Leadership and governance
The leadership and governance of health systems, also called stewardship, is arguably the most complex but critical building block of any health system. It is about the role of the government in health and its relation to other actors whose activities impact on health. This involves overseeing and guiding the whole health system, private as well as public, in order to protect the public interest.
It requires both political and technical action, because it involves reconciling competing demands for limited resources in changing circumstances, for example with rising expectations, more pluralistic societies, decentralization or a growing private sector. There is increased attention to corruption and calls for a more human rights based approach to health. There is no blueprint for effective health leadership and governance. While ultimately it is the responsibility of government, this does not mean all leadership and governance functions have to be carried out by central ministries of health.
Experience suggests that there are some key functions common to all health systems, irrespective of how these are organized:
- Policy guidance: formulating sector strategies and also specific technical policies; defining goals, directions and spending priorities across services; identifying the roles of public, private and voluntary actors and the role of civil society.
- Intelligence and oversight: ensuring generation, analysis and use of intelligence on trends and differentials in inputs, service access, coverage, safety; on responsiveness, financial protection and health outcomes, especially for vulnerable groups; on the effects of policies and reforms; on the political environment and opportunities for action; and on policy options.
- Collaboration and coalition building: across sectors in government and with actors outside government, including civil society, to influence action on key determinants of health and access to health services; to generate support for public policies and to keep the different parts connected – so called "joined up government".
- Regulation: designing regulations and incentives and ensuring they are fairly enforced.
- System design: ensuring a fit between strategy and structure and reducing duplication and fragmentation.
- Accountability: ensuring all health system actors are held publicly accountable. Transparency is required to achieve real accountability.
An increasing range of instruments and institutions exists to carry out the functions required for effective leadership and governance. Instruments include:
- sector policies and medium-term expenditure frameworks
- standardized benefit packages
- resource allocation formulae
- performance-based contracts
- patients' charters
- explicit government commitments to non-discrimination and public participation
- public fee schedules.
Institutions involved may include:
- other ministries, parliaments and their committees
- other levels of government
- independent statutory bodies such as professional councils, inspectorates and audit commissions
- nongovernment organization "watch dogs" and a free media.
This section on Leadership and governance is structured as follows:
Since the end of the socialist era in 1991, the Government of Zambia has developed complex mechanisms of leadership and governance. The National Health Policies and Strategies published the same year set the starting point for the development of far reaching health reforms in the following years, including the decentralization policy, the introduction of the Basic Health Care Package (please check the NATIONAL HEALTH STRATEGIC PLAN 2006-2010 for more information), and the early steps of Sector Wide Approaches in coordination with Cooperating Partners.
- There is strong political will and commitment
- There is clear and limited mandate of the MOH (Ministry Of Health) to provide oversight
- Leadership structures are in place
- Fiduciary responsibility over financial and other resources have been enhanced
- Partners goodwill
- Improved institutional capacity at all levels to provide oversight
- Existing of policy and strategic environment to support service delivery - FNDP (Fifth National Development Plan ), NHSP (NATIONAL HEALTH STRATEGIC PLAN), MDG (Millenium Development Goal), PRSP (Poverty Reduction Strategy Paper), Vision 2030
- Policies are largely donor influenced
- Lack of policy direction with the existing policy on secondary and tertiary services delivery management
- Weak documentation of the definition of the scope of the Health sector
- Long term reliance on vertical programmes
- Donor government creating parallel departments in the name of NGO (Non Government Organisation) creating unhealthy competitions
- Inadequate human resources to support leadership and oversight at all levels
- Inadequate oversight and quality assurance
- Limited implementation of health policy
- Inadequate capacity for leadership and management at various levels
- Poor compliance with government guidelines and regulations
- Revamp leadership management training MOH staff at appropriate level
- Induction of Health workers must be enhanced with regulations and guidelines
- Annual Performance Appraisal system should broaden to capture appropriate government regulations and guidelines
- MOH to provide leadership and ownership in policy formulation and implementation
- New engagement framework with cooperating partners and CSO (Central Statistical Office) should be developed-paris declaration and the three ones principle strengthened
- MOH to put in place policies and strategies that can strengthen secondary and tertiary health service management
- Promote integration of programmes
- Revise National Policy
Context and background of the health system
Organizational chart of the ministry of health
Organization and functions of the ministry of health
The Ministry of Health holds the central responsibility for medical care and preventive care services through its wide network of public health institutions, countrywide. In this regard, the MoH undertakes a package of basic health care services (attach BPHC) through its 11 programme areas, namely Epidemic Preparedness, Provision of 1st level referral services, Roll Back Malaria, HIV/AIDS/STIs, Tuberculosis, Integrated Reproductive Health, Child Health, Environmental Health, Mental Health, Oral Health and Nutrition (see section 2.3).
Other ministries and external entities are involved in the health system. Main ones include:
- The Ministry of Local Government and Housing works in close collaboration with the MOH regarding public health aspects in urban areas (cities and municipal councils), especially with respect to food hygiene, environmental health, and water and sanitation.
- The central Government cabinet office is held responsible of HIV/AIDS coordination, policy guidance and mobilization of resources, due to the cross-cutting nature of the epidemic. However, the Ministry of Health remains as the major implementer of HIV/AIDS programmes.
- The Churches Health Association of Zambia (CHAZ) is a privileged partner and receives grants from the MOH for delivering health services through their network of health facilities (approx. 30% of nationwide public health facilities with up to 50% in rural areas) through a Memorandum of Understanding.
The Ministry of Health holds a number of specific functions concerning the public health provision in the country, in coordination with peripheral levels and partners. These include:
- Regulation – The MOH holds the central responsibility regarding regulation, either be standard setting, policy making, definition of target, procedures, monitoring and evaluation, etc. Yet cooperation partners play a key role through the SWAp arrangements. Some functions are also delegated to provincial level with (complement… in case some regulation function are actually delegated!)
- Planning – Planning takes a bottom-up approach, starting from health facility with gradual consolidation at district, provincial and ultimately central level. In turn, according to the indicative planning budget obtained from Ministry of Finance and National Planning (MoFNP), the MOH and SWAp partners develop a planning and budgeting framework, which is divided for each province. The provinces themselves determine indicative planning figures to the district level; and districts to health facilities
- Service provision – Delivering defined packages of health service. When approved, the budgets from the above planning exercises are released on a quarterly basis to MoH, who in turn send to the provincial health offices, who in turn send to the district health offices. The 72 district health offices then send the funds to health facilities for service delivery.
- Financing – Mobilizing funds from Ministry of Finance and Donors. This is the role of MoH-HQ, with money coming largely from MoFNP and the international donor community.
- Administration – Administering the resources in the health system
- Monitoring and Evaluation – A Health Management Information System (HMIS), containing all prioritized indicators has been developed and the data captured at all public health facilities is sent to the national level for compilation into an HMIS on a quarterly basis. The HMIS data is compiled into an Annual Health Statistics Bulletin to inform all stakeholders of performance and progress on health indicators.
The HMIS captures data from health facilities to help with planning and implementation activities. Policy and implementation is guided by a balanced combination of top-down and bottom-up approaches, relying on the strategic principles of leadership, accountability and partnerships at all levels of the health system; with MoH serving a stewardship role in these processes.
Decentralization of the system
In the past two decades the structure of the Zambian health system has been subject to major changes with a first process of decentralization in the early 1990s, which was then revisited (with some form or recentralization) in 2006. Following the 1992 health reforms implementation (see section 1.3.1), the Ministry of Health (MOH) started decentralizing key management responsibilities to the district level, taking the form of deconcentration (passing some level of administrative authority to decentralized bodies as implementing entities), and devolution (passing responsibility and a degree of independence to decentralized bodies) (attach decentralization policy). Conceptually speaking, it mainly initiated a split between the functions of
- (1) decision making with a strong participatory approach and
- (2) technical and management support to service delivery.
It gave birth to the creation of boards, committees and teams from the central up to the community level as depicted in the following table.
Two of these bodies were granted a particularly prominent role:
- The Central Board of Health (CBoH), considered as a semi-autonomous entity with a mandate to implement government health policies, by purchasing health services from the District Health Management Teams (DHMTs), hospitals and other statutory bodies on behalf of government.
- The District Health Management Teams (DHMTs) which became the focal point of the district regarding administrative and financial control of the health system. I was given flexibility in terms of decision-making, though with a narrow decision space (Bossert, Chitah).
However, in 2005, the Zambian government decided to undertake a new form of country-wide decentralization involving all ministries. In this form of decentralization, the civic authorities will become the units of decentralized structures and the health system a unit within this local decentralised structure. Notwithstanding some positive outputs, the years of purchaser/provider split were perceived as having resulted into some duplication of functions, with an administrative costs escalation which had become intolerable by the mid-2000s (see the 2006 MOH report on organization structure). In 2006, the Government abolished the CBoH and related boards at different levels and started bringing back their functions, asset and staff under the MOH. However, the restructuring process is not yet finalized to date (late 2009), and the consequence on the health system are still unknown. According to the 2008 Mid-Term review on implementation of NHSP 2006-2010, “The abolition of the Boards appears to have led not only to a re-centralisation of decision taking, but also has taken away the ‘voice’ of people to influence and - to a certain extent - ‘own’ their health services. »
Influence of the ministry of health in the overall national policy framework
Health is a key social sector in Zambia. It holds the third position in Government Unit of Expenditures 2009 (8.9%), ranked next to Constitutional & Statutory Expenditure and the Ministry of Education (with respectively 14.2% and 19.0%). The health sector is also considered as a main development vector in the Poverty Reduction Strategic Papers (see the 2002 Zambian PRSP), and the Ministry of Health (MoH) benefits from the largest share of the savings made from debt cancelation.
Policies and guidelines set by the Ministry of Health apply to all health institutions in the Ministry of Defence as well as in the Ministry of Local Government and Housing, Ministry of Home Affairs and all the private sector institutions. There is also a close relationship between education and health. The University of Zambia School of Medicine trains doctors for the Ministry of Health. In addition, the Ministry of Higher Education trains paramedics for the MoH (Radiographers, Health Inspectors, Lab Technicians, etc). Beyond this, the ministry of Health and the ministry of Education interact in the school health and nutrition (SHN) programmes.
The MOH exerts a certain influence on the health agenda of other ministries by developing the policy framework, policies and guidelines governing the implementation of public health programmes and clinical care services. (see section 7.6)
Yet, the MOH’s influence also faces serious limitations, mainly due to financial constraints relayed through the ministry of Finance and National Planning. The IMF agreement (attach doc) included a number of ceilings on public expenditures as conditionality for enhanced support. It particularly affects human resources: as an example, in 2009, the Ministry of Health has been allocated less than 10% of funding earmarked for recruitment of staff to the civil service (2010-2012 MTEF Framework, MoFNP (2009) )
Public health provision is a complex issue with many facets to be considered and the interests of many stakeholders. Personal interest have to balance with professional interests. Hence other institutions are also involved in the provision of health services.
Some administrative and regulative functions are shared between the MOH and other actors.
- The National AIDS Council of the National Cabinet’s office holds a major role regarding coordination of HIV/AIDS activities.
- Local government agencies (health and civil authorities) have power to make bye-laws that govern health within their areas of jurisdiction.
- The Medical Council of Zambia sets standards of practice and monitors the activity all health professionals except nurses, who fall under the supervision and regulation of the General Nursing Council.
- The routine issues of professional practice are under the responsibility of professional associations that include (a) the Zambia Medical Association, (b) the Zambia Nurses Association, (c) the Pharmaceutical Society of Zambia, (d) the Zambia Faculty of General Practitioners and several other medical professional bodies.
Health service provision is mainly supported by Government-supported health facilities (87% of facilities, including CHAZ faith-based health facilities which account for 30% of total health services). Yet, there is also the private sector health system (6% - private clinics, private hospitals, including the Mining Industry) and pharmacy outlets, as well as private drug vendors selling medicines and other health products from less well-established and sometimes mobile retail outlets. In an effort to scale-up the provision of anti-retroviral drugs, several non-governmental organizations (NGOs) and civil society organizations (CSOs) have joined efforts to establish own facilities or partner with governments at public facilities in providing ART services, including PMTCT services from ante-natal care outlets.
Several consumer rights associations exist in Zambia to promote patients rights as well as serving to empower patients with particular needs in order to better take care of themselves. These include the Sickle Cell Association of Zambia, The Mental Health Association of Zambia, The Zambia Epilepsy Foundation, the Zambia Albino Foundation, the Zambia Diabetes Association and the Zambia Dental Association.
Alternative health care purchasers remain scarce as compared with other countries. Still there is a small and growing health insurance sector in Zambia, largely private in set up (Zambia State Insurance Corporation, Madison Insurance, and Professional Life Insurance). More recently, the Ministry of Health has started considering the option of Social Health Insurance scheme as a way to secure access to health care and to contribute to health financing. In addition, the MOH is also considering other mechanisms with mainly performance-based financing schemes to help alleviate financial barriers on the demand side, and the Zambia Health Workers Retention Scheme as means to retain and motivate health workers.
There is a certain tradition of trade unions in the Zambian health sector. Some health workers fall under the Civil Servants Association of Zambia as the big umbrella trade union in order to help bargain for better salaries and conditions of work. Other cadres of health workers have formed splinter unions in order to better focus on their interests. Such splinter unions include the Zambia Union of Nurses Organizations (ZUNO). ZUNO has received recognition from the Ministry of Health to serve as a trade union for nurses interests in Zambia (salaries, conditions of service, etc).
Policy making and health planning
Utilization of health information
Health activity planning
The MoH actively undertakes planning for the public health sector, including the CHAZ institutions. The planning cycle follows the Medium Term Expenditure Framework (MTEF) approach over a 3-year period but with a detailed activity budget for each following fiscal year. In addition to this, the national level HQ prepares a 5-year National Health Strategic Plan which guides MTEF planning and feeds into the 5-Year National Development Plans.
Health planning activities are placed under the authority of the Directorate of Planning and Development at MoH-HQ. It organizes and manages the activity on behalf of the MoH and is also the link unit to the National Development Plan. Within the Planning Directorate is also a Policy Unit, which is charged with formulating and processing policy recommendations into national health policies.
Planning and budgeting for primary health care in Zambia takes the form of “bottom-up planning” along an indicative planning figure: first health facilities develop their individual yearly planning ; then their proposals are submitted and consolidated into a district plan by the District Health Office; the provincial health office receives and scrutinises all district health plans for compliance to national level guidelines and compiles these into a provincial health plan; this plan is further scrutinized at national level for compliance to guidelines and set ceilings; finally the national level consolidates all provincial plans and budget into a national; level data for onward transmission to Ministry of Finance & National Planning.
Nevertheless, budget restrictions and ceilings often results in discrepancies between planning and disbursement as discussed in section 1.3.4. Also a study conducted by Equinet in 2005 on planning and budgeting for PHC revealed that some challenges still remain regarding the actual influence of local actors in the planning and budgeting processes at their health facility.
Policy dialogue and decision-making process
The MOH has progressively developed a very participative policy making process, materialized through its advances SWAp and related institutional arrangements. A number of meetings have been designed in that framework:
- A number of technical working groups which meet monthly or as convenient to provide inputs to main programmes or functional areas of the MOH ;
- The monthly Policy Committee meeting that reviews policies and their implementation, with a view to make the necessary adjustments for improved outcomes.
- The Sector Advisor Group (SAG) held on a 6-monthly basis, that provides a technical review of health programmes under the authority of the Permanent Secretary.
- Finally, around the end of each year:
- the Annual Consultative Meeting, chaired by the Minister and/or Deputy Minister of Health to discuss policy issues; and
- the Joint Annual Review (JAR) opened to a diversity of technical actors and focusing on health sector performance.
The SWAP secretariat is hosted in the MOH Directorate of Planning and Development. It sets the calendar of events and oversees its implementation. This calendar ensures stakeholder dialogue before, during and after policy implementation.
Based on this calendar, it sets the agenda of each of the meeting mentioned above, with notices circulated to participants soliciting for agenda items. Interested members may submit any issues they wished to be discussed. Relevant agenda items may be dictated by circumstances, e.g. communicating measures taken to global epidemics, such as the Swine Flu or SARS.
All these meetings are multi-stakeholder in nature, drawing participation from MoH, Government line ministries, Donors, UN agencies, NGOs, International NGOs, Civil Society Organizations, Faith-Based groups, Academic institutions, Research Institutions, trade unions, professional associations, and in some cases interested individuals.
In nearly all cases, policy formulation is based on evidence from local and international experience. As an illustration, the forthcoming Results Based Financing (RBF) policy is currently being developed along the following steps: a proposal was drafted and reviewed for approval, based on international experience; a pre-pilot intervention was suggested to evaluate the positive or negative impact of RBF on existing structures and mechanisms; the pilot phase got extended to 9 districts (one per province); if the results prove to be a success, then a policy will be developed to guide nationwide scaling up..
The HMIS and an Annual Health Statistics Bulletin are mainly used to assess policy outputs. In addition, specific independent teams are commissioned to assess policy outputs, with composition from external and international experts. Expert opinion is sought and valued by government.
Regulation, monitoring and evaluation
The Ministry of Health is in charge of setting standards for health service delivery, to ensure that everyone can be covered with services, with a focus on equity and universal coverage. In this regard, the MoH has adopted the Primary Health Care (PHC) approach with a strong focus on district health services including the health centre level.
Other forms of regulation exists: Result Based Financing approaches are currently being experimented as a mean to stimulate compliance of health care providers to a number of qualitative and quantitative targets; health care providers must adhere to a number of professional norms and ethics by renewing their licences (through the Medical Council of Zambia or the General Nursing Council) and proving that they have attended continuous professional development programmes. Are there still other ones?? Accreditation?? Others???
These various forms of regulation require the contribution of a diversity of actors, beside the MOH, among which:
- The monitoring and evaluation technical working group that sets standards or performance targets in service delivery to which service delivery institutions aspire to reach. In addition to MoH officials, these groups include participation by donors, academic institutions, NGOs, and other interested parties who volunteer to become members.
- Besides the MoH, some regulation, monitoring and evaluation functions are delegated to public statutory bodies, such as the Medical Council of Zambia, the General Nursing Council, the Pneumoconiosis Control Board and the National Food and Nutrition Commission. These are semi-autonomous bodies, who receive a grant from the Government to undertake their mandate. Their contributions are recognized by national authorities and the results used for policy making.
- The Central Statistical Office of the Ministry of Finance compiles national data and conducts complementary types of assessments in relation with health (as the 2-year Living Conditions Monitoring Surveys (LCMS) mentioned below).
The monitoring and evaluation procedures and documents for the health sector have been recently revamped following a reform of the HMIS (see section 6.3.1), bringing much more consideration to issues of primary health care reforms and universal coverage. In addition, the following monitoring programmes may provide useful complementary information: the Living Conditions Monitoring Surveys; the Zambia Demographic & Health Surveys; the Joint Annual Reviews; the Growth Monitoring Programmes
With these tools, the health system is now in a position to better address the issues of inequities in access and utilization of health services. Performance data contained in the HMIS is generally arranged to reflect the top 10 and bottom 10 performing districts, including consideration of inequities. In addition, the Zambian DHS provides information on access to and utilization of health services
The government has other projects ongoing that relate to regulation. It noticeably aspires to achieve universal access to safe and efficacious medicines and pharmaceutical supplies through the enactment of a National Drug Policy (NDP), as well as to safe blood through establishment of an effective national blood transfusion service.