UHC Forward: Towards Universal Health Coverage

Times of Zambia: This Op Ed was written by Dr. Emmanuel Kooma, a public health advocate based in Zambia.

ZAMBIA still has extreme and acute pocket of ill-health throughout the country.

At the centre of this is the human crises and the failure of the health system, which have both failed to prevent disease like typhoid, cholera and other diarrhoea diseases, year in and year out.

In addition, a failure also to protect the poor from the consequences of ill health.

Much of the burden of disease can be prevented with known and affordable technologies, if resources allocation is not skewed to curative services only.

The human resources problems need good planning and these problems have to be sorted out timely, reliably and in sufficient, sustained and affordable quantities to all health care institutions needing them.

We still have many institutions in Zambia run by the so called Classified Daily Employee (CDEs) and we are remaining only with three years before the Millennium Development Goals (MDGs) land mark.

Zambian prisons have been an epicentre of the resurgence of tuberculosis (TB) due to the underlying health status of inmates, overcrowding, and intermittent supply of TB drugs.

The public health system needs larger reforms to reduce the underlying risks and to enable more community – based health care.

The starting point for addressing effectiveness of the health system is therefore to define the elements of a clear and actionable agenda that recognises and responds to under-performances in some functional areas of the sector itself but which also acknowledges that success depends on a range of factors in the Zambian wider society.

The creation of stronger public health system is not an end in itself – it is a means to achieve better health outcomes.

Effective and equitable health systems are an absolute requirement for Zambia to achieve the MDGs as well as other goals such as those related to reproductive health and immunisation.

Further, more strengthening of the health system is essential, if the current increase in aid for health is to be well spent now and sustained in the future.

The first challenge for Zambia is not only to define clear priorities for improving the function of the health system but how are these priorities funded.

How do we reduce the disease burden that takes the biggest portion of financial resources? There seem to be a problem to change our mind set and the way of thinking towards public health system in Zambia. We need to recognise that the essential element of public health are interdependent.

A change in financing strategy will inevitably influence provider behaviour, the balance between curative and preventive care, client demand and so on and so forth.

Removing user charges, on the other hand, may increase utilisation among poor groups while having unexpected consequences in terms of demand for commodities, health workers motivation and quality of care. The poor need not pay same fees as the well to do, hence the demand for health insurance scheme which can fully demarcate the poor and able people.

Zambia should start promoting the Health Insurance Schemes if the gap between the poor and the rich is to be closed.

Accordingly, strengthening of the health system needs to be seen as an integrative part of a participating national health policy by all stakeholders for the preventive and curative public health systems. Actions to strengthen health systems will be drawn from a common menu, but specific agreed priorities and sequencing has to be determined by national circumstances.

A general point I want to make is that there are many ways to reflect the relationship between goals, functions and components of our health system.

Zambia should remember that the shortage of health service staff and poor financial mechanism to health priorities has become one of the most serious constraints to scaling up the response to poor sanitation, lack of safe water and food, hence high increase in communicable diseases such as cholera, typhoid, malaria, HIV\AIDS and tuberculosis .

Health workers are dying from varying causes and are leaving the public service for greener pastures because the conditions are becoming bad and getting worse compared to current livelihood demands and is now termed as “Brain haemorrage”.

Workers leave the public sector and join the private sector whose core business is just HIV/AIDS/TB and leaving the rest of the health problems to the health sectors with few staff.

Addressing the Zambian situation on human resources crises in the health sector requires some strategy to improve monthly pay, supplement and incentives for those working in poor rural areas of the country, let their now be efforts to upgrade the skill-mix of health workers in particular to strengthen the public health career path.

We need to strengthen the availability of essential emergency and surgical skills and knowledge of primary health care, better strengthened partnerships at all levels with private providers, non governmental organisations [NGOs] and community partners.

This in turn, will require reassessing of staff tasks and responsibilities and a review of job descriptions to ensure the appropriate allocation of tasks to various categories of health workers under various levels of the system from the community to health centre to district hospital and finally to district health office.

As migration is stripping our Zambian health system of vital personal efforts are required within the country to manage mobility without infringing upon individual’s human rights.

The key point here is that the crisis demands political as well as technical solutions because it is deeply associated with national priority setting (for example why should health workers get special treatment compared to other public sector workers) and because it often involves overcoming conflict interests at the core of national and international political process.

Human resource crisis needs the cooperation of multiple actors both within and outside Zambia and international institutions including those dealing with trade and migration and employment public policy bodies and regulatory requirements which must be part of the response.

Fair financing mechanism of the health system

The key question counter how the health system is financed and what proportion contributes to disease prevention and if prevention fails what goes to curative and how are the users pay for services themselves – either in the form of out -of-pocket contributions or should we balance payment through the health insurance schemes.

The system Zambia should choose now to promote the principle that whatever system of financing mechanism the country adopts, that system should not deter people from seeking and using services.

In most cases, this will mean that payments at point of service will need to be eliminated – or at least related ability to pay.

The financial systems should also – as a minimum – protect people from catastrophic expenditure if they become ill, promote treatment according to need and encourage providers to offer an expensive mix of curative and prevent services.

Towards a more equitable and pro-poor approach

Actions to strengthen health systems need to be grounded with an overarching health strategy which aims in particular to improve the health of the poor and vulnerable.

The limited resources we have are typically spent in urban areas, providing our health care facilities to serve relatively better-off and more local populations, while the rural poor and shanty township dwellers are more likely to seek care from expensive private providers.

As a result, our health system can itself contribute to poverty, when care payments push the poor or near poor into destitution, or when lack of access to care creates life long disability limiting earning power.

Zambia needs to strengthen or create “apro-poor” system that is likely to require either an increase or a reallocation of resources to prevention and promotion of primary level health care and out-reach services.

Let there be total transparent decentralisation of health services which bring service management closer to the people. This will allow services to be maintained and that locally-run services are genuinely more efficient and responsive particularly to the needs of the poor.

We need to start ensuring practical quality of care as an important issue. Quality and responsiveness are key elements in increasing demand for services.

For poor people in particular, a visit to the health care facility can be demeaning and humiliating experience. Introducing incentives for providers to deliver better quality of care must therefore be part of broader efforts to strengthen the system.

Differences between the poor men and women also need to be taken into account. Women and men are exposed to poverty differently, and respond in different ways.

A related but sometimes forgotten point is that services in poor areas are often costly to provide. Infrastructure may need to be re-established and staff paid incentives to work in remote locations.

That said these costs need to be compared with the price of providing tertiary care to the urban middle class, which as mentioned above often captures a disproportionate share of the health budget in Zambia.

In summary a “pro-poor” approach must imply establishing separate health services for the poor – although targeted out-reach services can be a useful tool for reaching poor communities. Rather, it means addressing the inequitable allocation of health staff and by shifting financial resources allocation towards services and activities which benefit the poor and marginalised.

The essence of a pro-poor approach is to renew or reinvigorate the primary health care strategy investments and public health and personal care services and improved access to health care facilities.

Equitable financial mechanisms and forming strengthened links with other sectors that influence health outcomes is very important such as [health, education, water, waste management, sanitation and the environment are quite essential.

Stewardship and Zambia`s Role

Stewardship refers to the oversight role of the state in shaping, regulating and managing health systems.

As a country we expected to provide the public and private health system, actors, policy direction and areas we are not doing well like poor waste management, sanitation, unsafe water and food.

Conditions have to be created for them to ensure oversight across the whole system with particular attention to equity concerns and to reconcile competing demands between prevention and curatives services for financial resources.

Zambia has a growing share of external funding channeled through diseases-specific initiatives and not diseases prevention specific initiatives which pose a particular challenge to the Government over sight function.

“Stewardship” as a short hand term describes the more political functions of the state in relation to health systems, with the implicit assumption that the other components are largely technical.

As discussed above, it shows this is not the case. The stewardship function itself includes several important managerial functions for example given regulation of insurance markets, setting and maintenance of professional standards and facility management and logistics.

In addition, stewardship covers areas influenced by overall Government policy and are thus subject to the different views of competing groups. These include oversight of human resource for health, the way in which financing is organised, the relationship with private sector and with voluntary organisations and not least, strategies for addressing inclusion and equity capacity needs to be built within the Zambian health system to manage human resources, services delivery and to ensure best possible results according to available resources. Delivery and to ensure best possible results according to available resources.

While stronger health systems are recognised as a prerequisite for achieving the MDGs, neither our financial sources and yearly planning have paid sufficient attention to systems strengthening in action but talking they have done so.

The drive to produce results for the MDGs has led many stakeholders to focus first on their own diseases priority. If and for Zambian health system is to be well spent and deliver equitable health outcomes stronger health systems are needed in the disease prevention and promotion.

This in turn will require looking beyond technical solution for specific interventions and address political, organizational and management constraints at all levels of service delivery.

As a country, let Zambia build systems that are relevant to the social, economic, cultural and political realities of our poor relatives and friends. Let there be a Disease Prevention and Control, Sanitation and Hygiene Directorate at Ministry of Local Government to specifically promote public health prevention and promotion activities and not a desk for public Health, currently in place.

Good public health systems contribute positively to the economy of the country. Let us re engineer our public health system in Zambia.

The current public health Government structures need to merge to independently solve public health issues in the country.

We should feel bad to continue having cholera and typhoid out-breaks just because of not having a structure that looks at sanitation issues. The existing structures should be revised and be strengthened under the local authorities.

Zambia is very rich in public health preventive and promotive personnel who are not supported materially and financially to prevent diseases and promote health. These officers have seen the incidence of malaria drastically reduce countrywide. This is because malaria has been funded very well.

Try to fund sanitation, you will see a very drastic reduction in diarrhea diseases. For example Health Management Teams with heavily funded activities for sanitation this year have not reported any case of cholera. Thanks to these Health Management Teams.

We are a tourism destination country and this industry might be threatened of such disease out-breaks like typhoid. Typhoid and cholera are about poor sanitation.

We should stop the outbreak of typhoid fever and cholera in Zambia forever. These are bad indicators for a country`s public health system.

This article aims to highlight the importance of having a strong public health system towards the achievement of the Millennium Development Goals, and to identify some factors that affect overall performance of our public health system so as to emphasize the need for a change on national scale.