2009年-世界发展银行全球_Zambia_Health_Sector_Public___Accounting_for_Resources_to_Improve_Effective_Service_Coverage_116页_1mb

Summary of the Zambia Health Sector Public Expenditure Review

Core Content

This document presents a comprehensive analysis of the Zambia health sector's public expenditure, focusing on resource accounting, budget allocation, and service delivery performance. It is based on three main components: the National Health Accounts (NHA), the Public Expenditure Tracking and Quality of Service Delivery Survey (PET/QSDS), and the Marginal Budgeting for Bottlenecks (MBB) modeling exercise. The study aims to improve the understanding of how resources are allocated, managed, and utilized within the health system to enhance service coverage and quality.

Main Objectives and Analytical Tools

• Objective: To assess the efficiency and effectiveness of public expenditure in the health sector and identify bottlenecks in service delivery.
• Tools Used:
  • National Health Accounts (NHA): To analyze total and per capita health expenditures, and their sources.
  • Public Expenditure Tracking (PET): To track the flow of funds and their use at the facility level.
  • Quality of Service Delivery Survey (QSDS): To evaluate the actual state of health facilities and services.
  • Marginal Budgeting for Bottlenecks (MBB): To model scenarios for scaling up service coverage and meeting the Millennium Development Goals (MDGs).

Key Findings

1. Health Expenditure Trends

• Donor Financing: Donor spending has increased rapidly, but a growing proportion is off-budget, and more is directed to administration than service provision.
• Government Spending: The Government of the Republic of Zambia (GRZ) contribution to health financing is declining, while discretionary funding is rising.
• Household Spending: Households spend more than expected on health, mainly in the private for-profit sector and on traditional healers.
• Cost Analysis: MOH facilities have higher labor costs, lower drug and capital expenditure compared to for-profit facilities.
• Per Capita Spending: Zambia's per capita total health expenditure (THE) is higher than its neighbors but lower than middle-income Southern African countries.

2. Public Expenditure Tracking (PET/QSDS) Results

• Inter-sectoral Allocation: Despite efforts, GRZ health allocations have not increased significantly. There is a lack of consensus between MOFNP and MOH on the sector's funding needs.
• MOH Allocation: Resource allocation within the health sector is based on inconsistent principles. District health management teams (DHMTs) do not always plan effectively, and hospital allocations are based on historical spending patterns.
• Geographic Allocation: Resource distribution is highly inequitable, with poorer and more remote provinces receiving less per capita funding.
• Fund Releases: MOH released more funds than budgeted in FY05, indicating improved fiscal discipline. However, DHMTs delayed releasing district grants, and some facilities received less than their allocated funds.
• Debt and Funding: A quarter of health facilities are indebted, mainly for utilities and transport. The imprest system is prone to delays.
• Fee Abolition: Fee abolition has led to a critical need for alternative income sources, especially for Urban Health Centers (UHCs) that rely heavily on fees. This could reduce staff morale unless replaced by other incentives.

3. Quality of Service Delivery

• Infrastructure and Equipment: Most infrastructure is outdated, but staff maintain it. There are significant deficits in utilities, communications, and transport. Medical equipment is generally functional, but non-medical equipment has high rates of non-functionality.
• Human Resources: High staff vacancies (33.5%) and absenteeism (21%) are major challenges. Clinical staff vacancies are particularly high (41.4%). These issues reduce the number of full-time equivalent (FTE) workers and increase patient waiting times (average: 65 minutes).
• Salary Management: Salaries are highly compressed and subject to delays, partial payments, and unauthorized deductions. These practices reduce worker motivation and lead to dissatisfaction (44% of staff).
• Drugs and Supplies: Drug availability declined in 2006 due to a 15% budget cut. Over 55% of hospitals and 46% of rural health centers reported expired drugs. Inappropriate drug use was found in 14% of facilities.

4. Bottlenecks in Service Delivery

• Despite reasonable service availability, bottlenecks exist in accessibility, utilization, timeliness, continuity, and quality of care.
• Bottlenecks are observed in all three types of service delivery: community-based, population-based outreach, and facility-based.

5. MBB Modeling Exercise

• MDG Projections: Current trends suggest Zambia is unlikely to meet its MDGs. Child health indicators are stagnant, and maternal mortality is increasing.
• Scaling Up: The MBB model outlines five steps to improve service coverage and reduce maternal and child mortality. These steps are sequential and prioritize "big-wins" such as reducing under-five and maternal mortality.
• Cost Estimates: Phase I would cost US$4.36 per capita annually, and Phase II would cost US$9.07 per capita annually.
• Expected Outcomes:
  • Phase I: 24% reduction in child mortality.
  • Phase II: 46% reduction in child mortality and 16% reduction in maternal mortality.

Key Recommendations

1. Obtain National Commitment to Increase Fungible Financing

• The government must recognize the health sector's crisis and coordinate with donors to ensure more flexible and fungible financing.
• MOFNP and MOH should align on the medium-term spending requirements of the sector.
• Donor shift from projects and basket funds to budget support should be welcomed by MOH to increase fungible resources.

2. Formulate an Overall Wage Strategy

• A comprehensive wage strategy is needed to address the human resource crisis.
• This strategy should be informed by the ongoing HRH productivity study and medium-term fiscal sustainability.
• Incremental approaches have not been effective; a sustainable and strategic approach is required.

3. Improve Payroll Management

• Salary management issues, though affecting a minority, have a significant impact on morale.
• Delays and partial payments should be eliminated to ensure timely and full compensation.
• The government should improve transparency and accountability in salary disbursement.

4. Strengthen Supply Chain Management

• There is a need to improve the availability and management of drugs and medical supplies.
• A more reliable and timely drug supply system should be established to ensure essential drugs are accessible to all facilities.

5. Enhance Service Delivery Monitoring and Evaluation

• Regular monitoring and evaluation of service delivery should be implemented to identify and address bottlenecks.
• The quality of patient care, especially in technical aspects, should be improved through better training and supervision.

Conclusion

The Zambia health sector faces significant challenges in resource allocation, service delivery, and human resource management. While donor financing has increased, it remains non-fungible and often overshadows national priorities. The government needs to increase its flexible funding and coordinate with donors to ensure effective resource use. A strategic approach to wage management, improved payroll systems, and better supply chain oversight are essential to enhance service coverage and quality. The MBB model provides a roadmap for scaling up services and meeting the MDGs, but its implementation requires strong political will, effective planning, and sustainable financing.