Table of Contents
EXECUTIVE SUMMARY 4
1. INTRODUCTION 7
2. COUNTRY CONTEXT OVERVIEW 8
3. HEALTH SECTOR LEVEL ANALYSIS 18
4. ANALYSIS OF INSTITUTIONS AND GOVERNACE ARRANGEMENTS – RULES OF THE GAME 28
5. ANALYSIS OF THE GOVERNANCE SPACES IN THE SECTOR 42
6. ANALYSIS OF MAIN AGENTS / STAKEHOLDERS 48
7. LINKING ANALYSIS TO PROGRAMME DEVELOPMENT 55
LIST OF FIGURES
1. Adult Literacy Rate by Province
2. Incidence of Poverty Level, head count by District in Eastern province, 2010
- Non Personal Emoluments (PE) Budget & Releases, 2004 -2011
- Comparison of Non PE MTEF Allocation, Budget and Releases 2010 -2013
- Levels of service delivery
6. Structure and functional relationships in the health sector
- Budget and Planning Calender at MoFNP and MoH
8. Key Stakeholders
9. Influential Actors at PMO level
- Actors staff members at a clinic consider influential
11. Possible channels of engagement
i
LIST OF TABLES
- Rural poverty distribution by sex of household head, 2010
2. Distribution of Respondents by who makes Selected Decisions at Household Level Men, Women or Both by Sex
- Staff Levels in Chipata District Quarter 1 2014
- State and Non State led Spaces and Actors
- Stakeholders’ Analysis of roles, interests, capacities and accountability
- Strategies – Approaches, methods, level of engagement, possible partners
ACRONYMS
AG Auditor General
AIDS Acquired Immune Deficiency Syndrome
BCHP Basic Health Care Package
CBH Central Board of Health
CD4 Cluster of Differentiation 4
CDC Centre for Disease Control
CDF Constituency Development Fund
CHAZ Churches Health Association of Zambia
CS Civil Society
CSOs Civil Society Organisations
CSPR Civil Society for Poverty Reduction
DDCC District Development Coordination Committee
DCMO District Community Medical Office
DIMM District Integrated Management Meeting
EAZ Economics Association of Zambia
EPWDA Eastern Province Women’s Development Association
GDP Gross Domestic Product
GNC General Nursing Council
GRZ Government of the Republic of Zambia
HCC Health Centre Committee
HIV Human Immuno-Deficiency Virus
HMIS Health Management Information System
IAPRI Indaba Agricultural Policy Research Institute
IIAG Ibrahim Indicators of African Governance
IMF International Monetary Fund
INGO International Non-Governmental Organisation
JCTR Jesuit Centre for Theological Reflection
LCMS Living Conditions Monitoring Survey
MCDMCH Ministry of Community Development Mother and Child Health
MCH Mother and Child Health
MDGs Millennium Development Goals
MMR Maternal Mortality Ratio
MNCH Mother, Neonatal and Child Health
MoH Ministry of Health
MP Member of Parliament
MSL Medical Stores Limited
MTEF Medium Term Expenditure Framework
NGOs Non-Governmental Organisations
NGOCC Non-Governmental Organizations Coordinating Council
NHCs Neighbourhood Health Committee(s)
NZP+ Network of Zambian People Living with HIV-AIDS
OBI Open Budget Index
PDCC Provincial Development Coordinating Committee
PEA Political Economy Analysis
PIMM Provincial Integrated Management Meeting
PMO Provincial Medical Office
PS Permanent Secretary
RCZ Reformed Church in Zambia
SAG Sector Advisory Group
SAP Structural Adjustment Programme
SMAGs Safe Motherhood Action Groups
SNDP Sixth National Development Plan
TB Tuberculosis
TFR Total fertility Rate
UN United Nations
ZDHS Zambia Demographic and Health Survey
EXECUTIVE SUMMARY
Background
This political economy analysis is intended to serve as a background paper for CARE Zambia’s use as the organisation designs new programmes in the health sector in Eastern Province. The analysis draws on official reports prepared by Government of the Republic of Zambia (GRZ), donors, academic institutions and multilateral organizations. It also draws upon nationally representative surveys and information from key informants, media and stakeholders that participated in a validation workshop.
The Issue
Having changed to multipartism in the early 1990s, Zambia is a stable country with sound macroeconomic indicators. She has experienced an average of 6% GDP growth in the past decade, inflation is below single digit and tax revenue is growing. However poverty is high especially in rural areas. Gender inequality is high too, with women and girls exhibiting lower literacy levels than males, lower participation in the formal sector as well as in leadership and decision making positions compared to males.
Though a low middle income country, Zambia has poor health outcomes compared to other countries in Southern Africa. It is off track to achieve most of the Millennium Development Goals apart from MDG 2 on attaining universal primary enrollment. Both MDG 4 and 5 on reducing Child Mortality Rate and Maternal Mortality Ratio would require significant efforts and resources if they were to be achieved by 2015. However, it is unrealistic to expect this to happen.
Health sector spending rose to a high of 11% of the discretionary budget but is projected to be maintained at just over 10% in the medium term. This is lower than the Abuja Declaration which requires countries to spend about 15% of their budget on health. The sector is characterized by low human and financial resources, inadequate infrastructure, equipment and supplies. Despite this, misapplication of resources and fraud is commonplace as indicated in several reports of the Auditor General and the scandals of 2005 and 2009. Elite capture is therefore common.
The sector has implemented several reforms over the past 22 years, chief among them were separation of policy and implementation functions, liberalization to allow private practice, decentralization and restructuring and introduction of user fees as a cost sharing mechanism. More recently has been the delinking of maternal and child health responsibility from Ministry of Health to that of Community Development Mother and Child Health. In the medium term are plans to move primary health care to local government. In all these measures the influence of and accountability to health users has been limited.
A key issue in the governance of the health sector is the lack of mechanisms for community engagement for purposes of accountability. Women, young people and men have limited opportunities to effectively determine the quality of services they receive.
Main observations
Zambia is a de jure legal - rational bureaucracy but in fact, it is a neo patrimonial system, where the state and exercise of power is personalised and patronage based. Nepotism, clientelism, patronage and corruption affect the use of public resources and decision making.
The health legal framework is characterised by a lacuna in legislation, an Act that provided for the organisation of the health sector was repealed in 2006 and has since not been replaced. Instead the sector operates under a myriad of policy documents and strategic plans, making follow up on policy implementation a challenge.
The regulatory system is weak, in some cases outdated and under-resourced making it somewhat ineffective. Conflict of interest is a real possibility as actors are practitioners, regulators and policy makers at the same time.
Service delivery is constrained by inadequate budgets, non-disbursements and shortage of skilled staff, equipment and commodities. These issues limit access to quality services as does distance to facilities.
Although the financing criteria take into account population and epidemiological considerations, it is still inequitable. Remote, poor and non-urban districts benefit less compared to their urban counterparts. The emphasis on curative and hospital level financing skews the criteria. Despite this there is limited demand side engagement among civil society.
Most spaces for engagement in the sector are state led at national, provincial and district levels. There are limited non-state led spaces of engagement. This seems to reflect the low level of civic engagement on health issues by civil society. Traditional civil society has been engaged in service delivery in the sector. A lack of skills, resources, being located in urban areas and donor dependence are contributory factors.
Non-state spaces exist at the community level but are not well articulated or utilized. Structures such as the Neighbourhood Health Committees (NHCs) are limited as accountability mechanisms between the health facility and communities. NHCs themselves are often not very gender balanced with women not taking up leadership roles. Stakeholders in the sector at community, district, provincial and national levels have different interests and positions which may not be apparent but which underlie their engagement.
After forming government in 2011 the Patriotic Front (PF) government changed the mandate of the Ministry of Community Development and Social Services to take on responsibilities of mother and child health. The Ministry’s key responsibilities were for social welfare programmes including safety nets. Mother and Child Health were dealt with by the Ministry of Health. The additional responsibilities resulted in the change of name to Ministry of Community Development, Mother and Child Health (MCDMCH). At the District level the District Medical Office was renamed District Community Medical Office and hived off from Ministry of Health to MCDMCH. However, MCDMCH does not have the capacity at the provincial and district level to effectively discharge its additional role. MCDMCH relies on the Provincial Medical Office to ensure planning and budgeting and to monitor performance at district level. However, communication between the Provincial Medical Office and the MCDMCH is not smooth. District Community Medical Office members of staff prefer to be under the Ministry of Health (MoH) to being assigned to Ministry of Community Development, Mother and Child Health (MCDMCH). Given these issues, strategies to increase the influence of excluded groups especially women have to be multi-faceted. Such strategies would need to address both the supply and demand side.
Supply side issues include budgets; allocation, disbursements and utilization. Transparency and accountability for health outputs are equally necessary to monitor. NHCs report that there is limited transparency in the use of resources assigned to community programmes, health centre staff often do not account for the use of these resources. Because of perverse incentives, health centre staff may focus on certain health programmes to the detriment of others resulting in poor outputs.
Strategies for engagement need to take into account patriarchy and other social cultural norms that contribute to women’s low position and the capacity of civil society at different levels. The role of participatory methodologies and media especially radio would be important.
In order to be effective it is necessary to work with different stakeholders so as to gain support and reduce opposition. Reliance on state- led spaces only should not be the norm but carving out new ways of engaging and bringing decision makers to the table is essential. Working within state-led spaces should be pursued but as a commitment to empowerment. Citizen-led mechanisms will need to be improved and increased to provide adequate pressure on state-led spaces to respond to citizens’ demands.
1. INTRODUCTION
1.1 Background
Health care provision and improved performance is a high priority of the Government of the Republic of Zambia (GRZ) as indicated in several policy documents such as Vision 2030, Sixth National Development Plan (SNDP), National Health Policy and Strategic Plan as well as in the Patriotic Front’s party manifesto. Achieving a good health system is a function of a number of factors with governance of the sector being a key issue. How decisions about allocation and management of resources are made and implemented, who benefits or is excluded are important to understand. This is the reason this study has been commissioned. The study which has been commissioned by Care Zambia is intended as an analysis of the political economy of health with particular reference to Eastern Province. Political Economy Analysis (PEA) is concerned with the interaction of political and economic processes in a society: the distribution of power and wealth between different groups and individuals, and the processes that create, sustain and transform these relationships over time[1].
Care International Zambia has worked in Zambia since 1992 partnering with local non-governmental organisations to deliver a range of programmes aimed at improving the lives of the poor, vulnerable and socially excluded people. Core programme areas include women’s empowerment, natural resource management, climate change, maternal/child/neonatal health, governance and accountability. Care emphasises a rights based approach to development engagement. Care is planning a number of interventions that will include mobilisation of communities to increase their engagement in monitoring the delivery of health services with a focus on HIV & AIDS, MNCH and Nutrition. Care has therefore commissioned this political economy study of the health sector at national and local level to feed into the design of new programmes. The specific research question is: Given the current political economy context of the health system in Eastern Province, how can excluded citizens, particularly women, influence the quality of maternal, child and HIV health services delivered in the province?
1.2 Process
The study relied on literature review of GRZ, donor, Civil Society Organisations (CSO) and reports written by academics. Other sources included interviews with key stakeholders at national, provincial and district levels in government, donor community and civil society. Members of several Neighbourhood Health Committees (NHCs) and staff at one clinic were also interviewed. The report has incorporated comments provided at a validation workshop organised by CARE.
A key limitation at the time of preparing report was the inability to conduct interviews with general community members as well as with a wide range of government officials. A major concern has been the difficulty associated with obtaining responses from MoH for the release of current data.
1.3 Framework
Using the Care Governance and Context Analysis and Programme Design Guidance Note as a framework, the report is structured as follows; following on this first section, section two provides a high level country political economy context, section three focuses on the PEA of health sector at both national and Eastern Province level. Section four includes a stakeholder analysis as well as a discussion of spaces. The last section includes the potential strategies for increased citizen influence on use, quality and equity of health services in eastern province and at the national level.
2. COUNTRY CONTEXT OVERVIEW
2.1 Economy
A stable, peaceful country with multi-partism as the accepted political settlement and an economy growing at an average of 6.4% per annum in the last decade[2], Zambia attained low middle income status in 2011. In the late 2000s Zambia experienced a turnaround of the economy arising from a surge in demand for copper, growth in construction, finance, telecommunication and tourism sectors and prudent economic management. Macroeconomic indicators are showing well; inflation has been at single digit, hovering at 7%, debt fell after Highly Indebted Poor Countries’ Initiative (HIPC) and revenue to GDP ratio has improved from 18% to 20%. Zambia’s GDP is above that of other developing countries in Sub Saharan Africa[3]. These gains were accompanied by a marked improvement in the World Bank’s Doing Business Report, which placed Zambia among the top ten reformers in 2010[4]. Zambia’s external ratings have been buoyed by favourable credit ratings, enabling the country to borrow externally on the open market.