Understanding Zambia’s
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 2006-2010

Challenges

Way Forward

Take Home Messages

Q&A
Background to the Health
Reforms

80’s and early 90’s Zambia’s 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 1995-1998; 1998-2000; 2001-2005
and 2006-2010
Fifth (5th) Plan to cover the period 2011-2015
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
60
45
40
50
35
40
30
25
30
20
20
15
10
10
5
0
%
20
Top 10%
To
p
e
dl
id
Bottom 10%
M
Bo
tto
m
20
20
%
%
0
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
250
200
150
100
50
0
Early 2000s
Bottom 20%
Upon MDG Attainment with EquallyDistributed Gains
Average
Top 20%
NEED TO FOCUS BETTER …
4/8/2015

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
13
13
The OBJECTIVES of Zambia’s
Health Plan

The Plan’s Vision : “Equity of
access to assured quality, costeffective and affordable health
services as close to the family
as possible”

The Plan’s Key Principles start
with: “Equity of access...”
Three Illustrative OPERATIONAL
TARGETS of Zambia’s
Health Strategic Plan 2006-10

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 2011-15 targets to attain the
MDGs
Zambia’s Human Resources
for Health Strategic Plan 2006-10
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
Zambia’s Human Resources for
Health Strategic Plan 2006-10 …
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.”
Zambia’s Human Resources for
Health Strategic Plan 2006-10 …
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
2009-2010
NHS P e stim a te d fin a n cin g g a p 2009-2010
2000
' in m illio n U S $
1600
756.18
1200
93.86
154.65
S c enario 1
S c enario 2
800
400
0
GRZ
SWAp
P roject
S c enario 3
F inancing 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
Isn’t Donor Collaboration Wonderful?
GTZ
WHO
CIDA
UNAIDS
RNE
INT NGO
3/5
UNICEF
Norad
WB
Sida
USAID
UNFPA
MOF
UNTG
CF
DAC
GFCCP
PRSP
PEPFAR
GFATM
HSSP
MOH
PMO
MOEC
SWAP
CCM
CTU
NCTP
CCAIDS
NACP
LOCALGVT
CIVIL SOCIETY
PRIVATE SECTOR
Source: WHO: Mbewe
Verticalization of Aid leads to Fragmentation
and Poor Results: Child Health
Case
management
Drug
Use
Community
Management
Nutrition HIV/AIDS
Skilled
birth
attendance
New born
care
Malaria
PMTCT
Health
system
Maternal
health
Safe and
Supportive
Environment
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
2006-10 as we prepare & implement the NHSP 2011-15

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
INDICATOR
ZDHS
1990
ZDHS
1996
ZDHS
2002
ZDHS
2007
Infant Mortality
Rate per 1000
107
109
95
197
649
Under Five
191
Mortality Rate
per 1000
Maternal
Mortality Ratio
per100,000
New Malaria
373
cases per 1,000 (HMIS 05)
70
NHSP
TARGET
(2010)
NS
MDG
TARGET
(2015)
36
168
119
134
63
729
591
547
162
412
358
252
94/1000
(HMIS 06) (HMIS 07) (HMIS 08)
<121/1000
32
HRH IS KEY
Expanded Outputs
- Tutors
- Clinical Instructors
- Books, Computers, Models
- Infrastructure & Equipment
- Operational Grant
33
END of Presentation
I Thank You