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Thursday, August 29, 2013



Katele Kalumba

Health Reforms at Work! This was the optimism Boniface Kawimbe and I had in 1992. A new beginning for the health sector. How does a vision of public health reform erode so quickly? Our learned readers of Zambian print media have been treated to a mixed grill of in-depth critical reviews of Zambia’s health reforms. From  our  colleagues in The Post, we heard Gilbert Mudenda's indictment of  what he terms "cosmetic" changes,  and  Carolyn Banda's dissection of the Health Bill  published in the media by no other than the then Minister of Health Michael Sata appeared to raise a “red card” on health reforms as early as 1995. Her conclusion was simple, donors back off, because the said bill has nothing to do with improving health services. From the Times of Zambia, and during the same year, we  read Gondwani Chirambo's critique of health financing schemes: they are good and they are bad because they hurt the poor. Well, something along that line. Between 1998 to 2000, hell had broken loose for the health sector. The real crush came with the junior doctors strike and their subsequent dismissal. What went wrong? The ideas of health reforms as formulated in 1991-1992 or leadership? Reading from our media, the answer has been difficult to come by.

I have great respect for all these colleagues for their genuine attempts at trying to decipher what Zambian health reforms were about and to be able to be conclusive about the underlying substance or lack of it. Some years ago, 1991 to be precise, when at the aegis of UNICEF, I wrote about  the dynamics of demand regulation in basic education policy, I recall reading Professor Kelly's words about  basic education in Zambia. He wrote: “A declining economy and an expanding population are on widely diverging tracks. The gaps cannot be spanned by tapping additional sources within the public semi-state, private or foreign sectors. What is needed is something that Zambia has not yet thought about, a new method of making educational provision that will make a much smaller demand on resources than the traditional hierarchic institutional modality that few have dared to question”. I agreed with Professor Kelly's analysis. Lazy thinking is one of the greatest dangers to development. The challenge for Zambia's health development was similar to that facing education but even somewhat more complicated by the extent of entrenchment of professional elements..

For Health sector, continuing with reforms is an imperative to effective health services delivery and to prospects for improving health for Zambians. The questions they have raised are begging for answers. And, only bold, clear minded leadership across the board is needed to address the many complex issues in Zambian health reforms.

In the midst of the growing revisionism, I wish to spend time to restate what health reforms were about and to challenge my colleagues who are critical of the path we took as Ministers of Health then that they address themselves to the central rather than euphemeral issues. I will define what I think,, is the impetus which drove our new vision for health reform.

Aware of the four major factors of macroeconomics, epidemiology, envornment and demography as  determinants of health problems in Zambia, the MMD government reformulated our national health policy in a manner that made certain things do-able. The impact of macroeconomic distortions, epidemiology,enviroment and demography have always been facilitated by more specific institutional processes. The proliferation of health providers, the changing patterns of health work and in particular the Third World conditions of health work forced upon the MMD health policy makers the need to recast our health vision in the context of quality over and above the quantity of services provided. The MMD reforms in health care which had received international acknowledgement, were based upon a simple but fundamental vision. This vision was ans still remains to provide Zambians, with equity of access to sustainable and cost-effective quality health care as close to the family as possible.

Equity of access does not mean giving every Zambian village an ambulance and a surgeon. It means providing opportunities for those who seek to use health services, a choice to do so without discrimination. Health for all, implicit in this access principle does not mean equal health. It simply means that within our socio-geographic boundaries, we can access affordable health care when we need it.

Equity of health policies has always been a difficult concept. Our understanding was that equity refers to the extent to which no group or individual receives less than a minimum benefit level or a maximum cost level of health care. We can thus talk in terms of equity of health benefits or equity of health costs. Hence, in access terms, a basic level health package for all that is optimally costed for users minimises the equity constraints for society while allowing for those who can afford higher cost services to have that choice on the principle of individual responsibility for health.

The policy implications  of equity of access to cost-effective quality health care rests upon a resolution of a complex equation involving efficiency, effectiveness and equity. The issues here rest upon a combination of possibilities: that a society can allocate benefits more equitably through increasing the amount of benefits , reducing the population, or diluting the level of benefits. And that a society can distribute costs more evenly by decreasing the sum of the total cost burden, or increasing the relevant (contributing) population in order to spread the costs broadly, or raising the cost level that the members of society are willing to accept. User fees, cost-sharing schemes like prepayment, and many other initiatives like the Mwase Mphangwe Initiative as an in-kind payment for health had all been attempts at figuring out the most satisfactory ways to keep both benefits and costs of health equitably distributed.

The second principle is cost-effectiveness. Health care, costs money. The vehicles to transport the sick and medical supplies, the autoclaves, orthopaedic tables, catheters, antibiotics, and so forth, all cost a lot of money. Someone pays for these services. In Zambia, it is the individual and corporate taxpayer.  The more we tax these people in order to provide free health services, the less money there is in savings for them to invest in improving the economy. Needless to say, that what they pay in tax is not enough to meet our national health costs.

Some of our people may not know that if a Zambian goes to the rural health centre anywhere in the country today as was the case in the 1990s, and gets herself a tetracycline, it is probably paid for by the Swedish and Dutch taxpayer and not by Zambians.  That is a fact. But do the people in Sweden or the Netherlands owe Zambians their health? They have carried us this far out of goodwill. As Zambians, we  have to pay for the costs of the panadols we consume. As long as we can answer how cost is efficiently and reasonably distributed, we also address the question of sustainability.

Cost-effective health care means tailoring our health services according to our means, doing what costs less but provides results intended or desired.  If more Zambians, apart from the few taxpayers who now do, contributed towards the costs of services they use, we can have more and better services. Our health services now operate in the same manner as when one man or woman works to feed a household of twenty adults. In this household, no one else wants to work or contribute. The fact is, one day, that person will collapse.

Zambian taxpayers, who are estimated at 350,000 are fed-up of higher taxes to support free services for almost 13 million Zambians.  And I think, when they complain, we all agree, pointing fingers at the government as a culprit. True, waste in government is part of the problem but free services are a much larger burden for the few in comparison to the cost of government bureaucracy. It is a concern today of course that in the quest for decentralization, we have increased the ci]ost of government by creating unsustainable District administrations. Each new district means new infrastructural demands.  The demand culture in our country is based upon the philosophy of entitlement.  Zambians insist that government provides more and better health services without putting a price on it for the majority to pay. The assumption is that government makes money on its own. It doesn't.  The people of Zambia make money. The more people make money and contribute to the cost of health care, the more and better services we can all have access to.

In addition to asking more Zambians to contribute, cost-effectiveness also means improved efficiency in the management of health resources by health workers. Poor prescription practices, inefficient surgical procedures, incompetence, pilfering of supplies, all cost the taxpayer more money. The patient who is not properly treated will stay longer in the hospital or come back sooner rather than later at an even greater cost to the taxpayer.

That brings me to the other principle, quality care. Quality in health care is the effectiveness with which we attend to the health needs of the population. For the patient in a clinical setting, quality care means the absence of side-effects arising from treatment, ( in technical terms iatrogenic effects), it means a reduced stay in a hospital bed, a positive feeling about the amount of attention received and the way it is provided. It also means access to services when a patient needs them; acceptability of services to the patient; a voice or say in the treatment provided, and last but not least, trust in those treating you and caring for you. When these things are not experienced by the individual who passes through the doors of our health institution, then the job of health care has been less than quality assured.

Finally, our health vision refers to emphasis on family as a focus of our services. The reason is simple. The first health provider is a family member. Sometimes the only "doctor" is a family member who brings home an assortment of herbal medications from the surrounding bushes and beyond.

 It is within the family that decisions to take any of us to the hospital are made. It is family members who will pay for transport bills and ensure that after discharge, the necessary home care to ensure restoration to normal activity, including good nutrition and emotional support, are done. And indeed, after all treatment fails, it will be the family that will have to escort us to our resting places seven feet under.

As Zambians, we all know that in matters of health practice, it is often the woman in the household who knows anything about underfive clinics, CDD, UCI, HEPS, and boiling water to prevent cholera. It is this health worker we must strengthen our partnership with, by organizing our health services conscious of the fact that she is only human. If health services are not designed in this gender sensitive manner, they will fail to produce quality care.

At this point, let me turn to the issues of ethical behaviour. If the principles I have described which lie behind our health services reforms are sound, then the professional conditions necessary to effect them must be specified. The existence of health professions presupposes an ethical principle. Yet, on two separate occasions in two Hospitals in 1995 and during the unfortunate doctors strike that was precipitated by the leadership crisis in the health Ministry during the Nkandu Luo-Ernest Mwansa- David Mpamba era, I came face to face with a depressing reality.  I was told by some young doctors, "who cares about professionalism". I argued, and perhaps in vain (but I hope not) that that is all that makes a difference between plumbers and medicine men and women.

I understood the anger by the junior doctors. What I have never understood is the zeal with which these three ministers believed firing junior doctors was the best policy response to the crisis in health care that the young doctors had identified in their complaints? It is now with hindsight, interesting, that these ministers were after Chiluba’s failed “Third Term” bid which I personally despised, championing order. Having directly been responsible for firing 300 junior doctors, they now wanted to present themselves as the heroes of the suffering public? God help us. This is just a simple question of leadership.