Presentation at Marga Klompe
symposium , Tilburg University
Netherlands
16th November 2012
Derrick Mweemba
Assistant National Health Coordinator
Zambia Episcopal Conference
EVOLUTION OF CARE GIVING IN
ZAMBIA
 The history and evolutionary course of caregiving
in Zambia recognizes the wider policy and
structural Health reform process from the late
1970s to 1990s.
 The Alma Ata Declaration of 1978 provided the
impetus and direction for the Zambian
government to make primary health care the key
channel for the delivery of health services.
Cont…
• Community participation was already a key
feature of the Zambian health system as
demonstrated by 30% of the rural facilities being
developed on self-help basis and the existing
policies at that time of free medical services
(Kasonde, J., Martin, J., 1994).
• Due to some health system management
challenges, reform processes took place under the
Medical Services Act of 1985, resulting in semiautonomous Hospital Management Boards for all
major Hospitals (Raken, J.P., 2004).
Cont..
• The Medical Services Act of 1985 was subsequently
repealed and replaced by the National Health Services
Act, which came into operation on March 2, 1996.
• The new Act established the Central Board of Health
(CBOH) (Melle, L., 2012). CBOH was designed to
monitor, integrate, and coordinate the programs of
the Health Management Boards, whereas the Ministry
of Health (MoH) was now a policy-making and
regulatory body (Bossert, et.al. 2000; Foltz, 1997).
• Thus, the reorganized health delivery system was now
based on four levels with the MoH at the apex and the
lowest level being the health centers/health post.
Cont…
• In the midst of above complex policy reforms related
to care giving, communities in Zambia were playing a
key role in the delivery of health services.
• In the Zambian cultural context, nuclear and
extended family always unite in support of people
with illness. Hence, as HIV developed into AIDS in
the 1990s, family members cared for most patients in
homes (Illife, J., 2006).
Cont..
 In 1987, medical workers in Zambia made first
attempts to reach those dying of AIDS in their homes.
This hospital-based home care model, pioneered by
Salvation Army in the southern part of the country to
care for tuberculosis (TB) and Leprosy patients, was
extended to People Living with HIV&AIDS
(PLHIV/AIDS) (Iliffe 2006) due to insufficient hospital
bed spaces for the growing number of AIDS patients
(Malama, M., 1994; Myslik et al 1997).
Cont…
• Between 1988 and 1990, the Catholic Church and
Chaikankata Hospital of the Salvation Army
established large home-based care programmes.
• By 1993, about 30 Mission hospitals were
providing Hospital-Based Home Care to
PLHIV/AIDS. Due to swelling costs associated
with travel and time, travelling clinical health
workers were supplemented, in some cases even
replaced, by trained ‘lay’ people based in the
community.
Cont…
 According to the Zambia National Minimum
Standards for Community and Home-Based Care
Organizations (2007), the community and homebased care movement in Zambia evolved,
primarily as a faith-based response to care for the
chronically ill.
Policy and Guidelines
 The Sixth National Development Plan (SNDP)
provides the overall framework for all
Government’s Social and Development efforts
and lists four key health priorities in the area of
HIV and AIDS. Among these priorities listed is a
focus on accelerating universal access to ART and
Care and Support for PLHIV, their Caregivers, and
families.
Policy and Guidelines
 Community care and support is recognised within
the National AIDS Strategic Framework as an
integral component of the continuum of care
particularly in the context of ART. As recent as
2005, the NAC and MoH in partnership with other
actors in the HBC Forum, recognized the need for
standards for HBC. Through collaborative efforts,
the Zambia National Minimum Standards for
Community and Home Based Care was launched
in 2007 by National AIDS Council and Ministry of
Health.
SUMMARY
 The Ministry of Health has done well in the area
of decentralizing care. The Policy framework and
Guidelines in place provide for a conducive
environment for various actors to provide cares.
 Local and international NGOs and Faith based
organizations have flourished without hindrance
though with challenges.
NATIONAL COMMUNITY HOME
BASED CARE ALLIANCE
 The formation of the National Community Home
Based Care Alliance is as a result of the Home
Based Care Situation analysis (Scan) conducted
with support from CORDAID and the
recommendation of the subsequent follow up
Home Based Care experts meeting held in June
2010.
Background Cont…
 The goal of the Experts Meeting on CHBC was to
bring together Zambian HBC experts and
stakeholders from Government, NGO, CBO,
beneficiaries, and Donor agencies to discuss the
main findings of HBC situation analysis,
brainstorm its status, challenges and future.
KEY FINDINGS
• Lack of caregivers coordination body (Alliance).
This has resulted in poor coordination of care
givers and as such, there is no strong voice for the
Caregivers and recognition for the wonderful
work they do under HBC.
• There was duplication of efforts in CHBC due to
poor coordination at various levels
• Pediatric HBC: -There were no standard
Identification criteria for pediatric AIDS and
volunteers and staff lacked technical capacity to
manage the HIV positive babies at home.
Findings cont…
• There was Lack of standardized packages of
Home Based Care for CHBC providers and Care
Givers despite having the minimum standards for
HBC as provided for by the Ministry of Health.
• There were no Standardized Incentives for care
givers
• There was poor referral system between
Community HBC programs and Health facilities.
This resulted in poor or no feedback from Health
facilities.
• There was still a big gap in addressing the needs
of asymptomatic HIV positive clients
Findings Cont…
• The CHBC experts felt that HBC organizations were
still operating in a parallel system and government’s
expectations were not adequately met.
• There was lack of quality assurance mechanism and
monitoring system. Community HBC actors,
therefore, operated on their own with limited or no
supervision at all. Accountability was often seen as
accountability only to the funding partners.
KEY FOCUS AREAS OF CHBC ALLIANCE
• To re-define Home Based Care under the Current situation
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•
•
•
•
of ART in Zambia.
To re-define Home Based Care components and focus areas
as a matter of urgency to respond to the emerging needs of
Prevention, Treatment, Care and Support.
To re-define the role of Caregivers in Home Based Care
under the current situation of ART in Zambia
To advocate for recognition and appreciation of HBC
Caregiver and the work that they do
To Lobby Government and Donors to continue to fund
Community Home Based Care.
Review and update the Data Base for CHBC providers in
Zambia in Liaison with NAC and MOH.
Cont…
• Review and up-date Home Based Care Guidelines
•
•
•
•
in liaison with Ministry of Health
Harmonize and Standardize M&E Tools and
systems at all levels of CHBC service provision.
Standardize Training Manuals for Caregivers to
incorporate Palliative Care and Pediatrics HBC.
Promote Documentation and replication of best
practices in CHBC in Zambia
To strengthen linkages between CHBC, DHMT’s
and Health Institutions in all districts
Contd…
• Promote Male involvement in CHBC
• Lobby Ministry of Health for accelerated ART
services
• Lobby Key Stakeholder such as Ministry of
Health, National AIDS Council, Palliative Care
Association of Zambia and CHAZ to support the
work of the Alliance
• Facilitate formation of Caregiver Alliance.
OUR IMMEDIATE PLANS
• To Lobby Donors for funds for the operation of the
•
•
•
•
Alliance
To strengthen the functioning of the CHBC Alliance
To develop Operational Guidelines (Constitution) for
the Alliance
To Develop Joint Strategic Framework, Monitoring
and Evaluation Framework, Annual Work-plans, and
Resource Mobilization Plan.
To continue to lobby Government to recognize the
role Community Caregivers play in realizing the
vision of the Government which aims at bringing
Equitable Health Care Services as close to the family
as possible
Contd…
• To
strengthen links between community
structures such as community neighborhood
health Committees and the District Health
Management Teams who oversee health care
services in the districts.
• These community structures are key to the well
functioning of the ministry of Health and
Community Based Organizations.
ORGANIZATIONS THAT MAKE UP THE
ALLIANCE
• Zambia Episcopal Conference (ZEC)
• National AIDS Council (NAC)
• Churches Health Association of Zambia (CHAZ)
• The Salvation Army
• STEPS OVC (Catholic Resource Services)
• World Vision Zambia (WVI)
• Ministry of Health (MoH)
Contd…
• People’s Process on Housing and Poverty in
•
•
•
•
•
•
Zambia (PPHPZ)
Council Of Churches in Zambia (CCZ)
Evangelical Fellowship of Zambia (EFZ)
Zambia Interfaith Networking Group on
HIV/AIDS in Zambia (ZINGO)
Zambia Homeless and Poor People’s Federation
(ZHPPF)
Network of People Living with HIV (NZP+)
True Vine Community Home Based Care
Contd…
 Titandizane Community Home Based Care
 Good Samaritan community Home Based Care
Just to mention a few.
CHALLENGES – CHBC ALLIANCE
 Lack of funding to enable us develop key
operational documents to guide the Alliance
 Bureaucracy in some of the government
Ministries and departments
 Lack of commitment in some lower level
structures of government
in implementing
recommendations
from
civil
society
organizations.
Challenges cont…
 No standardized incentives for Caregivers
 No voice and platform to showcase what they do
 Usually caregivers have little or no in-put in
program design
 Client/Caregiver ratio is high resulting in most
Caregivers doing a lot more work than others.
 Caregivers are themselves vulnerable requiring
support
Cont…
 International NGOs are concentrated in urban
and peri-urban areas leaving the rural
population under served.
 Duplication of efforts – usually several NGOs
would be doing same activities within the
same catchment area.
 Double counting of clients.
 Certain NGOs feel they have no obligation to
report to NAC or MoH on what they are doing
Way forward
 The
CHBC Alliance shall endeavor to lobby
Government to recognize Caregivers as an integral
part of the Health Delivery system in Zambia and as
such include them in the mainstream Health Care
System.
 Government acknowledges the role of Caregivers in
the HIV response but demands that caregivers be
trained in a standard curriculum and be accredited to
a recognized body.
 As an Alliance, we shall endeavor to align our work to
standards set by Government.
Way forward cont…
 The Alliance shall come up with a regulatory
framework which shall be used to regulate its work.
 Currently the Alliance is being guided by HBC
Minimum standards set by the Government.
 The Alliance shall facilitate Caregivers meetings as a
platform to share experiences and learn from each
other. Guidelines on how caregivers’ meetings will be
conducted have already been developed
Way forward cont…
 The alliance shall work hard to strengthen community
structures such as community neighborhood Health
committees, Community social Welfare committees
and linkages with government to bring Health Care as
close to the Households as possible.
 A series of meetings with MoH have been held with
MoH promising to write to Provincial and District
Health Offices to work with the Alliance. This needs to
be followed up and strengthened.
Thank you for listening
 Asante sana
 Dzikomo
 Tatenda