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Health system challenges and
opportunities in Zambia
February 6, 2013
Swedish Health Care Delegation to Zambia
Göran Tomson
Professor of International Health Systems Research
www.ki.se/phs/hsp
Need to reframe policies and thinking for the
multipolar world of the 21st century.
New world view based on global responsibilities,
interdependence and partnership.
Innovations
Systems thinking
Evidence Informed Policies climate
PPP/PPDP
Smart care
Cola road
February 21, 2013 3
Annual GDP Growth in Zambia
Source: World Bank, 2012
February 21, 2013 4
Burden of Disease in Zambia,
2008
Cause Estimated deaths per 100,000
population
HIV/AIDS 324.0
Cardiovascular diseases 180.5
Respiratory infections 148.0
Perinatal conditions 130.3
Diarrhoeal diseases 113.6
Malaria 103.5
Unintentional injuries 90.2
Respiratory diseases 50.9
Malignant neoplasms 50.6
Intentional injuries 49.4
Source: WHO, 2008
February 21, 2013 7
Source: NHSP11-15
Sources of
health financing Government
expenditure 8,5% of
national budget (lower than
Abuja target)
1% earmarked tax on
interest earnings
Challenges National Health
Insurance Scheme not
developed
No Health Care
Financing Policy
Unpredictable support
from donors.
Source: Sundewall, PhD Thesis, 2009
Human resources
Category of Health Workers Number in 2010 Recommended Training
institutions
Medical Doctors 836 2,300 1
Nurses 7461 16,732 37
(10 PNFP) Midwives 2471 5,600
Paramedical Practitioners 1462 - 1
Dentists 246 633 1
Pharmacists 317 347 1
AHWO (2010)
Availability and Access to Essential
Medicines
February 21, 2013 10
Main challenges
- Limited storage capacity
- Poor communication in supply
chain
- Logistics system: poor
integration, supervision and
staffing
- Access problems in rural areas
- Irrational use of medicines
(poor implementation of NDP)
Strengths and Opportunities
- Appropriate pharmaceutical
policies and regulations
- New pilot models of drug
supply logistics
- Improved disbursement of
funds for procurement of
medicines
Source: NHSP11-15
Source
Of Funds
Procurement
Agent/Body
Point of first
warehousing
Point of 2nd
warehousing
Point of 3th
warehousing
WORLD
B
A
N
K
P
E
P
F
A
R
D
F
I
D
U
S
A
I
D
Medicines supply systems in Zambia. 2007
U
N
I
C
E
F
W
H
O
C
H
A
Z
Z
A
N
A
R
A
C
H
A
I
J
I
C
A
WORLD
VISION
U
N
F
P
A
Z
A
B
A
R
T
ESSENTIAL
MEDICINES ARVs MALARIA TB OI
ARVs
Ped
REAGENT
Blood safety
(+ test HIV)
VACCINES CONDOMS Contraceptives MEDICAL
Supplies
Categor
y of
Products Color
U
N
I
C
E
F
C
H
A
S
O
C
-
F
H
BOSTO
N
UNIVE
RSITY
U
N
F
P
A
C
I
D
R
Z
Z
A
B
A
R
T
C
A
R
E
Malaria Centre CARE PROVINCIAL STORE DISTRICT
STORE
PROV.
STORES DISTRICT STORES
HEALTH FACILITY DISTRICT STORE
HF
GOVERNMEN
T
BILATERAL
DONOR
MULTILATERAL
DONOR
NGO/PRIVAT
E
J
I
C
A
B
G
A
T
E
S
M
O
H
C
M
S
WORLD
VISION
WORLD
B
A
N
K
U
S
A
I
D
MOH CMS ZAMBART
STORE
C
R
S
DS
ITN
PATIENT
CHA
STORE
CIDRZ
STORE
HF
HEALTH
FACILITY
A
X
I
O
S
HF
U
N
I
T
A
I
D
GLOBAL
FUND
C
D
C
G
L
A
S
E
R
M
O
H
C
LI
NT
ON
HC
HOME
BASED CARE
Zambia
Source: Bigdeli et al, Health Policy Plann, 2012
Access to medicines from a health system perspective
SWOT analysis of Health Information
System
Source: NHSP11-15
Source: AHO WHO Africa, 2010
Source: WHO, 2010
Non-Communicable Diseases (NCDs)
needs in Zambia
Source: NHSP11-15
Ownership of Health
Facilities
Province Zambia
Public Health Facilities 1,489
Mission Health Facilities 122
Private Health Facilities 271
Total 1,882
Challenges
• Infrastructure
• Medical equipment Theatre and anaesthesia
Health technology
management and maintenance
Maternity equipment
CSSD and general nursing
equipment
Laundry and kitchen
equipment
Source: NHSP11-15
• “Mapping” of the private sector in partner countries showing its increasing role in health care (e.g. Zambia)
• PSP found a neglect of quality of care and an overprescription of drugs often linked to private sector care
• Public private partnerships were emphasized as one of the main areas of innova-tion in health with many options for governments to work with the private sector.
Geographical mapping of health providers in Zambia
• Private health care in Zambia – Findings from provider and client surveys in two districts (Lundazi and Chingola) (Wake et al 2008)
• Interviews about providers’ challenges and experiences including relations with public sector
Quality problems identified among informal providers and
drug stores Little formal cooperation between government
and for-profit providers
368 health providers were mapped: 59% located in rural areas, 90% private for-profit while 5% were either government or private not-for-profit, 60% of providers were informal
The quality of private pharmacy services in a province of Lao PDR
A randomized trial, pre-experimental and cross sectional study including quantitative and qualitative methods by Syhakhang et al, 2002 (similar study by Chuc et al, 2002)
Improvement of practice of private pharmacies including the provision of better quality drugs through regulatory interventions e.g. inspections, information, and distribution of regulation documents to drug sellers and sanctions.
“Most private pharmacies were managed by non-pharmacists. The quality of practices was low, with 59% of the encounters not receiving any information on drug use, 47% of purchased drugs had no label and 26% of all drugs were mixed in the same package.”
Governance
Private sector a complement to the public sector in health service
delivery
Collaboration and coordination between the two sectors for health
systems strengthening
“What our government has done is
make clear that we accept the role of
the private sector and the
collaboration between public and
private” (Hon. Dr. Joseph Kasonde,
MP, Minister of Health)
An evidence-based policy
brief proposing an
(1) incremental versus a
(2) comprehensive option
for integrating mental health
into primary care:
(1) pilot project
(2) comprehensive,
national plan.
Towards Universal Health Coverage (UHC)
“The goal of universal health coverage is to ensure that all people
obtain the health services they need – prevention, promotion,
treatment, rehabilitation and palliation – without risk of financial ruin or
impoverishment, now and in future.” (M. Chan, WHO, 2012)
Innovative ways of reaching UHC
The results chain for UHC
Task shifting in the scale-up of
interventions to improve child survival:
an observational multi-country study in
Bangladesh, Brazil, Uganda and
Tanzania Task shifting from health workers with longer duration of
training (doctors, clinical officers) to those with shorter
duration of training (nurses, midwives and nurse assistants)
did not compromise quality of child care linked to the
Integrated Management of Childhood Illness (IMCI).
Task shifting could be used as a strategy for increasing
coverage of IMCI and other child survival interventions
in underserved areas faced with staff shortages.
Source: Huicho et al, Lancet, 2008
Telemedicine to improve the quality of
paediatric care: an operational research study
Source: Zachariah et al, Trop Med Int Health, 2012
The “polypill” to reduce deaths from
cardiovascular disease
Source: TIPS, Lancet, 2009
Opportunities for Public Private Partnership
in the Zambian health sector
Telemedicine
Establishment of hi-tech Hospitals for treatment
of specialized cases
Diagnostic centres
Drugs logistics supply chain and storage
Hospital fleet management and repair
Laundry services
Repair of medical equipment.
Training of health personnel (medical school and
nursing school)
Source: Zambia Development Agency, 2011