Key health challenges for Zambia - ACCA Global

32 Pages·2013·0.39 MB·English

Key health challenges for Zambia
About ACCA
ACCA (the Association of Chartered Certified
Accountants) is the global body for professional
accountants. We aim to offer business-relevant, first-
choice qualifications to people of application, ability and
ambition around the world who seek a rewarding career
in accountancy, finance and management.
Founded in 1904, ACCA has consistently held unique core
values: opportunity, diversity, innovation, integrity and This paper provides an oversight
accountability. We believe that accountants bring value to
into some of the key issues facing
economies in all stages of development. We aim to
develop capacity in the profession and encourage the the health sector in Zambia and
adoption of consistent global standards. Our values are
describes the role professionally
aligned to the needs of employers in all sectors and we
ensure that, through our qualifications, we prepare qualified accountants can play in
accountants for business. We work to open up the
delivering the country’s health
profession to people of all backgrounds and remove
artificial barriers to entry, ensuring that our qualifications agenda.
and their delivery meet the diverse needs of trainee
professionals and their employers.
We support our 154,000 members and 432,000 students
in 170 countries, helping them to develop successful
careers in accounting and business, with the skills needed
Contents
by employers. We work through a network of over 80
offices and centres and more than 8,400 Approved
Employers worldwide, who provide high standards of Foreword 3
employee learning and development.
1. Introduction 5
2. The health system in Zambia 6
3. Roundtable discussion 1:
Health sector reform and why this is necessary
for national development 19
4. Roundtable discussion 2:
Should investment focus on preventative or
curative care? 22
5. Roundtable discussion 3:
National Health Insurance in Zambia 24
6. Roundtable discussion 4:
How collaborative technology can be used to
improve the provision
of healthcare 25
7. Roundtable discussion 5:
The role of the accountancy profession in
healthcare delivery 26
8. Conclusion 28
References 29
© The Association of Chartered Certified Accountants,
A2pril 2013
Foreword
I would like to thank the ACCA for I would like to appreciate the
organising the health forum to which my contribution made by the accountancy
office was invited. The participation of profession towards health service
the Ministry of Health during this delivery in Zambia. Professional
meeting was key as it provided an accountants have played a critical role
opportunity for the health care in helping build capacity in the health
providers to interact with the sector and in strengthening health
participants and give an insight into systems in areas such as financial
challenges faced by the health care reporting and good governance. The
sector in the resource mobilisation and accountancy profession is critical to the
how these challenges could be delivery of quality health care in that the
addressed through concentrated prudent utilisation of financial resources
efforts by professional bodies such as translates into improved health service
ACCA. delivery.
As a way of addressing these Lastly, I thank the ACCA for partnering
challenges, the Ministry proposes to with the Ministry of Health in trying to
introduce a Social Health Insurance address challenges faced in the
which will soon be implemented and provision of health care in Zambia.
with this, it is our hope that we will
realise our mission of providing Hon. Minster of Health,
equitable access to cost effective, Dr Joseph Kasonde
quality, health care services as close to
the family as possible.
KEY HEALTH CHALLENGES FOR ZAMBIA 3
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1. Introduction
The Zambian government has set itself Speakers at the event included: The wide-ranging discussions focused
the ambitious target ‘To provide on five key themes:
equitable access to cost effective, • Hon. Christopher Mulenga MP,
quality health services as close to the deputy minister of health • health sector reform and why this is
family as possible’ (MOH 2011: page x). necessary for national development
Achieving this objective will require • Dr Faston Goma, dean, School of
significant health reform: limited Medicine, University of Zambia • whether investment should focus on
resources, high levels of poverty, poor preventative or curative care
physical infrastructure, geography and • Dr Lackson Kasonka, managing
sparse population in rural areas all director, University Teaching • National Health Insurance in Zambia
hamper the delivery of health care Hospital
services and create challenges for • how collaborative technology can
policymakers and planners. • Dr Tim Meade MD, medical director, be used to improve the provision of
Corpmed Medical Centre health care
A greater insight into some of these
issues was provided at a health • Mr Patrick Phiri, technical expert • the role of the accounting
conference organised recently by the manager, Deloitte & Touche profession in health care delivery.
Association of Chartered Certified
Accountants (ACCA) in Lusaka. The • Mr Mark Millar, interim chief
event gave politicians, health executive Milton Keynes NHS
policymakers and senior ACCA Foundation Trust, England and
members employed in the field of ACCA council member.
health the opportunity to discuss some
of the key health challenges facing
Zambia, to debate potential solutions
and then to consider the role that
ACCA accountants can play in
supporting the government to achieve
its goal of improving the health of the
population.
KEY HEALTH CHALLENGES FOR ZAMBIA 5
2. The health system in Zambia
Located in sub-Saharan Africa, Zambia Zambia is classed as a lower-middle- districts and through encouraging local
is a landlocked country covering an area income country but, through successive representation on health management
of approximately 752,614 sq. km. five-year development plans (Vision boards. The Ministry of Health (MOH)
Formerly a British colony, Zambia 2030), the government aims to was given responsibility for policy,
attained independence in 1964 and transform Zambia into ‘a prosperous financing and regulation, and a new
since that time has been politically middle-income nation by 2030’ organisation, the Central Board of
stable. For administrative purposes (Government of Republic of Zambia Health (CBOH), was tasked with service
Zambia is divided into 10 provinces, of 2011: xii). Despite an annual average implementation.
which two (Lusaka and Copperbelt) are economic growth rate averaging 6.1%
classed as urban and eight as rural; the over the period 2006–10, however, 67% By 2005, the health policy had become
provinces are subdivided into 72 of the rural population and 20% of the outdated and the Health Services Act
districts. urban population live in extreme 1995 was repealed. A year later, in
poverty (UN Development Programme 2006, the CBOH was dissolved, being
Over the last 10 years the population of 2011). replaced with the current four-tier
Zambia has increased at an average structure:
rate of 2.8% a year, reaching 13.47m in Zambia’s health policy, created in 1992
2011. The most heavily populated and becoming operational with the • MOH, with responsibility for policy,
provinces are Lusaka (2.2m) and Health Services Act 1995, is intended to regulation and standard setting
Copperbelt (2m). The country has a very ‘provide the people of Zambia with
young population with 45.4% below the equity of access to cost-effective, • Provincial Health Offices, with
age of 15 and 20.8% in the age range quality healthcare as close to the family responsibility for performance
15–24. The vast majority of the as possible…’ (MOH 2005: 1). The aim of management at the provincial level
population work in the informal sector the policy was to provide a service that
(Table 2.1). was responsive to local needs by • District Health Offices, with
decentralisation of decision making to responsibility for coordination,
planning and support at district
level
Table 2.1: Distribution of currently employed persons aged 15 years and above by • Neighbourhood Health
(institutional) sector and sector of employment, 2008 Committees, with responsibility for
overseeing services at the
Sector Formal Informal Total community level.
Central government 209,546 0 209,546
In addition, national units were
established to oversee specific health
Local government 26,891 0 26,891
programmes, including the National
Malaria Control Center, Reproductive
Parastatal 40,000 0 40,000
Health Unit, Tuberculosis and Leprosy
Private 225,012 659,213 884,226 Control Unit, and National Aids Council.
NGO/church 13,485 17,479 30,964 Health care is provided by a multitude
of providers, including the MOH, church
International organisations 4,675 2,059 6,734
organisations, the private sector (both
not for profit and for profit) and
Households 0 3,969,991 3,969,991
alternative providers. The vast majority
Others 2,566 50,842 53,408
Total 522,176 4,699,585 5,221,761
Source: Labour Statistics Branch, (2010): 58
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of health facilities (1,489) are owned and gatekeeper in place, tertiary hospitals Many of the key determinants of health
operated by the public sector. These have no option but to invest time and are outside the direct scope of the
are supplemented by 122 mission health resources treating these patients, which health sector.
facilities and 271 private health facilities. often results in longer waiting times for
those more critically ill. • There is often poor access to safe
Zambia operates a pyramid water and sanitation. Only 41% of
classification structure of health care Huge disparities in access to care place homes have access to safe water
provision: further pressures on the system. In rural and 25% (37% in rural areas and 2%
areas, for example, only 46% of in urban) of homes have no toilet
• tertiary or specialist care is provided residents live within a 5km radius of a facilities. It has been estimated that
in Level 3 hospitals health centre and many have to travel 80% of preventable diseases in
more than 50km to reach their nearest Zambia relate to poor sanitation.
• provincial-level care is provided in health facility. Access to medical care
Level 2 hospitals in more remote areas is further limited • Malnutrition. This is a contributory
by the national shortage of clinical staff: factor in nearly half (42%) of all
• district-level care is provided in some health facilities are run by deaths in children under five years of
Level 1 hospitals unqualified staff. age.
• community-level care is provided In an effort to address these issues the • Lack of education, particularly
through health posts and health government has recently introduced a among females. Although literacy
centres. basic health care package that sets out rates have improved significantly (it
the levels of service that should be was estimated that nationwide 64%
The structuring of the health system provided at each tier of care. It also of females and 82% of males were
suggests that a managed hierarchal includes the commitment to invest in literate in 2009) the number of girls
referral system is in operation, but new intensive care unit (ICU) equipment graduating from secondary school is
owing to undeveloped communication for all provincial hospitals, to purchase just 17.9%.
systems and limited availability of more ambulances and to promote
ambulances, referral systems between mobile hospitals for Level-2 care. • Gender discrimination.
the different levels of care are often
poor. In addition to the tiered system of care • Climate variability and change. A
identified above, health care is provided study based in Lusaka found that an
The system also suffers from having no for those in hard-to-reach areas by increase in temperature of just 1°C
gatekeeper in place to manage the mobile health services and the Zambia six weeks before a cholera outbreak
right-siting of patients, ie ensuring that Flying doctors’ service. increased the number of cases by
patients are treated at the right time, in 5.2%.
the right place by the right clinical team Zambia faces a double disease burden.
and at the lowest possible cost. Instead, There is high prevalence of Other key factors include poor road
resource and capacity constraints at the communicable diseases including HIV/ networks (particularly in the rainy
lower levels encourage many patients Aids, tuberculosis (TB), malaria, season), an insufficient number of
suffering only minor complaints to diarrhoea and intestinal worms vehicles for transportation, and limited
self-refer to Level 3 hospitals. (In 2009, as well as rising incidence rates of access to electricity. The country’s
for example, only 46.5% of health non-communicable diseases such as electricity is predominately consumed
centres employed two or more diabetes mellitus, cancer and chronic by the mines so, according to the
professionally qualified staff.) With no respiratory disease. Ministry of Energy, more than three-
quarters of the population depend on
wood fuel for their household energy
needs.
KEY HEALTH CHALLENGES FOR ZAMBIA 7
THE MILLENNIUM DEVELOPMENT Table 2.2: Millennium Development
GOALS Goals
In September 2000, Zambia was one of 1. Eradicate extreme poverty and hunger
the 189 member states of the United
Nations to sign the Millennium
2. Achieve universal primary education
Declaration that pledged to end
extreme poverty and deprivation by
2015. This declaration led to the 3. Promote gender equality and empower
development of eight specific women
Millennium Development Goals (MDGs),
4. Reduce child mortality
each of which is linked to a number of
targets and indicators (Table 2.2).
5. Improve maternal health
Three of the MDGs relate specifically to
health:
6. Combat HIV/AIDS, malaria, and other diseases
• Goal 4 – Reduce child mortality
• Goal 5 – Improve maternal health
7. Ensure environmental sustainability
• Goal 6 – Combat HIV/AIDS, malaria,
and other diseases.
8. Develop a global partnership for development
Zambia’s national health priorities, as set
out in the National Health Strategic Plan
Source: UNDP 2011
(NHSP) 2011–15, are closely aligned to
achievement of these three MDGs as
well as to resolutions of the World
Health Assembly that have been ratified
and signed by Zambia: the Roll Back
Malaria (RBM) strategy, the Stop TB
strategy and the Abuja target of
committing 15% of the national budget
to health.
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Results from the Zambia Demographic
and Health Survey 2007 suggest that
Goal 4: Reduce child mortality
Zambia is making good progress
towards this goal. The under-five
Target: Reduce by two-thirds, between 1990 and 2015, the mortality rate
mortality rate reduced from 190.7 per
among the under-fives.
1,000 live births in 1992 to 119 per 1,000
live births in 2007. Over the same
Table 2.3: Goal 4 indicators
period, the infant mortality rate fell
from 107.2 per 1,000 live births to 70 per
1992 2007 MDG 2015
1,000 live births (Table 2.3).
target
Under-five mortality (deaths per 1,000 live 190.7 119 63.6 The proportion of one-year-old children
births) reported to be immunised against
measles in Zambia increased from 77%
Infant mortality (deaths per 1,000 107.2 70 35.7 in 1992 to 85% in 2007. Annual
live births
immunisation rates fluctuate, however,
and are dependent on the number of
Proportion of one-year-old children 77% 85% 100%
immunised against measles recorded instances of the disease and
(Africa Health Observatory/WHO 2010–13) on available resources. In 2004 there
Source: UNDP 2011 were just 28 recorded deaths from
measles so over the next few years
immunisation rates fell and the disease
resurfaced. In response, during 2012,
the government instigated a new
campaign to vaccinate all children
between the ages of 9 months and 47
months. Although many older children
will remain unprotected it is hoped that
this will be sufficient to stem future
outbreaks.
In addition to measles the MOH is
working to reduce a number of other
preventable childhood diseases by
expanding the Reaching Every District
(RED) programme.
This aims to improve the supply-chain
management of vaccines – to include
availability, distribution, storage and
safe injection technologies – and to
ensure that 80% of children in each
district receive three doses of DPT
(diphtheria, pertussis (whooping cough)
and tetanus) vaccine.
KEY HEALTH CHALLENGES FOR ZAMBIA 9
Goal 5: Improve maternal health
Target 5a: Reduce by three-quarters, between 1990 and 2015, the
maternal mortality ratio.
Target 5b: Achieve, by 2015, universal access to reproductive health.
Table 2.4: Goal 5 indicators
1996 2007 MDG 2015
target
Maternal mortality ratio 649 591.2 162.3
(deaths per 100,000 live births)
Proportion of births attended by skilled Not 46.5% Not
health personnel known specified
Contraceptive prevalence rate (any modern 11.2% 24.6% Not
method) specified
Source: UNDP 2011
Of the three MDGs related to health, maternal death it is estimated there are assisted by a nurse, midwife or physician
this is the one that Zambia is least likely 30 disabilities. Accessing treatment is and only 39% sought postnatal care
to achieve. difficult: the repair of fistulae, for within two days of the birth.
example, is currently undertaken at only
Although the maternal mortality rate four sites, though there are plans to Inadequate infrastructure, shortages of
has reduced from 649 per 100,000 live extend this to 10 sites. equipment and insufficient clinical staff
births in 1996 to 591 per 100,000 live limit access to care – only 53 out of 72
births in 2007 there is still a long way to A contributory factor to the high districts, for example have health
go to achieve the MDG target of 162 per mortality and morbidity rates is thought workers trained in emergency obstetric
100,000 live births in 2015 (Table 2.4). to be the number of teenage and neonatal care (EmONC).
pregnancies. Contraceptive prevalence
Around three-quarters of these deaths rates are slowly rising – from 11.2% in The MOH plans to address these
are caused by complications such as 1996 to 24.6% in 2007 – but the total challenges through:
obstructed labour, eclampsia or fertility rate at 6.2 births per woman
haemorrhage; problems that could have remains high. • expansion of the EmONC
been treated with skilled care. A key programme
factor in reducing maternal mortality The Central Statistical Office Zambia
rates, therefore, is access to antenatal reported that although 94% of women • expansion of the focused antenatal
care and presence of a trained nurse, sought antenatal care during their care programme
midwife or physician at the birth. pregnancy, only 19% presented in their
first trimester, resulting in the omission • scaling up the Preventing Mother to
Disability such as obstetric fistula is of key interventions. Fewer than half of Child Transmission of HIV (PMTCT)
another risk of childbirth; for every the women (46.5%) had a delivery programme.
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