Health Reforms in Zambia

HEALTH REFORMS By DR Ph.D P. M Zimba MPH, BSc EH, Dip MOF, Dip EHT Environmental Health Unit  INSPIRATION CORNER Proverbs 15v1 A soft answer turneth away wrath: but grievous words stir up anger. Vision of the Health Reforms The vision of the health refo...

HEALTH REFORMS By DR Ph.D P. M Zimba MPH, BSc EH, Dip MOF, Dip EHT Environmental Health Unit  INSPIRATION CORNER Proverbs 15v1 A soft answer turneth away wrath: but grievous words stir up anger. Vision of the Health Reforms The vision of the health reforms in Zambia is to “provide equity of access to cost-effective, quality health care as close to the family as possible.” Zambia has been implementing health reforms since 1992 under the framework of the Sector Wide Approach (SWAP), which takes a holistic development view of the sector  Concepts and Definitions A reform according to Oxford English Dictionary is defined as “ The amendment, or altering for the better, of some faulty state of things, especially of a corrupt or oppressive political institution or practice; the removal of some abuse or wrong”  What is reform process? Reform consists of changes and improvements to a law, social system, or institution. A reform is an instance of such a change or improvement. Health sector reform deals with equity, efficiency, quality, financing, and sustainability in the provision of health care, and also in defining the priorities, refining the policies and reforming the institutions through which policies are implemented. Health sector reform is a sustained process of fundamental change in policy and institutional arrangements of the health sector, usually guided by the government. It designs to improve the functioning and performance of the health sector and ultimately the health status of the people.  The health sector is basically a network of relationships These key institutions can simply be classified as: (a) State or government institutions such as Ministry of Health and its subsidiary public institutions responsible for national health development; (b) Health care providers in public, private, NGO and traditional sectors; (c) Resource institutions such as training institutions and research centres; (d) Purchasers of health care such as insurance funds, health authorities or health maintenance organizations; (e) Other sectoral agencies & Socioeconomic & political environment; (f) Organized interest groups (g) The population at large  Successful efforts to develop health systems are the result (a) Continuous and sustained political, social and financial commitment of successive governments; (b) Strong management capabilities for implementation; (c) Well-oriented, trained and committed health administrators, professionals and workers; (d) Effective decentralization of administrative and technical decisions and responsibility; (e) increasing community action for health; (f) Widespread deployment of affordable health protecting and life-saving technologies (g) Sustained financing of development programmes.  Reforms beyond the health sector The usual focus of reform by governments, and, more particularly, by donors, has been the overall size of the civil service, including that in the health sector. Reducing the number of staff, Introducing new pay scales and grading schemes, Separating political and executive functions and decentralization and privatization efforts are a few examples of civil service reforms introduced in most countries of the world, including those in Zambia ISSUES IN HEALTH SECTOR REFORM The process of reform is also proceeding rapidly in many countries. The reforms sometimes are highly political and fiercely contested processes Most countries usually focus attention on the contents of the reform, rather than on the process. INVESTMENT OPPORTUNITIES IN THE HEALTH SECTOR IN ZAMBIA Since 1992 the Government of Zambia has been implementing health reforms whose vision is to create environments that are conducive to health. Over the years, the success of the health reforms has made Zambia a favorable destination for Foreign Direct Investment (FDI) in health. This is because the Zambian Government has realized the comparative advantage that the private sector has in providing health care services. Hence Government has developed a policy that allows public private sector partnerships.  Priority Areas for Investment in the Health Sector Under Statutory Instrument N0 27 of 2007, the following areas in the health sector have been declared as priority sectors for investment by the private sector: Medical Services Manufacture of Pharmaceutical products Medical Laboratory Services Diagnostic Services Repair and Maintenance of medical equipment Provision of laundry Service to medical institutions Ambulance services Education & Training (Human Resource for Health Development)  Public private partnership A Public-Private Partnership (PPP) is a partnership between the public sector and the private sector for the purpose of delivering a project or a service traditionally provided by the public sector.  Privatization Privatization describes the process by which a piece of property or business goes from being owned by the government to being privately owned. It generally helps governments save money and increase efficiency, where private companies can move goods quicker and more efficiently.  Quasi markets in the public sector Outsourcing in the public sector creates so-called Quasi- markets for services that are primarily funded by taxes. The phrase Quasi-market emphasizes the distinction between markets for tax-financed services and typical markets, specifically that the consumed services are paid for by a third party the government.  Health Systems: Decentralization Decentralization in the civil service has been the most common type of reform in the Region. The term "decentralization" embraces a variety of concepts which must be carefully analyzed in any particular country before determining if projects or programs should support reorganization of financial, administrative, or service delivery systems. Decentralization is the transfer of authority and responsibility for public functions from the central government to subordinate or quasi-independent government organizations and/or the private sector—is a complex multifaceted concept.  Health systems: Decentralization Cont. Some countries have delegated the responsibility and functions of central government units to more autonomous and or specialized types of government agencies or specialized functional agencies, or the parastatals (e.g. establishment of national health research institutes, national nutrition centers and research and training institutes). In some cases, decentralization also refers to the transfer of functions from government to nongovernmental organizations, including private for-profit enterprises and NGOs in the established sense of the term.  Objectives of decentralization The main objectives of decentralization are to improve the delivery of services by the public sector and to enhance the quality of life of citizens. Decentralization of government programs is said to increase efficiency and effectiveness due to reduction of congestion in communications, Quicker reaction to unanticipated problems Improved ability to deliver services, Improved information about local conditions More support from beneficiaries of programs.  Advantages of Decentralization Decentralization is a development strategy that supports pro- poor, and pro-nature and protects regional features in the development process in the age of globalization when the entire world is interconnected and has become a little village. This procedure will aid in democratizing decision-making, bringing out the voices of the most marginalized and depressed people, and representing local communities. To put it another way, they are in charge of making the appropriate plans, strategies, and decisions to increase competence at every level, ultimately maximizing the company’s overall production. Advantages of Decentralization Cont. In a system like this, a company’s top management delegates decision-making authority for the firm’s everyday operations to the middle and lower levels of management. The power-sharing among the central, state, and local governments is also another advantage that leads to better management by decreasing the probability of conflicts.  Types of Decentralization Types of decentralization include political, administrative, fiscal, and market decentralization. Drawing distinctions between these various concepts is useful for highlighting the many dimensions to successful decentralization and the need for coordination among them. Nevertheless, there is clearly overlap in defining any of these terms and the precise definitions are not as important as the need for a comprehensive approach. Political, administrative, fiscal and market decentralization can also appear in different forms and combinations across countries, within countries and even within sectors.  Political Decentralization Political decentralization aims to give citizens or their elected representatives more power in public decision-making. It is often associated with pluralistic politics and representative government, but it can also support democratization by giving citizens, or their representatives, more influence in the formulation and implementation of policies. Advocates of political decentralization assume that decisions made with greater participation will be better informed and more relevant to diverse interests in society than those made only by national political authorities.  Political Decentralization Cont. The concept implies that the selection of representatives from local electoral jurisdictions allows citizens to know better their political representatives and allows elected officials to know better the needs and desires of their constituents.  Administrative Decentralization Administrative decentralization seeks to redistribute authority, responsibility and financial resources for providing public services among different levels of government. It is the transfer of responsibility for the planning, financing and management of certain public functions from the central government and its agencies to field units of government agencies, subordinate units or levels of government, semi- autonomous public authorities or corporations, or area-wide, regional or functional authorities.  Administrative Decentralization Cont. The three major forms of administrative decentralization : deconcentration, delegation, and devolution -- each have different characteristics. Deconcentration: which is often considered to be the weakest form of decentralization and is used most frequently in unitary states Redistributes decision making authority and financial and management responsibilities among different levels of the central government. It can merely shift responsibilities from central government officials in the capital city to those working in regions, provinces or districts, or it can create strong field administration or local administrative capacity under the supervision of central government ministries. Administrative Decentralization Cont. Delegation: is a more extensive form of decentralization. Through delegation central governments transfer responsibility for decision-making and administration of public functions to semi- autonomous organizations not wholly controlled by the central government, but ultimately accountable to it. Governments delegate responsibilities when they create public enterprises or corporations, housing authorities, transportation authorities, special service districts, semi-autonomous school districts, regional development corporations, or special project implementation units. Usually these organizations have a great deal of discretion in decision- making. They may be exempt from constraints on regular civil service personnel and may be able to charge users directly for services.  Administrative Decentralization Cont. Devolution: A third type of administrative decentralization is devolution. When governments devolve functions, they transfer authority for decision- making, finance, and management to quasi-autonomous units of local government with corporate status. Devolution usually transfers responsibilities for services to municipalities that elect their own mayors and councils, raise their own revenues, and have independent authority to make investment decisions. In a devolved system, local governments have clear and legally recognized geographical boundaries over which they exercise authority and within which they perform public functions. It is this type of administrative decentralization that underlies most political decentralization.  Administrative Decentralization Cont. Fiscal Decentralization: Financial responsibility is a core component of decentralization. If local governments and private organizations are to carry out decentralized functions effectively, they must have an adequate level of revenues Either raised locally or transferred from the central government As well as the authority to make decisions about expenditures. Fiscal decentralization can take many forms a) self-financing or cost recovery through user charges, b) co-financing or co-production arrangements through which the users participate in providing services and infrastructure through monetary or labor contributions; c) expansion of local revenues through property or sales taxes, or indirect charges; d) intergovernmental transfers that shift general revenues from taxes collected by the central government to local governments for general or specific uses; e) authorization of municipal borrowing and the mobilization of either national or local government resources through loan guarantees. In many developing countries local governments or administrative units possess the legal authority to impose taxes, but the tax base is so weak and the dependence on central government subsidies so ingrained that no attempt is made to exercise that authority. Administrative Decentralization Cont. Economic or Market Decentralization: The most complete forms of decentralization from a government's perspective are privatization and deregulation because they shift responsibility for functions from the public to the private sector. Privatization and deregulation are usually, but not always, accompanied by economic liberalization and market development policies. They allow functions that had been primarily or exclusively the responsibility of government to be carried out by businesses, community groups, cooperatives, private voluntary associations, and other non-government organizations.  Administrative Decentralization Cont. Privatization can range in scope from leaving the provision of goods and services entirely to the free operation of the market to "public-private partnerships" in which government and the private sector cooperate to provide services or infrastructure. Privatization can include: 1) allowing private enterprises to perform functions that had previously been monopolized by government; 2) contracting out the provision or management of public services or facilities to commercial enterprises indeed, there is a wide range of possible ways in which function can be organized and many examples of within public sector and public- private institutional forms, particularly in infrastructure; 3) financing public sector programs through the capital market (with adequate regulation or measures to prevent situations where the central government bears the risk for this borrowing) and allowing private organizations to participate; and 4) transferring responsibility for providing services from the public to the private sector through the divestiture of state-owned enterprises.  Deconcentration Deconcentration, is the term referring to: “The process by which the agents of central government control are relocated and geographically dispersed” (Sayer et al.). “Administative decentralization, i.e. a transfer to lower-level central government authorities, or to other local authorities who are upwardly accountable to the central government” (Ribot 2002 in Larson). “The transfer of administrative responsibility for specified functions to lower levels within the central government bureaucracy, generally on some spatial basis”. “  Deconcentration One of administrative decentralization which redistributes decision-making authority and financial and management responsibility among levels of the central government; there is no real transfer of authority between levels of government. It may involve only a shift of responsibilities from federal forest service officials of the capital city to those stationed in provinces, districts, etc”.  Delegation Delegation refers to the transfer of responsibility for specific tasks from one person to another. From a management perspective, delegation occurs when a manager assigns specific tasks to their employees. Delegation is commonly defined as the shifting of authority and responsibility for particular functions, tasks or decisions from one person (usually a leader or manager) to another  Devolution Devolution , refers to the transfer of ‘natural resource management to local individuals and institutions located within and outside of government’ (Edmunds et al. 2003:1), though some people use ‘devolution’ only in reference to direct community transfers” “The transfer of rights and assets from the centre to local governments or communities. All of these processes occur within the context of national laws that set the limits within which any decentralised or devolved forest management occurs” (Sayer et al.). “The transfer of governance responsibility for specified functions to sub- national levels, either publicly or privately owned, that are largely outside the direct control of the central government” (Ferguson and Chandrasekharan).  Devolution “One form of administrative decentralization which transfers specific decision making powers from one level of government to another (which could be from lower level to higher level of government, in the case of federations, or government transfers decision-making powers to entities of the civil society. Regional or provincial governments, for example, become semi autonomous and administer forest resources according to their own priorities and within clear geographical boundaries under their control. Most political decentralization is associated with devolution”  Impact of decentralization on the health system and service delivery Substantial influence on the effectiveness of public policy in improving a population's health. Reduces the damage that a single data breach can inflict. Enchances smooth communication Motivation of the subordinates, promotion of expansion, people being more adapt at managing resources Knowing where to spend their money Lastly diversification which is also facilitated by decentralization ANY QUESTIONS