Zambia's Health System
The vision of the health reforms in Zambia is to “provide equity of access to cost-effective, quality health care as close to the family as possible.”
Zambia has been implementing health reforms since 1992 under the framework of the Sector Wide Approach (SWAP), which takes a holistic development view of the sector. In the SWAP, resources from government and other stakeholders are pooled so as to ensure efficient utilisation of resources. The mission of the health sector is to significantly increase life expectancy in Zambia by creating environments and encouraging life styles that support health. The financing of the basic health care package is a priority to try to reduce both morbidity and mortality rates and contribute to poverty reduction.
The Zambian health policy stipulates that “every able-bodied Zambian with an income should contribute to the cost of his or her health”. However, exemptions exist based on age (children under 5 and adults over 65), diseases (TB, HIV/AIDS, STDs, Cholera and dysentery; safe motherhood and family planning services; immunisation; and treatment of chronic hypertension and diabetes) and other factors. This is aimed at enhancing an equitable and appropriate delivery of health services to all Zambians, but in practice is not implemented due to lack of resources.
There is inequitable access to basic health services in Zambia between provinces and between urban and rural areas. In urban areas, 99 percent of households are within 5 kilometres of a health facility compared to 50 percent in rural areas. In Zambia, household expenditures on health vary according to location. Poor households spend the highest proportion of their income on health, which can be up to 10% of total expenditure when in kind costs are included. Long distances and cost and lack of transport in a large but sparsely populated country like Zambia is a key determinant of health seeking behaviour.
A lack of human resources is also present in Zambia impacting the delivery of services. This problem is due to three factors:
For example in 2003 from 42 graduates from the Medical School only 20 stayed in the public sector the rest went to the Private Sector or abroad. This is due to the financial resources and conditions of service not being very attractive compared to abroad and the private sector.
The Public Welfare Assistance Scheme introduced in 1995 was intended to address inequalities in access. Chronic patients who cannot pay are supposed to be referred to the District Social Welfare Office for assessment. However, the referral system has not functioned well and those who cannot pay fail to access services.
An increasing disease burden and decreasing resources in Zambia, led the government in 1993 to introduce a Cost Sharing scheme.
A general lack of information exists with regards to cost-sharing schemes, fees needing to be paid and referral pathways. While the basic health care package at first point of referral level has been identified and cost at $11.5 per capita, the health sector has made available only $10.5 per capita for the whole system.
The estimates of expenditure in the Transitional National Development Plan (2002-2005) show an expenditure for Health of Kwacha 195,200,000,000 (US $ 4,153,190) and for HIV/AIDS of Kwacha 130,940,546,000 (US$ 2,785,970) for a total budget of Kwacha 7,131,349,321,215 (US$ 1,517,308,366).
Zambia is in the process of an ambitious program of health sector “decentralisation.” The start of this decentralisation started with the Medical Services Act of 1985. This act created semiautonomous hospital management boards for all major hospitals (more than 200 beds).
In 1992 the hospital boards, appointed by the Minister of Health, were given the authority to set fees and manage staff. In the same year further legislation was enacted requiring the districts to establish District Health Boards to oversee the districts. These were finally created in 1994 and acted as employers/supervisors of the District Health Management Teams.
District Health Management Teams were set-up in 1993 to act as technical managers of the district health offices in each of the country’s districts. The Health Reform Implementation Team was also established in this year to act as a coordinating body to promote the full implementation of the legislated reforms. This body was independent from the Ministry of Health and collaborated closely with international aid organisations.
Resources at a District level are allocated on per capita basis taking into account population density, price of fuel, likelihood of epidemics, and the presence of a bank. At the level of hospitals allocation is based on cost per bed day. Standard bed/population ratios are used to determine the number of beds per given population for 1st, 2nd, and 3rd level hospitals. For other hospitals allocations are based on budgets, subject to availability of resources.
The lowest administrative level for health is the Area Boards of Health, which are set-up to divide the population into manageable health districts. These are still in the process of being established. Their function is to:
These Area Boards of Health would then report to District Health Board. Their role is:
The next level is the Provincial Health Office. This office has 6 main areas of activity:
In 1995, the National Health Service Act was accepted. It called for a significant change in the role and structure of the Ministry of Health and called for the establishment of an autonomous health service delivery system. This led to the creation of CBoH. The mandate of the CBoH was to “monitor, integrate, and coordinate the programs of the Health Management Boards”.
The Ministry of Health’s role became one of primarily a policymaking and regulatory institution. The Ministry of Health no longer had any direct involvement in health service delivery, these were contracted to the CBoH.
The CBoH has 4 directorates:
The last echelon, the Ministry of Health, tasks include:
Zambia has been implementing health reforms since 1992 under the framework of the Sector Wide Approach (SWAP), which takes a holistic development view of the sector. In the SWAP, resources from government and other stakeholders are pooled so as to ensure efficient utilisation of resources. The mission of the health sector is to significantly increase life expectancy in Zambia by creating environments and encouraging life styles that support health. The financing of the basic health care package is a priority to try to reduce both morbidity and mortality rates and contribute to poverty reduction.
The Zambian health policy stipulates that “every able-bodied Zambian with an income should contribute to the cost of his or her health”. However, exemptions exist based on age (children under 5 and adults over 65), diseases (TB, HIV/AIDS, STDs, Cholera and dysentery; safe motherhood and family planning services; immunisation; and treatment of chronic hypertension and diabetes) and other factors. This is aimed at enhancing an equitable and appropriate delivery of health services to all Zambians, but in practice is not implemented due to lack of resources.
There is inequitable access to basic health services in Zambia between provinces and between urban and rural areas. In urban areas, 99 percent of households are within 5 kilometres of a health facility compared to 50 percent in rural areas. In Zambia, household expenditures on health vary according to location. Poor households spend the highest proportion of their income on health, which can be up to 10% of total expenditure when in kind costs are included. Long distances and cost and lack of transport in a large but sparsely populated country like Zambia is a key determinant of health seeking behaviour.
A lack of human resources is also present in Zambia impacting the delivery of services. This problem is due to three factors:
- Medical staff leaving abroad mainly to the US and UK
- Medical staff leaving the Public Sector for the Private Sector in Zambia
- The impact of HIV/AIDS on health workers
For example in 2003 from 42 graduates from the Medical School only 20 stayed in the public sector the rest went to the Private Sector or abroad. This is due to the financial resources and conditions of service not being very attractive compared to abroad and the private sector.
The Public Welfare Assistance Scheme introduced in 1995 was intended to address inequalities in access. Chronic patients who cannot pay are supposed to be referred to the District Social Welfare Office for assessment. However, the referral system has not functioned well and those who cannot pay fail to access services.
An increasing disease burden and decreasing resources in Zambia, led the government in 1993 to introduce a Cost Sharing scheme.
A general lack of information exists with regards to cost-sharing schemes, fees needing to be paid and referral pathways. While the basic health care package at first point of referral level has been identified and cost at $11.5 per capita, the health sector has made available only $10.5 per capita for the whole system.
The estimates of expenditure in the Transitional National Development Plan (2002-2005) show an expenditure for Health of Kwacha 195,200,000,000 (US $ 4,153,190) and for HIV/AIDS of Kwacha 130,940,546,000 (US$ 2,785,970) for a total budget of Kwacha 7,131,349,321,215 (US$ 1,517,308,366).
Zambia is in the process of an ambitious program of health sector “decentralisation.” The start of this decentralisation started with the Medical Services Act of 1985. This act created semiautonomous hospital management boards for all major hospitals (more than 200 beds).
In 1992 the hospital boards, appointed by the Minister of Health, were given the authority to set fees and manage staff. In the same year further legislation was enacted requiring the districts to establish District Health Boards to oversee the districts. These were finally created in 1994 and acted as employers/supervisors of the District Health Management Teams.
District Health Management Teams were set-up in 1993 to act as technical managers of the district health offices in each of the country’s districts. The Health Reform Implementation Team was also established in this year to act as a coordinating body to promote the full implementation of the legislated reforms. This body was independent from the Ministry of Health and collaborated closely with international aid organisations.
Resources at a District level are allocated on per capita basis taking into account population density, price of fuel, likelihood of epidemics, and the presence of a bank. At the level of hospitals allocation is based on cost per bed day. Standard bed/population ratios are used to determine the number of beds per given population for 1st, 2nd, and 3rd level hospitals. For other hospitals allocations are based on budgets, subject to availability of resources.
The lowest administrative level for health is the Area Boards of Health, which are set-up to divide the population into manageable health districts. These are still in the process of being established. Their function is to:
- Recruit and support Health Workers
- Request training from the district as necessary
- Monitor and support the function of Health Centres
These Area Boards of Health would then report to District Health Board. Their role is:
- Primary management unit in the decentralised health system
- Administer the affairs of the district health services
- Responsible for planning for the district
- Responsible for ensuring that local priorities are recognised and addressed
- Responsible for coordinating with other sectors e.g. agriculture, local government, etc.
- Responsible for monitoring performance of HCs and level 1 hospitals against established standards
- Responsible for providing training to district staff
The next level is the Provincial Health Office. This office has 6 main areas of activity:
- Technical Support Function
- Development of Action plans and budget
- Advice on implementation of action plans
- Provide counselling on specific identified needs
- Training
- Financial Management
- HR development
- Epidemic preparedness
- Monitoring and evaluation
- Action plan implementation
- Quality assurance
- Financial management
- Systems development and management of districts
- Health management information system and health research
- Logistical Support
- Supply of equipment, drugs, vaccines, etc. supplied from national level
- Economy of scale functions e.g. maintenance of cold chain
- Communication – national policies – instructions for District Health Boards
- Mediation
In 1995, the National Health Service Act was accepted. It called for a significant change in the role and structure of the Ministry of Health and called for the establishment of an autonomous health service delivery system. This led to the creation of CBoH. The mandate of the CBoH was to “monitor, integrate, and coordinate the programs of the Health Management Boards”.
The Ministry of Health’s role became one of primarily a policymaking and regulatory institution. The Ministry of Health no longer had any direct involvement in health service delivery, these were contracted to the CBoH.
The CBoH has 4 directorates:
- Technical Support Services – responsible for conducting performance audit of the health boards, monitoring and providing technical support to service provision, and capacity building of the health boards
- Clinical Care and Diagnostic Services – responsible for planning, monitoring, and evaluating provision of diagnostic and pharmaceutical services
- Public Health and Research – responsible for developing guidelines on epidemiology, environmental health, health promotion, and mental health, for developing and maintaining the HMIS, and for facilitating research on all health activities
- Health Services Planning – responsible for the planning and contracting of health services, providing financial management, developing partnerships in health, and providing national level human resource planning and training.
The last echelon, the Ministry of Health, tasks include:
- Development of sectorial policies and ratification of technical ones
- Formal strategic planning
- Legislation
- Resource mobilisation
- External relations
- Performance audit of CBoH