Health system challenges and

opportunities in Zambia

February 6, 2013

Swedish Health Care Delegation to Zambia

Göran Tomson

Professor of International Health Systems Research

goran.tomson@ki.se

www.ki.se/phs/hsp

Need to reframe policies and thinking for the

multipolar world of the 21st century.

New world view based on global responsibilities,

interdependence and partnership.

Innovations

Systems thinking

Evidence Informed Policies climate

PPP/PPDP

Smart care

Cola road

February 21, 2013 3

Annual GDP Growth in Zambia

Source: World Bank, 2012

February 21, 2013 4

Burden of Disease in Zambia,

2008

Cause Estimated deaths per 100,000

population

HIV/AIDS 324.0

Cardiovascular diseases 180.5

Respiratory infections 148.0

Perinatal conditions 130.3

Diarrhoeal diseases 113.6

Malaria 103.5

Unintentional injuries 90.2

Respiratory diseases 50.9

Malignant neoplasms 50.6

Intentional injuries 49.4

Source: WHO, 2008

February 21, 2013 7

Source: NHSP11-15

Sources of

health financing Government

expenditure 8,5% of

national budget (lower than

Abuja target)

1% earmarked tax on

interest earnings

Challenges National Health

Insurance Scheme not

developed

No Health Care

Financing Policy

Unpredictable support

from donors.

Source: Sundewall, PhD Thesis, 2009

Human resources

Category of Health Workers Number in 2010 Recommended Training

institutions

Medical Doctors 836 2,300 1

Nurses 7461 16,732 37

(10 PNFP) Midwives 2471 5,600

Paramedical Practitioners 1462 - 1

Dentists 246 633 1

Pharmacists 317 347 1

AHWO (2010)

Availability and Access to Essential

Medicines

February 21, 2013 10

Main challenges

- Limited storage capacity

- Poor communication in supply

chain

- Logistics system: poor

integration, supervision and

staffing

- Access problems in rural areas

- Irrational use of medicines

(poor implementation of NDP)

Strengths and Opportunities

- Appropriate pharmaceutical

policies and regulations

- New pilot models of drug

supply logistics

- Improved disbursement of

funds for procurement of

medicines

Source: NHSP11-15

Source

Of Funds

Procurement

Agent/Body

Point of first

warehousing

Point of 2nd

warehousing

Point of 3th

warehousing

WORLD

B

A

N

K

P

E

P

F

A

R

D

F

I

D

U

S

A

I

D

Medicines supply systems in Zambia. 2007

U

N

I

C

E

F

W

H

O

C

H

A

Z

Z

A

N

A

R

A

C

H

A

I

J

I

C

A

WORLD

VISION

U

N

F

P

A

Z

A

B

A

R

T

ESSENTIAL

MEDICINES ARVs MALARIA TB OI

ARVs

Ped

REAGENT

Blood safety

(+ test HIV)

VACCINES CONDOMS Contraceptives MEDICAL

Supplies

Categor

y of

Products Color

U

N

I

C

E

F

C

H

A

S

O

C

-

F

H

BOSTO

N

UNIVE

RSITY

U

N

F

P

A

C

I

D

R

Z

Z

A

B

A

R

T

C

A

R

E

Malaria Centre CARE PROVINCIAL STORE DISTRICT

STORE

PROV.

STORES DISTRICT STORES

HEALTH FACILITY DISTRICT STORE

HF

GOVERNMEN

T

BILATERAL

DONOR

MULTILATERAL

DONOR

NGO/PRIVAT

E

J

I

C

A

B

G

A

T

E

S

M

O

H

C

M

S

WORLD

VISION

WORLD

B

A

N

K

U

S

A

I

D

MOH CMS ZAMBART

STORE

C

R

S

DS

ITN

PATIENT

CHA

STORE

CIDRZ

STORE

HF

HEALTH

FACILITY

A

X

I

O

S

HF

U

N

I

T

A

I

D

GLOBAL

FUND

C

D

C

G

L

A

S

E

R

M

O

H

C

LI

NT

ON

HC

HOME

BASED CARE

Zambia

Source: Bigdeli et al, Health Policy Plann, 2012

Access to medicines from a health system perspective

SWOT analysis of Health Information

System

Source: NHSP11-15

Source: AHO WHO Africa, 2010

Source: WHO, 2010

Non-Communicable Diseases (NCDs)

needs in Zambia

Source: NHSP11-15

Ownership of Health

Facilities

Province Zambia

Public Health Facilities 1,489

Mission Health Facilities 122

Private Health Facilities 271

Total 1,882

Challenges

• Infrastructure

• Medical equipment Theatre and anaesthesia

Health technology

management and maintenance

Maternity equipment

CSSD and general nursing

equipment

Laundry and kitchen

equipment

Source: NHSP11-15

• “Mapping” of the private sector in partner countries showing its increasing role in health care (e.g. Zambia)

• PSP found a neglect of quality of care and an overprescription of drugs often linked to private sector care

• Public private partnerships were emphasized as one of the main areas of innova-tion in health with many options for governments to work with the private sector.

Geographical mapping of health providers in Zambia

• Private health care in Zambia – Findings from provider and client surveys in two districts (Lundazi and Chingola) (Wake et al 2008)

• Interviews about providers’ challenges and experiences including relations with public sector

Quality problems identified among informal providers and

drug stores Little formal cooperation between government

and for-profit providers

368 health providers were mapped: 59% located in rural areas, 90% private for-profit while 5% were either government or private not-for-profit, 60% of providers were informal

The quality of private pharmacy services in a province of Lao PDR

A randomized trial, pre-experimental and cross sectional study including quantitative and qualitative methods by Syhakhang et al, 2002 (similar study by Chuc et al, 2002)

Improvement of practice of private pharmacies including the provision of better quality drugs through regulatory interventions e.g. inspections, information, and distribution of regulation documents to drug sellers and sanctions.

“Most private pharmacies were managed by non-pharmacists. The quality of practices was low, with 59% of the encounters not receiving any information on drug use, 47% of purchased drugs had no label and 26% of all drugs were mixed in the same package.”

Governance

Private sector a complement to the public sector in health service

delivery

Collaboration and coordination between the two sectors for health

systems strengthening

“What our government has done is

make clear that we accept the role of

the private sector and the

collaboration between public and

private” (Hon. Dr. Joseph Kasonde,

MP, Minister of Health)

An evidence-based policy

brief proposing an

(1) incremental versus a

(2) comprehensive option

for integrating mental health

into primary care:

(1) pilot project

(2) comprehensive,

national plan.

Towards Universal Health Coverage (UHC)

“The goal of universal health coverage is to ensure that all people

obtain the health services they need – prevention, promotion,

treatment, rehabilitation and palliation – without risk of financial ruin or

impoverishment, now and in future.” (M. Chan, WHO, 2012)

Innovative ways of reaching UHC

The results chain for UHC

Task shifting in the scale-up of

interventions to improve child survival:

an observational multi-country study in

Bangladesh, Brazil, Uganda and

Tanzania Task shifting from health workers with longer duration of

training (doctors, clinical officers) to those with shorter

duration of training (nurses, midwives and nurse assistants)

did not compromise quality of child care linked to the

Integrated Management of Childhood Illness (IMCI).

Task shifting could be used as a strategy for increasing

coverage of IMCI and other child survival interventions

in underserved areas faced with staff shortages.

Source: Huicho et al, Lancet, 2008

Telemedicine to improve the quality of

paediatric care: an operational research study

Source: Zachariah et al, Trop Med Int Health, 2012

The “polypill” to reduce deaths from

cardiovascular disease

Source: TIPS, Lancet, 2009

Opportunities for Public Private Partnership

in the Zambian health sector

Telemedicine

Establishment of hi-tech Hospitals for treatment

of specialized cases

Diagnostic centres

Drugs logistics supply chain and storage

Hospital fleet management and repair

Laundry services

Repair of medical equipment.

Training of health personnel (medical school and

nursing school)

Source: Zambia Development Agency, 2011