THE Treatment Advocacy and Literacy Campaign (TALC) says it is important that the government becomes magnanimous enough by starting to own the ART programme for purposes of sustainability as it will definitely be a disaster if partners were to pull out for one reason or another.
Justifying the need for an increased budgetary allocation to the Ministry of Health in the 2020 budget, TALC national director Felix Mwanza stated in submissions to the Ministry of Finance that currently, Zambia had put more than 900,000 people on Antiretroviral Therapy (ART) life-prolonging drugs, which was commendable.
Mwanza said most people on ART were supported by bilateral and multilateral partners like PEPFAR and global initiatives such as the Global Fund to fight HIV/AIDS, TB and Malaria.
“Since the ultimate goal of putting people on ART is for them to reach ‘Viral Suppression’ and become ‘Undetectable and Untransmissible also widely known as ‘U=U’, it is imperative that the MoH is assisted with adequate resources to ensure that the U=U goal is attained. Further, though the partnership with PEPFAR, Global Fund, Bilateral and Multilaterals has greatly helped us as a country, there is no guarantee that such support will continue forever,” he said.
“It is therefore, important that the Zambian government becomes magnanimous enough by starting to own the ART programme on its own for purposes of sustainability as it will definitely be a disaster if the above mentioned partners were to pull out for one reason or the other. To sustain over 900,000 PLHIV on ART, the MoH will need an increase in the 2020 budget allocation.”
Mwanza said in government institutions, Churches Health Association of Zambia (CHAZ), the mining companies, parastatal organisations, private clinics and traditional healers provide health care.
“However, majority of our people access their health services from public health facilities run by the government comprising the health posts, health centers, level one hospitals, level two hospitals and level three hospitals respectively. The National Health Strategic Plan defines the framework within which both public and private service delivery is organised, based on the Zambia Basic Health Care Package. The details of the five levels of health care are as follows,” he said.
He said the third level hospitals were also called specialist or tertiary hospitals and were the biggest referral hospitals in Zambia, catering for approximately 800,000 people and and have sub-specialisations in internal medicine, surgery, paediatrics, obstetrics, gynecology, intensive care, psychiatry, training and research.
“All complicated cases not attended to at the second level hospitals are referred to third level hospitals. In 2008, there were six third level hospitals in Zambia. The picture has now drastically changed with more third level hospitals to be commissioned as they were either being upgraded or under construction,” he said.
He said the second level hospitals – the provincial or general hospitals – intended to cater for between 200,000 and 800,000 people; with services in internal medicine, general surgery, pediatrics, obstetrics gynecology, dental, psychiatry and intensive care services.
He said first level hospitals, also referred to as district hospitals, were the third largest levels of care after the second and the third level referral hospitals.
“These serve a population of between 80,000 and 200,000 and provide services such as medical, surgical, obstetric services and all clinical services in support of health centre referrals. In 2008, there were 72 first level hospitals. A total of 15 first level hospitals were currently under construction in Zambia in the 2018 financial year,” he said.
“There are two types of health centres in the health care delivery system in Zambia. These include urban health centres and rural health centres, which serve a catchment population of between 30,000 to 50,000 people; serving a catchment area of 29km or a population of 10,000 people. It is government policy to provide at least one first level hospital in each district, which should operate as a referral hospital to satellite health centres.”
Mwanza said there was a small but growing private health sector comprising of the profit organisations (private clinics and hospitals); the private not-for profit organisations (such as the Churches Health Association of Zambia) and an increasing number of NGOs that operate at community level.
He said the Public Private Partnership policy aims at consolidating achievements by strengthening the implementation, functioning and performance of District Health Committees, Health Centre Committees and Neighbourhood Health Committees.
“The main actors in the health care delivery system, therefore, are, the Government through the Ministry of Health (MoH), the cooperating partners (CP’s), Non-Governmental Organisations (NGOs), the Provincial and District Medical Offices (PMOs and DMOs), Hospitals and Health Facility Managers,” he said.
“The structures for coordination and implementation include the Ministry of Finance, the Health Sector Advisory Group (SAG), the MoH headquarters, Statutory Boards, PMOs, DMOs, Health facilities (provincial, mission and district hospitals, health centres, and health posts). Each of these institutions has specific coordination and implementation functions.”
Mwanza said the main sources for funds in the Zambian Health sector were the Ministry of Finance, the cooperating partners, multilateral and bilateral partners, households, and employers.
He said prior to 2000, the major employer active in the health sector was the Zambia Consolidated Copper Mines (ZCCM), which operated a number of health facilities for its employees.
He said two strategic approaches had been proposed to break the dilemma of healthcare financing in Zambia, establish a social health insurance programme so that tertiary care could be funded aside from budgetary sources, and adopting the public private partnership (PPP).
“As can be seen above, the Ministry of Health is the custodian of health service delivery in the country and as a ministry, it is expected to ensure that all health facilities as described above are well stocked with all drugs, diagnostic equipment, and reagents and resourced with all qualified and skilled personnel to provide health services to our people. Having given the above background, it is now our privilege to submit as follows,” he said. “The 650 Health Posts. Like we noted in our 2018 submission to the budget making process, tremendous progress has been made following the pronouncements that the government was going to construct 650 health posts throughout the country. These health posts are predominantly in rural areas of Zambia or indeed in areas that are hard to reach. At the time of our submission last year, over 150 health posts had been constructed and though some had been inaugurated, a lot more were still in the process of being officially launched and opened to members of the public. To date, we note that over three quarters of health posts have been completed but we still have areas where these structures are to be erected, commissioned, handed over to the community and resourced both with drugs and human personnel to run them.”
Mwanza said health posts were a critical structure in delivering health services.
He said such facilities were supposed to be well resourced with drugs, human resource and that the staff is well motivated and housed.
Mwanza said this would entail that the government, through the MoH, needed to spend a little more in order to provide quality and sustain health services delivery to the people.
Mwanza said in countries such as the UK, Spain, Italy and the Nordic countries, the government had a high degree of involvement in the commissioning or delivery of health care services and access is based on residence rights not on the purchase of insurance.
He said this was also the case for Zambia where government has a huge stake in the provision of health services despite the newly introduced health insurance which was still in its infancy stage and was not sure whether it would come to fruition.
Mwanza said the government therefore, would still need more resources to continue providing quality health services to its people.
He said due to government’s major involvement in public health service delivery, the burden on the MoH to ensure that it delivers on this undertaking was huge and challenging.
“For purposes of sustainability, TALC hereby submits that the MoF allocates more resources in the 2020 budget than before so that the MoH can achieve Universal Health Coverage using Primary Health Care as a conduit of attaining SDG goal number 3,” he said.
On Sexual Reproductive Health (SRH) Commodities and Services, Mwanza said in Zambia the unmet need for contraception was high among married and unmarried female adolescents aged 15–19.
He noted that adolescent pregnancy was high with 28.5 per cent of girls aged 15-19 have ever been pregnant or had a live birth.
“In rural areas 37 per cent report ever being or having live birth compared with 20 per cent in urban areas. The highest rates are in rural communities of North Western, Western and Eastern provinces where the proportion of ever-pregnant females was 44 per cent, 46 per cent and 43 per cent, respectively, while in urban areas of the same provinces it was 34 per cent. Between 2010 and 2016 a total of 120,024 in-school girls (103,621 in primary and 16,403 in secondary schools) became pregnant and for many that marked the end of their education,” he said. “Data from the Ministry of Education, shows that on average, there are over 15,000 pregnancies reported each year among schoolgirls, and more than 80 per cent of these pregnancies occur in rural areas. The recent announcement from Eastern Province Health Office that over 5,000 teenage pregnancies were recorded from January to September 2018 shows that there is a big gap in accessing Sexual Reproductive Health (SRH) services for girls and young women in rural areas.”
Mwanza said such inequities in SRH commodities and services as shown above, especially in rural areas as compared to urban areas will obviously call for more resources for MoH to narrow the gap and improve on service delivery in this area.
“We further advocate for at least a 10 per cent Constituency Development Fund (CDF) to be allocated towards SRH commodities and services in every constituency,” he said
On Test and Treat, Mwanza said in line with the World Health Organisation recommendations, Zambia hadee embarked on Test and Treat interventions for all those that test HIV positive regardless of their CD4 count as commencement of one on ART was no longer dependent on a CD4 count threshold.
He said this intervention has had a paradigm shift on the treatment cascade and will entail that the government has to spend more on the ART programme as more and more people will be put on ART now.
Mwanza said the government through MoH needs to allocate more resources to the ART programme for it to be successful.
He said the Test and Treat intervention has huge cost implications.
Mwanza said as Zambia expands its health systems to improve service delivery throughout the country by coming up with new health facilities the need for human resources for health at all levels become even more pronounced.
He said according to MoH reports Zambia has a staff deficit among all cadres of Human Resource for Health.
“A Health System that is devoid of Health Equipment and infrastructure is a danger to the people that it is supposed to serve. As the health system expands, there also comes the need to equip all facilities with the requisite equipment and reagents to diagnose various ailments that members of the general public present with. This too, calls for the deployment of right people to operate and maintain such sophisticated equipment at various facility levels,” he said.
“All our health facilities are understaffed and the client to staff ratio is too big resulting in staff burn outs due to the overwhelming numbers of clients being seen by a single clinician. Lack of equipment, reagents and trained technicians to operate and maintain equipment are themselves barriers to having a proper diagnosis done. With certain tests requested being very expensive and out of reach by ordinary citizens. To address this gap, the MoH needs to be supported adequately with an increased budgetary allocation so that they can provide such services to members of the public that cannot afford them.”
Mwanza said the expansion of all health systems will entail that more drugs will be prescribed at every health facility.
He said there had been a notable improvement in the budget allocation towards drugs procurement.
“However, even with such improvements in the supply chain, drug stockouts and shortages have been reported in most of our public health facilities. This coupled with bureaucratic procurement procedures and late disbursement of funds to the ministry has exacerbated the situation to an extent that some facilities run out of drugs not that there is a stockout but due to systemic hiccups,” he said.
“Due to our observations above, it is important that the budgetary allocation to MoH under this budget line is increased substantially in order for the ministry to streamline its operations and continue providing quality services to members of the general public. We want to see the ‘prescription without medicines era’ come to an end in the 2020 budget.”
Mwanza said with 650 health posts; UHC; SRH commodities and services; over 900,000 PLHIV on ART; Test and Treat; HRH and Equipment and Drugs as interventions that shall all need scaling up the MoH of health responsibilities are huge and will need a lot of support in terms of resources.
“Our fair assessment of the costs that shall need support from the Ministry of Finance is that at least 18 per cent of the 2020 National Budget should be allocated to the ministry of health in order for them to meet citizens’ expectations. TALC is available to justify this submission if requested to do so. Please do not hesitate to get in touch with the undersigned should you need any clarification regarding this submission,” said Mwanza.