insulin Foundation, nd.) with exemption of the aged (above 65years) and those with specific diseases like HIV/AIDS, Tuberculosis, and Cholera. Programs like safe motherhood and family planning and immunization are exempted from paying (International Insulin Foundation, nd.). The payment was on a cost sharing basis, in the form of user fees, with the Government contributing the lion share (Chankova et al. 2006). Abolition of these user fees in the rural areas of the country in 2006 saw a 30% increase in the usage of health facilities (ibid; The National Archives, 2007).

The Central board of Health, CBoH, used to be responsible for the running of the hospitals and staffing leaving the MOH with the primary function of policy formulation until its dissolution in 2006 (Chankova et al. 2006). The District Health Management team is in-charge of the district hospitals and health care in the 72 districts of Zambia. These report to the provincial health teams at the 9 provincial headquarters. The provincial health management teams in Zambia’s nine provinces (CIA, 2010) report to the ministry of health. This is equally the channel of flow of resources.

The Ministry of Health derives its financial resources from the annual national budget and donations from up to 15 major international partners (Schatz, 2008; Masiye, 2007). Most of the international organizations contribute directly for specific programmes such as malaria (Bill Gates Foundation), etc. (Schatz, 2008). In 2006 alone, the Global Funds for AIDS, Tuberculosis and malaria donated one hundred and twenty million US dollars ($120m) to the ministry of health (Masiye, 2007). These resources are distributed on basis population densities (number of hospital beds), and likelihood of epidemics (International Insulin Foundation, nd.).

In the districts, the population densities determine the size of hospitals with the number of in-patient beds provided according to standardized bed/population ratios (ibid).

Lack of Human resources is the major issue plaguing the Zambian health system with number of health personnel per 100,000 population way below the recommended WHO ratio of 20 physicians and 143 nurses per 100,000 population (Chankova et al, 2006; Schatz, 2008). Zambia had an estimate of 7physicians and 113 nurses (Chankova et al, 2006) as at 2006. This shortage has been attributed to massive emigration of health personnel to neighboring African countries and the developed world. Lack of expansion of training institutions to match the growth in the population has also been indicted. This has necessitated the introduction of “rural retention programme” to keep doctors especially in the rural areas which have dire need (Schatz, 2008). The rural retention programme provided doctors with an extra monthly allowance, a car loan and a onetime housing upgrade allowance (ibid) for a three year stay in a rural community.

The Zambian health system is designed in such a way to ensure equity of access for all its citizens. In the cities 99% of households live within a 5km radius of a health facility (International Insulin Foundation, nd.). Sparse population of the rural areas has modified this statistic to 50% of households living within the 5km radius of a health facility. In the very remote areas of the country, health centers run by registered and enrolled nurses provide basic health care. This health centers are usually within a hundred kilometer range of a primary level hospital that has one or two functional ambulances for instant evacuation of the very ill from this health centers to the primary and sometimes secondary level facility. All the health facilities are interconnected with long distance radio system. A percentage of the monthly subvention from the Ministry of Health, through the Provincial and then District Health offices is earmarked for fuel for the ambulance to prevent stock out of fuel. A broken down ambulance is an emergency that must be instantly reported to the District Health Management team. A functional ambulance must be standby at all times for quick response to emergencies especially maternal emergencies in an effort to meet up the WHO millennium development goals.

EVALUATION:

World Health Organization (2000) outlined the functions of a health system as resource generation, accountable management of resources, service provision and responsiveness. Evaluation of the Zambian health system can be looked at from different sections: input (resource generation), process (management) and output (service provision and responsiveness). Outcome, produced by the interaction of the output with the community/environment over a period of time can also be an indicator the functionality of the health system.

Resource generation refers to physical capital, human resources (Merson et al. 2006) and revenue collection. This is already lopsided considering the massive emigration of health workers to neighboring African countries and developed nations in search of greener pastures (Schatz, 2008); no improvement in medical educational facilities despite increasing population; and the ravaging effects of HIV/AIDS on the health workers (ibid; International Insulin Foundation, nd.). Human resources are much lower than the projected needs of the system. In addition to this health facilities are below projected levels as of date with postponement of planned upgrade restructuring of many hospitals and building of new ones as planned especially in the hinterland. The MOH however, is prompt with provision of equipment such as X-ray machines, Ultrasound machines, etc. so much so that it is a wonder to see the amount of machinery in these so called rural hospitals, Kawambwa District Hospital being a good example. Government is however doing a lot to combat the manpower shortages with the recent moves of proliferation of quality nursing institutions and the bonding of health workers for a number of years after investing in their education. There was even a move to ensure that neighboring countries who employ Zambian doctors pay the Government of Zambia a stipulated amount of money depending on the number of years post graduation, the more the years, the less the amount.

It is heartwarming though that the MOH is still receiving grants for its health programs (Zambian Watchdog, 2010; Zinyama & Munalula, 2009). International grants, annual budgetary allocations and user fees in the urban areas comfirm that the health system is adequately procuring resources. Monthly distribution of

these resources can be ascertained from the MOH monthly allocation records as well as from the Provincial and District health offices. The promptness and appropriateness of these disbursements can easily be ascertained.

Process evaluation will be geared towards checking how effectively the generated and received resources, including the capital and labor are put to use in generating services. This is actually the function of management, building the bridge between scarce resources and provision of essential services (Merson et al. 2006). Is there equity in the distribution of health facilities, equipment and personnel, taking into consideration the topography of the different localities? Is the equity of access constantly improved upon to ensure most citizens are effectively provided with meaningful health care despite their location? How efficient is the channel of communication? How are drugs distributed? Is it haphazardly or according to perceived needs with focus on predominant illnesses in different geographical locations?

The quality of planning and implementation of health programs such as the procurement and distribution of insecticide treated mosquito nets; periodic spraying of sections of the population to reduce mosquito burden is a good assessment of the malaria prevention program funded by the global funds (Zambia Watchdog, 2010). Frequency of periodic training and opportunities for staff development is a pointer of the quality of the health system. Is the staff constantly updated on emerging diseases and the constantly improving methods of management of these illnesses? Are the staff capacities, strengths and weaknesses taken into account when rolling out the training programs and even the distribution of equipment? These capacity building programs improve the psyche of the staff, ensuring their hearty participation (Naidoo and Mills, 2009) and consequently better health and constantly improving health delivery. The quality and reach of awareness campaigns for the predominant illnesses (HIV/AIDS, malaria, Tuberculosis) and programmes of MOH (immunization, maternal and child health services) is a pointer of the quality of the health system.

What is the organizational culture like? Too much control from the center can result in rigidity and loss of ingenuity (Garside, 1999) while too much flexibility

can lead to chaos. Management should be predisposed to unlearning and learning new beneficial practices (ibid) that can greatly benefit the health system. Traditional bureaucracy and professionalism are the identifiable models of management in place (Hunter, 2007) in the country; however gravitation towards the new public management model where the units of the health system operate in a competitive manner will improve performance (ibid).

Evaluation of service provision/output is a huge cornerstone in this critical evaluation of the health system of Zambia. This should be approached differently at the different health delivery levels. What services are supposed to be offered at the health center level, are they actually offered efficiently (Beghin, et al 1989) or do the staff here just serve as a referral stand, sending small cases of mild dehydration to the primary hospital centers where the few nurses and doctor (or rarely two doctors) are already being overwhelmed by the patient load. A very functional health center level will boost health care. This is the level of care closest in location to families. It is also the major type of health care in the remote areas. The citizens will benefit immensely from a functional health center. This will equally reduce the patient load at the primary level hospital.

At the primary hospital setting are patients timely, adequately and appropriately managed? Are we referring for the right reasons and in the right direction (ibid)? What is the 24hour survival percentage (ibid)? What is the average waiting time for the outpatients and emergencies? This could make a whole lot of difference in the survival rate especially emergencies.

Same questions apply to both secondary and tertiary hospital settings. Do these hospitals waste precious time and resources managing patients that could have been adequately managed by the lower level institution? How long is the surgical waiting list? Long waiting lists for surgeries seem to be the norm in many big hospitals even in the developed world (Navarro, 2000). Is post-surgical infection at a minimal level? This is a pointer to the skills of the surgeon and the sanitary conditions of the hospital. What is the cure rate for the curable diseases? How many patients die of avoidable causes? Are patients being over treated/undertreated in terms of drug availability and use?

How do patients access the health institutions, with referrals or at will? How are they treated on arrival, bearing in mind that in many publicly funded institutions, patients are not treated with dignity and courtesy. Is there enough confidentiality measures put in place to ensure that patients folders are data are safely stored away? I remember a certain time that residents in a town who were HIV positive refused accessing health care in the district hospital because a laboratory staff was broadcasting their status. They rather preferred to travel to another town about 60kms away for their routine HIV/AIDS care, some even going as far as the provincial headquarters, 240kms away.

How efficient is the referral system, the communication system and the ambulance services? Is there a two way referral system effectively in place?

Is there equity of treatment for differing groups of people in the health institutions? Is their social status considered above the risk of illness (WHO, 2000)?

How responsive is the system to emergencies, disasters, outbreaks of epidemics and unforeseen eventualities? Are there any written protocols to be followed for these types of eventualities? Are there any emergency funds and planned buffers to facilitate response and cushion effects of these occurrences (Brown, 1992)? How does the system respond to other kind of changes such as short fall of financial resources? The Global Funds suspended grants in the wake of the scandal that rocked the Ministry of Health in 2009 following the discovery of embezzlement of funds by high ranking executives of the ministry including the Minister of Health himself (Zambian watchdog, 2010). What adjustments were made to ensure quality health care were uninterruptedly provided for the citizens? Health care was obviously provided as we know that hospitals did not shut down during the period but what quality?

Different methods will be employed to answer the above questions. Hospital registers will give a good account of the type of patients and where they come from as well as access mode, that is, with or without referral. Outcome of treatment may also be gleaned here. Random sampling (Bruce et al. 2008) of patients/clients records will be a window to management techniques and

protocols for different types of ailments. Passive and participatory observations of hospital proceedings (Green & Thorogood, 2009) will reveal so many things about the attitude of staff and response to situations and clients. Interviews of management staff in the ministry of health, provincial and district offices and some selected hospitals will elucidate a lot issues and practices. Interviews of randomly selected current in and out-patients as well as previous patients traced from hospital records will be invaluable.

Press releases and archives as well as Government archives can be useful resources of assessing the ability of the health system to respond to eventualities.

Outcome of the health system which is directly related to the goals of the health system (Zimmerman, 2004) is the result of interaction of the system output with the environment. Outcomes are the sustained effect of the health system on the entire population. Demographic studies will reveal the distribution of health among the country’s population. Any significant changes in death rates? Has the disease burden reduced? Are the citizens more enlightened about disease conditions and better able to protect themselves such as the roll out of use of insecticide treated mosquito nets (Zambian Watchdog, 2010)? How is the current access of the health facilities by different age groups and sexes? Acceptability by the masses should also be assessed. Do the masses trust, rely on and accept their health care providers? What are the issues they have against the system?

We must not also forget the internal assessment of the health system as it pertains to staff conditions of service. Are staffs generally happy with their work? Are their work conditions and environment conducive and safe? Do they have access to training and retraining? Questionnaires will be very useful in obtaining this kind of information.

CONCLUSION:

The Zambian health system is a well organized system. It is quite impressive in comparism to the non-existent or malfunctional health systems of a lot of African countries (Beghin et al. 1989). However, continuous evaluation and improvement will keep the system viable and focused sustaining their competitive edge (Feuer

& Chaharbaghi, 1995) at a time like this when privatization is the sing-song of most Governments.

Zambians, let all hands be on deck to sustain and improve what you have!

Word count: 2,529.

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