What did Zambia do?

1. 1991: Governance structures established at district and community level

• MoH was reorganized to maintain responsibility for national level policy making, regulation and M&E while implementation responsibility was shifted to provincial and district levels through establishment of new management structures at district and community levels.

• Reduction in MOH staff size, from 400 to 67 by 1996.

• District and community governance structures are currently in-practice

2. 1993: District community action planning

• District Health Management Teams (DHMTs) and Neighbourhood Health Committees (NHCs) were established with roles in planning, budgeting, advocacy and service delivery oversight. District Health Boards employed DHMTs.
• NHC membership is drawn from all sectors (government, NGOs, CBOs, private sector) and includes health workers at all levels. NHCs select CHWs and supervise operations.

• Ensured bottom-up planning - DHMTs collate work plans and budgets which are approved by District Health Boards and central level.
• In district studied by EGH, >80% of facilities have active neighbourhood health committees which has promoted grassroot involvement in PHC and improved service delivery for rural populations (e.g., Exemplar districts with active neighbourhood health committees allocated 50-60% of funds to rural health centres)

• District community action planning is currently in- practice.

3. 1993: Sector-wide coordination

• Implemented a sector-wide approach (SWAp) to facilitate government-donor coordination for planning, financing, and monitoring of health activities

• Enabled donors to channel funding directly to districts and provide improved coordination between national financing process and district needs and decision making

• Basket funding discontinued in 2009 due to increases in off-budget disease-specific donor support, not housed under the SWAP Coordination structures for MoH and donors still exist today. Financial spending now monitored by District Health Office using Navision accounting package.

 4. 1993: Donor pooled funds (district basket)

• District basket funding pooled government and donor financing into a common fund and earmarked it for PHC. Since PHC was mainly managed at district level, much funding was held and managed there.

• Enabled resource transfer to and management at district level and improved coordination to harmonize government and donor resources aligned to government priorities

• Basket funding discontinued in 2009 due to increases in off-budget disease-specific donor support, not housed under the SWAp. Coordination structures for MoH and donors still exist today. Donor funds now monitored using Navison accounting package.

 5. 1993: National health benefits package

• National government defines an essential health benefit package (EHBP) by measuring the cost effectiveness of various PHC interventions.
  
• The essential package is re-costed regularly, and provides the basis for guidelines for funding districts.
  
• The package also covered HRH and supplies, and was used to guide planning for the skills and staff mix for facilities at all levels, based on disease burden and population.

• The EHBP definition process highlighted how potentially efficient it would be to invest in cost-effective PHC interventions, particularly prevention - led to a commitment to dedicate 60% of health care resources to PHC.

• EHBP expanded to include second and third- level hospital level resources in 1998 and is being assessed for the potential to include secondary and tertiary services.

 6. 1994: National health strategic plan

• Stated national vision to "provide Zambians with equity of access to cost-effective quality health care as close as possible".
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  Developed process to coordinate stravtegic planning across levels - action and budget plans developed by communities are informed by national strategic plans and are reviewed for funding by the district.

• Strategic planning has expanded to include disease specific strategies as well as plans for specific functions of the health system (e.g., HR, information technology)

• National health strategic planning has existed in 5-year cycles ever since first initiated in 1994. Bottom-up strategic planning is currently in practice.

 7. 1994: Performance- based financing

• Performance-based financing made population-based district funds contingent on satisfactory performance audits and financial reports.
• Majority of district budgets are allocated to staff payments. which are cleared centrally;districts control only "10-20%" of total cash budgets through operational grants for emergencies and acute need.

• Improved equity in the distribution of resources based on geography, population, and material need.
• Greater prioritization of PHC facilities by ensuring resources did not automatically flow to secondary/ tertiary facilities in more populous or affluent geos.
• Increased accountability for performance while enabling greater autonomy through greater predictability of funds and clearer facility policies.

• Performance-based financing is currently in- practice.

 8. 1995: User fee exemptions and removal

• User fee exemptions were implemented for certain populations (e.g., age requirements, pregnant women, disease categories, means- tested qualification). 

• User fee exemptions increased the affordability of care and enabled access to PHC services for vulnerable populations.

• User fees are still exempt for specified populations.

 9.1996: Digitized information systems

• HMIS created to digitally monitor health inputs, outputs, and outcomes data. Data collection is paper-based at facility level, then digitized aggregated + digitized by District Health Office.
• District financial data is collated annually by DHMTs and fed back to MoH.
• Financial and Administrative Management System established, initially at district level and then scaled up.
• Additional information systems established for Community-based activities and outreach with reporting from CHWs as well as Electronic Logistics Management System for drugs and medical supplies.

• Implementation of national information systems improved data sharing and care coordination across facilities.
• Implementation increased the interoperability of data records and information across facilities and enabled health workers with improved measurements for care decisions.
• Establishment of FAMS contributed to more transparent reporting on how funds were being used.

• Digital informationn systems are currently utilized.

 10. 1996: Administration and coordination of health service delivery

• The Central Board of Health (CBoH) was established as an autonomous public agency and engaged by MoH through a purchaser-provider agreement. It was responsible for governing service delivery, priority setting, resource management and performance monitoring.
• Later (2000-2004), the allocation formula was revised to reflect material deprivation and poverty levels to ensure greater equity in allocation decisions.

• CBoH shifted resource allocation models from population-based allocation to performance contracts based on performance audits, financial reports, and performance review of district basket funding. When CBoH dissolved, the allocation formula changed to adjust for material deprivation to improve equity, and channel more resources to PHC and lower-level facilities.

• CBoH operated from 1996-2006. It was dissolved in 2006 due to political reasons and certain functions were reabsorbed by MoH. The legacy of CBoH left a cadre of professionals with management and evaluation capacity.

 11. 1999: PHC services

• Districts have invested more spend into community health assistant (CHA) and community health worker (CHW) outreach efforts which include home- based care, field visits, and other community-driven PHC initiatives.
• Child health week introduced to provide under-5 immunization and nutritional supplementation; range of services expanded over time.

• Community outreach ensures essential health services are accessible depending on needs - irrespective of situational factors.
• Increased household coverage per CHW and more than doubled household visits in rural areas.
• Improved geographic and financial access to health services (e.g., Decrease in travel time to PHC facilities).

• CHWs and CHAs are still in-practice today and exemplar districts continue to provide community outreach to supplement physical infrastructure in rural areas.

 12. 2000: Infrastructure expansion

• National policies focused on investing in close to community service delivery prioritized expanding physical health infrastructure (e.g., health posts) in hard-to reach areas.

• Additional infrastructure improved geographic and financial access to health services (e.g., Number of facilities increased more than 2x from 2000 to 2017).

• Number of facilities continue to increase as part of Zambia's 2030 vision to expand access and close the rural coverage gap.

 13. 2003: Health worker retention scheme

• In response to HRH crisis, the Health Workers. Retention Scheme (HWRS) was launched in 2003 to recruit and train local doctors to deploy in rural areas; it was later expanded to include all clinical cadres. Highest benefits were given to staff in most remote locations.

• CHW absenteeism and retention has improved (90% decrease through 2010), and professionalization of health workers alleviated the clinical staff gap in rural areas.

• HWRS is currently in- practice and has expanded across Zambia provinces.

 14. 2006: Zambia Vision 2030*

• Outline of the long-term development policies of Zambia - including "equitable access to quality health care by 2030".
• The vision prioritized equity by setting a target to increase the population of rural households within 5km of a health facility by ~30% by 2030.

• Elevated equity as focal objective in Zambia's health agenda.
• Increased investment in health resources to help close the coverage gap in rural areas (e.g., health facility expansion, HRH optimization)

• Vision 2030 is currently in-practice and has set Zambia's agenda of facility and CHW expansion.

 15. 2006: Digital procurement systems*

• Digital procurement systems collate financial and supplier data at the district level to inform DHMTs on HR and procurement decisions for drugs and supplies.

• Informed procurement decisions on drugs and supplies.

• Digital procurement systems are currently in- practice.

 16. 2006: National health strategic plan

• The national strategic plan from 2006-2010 established a target to increase the full immunisation and PHC coverage rates for children by ~40+%

• Prioritized vaccine and essential health service delivery.
• Encourages implementation of data tools to track PHC coverage and immunization across populations.

• Strategic plans are refreshed every five years, and essential PHC coverage continues to be reflected as a priority.

 17. 2008: National health operational plans*

• Plans provided details to improve training, supervision, and coordination of health worker responsibilities, and to identify appropriate performance indicators for the workforce.

• Increased investment in innovative renumeration and incentive schemes to retain health workers.
• Identified KPIs and data-driven targets to measure and track health worker performance.

• National and subnational health operational plans are currently in-practice.

 18. 2008: Results based financing

• Provision of incentive payments to both district-level management and health facilities based on performance.
• Supported the improvement of data quality, with incentives applied to data collection, analysis, and reporting.

• The donor-funded program concluded in RBF donor-funded 2019 but scaled to provide support program concluded in across Zambia (all 10 provinces).
• Increased both the availability and quality of data generated by the HMIS to inform evidence-based decision making.

• RBF donors-funded program concluded in 2019, but results-based financing mechanisms are still deployed by many provinces.

 19. 2011: User fee removal at all PHC facilities

• User fees removed, starting in rural areas (2006) and later at all PHC facilities in the country (2011).
• Additional reforms like performance-based financing and budgeting process improvements further improved the cost of care.

• User fee removal improved financial access to care and promoted equity-oriented health financial policies - discrepancies in PHC coverage across income groups improved 30+% across core indicators.

• User fee exclusions are currently in-practice.

20. 2013: Community health assistant strategy

• National strategy to scale community health assistant (CHA) workforce was launched in 2013, with goal to increase coverage of home-based care interventions across conditions and close the rural coverage gap.

• CHAs increased "2x by 2020, and first cohort of community health assistants spent 80% of time on community outreach.

• CHA and CHW incentive schemes are currently in- practice and additional cohorts of CHAS/CHWs have been launched.

 21. 2014: Rural health and community health incentive schemes

• As extension of the Health Workers Retention Scheme (HWRS), the HWRS Sustainability Strategy implemented in 2014 identified monetary and non-monetary incentives to recruit and train CHWs.

• Professionalization and renumeration of CHWs alleviated the clinical care gap in rural areas and decreased absenteeism across the country.

• CHA and CHW incentive schemes are currently in- practice and additional cohorts of CHAS/CHWs have been launched.

 22. 2015: Sustainability strategy*

• Sustainability strategy for Health Workers Retention Scheme initiated in 2015 to identify additional non-monetary incentives that are cost- effective.

• Steady increase in doctors' and nurses' availability. Density increased from 7.1 to 10.2 per 10K population between 2005- 2019.

• CHA and CHW incentive schemes are currently in- practice and additional cohorts of CHAS/CHWs have been launched.