Zambia Political Economy of Health in Eastern Province€¦ · commissioned. The study which has been commissioned by Care Zambia is intended as an analysis of the political economy

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2014

MulimaAkapelwa

For:CAREZAMBIA

PoliticalEconomyAnalysisoftheHealthsector–EasternProvince

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TableofContentsEXECUTIVESUMMARY.................................................................................................................................4

1. INTRODUCTION................................................................................................................................7

2. COUNTRYCONTEXTOVERVIEW...........................................................................................................8

3. HEALTHSECTORLEVELANALYSIS.......................................................................................................19

4. ANALYSISOFINSTITUTIONSANDGOVERNACEARRANGEMENTS–RULESOFTHEGAME................29

5. ANALYSISOFTHEGOVERNANCESPACESINTHESECTOR..............................................................43

6. ANALYSISOFMAINAGENTS/STAKEHOLDERS..................................................................................49

7. LINKINGANALYSISTOPROGRAMMEDEVELOPMENT........................................................................56

Deleted: 18

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Deleted: 55

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LISTOFFIGURES

1. AdultLiteracyRatebyProvince2. IncidenceofPovertyLevel,headcountbyDistrictinEasternprovince,20103. NonPersonalEmoluments(PE)Budget&Releases,2004-20114. ComparisonofNonPEMTEFAllocation,BudgetandReleases2010-20135. Levelsofservicedelivery6. Structureandfunctionalrelationshipsinthehealthsector7. BudgetandPlanningCalenderatMoFNPandMoH8. KeyStakeholders9. InfluentialActorsatPMOlevel10. Actorsstaffmembersataclinicconsiderinfluential11. Possiblechannelsofengagement

LISTOFTABLES

1. Ruralpovertydistributionbysexofhouseholdhead,20102. Distribution of Respondents by who makes Selected Decisions at Household Level Men, Women or Both by

Sex 3. StaffLevelsinChipataDistrictQuarter120144. StateandNonStateledSpacesandActors5. Stakeholders’Analysisofroles,interests,capacitiesandaccountability6. Strategies–Approaches,methods,levelofengagement,possiblepartners

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ACRONYMS

AG AuditorGeneral

AIDS AcquiredImmuneDeficiencySyndrome

BCHP BasicHealthCarePackage

CBH CentralBoardofHealth

CD4 ClusterofDifferentiation4

CDC CentreforDiseaseControl

CDF ConstituencyDevelopmentFund

CHAZ ChurchesHealthAssociationofZambia

CS CivilSociety

CSOs CivilSocietyOrganisations

CSPR CivilSocietyforPovertyReduction

DDCC DistrictDevelopmentCoordinationCommittee

DCMO DistrictCommunityMedicalOffice

DIMM DistrictIntegratedManagementMeeting

EAZ EconomicsAssociationofZambia

EPWDA EasternProvinceWomen’sDevelopmentAssociation

GDP GrossDomesticProduct

GNC GeneralNursingCouncil

GRZ GovernmentoftheRepublicofZambia

HCC HealthCentreCommittee

HIV HumanImmuno-DeficiencyVirus

HMIS HealthManagementInformationSystem

IAPRI IndabaAgriculturalPolicyResearchInstitute

IIAG IbrahimIndicatorsofAfricanGovernance

IMF InternationalMonetaryFund

INGO InternationalNon-GovernmentalOrganisation

JCTR JesuitCentreforTheologicalReflection

LCMS LivingConditionsMonitoringSurvey

MCDMCH MinistryofCommunityDevelopmentMotherandChildHealth

MCH MotherandChildHealth

MDGs MillenniumDevelopmentGoals

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MMR MaternalMortalityRatio

MNCH Mother,NeonatalandChildHealth

MoH MinistryofHealth

MP MemberofParliament

MSL MedicalStoresLimited

MTEF MediumTermExpenditureFramework

NGOs Non-GovernmentalOrganisations

NGOCC Non-GovernmentalOrganizationsCoordinatingCouncil

NHCs NeighbourhoodHealthCommittee(s)

NZP+ NetworkofZambianPeopleLivingwithHIV-AIDS

OBI OpenBudgetIndex

PDCC ProvincialDevelopmentCoordinatingCommittee

PEA PoliticalEconomyAnalysis

PIMM ProvincialIntegratedManagementMeeting

PMO ProvincialMedicalOffice

PS PermanentSecretary

RCZ ReformedChurchinZambia

SAG SectorAdvisoryGroup

SAP StructuralAdjustmentProgramme

SMAGs SafeMotherhoodActionGroups

SNDP SixthNationalDevelopmentPlan

TB Tuberculosis

TFR TotalfertilityRate

UN UnitedNations

ZDHS ZambiaDemographicandHealthSurvey

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EXECUTIVESUMMARYBackground

ThispoliticaleconomyanalysisisintendedtoserveasabackgroundpaperforCAREZambia’suseastheorganisationdesignsnewprogrammes in thehealthsector inEasternProvince.TheanalysisdrawsonofficialreportspreparedbyGovernmentoftheRepublicofZambia(GRZ),donors,academicinstitutionsand multilateral organizations. It also draws upon nationally representative surveys and informationfromkeyinformants,mediaandstakeholdersthatparticipatedinavalidationworkshop.TheIssue

Having changed to multipartism in the early 1990s, Zambia is a stable country with soundmacroeconomic indicators. She has experienced an average of 6% GDP growth in the past decade,inflation is below single digit and tax revenue is growing. However poverty is high especially in ruralareas.Gender inequality ishigh too,withwomenandgirlsexhibiting lower literacy levels thanmales,lowerparticipationintheformalsectoraswellasinleadershipanddecisionmakingpositionscomparedtomales.Thoughalowmiddleincomecountry,ZambiahaspoorhealthoutcomescomparedtoothercountriesinSouthernAfrica.ItisofftracktoachievemostoftheMillenniumDevelopmentGoalsapartfromMDG2on attaining universal primary enrollment. BothMDG 4 and 5 on reducing ChildMortality Rate andMaternalMortalityRatiowouldrequiresignificanteffortsandresourcesiftheyweretobeachievedby2015.However,itisunrealistictoexpectthistohappen.Health sector spending rose to a high of 11% of the discretionary budget but is projected to bemaintained at just over 10% in the medium term. This is lower than the Abuja Declaration whichrequires countries to spend about 15% of their budget on health. The sector is characterized by lowhuman and financial resources, inadequate infrastructure, equipment and supplies. Despite this,misapplication of resources and fraud is commonplace as indicated in several reports of the AuditorGeneralandthescandalsof2005and2009.Elitecaptureisthereforecommon.Thesectorhasimplementedseveralreformsoverthepast22years,chiefamongthemwereseparationof policy and implementation functions, liberalization to allow private practice, decentralization andrestructuringand introductionofuser fees as a cost sharingmechanism.More recentlyhasbeen thedelinking of maternal and child health responsibility from Ministry of Health to that of CommunityDevelopmentMotherandChildHealth. Inthemediumtermareplanstomoveprimaryhealthcaretolocal government. In all thesemeasures the influence of and accountability to health users has beenlimited.Akeyissueinthegovernanceofthehealthsectoristhelackofmechanismsforcommunityengagementforpurposesofaccountability.Women,youngpeopleandmenhavelimitedopportunitiestoeffectivelydeterminethequalityofservicestheyreceive.Mainobservations

Zambia is ade jure legal - rational bureaucracybut in fact, it is a neopatrimonial system,where thestateandexerciseofpowerispersonalisedandpatronagebased.Nepotism,clientelism,patronageandcorruptionaffecttheuseofpublicresourcesanddecisionmaking.

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The health legal framework is characterised by a lacuna in legislation, an Act that provided for theorganisation of the health sectorwas repealed in 2006 andhas since not been replaced. Instead thesector operates under amyriad of policy documents and strategic plans,making follow up on policyimplementationachallenge.The regulatory system is weak, in some cases outdated and under-resourced making it somewhatineffective. Conflict of interest is a real possibility as actors are practitioners, regulators and policymakersatthesametime.Servicedeliveryisconstrainedbyinadequatebudgets,non-disbursementsandshortageofskilledstaff,equipmentandcommodities.Theseissueslimitaccesstoqualityservicesasdoesdistancetofacilities.Althoughthefinancingcriteriatakeintoaccountpopulationandepidemiologicalconsiderations,itisstillinequitable.Remote,poorandnon-urbandistrictsbenefit less compared to theirurbancounterparts.The emphasis on curative andhospital level financing skews the criteria.Despite this there is limiteddemandsideengagementamongcivilsociety.Mostspacesforengagementinthesectorarestateledatnational,provincialanddistrictlevels.Therearelimitednon-stateledspacesofengagement.Thisseemstoreflectthelowlevelofcivicengagementon health issues by civil society. Traditional civil society has been engaged in service delivery in thesector.Alackofskills,resources,beinglocatedinurbanareasanddonordependencearecontributoryfactors.Non-statespacesexistatthecommunitylevelbutarenotwellarticulatedorutilized.StructuressuchastheNeighbourhoodHealthCommittees(NHCs)arelimitedasaccountabilitymechanismsbetweenthehealthfacilityandcommunities.NHCsthemselvesareoftennotverygenderbalancedwithwomennottaking up leadership roles. Stakeholders in the sector at community, district, provincial and nationallevels have different interests and positions which may not be apparent but which underlie theirengagement.After forming government in 2011 the Patriotic Front (PF) government changed themandate of theMinistryofCommunityDevelopmentandSocialServicestotakeonresponsibilitiesofmotherandchildhealth. TheMinistry’s key responsibilities were for social welfare programmes including safety nets.Mother and Child Health were dealt with by the Ministry of Health. The additional responsibilitiesresulted in the change of name to Ministry of Community Development, Mother and Child Health(MCDMCH). At theDistrict level theDistrictMedicalOfficewas renamedDistrictCommunityMedicalOffice and hived off from Ministry of Health to MCDMCH. However, MCDMCH does not have thecapacityattheprovincialanddistrictleveltoeffectivelydischargeitsadditionalrole.MCDMCHreliesontheProvincialMedicalOfficetoensureplanningandbudgetingandtomonitorperformanceatdistrictlevel.However,communicationbetweentheProvincialMedicalOfficeandtheMCDMCHisnotsmooth.DistrictCommunityMedicalOfficemembersofstaffprefertobeundertheMinistryofHealth(MoH)tobeing assigned toMinistry of Community Development, Mother and Child Health (MCDMCH). Giventheseissues,strategiestoincreasetheinfluenceofexcludedgroupsespeciallywomenhavetobemulti-faceted.Suchstrategieswouldneedtoaddressboththesupplyanddemandside.Supply side issues include budgets; allocation, disbursements and utilization. Transparency andaccountability for health outputs are equally necessary tomonitor. NHCs report that there is limitedtransparencyintheuseofresourcesassignedtocommunityprogrammes,healthcentrestaffoftendo

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notaccountfortheuseoftheseresources.Becauseofperverseincentives,healthcentrestaffmayfocusoncertainhealthprogrammestothedetrimentofothersresultinginpooroutputs.Strategies for engagement need to take into account patriarchy and other social cultural norms thatcontribute to women’s low position and the capacity of civil society at different levels. The role ofparticipatorymethodologiesandmediaespeciallyradiowouldbeimportant.In order to be effective it is necessary toworkwith different stakeholders so as to gain support andreduceopposition.Relianceonstate-ledspacesonlyshouldnotbethenormbutcarvingoutnewwaysof engaging and bringing decision makers to the table is essential. Working within state-led spacesshould be pursued but as a commitment to empowerment. Citizen-led mechanisms will need to beimproved and increased to provide adequate pressure on state-led spaces to respond to citizens’demands.

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1. INTRODUCTION1.1Background

HealthcareprovisionandimprovedperformanceisahighpriorityoftheGovernmentoftheRepublicofZambia(GRZ)asindicatedinseveralpolicydocumentssuchasVision2030,SixthNationalDevelopmentPlan(SNDP),NationalHealthPolicyandStrategicPlanaswellasinthePatrioticFront’spartymanifesto.Achievingagoodhealthsystemisafunctionofanumberoffactorswithgovernanceofthesectorbeingakeyissue.Howdecisionsaboutallocationandmanagementofresourcesaremadeandimplemented,who benefits or is excluded are important to understand. This is the reason this study has beencommissioned.ThestudywhichhasbeencommissionedbyCareZambiaisintendedasananalysisofthepolitical economyof healthwith particular reference to Eastern Province. Political EconomyAnalysis(PEA)isconcernedwiththeinteractionofpoliticalandeconomicprocessesinasociety:thedistributionofpowerandwealthbetweendifferentgroupsand individuals,andtheprocessesthatcreate,sustainandtransformtheserelationshipsovertime1.

Care International Zambia has worked in Zambia since 1992 partnering with local non-governmentalorganisationstodeliverarangeofprogrammesaimedatimprovingthelivesofthepoor,vulnerableandsocially excluded people. Core programme areas include women’s empowerment, natural resourcemanagement, climate change, maternal/child/neonatal health, governance and accountability. Careemphasises a rights based approach to development engagement. Care is planning a number ofinterventionsthatwillincludemobilisationofcommunitiestoincreasetheirengagementinmonitoringthe delivery of health serviceswith a focus on HIV& AIDS,MNCH andNutrition. Care has thereforecommissionedthispoliticaleconomystudyofthehealthsectoratnationalandlocal leveltofeedintothedesignofnewprogrammes.Thespecificresearchquestion is:Giventhecurrentpoliticaleconomycontext of the health system in Eastern Province, how can excluded citizens, particularly women,influencethequalityofmaternal,childandHIVhealthservicesdeliveredintheprovince?

1.2Process

ThestudyreliedonliteraturereviewofGRZ,donor,CivilSocietyOrganisations(CSO)andreportswrittenby academics. Other sources included interviews with key stakeholders at national, provincial anddistrict levels in government, donor community and civil society.Membersof severalNeighbourhoodHealthCommittees (NHCs) and staff atone clinicwerealso interviewed. The reporthas incorporatedcommentsprovidedatavalidationworkshoporganisedbyCARE.

A key limitation at the time of preparing reportwas the inability to conduct interviewswith generalcommunitymembersaswellaswithawiderangeofgovernmentofficials.AmajorconcernhasbeenthedifficultyassociatedwithobtainingresponsesfromMoHforthereleaseofcurrentdata.

1.3Framework

UsingtheCareGovernanceandContextAnalysisandProgrammeDesignGuidanceNoteasaframework,the report is structured as follows; following on this first section, section two provides a high levelcountrypoliticaleconomycontext, section three focuseson thePEAofhealth sectoratbothnationalandEasternProvincelevel.Sectionfourincludesastakeholderanalysisaswellasadiscussionofspaces.

1UnsworthS.andWilliams,G.(2011),“WorkingwithaPoliticalEconomyApproach:ADEVCOConceptPaper”

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The last section includes the potential strategies for increased citizen influence on use, quality andequityofhealthservicesineasternprovinceandatthenationallevel.

2. COUNTRYCONTEXTOVERVIEW2.1 Economy

A stable, peaceful country with multi-partism as the accepted political settlement and an economygrowingatanaverageof6.4%perannuminthelastdecade2,Zambiaattainedlowmiddleincomestatusin 2011. In the late 2000s Zambia experienced a turnaround of the economy arising from a surge indemand for copper, growth in construction, finance, telecommunication and tourism sectors andprudent economic management. Macroeconomic indicators are showing well; inflation has been atsingledigit,hoveringat7%,debtfellafterHighlyIndebtedPoorCountries’Initiative(HIPC)andrevenuetoGDPratiohasimprovedfrom18%to20%.Zambia’sGDPisabovethatofotherdevelopingcountriesinSubSaharanAfrica3.Thesegainswereaccompaniedbyamarked improvement intheWorldBank’sDoingBusinessReport,whichplacedZambiaamongthetoptenreformers in20104.Zambia’sexternalratingshavebeenbuoyedbyfavourablecreditratings,enablingthecountrytoborrowexternallyontheopenmarket.

The economy is vulnerable as it is predominantly reliant on copper earnings. Zambia has not beensuccessful at diversifying its economy from copper despite the country having good arable land andwaterbodies.Agriculturalproductivityremainslowandispredominantlysmallholderbased.Thesectoremploysabout70percentoftheruralpopulationbutitscontributiontoGDPislow.Theportionofthepopulationemployedintheagriculturalsectorhasshownadecliningtrendbetween2000and2010.

WhilstMacroeconomicindicatorshaveperformedwell,monetaryandfiscalaspectsarebeginningtoraiseconcern.Theexchangerateplummetedsignificantlyin2014,fallingtoK6.7tothedollarasofthesecondweekofMay5.Thiswasattributedtolowinflowsfromthefallofcopperprices.TheIMF’sArticle4Reportof2013raisesfiscalconcernsthat“Virtuallyallcategoriesofspendinghavedeviatedsubstantiallyfromapprovedlevels.Thesharpincreaseinwages(45percent,comparedtothebudgeted9.1percent),andthelargeoverrunsonsubsidies—4.0percentofGDP,comparedtoabudgetoflessthan0.7percent—forcedthegovernmenttomakesharpcutsingoodsandservices,intergovernmentaltransfers,andcapitalspending.”6Deficitsarealsohigherthaninitiallyplanned.GRZwouldneedtoreduceplannedexpenditureongoodsandservicesinordertocontainthebudgetdeficits.Suchareductionwillinevitablyaffectdeliveryofhealthservices.

2.2 PovertyandSocialindicatorsZambiaranks164/186ontheUNHumanDevelopmentIndex7,whichisbyallindicationsalowstandingforacountrythathasnotexperiencedwar.Povertyreductionisconstrainedbypoorpolicyarticulationandimplementationandanurbanbiasindevelopment.

2CentralStatisticalOffice,NationalAccounts3http://www.worldbank.org/country/Zambia/overview4WorldBank,2010,DoingBusiness,ReforminginDifficultTimes5Localmediareports6IMFCountryReportNo.14/5ZAMBIA2013ARTICLEIVCONSULTATION7UNDP2012

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Povertyaffects60.5%ofthepopulationwithruralareasbeingworseoffat77.9%livinginpoverty.Over57.7%oftheruralpopulationliveinextremepoverty8comparedtoonly13.1inurbanareas.Thetablebelowshowstheincidenceofruralpovertyamongfemaleandmaleheadedhouseholds.Femaleheadedhouseholdsinruralareasaremoreaffectedbypovertyandlesslikelytobenon-poorcomparedtomaleheadedhouseholds

Table1:Ruralpovertydistributionbysexofhouseholdhead,2010

PovertyDistribution2010 Male FemaleOverall 77.5% 79.8%Extreme 57.1% 60.4%Moderate 20.4% 19.4%Non-Poor 22.6% 20.2%Source;LCMS2010

Between 2006 and 2010 there was a decline in overall poverty from 67.4% to 62.4% among femaleheaded households. The decline is most likely attributable to NGO and GRZ programmes targetingextremely poor female headed households. Poverty among male headed households reduced onlymarginally from61.7 to60.1%. Femaleheadedhouseholds aremore likely to live inextremepoverty(44.4%) compared to male headed counterparts (41.9%). Households headed by individuals with noeducation or only primary school level education have a high incidence of poverty. The incidence ofpovertyishigheramongsmallscalefarmersandhasbarelychangedsince2006.

EasternprovinceisthethirdpoorestprovinceafterLuapulaandWestern9.Povertystandsat77.9%withextremepovertyat58.7%in2010havingincreasedfrom56.4%in2006.Contributoryfactorscouldbethelowearningsfromforsmallscalefarmersthattillonaverageaboutahectare.Otherfactorsincludethenon-availabilityofoff-farmearningopportunitiesinruralareas.

TheLivingConditionsMonitoringReport(LCMS)doesnotcontainpovertydistributionbysexofheadofhouseholdatprovinciallevelbutastudybyIndabaAgriculturalPolicyResearchInstitute(IAPRI)includesthisinformation.TheIAPRImethodologygoesbeyondthesimpledichotomyoffemaleormaleheaded.Households are categorised bywhether or not there aremale and female adults (over 18 years old)present in thehousehold.This is referred toas thegenderhousehold type.Forexampleahouseholdwith a widowed woman living with her 18 year old son would be categorised as male and femalehousehold type under this typology. Using this classification, the IAPRI study shows that 81.2% ofhouseholds in Eastern Provincewere ofMale and Female adults, 15.5%were Female only and 3.2%wereofMaleadultsonly.10

Povertyaffected79.8%of theMaleandFemaleadults in theprovince,whilst85.4%ofFemaleadultslivedinpovertyand60.5%ofMaleadultslivedinpoverty.

The LCMS shows that people in rural areas point to inability to afford agricultural inputs, 28.4%,followedbylackofcapitaltostart/expandagriculturaloutput7.3%asthekeyreasonsfortheirpoverty.

IncomeinequalityishighwithaGinicoefficientof0.65increasingfrom0.60in2006.TheGinicoefficientinruralareasdisplayedaworseningtrendfrom0.54to0.60between2006and201011.Highinequalitylimits the benefits of growth for the poor. The 2010 LCMS indicates that urban households reported

8CentralStatisticalOffice,2012,LivingConditionsMonitoringSurveyReport2006-2010,Lusaka9LCMS2010,beforedeclarationofMuchingaProvince10TemboS.,SitkoNicholas,2013,TechnicalCompendium:DescriptiveStatisticsandAnalysisforZambia,IndabaAgriculturalPolicyResearchInstitute(IAPRI)Working76,Lusaka11LivingConditionsSurveyReport2006-2010

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monthlyaverageincome(K1,917,000oldcurrency)morethantwicethatreportedbyruralhouseholds(K664,000).EasternProvincereportedthelowestmeanmonthlyincomeatK607,000.Lackofmoneycanbeabarriertoaccesshealthcareespeciallyiftransportcostshavetobeincurred.PatientsmayalsonotbeabletopayfordiagnosticservicessuchasX-rayandotherlaboratorytests.

2.3 Culturalandsocialnorms

RelationsinZambiansocietyareunderlainbystrongsocial-culturalnormsthattendtoputwomenandgirls inadisadvantagedposition.Predominantlyapatriarchalsociety,menoccupyleadershippositionsintraditionalsocietyaswellasmoderndaysystems.Culturalbeliefsandnormsdiscouragewomenfrombeingactive inpublic lifeand fromspeakingandvoicing their views.Culturallywomencannot inheritpropertynorownland,indeedwomenownlessthan20%ofstatutoryland.Itisnotuncommonforruralfamiliestoopttotaketheirmalechildrentosecondaryschoolthanthefemales.Thegirlchildisseenashavingtheoptionofmarriage.Findingsofthe2012National2012GenderPerceptionSurvey12confirmthatwomenareregardedassubordinatetomen,have littlevoiceorautonomyand littleornostatuswithin communities. The negative effects of the cultural and social norms are exhibited in the highgenderinequalityasexplainedbelow.

Femaleshave lower literacy levels thanmales,howeverthesituation is improving.AdultLiteracyRate(15yearsandolder)is91.6percentforfemalesand96.7percentformales.Thisnationalaveragemasksthedisparitybetweenruralandurbanareas,whereruralfemaleshaveliteracyrateof67.2percentandmales82.3percent.

Thelowlevelsofliteracyandlowerattainmentofeducationforwomencomparedtomenmakewomenunlikely to hold leadership positions in community groups. Most executive positions in communitygroupsorassociationsrequireabilitytoreadandwrite.DuringtheLundazifieldtrip,membersofNHCwhoweremostlymale,indicatedthatthelownumberoffemalechairpersonsofNeighbourhoodHealthCommitteeswasduetowomen’sinabilitytoreadandwriteandtheirlackofconfidencetoholdpublicoffice(explainedtomebymen).

2.4 Decisionmakinginthehomeandatcommunitylevel

Findingsfromthe2012GenderPerceptionSurveyindicatethatabouthalfofrespondents(48.3%)saiddecisions at community level weremade by men. Only 3.4% reported that decisions weremade bywomen.However,44.8%ofthesamplereportedthatdecisionsatcommunitylevelaremadejointlybyboth men and women. As observed at community level, decisions at household level areoverwhelmingly reported to be made by men (68.1%). The table below shows who makes selecteddecisions. It seems men have a predominant role although both men and women seem to beincreasinglymakingjointdecisions.

FindingsfromEasternProvinceintheIAPRI(2013)studyshowthatmalesmakedecisionsonlanduseinmales and femalesGenderHousehold Type.Men alsomadedecisions on the sale ofmost crops andlivestock. Bothmales and femalesdecided theuseof revenue from saleof livestock. Butwomen arelikely to have decisions over larger incomes realised from the sale of livestock13. This seems counterintuitivebutitcouldbeanindicatorthatthegendermessageismakingamark.

12MinistryofGenderandChilddevelopment,2012National2012GenderPerceptionSurvey,GovernmentoftherepublicofZambia,Lusaka13TemboS.,SitkoNicholas,2013,TechnicalCompendium:DescriptiveStatisticsandAnalysisforZambia,IndabaAgriculturalPolicyResearchInstitute(IAPRI)Working76,Lusaka

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Table 2: Distribution of Respondents by who makes Selected Decisions at Household Level Men, Women or Both by Sex

Selected Decisions Who Makes Decisions

Sex of Respondent All

Female Male

Wife's Health

Man 39.6

44.1 41.6

Woman 17.8

9.9 14.3

Both 42.7

46.0 44.1

Total (n) 776

624 1,400

Children's Health

Man 15.3

18.8 16.9

Woman 23.2

15.1 19.6

Both 61.4

66.1 63.5

Total (n) 770

623 1,393

Major household purchases

Man 40.8

41.8 41.2

Woman 14.5

8.8 11.9

Both 44.8

49.4 46.8

Total (n) 775

624 1,399

Daily household purchases

Man 7.1

8.2 7.6

Woman 73.8

68.1 71.3

Both 19.1

23.7 21.2

Total (n) 775

624 1,399

Number of children

Man 31.8

33.6 32.6

Woman 11.2

5.9 8.9

Both 57.0

60.5 58.5

Total (n) 774

622 1,396

Children's school

Man 27.7

28.7 28.2

Woman 11.7

8.7 10.3

Both 60.6

62.6 61.5

Total (n) 772

620 1,392

Wife's employment

Man 38.7

40.8 39.6

Woman 24.0

20.9 22.6

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Selected Decisions Who Makes Decisions

Sex of Respondent All

Female Male

Both 37.4

38.3 37.8

Total (n) 771

622 1,393

Husband's employment

Man 60.5

61.6 61.0

Woman 6.5

4.5 5.6

Both 32.9

33.9 33.4

Total (n) 768

623 1,391

Wife's income

Man 24.5

25.7 25.1

Woman 30.1

25.9 28.2

Both 45.3

48.4 46.7

Total (n) 770

622 1,392

Visit to relatives

Man 31.2

33.0 32.0

Woman 11.6

8.7 10.3

Both 57.3

58.3 57.7

Total (n) 770

618 1,388 Source: Gender Perception Survey

2.5 GenderInequalityZambiaranks136outof148countriesintheUNGenderInequalityIndex14.Genderinequalityisseeninthe disparities between men and women in educational attainment, employment and access toresources.Gender inequality is pervasive;womenandgirls have loweducational attainment, are lessrepresented in paid employment, face high rates of HIV and aremore at risk. Though women formabout 80% of the labour force in agriculture they have little control of and access to productiveresourcesandassets.WomenbenefitlessthanmenfromtheFarmerInputSupportProgramme.

Sex differentials show that of those aged 25 years and older, that ever attended school, a highpercentage of females 56.9% indicated primary education as the highest level attained compared to39.7percentformales.Atsecondaryandtertiarylevelsmaleshadhighercompletionratesof42.6and17.5percentrespectively.Femaleshadcompletionratesof31.4%forsecondaryand11.3percentfortertiary15. The lower level of educationputswomen at a disadvantage in the labourmarket. Further,education is correlatedwith poverty, therefore female headedhouseholdswith only primary level ofeducation are more likely to be poor than their male headed counterparts with higher educationalattainment.The loweducationalattainment inwomencan impactquitenegativelyon theirchildren’shealthandeducation.Italsocanlimittheiruseofmodernfamilyplanningmethods.

14UNDPHumandevelopmentReport201315CentralStatisticalOffice,2010censusofpopulationandHousingNationalAnalyticalReport,Lusaka

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Mainreasonsfornotobtainingsecondaryeducationislackoffinancialresources,duetoculturalnormsruralparentsaremorelikelytosupportasonthanadaughter.Otherreasonsarethelongdistancestosecondaryschoolsinruralareas,makingschoolingariskforthegirlchild.Thereforegirlsmayopttostayathome.Poverty affectswomenheadedhouseholds more thanmale headedhouseholds16.Womenhave lessaccesstoproductiveresourcessuchaslandandcapital.AFinScope17studyindicatedthatwomenintheinformalsectoroftenstartoutwithlesscapitalthanmenandarelessskilled.

SocialculturalnormscontributesignificantlytothelowpositionofwomeninZambiaandareafactorinthehighratesofgenderbasedviolenceandearlymarriageandpregnanciesinthecountry.

The practice of early/child marriage is prevalent in Zambia. According to the 200718 ZambiaDemographic and Health Survey (ZDHS), two in five girls are married before they are 18, with littlechangesincethe2002ZDHS.Childmarriageoccursmorefrequentlyamonggirlswholiveinruralareas:in2007,womenaged20-24inruralareasweretwiceaslikelytohavemarriedbeforeage18thantheirurbancounterparts.Provincialdifferencesintheprevalenceofearlymarriagerangefrom60%inEasternProvinceto28%inLusakaProvince(ZDHS2007).Earlymarriageandpregnancyarealsoassociatedwithmaternalmortalityduetocomplicationsandinducedabortions.

2.6 WomenindecisionmakingpositionsWomenarelessrepresentedindecisionmakinginthepublicrealm.Femalesmakeup9%ofparliament,(after nullification of some seats), 6% of local Councillors, 17% of Permanent Secretaries, 23% ofDirectorsand21%ofAssistantDirectors inthecivilservice(2013).Theprivatesectorfarenobetter,asurvey conducted by Federation of Employers in 2011 shows that females formed 17.2 percent ofemployeesinsampledorganisationsandonly21.6percentwereinseniormanagementwhereas90.9%ofheadsofinstitutionsweremale19.

Mostpositions in traditional structuresof authority, arranged in a systemof chiefs andheadmenareheldbymen.

2.7 EmploymentFormalemployment ispredominantlyoccupiedbymales.The2010LCMS indicatesthatonly10.5%offemaleswereintheformalsectorwhereas24%ofmaleswereinthesector;foreveryonefemaleintheformalsectorthereweremorethantwomales.Womenaremorelikelytobeintheinformalsectorwiththree times as many females being unpaid family workers as there are males. The minimal earningopportunities make women and girls economically dependent on males thereby contributing to thesubservienceofwomen.Thepublicsectorispredominantlymale;thiscouldcontributetolowusageofservices bywomen and girls. The sex of a publicworker can be a barrier to use of a service in ruralcommunities.InEasternprovincetheDistrictCommunityMedicalOfficeindicatedthatthereweremoremalecliniciansthanfemales.

2.8 HIVAIDS

16CentralStatisticalOffice2010,LivingConditionsMonitoringReport2006201017FinMarkandAfricanheights,2010,FinscopeStudy2009,FinancialSectorDevelopmentPlan,GRZ18TherehasnotbeenDHSsince2007.19MinistryofGenderandchildDevelopment,2011,GenderStatusReportbaseline,RepublicofZambia,Lusaka

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In the2007DHS,HIVprevalence in adults aged15-49 yearswas14.3%. The2006-07Antenatal ClinicSentinelSurveillanceforHIVandSyphilis, (ANCSS)showedthatthemeansiteprevalenceforpregnantwomenaged15-49yearsin22siteswas16.6%.SpectrumestimatesoftheHIVprevalenceinadultsaged15-49yearssuggestthattheZambianHIVepidemichasbeenfairlystableoverthelast15yearswithaverymodestdeclineaftertheinitialpeakprevalence(MOT2009).AccordingtoSpectrumestimates,adultHIVprevalencepeakedinthemid-1990satabout16%andhasslowly declined since then to just above 12.7% (Spectrum 2013), and continues to fall. Zambia'sepidemichasseenconsiderableheterogeneitybyage,gender,geography,migration,education,maritalstatus,couplesandsub-populations.Femalesaremore likely tobeHIVpositive thanmales.Prevalenceamong females is16.1%whilst formalesitis12.3%20.Urbanareashaveahigherprevalence(20%)comparedtoruralareas10%21.WomenandgirlsareathigherriskofcontractingtheHIVvirusduetoanumberofreasonsincludinginabilitytonegotiatesafesex,economicdependencyonmaleandgenderbasedviolencefuelledbynegativesocialnorms.Howeverfemalesaremorelikelytoseektreatmentthanmales.Therateofnewinfectionshasbeenslowingdown,byendof2013atotalof598,509wereestimatedtobe on ARV treatment, out ofwhich 6.75were children. In 2012, a total of 564 health facilitiesweredispensingARVsinZambia,whichisanincreasefrom509in2011(HMIS,2013),andwhichishigherthan2013and2015targetsof400and500,respectively.HIVtreatmentisconstrainedbydowntimeinCD4testingmachinesinhealthcentres.ThiswasanissueraisedduringfieldworkinEasternProvince.

2.9 MaternalMortality,InfantandChildMortalityRatesZambia isoff-track tomeetingallbutoneMillenniumDevelopmentGoal (achievinguniversalprimaryeducation). MaternalMortality Ratio observed through the 2010 Census at 48322 is above theMDGtargetof162.MaternalMortalityRatio fromthe lastZDHSof2007wasat591. InfantandUnderFiveMortalityRatesremainhighat76and138respectivelyper1000livebirths.

Maternalmortality isdrivenby longdistancestofacilities, lackandcostoftransportation,shortageoftrainedstaff,inadequatefacilitiesandlackofmedicalsuppliesandinadequatereferralsystems.Culturalfactorsalsoplayapartastheyaffectdecisiontoseekcareandarelinkedtothelowstatusofwomeninsociety.

Malaria:

Malariacontinuestobetheleadingcauseofmorbidityandmortalityinthecountry23.EasternprovinceisoneofthemostaffectedprovincesinZambia,60.2%0frespondentsreportedtohavesufferedfromfever/malaria24.ThisissecondonlytoCopperbeltwith61.1%.Havingahighdensityandtheinsufficientsupply and use of Insecticide Treated Nets could be contributory factors. Because women aremore

20UNICEFResources,<www.unicef.org/Zambia>21InformationfromNationalAidsCouncil,22CentralStatisticalOffice,2012,Zambia2010CensusofPopulationandHousingNationalAnalyticalReport,GovernmentoftheRepublicofZambia,Lusaka23MOH2013NationalHealthPolicy24LCMS2010,andInterviewwithPMO’soffice

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involved in caring for the sick thanmalemembers of families, a high disease burden affectswomenmore.Malnutrition:Zambiahasoneofthehighestratesofchildhoodundernutritionintheworld25:• 46%ofunder-5childrenarestunted,5%acutelymalnourished(wasted)and15%underweight26• 53%ofZambianchildrenhaveVitaminAdeficiencyand46%haveirondeficiencyanaemia.27• 9.3%ofthechildrenarebornunderweightindicatingpoormaternalnutrition.28

Other countries in the region suffer from very high and/or deteriorating levels of stunting forchildrenunderage3are:Niger,Zambia,Malawi,Rwanda,andMadagascar,withlevelsover30%.29With the exception of DRC Congo where data is not available, all but one of the countriesneighbouringZambiahavebetteroutcomesonchildnutrition.Easternprovincehas thehighest levelof stunting in the country.Amedia reportquotingMedicalOfficerKennedyMalamaindicatedthat50%ofchildrenagedbetween6monthand59monthsarestunted.Thisforms45%ofthetotalpopulationofstuntedchildreninthecountry.30

One of the main reasons in Eastern province could be due to the high levels of aflatoxins found ingroundnuts.Theprovinceisoneoftheleadingproducersandthecropismainlyproducedbywomenforfoodconsumption.Aflatoxinsareassociatedwithvariouseffectscausingillhealth.

Someof the reasons for the high levels ofmalnutrition in Zambia could be due to over emphasis bygovernmentonmaizeproductiontothedetrimentofotherfoodcrops.Between2006-2011,40-91%ofthebudgetinagriculturewasassignedtoinputsupply(maizeandfertiliser)andmaizepurchasingbytheFoodReserveAgency.TheZambiandietischaracterisedbyhighstarchandlowproteinandvitamin.

Thedependenceon rain fed agriculture coupledby a lackof irrigation farming in small scale farminghouseholds is another factor. Long drymonthsmost of the year and lack of irrigation facilitiesmakegardening for vegetables onerous and therefore it is not common. However, various communityinitiativesareaddressingthisproblem.

2.10 GovernmentEffectivenessWithascoreof59.6/100,Zambiaranks12thinAfricabutismiddleof12SouthernAfricancountriesonthe Mo Ibrahim Index of African Governance (IIAG). Malawi, Mozambique, Swaziland, Madagascar,Angola and Zimbabwe areworse off. Of the four categories including security, human development,sustainable economic opportunity and corruption, Zambia scores poorly in Human Development andSustainableEconomicOpportunity.

Government effectiveness as measured by theWorld Bank shows that 60 out of 200 countries rateworsethanZambia.Thisshowsthatonlyaquarterofcountriesareworseoff.The indicatormeasuresquality of government services, the quality of the civil service and its independence from political

25TheLancet200826LCMS2010;CSO;2007.27NationalFoodandNutritionCommission200328CSO;200729PopulationReferenceBureauReducingChildMalnutritioninSub-SaharanAfrica:SurveysFindMixedProgress<www.prb.org/publications/Articles2008/stuntingssa.aspx>30ZambiaInformationServicereport,December2013

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pressures,thequalityofpolicyformulationandimplementationandthecredibilityofthegovernment’scommitmenttoitsstatedpolicies.

In2013TransparencyInternationalranksZambia83/177countriesonitsGlobalCorruptionPerceptionIndex with a score of 38/100. This was a point of improvement from 2012. There have been someimprovements in the capacity to tackle corruption.Onothermeasures such as human rights, Zambiaregistered serious concerns in the US Embassy Human Rights Report of 2013, specifically arbitraryarrests, extra judicial killings, prolonged pre-trial detentions, restrictions in freedoms of speech,assemblyandpress,governmentcorruption,violenceanddiscriminationagainstwomenandchildabuseamongothers.

Government effectiveness is hampered by capacity limitations that include “weak organizationalsystems;inadequateandunreliablepolicy-cum-planningdatabase;andpoorfinancialmanagementandaccounting systems that tend to threaten accountability.”31 Public services are plagued by staffshortages,absenteeism,unmotivatedstaffandshortagesandmisapplicationofcommodities includingdrugs.

Policymaking is often not informed by adequate consideration of a problem, the number of peopleaffectedortheviableoptions.Itisnotunusualforpoliticalleaderstomakepolicystatementsforwhichtechnocratswillhavetoworkinreverseinordertocraftplausiblepolicymechanisms.Acaseinpointisthe purchase of the mobile hospitals by the Rupiah Banda government. This decision was stronglycriticised in the 2011 Auditor General’s Report for among other things; lack of a feasibility study toimplementtheprogramme,failuretodevelopspecificationsbytheMinistryandthehighcostofrunningmobileservices32incomparisontothenumberofbeneficiaries.Thiswasaclearexampleofapoliticallydrivenpolicypronouncement.Anotherexampleisfiringofnursesfromthepublicsectoraftertheywentonstrike.ItisbelievedthatthePresidentmadethedecisionagainsttechnocrats’consideredopinion.Astrongmessageaboutnotchallengingthegovernmentwasmadethenandsentshiversamonghealthworkers.Thealreadyconstrainedpublicsectorwasputunderfurtherstrainbythesuddenterminationofemploymentofover400nurses.“Zambia’sOpenBudgetIndex,(OBI)2012scoreis4outof100,whichiswellbelowtheaveragescoreof43 for all the 100 countries surveyed. It is also below the score of all other countries in the region:Botswana, the Democratic Republic of Congo, Malawi, Mozambique, Namibia, South Africa, andZimbabwe.Zambia’sscoreindicatesthatthegovernmentprovidesthepublicwithscantinformationonthe national government’s budget and financial activities during the course of the budget year. Thismakesitchallengingforcitizenstoholdthegovernmentaccountableforitsmanagementofthepublic’smoney”.

2.11 LegalRationalaspectswithNeopartrimonialism

TheConstitutionprovidesthelegalframeworkforgovernanceofthecountrythroughthethreearmsofgovernment; the Legislature, Judiciary and the Executive. Though independent in law, they are inpractice dominated by the Executive33. Zambia’s system is characterised by a strong presidencywithhighlypersonalisedrulesofthegame.

31OxfordpolicyPaperEvaluationofJASZinUSAIDStrategy2011-2015 32ReportoftheAuditorGeneralontheFinancialAccountsfortheFinancialYearended31December201133SimutanyiNandS.Unsworth2011,CountryLevelPoliticalEconomyAnalysis

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Mutesa,EberleiandothersnotethatthoughZambiaisalegal-rationalbureaucracy,itisinfactaneopatrimonial system, where the state and exercise of power is personalised and patronage based.Nepotism, clientelism, patronage and corruption affect the use of public resources and decisionmaking34.Thissystemhascontinuedoversuccessivegovernments,withthePresidentdistributingrentsthrough appointments to quasi government bodies, the foreign service and by the Executive wingawardinggovernmentcontractstorulingpartyconnected‘companies’amongotherways.

Simutanyinotesthat theJudiciarytendsto favourtherulingparty inpoliticalcases.Therehasbeenasignificantnullificationofparliamentaryseatsheldbytheoppositionsince2011elections.Alsothefightagainstcorruptionismarredbytheapparentfocusoncasesofformerrulingpartyofficialsorindividualsthathavefallenoutwiththerulingparty.Officialsinasittinggovernmentarehardlyprosecuted,unlessthepresidentsanctionssuchactions,whichisrare.

Abuseofoffice,misapplicationresourcesandtheftinvolvingtheeliteisendemicasindicatedbycasesofgrand corruption, extortion by ruling party officials, diversion of public funds, subversion of financialsystems,unretired imprestandunbankedcashamongothers.Thescourge isperpetuatednotonlybypoliticiansbut largelybycivil servants themselves.AuditorGeneral’s reportscontinue todemonstratethiscrisisineachyear’sreport.

DespitetheseshortcomingsZambiahasshownresilienceandstability;runningareasonabletaxsystem,directing public resources to public services and infrastructure and at times drawing back frompartypositions in the faceofhugepublicoutcryas in thecaseof the third termdebateofChilubaand thewithdrawalofstatutoryinstrumentsonforeignexchangebythePFgovernment.

Successivegovernmentshaveimplementedpolicyreforms,albeitwithvaryingdegreesofsuccessacrossdifferent sectors. However development outcomes are constrained by the practice of the elites ingovernmentandpoliticalleadership.Resourcediversionisrampantwithoutredress.

Mutesaconcludesthatthesituationatcentralgovernmentcontraststhatatthe local levelwhere linedepartmentsareheavilyconstrainedbylackofcapacity.Theylackbasicinfrastructure,budgetresources[andhumanresources35]toeffectivelyimplementpolicypronouncementsmadebycentralgovernment.At the local level the problem is not one of neo-patrimonial interests but of lack of governmenteffectiveness36.

2.12 KeyInfluencersinZambia

ThefollowingarethekeygroupsthattheExecutivetakesnoticeof;therulingparty,theChurchandtheTradeUnions.RegionalbodiessuchasSouthernAfricaDevelopmentCommunity,SADCandtheAfricanUnion,AU,seemtohavenoinfluenceonthecountry.WhereasZambiaisasignatorytoSADCprotocolson50percentrepresentationofwomenthisisnotenforcesatallinthecountry.

Trade Union influence has weakened as has that of donors. Donors influence has reduced with thereducingproportionofthenationalbudgetwhichtheyfinance.Theprivatesectorandthepublicsectorbureaucracyare importantas theycan frustratepolicies.Traditionalauthorityandthemediaseemto

34EberleiW,PMeynsandFredMutesa,2005,PovertyReductioninpoliticalTrap,ThePRSprocessandNeopatrimonialisminZambia,UNZAPress,Lusaka35Ownemphasis36MutesaFred,2005,‘TheNexusBetweenPublicResourceManagementReformsandNeopatrimonialPolitics’inEberleiEtal,

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haveminimal influence. However, there have been recent shifts in the influence of onlinewatchdogmedia,whichhavegainedprominence37.

37Simutanyietal

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3. HEALTHSECTORLEVELANALYSISSTRUCTURALISSUES

3.1 DemographicsZambia’s population of 13million is largely sparsely distributed except in urban parts of Lusaka andCopperbeltprovinces.Nearlyhalfofthepopulation(45%)isunder15yearsofage.Bothcharacteristicsof thepopulationposeparticular challenges inhealth servicedeliverywith regard toaccessibilityandadequacy.

Overtwo-fifthofthepopulation,60.5%resides inruralareasand39.5%inurban.Zambia isthereforehighlyurbanizedby regional standards.Due to the collapseof theeconomy in theearly1990s,manyurbandwellersreturnedtoruralareasinsearchofalivelihood.Thisurbantoruralmigrationcausedthepercentageofruraldwellerstogrowbetweenthe1990to2000census.The2010censussuggeststhatthetrendhasreversed,dueinparttoeconomicopportunitiesinurbanregionssince2000,coupledwithstagnantgrowthinmuchoftheruraleconomy.38Zambia’s population grew at a rate of 2.8% per annum during the 2000-2010 periods. This was anincreasefromtheannualrateof2.7%and2.4%recordedduringthe1980-1990and1990-2000periods,respectively.Thepopulationgrowthrateof2.8%perannumduringthe2000-2010periodmakesZambiaoneofthefastestgrowingpopulationsintheworldranked13thin2013.UrbanZambiaisexperiencingadramaticincreaseinpopulation.Whilethismaybepartiallyexplainedbyincomeopportunitiesinurbanareas,thereisarealfearthemuchofthisgrowthisbeingdrivenbypushfactorsinruralZambia,whereincomeopportunitiesmaybedeclining.39TotalFertilityRate(TFR)ishighat6,increasingto7inruralareasby2010.TheTFRwaslowerinwomenwith higher educational attainment.40 Barriers to rural women’s access to fertility control includeabsenceof services, social cultural normswhich favour high fertility rate and ignorance coupledwithnegativemythsaboutbirthcontrol.Children,girlsandwomenareparticularlyvulnerablefacingcomparativelyhighratesofundernutrition,HIVAIDSandgenderbasedviolence. Infant,ChildandMaternalMortalityaremajor concerns to thehealthsector.41TypicalofaruralprovinceEasternProvincehaslowadultliteracylevels,thelowestofallprovincesat66.5percentasFig1belowdemonstrates.School attendance is lowest for Eastern province, with 63.2 percent of 7 – 13 year olds attendingprimaryschool.Grossprimaryschoolattendance(attendanceregardlessofageforgrade)at81.8isstillthelowestofthe10provinces.Someofthereasonsforsituationaretheprevalenceofearlymarriages

38TemboSandNicholasSitko,2013,TechnicalCompendium:descriptiveAgriculturalStatisticsandAnalysisforZambia,Workingpaper76,IndabaAgriculturalPolicyResearchInstitute,Lusaka39Ibid40CentralStatisticalOffice,2012,Zambia2010CensusofPopulationandHousingNationalAnalyticalReport,GovernmentoftheRepublicofZambia,Lusaka41MinistryOfHealth,2011,NationalHealthStrategicPlan2011-2015

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in theprovince,especially forgirls.Additionally,certainpracticessuchasboysbeingassignedtoherdcattleforafewyearsinordertoearnacow,keepchildrenawayfromschool.

Figure1:AdultLiteracyRatebyProvince

Source:Census2010,AnalyticalReport

Thisdemographicprofileandsocio-economiccharacteristicscanhavenegative implications forhealthseeking behaviour and affect determinants of health. Lack of education and low literacy levels canimposelimitationsonruralwomen,menandyoungpeople’sagency.

Themajorityofthepopulationintheprovinceresidesinruralareas,87%.Theprovincehashigherthanaverage poverty levels with the poorest districts being Katete. The Figure 2 below above shows thedistributionofpovertyintheprovince.

Figure2:IncidenceofPovertyLevel,headcountbyDistrictinEasternprovince,2010

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Source:LCMS2010,GraphbyIAPRI20131LCMS2010,GraphproducedbyIAPRI,2013

Most of Zambia’sworking population (12 years and above) is employed in the informal sector 82.6%withinformalagricultureabsorbing95%oftheworkingpopulationinruralareas42.ThepictureisnotsodifferentforEasternProvincewhere93.5%areemployedintheinformalsectorand6.5%intheformalsector.ThisissimilartothepatterninLuapulaandNorthernprovinces.Easternprovincehasthehighestproportionofpeopleinvolvedininformalagricultureasaformofemploymentat89.7%andthelowestinvolvedinnon-agriculture.Thisshowsthatagricultureisthemainstayofthepopulationbutremainsatasmallscalelevel.Cattle,pigsandchickenarethemaintypesoflivestockrearedintheprovince.Mostagricultural households (60.6%) own cattle, fourth highest province, 60.8% households own pigs(highestprovince),and97.2%ownchicken(comparablewithotherprovinces)andgoats38.5%.Saleoflivestockprovidesopportunitiesfornon-cropearningsespeciallyintimesofstress.

3.2 HistoryofReforms3.2.1 Colonialperiod

Asignificantnumberofmissionfacilitiesaroseduringthecolonialperiodinresponsetothedeprivationfaced by local populations. It is noted that during colonial period provision of health services werelargelyasavehicletoachieveahealthypopulationfortheindustrialworkforceontheCopperbeltandalongthelineofrail.Therewasnoincentivefortheprovisionofhealthservicesinruralareas.Thisisthegap that the missionaries filled with their services. Mission hospitals are now largely supported bygovernmentfunding.

3.2.2 From1964to1992(Independencetoreintroductionofmultipartism

42LCMS2010

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Thepost-independenceera saw theemphasison the ideal toprovidehealthcare toallpeople in thecountry.Theguidingphilosophyduringthistimewasoneofhumanismbutitsimpactonvarioussectorswaslimited.Despitetheaimofprovidinghealthservicestoallpeoplethroughoutthecountry,resourceallocationcontinuedtobebiasedtowardsurbanareasasseenfromanalysisofthesecondandfourthnationaldevelopmentplans.43Becauseofthebiastowardsfundinghospitals,mostofwhichareurbanlocated,ruralareashavecontinuedtoreceivelowerthanneededresourcesforhealthservices.Thisisafeature that has continued in all development plans to date.With the fall in copper prices, thehugedebtburdenandmismanagementoftheeconomythroughitsparastatals,Zambiafacedaseriouscrisisin the 1980s. The economy all but collapsed. Public resources were limited resulting in significantshortagesofdrugsandessentialcommoditiesinhealthfacilities.Thiswascoupledbytheemergenceofabraindrainfromthesector.

3.2.3 StructuralAdjustmentProgramme,LiberalisationoftheeconomyandHealthreforms1992–2006Permittingprivatemedicalpractice

Private for profitmedical serviceswere actively prohibited during theUnitedNational IndependenceParty(UNIP)era.Thishappenedaftertheintroductionoftheonepartystateandnationalisationin1972reforms by the UNIP government of Kaunda. Upon reintroduction of multiparty in late 1991, theeconomy was liberalised. This ushered in an opening of private enterprise in services previouslyprovidedbythestate,notleastinhealthcare.

Reformers leading the reform process in health advocated liberalisation of health services to allowcitizens to have a choice in accessing health care. Other reasons were to allow Doctors earn morethrough the private sector. Notable consequences of this were: public health workers taking onsecondaryjobsintheprivatesector.Insomecasesthiswouldbedoneatthetimeanindividualshouldbe on duty in a public facility. This in somewaymeant the public sectorwas subsidising the privatesector. This practice continues to date, doctors are perceived by the public to be among the mainculprits.Otherpracticesfrowneduponbythepublicisdoctors’diversionofpatientsfromagovernmenthospitaltotheirownprivatepracticehavingbeenconvincedthattreatmentatthepublichospitalwouldbeprotracted.

Due to thepracticeof secondary jobs toaugment incomes,healthworkers tend to spend their sparetimemeantforrestonsecondaryjobs.Asaresulttheyarelikelytobetiredwhenondutyinthepublicsectorandaremorelikelytomakemistakesorberudetopatients.

Theemergenceofprivatelyprovidedcarehasofferedthegrowingmiddleclassachoicewhichthepoorcannotafford.Themiddleclassenjoysbenefitsofprivatemedicalschemespaidfortheiremployers.Consequentlythegovernmentisshieldedfromdemandsforbetterhealthcarefromthemiddleclass/non-poor.Thegovernmentcanoverlookcallsforbetterhealthservicefrompublichealthworkersbecausetheylackastrongvoiceandarenotmobilised.

Government is supportive of an expanded private sector and is working out a Memorandum ofUnderstandingwithoneofthenewhospitals.The2011-2015nationalhealthStrategicPlanforinstanceindicates that “deliberate efforts shall be directed at promoting private sector participation including

43MwansaLengweK,1989,JournalofSocialDevelopmentinAfrica,Rural-UrbanHealthCareImbalancesinZambia:ForcesandOutcomes<archive.lib.msu.edu/...>

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PPPs, collaboration in researchanddevelopment, and strengthening coordination,harmonizationandcross sector referrals.’ This could include referrals from both rural and urban areas; howeverimplementationisyettobeseen.Currentlytherearenoreferralsfrompublichospitalstoprivateonespaid for by public funds or vice versa. Monitoring by civil society would be required to ensure thatpatients from rural areas alsobenefit from such referrals. Thegovernmentnowpromotes apolicyofPrivate-PublicPartnershipsinordertocontinuediversifyingtherangeofoptions.3.2.4 Separationbetweenpolicyandimplementationfunctions;CreationofCentralBoardofHealth(CBH)Along with the reintroduction of the multiparty system, liberalisation of the economy andimplementation of a strict Structural Adjustment Programme (SAP) in the early 1990s were majorreformstothehealthsector.FunctionsinthesectorweresplitbetweentheMinistryofHealthandtheCentral Board of Health. TheMinistry retained responsibility for allocating the public health budget,setting policy, dealing with donors and maintaining/developing legislation. CBH was responsible fordisbursing and overseeing grants to District and Hospital Boards. The CBH was responsible forcoordinationandwasquiteeffectiveinensuringadoptionofnewguidelinesandsystemsbythenewlycreatedBoards.TheCentralboardwascreatedin1994withDistrictHealthManagementTeams(DHMT)and Hospital Boards formed a year later. Creation of Boards enabled the de-linkage staff from theMinistrytoplacethemundertheBoards.ThiswasduringthepushbyIMFandWorldBanktoreducethesize of the public service. Health workers especially nurses were encouraged to go on voluntaryseparation. The policy proved disastrous, to date Zambia has failed to produce required numbers oftrainedpersonnel.SeparationofpolicyfromimplementationallowedmoredecentralisingthroughcreationofBoardsandDistrictManagement Teams for implementation. Additionally this enabled participation of citizens inhealthsector.

3.2.5 DissolutionofBoards

The Boards were abolished in 2006 apparently because of problems in negotiations with the sectorUnions and fiscal constraints. By abolishing the Boards the Ministry regained control over the HRfunction. Other reasons for the abolition of the Boards were due to the disparities in entitlementsbetweenstaffoftheMinistryandtheBoardsandensuingconflictofinterest.ItissuspectedtoothattheissueoftechnocraticcapturebytheBoardscannotbeoverruled.TheBoardswereabsorbingsignificantproportionsofthehealthbudget.

TheGovernanceandManagementCapacityStrengtheningPlannotesthattheabolishingoftheCentralBoardofHealth (andwith it theDistrictBoards)has resulted ina re-centralisationofdecisionmakingand has taken away the voice of people to influence health service44. One of the other effects ofrecentralisationispoorpolicymonitoringbytheMinistry.VariousunitswithinMoHareresponsibleformonitoring and coordination using health Management Information Systems, (HMIS), financialmanagement systems, performance monitoring, quarterly reviews and Joint Annual Reviews whichincludedonorsandsometimescivilsociety.Howeveritseemskeepingpacewiththevariouspolicyareasisachallenge.Forexamplesince2006theMinistryhasnotbeenabletoproduceanuptodateNationalHealthSectorAccounts.

44MinistryofHealth2012,GovernanceandManagementCapacityStrengtheningPlan2012-2016,GovernmentoftheRepublicofZambia,Lusaka

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3.2.6 Userfeespolicy

Reforms of the early 1990s saw the implementation of user fees for health services throughout thecountry. However it must be noted that this was the period of strict implementation of SAP by theMovement for Multiparty Democracy (MMD) government as demanded by the Bretton Woodsinstitutions.Thekeymessageoftheseinstitutions,i.e.theIMFandWorldBankwastheaspectofacostsharingmechanismbetweengovernmentandhealthusers inordertoreducethefiscalburdenontheState.ThepolicywasalsotoutedasamechanismforincreasingownershipbyordinaryZambians.

Littlefeeswasactuallycollectedandby1996contributedonly2-8%ofdistrictbudgets.In2006,feesinEastern Province contributed between 0.5 – 1% of district budgets45. However the policy has beencontroversial and inconsistent. Officially the policy was intended to generate a sense of ‘ownership’amongthepublicbutmosthealthuserssaw itasa fundraisingmechanism.Ruraldwellerswereverycritical of theuser fees as theyhad financial constraints and felt itwasunfair for the government toexpectthemtopayforhealthservices.

Healthworkersgenerallysupporteduserfeesastherevenuegeneratedcontributedtopluginadequatefunding from the government. Fees were used to pay staff bonuses as well as purchase cleaningmaterialsaswellasfuelforoutreachactivities.NeighbourhoodhealthCommitteesbenefitedtoofromtheallowances.

Therewasadeclineof35%inhealthserviceusagefollowingtheintroductionofuserfees46.In2006userfeeswere scrapped in rural areasandusage increased.A studybyMoH indicated that “following theremovalofuserfeesinmostfacilitiesthenumberofpatientsseekinghealthcareserviceshasdoubledinalmostallfacilitiesthatwerevisited”47.Healthworkersthereforewerefacedwithanincreasedpatientburden. User fees for peri-urban areas were scrapped in 2011 by the Patriotic Front Government.Incomefromfeesissaidnottohavebeencompensatedbythegovernmentresultinginfacilitiesfailingtocarryoutsomeactivities.

3.2.7 Healthinsurancepre-paymentscheme

Aninsuranceschemewasintroducedafewyearsafteruserfeeshadbeenimplemented,butonlyonaverylimitedscale–mainlyinsomeurbanareas.Theschemeseemedinmanywaysmoreattractivetohealthcareusersthantheuserfees.Therequiredpre-paymentwas500kwachapermonthperperson.Thiswaspaymentbeforeneedarose.Individualswhohadmettheirmonthlycontributionenjoyed‘freeservices’athealthfacilities.Nonschememembershadtopay2500kwachaeachtimetheyvisitedahealthcentre48.Themechanismwashoweverabandonedbeforeitcoulddevelopfullyandlessonslearntfromit.Thismayhavebeenduetologisticalreasons,suchasaccountingformoniescollectedathealthcentres.

45MinistryofHealth,FinancialReport:1Januaryto30June200646ErikBlasandMELimbambala,2001,UserPayment,DecentralisationandHealthserviceutilisationinZambia,HealthpolicyandPlanningJournal,16,OxfordUniversityPress47MinistryofHealth2006,SummaryReportOnTheAssessmentOfTheImpactOfTheUserFeeRemovalPolicyOnSelectedDistricts48SjaakVanDerGeest,MubianaMacwan’gi,JollyKamwanga,DennisMulikelela,ArthurMazimbaAndMundiaMwangelwa,Userfeesanddrugs:whatdidthehealthreformsinZambiaAchieve?

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Otherreformsrelatetotheprocurementanddistributionofdrugs.Currentlyhealthcentrescanobtaindrugsdirectly fromMedicalStoresLimited,MSL, (aquasi-government institutionwhich is fully fundedby public funds), by-passing the DistrictManagement structures. Thismeasure is intended to reducedelays in receipt of drugs.Medical Stores is in the process of setting up hubs in certain provinces tofurthercutdowntimeinclinics.Howeveritseemstherearestillteethingproblemsashealthfacilitiesdonotseemtomakerequests inatimelymanner.Thissometimesresults instockoutathealthfacilitieswhilstMSLhasinstockneededcommodities.

The procurement of medical supplies is one of the areas where there have been significantinefficiencies,mainlybroughtaboutbyMoHpoormanagementoftheprocessandfundingtoMSL.Rentseekingintheprocurementprocesscannotbeoverlooked.Thesemi-autonomousMSLnowseemsinabetterplacetofunction.

3.2.8 Hiving-offMaternalandChildHealthfromMOHtoMCDMCH

In2011thePFgovernmentmovedresponsibilityforMaternalandChildHealth(MCH)fromMinistryofHealthtoMinistryofCommunityDevelopment.ThePFgovernmentbelievesthatMCDMCHisclosertothepeopleandthereforebetterplacedtodischargeMCHfunctions. Inrealitythis isnotthecase.TheMinistry isoneofthemost lowlyresourcedanddoesnothavethatnumberofstaffonthegroundtocoverthepopulationindistrictsandwards.ItseemstheMoHofficialsdidnotrenderthenecessarylevelofcooperationrequiredtotheMCDMCHtomakethemovesmooth.Therewasan issueofpowerplay.Lossofcertain responsibilitiesalsomeansloss of revenue and other benefits associated to programme implementation. Apparently some stafffromMoHrefusedtomovetoMCDMCH.Upto2013MoHstillreceivedallfundsforthehealthsectorandthendisbursedtoMCDMCH.MCDMCH does not have the capacity for the new role, this is the case at the provincial and districtlevels.MCDMCHindicatedthatthereproblemsinobtainingreportsdirectlyfromDistrictsasreportingisstillbeingdonethroughPMO.SomestaffinEasternProvinceindicatedthatitisnotintheirinteresttoseetheshiftofMCHtoMCDMCHsucceed.DonorsalsoindicatethattheyhavebeenunabletodevelopnewprogrammesofsupportwithMCDMCHduetolackofclarityandcapacityissues.

3.2.9 LikelychangesinthemediumtermReallocationofPrimaryHealthCareresponsibilitytoLocalAuthorities

FurtherpolicychangeslikelyinthemediumtermincludeshiftofresponsibilityforPrimaryHealthCaretoLocalAuthorities.Thiswillbedependentonimplementationofthedecentralisationpolicy.Thepolicyisdesigned to increasedecisionmakingand fiscal spaceat the local level.Communityparticipation inplanningisalsosettoimprove.HowevertheseAuthoritiesarestilllargelyill-equippedtohandlesuchatask. The PF government seems keen to implement decentralisation, pointing to the creation of newdistrictsasoneofthestartingpoints.TheMTEF2014-2016pointstothispriority.Currently, local authorities fall under theMinistry of Local Government and are responsible for localservicessuchas townplanningandprovisionofmarketplaces,garbagecollection,street lighting,andmaintenanceofstreets,recreationalparksandbeerhalls.TheynolongerhaveanyhousingstockasallhousingstockwassoldoffduringtheSAPinthe1990s.Localauthoritiesarepoorlyfundedandhavelow

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local revenue asmost of the revenue collection and distribution tasks were taken up by the centralgovernment.Most local authorities have significant liabilities arising from non-payment of severancepackages to former staff. There is limited skilled human resource capacity for their mandate asauthoritiesfailtoattractandretainqualifiedstaff.Somedonorshaveoverthepastfewyearssupportedcapacity development in development planning in selected authorities. There are now moves bygovernment to improve the capacity of local authorities in readiness for decentralisation. There stillremainkeyquestionsabouttheextentofdecentralisationorwhetheritwouldbeacaseofdevolution.It isanticipated thathealthpersonnelatprovincialanddistrict levelswillbe transferred to respectivelocalauthorities.Thereisnoclearroadmapofhowthisexercisewillbeimplemented.ChallengeswillincludethelikelyresistancefromMoHstaffbynotgivingitfullsupportandexpertisetomaketheshiftworkasseemedtobethecasewiththeinitialphaseofrelocationofMCHresponsibilitiestoMinistry of Community DevelopmentMother and Child Health (MCDMCH). However the firing ofnurses on strike by the PF government seemed to have sent a strong message that public workersshouldnotchallengethegovernmentorimpedeitsprogrammes.Theover400nursesfiredinlate2012wereaskedtoreapplytothegovernmentforre-employment.

3.2.10 Introductionofsocialinsurancescheme

Planstobroadenfinancingforhealthcarethroughasocialinsuranceschemeareatanadvancedstage.This is likely to be implemented in a phased approachwhichwill involve deductions from salaries ofpublicserviceworkersbeforeincludingthoseintheprivatesector.Thegovernmentwouldstillneedtowork out how best to involve the informal sector which absorbs the majority of the labour force.Coverageoftheruralpopulationinthisschemewillbeespeciallychallenging.Governmentiscurrentlycompletingastudyonhowtheinformalsectorwillbebrought intothescheme. Itcouldbelikelythatthewideningfinancialinclusionoccurringinthecountrycouldpresentachannelforvoluntarypaymentsby individuals. Zambia has experienced an expansion in financial institutions dealing with moneytransfers, savingsandotherpackages.Thesecouldbeusedaspaypointsbyruraland informalsectorindividuals. Government’s desire to expand the social cash transfers scheme to the poorest in ruralareascouldhelpcoverageofthepoorinruralareas.

3.3 IdeologiesandValuesThesector’svisionistohaveahealthyandproductivepeople,withagoaltoimprovethehealthstatusofpeopleinZambiainordertocontributetosocio-economicdevelopment.TheMinistryseekstodothisbyprovidingequitableaccesstocosteffective,qualityhealthservicesasclosetothefamilyaspossible.

Keyprinciplesdirectingthesectorareprimaryhealthcareapproach,equityofaccess,affordability,costeffectiveness,accountability,partnerships,decentralisationandleadership;cleancaringandcompetenthealthcareenvironment.Othersaregendersensitivity,qualityassuranceandqualitycontrolandglobalhealth49.

Whilstalotisbeingdonetoachievethevision,goalandmissionstatementandpracticetheprinciples,thereareinsomecasescontradictorypractices.Thehealthsystemismainlycurativefocusedonhospitalcarewhichabsorbsdisproportionateresources.Healthpostsareinshortsupplyinruralareas.The2009Health Public Expenditure Review notes that 3000 health posts are required. Data from the NHSP

49NationalHealthStrategicPlan2011-205andtheNationalHealthPolicy2013

27

indicatesthatasof2010only275wereinplace.Thislimitsthecapacitytoprovidequalityhealthcareasclose to the family as possible. Due to long distances to health facilities in rural areas, shortage oftrainedstaffandlackofequipment/medicalsuppliestodealwithobstetrics,maternalmortalityratioremainshigh.Thefocusoncurativecareresultsinlessresourcesbeingchannelledtopreventivehealthat community level, therebyaffecting the capacity todealwithdisease that contribute tohigh infantandchildmortalitysuchasmalariaanddiarrhoea.ZambiaisnotlikelytoachieveMDG4and5by2015withcurrenttrends,significantadditionaleffortisrequired.

The curative facility based orientation is reinforced by hospitals tending to attract vertical resourcesmorethanhealthcentres.50Becausethesector isseverelyunderstaffedpatientshavetowait for longperiods before they are attended to. As a result the length of time spent on patient care iscompromised.51

Whilstcommunityparticipationandaccountability isespousedinpolicydocuments,thereality isafarcry from the principle. Communities are involved throughNeighbourhood Health Committees (NHCs)which seem to focus onmobilisation of health seeking behaviour. Participation in planning at heathfacility level is not universally undertaken.52 Fieldwork in Chipata and Lundazi Districts revealed thathealth centre facility staff do not listen to the views of NHC andminutes ofmeetings are not takenseriously.

Ngulubeetal,ina2004studyonparticipatorygovernanceinhealthfoundthat“allkeystakeholdersatdistrict level,whether fromHealth Centre Committees (HCCs), frontline healthworkers and from theDHMTwereunanimoustosaythatHCCshavemadeanimpactandtheirvaluetothehealthsystemwasacknowledged. However, this impact was limited in terms of the desired equity goals and coverage.TherewasconsensustoothatHCCshadlittleornoimpactamongvulnerablegroupsandin importantdecisionmaking roles at the health centre, especially in relation to clinical care services. Channels ofcommunication have been developed between the health system and HCC in health promotion andprovisionofpreventiveservices.Eventhen,therewerestillproblemsintheflowofinformation,whichwas usually one way from the health system to communities, with feedback being rare andineffective”53.

There is a need to improve in practice the implementation of the principles espoused in policydocuments.Theredoesnot seemtobesufficientpoliticalwillwithin thesector toensurecommunitycommitteesfunctionasastructurefordownwardaccountability.Genderconcernsdonotseemtobeadequatelyaddressedinthesector.Forexampleitisonlyrecentlythathusbands/partnersareencouragedtotakeupfamilyplanningandfatherstobeinvolvedinunder-fiveclinicsforchildren.MalelowuptakeofVCTforHIVneedsmoresupport.Thesectoralsorecognisesthatit is ineffectiveinaddressing/applyingexemptionstotheverypoor. Inruralareaswheresocialwelfaremechanismsmaynotworkwellthiscouldpresentasignificantproblem.Mostdiagnosticserviceshavetobepaidforbyindividuals.

50PicazoO.FandFengZeng,2009,ZambiaHealthSectorPublicExpenditureReview;AccountingforresourcestoImproveEffectiveservicedelivery,WorldBank,WashingtonDC51Ibid52FindingsfrominterviewswithNHCinChipataandLundaziDistricts53 NgulubeT,J.,L.Mdhlulietal,2004,Governance,participatorymechanismsandstructuresinZambia’shealthsystem:AnassessmentoftheimpactofHealthCentreCommittees(HCCs)onequityinhealthandhealthcare

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3.4 PerceptionResultsof the2012AfroBarometer indicate that ruraldwellers seehealth related issuesas themostimportantproblem that thegovernment shouldaddress54. This couldbedue to longdistance, lackofstaffandinadequatecommoditiesandfacilities.

A reviewofpublicexpenditure in the sector found that there seems tobeageneralpositiveattitudeamong health service users about staff friendliness and provision of information on health facilities,rating about 89 -95%. However patient’s rating on technical aspects (such as explaining what aprocedureordrugwasfor)wasmuchlower40-42%.55

A study conducted in 1999 found in general, a positive appreciation of the quality of care provided.Household respondents from rural areas aremore likely to report that the general standard of healthservices is good while urban respondents are more critical of services being offered at various healthfacilities.56Thiscouldbeattributabletothelackofchoiceinruralareas;lackofinformationonstandardof service as opposed to urban areas. Availability of these aspects couldmake urbanites to bemorecritical. Todate,mediareports fromurbanareasoftenportrayadimviewheldbypatientsregardingservicesandconductofstaffinhealthfacilities.

54RuralnetAssociates,SummaryofResults;AfrobarometerRound5SurveyInZambia,201355Ibid33–WorldBank2009HealthSectorPublicExpenditureReview56JollyKamwanga,MubianaMacwan’gi,SjaakvanderGeest,1999,HealthReformsAndTheQualityOfHealthCareInZambia,Amsterdam,

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4. ANALYSISOFINSTITUTIONSANDGOVERNACEARRANGEMENTS–RULESOFTHEGAME

4.1 LegalandregulatoryFramework

Constitution

Chapter One Part IX of the Constitution of Zambia includes Directive Principles of State Policywhichguide the Executive in formulation and implementation of national policies. The application of theDirectivePrinciplesofStatePolicymaybeobservedonlyinsofarasStateresourcesareabletosustaintheirapplication,orifthegeneralwelfareofthepublicsounavoidablydemands,asmaybedeterminedbyCabinet.Cap111statesthatthe“DirectivePrinciplesofStatePolicyshallnotbejusticiableandshallnot thereby, by themselves, despite being referred to as rights in certain instances, be legallyenforceableinanycourt,tribunaloradministrativeinstitutionorentity”.Cap112(d)refersspecificallytohealth in thedirective to statepolicy that “State shall endeavour toprovide cleanand safewater,adequate medical and health facilities and decent shelter for all persons, and take measures toconstantlyimprovesuchfacilitiesandamenities”57.CivilsocietyiscampaigningforinclusionoftheBillofrightsasafundamentalpartoftheConstitution;thiswouldincludetherighttohealthservices.Policymeasures

TheNationalHealthPoliciesandStrategiesof1992wereoperationalisedbytheNationalHealthServicesActof1995.HowevertheActwasrepealedin2005andhassincenotbeenreplacedtoreflectthepost2005 situation. This means the country’s legislature including the Committee on Health, SocialDevelopmentandSocialWelfarehasnotdebatedtheprovisionofhealthcaretoZambiancitizenssincetherepealofthe1992Act,showingthetechnocraticandExecutivedominanceinthegovernanceofthecountry.

Healthreformsofthe1990sresultedinanumberofinitiativesincluding,decentralisation,developmentandimplementationoftheBasicHealthCarePackage(BHCP),whichdefinesthepackagesofhealthcareservicestobeprovidedatthedifferent levelsofhealthservicedelivery; Establishmentofappropriateinstitutionalframeworksforefficientandeffectivemanagementofthesector,includingastrongSWApgovernancesystem,allowingactiveparticipationofall thekeyhealthpartners, in themanagementofthe health sector, and the continuous review and realignment of the health system structures;Monitoringandevaluationframeworksthatarebroadbased,involvingactiveparticipationofallthekeyhealth sector partners, including the cooperating partners and civil society, through the establishedSWApcoordinationandgovernancestructures.

AnewpolicywasdevelopedinJune201358whichbringstogetherseveralprogrammepoliciesrelatingtochildhealth,reproductivehealth,HIVamongothers.Thelackofanacttoprovideaframeworkforthe

57S.A.Sichembe,AssistantCommissionerForLawRevision,TheLawsOfTheRepublicOfZambia,1995Edition(Revised),PreparedUnderTheAuthorityOf;TheLawsOfZambia(RevisedEdition)Act

58MinistryofHealth,2013,NationalHealthPolicy;ANationofHealthandProductivePeople’,GovernmentoftheRepublicofZambia

30

organizationofhealthserviceshascreatedasituationwherethehealthsectoroperatesinalegislativevacuum. Much activity has gone into developing specific areas of policy without the benefit of aframework to ensure consistency, harmonization, and alignment of all specific health policies andlegislation. There is an apparent disconnect between policy formulation and implementation, withrelativelyweakattentiongivento the latter.Linkedto that is the lackofa frameworktomonitorandevaluatetheimpactsofnewpoliciesandlegislation.59

4.2 RegulatoryBoardsThe Ministry has service delivery and regulatory boards. Service delivery statutory boards providespecialised support services to core health service delivery facilities. Regulatory statutory boards areresponsible for enforcing specific government policies, legislation and regulation related to health.TheseincludeZambiaMedicalProfessionalCouncil,GeneralNursingCouncil(GNC),thePharmaceuticalRegulatoryAuthority,theRadiationProtectionBoardandtheOccupationalHealthServicesBoard.Theseexistinlawandpolicyasmostofthemarestatutorybodies.TheBoardsareillfinancedandequippedtoeffectively discharge their roles. Therefore inspections, law enforcement and accreditation are notroutinely carried out.During field visits health staff indicated that someof the regulatory boards areinefficient;thisseemstobethecasewiththeGNC.Itfailstorenewpracticinglicensesortoeffectivelymonitortrainingstandardsinatimelymanner.

The authority of statutory regulatory bodies neither extends to the regulation of patient safety andquality assurance amongpublic sector health careproviders, nordoes it incorporate the registration,inspection and enforcement of health care establishments owned by the mining companies.60 Theprivate sector is alsopoorly regulated.Conflictof interest among theactors in the regulatorybodies,Ministryandprivatepracticecannotbeoverruled.Becausetheytakeondifferentrolesatthesametimeitislikelythatthesameindividualscanbefoundinallareas.

4.3 DecisionmakingPolicyandmanagementDecision making is conducted in a much formalised manner with several meetings at every level ofmanagementparticularlyinpolicyandprogrammeissues.Infactakeycharacteristicofthehealthsectoratthenationallevelisthemyriadofmeetingsandworkshops,todiscussamongotherspolicies,reports,andguidelines.InprocurementIssuesrelatedtoprocurementhoweverseemtotelladifferentstory.Formalmotionsare inplace forconsideration of bids but under-hand and insider information and collusion with the private sectorsuppliersoftenresultsincontractsbeingallocatedto‘connected’companies.

Staffinglevelsandrecruitment,largeprocurement

59IndependentReviewTeam,2008,ReportoftheZambiaNationalHealthStrategicPlanNHSPIV2006-2010GustafEngstrand,2013,ReportontheHealthCareSectorandBusinessOpportunitiesInZambia,SwecareFoundation60GustafEngstrand2013

31

Decisions about staffing, large procurement and construction are done at the national level.ProcurementforlabourbasedconstructionworksisdonebytheDCMO.DecisionsatDCMOlevelseemtobemadeinaparticipatorymannerthroughweeklymanagementmeetings.

RecruitmentisdonebytheparentMinistryMCDMCHwithinputfromDCMO,however,finalallocationofnumbersisatnationallevel.Thereisnoguaranteethatnumbersofstaffingrequestedwillbesuppliedbythenationallevel.TransferofstaffcanbedonebyDCMO.Recruitmentofstaffismeritbased.

AppointmentofPermanentSecretary(PS)Decisionsregardingappointmentstopermanentsecretary levelaredecidedbythePresidentandmaynot always be onmerit. According to the rules appointments should bemade by the Public ServiceCommissiononmerit.HoweverthePresidentappointsPSsandmaynotevenconsult,thereforethereisnotransparencyintheaction.Individuallobbyforpositionsatpermanentsecretaryleveliscommon.ProjectsandprogrammesWhilst there are formal systems for decision making these are at times overruled by politicalinterference.Electionperiodsgiverisetoopportunitiesforpoliticallymotivatedprojects.DirectivesareoftenchannelledinformallyfromhighlevelnationalfiguresthroughtothePermanentSecretaryoftheprovince. Eastern Province is due to hold several parliamentary by-elections. Already during the timespentinthefield(May2014)weweretoldthattherewerefranticmovesforthesectortoimplementprojectsinKasanengwaconstituency.TheintroductionofmobilehospitalsbyRupiahBandaintimefor2011electionyearisanothercaseinpoint.

4.4 AllocationofFundingThesectorisfinancedfromtaxrevenueanddonorinflows.Domesticfundingonhealthincludestaxleviedoninterestearnedonbanksavings.In2011allocationtohealthrepresented8.5%ofthenationalbudget61.Thisincreasedto11.3%ofthenationalbudgetin201362.Thegovernmenthealthbudgetwasonaverage10.4percentofthenationalbudgetbetween2000and2009.ZambiahasnotbeenmeetingtheAbujatargets,whichrequirethat15percentofdomesticdiscretionaryresourcesarespentonhealth.ThereisanunfortunatetrendofincreasedbudgetallocationtotheMoHheadquarters,whichnowstandsatalmosthalfofthetotalhealthbudget.AccordingtotheMTEF2014-2016GreenPaper63,overthemediumterm,allocationtothehealthfunctionisprojectedat10.5percentoftotalexpenditure.ThoughZambia’spercapitatotalhealthspendinghigherthanitsneighbours(Malawi,TanzaniaandMozambique),itshealthindicatorsarenotanybettersignifyingpooreffectiveness.Currentresourcesareinadequatetomeettheneedsofthesector.Donorfinancingmakesasignificantproportionofhealthfinances,constitutingabout40%ofthebudget.Zambia’s accession to the LowerMiddle Income status has resulted in a number of bilateral donorscuttingaidtothecountry.ThecorruptionscandalexperiencedattheMinistryofHealthin2009alsoledto cuts in donor aid. Of the available donor funds significant amounts are vertical funds and are offbudget.ThesetargetprogrammesforHIVAIDS,MalariaandTB.Thesefundsareunpredictableandare

61Ibid2362MinistryofFinanceandNationalPlanning,2013BudgetSpeech,GovernmentoftherepublicofZambia,Lusaka63MinistryofFinanceandNationalPlanning,2013,MediumTermExpenditureFramework,2014-2016,Lusaka

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not flexible. In recent years donor and vertical funds have increased substantially whist GRZ hasreduced.Becausetheytargetcertainfacilities,theytendtocreatedisparitiesinqualityofservice.Private fundingofhealth constitutesa significantproportionof the sector. This ismainly at for-profithealthfacilities.Forprofithealthfacilitiesarepredominantlyinurbanlocations.

Thereareinequitiesingeographicallocationofresources;thepoorest,mostremoteandleasturbanisedprovinces receive the lowest per capita MOH releases.64 Major challenges in health care financingincludethelackofanappropriatehealthcarefinancingpolicy,absenceofafinancingformulaatsomelevelsof care,non-completionof theSocialHealth InsuranceSchemeand theweakharmonisationofvarioussourcesoffunding.65Fig3belowshowsapositiveoutturnonactual fundingcompared tobudget formostyears.Beinganelectionyear,2011seemedanexception.Somefactorsforincreasedfundingcouldincludemoniesfromdonors which may not have been budgeted for, better tax revenue or better negotiation with theMinistry of Finance by the Ministry of Health. However Fig 4 shows an opposite trend wheredisbursementsarebelowbudgetandMTEFallocation.Eastern Province DCMO received a grant totalling K579,213 per month in 2013 this has risen toK637,000in2014.Howeverdisbursementsarenotalwaysmade.In2013eightofthetwelveexpectedmonthly disbursements were received. By May 2014 only 1 of 4 monthly disbursements had beenreceived severely jeopardizing service delivery. Some services affected include Child health serviceswhichhadtobecutresultinginfailuretoholdmonthlyimmunizationoutreach.Thenon-availabilityofmoney/lowtaxcollectionisgivenasareasonfornon-disbursementbyMoFNP.

Figure3:NonPersonalEmoluments(PE)Budget&Releases,2004-2011

Source:MoFNP

64WorldBankPER65MoH,2011,NHSP2011-2015

33

Funding to other DCMOs in the province in 2013 also show lack of disbursement for theGRZ/Donorbasket fund which comprises the grant. Districts that receive vertical funds as well as Results BasedFinancingcoveredupthisdeficit.ForexampleLundazididnotreceiveasignificantportionofthebasketfundbuthadanoverallsurplusexpenditure66.

4.5 AccesstoandcontroloverresourcesTheMinistryofFinanceandNationalPlanningallocates funds toallministries.TheMinistryofHealthdisburses funds to tertiary, second third level hospitals, PMOs andMedical Stores Limited.MCDMCHdisbursesfundstoDCMOswhichinturndisbursetohealthcentres.Allocationisbasedonaformulathattakesintoaccountpopulation.Howeverthecriteriastillhassignificantweaknesses;itdoesnottakeintoaccountgeographicalcharacteristicssuchassizeandtheterrainnordoesittakeintoaccountworkloadat health centres, i.e. number of staff. Some big provinces/district with hard to reach areas wouldrequiremoreresources.KeychallengesindisbursementsoffundsstilloccurbetweentheMinistryofFinanceandthatofHealthandbetweenMinistryofHealthtoProvincesandhospitals.ThisseemstoapplytoMCDMCHaswell.Itisnotuncommon for clinicsandhospitalsnot tobe funded fora coupleofmonths. In theyears2011 -2013thehealthsectordidnotreceivethefullamountallocatedinthebudget.Reasonsforthisincludeinsufficient funding, pressures from the increasing deficit and diversion of funds to other unplannedprogrammes. The Auditor General’s report of 2012 showed that the PF government had anunprecedented budget overrun. This practice could continue as the government focuses oninfrastructuredevelopmentinthemediumterm.

Itseemsthatdistrictsandhealthcentressuffer themost fromthe lackofdisbursementsas thesearethe points of direct service delivery. Ironically at the central level resources seem to be available tocover non-essential issues such as international travel and workshop allowances. In early 2013 theMinister of Finance called on governmentministries to reduce international travel in order tomakemoneyavailableforservicedelivery.

UsageoffundsatPMOandDCMOlevels

The ProvincialMedical Office and District CommunityMedical office has some discretion in decisionmakinginapplicationoffunds.WhilstatthenationalleveltheMinistryofHealthsetsbudgetlimitsandgives direction on strategic issues for planning, the PMO has some discretion on which healthprogrammes to focus on. The DCMO has some limited discretion; guidelines from MOH prescribeproportionsoffundstobeallocatedasfollows;

- Communityallocation-10%,(interviewswithsomegroupsinLundazidistrictindicatethiscouldbeatotalofaboutK600–K800tobeallocatedtouptotenzones)

- Utilitiesandadministrationcost-15%- Outreach-45%-50%- Clinical-28%-45%

Access to funds by NHC is limited to the small amounts allocated to purchase of requisites forcommunity health programmes. NHC complained that monies are obtained by health staff andpurchasesmadebutnoreportingisdonetotheNHC.

66MoH,2013SAG,Financialreport

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Access tomoney fromResults Based Financing programmeof theWorld Bank is inequitable; despiteNHCandcommunitypromotersmobilisingcommunitiesthereisnobonuspaidtotheNHC.

Figure4:ComparisonofNonPEMTEFAllocation,BudgetandReleases2010-2013(ZMKnotrebased)

Source:MoFNPdata

InformalrulesanddefactobehaviourManagement is guided by rules and fund allocation follows set guidelines. However procurementprocessesarelargelyopaquewithinformalagreementsonwhomtoprocurefromandwhomtopay.

At facility level, professional staff’s dissatisfactionwith conditionsof serviceoften results in absencesand reporting lateand leavingearly.Thereseems tobeanagreedcodeofbehaviour to ‘workasyouearn’.

AcomplaintraisedinEasternprovinceistheunfairlylongworkinghoursruralworkersputincomparedtotheirurbancounterparts. Thoughconditionsofserviceprovidethatstaffshouldtakedaysoffafternightduty,thisisnotpracticed.Thestaffshortageatfacilitylevelmakestime-offvirtuallyimpossible.Asaresulthealthworkersbecomestressedandlikelytodisplayabadattitudetopatients.Thereforeboththeemployerandtheemployeesadoptinformalpracticesthatdefythelaiddownrules.

4.6 ImplementationIssuesandServicedeliveryMOH developed an objectivemethod for allocating resources, based on a cost-effectiveness analysisthat was reasoned, technical, and transparent. The Basic health Care Package (BHCP) comprisedimmunization, reproductive health, prenatal care, HIV/AIDS prevention, treatment of tuberculosis,malaria, diarrhoea, respiratory and sexually transmitted diseases, and some basic surgical care.67 The

67WorldBankHealthCarereformsinZambia<http.info.worldbank.org/etools/...>

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BHCPdefineshealthcareservicesexpectedtobedeliveredatvariousdefinedlevelsofthehealthcaredeliverysysteminZambia.Itisacornerstoneofthehealthsystem,withinterventionsthatareevidence-based, cost-effective and affordable in the long-term and complemented with a functioning referralsystem. The elements of the BHCP are selected on the basis of an epidemiological analysis of thosediseasesandconditionsthatcausethehighestburdenofdiseaseanddeath.InterventionsintheBHCPareprovidedfreeofchargeoratnominalfeesthroughoutthecountrywhilethoseinterventionsoutsidetheBHCParesubjecttovariousdegreesofcost-sharing.TheprinciplesthatformthebasisforfundingtheBHCPare:Equity inhealthoutcomes;Accesstoeffectivecare;Effectivenessofresourceallocationand resource use and the greatest impact on health status by addressing the highest occurringdiseases.68Annex1 showsa typical spending reportbyoneof theDistrictCommunityMedicalOffice,whichshows1stlevelreferralasthehighestspend.Expendituresinotherareasofhealthservicedeliverydo reflect thebasichealthpackageprioritiesofMalaria,ChildHealth, IntegratedReproductivehealthand tailing the list is the Environmental Health component. This demonstrates further the focus oncurativecareasseenfromtheamountsspentof1streferralandthecomparedtoenvironmentalhealth.

Some of the critical bottlenecks to improved service delivery in the health sector include humanresource shortages in provider institutions, low levels of government funding for infrastructureinvestments, information systems and service provision, an inefficient pharmaceutical managementsystem,andapolicyandregulatoryframeworkthat isoftennotsufficientorcontemporaryenoughtoadequatelyaddressservicedeliveryshortfalls.Therearestaffshortagesateachlevelofserviceresultinginserviceusershaving towait longbeforebeingattendedto.The JointEvaluationofsupport toanti-corruption efforts notes that the sector is in crisis leading to an overall lack of progress in servicedeliveryoutputssuchaspercentageofbirthsattendedbyskilledhealthworkers.

InEasternProvinceservicesthatseemto lagareNutrition,CD4testingandmaternalhealth.Thiswasreiteratedatmostof theclinicsvisited.Food formalnourishedchildren isnotoften in stockandCD4testing machines are broken down making patients go to clinics several times before they obtain aservice.

Healthcareusersperceivegoodservicedeliverytobeavailabilityofdrugs,staffandnothavingtowaitlongperiodstobeattendedto.Thoughdrugsupplyhas improvedoverthepastfewyears,patientsattimesstillhavetogoawaywithoutanydrugs.Inruralareaswheretheoptiontopurchasefromprivatesuppliersislimited,havingtomakereturntripstothehealthfacilitycanbequitefrustrating.

4.7 HumanResourcesforHealthShortage of staff is endemic in the health sector. TheNational Human resources forHealth StrategicPlan indicates that in 2010 Zambia had a gap of over 60% for Clinical Officers and Doctors for theofficiallyapprovedrequirement–calledthe‘Establishment’.Thegapfornurses,midwivesanddentistrystaffwasover50%.Theoutput from the training schools is not adequate tomeet thegapsannually.Attrition of staff is another contributor; some interviewees in Eastern province pointed out that theprojects under INGOs and vertical fundswere also pulling away clinical officers and nurses from thegovernment.Thecountryislikelytocontinuetodependofexpatriatestofillthegap.Tofillthehumanresourcegap,thesectorispilotingtheuseofcommunityhealthworkersaswellasbringinginexpatriatestaff.

68MoH,ZambiaNationalHealAccountsreport2003-2006,March2009

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ForexampleTable3belowshowingthestafflevelsinChipataDistrictindicatesanofficialshortageof10enrollednursesand18EnrolledMidwivesasatfirstquarter2014.Howeverthisisunderstatedasthereare new clinics that have opened but have not been put on the Establishment. Further, the numberprovidedbytheEstablishmentdoesnotnecessarilymeetthecatchmentpopulationatahealthcentre.The Establishment reflects onlywhat the resource envelop can support and notwhat the populationrequires.Othersystemicissuescontributingtoshortsupplyofstaffarethe‘freezing’ofmidwiferystaffpositionscausingtrainedstafftomovetootherdistrictsandprovinceswherevacanciesareopen.Thisseemstoflyinthefaceofeffortstopromoteincreasedattendedtodeliveries.Implementationofastaffretention scheme has been fraught with challenges. Some of these include financial burdens andunequalapplicationofruralhardshipallowances.Table3:StaffLevelsinChipataDistrictQtr12014

CADRE MedicalOfficer

MidwiferyLicensed

RegisteredNurse

Registeredmidwife

ZambiaEnrolledNurse

ZambiaEnrolledMidwifery

ESTABLISHMENT 6 4 51 5 112 64EXISTING 2 4 49 5 102 46VARIANCE 4 0 2 0 10 18CADRE Clinical

OfficerEnvironHealthtechnician

OtherParaMedical

Tutor Admin CDEs Total

ESTABLISHMENT 17 42 27 5 30 233 596EXISTING 18 37 25 5 33 212 539VARIANCE 1 5 2 0 0 21 57

4.8 StructureofservicedeliveryThesector is setup ina four tier systemas shown inFig5,withhealthposts,healthcentres,DistrictHospitals,GeneralHospitalsandTertiaryHospitals.TherearetwoLeveltwoHospitalsinChipataDistrictandoneLevelonehospital.Therearenodistricthospitals.Government’spolicy istoconstructdistricthospitals in each district. The creation of new districtswill addmore strain on the already stretchedresourcesofthesector.This isbecauseeachdistrict isrequiredtohaveahospital.Threenewdistrictswere created in the province. These will require additional health posts. It is quite likely that thesemeasures will be implemented to a certain extent in the medium term. The MTEF states that “inparticular,governmentwillscaleuptheconstructionofhealthposts,clinicsandreferralhospitalsaswellasprovidethenecessarymedicalsuppliesandequipment”.However,fiscalconstraintsarisingfromanalreadyovercommittedcapitalbudget,lowerthanexpectedmineralandothertaxearnings,devaluationoftheKwachaandincreasedinflationcouldjeopardisetheseplans.

Figure5:Structureofservicedelivery

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4.9 AccessAlthoughZambia’svisionistoattainuniversalaccesstocosteffectivequalityhealthservice,fewerthan30%oftheruralpopulationlivelessthan1kmawayfromahealthfacilitywith28%beingbetween6–15 kmaway.Distance is oneof the barriers to accessing health care forwomen, expectantmothers,children, the elderly and the poor. The lack of readily available transport compounds the situation.LiteraturefromCAREindicatesthatsomehouseholdsareasfaras26Kmfromahealthfacility.

Becausehealthfacilities inruralareashavestaff limitations,healthusersmaynotnecessarilyaccessaminimal levelofserviceoncetheyreachaphysicalhealthfacility.ShortagesoftrainedpersonnelhavesometimesresultedinClassifiedDailyEmployeesattendingtopatientsintheabsenceofClinicalOfficersof nurses. Further, due to staff shortages, patientsmay have to wait for a long period before beingattendedto.InsomecasesaccesstothehealthcarepackageaspromotedintheZambianhealthsystemis constrained by break down of equipment, as a result diagnostic services can be unavailable anextendedperiodoftime.4.10 DecentralisationPlanning,managementandresourcesdecisionsaredecentralisedtothedistrictlevel.ItisfeltbysomethattheabolishmentoftheCHBhascontributedtotherecentralisationoftheMinistry.However,theMinistry of Health has been among the early starters in implementing significant decentralisationcomparedtootherMinistries

ManagementofstaffissomewhatdecentralisedwithDCMOsandPMOsabletotakedisciplinaryaction.During fieldvisitweheard that therehavebeencaseswhen theprovincialPermanentSecretary firedmedicalstaff.Thisseemstobeinconsistentwithpublicserviceemploymentpractice.

4.11 InstitutionalcapacitiesPerhaps one of the enduring characteristics of the health sector in Zambia and particularly in ruralprovincesisthatitisasectorincrisis.Asindicatedinearliersections,staffshortagesandmaterialsareendemic in rural areaswith Easternprovincenotbeing anexception. FinancialManagement capacityalsoseemstobefairlyproblematic.

Humanresourcecapacityislimitedandtrainingoutputislowerthanneeded.Performanceassessmentalso seems to be weak. A recently introduced Annual Performance Assessment System has noteffectivelytakenrootinEasternProvince.Someclinicstaffreportedthattheyhadnotusedthesystemsinceitsintroductionin2013.

4.12 Accountabilityrelationships4.12.1 VerticalAccountability

The highest level of accountability in the Ministry of Health and the Ministry of CommunityDevelopment andMother and Child Health is at theMinisterial level. Ministers are accountable toCabinetandultimatelytothePresident.

The MOH is overall responsible for PMOs and hospitals, excluding district Hospitals. The DCMO isanswerable to theMCDMCHand in somecases,with the split of roles still has to report through thePMOs.Fig6depictstheserelationships.

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The relationship between NHCs and health facility staff is not exactly hierarchical but neither is itcollegiate. NHCmembers often receive ‘instructions’ or requests from the facility about what to do.BecausetheNHCarenot foundationallygrounded inthesystemtheytendtobeoverlooked. InmanycasesNHCreceiveinformationaboutreceiptoffundsandcommoditiesathealthfacilitiesbuttherearenoformalchannelsfordownwardaccountabilityfromthehealthfacilities.The relationship between communities and NHC is also a weak one. Ngulube et al note that NHCmemberswereknowntolessthan20percentofmembers.Becausetheredoesnotseemtobeastrongcultureofnon-statedeliberativespaces(orcollectiveaction)incommunities,therelationshipbetweenNHC and communities is ad hoc with NHC mainly exercising a role as conduits of information fromhealth facilities. Through ad hoc meetings community members can then express their views abouthealthfacilityservices.Becauseoflogisticalproblemsmeetingsdonotnecessarilyreachallpartsofthecommunity.ThereislimiteddemocraticexerciseonwhoiselectedtoNHC.ThereseemtobemorementhanwomeninNHCs.

VerticalfundsseemtohaveasignificantinfluenceonactionsatPMOandfacilitylevel.Thisseemstobeindirectproportiontothesizeofresourcestheybringintothesystem.Howevertherelationshipisnothierarchical.HealthstaffstatedthatsomeINGOprojectcloselymonitorresponsestorecommendationstheymaketotheclinic.Ifthesearenotactedonafterafewvisits,theINGOsreportonthelackoffollowuptotheDCMOandthePMO.Thereforeclinicsarewaryofbeingreportedtohigherauthorities.

Figure:6:Structureandfunctionalrelationshipsinthehealthsector

MoHMCDMCH

Regulatorybodies

StatutoryBoardsTertiary

HospitalPMO

SAGs

General/2ndlevelhospital

Communities,NCH,HCC

DCMO

DistrictHospitals

DistrictHealthCentres

HealthPosts

PrivateProviders

Cabinet/RespectiveMinisters

ParliamentAuditorGeneral’Office

Committees

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Source:Own

4.12.2 HorizontalAccountability

PublicAccountsCommittee(PAC)

Parliamentary Committees provide an oversight function on the health sector. The Public AccountsCommitteediscussesAuditorGeneral’sreportsoftheMinistriesdealingwithhealthmatters. InrecentyearsresponsesbytheExecutivetotheCommitteehas improved.ThiscouldbeduetotheincreasedscrutinybytheCommitteeandthehighlevelsofpublicdissatisfactionwithlackoffollowupontheAG’sreports. Provincial and district level healthmanagement structures do not appear before parliamentcommittees. Unlike with the portfolio committees, space for civil society to make presentations onissuescontained intheAG’sreport isvery limited.Becausethere isa lagofabouttwoyearsbetweentablingoftheAG’sreportandtheyearofAudit,therecouldbelostopportunitiesforredressofissues.However,longstandingsystemicweaknessescouldbeaddressedthroughPAC.

CommitteeonHealth,CommunitydevelopmentandSocialWelfare(aportfoliocommittee)

The portfolio Committee on Health, Community Development and Social Welfare is mandated toprovidescrutinyasoutlinedinthetextboxbelow.

FunctionsoftheCommittee:

i. Study,reportandmakerecommendationstotheGovernmentthroughtheHouse,onthemandate,managementandoperationsoftheMinistriesofHealth,andCommunityDevelopment,MotherandChildHealth,departmentsand/oragenciesundertheirportfolios;

ii. CarryoutdetailedscrutinyofcertainactivitiesbeingundertakenbytheMinistriesof

Health,andCommunityDevelopment,MotherandChildHealth,departmentsand/oragenciesundertheirportfoliosandmakeappropriaterecommendationstotheHouseforultimateconsiderationbytheGovernment;

iii. Make,ifconsiderednecessary,recommendationstotheGovernmentontheneedto

reviewcertainpoliciesandcertainexistinglegislationrelatingtotheMinistriesofHealth,andCommunityDevelopment,MotherandChildHealth;

iv. ExamineannualreportsoftheMinistriesofHealth,andCommunityDevelopment,

MotherandChildHealth,departmentsandagenciesundertheirportfoliosinthecontextoftheautonomyandefficiencyofGovernmentministriesanddepartmentsanddeterminewhethertheaffairsofthesaidbodiesarebeingmanagedaccordingtorelevantActsofParliament,establishedregulations,rulesandgeneralorders;and

v. ConsideranyBillsthatmaybereferredtoitbytheHouse.

Source:CommitteeonHealth,CommunityDevelopmentandSocialWelfare,Reportonthe

DistributionofMedicinesandMedicalSupplies,2013,NationalAssemblyofZambia

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TheCommitteeseemstohavemuchlesspowerovertheMinistry.ThiscouldstemfromthefactthattheCommittee does not scrutinise performance of theMinistry per se. The committee dealswith otherministriesinitsportfoliotherebyreducingitsdepthofengagement.Parliamentportfoliocommitteesselecttopicsforscrutinyandinvitestakeholdersfromgovernment,privatesector,civilsocietytomakepresentations.Thisprovidesanopportunityforengagementbycivilsociety.Becausesometopicsareself-selectedbytheCommittee,therecouldbelimitedstrategiclinkstoCivilsociety’sareasofinterest.In2013theCommitteereviewedtheAG’sreportontheDistributionofMedicinesandMedicalSuppliescalledvariousstakeholdersandmadeseveralobservationsandrecommendations.ResponsesofGovernmentMinistriestoParliamenthaveimprovedovertime,thoughmorecouldstillbedone.Themixednatureofparliament,i.e.oppositionpartieshascontributedtothisdynamic.TheupcomingplanningandbudgetpolicyandBillcouldfurtherimprovetheresponsivenessoftheExecutive.Additionallythenewconstitutionislikelytostrengthenparliament’soversightrole.SectorAdvisoryGroup

SectorAdvisorygroupscouldbetermedasotherformsofhorizontalaccountability.Thesehoweverarenotprovidedinlaw.ThekeyreasontheyseemtorunisbecausedonorsareactiveintheSAGsandMoHneeds donor funds. MoH presents reports on performance as well as budget needs. Donors oftenexpress their concerns over implementation of policies and inequities in the sector. CSOs areweaklyinvolved.OneoftheweaknessesoftheSAGisthatitisnotdealingwithmorestrategicissuesbutseemsto focus on reporting past activities and plans. Donors do not seem to have success in altering theformatofSAGmeetings.Civil societycouldmake this spaceusefulby improving theirevidencebasedadvocacy.

4.12.3 Diagonal/CitizenAccountability

Thereareno legallybindingprovisionsformechanismsofdiagonalaccountability inthehealthsector.Mechanisms to provide for community engagement in planning and budgeting, receive performancereports at health facility level or provide a platform for community members to question serviceproviders are not provided for in the law. Policy statements espouse the principle of communityengagement through Neighbourhood health committees but in practice this does not happenuniversally.Thereforetransparencyathealthfacilitylevelanddistrictlevelislimited.Few NGOs have promoted projects on citizen accountability by calling service providers tomeetingswithin thecommunity todiscuss resultsofmonitoringactivities.Theseprojectshavebeenona smallscalebutwheretheydoexisttheyhavehelpedtoshiftpowerrelationsbetweenserviceprovidersandserviceusers.Examplesofthis includeCSPRandWorldVisionZambia.Theirmethodsdiffersomewhatbuttheyincludeaspectsofsocialaudit,monitoringofservicesandfacilitatinghealthusersandserviceproviders’discussionoffindings.

4.13 ResponsivenesstoneedsofserviceusersTo improve responsiveness at facility level two mechanisms have been in use. The first being thesuggestion box, which should be opened by the Health Centre Committee, HCC. The HCC includes 2representativesfromtheNHC.Howeverthereseemedtobelowusageofthesuggestionbox.Thiscould

41

beduetoanumberoffactors;thelowliteracyrateintheprovince,difficultyinfindingpapertowriteonorthetimetowritesuggestionsandlackofconfidenceinitsusefulness.Asecondmechanismcurrentlypursuedistheopeningofacomplaintsdesk.Amemberofstaffisassignedasthecomplaintsofficertowhomcommunitymemberscango.Thisisamorerecentinnovation.Howevertherearedoubtsabouthoweffective itwouldbegiventhat individualsseemto feeluncomfortabletoopenlycomplaintoanofficial.Thereisasensethattheycouldbevictimised.

AfrequentlyreferredtomethodofseekingredresswaswritingtopoliticallyappointedpersonssuchasPermanentSecretariesorProvincialMinisters.Followupseemedtobeeffectiveandhealthfacilitystaffare cautious about their practices so as not to be found wanting. In other areas, ‘politically linkedpersons’e.g.whoseemedtobe linkedwitheachpoliticalregimeandhavestrong linkstoaruralareaareusedas channelsor referencepointsby villagers. In Lundaziweweregiven thenameofBizwayoNkunikaasonesuchperson.

A feature observed from civil society work is the sensitivity of government to media reports whichreflect poor service standards. The use of television has been very effective in generating responsesfrom the highest levels. This is especially the case when the rural and poor individuals speak forthemselves on television about their experiences. Such type of engagement requires significantresourcesasnationaltelevisionspaceisexpensive.

It is difficult to estimate how the health sector responds to different categories of users, i.e.womenversusmen,ruralversusurban,poorversusnonpoor.Thisisbecauseofalackofevidenceinthisarea.However, experiences from the user fee period indicate that health workers tended to be moreattentivetothosethatpaidfeesthanthoseonexemptions.

4.14 CorruptionThemajorityoftheruralpopulationinZambia(74%)69indicatethattheyhaveneverhadtopayabribe,give a gift or do a favour to government officials in order to get treatment at a local health clinic orhospital.NHC interviewsalso indicated thatbriberywasnot common.Therewerea fewcaseswheresomepeopledidnotqueueupforserviceswhenotherpatientshadlinedupasearlyas05:00.Insuchcases communitymembers suspected thatbribeshadbeenpaid. This seems tobe the casewithHIVAIDSrelatedservices.Nonethelessfraud,inthesectorremainsaproblemasindicatedbythescandalsof2005,2009andtheAuditor General’s reports. Public financemismanagement, as reported by AG in the health sector issystemic and entails cases of misappropriation, lack of reconciliation of bank accounts, unretiredimprests, loss of stores, poor project management and failure to follow procurement rules andprocedures70.Thereportfurthernotesthatanecdotalevidenceseemstoindicatethatcorruptioninthehealthsectoroccursatalmosteverylevelalongthevaluechainwiththeexceptionofpolicymakingandregulation, namely: planning and budgeting (including budgets for training and workshops), donorfinancing (SwedishandDutchbasket financingaswellasGRZ financing), fiscal transfers,managementand programme design, tendering and procurement, construction, operations andmaintenance, andpaymentforservices.69Afrobarometer2013,Round5,ZambiaResults70NoradJointEvaluationSupporttoAnti-Corruptionefforts,Zambiacountryreport2011,NorwegianAgencyforDevelopmentCooperation,Oslo

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Transparency International shows that in 2013 Zambia scored 38 out of 100 on the CorruptionPerceptionIndex71.TherehavenotbeenanyspecificstudiesonthehealthsectorbyTiZinZambia.

Grandcorruptionnegativelyaffectsservicedelivery,deprivingthepoor,whomainlyrelyongovernmentservices, of essential services. There is a case of corruption and money laundering being currentlyprosecuted in the courts in Eastern Province. The case involving an accountant at theDistrict HealthOffice further demonstrates the point made above regarding corruption at all levels. Corruption athealthfacilityleveldoesnotseemtobewidelyexperienced.NHCmembersstatedveryfewoccasionsofcommunitymembers raising concernaboutpetty corruption (bribespaidnot towait inaqueue)andlackoftransparencyinhiringofclassifieddailyemployees.Therehavebeenreportsinpublicmediaofhealthworkersbeingarrestedfordiversionofdrugsfromhealthcentres.Drugswerebeingchannelledto private sector pharmacies and the openmarket. Both reports in 2013 occurred in small towns. Itseemsthattheoversightofdrugusageisweakandaccountabilityabsent.Drugsalsotendtobeinshortsupplyduetothepracticeofusersunnecessarilyreportingillnesswhentheyhearthatthereisasupplyofnewdrugsatthefacility.Thisdonesothattheystockupdrugsathomesothatwhenthefacilityrunsout,individualswouldhavetheirownhomesupply.

Poor financial management continues due to a number of reasons. Some of these include; lack ofeffectivemechanisms todealwith issuescited inAuditorGeneral’s reports, collusionbycivil servantsand wilful contravention of financial regulations by civil servants. Governance and ManagementCapacityStrengtheningPlanof2012seemstoindicatethatmostrecommendationsoftheforensicaudithadnotbeenimplemented.Someotherreasonsforpoorprosecutionofcorruptcasesinhealthseemtoarisebecauseproceedsarechannelledtopoliticalpartiesforelectioncampaigns,particularlytherulingparty.

Anti-corruptionlawsdonotseemtobestrongenough,courtcasestendtotakelong,prosecutionweakand sentencesminimal (3 – 5 years). As summarised by theWorld Bank (2008), “Zambia today is inmanywaysahybridcase:therent-seekingstatehasbeenpartiallysupplantedbyanascentinstitutionalenvironment that nominally/rhetorically rejects rent-seeking and corruption, but is powerless to stopindividual(includingpetty)rent-seekingandcorruption.”

71TransparencyinternationalZambiaPressStatementonthelaunchoftheglobal2013CorruptionPerceptionIndex

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5. ANALYSISOFTHEGOVERNANCESPACESINTHESECTOR

5.1 StateLedSpaces-InvitedSpacesTheanalysisaboveshowsthatcurrentlymostspaces/forumsarestateled.Thereislimitedparticipationofnon-stateactorsinsuchspaces.InsomecasessuchasatDistrictlevel,opportunitiesforcivilsocietyengagementexistsbuttherearehardlyanyactorstotakeupthespace.ThereisalowpresenceoflocalCSOsinthehealthsector.5.1.1 InvolvementinplanningandbudgetingprocessesFigure7:BudgetandPlanningCalenderatMoFNPandMoH

NationallevelplanningcycleisguidedbytheMTEFandthebudgetprocess.Thereforesectorplanninghavetofeedintothesetwoprocessesasthediagramaboveshows.TheMTEFgreenpaperwasinthepastpublishedinthenationalnewspaperstofacilitatepublicdiscussionbutwiththenewgovernmentofPF thisdoesnot seem tobe systematic. The2013MTEFwasnotpublished.Planning in thehealthsector is said to be bottomup. In practice once the resource envelop is announcedbyMoFNP,MoHcascadesthisdownwards,indicatingbudgetceilingsandprogrammepriorities.HealthfacilityplanningiscarriedoutinthecontextoftheresourceenvelopandisconsolidatedatDistrictsandProvincialLevel.Discussionoftheresourceenvelopisclosedwithinthesector.

MCDMCHstillreliesonPMOstoconsolidateplansandbudgetofthedistrictsentities.MoHsubmitsitsplans toMoFNPwhichholdsbudgethearings. It is atbudgethearings that the sectorMinistryhas todefend itsproposedbudget.BecausehealthwasdeclaredapriorityMinistry it seems that it receives

44

someconsideration.Howevertheresourcesallocatedarenotenoughfortheneedsathand.Withthesplitofresponsibilities,itmustbeassumedthatMCDMCHwilldefenditsbudgetforMCHactivities.

TheplanningandbudgetingprocessissoontochangewithapolicydocumenttobelaunchedtogetherwithanAct. It ishopedthenewActwillmaketheplanningand implementationbinding, improvetherole of parliament, the links between policy, impact, outcome and outputs and also improveparticipatory review and planning of budgets at district levels. Therefore there will be new spacesintroducedat thedistrict level.72 Thebudget formatwill also change fromActivityBased toOutcomeBasedBudgeting,therebylinkingmorecloselytodevelopmentoutcomes.Thisprovidesanopportunityfor INGOstoadvocatefor implementationofproven interventionstoaddressmortalityandmorbidityandotherconcerns.

MoHpolicydocumentsemphasisetheroleofcommunityandcivilsocietyengagementinplanningandbudgeting of services. In reality this often does not work. Planning at the provincial level includesinternationalNGOsinvolvedinhealthprogrammestoalimitedextent.ThisisintendedmoreforINGOstoidentifyprogrammeswhichtheycansupportthantodeterminethepriorities.Thereforethescopeofthisspaceisverylimited.

PlanningattheDistrictlevelisratherclosed.Itinvolvesonlytheofficialsinthemanagementteamwithnoformalinvolvementofcivilsocietygroups.Othercivilsocietygroupsinvolvedinmonitoringofhealthservicesarenot invited toparticipate inplanningprocesses. Therearenomechanisms for systematicinvolvement ofwider civil society in determining resource allocation and use. A senior official in theprovince indicatedthattherewasno ‘politicalwill’ to institutionaliseparticipation.Thereasonforthiscould be the perception that health service delivery is too specialised for ordinary people to engage.Anotherfactoristheabsenceofadvocacyorientedcivilsocietyconsistentlyengagedinhealthissues.

At health centre level: guidelines stipulate involvement of communities in planning and budgeting.Healthcommunitiesinterviewedreportedthatthishappensvaryinglyacrosshealthcentresandhealthposts. The amount to be allocated to community activities is negligible, in Lundazi district it rangedbetween K1,900 -K2000 to be distributed among health committees in ten zones. The money isinsufficienttopurchasematerialsrequiredforchlorinationofwellsandtoolsforclearinggrasstoreducemosquito habitats. This is a disincentive; as the amount is too negligible to plan realistic communityprogramme components. The removal of user fees is also pointed as one of the reasons thatneighbourhood committees are no longer effectively involved in budgeting and planning.When userfeeswere inplace,NeighbourhoodHealthCommitteesandcommunitymemberswere incentivisedtoparticipateindetermininguseofresources.Healthcentreofficialsseemedtorespectthisdynamicthaniscurrentlythecase.Itseemsthereforethatthiscreatedspacehasanumberofchallenges.

Despitethetokenisticinvolvementofcommunityhealthcommitteesinplanningandbudgeting,healthworkers interviewed reported thatmost community health committeemembers did not have a highlevelofeducationandlackedskills.ThisimpliesalowvalueplacedonNHCinvolvement.

Neighbourhoodhealthcommitteesandtheirassociatedrespectivehealthgroups(SMAGs,TBtreatmentSupporters,Growthmonitorsetc)are intended togeneratedemandwithin thecommunity.Theyalsoarea linkbetweenthecommunityand thehealthcentre, therebybeingaquickmechanismto report72CAREneedstocloselymonitordevelopmentsinthisareasoastofollow–upwhenthepolicyandtheActarelaunched.

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anyoutbreakofadisease.ThelinkbetweencommunitiesandNHCinrelationtoexpectedstandardsofoperationathealthfacilitiesisveryweak.Therearehardlyanymeetingsheldtodeterminecommunityprioritiesthatneedtobechannelledtohealthfacilities.Communitiesseemtofocusonlyonexpectedbehaviourofhealthproviders.Thesystemisnotdesignedasanaccountabilitymechanism;therearenomeansthroughwhichhealthfacilitymembersofstaffgiveaccounttocommunitymembers.

WhilstmostNHCseemtohaverelativeinfluenceathealthfacilitylevelinsuchareasasthemannerinwhich health officials speak to patients and provision of items for patients’ use, some felt theywerepowerlesstoeffectchange.Insomecasesitwasreportedthatvocalmemberscouldberemovedfromthecommitteebyhealthofficials.

ThereisapotentialforcivilsocietyorganisationstoworkwithNHCandcommunitiestobuildtheirskillsandunderstandingofdemand-sideaccountability.Howeverthishasnotbeendoneexclusivelybefore.SuchaninitiativewouldneedtobelinkedwellwiththeMCDMCHinordertoensurebuy–in.ItseemsthattheMinistryisinterestedinaprogrammethatwouldhelpcommunitiestobettermonitordeliveryofhealthservices.Thereforethisisanemergingopportunity.

Women and youngpeople are notwell represented inNHCs despitewomen forming themajority ofmembershipof communityhealthgroups.A reason for this couldbe the low literacyandeducationalattainmentofwomenandthe lackofconfidence.Theabsenceofyoungpeoplecouldbeexplainedbythelackofmonetarybenefitassociatedwithhealthvolunteerwork.

5.2 ProvincialandDistrictDevelopmentCoordinatingCommitteesTheseareotheravenuesofState-ledspaces.Thepotentialtogeneratetransformationalchangeinthesemeetings is very limited.Bothmeetings aredesignedas information sharing forumsandhave limitedparticipationofcivilsocietyorganisations.Civilsocietyparticipatesoninvitationatthediscretionoftheconvenors. District Development Coordinating Committees (DDCC) operate through a system ofsubcommitteesineachdistrict.ThisiswherethereispotentiallyroomtoinfluencethecontentofissuestobepresentedtotheDDCCandthePDCC.Howeverduetothelimitedcapacityandnumbersofcivilsocietyactorsatdistrictlevel,thepotentialisnotrealised.InvitedspacesatdistrictandprovinciallevelshavelimitedscopeandarepoorlyutilisedbyCSOs.Table4:StateandNonStateledSpacesandActors

LEVEL STATE–LED NONSTATE–LED ACTORSTO

INFLUENCE

COMMUNITY • NeighbourhoodhealthCommittees

• Growthmonitoringgroups

• Childhealthmeeting• Neighbourhoodhealth

committee

• VillageBanking&Savingsgroups

• Womenclubs• Villagegatherings• Supportgroups;male&

female• SMAGS• Villagedevelopment

committee

• Chiefs• Areacouncillor• Nurseincharge• Media

DISTRICT • DistrictIntegratedmeetings

• DistrictAIDSTaskForce• Districtwaterand

• Civilsocietyforum• NZP+Policydialogue• CSPRInterfacemeetings• NGOQuarterlyreview

• DistrictMedicalOfficer

• DistrictCommissioner

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LEVEL STATE–LED NONSTATE–LED ACTORSTO

INFLUENCE

sanitationandeducation

• Districthealthsubcommittee

• DistrictGendersubcommittee

• TB/HIVCoordinationcommittee

meetings• TB/HIVCoordination

committee• NGOPartnersmeetings• DistrictWomen

developmentAssociation

• NGOs• Media

PROVINCIAL • ProvincialDevelopmentCoordinatingCommittee

• ProvincialTaskForce• Provincialwater

sanitationandeducation

• ProvincialIntegratedmeeting

• TB/HIVcoordinationbody

• Partnersmeetings• Provincialepidemic

committee

• Provincialwomen’sdevelopmentassociation

• CSPRmeetingsatprovinciallevel

• NZP+Dialoguemeetings• Planningandreview

meetingsbyINGOs• NGOCCconsultative

meeting• Nutritionlearningand

practiceforum

• Provincial

MedicalOffice• Media• Chiefs• CSPR

NATIONAL • SectorAdvisoryGroups• GlobalFunds• NationalAIDS

Commission• Parliamentcommittees• TechnicalWorking

Groups• CooperatingPartners

meetings• DonorRoundTable

meetings• NationalTB/AIDS

coordinationmeetings

• Nationalwatersectorforum• NZP+Generalassembly• Constitutionalcoalition• Socialforum

• Ministryof

Health• Ministryof

Community,DevelopmentMotherandChildHealth

• Donors• Firstlady

5.3 Meetings convened by District and Provincial Health Offices on specific healthmatters

TheTable4aboveshowsasignificantnumberofspacesatwhichcivilsocietycanhaveaninfluenceinspecificmatters such as TB,Water and Sanitation and IntegratedManagementMeetings. Influencingthe agenda setting and providing evidence about service delivery at such meetings could result in

47

positive changes.However, theeffectivenessofPDCCandDDCC is limited. Theyareapolitical forumwhere the health sector shares information and to an extent gives account to politically appointedofficials (Permanent Secretary and District Commissioner), yet health sector officials’ loyalty and keyaccountabilitylieswiththeparentministry.5.4 NationallevelspacesThekeyStateledspacesaretheSectorAdvisoryGroupsandtheTechnicalWorkingGroups.SAGsseemtobelargelyaforumforaccountabilitytodonorsaswellasoneatwhichdonors’continuedbuy- in ismaintained.SAGmeetingsaresometimesill-usedandprovidelittleroomforcivilsocietyinfluence5.5 Civilsocietyled-ClaimedspacesOnlyacoupleoflocalNGOssuchasCSPRandNZP+engageinclaimingspaceonhealthrelatedissues.CSPRmonitorsbudgetandservicedelivery inanumberof sectors includinghealth.Through interfacemeetingshelduptotwiceayear,fundsallowing,theybringtogether;staffathealthfacilities,decisionmakers from DCMO and communities to discuss findings and agree on a way forward.Whilst thesemeetings have helped to change power relations73 among the actors, they are at times not fullyattendedbydutybearers.Becausethereisno‘stick’associatedtonotparticipating,dutybearerseasilyfindreasonsnottoattendsuchmeetings.The use of local radio stations by community groups and NGOs on governance issues has proved toimprovedutybearer’s responsiveness74.Howevernewspaper reports ofGRZ’ plan to fund rural radiostationscouldspellanendtotheirindependenceandexposureofservicedeliveryfailures.NZP+doescreateclaimedspacetodiscussqualityofHIVAIDSservices.Howeverbothorganisationsfaceresource constraintsandareunable to consistentlyhold these spaces.75CSPR runs itsprogrammes intwodistrictsofChipataandMambwe.Itislikelythattheorganisationwouldbeinterestedinexpandingitsmonitoringandcitizenengagementactivitiestootherdistricts.Decisionsreachedinbothinvitedandclaimedspacesmaynotalwaysbe fundamental; someof the issuesarestructural suchas inadequatestaffing, funding or availability of equipment.However positive responses on issues raised in claimedspaceshaveimprovedservicedeliveryinsomecases.World Vision Zambia through its Citizen Voice and Action programmeworkswith the education andhealth sectors in some districts. The programme facilitates a discussion of service delivery andidentification of bottlenecks among community members. Identified issues are discussed by acommitteeofrepresentativeswithhealthserviceprovidersatfacilitylevel.Attimesissuesaretakenuptothedistrictlevel.Theprogrammeisstillinanascentstagebutitseemstobebearinggoodresultsingeneratingresponsivenessamongserviceprovidersanddecisionmakers. Endogenousspacesatcommunitylevelthatcanfacilitatewomen,menandyoungpeople’sinvolvementinthedeliveryofhealthservicesarelimited.Thereisalimitedcultureofcitizenledmovementsoutsideoforganisedcivilsocietyorganisations.Thiscouldbeduetothelonghistoryofonepartystatepoliticsthatcurtailedthepracticeofcitizenship.AreportbyCivicusonthestatusofcivilsocietyinZambiafound

73PlessingJ,2014,ExternalReviewofCSPRBudgetExecutionandServiceDeliveryProject74BBCMediaActionProject2013,75InterviewwithNZP+

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lowscores forcivicengagement inthecountry.76Civil society ismainlyactive inurbanareaswith lowlinkages to rural areas. During field visits to Lundazi interviewees indicated that there were noorganisations in their districts that worked with communities on issues of rights. Most commonlypointedoutweretheINGOsworkinginthehealthsector.

5.6 CivilsocietyspaceandcapacityThe NGO Act of 2009 has provisions that could be used to limit the operation of civil societycountrywide.TheActprovidestoomuchdiscretiontotheMinistertodeterminewhereNGOscanworkandincludespunitivemeasuresforminorissues.SeveralNGOshaveresistedregistrationandcalledforanamendmentoftheAct.Further, the declining availability of donor funds upon which most organisations rely has set manyorganisationstoscalebacktheiroperationssignificantly.Turnoverofpersonnelisaconstantchallengeinthesector.Consequentlyskillsoncedevelopedinanorganisationtendtobelostconstantly.Whilstcivilsocietyorganisationhasshownastrongcapacitytoformcoalitionsonkey issues,theyareweakonusingevidencebasedmethodologies.Thisweakenstheiradvocacy.Theirtendencytobemainlyinurbanareaswithpoorlinkagestoruralhardtoreachareassomewhatminimisestheireffectivenessandvoice.

76ZambiaCouncilforSocialdevelopmentandCivicus,2010,ThestatusofCivilSocietyinZambia:ChallengesandFutureProspects

49

6. ANALYSISOFMAINAGENTS/STAKEHOLDERSFigure8:KeyStakeholders

HEALTHSECTOREASTERNPROVINCE

ExecutiveInstitutionsPresidentofZambiaMinisterHealthMinisterCDMCHOtherSectorMinistriesPSHealthPSCDMCHPSEasternProvinceDistrictCommissioners

DonorsBilateralMulti-laterals

InternationalNGOSCARECDCCIDRZWVZ

ElectedOfficialsMPsParliamentCommitteesWardCouncilors

TraditionalAuthorities

UnrulycivilsocietyCadresProtesters

LocalCivilSocietyorganisationsCSPRNZP+YouthorgsZCSDCommunityHealthGroupsCitizensHealthServiceusersWomenDevelopAssociationsTradeunions

ProfessionalRegulatorybodies

MediaorganisationsLocalRadioStationsTelevisionStations

ReligiousorganisationsMissionHospitalsCHAZCatholic,Anglican,RCZbodiesMuslimbodies

PrivateSectorBusinessAssSuppliersBusinessleadersChambersofCommerceFarmersUnion

PoliticalPartiesRulingPartyOppositionParties

Judiciary

50

6.1 InfluencersThe Fig 9 below demonstrates the influential organisations on the PMOs office with 3 being highestinfluence.StakeholdersidentifiedasmostinfluentialbythePMO’sofficewere:MinistryofHealthPolicyDepartment,CabinetOfficeandthedonorNGOCentreforDiseaseControl,CDC.Thelatterisinfluentialbecause of the huge resources it brings in the sector at the provincial level. The ProvincialAdministrationthatconvenesthePDCCisseenashavingmediuminfluence.Thisseemstoimplythattoinfluence the PMO’s office one would have to leverage the power that MoH Policy Departmentpossesses.PutintoquestionistheeffectivenessofthePDCCmeetings.

Figure9:InfluentialActorsatPMOlevel

The following diagram depicts views of health facility workers at Mwase in Lundazi, indicating thatcommunitymembers are seen asmoderately influential, whereas the DCMO and Cabinet were veryinfluential, traditional leaderswere at the same level as the community and the PMO. Thenature ofinfluenceinsomecasesrelatedtoverticalaccountabilityrelationship.

Figure10:Actorsstaffmembersataclinicconsiderinfluential

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6.2 StakeholderAnalysis

Table5:Stakeholders’Analysisofroles,interests,capacitiesandaccountability

Organisation Rolesandresponsibilities InterestsandIncentives CapacitiesandResources AccountabilityandInfluenceMOFNPBudgetoffice

Official:• Ensureplanningand

budgetingtakesplaceinMDSA

• Developnationalbudget• NegotiatewithMDSAfor

realisticexpenditureplans• Presentbudgettonational

parliament• DisbursefundstoMDSA• Developtaxpolicy• Debtcontractionand

managementUnofficial:• Ensurefundsavailablefor

OfficeofthePresidentStateHouseexpenditure

Representsformal:ThePresidentTheMinisterTaxpayers

• Allocationoffundsforhealthactivities

• Containexpendituretomanagedeficit

• Somewhatsupportspeopleengagementinplanning&budgeting

• Provideareasonablelevelofmoniesforservicestocontinue

Incentivestocollaborate:• toreduceresourcecapture

atlowerlevelsDisincentives:CitizenscrutinyexposesnondisbursementTodirectmoremoniesatlocallevelmayreduceamounttoitselfGainpoliticalsupportLosesupportfrompoliticianswhomayseeinitiativeas‘workoftheoppositiontoexposeweaknessesinthesystem’

• Capacityforpolicyformulation

• Growingcapacitytomonitorgovernmentprogrammes

• Lackofcapacitytoensurelowerlevelsareinclusiveofpoorpeople’needs

• Inadequatecapacityensureoutcomebasedbudgeting

• Inadequatecapacitytodevelopaworkingmodelforthefinancingofhealth

Resources:Governmentfundsatitsdisposal

Linkedto:MinisterofFinanceThinktankse.g.ZIPARDonorsCivilsociety-advocacygroupsEAZPrivatesectorAllegiancetorulingpartyPoweroverdecisionmakers:ControloftreasurycandecidewhentodisbursemoneyInformationdisclosurereducingVerticalaccountabilitytoMinister,President,CabinetOfficeDonors

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Organisation Rolesandresponsibilities InterestsandIncentives CapacitiesandResources AccountabilityandInfluenceMinOfCommunityDevelopmentMotherandChildhealthMinisterandPermanentSecretary,DirectorofMNCH

ImplementMCHpolicyDevelopoperationalguidelinesOverseestandardsinDistricthospitals,healthcentresandposts

TomakethesplitasuccessEnsureservicesareincreasedCareerprogressionInfavourofcommunitymonitoringLowperformancemanagementLowserviceoutputachievementHighrewardsforseniorofficialsInternationaltravelforseniorofficialsLongworkinghoursforfacilitystaffLackofrewardforlonghoursorruralstaff

LowplanningcapacityinhealthissuesLatedisbursementofgrantstodistrictsNoteffectivelyresponsivetoneedsofruralexpectantmothers–e.g.ambulancesreadilynotavailableinruralareasAllocationstocommunityhealthprogrammesnegligibleLowconveningpoweroverprovincesthatsuperviseDistrictsMinistryinadequatelypresentedinProvinceanddistrictRatheraweakMinistryRideonPresidentialdecreeonsplitUnderresourcedfortaskfinancially,humanresourceandphysicalPocketsofresistanceseenfromunclearcommunicationchannelsbetweenProvincesandMinistry

LinkedtootherMinistries,DonorsLinkedtopoorandmarginalisedgroupsthroughsocialtransfersLowinfluenceinCabinet,overthePresidentPoweroveroperationsofNGOsPowertoregisterorderegisterNGOsInformationsharingexercisedtoamediumlevelInformationnotsharedonadhocbasisVerticalaccountabilitytocabinet,presidentHorizontalaccountabilitytoparliament,Nodownwardaccountability

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Organisation Rolesandresponsibilities InterestsandIncentives CapacitiesandResources AccountabilityandInfluenceMINISTRYOFHEALTHATNATIONALLEVEL

-AllocationanddisbursementoffundstoHospital,PMOsandDCMOs-provideadequateandefficientpolicyMonitorImplementationDonormanagementandcoordination

-EmploymentTrainingTravelopportunitiesAllowancesContributetoeffectivedeliveryofhealthservicesProfessionaldevelopmentCareerprogressionDis-incentivisedbysplitofrolestoMCDMCH

-hashumanandphysicalresources-infrastructureisinadequateInadequatemonitoringcapacity

-permanentsecretary-ministerofhealth-externalagencies-civilsociety-cooperatingpartnersInfluentialonthepoliticalleadershipevenatStateHouse

DCMOstaff OverseehealthpostsandcentresDisbursefundstohealthfacilitiesSupervisionTechnicalsupportMonitoringRepresentspoliticalinterests/PresidentMarginalisedgroups(informal)

Interests:GoodservicedeliverytocommunityReduceMMRandIMRandU5MRProfessionalprogressionLikelytobeinfavourofincreasedinvolvementofwomenandmarginalisedgroupsIncentives:makethegovernmentclosertothepeopleDemonstratethatMinistryiscapableDisincentive:BelongingtoMCDMCH–wouldratherremainwithMoH

Limitedcapacitytomonitorwhetherhealthcentresdoincludewomenandmarginalisedgroups,LimitedlogisticsPoliticalinterferenceattimes

NottransparentinfundreleaseDoubleaccountabilitytoPMOandDirectorMCHatMCDMHCFundsreceivedfromparentministryProfessionalhierarchyHorizontalreportingtoPermanentSecretaryintheProvince

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Organisation Rolesandresponsibilities InterestsandIncentives CapacitiesandResources AccountabilityandInfluenceOverloadofworktomonitorimplementationLikelytowinpublicsupportLikelytowinpoliticalleader’ssupport

HeadsofHealthPostsandcentresstaff

FrontlinepointsofdeliveryRepresents:SelfProfession

InterestsProfessionalsatisfactionJobopportunityMaynotbefullyinfavourofincreasedinfluencebywomenandmarginalizedgroups,Incentive:RecognisedifseenasimplementingwellDisincentive:MayincreaseworkloadNotbeingrecognizedbyseniormanagementforeffortWincommunitysupport

Lowresources–fewstaff,inadequatebudgetOverworkedLowappetiteforcommunitychallenge

Linkedthroughnetwork,Union,InadequatemechanismsforsharinginformationProfessionalskillandcompetence

InternationalCSOs

ImproveHIVAIDS,maternalChildandNeonatalservicedeliverytthepoor

PromoteimplementationofguidelinesDemonstrateandpromotenewwaysofworkingObtainResearchdata

Wellresourcedfinanciallyandinstaffing

TocountrymanagersToheadquartersintheircountriesInfluentialongovernmentifhavebigresourceenvelop(CDC)Knowledgeandexpertiseasasourceofpower

Neighbourhood Mobilizecommunityforincreased Tohavehealthyfamiliesand Lowlycapacitytoconvene

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Organisation Rolesandresponsibilities InterestsandIncentives CapacitiesandResources AccountabilityandInfluenceHealthCommittees

healthseekingbehaviourBridgebetweenhealthfacilityandcommunityPublichealtheducationincommunitiesParticipateinplanningandbudgetingintheHCCRepresentcommunityinterests

communitiesToserveforphilanthropicandspiritualfulfilmentTogainemploymentinthesectorBerespectedincommunityEarnallowancesandotherbenefits,e.g.bicyclesTobenefitfromResultsBasedFinancing

communityengagementLowcapacityinresourcestoreachallareasofzones

NotstronglyaccountabletoeitherthecommunityorthehealthfacilitySomeinfluenceinthecommunitySomelimitedinfluenceatfacilitylevelinorganizinghealthusers

CommunityvolunteergroupsSMAGS,Nutrition,HIVAIDSSupportgroups)

Generatedemandforhealthservices

ReceivetrainingBerespectedincommunityPromotebetterhealthforafflictedindividualsEducatetheirfamiliesandcommunities

Lowlyresources,dependentonINGOallowances

TohealthfacilityINGOprogrammesInfluentialoncommunitymembersneedingservices

Citizens:women,youngpeople,men,children

HavegoodhealthpracticesCitizenship

ToreceivegoodhealthcareTomeettheirrightstodevelopmentrightsReceivefreeservices

LargelylowlyresourcedLowaccesstoinformationaboutservicesandgovernmentWomenlowliteracyYounggirlsandwomeninruralareaslackVoice

TofamilyLooselytoheadmen

CHIEFSATCOMMUNITYLEVEL

-Lawmakers(customary)-monitorandoverseer-Adjudicator-Governor-Custodianoftraditionalnorms

-Wellbeingofthesubject-infavourofservicedelivery-Gainpopularity-Recognition-Dignity

-capacitytolobby-influenceonservicedelivery-mobilization-humanresource-land

-Districtcommissioner-Parliament-DistrictDevelopmentcommissioncommitteeHouseofchiefs

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7. LINKINGANALYSISTOPROGRAMMEDEVELOPMENT

7.1 keyissuesfromtheanalysisThe foregoinganalysis shows thatproblems in servicedeliveryarea resultof issuesbothatnational,district and facility levels. Disbursements from national level are at times inadequate, at times notforthcoming,whilst district levelmay alsodelay todisbursedue failureby facilities to retire previousallocations. District level supervisors neither do provide adequate performance management nor dotheydemandthathealthfacilities involvecommunitymembersrealistically inplanning,budgetingandmonitoring. Community members are poorly linked to their NHC representatives and NHCs seem tofunctionmainlyasamechanismtogenerateheathserviceusage,andhelpoutinthefaceofcriticalstaffshortages.TherelationshipbetweentheNHCandthehealthfacilityisnotcouchedasanaccountabilitymechanism.Social accountabilitymechanisms tend to focus on provision of information to citizens to incentivisethem into action. This is basedon the assumption that information about service standardswill spurcommunitymemberstoinfluenceservices.Howeverotherfactorsneedtobetakenintoaccountsuchastheabilityofcommunitymemberstoorganiseandhaveagency.Thepoor,especiallywomenwithloweducationmaynotbeabletodoso.Currently,right-basedcivilsocietyinitiativestoinfluencehealthservicedeliveryarealmostabsent,weakandpoorlylinkedtograssrootsactors.Theanalysisshowsthatcurrentstate-ledmechanismsinhealtharenotright-basedbutaremoreonesided; tohelphealthcentresachieve increasedutilisation.Linksbetween NHC and community members seem to be weak and are mainly exploited to transmitinformationfromthehealthfacility.Anystrategytoincreasecitizeninfluencehastotakeintoaccountthefollowingfactors:

• Absenceofendogenousspacesforcollectiveaction• Limitedscopeofstateledspaces• Lack of interaction between health related state-created structures andwider civil society in

advocacy• Limitedcivilsocietyledspacesandaction• Traditionallylowparticipationofwomen• Lowknowledgeofcitizenrights,entitlementandresponsibilities• Statefailures(inadequateandirregularfunding,lowstafflevels,lackoftransparency)• Lowstateresponsivenesstocommunityissues

Somecommonlyadoptedapproachestoenhancesocialaccountabilityincludethosethatfocuson:

a. Participatoryplanningandbudgetingb. Participatorypublicexpendituremanagementcyclec. Monitoringofservicedeliverystandardsthroughsocialauditsandreportcardsd. Userfeedbackorperformanceoutcomestocatalyzeserviceproviders

Alltheabovedependoninformationandassumethecapabilityofcommunitygroupstouseinformationand to have agency andwillingness of the service providers to listen. This is often not the case andwouldthereforemeaninvestingtobuildthesecapabilities.

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Experience suggests that demand-side focus alone is may be insufficient to bring about change.Accountabilitymechanismsalsoneedtohavethesupportiveroleofthebureaucracy.Itseemsalsothattheroleofthepoliticallevelshouldnotbeoverlooked.7.2 KeyIssuestoaddressinprogrammedevelopment7.2.1 Budgetforhealthservices

(i) Amounts:Althoughthebudgetforhealthserviceshasbeenontheincrease,itisstillinadequatetomeet the needs of the sector. The need is acute for maternal, child health and HIV AIDSprogrammes, where rural health centres lack ambulance services, are unable to holdimmunization outreach services regularly and unable to test for CD4 count in individualscommencingARVtreatment.

(ii) Allocation: Allocation to the health sector still falls short of the Abuja declaration of 15% of

national budget. Further, allocations tend to be curative focused with hospitals gainingdisproportionatelymorethanruralhealthcentres.

(iii) Disbursements: There are cases when disbursements to health centres are not made for acoupleofmonthsormoreatatime.Thispracticedisadvantagesruralpeoplewhodependsolelyonpubliclyprovidedhealth services.Most ruraldwellers lack choice to seekhealth care fromprivate providers. Private for profit services are not available in rural areas and if theywereavailabletheywouldbeoutofthereachofmostpeople.

(iv) Utilization:Theuseoffundsathealthfacilitylevelcouldbebettertargetedtowardssupportinghealthmaternal,neonatal/childandHIVAIDSprogrammes.

7.2.2 CivilSocietyCapacity

The near absence of civil society engagement in health sector demand side governance isattributabletoanumberoffactorsincluding;

• Lackoftechnicalcapacitytoengage• Donordependence,makingorganisationsactiveindomainssupportedbydonors• Civil societyhasbeenheavily involved inservicedelivery,especially in theareaofHIV

and AIDS and has not developed skills necessary for advocacy and interrogation ofhealthpoliciesandprogrammes

• Lackoflogisticalcapacitytobeactiveinruralareas• Continuousturnoverinorganisations,makingretentionofskillsachallenge• Women’s capacity to participate at leadership levels in community groups and

associational life is limited. This is often due to lack of skills and low confidenceoccasionedbyloweducationalattainmentand/orilliteracy.

7.2.3 CulturalandSocialnorms

Rural society tends to be governed by strong cultural and social norms which are unfair onwomen.Patriarchy is thenorm; thisoften translates in the low investment in girls’ education(especiallyatsecondary level),earlymarriageandpregnancy,violenceagainstfemales, lackofproductive assets and limited access to resources and above allwomen’ lackof voice.Normshaveastrongeffectonwomen’swillingnesstoparticipateinleadershippositionsatcommunitylevels.Womenwho are strong and vocal can be ridiculed in their community as taking on a

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man’sworld.Otherprogrammeshavefoundthatwidowed,singleorelderlywomenaremorelikely to fully participate in associational life than younger married women. Because womenbear the burden of household chores and fending for their families, taking an active role incommunityissuescanbeaburdenontheiralreadylimitedtime.

7.2.4 SpacesforengagementForumsforcivilsocietyinfluenceonservicedeliveryarelimited.Thecommonspacesarethoseprovidedby theStateatnational,provincialanddistrict level.Spacesprovidedbycivil societyareevenmorelimited.KeyissuesregardingSpaceforinfluenceare:

• Lackofinclusivenessofstate-ledspaces(toofewCSOsareinvited)• Inadequatecapacityof civil society tomakeuseofSpace,due to inability togenerate

evidenceforinfluenceaswellasabsenceofcivilsocietyorganisationsatdistrictlevel• The restricted nature of State led spaces at community level. Health Centre Health

Committees lack transparency and are not adequately designed as accountabilitymechanismstocommunities.

• MaledominatedNeighbourhoodHealthCommittees.Womenarehardly in leadershippositionsandrarelyrepresentthecommunitytotheHealthCentreCommittee.

• Inability of community representatives to exercise Voice. The challenge functionbetweenNeighbourhoodHealthCommittees andHCC is almost absent. Further,NHCoftenlackthecapacitytoengageeffectivelywithhealthfacilitystaff.NHCalsolackthecapacity to engage effectively with community members whom they ought torepresent.Thiscouldbeduetobothlogisticalandskillsinadequacies.

• Communitiesthemselvesmaylackfullawarenessoftheservicestandardstoexpect.7.3 StrategiesTable6:Strategies–Approaches,methods,levelofengagement,possiblepartners

Approach Methods LevelofEngagement PossiblePartnersNationalbudgetAdvocacy Budgetanalysisdata

Synthesisandpackagingofanalysis

• Nationalspaces-SAGs• JointParliamentary

CommitteeonEstimates

Existing coalitionon budgetadvocacy (CSPR,JCTR,Caritas)NGOCCPink Ribboncampaign

MonitoringbudgetutilizationatcommunitylevelthroughscorecardTrackingexpenditure

• Healthfacility• District – District

Integrated Managementmeeting, DistrictDevelopmentCoordinatingCommittee

• Province – ProvincialIntegrated ManagementMeeting, ProvincialDevelopmentCoordinatingCommittee

CommunityGroups–SMAGs,NHCWomen groups –EPWDA,NGOCC

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Approach Methods LevelofEngagement PossiblePartnersParticipatorybudgeting • Healthfacility

• Ward for ConstituencyDevelopmentFund

Communitygroups – SMAGs,NHC,Womengroups,NZP+ SupportGroups

Lobbyofficials Meet decisionmakers –individuallyBroker spaces betweenCSOs and decisionmakers

National• Planning Depts in

MoHandMCDMCH• Parliament

Committeeonhealth• Provincial Permanent

Secretary• Provincial Medical

Officer• District Community

MedicalOfficer• DDCC Subcommittee

onhealth

PerformanceMonitoring SocialauditsSocial analysis andactionInterface meetingsbetween communitiesandserviceproviders

HealthfacilityDCMOPMO

Communitygroups,NHCsMedia – Radiostations

CitizenandcivilsocietyCapacitydevelopment

Enhance participation,power and voice forwomenandgirlsBuild understanding ofrights and servicestandardsamonghealthusersBuild skills formonitoring and socialauditsUseofevidenceSocial analysis andactionCoordination amongcivilsociety

• Community• District• Provincial• National

Civil societygroups–EPWANZP+CSPRCommunitygroupsMedia – radioBreeze

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7.3.1 StructurestoInfluenceandActorstoBringIn

Thediagrambelowprovidesavisualofhowengagementinhealthsectorcouldlooklike.Figure11:Possiblechannelsofengagement

JointCommitteeofEstimatesCommitteeonHealth

Communities

IndividualmeetingswithMCHMCHMoH

PDCC

PIMM DDCC

DIMM SubcomonHealth

RuralHealthCentres

Consolidationofissues&data

RHC

NHCsCDF

MPs,Chiefs,Media(radio)

MPs,

PS,Minister,MP

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Annex1:ExtractfromFinancialReporttoSAG;ExpenditureJan–Dec2013

PETAUKE

DCMO Income Analysis Budget Actual Variance Note

s Non Cash Income K"000" K"000" K"000" Drugs from MSL 0 14,258 14,258 1 In Kind / Donations Total Non Cash Income - 14,258 14,258

Cash Income K"000" K"000" K"000" Basket (GRZ / Co-operating Partners) 5,264 3,947 (1,317) 2 Vertical / Programme Funds - - Medical levy 0 - User fees - - Other - 883 883 3 Total Cash Income 5,264 4,830 (434)

Bank and cash b/f 1,052 Available for spending

5,882

Total expenditure 5,522 Bank and cash c/f 360

Expenditure Analysis Budget Actual Variance Per Service Delivery Mode K"000" K"000" K"000" Provision of 1st level Referral service 2,104 1570 534 4 Health Centre Clinical Care Services 796 786 10 4 Health Centre Outreach Services 716 923 (207) 5 Community Health Services 528 520 8 4 Total 4,144 3,799 345

Prg 5024 Health Service Delivery K"000" K"000" K"000" Provision of 1st level Referral service 2,104 1570 534 4 Roll Back Malaria 372 428 (56) 5 HIV/AIDS/STIs 280 241 39 4 TB 228 161 67 4 Integrated Reproductive Health 352 324 28 4 Child Health 368 674 (306) 5 Environmental Health 180 176 4 4 Mental health 40 32 8 4 Oral Health 60 19 41 4 Nutrition 60 15 45 4 Epidemics Preparedness 60 39 21 4

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Others Public Health Interventions 40 120 (80) 5 Prg 5024.Total Health Service Delivery 4,144 3,799 345

Prg 5025. Health Systems Management K"000" K"000" K"000" Performance Assessment 80 105 (25) 5 Supervisory visits 104 131 (27) 5 Administrative Costs 936 1323 (387) 5 Remuneration for contractual employees Other Personnel Emoluments - 102 (102) 5 Infrastructure Development 62 (62) 5

Total Health Management Systems 1,120 1,723 (603)

Grand Total 5,264 5,522 (258)

Debt Analysis (K"000") Total Current 30 days 60 days 90

days 882 0 0 882 0

Imprest Analysis (K"000") Total Current 30 days 60 days 90

days 0 0 0 0 0

Notes: 1.MSL Drugs K14,258:HC Kits K4,143,Essential Drug & supplies K5,815 and ARVs K4,300

2.Adverse variance K1,317 due to non receipt of March/Nov and Dec 2013 in the period under review

3.Other funds K883 include: CSO K11.4,COMBOR K6 , Transfer Old Account K277,CDC PHO K175,PHO-Infrastructure K100 and PCV K21 and UNICEF Funds k298.60

4.Favourable expenditure variances on these budget lines due to non receipt of March/Oct to Dec 2013 grants in the period under review and delayed activity implementation in some cases.

5.Adverse expenditure variances due to other funds received as per note 3 and b/f from 2012

6. Over expenditure on allowances 7% due to other vertical program funds received in the period.

7. Other Personnel Emoluments K882: leave travel K222,Leave terminal K168, Long service bonus K492.