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TOSHIBA

CRITICAL EVALUATION
HEALTH 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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