MAIN REPORT. Mapping of Health Links in the Zambian Health Services and Associated Academic Institutions under the Ministry of Health

Transcription

1 Tropical Health and Education Trust UNITED KINGDOM Ministry of Health ZAMBIA Mapping of Health Links in the Zambian Health Services and Associated Academic Institutions Submitted to: The Executive Director Tropical Health and Education Trust (THET) 210 Euston Road, London NW1 2BE UNITED KINGDOM and The Permanent Secretary Ministry of Health Ndeke House, Haile Selassie Avenue PO Box 30205, ZAMBIA 26 Wusakili Crescent, Northmead PO Box 39485, Tel/Fax: ,

2 CONTENTS PAGE ACRONYMS USED...III FOREWORD AND ACKNOWLEDGEMENTS...V 1 EXECUTIVE SUMMARY INTRODUCTION METHODOLOGY AND APPROACH EXISTING HEALTH LINKS POTENTIAL AREAS FOR FUTURE LINKS PROPOSED PROCESS FOR IDENTIFYING FUTURE LINKS CONCLUSION CONTEXT BACKGROUND INTRODUCTION DEFINITION OF LINKS THE TROPICAL HEALTH AND EDUCATION TRUST METHODOLOGY AND APPROACH PROBLEMS ENCOUNTERED THE HEALTH DELIVERY SYSTEMS IN ZAMBIA DEMOGRAPHIC AND SOCIAL-ECONOMIC CONTEXT ORGANISATION AND MANAGEMENT MAIN PROBLEMS AND CONSTRAINTS THE HUMAN RESOURCE CRISIS SECTOR STRATEGY AND PRIORITIES SECTOR PERFORMANCE EXISTING HEALTH LINKS OVERVIEW PROVINCIAL HEALTH OFFICES AND DISTRICT HEALTH MANAGEMENT TEAMS CENTRAL HOSPITALS ( 3 RD LEVEL HOSPITALS ) PROVINCIAL AND DISTRICT HOSPITALS (1 ST AND 2 ND LEVEL HOSPITALS) HEALTH CENTRES AND HEALTH POSTS HEALTH TRAINING INSTITUTIONS STATUTORY BOARDS AND OTHER UNITS POTENTIAL AREAS FOR FUTURE HEALTH LINKS OVERVIEW GENERIC POTENTIAL AREAS FOR FUTURE LINKS PROVINCIAL AND DISTRICT HEALTH MANAGEMENT LEVEL HOSPITALS AT ALL LEVELS HEALTH CENTRES AND HEALTH POSTS HEALTH TRAINING INSTITUTIONS STATUTORY BOARDS PROPOSED PROCESS FOR IDENTIFICATION OF FUTURE LINKS...52 i

3 8 APPENDICES...53 APPENDIX I: TERMS OF REFERENCE...1 APPENDIX II: TRENDS FOR TOP 10 MAJOR DISEASES IN ZAMBIA, APPENDIX III: STAFFING LEVELS AND WORKLOADS...3 APPENDIX IV: DISTRIBUTION OF CORE HEALTH WORKERS BY PROVINCE...5 APPENDIX V: CONSOLIDATED LIST OF EXISTING LINKS...1 APPENDIX VI: LIST OF INSTITUTIONS AND PERSONS INTERVIEWED...1 APPENDIX VII: LIST OF DOCUMENTS/LITERATURE CONSULTED...1 APPENDIX VIII: REPORTS/FEEDBACK FROM LINK PARTNERS...3 ii

4 ACRONYMS USED Acronym used Definition AU African Union The Consultant CBOH Central Board of Health Chainama Chainama Hills Hospital and College for Health Sciences CHAZ Churches Health Association of Zambia COMESA Common Market for East and Southern Africa CPs Cooperating Partners DRC Democratic Republic of Congo DTSS Director of Technical Support Services DHMT District Health Management Board DHMBs District Health Management Boards DHMTs District Health Management Teams FNDP Fifth National Development Plan FNDP Fifth National Development Plan GNCZ General Nursing Council of Zambia Global Fund Global Fund against HIV/AIDS, TB and Malaria HCs Health Centres HMIS Health Management Information System HPs Health Posts HSSP Health Services Support Program HIPC Highly Indebted Poor Countries HIPC Highly Indebted Poor Countries HMBs Hospital Management Boards HMTs Hospital Management Teams HIV/AIDS Human Immuno-Deficiency Virus/Acquired Immunity Deficiency Syndrome HR Human Resources HR Plan Human Resources for Health Strategic Plan CPs International Cooperating Partners JLI Joint Learning Initiative on Human Resources for Health and Development Links Long-term International Health Links MMR Maternal Mortality Ratio MCZ Medical Council of Zambia MTEF Medium Term Expenditure Framework MDGs Millennium Development Goals MOH or the Ministry Ministry of Health M & E Monitoring and Evaluation NDP National Development Plan NHSP National Health Strategic Plan NHSP 2006/10 National Health Strategic Plan 2006/10 iii

5 NHSP National Health Strategic Plan PRA Pharmaceutical Regulatory Authority PRSP Poverty Reduction Strategy Paper PRSP Poverty Reduction Strategy Paper PHO Provincial Health Office STIs Sexually Transmitted Infections SADC Southern African Development Community SAP Structural Adjustment Programme SAP Structural Adjustment Programme ToRs Terms of Reference Zambia or the Government The Government of the Republic of Zambia TDRC Tropical Disease Research Centre THET Tropical Health and Education Trust TB Tuberculosis UK United Kingdom UN United Nations USA United States of America USA United States of America UNZA University of Zambia UTH University Teaching Hospital UTH University Teaching Hospital ZHIP Zambia Integrated Health Programme ZNBTS Zambia National Blood Transfusion Service ZNFDS Zambia National Flying Doctor Services iv

6 FOREWORD AND ACKNOWLEDGEMENTS Zambia is currently faced with the challenge of achieving the Millennium Development Goals ( MDGs ) by 2015 and national health priorities. Even though the country has shown commitment to this aim, there are a number of significant problems and constraints, undermining its efforts. These problems are diverse and require concerted efforts by all the main stakeholders. The country has identified partnerships as one of the key strategies for addressing some of its problems and constraints, and has embarked on the process of strengthening partnerships with all the key stakeholders, including the communities, the private sector, the civil society and the international community. In this respect, one type of partnerships that has been identified is the establishment of international health links ( Links ) between the public health service and training institutions in Zambia, with their counterpart institutions in other countries. Even though currently there are just a few institutions benefiting from Links, it is generally recognized that Links provide significant opportunities for meaningful and sustainable improvements in the health sector. The mapping of Links is considered as the first step towards the establishment of an appropriate strategic framework for the promotion, planning, coordination and management of the Links, to ensure that full benefits are derived. It is also considered as the beginning of a long-term partnership between the Zambian Ministry of Health ( MOH ) and the Tropical Health and Education Trust ( THET ) of the United Kingdom ( UK ). Even though this assignment was complex and challenging, I am pleased to note that, through our joint efforts, it has been successfully completed. In this regard, I wish to take this opportunity to acknowledge, with thanks, all the people and institutions that contributed to this process. Special thanks go to: Dr. S K Miti, Permanent Secretary, MOH, for providing leadership to this process, and Nicholas Chikwenya, for coordinating the assignment; members of the counterpart team from THET; and CAN Investments Limited, led by Alex Chikwese, who were the consultants on this assignment. Last, but not the least, I wish to thank all the Zambian health service and training institutions, and the international Links partners which participated in this mapping. I thank you all. Dr. David Percy Director of Health Strategy Tropical Health and Education Trust v

7 1 EXECUTIVE SUMMARY 1.1 Introduction The Zambian health sector is faced with the challenge of achieving the health related MDGs and National Health Priorities. At the same time, the sector is inundated with significant problems and constraints, particularly the human resource crisis, which is significantly undermining its performance. In their efforts to find solutions to some of these problems, some health service and training institutions have established Links with counterpart institutions abroad, which have provided opportunities for capacity building, staff training, technical exchange programmes and material support to these institutions. However, most of these Links are not properly coordinated at both the institution and sector levels, and do not therefore fully address the sector priorities. In view of the foregoing, MOH has entered into a strategic partnership with THET to develop an appropriate strategic framework for the promotion, coordination and management of the Links, so as to focus them at sector priorities and realize their full potential. Given this background, THET, in conjunction with MOH, engaged CAN Investments Limited, a Zambian registered management consulting firm, to conduct a mapping of the existing Links between the public health service and training institutions in Zambia, and their counterpart institutions in other countries. This report presents the findings of the mapping and recommendations on the potential areas for future Links. 1.2 Methodology and Approach The methodology and approach adopted for this assignment involved: Breaking down the assignment into the following phases: project inception; desk review and requirements definition; field visits and feedback from existing Links; and reporting; Visiting and contacting a large number of health service and training institutions throughout the country; and Designing and application of an interview tool/questionnaire, which was used for structured interviews during the field visits. 1.3 Existing Health Links The mapping established and confirmed the following: The concept of Links is not widely understood and applied by most health service and training institutions within the public health sector in Zambia; 1

8 Some public health service and training institutions in Zambia have successfully established Links with international counterpart organizations from various countries; The Links are mainly concentrated at a few institutions, while majority of the institutions do not have any Links. The institutions identified with the highest numbers of Links include: The University of Zambia ( UNZA ) School of Medicine, together with its associated hospital, the University Teaching Hospital ( UTH ); The Chainama Hills Hospital and College for Health Sciences ( Chainama ) in ; St. Francis Mission Hospital in Katete, Eastern Province; Chilonga Mission Hospital in Mpika, Northern Province; and Monze Hospital in the Southern Province; Most of the hospitals, including Ndola Central Hospital, Kitwe Central Hospital and Arthur Davison Children's Hospital, which are among the four largest hospitals in the country, have never had any Links; and Currently, there is no framework to guide and promote the targeting, establishment, coordination, monitoring and evaluation of the Links, particularly at sector level. 1.4 Potential Areas for Future Links All the institutions visited by the mapping team acknowledged the importance of Links and expressed interest in developing appropriate Links with counterpart institutions in the UK and other countries. On the other hand, most of the major problems faced by these institutions are similar, and as such, the potential areas for future Links are mostly generic. In this respect, the following have are identified as the potential areas for focusing future Links: Technical exchange programmes involving staff at various levels, particularly in specialized core areas, aimed at providing knowledge and skills transfer; Short and long-term secondment of consultants and other experts in specialized areas, with emphasis on core service areas at every level, on a gap filling basis; Staff training and capacity building for both medical, technical and support staff, through short and long-term training programmes, including: Short-term training programmes conducted by visiting professors and experts from Link partners, in specialized areas; and Scholarships for medium and long-term training; Collaboration in research and development activities; Support to systems development in technical fields, including core health programmes, supervision, and monitoring and evaluation; 2

9 Support to knowledge sharing and continuing education, through the provision of e- learning opportunities and promotion of the use of modern ICTs, including facilitation of internet connectivity, internet-based knowledge exchange with the British National Formulary and other international sources of essential medical journals and publications; Specialist support to repairs and maintenance of medical equipment. Currently, there are no in-house expertise in this area, resulting into frequent breakdowns and premature write-offs of various equipment; and Material support in identified priority areas, including infrastructure development, equipment and auxiliaries, drugs and medical supplies, and other forms of material support, on a gap filling basis. Actual scoping of focus areas for each individual institution should be based on the priorities and status of the particular institution, and on gap filling basis. 1.5 Proposed Process for Identifying Future Links In order to improve the coordination and management of Links, it is proposed that the process of identifying priority areas for Links should be linked to the health sector planning process and be aligned to the national health strategic plan. The process should form part of the each institution s medium term expenditure framework ( MTEF ) and annual action planning process. Further, implementation of Link activities should be managed in a transparent and accountable manner, and captured under the monitoring and evaluation arrangements, which are in practice within MOH and the respective institutions. 1.6 Conclusion Even though the concept of Links has not been widely understood and applied in the Zambian health sector, some institutions have established significant numbers of Links. It is generally acknowledged that, if properly planned and managed, Links provide significant opportunities for health sector strengthening and capacity building, for longterm sustainable development. All the institutions which participated in the mapping expressed their interest in developing Links. The mapping provides a sound basis for the development of an appropriate strategic framework for planning, coordination and management of Links, which is urgently needed for the sector to realize full benefits from the Links. 3

10 2 CONTEXT The Zambian health sector is faced with the challenge of achieving the health related MDGs and National Health Priorities, aimed at improving the standards of health service delivery and health status of the people throughout the country. At the same time, the sector is inundated with significant problems and constraints, including: a high and complex disease burden; the human resources crisis, with critical shortages of qualified health workers at all levels of health service delivery; erratic supply of drugs and medical supplies; poor conditions of infrastructure, particularly in rural areas; and shortages of transport and communication. The country has identified the human resources crisis in the health sector as one of the most significant factors undermining its efforts to improve health service delivery, and also a major obstacle to achieving the MDGs and national health priorities. In order to address this crisis, the Government has developed a five year Human Resources for Health Strategic Plan 2006/10 ( HR Plan ). It has also prioritised human resources in the National Health Strategic Plan 2006/10 ( NHSP 2006/10 ) and the Fifth National Development Plan ( FNDP ). One of the key strategies identified in the HR Plan is the need to establish and strengthen partnerships with key stakeholders, including the need to develop new and strengthen the existing long-term Links between the Zambian health service delivery and associated training institutions, and their counterpart institutions from other countries, particularly the developed countries. Such Links are expected to significantly contribute to the mitigation of the impact of the human resources crisis and the other major problems and constraints affecting the health sector, through various initiatives, including technical exchange programmes, training and capacity building for health personnel, material support to individual health service and training institutions, and other means. In line with this strategy, in January 2007, the MOH established a strategic partnership with THET, the coordinating body for international Links in the United Kingdom ( UK ). Under this partnership, THET would facilitate the promotion and establishment of appropriate, efficient and effective Links between hospitals and health training institutions in the Zambian public health sector, with their counterparts in the UK and other developed countries. In this respect, THET, in collaboration with MOH, engaged ( Consultant ), to conduct a mapping of existing Links and identify potential areas that would require new Links. This exercise is expected to form the basis for the development of a strategic framework to guide and facilitate the efficient and effective promotion, coordination and management of the Links, in line with the priorities set out in the HR Plan, NHSP 2006/10 and FNDP. This report presents the findings, observations and recommendations of the mapping assignment, conducted between February 2007 and. The report has been prepared in line with the guidelines provided in the terms of reference for this assignment. 4

11 3 BACKGROUND 3.1 Introduction The global community is currently faced with a critical shortage of qualified health workers, which is adversely affecting health service delivery and undermining the efforts to achieve the MDGs in the developing poor countries. In 2004, the Joint Learning Initiative on Human Resources for Health and Development ( JLI ), which is a collaborative effort of more than 100 experts, estimated the global shortage of human resources for health at 4 million doctors, nurses and midwives (J Ambulatory Care Manage, Vol. 29, No. 1, 2006, pp ). The crisis is reported to have been most severe in Sub-Saharan Africa, where shortages of core health workers was estimated at 1 million, representing approximately two times the core health workers currently in posting. While the crisis is attributed to several factors, such as the low outputs from health training institutions and the increased mortality levels among health workers due to HIV/AIDS, migration of health workers from these countries to richer countries is by far the biggest problem. It is estimated that during 2002/2003 alone, more than 3,000 nurses from Ghana, Kenya, Nigeria, South Africa, Zambia and Zimbabwe were registered to practice in the UK (Buchan and Dolvo, 2004). In Zambia, the shortage of appropriately qualified health workers has since reached a severe crisis and is a serious obstacle to the country s efforts to implement the MDGs and national health priorities, in line with the NHSP 2006/10, the FNDP and Vision This crisis is largely attributed to: The poor terms and conditions of service in the public health sector, which have led to migration of core health workers from the public health institutions to the private sector within the country, and overseas, mostly to the UK, Australia, New Zealand and the United States of America ( USA ); The high mortality levels among core health workers, due to HIV/AIDS; The impact of the HIV/AIDS epidemic on the disease burden, consequently increasing the workloads for core health workers; and The dwindling outputs at the various health training institutions. The most affected facilities are secondary and tertiary level hospitals, which have lost both qualified and experienced consultants, doctors, nurses and other paramedics. Training institutions have equally been affected, through the migration of lecturers and tutors in search of better conditions of service. In its efforts to address the crisis, the Ministry is employing various approaches, including the recruitment of doctors from overseas and establishment of Links. In this respect, in 2005, approximately 44% of the doctors in post were non-zambians. Further, managers at some health facilities and training institutions have established Links between their respective institutions and counterpart institutions abroad. 5

12 Through such Links, medical experts from foreign countries have visited hospitals and training institutions to provide services, teaching or service development, material and technical support, on a gap filling basis. There have also been some reciprocal teaching visits and attachments by Zambian staff overseas. While such Links have resulted in transfer of knowledge and skills to health workers in Zambia, and capacity building for the affected institutions, there are concerns that such efforts might have resulted in fragmentation and duplication of efforts by the parties. In most cases, such Links have been through individual efforts and have not fully addressed the priority areas requiring capacity building within the respective health institutions. Given this background, MOH has identified the need to improve the management, coordination, monitoring and evaluation of the Links, through the identification of already existing Links and using a holistic approach to identifying areas and institutions requiring capacity building, in line with the NHSP 2006/10 and the HR Plan. In this respect, MOH in partnership with THET, has identified the need to conduct a mapping of Links in the Zambian health service delivery and associated training institutions under the Ministry, which would form the basis for the development of the strategic framework to facilitate appropriate coordination and management of the Links. 3.2 Definition of Links Links are generally understood as long-term partnerships between health institutions in less developed countries and their counterpart institutions overseas. The primary aim of the Links is to strengthen health care by supporting the development of skills of health care workers, and strengthening health care systems and processes. Health institutions involved in Links are initially hospitals, but often also involve their associated academic training institutions medical, nursing and allied health professional schools to address curriculum and faculty needs. Fully developed Links are interdisciplinary, and responsive to priorities determined by the partner based in the less developed country. This makes them relevant to the local context and sustainable in the long run (Extract from: THET, An Introduction to International Health Links). 3.3 The Tropical Health and Education Trust THET is a UK based coordinating body for Links, with over 15 years experience in supporting Links. It is an independent charity supported by international partners, volunteers, several donors and the UK Government. THET s vision is to facilitate the development of Links between UK health institutions, their associated academic partners, such as medical, nursing and allied health professional schools in the UK universities, and equivalent health care institutions in other parts of the world (Extract from THET s website, thet.org.uk). Currently, THET s main support is concentrated in Ethiopia, Ghana, Malawi, Uganda and Somalia. They also provide advice and guidance to UK Links in other least developed countries [as defined by the UN] and countries with a critical shortage of health workers [as defined by the WHO 2006 World Health Report]. 6

13 3.4 Methodology and Approach In order to fully address the TORs (See Appendix I) and ensure high quality deliverables, the methodology and approach adopted involved breaking down the assignment into the following phases: Project Inception The primary objective of the inception stage was to provide the Consultant with an opportunity to clearly understand the assignment, scope the work, develop and agree with THET and MOH on the project work plan, methodology/approach and coordination of the assignment, and also to complete the administrative formalities for the assignment. This phase culminated into the inception report, submitted by the Consultant at the commencement of the assignment Desk Review and Requirements Definition This phase was intended to help the Consultant to fully appreciate the background and context of the assignment, the health sector, the extent of the human resources crisis and also to determine the requirements for the assignment. The main tasks included: a) Identification and collection of the relevant data and information. A list of the documents collected and consulted is provided at Appendix VII. These included: Information on THET and the Links, particularly on its mandate, objectives and activities, and the concept of Links and how they operate. This involved reviewing the available documentation on THET obtained from MOH and through searching on the internet, particularly on the THET website; Information on the public health sector and the human resources crisis. Key documents collected and reviewed included the 2000 National Census Report, FNDP, NHSP 2006/10, HR Plan, Mid-Term Review report, list of health facilities in Zambia, Health Facilities Mapping Report 2006, Joint Annual Review Reports for 2005 and 2006, and Annual Action Plans and Progress Reports for 2006 for MOH head office and the health facilities covered by the mapping; and Other documents included local and international papers on the human resources for health situation in the world and in Zambia, and other relevant documents obtained from MOH and other sources; b) Review of these documents to establish the current situation and determine the requirements; and c) Identification of critical issues and impediments, and proposing the way forward. 7

14 3.4.3 Field Visits and Feedback from Existing Links Extensive field visits were conducted, covering all the nine provinces of Zambia. In this respect, a total of 68 facilities were visited, comprising: 27 hospitals, 21 health training institutions, 4 statutory boards and 24 other health related institutions, to collect information on the human resource situation, existing Links and the need for new Links. A list of facilities surveyed is provided at Appendix VI. The main tasks included the following: Reviewed the list of hospitals and health training institutions, and identified the facilities to be visited and those to be just contacted in writing, including their locations and contact details. This was later discussed and agreed with MOH; Designed a standard questionnaire for circulation to all the hospitals and health training institutions in the public health sector. A letter requesting for appointments was sent out to the targeted facilities, with the questionnaire and letter of introduction from the Permanent Secretary of MOH; Carried out physical site visits to the targeted facilities to discuss the Links and collect relevant data. Discussions with these facilities took the form of semistructured interviews. The documents collected included corporate profiles, actions plans, progress reports, reports on the past and existing Links and other documents relevant to this assignment; Sent out a letter, together with the questionnaire and letter of introduction from the Permanent Secretary, to the facilities that were not going to be visited, requesting for written submissions; and Identified foreign institutions involved in the existing Links, the nature of their links and their contact details. Wrote to these institutions, via , requesting feedback on their involvement and evaluation of their Links. Also searched the websites of some of these Links, to obtain more information Reporting During the course of this assignment, three reports were prepared and submitted to MOH and THET, as follows: Inception report, which was submitted at the beginning of the assignment and provided the roadmap for this assignment; Draft main mapping report, describing the process, findings and recommendations. Submitted for review and comments; and This final version of the main mapping report, which has taken into account the comments and corrections obtained from all the reviewers. 8

15 3.5 Problems Encountered During the course of this assignment, a number of challenges were encountered which had an impact on the conduct of the assignment. The major ones included: Field Visits The TORs required the Consultant to contact all the hospitals and health training institutions under MOH, in both urban and rural areas. Considering the vastness of the country and the accompanying physical barriers, including poor conditions of the roads in most of the rural areas, it was not feasible to physically visit all these facilities within the duration of this consultancy. In this respect, the Consultant and MOH had to agree on the list of facilities to be physically visited, while the rest of the facilities were to be contacted in writing and/or by telephone. Securing appointments for the visits also presented some difficulties. In some cases, the appointments were rescheduled several times, resulting in significant delays. Further, in most cases, documentation on the existing Links was not available, particularly regarding the scope of activities covered, quantification of the support provided and evaluation of the Links Written Feedback from the Facilities Feedback from institutions which were not visited was generally poor. Most of them did not respond Feedback from the Links Contacting those identified to have Links with Zambian health sector institutions also presented its own challenges. Whilst some institutions provided us with contact details of their Links, others did not have such information. This made it difficult to contact these contacts, which made us resort to internet searches. This led to significant delays. However, not withstanding these problems a number of Link partners responded. Some of these reports are provided at Appendix VIII. 9

16 4 THE HEALTH DELIVERY SYSTEMS IN ZAMBIA 4.1 Demographic and Social-Economic Context Zambia is a landlocked country located in the southern part of Sub-Saharan Africa. It covers approximately 752,614 square kilometres and shares borders with eight countries, namely, Tanzania and the Democratic Republic of Congo (DRC) in the north, Malawi and Mozambique in the east, Zimbabwe, Botswana and Namibia in the south, and Angola in the West. Zambia is a former colony of Great Britain and a member of a number of international and regional social-economic groupings, including the Commonwealth, United Nations ( UN ), African Union ( AU ), Southern African Development Community ( SADC ), and Common Market for East and Southern Africa ( COMESA ). The capital city is and the official language of communication is English. The population is currently estimated at 11.7 million people (UNAIDS, 2006) and distributed equally at 50% males and 50% females. The average annual population growth rate is 2.7% and life expectancy at birth is at 47.5 years for males and 51.7 years (CSO, 2000). The country is sparsely populated, with an average population distribution rate of 16 people per square Kilometre, and a high dependency ratio, with 47% of the total population being under the age of 15 years, and 38% of the population living in urban areas. All these factors present significant obstacles and challenges to socialservice delivery. Currently, Zambia is among the Sub-Sahara African countries faced with significant social-economic challenges, including a weak economy, high poverty levels and weak social service delivery systems, particularly in the rural areas. The country is now listed among the least developed countries, with an overall poverty incidence rate of 67% and 72% of its rural population classified as being in extreme poverty. The health sector is challenged by various factors, including a high and complex disease burden, compounded by: the high incidence of malaria, HIV/AIDS and other epidemics; critical shortages of qualified health workers; erratic supply of essential drugs and medical supplies; underdeveloped infrastructure, particularly transport and communication infrastructure in rural areas; and inadequate funding for basic health care services. Notwithstanding this difficult situation, the country is committed to significantly improve its social-economic condition, including the standards of living and health status of its people. In this regard, the country has made commitments to several regional and international initiatives focused at social-economic development, including the MDGs, the Highly Indebted Poor Countries ( HIPC ) initiative, and the Abuja and Maputo Declarations on health. The country, in collaboration with its international cooperating partners ( CPs ), has also initiated various local initiatives aimed at ensuring meaningful and sustainable social-economic development, which have included: the Structural Adjustment Programme ( SAP ); the Poverty Reduction Strategy Paper ( PRSP ); the FNDP and Vision 2030 and the NHSP 2006/10. 10

17 However, even with all these initiatives and the associated significant achievements, the health sector is still faced with significant constraints and challenges, requiring concerted efforts and collaborative actions by the Government and other key stakeholders, including need to further strengthen collaboration with both local and international partners for development. 4.2 Organisation and Management Overview Since 1992, the Zambian health sector has been undergoing comprehensive reforms, aimed at enhancing the capacity of the sector to significantly improve health service delivery and health standards of the people. These reforms included organizational and management restructuring, based on the principles of decentralization and partnership, aimed at devolving key management responsibilities and resources to district level, and strengthening broader participation in the management of public health services. This was addressed through the establishment of three important mutually complementary organization structures, namely: The MOH head office, responsible for policy formulation, supervision, monitoring and evaluation of the whole sector; A structure providing for popular public participation, responsible for policy interpretation, decision-making and control of health service delivery at various levels. This structure included: the Central Board of Health ( CBOH ) board, at national level; District Health Management Boards ( DHMBs ), at district level; Hospital Management Boards ( HMBs ), at hospital level; and Neighbourhood Health Committees and Health Centre Committees, at community level; and A structure providing for efficient and effective management and technical implementation of service delivery. This structure was intended to ensure that health services are managed and implemented in a technically competent manner and conform to best practices. The structure included: management teams at MOH and CBOH, at national level; Provincial Health Offices ( PHOs ), at provincial level; District Health Management Teams ( DHMTs ), at district level; and Hospital Management Teams ( HMTs ), at hospital level. To provide for efficient and effective support and regulatory services to the core health service delivery facilities, the Government also established two types of statutory boards, the service and statutory boards. However, following over 12 years of implementation of these reforms, the government identified a number of weaknesses associated with the established organization and management system. The main weaknesses and problems included the observed duplication of some roles and responsibilities among the MOH and CBOH head offices, 11

18 at national level, and the obstacles related to the huge financial outlays required for separation of employees transferred from the civil service to the new structures, as they were expected to enter into direct employment contracts with their respective boards. In this respect, since 2005, the public health sector has been undergoing another major restructuring, which has led to the dissolution of the CBoH, together with the hospital and district health management boards. Under this new arrangement, the functions of MOH and CBOH at the top, have been merged and the management and control of all stateowned health facilities and services is now directly under MOH, through the Provincial Health Offices. However, in order to ensure continued popular public participation in the management of health services, the hospital and district management boards are being replaced with advisory councils, while the hospital and district management teams have been maintained. The restructuring process has now reached its final stages Health Sector Structure The health sector in Zambia is liberalized and comprises of three types of service providers, namely, state-owned health facilities, faith-based health facilities, under the coordination of the Churches Health Association of Zambia ( CHAZ ), and the private sector State-Owned Health Facilities The public health sector combines state-owned and faith-based health facilities. However, the organization and management of faith-based health facilities is discussed separately in Section below. Most state-owned facilities are owned and controlled by MOH, with a few falling under the Ministry of Defence and Ministry of Home Affairs. The Ministry of Defence has only one hospital, the Maina Soko Military Hospital in, and a few clinics located at the various military locations around the country. On the other hand, the Ministry of Home Affairs does not operate any hospitals, but has some clinics at their police and prison service stations. State-owned health facilities under MOH are located in all the 72 districts of the country and include 3 rd Level hospitals, 2 nd Level hospitals, 1 st Level hospitals, health centres ( HCs ) and health posts ( HPs ) Faith-Based Health Sector Faith-based health facilities are owned by various religious organisations, predominantly Christian organizations from different denominations and countries. These facilities are spread across Zambia, mainly in rural areas, and include 31 hospitals, 69 rural health centres and 25 community-based organisations. Administratively, these facilities are independently managed by their respective sponsors. 12

19 However, in order to provide for appropriate technical support and coordination, they are organized under the Churches Health Association of Zambia ( CHAZ ), which is an inter-denominational non-governmental umbrella organisation for Christian church health facilities in Zambia. It is the second largest provider of health care services in Zambia, after the Government, and currently contributes 30% of the overall health care services in Zambia, and 60% in rural health areas. Although these facilities are owned and managed by their respective sponsoring faithbased organizations, they provide free medical care services to the general public, and supplement the Government s efforts. These facilities are officially recognized as public facilities and are therefore provided with Government grants for staff salaries and operations. They also have a strong linkage with the District Health Management Teams ( DHMTs ), which are responsible for coordinating all public and faith-based health service delivery institutions within the respective districts. In addition, they also receive financial and technical support from their respective sponsoring faith-based organizations, and other well wishers and Links Private Health Sector The private health sector includes hospitals and health centres/clinics owned by private investors, the privatized mining companies and the civil society/non-governmental organizations ( NGOs ). Private health facilities provide basic health care services at health centre level, and general medical and specialized services at hospital level. The contribution of this sub-sector could be estimated in the range of 10% to 15%. These facilities are predominantly concentrated in the mining and other urban areas, with minimal presence in rural areas. Private health facilities are registered corporate entities and managed as private businesses. Currently, the supervision, monitoring and evaluation of the performance of this sector by MOH is weak and needs further strengthening Traditional Health Practitioners Alongside modern medical facilities, traditional health therapy is also offered by various individuals and registered entities. They mainly offer herbal remedies and spiritual healing services. Whilst these services are managed as private businesses, they are coordinated by the Traditional Health Practitioners of Zambia ( THPAZ ), an association formed and registered to promote and advocate for traditional health therapy. Currently, there are increasing claims by various traditional health practitioners that they have discovered herbs to cure HIV/AIDS, which claims are still being subjected to scientific verifications and trials. 13

20 4.2.3 Existing Health Facilities Health service facilities include: the core facilities, such as hospitals, health centres and health posts; statutory boards; and health training institutions; all operating at different levels of service delivery Core Health Service Delivery Facilities Table 1 below presents a summarised analysis of the existing core health service delivery facilities in Zambia: Table 1: Summary of Existing Health Facilities in Zambia Health Hospitals Centres Health Posts Total Type of Provider Number Number Number Number Public/Government 58 1, ,129 Faith-based/CHAZ Private Total 114 1, ,377 Source: Ministry of Health and Churches Health Association of Zambia, 2007 Below are the summarized descriptions of these facilities, starting from the health posts, at community level, to central hospitals, which are the highest and most sophisticated referral facilities: Health Posts ( HPs ): Are intended to serve small communities with populations of approximately 500 households (3,500 people) in the rural areas, and 1,000 households (7,000 people) in the urban areas, and are supposed to be established within 5Km radius for sparsely populated areas. The number of HPs required throughout Zambia is 3,000, however only 45 are currently available, including 1 private facility; Health Centres ( HCs ): These include Urban Health Centres, intended to serve urban communities with catchment populations of between 30,000 and 50,000 people, and Rural Health Centres, servicing catchment areas of 29 Km radius or population of 10,000 people. The national target for HCs is 1,385, but currently 1,218 are available, including Government, faith-based and private HCs; 1 st Level Referral Hospitals: These are hospitals at district level, intended to provide referral services in medical, surgical, obstetric and diagnostic services, including all clinical services to support HC referrals. Such facilities are found in most of the 72 districts and are intended to serve catchment populations of between 80,000 and 200,000 people. Currently, there are a total of 89 such facilities, comprising 72 government/faith-based facilities and 17 private facilities; 14

21 2 nd Level Hospitals: These are provincial general hospitals, intended to provide subspecialised referral services in internal medicine, general surgery, paediatrics, obstetrics and gynaecology, dental, psychiatry and intensive care services. They are also intended to act as referral centres and provide technical back-up for 1 st level hospitals, and offer training services. These facilities are intended to cover catchment populations of between 200,000 to 800,000 people. Currently there are a total of 20 second level hospitals. Two provinces, namely Southern and Copperbelt, have 5 and 3 second level hospitals respectively. MOH has observed the need to rationalize the distribution of these facilities through right-sizing; and 3 rd Level Hospitals: These are also known as central hospitals and are meant to provide specialised services in internal medicine, surgery, paediatrics, obstetrics, gynaecology, intensive care, psychiatry, training and research, and also act as referral centres for 2 nd level hospitals. The scope of coverage for such facilities is a catchment population of 800,000 people and above. Currently there are only 5 such facilities in the country, including the UTH and Chainama in and 3 others on the Copperbelt Province, namely, Ndola Central Hospital, Kitwe Central Hospital and Arthur Davison Children s Hospital in Ndola Health Statutory Boards Two types of statutory boards, regulatory and service, have also been established to provide support to the Ministry and the health delivery system. Statutory boards play an important role in the implementation of the overall Government health policy and regulation of the health sector. Regulatory boards are responsible for enforcing specific Government Laws and policies, while service statutory boards provide support services to the core health service delivery facilities. Administratively, statutory boards are managed by boards of directors appointed by the Minister of Health, in accordance with the relevant statutes, and are technically responsible to MOH, through the office of the Director of Technical Support Services ( DTSS ). Regulatory boards currently include the Medical Council of Zambia ( MCZ ), General Nursing Council ( GNCZ ), Pharmaceutical Regulatory Authority ( PRA ), Food Safety and Food Quality Control Services Unit, Environmental Health and Epidemiological Trends Unit, Radiation Protection Board, Radiology and Medical Devices Control Unit and the Medical Laboratory Regulatory Services Unit. On the other hand, service statutory boards are responsible for providing specific services in support of the health delivery system and include the National Food and Nutrition Commission (which is partially regulatory and partially service), Zambia National Flying Doctor Services ( ZNFDS ), Zambia National Blood Transfusion Service ( ZNBTS ) and the Tropical Disease Research Centre ( TDRC ). 15

22 Health Training Institutions The public health sector also includes a number of health training institutions providing various types of pre- and in-service training for health workers. These institutions play a pivotal role in the production of appropriately trained health workers, including medical doctors, nurses, clinical officers and paramedical staff for the Zambian health sector. These institutions include: UNZA School of Medicine,. This is the only medical school in the country for producing medical doctors. The school also offers training at lower levels in various health disciplines, including BSc. Degree Bio-Medical Sciences, Degree in Post-Basic Nursing, Degree in Anaestasia, and others; Chainama Hills College of Health Sciences,. Chainama College commenced its operations in 1936 and is the oldest health training institution in Zambia. It produces medical cadre in various disciplines, at diploma and advanced diploma levels, including environmental health, clinical medicine (general), clinical medicine (mental health), clinical medicine (medical licentiate), nursing (various specializations), counseling and other fields; Nursing training schools for registered and enrolled nurses, located throughout the country. Currently, there are a total of 19 nursing schools in the country. During 2007, MOH is committed to renovating and re-opening 3 nursing schools; 2 colleges for training of medical laboratory technologists, which include the Evelyn Hone College in, the Ndola School for Bio-Medical Sciences on the Copperbelt; and Other training institutions for other health cadres, paramedics, including the UTH School of anaestasia and the Dental School. 4.3 Main Problems and Constraints MOH is committed to the successful implementation of the NHSP 2006/10, whose vision is to ensure Equity of access to assured affordable health care services, as close to the family as possible. However, there are a number of constraints and challenges which are adversely affecting the health sector. These include: High and complex disease burden, compounded by the effects of HIV/AIDS and malaria. According to the Health Management Information System ( HMIS ) report for 2006, the top five leading causes of morbidity and mortality included: malaria, respiratory infections (non-pneumonia), diarrhea (non-blood), trauma (accidents, injuries, wounds, burns) and eye infections. Even though HIV/AIDS is not included in this list, it is responsible for a larger portion of morbidities and mortalities. HIV/AIDS has seriously devastated the health sector and overstretched the limited human, financial and material resources available; 16

23 Critical shortages of appropriately qualified core health workers and teaching staff in training institutions; Inadequate funding to the health sector. The Government has made a commitment to increase funding to the health sector to 14% of the national budget, however, this has not been achieved yet and funding is now about 12% of the budget. However, the Government and its international cooperating partners are making significant efforts to continue improving funding to the sector; Erratic supply of essential drugs and medical supplies, and poor logistics management. This problem has significantly undermined health service delivery, specially in the rural areas, which are difficult to reach; Inadequate and poor state of essential health infrastructure and equipment, including mothers shelters, basic equipment and tools; Poor transport and communication facilities to facilitate efficient and effective communication and transportation in support of health services. This is due to a combination of factors, including poor geographical access, poor state of public transport and communication infrastructure and lack of reliable motor vehicles and communication systems; and Inadequate facilities and systems to support efficient and effective information, education and communication of health programmes and messages to the public. This includes the inadequate investment in appropriate modern ICT, which has made it difficult for the health sector to benefit from the new technological innovations, with potential to significantly improve health service delivery. 4.4 The Human Resource Crisis Zambia is among the Sub-Saharan African countries that are most affected by the critical shortages of human resources for health, with severe shortages of appropriately qualified health workers at all levels of the health service delivery system and training institutions. Over the past three to four decades, the number of doctors has actually declined from 1,283 in 1975 to 646 in 2005, whilst the population has continued to grow at over 2.7%. In 2005, staffing levels in the health sector were estimated at 23,176, representing 47% of the recommended staff establishment of 49,360 (HR Plan, MOH, Zambia, 2005). Consequently, the workloads for health workers have drastically worsened, as evidenced by the Doctor to Population ratio, which has continued to deteriorate and is currently estimated at 17,589:1, against the recommended 4,940:1. Table 2 presents a summarised analysis of staffing levels and staff workloads in the Zambian health sector. A more detailed analysis is presented at Appendix III. 17