PANOS London - Monday, May 19, 1997
Pelekelo Lisaniso

It works like this: instead of waiting for donors to tell him what to do as a condition of loans or grants, Health Minister Katele Kalumba has drawn up his own plans for reconstructing the health system, and asked donors to fund them.

They pay into what Kalumba calls a "basket," from which the Health Ministry distributes the 'bread' in the way that it thinks will most efficiently rebuild the health system and implement the national health plan.

"We don't want individual projects 'made in Japan', 'made in the USA' etc. We don't want project funding, but sector funding. I call it 'basket funding'," Kalumba told Panos Features.

For example, many countries have found that donors for child immunisation often create projects which are quite separate from a country's health system. Ignoring it, and coming in direct to the children, they may save lives -- but do nothing to build up the health infrastructure, and may even end up demoralising health professionals.

In Kalumba's scheme, the immunisation donors pay into his basket, and he uses the money to immunise children through the Zambian health system, thus helping it grow.

"I've told a team from theold Bank that came here: 'learn from us. We will make mistakes; but we will learn from our mistakes.' The process of social learning requires that yo embrace error," he said.

One error may be that patients who cannot afford it are being asked to pay. This was evident in a research project commissioned by the Swedish development agency SIDA very early in the project implementation:-

"On 13 July 1994 in Lewanika Hospital, Mongu, a member of the research team engaged in interviewing staff witnessed the arrival of an acute malaria case, a boy of about 14. His penniless parents were turned away by Registry staff, as they did not have K wacha 300 (0.23 dollars) for registration or K 500 (0.38 dollars) to see a clinical officer. They left to seek help from relatives in the town, but within two hours the boy was brought back dead," the report said.

In 1997, the problems remain -- one needs look no further than the congested Luanga township of Lusaka, where talk of health reforms means little.

Here, Joyce Phiri, unemployed mother of four, and her husband -- also unemployed -- scrape a living by street-vending.

The couple have managed to build a two-roomed house in the shanty town, but it lies close to the main sewerage plant of Lusaka. They have a shallow pit latrine. Tap-water is rarely available -- a borehole sunk close to the sewerage outfall is their main source of driking water.

"For our health, we have been told that we should get a pre- payment insurance scheme, but some of us just can't afford to pay the K 800 (0.61 dollars) eery month -- so we just stay at home when we fall ill," Mrs. Phiri said.

"Most of us suffer a lot from malaria," Ruth Chikuni, a neighbour, said, pointing at the sewerage ponds.

"We are always sick here. And as for me, it's even worse because our house is rented. We pay K 18,000 a month (14 dollars) and sometimes we have to go to bed without eating So when it comes to paying for medical treatment, i s indeed a luxury, even thou gh it is a matter of life and death."

Another neighbour, 31-year-old Afaleti Sakala, said there aren't enough doctors or medicines in the shanty town. "We are often given prescriptions to go to town to buy medicines -- but are these reforms? Reforms to be told to buy in town? That's why we have a lot of private clinics mushrooming," she said.

But Health Minister Kalumba vigorously defends hireforms, saying his government, on assuming power in 1991, was faced with such problems of infrastructure and misallocation of resources, "very little was trickling down to the basic health problems of ou r people."

"We were losing most of our manpower to South Africa, Botswana and so on because of very poor conditions of work," Kalumba said. "At the same time we were faced with epidemics of cholera, very virulent forms of malaria, and the collapse of local government.

"On top of that our national debt per capita was the worst in the world, and our relatinship with donors was very poor. That's the environment in which we had to try to improve the health status of our people Starting from there, we set the goal of a h e alth system that was equitable, cost-effective, quality-assured, and as close to the family as possible. That's the vision we still have."

Kalumba said he is reviewing a wide range of "financing mechanisms" for payment of medicare, including user fees, pre- payment shemes and payment in kind.

"For example, the Jerusalem community in Chipata said they wanted a maternit block, and with our technical advice they built it themselves, and paid for it themselves with a community charge in maize, sold at the market."

"Poverty yes; dependency and patronage no," the minister declared. "Don't make the poor less human because you give them your food relief or concessions on this or that. People want to contribute. But user fees should not just be in terms of money."

User fees or not, many problems remain -- there have been a rash of cholera cases and a recent outbreak of suspected bubonic and pneumonic plague in the Southern Province shows much work needs to be done.

But Kalumba claims the policy is working -- doctors have been lured back and morale in the health system is rising; HIV incidence in the 15-19 age group is beginning to fall; family planning coverage has increased significantly; and immunisation overage

is the highest ever (polio coverage is 85 percent now, compared to only 40 percent in 1991.)

Optimistically, Kalumba believes Zambia can fund its own health care without donors from the year 2001. "Nothing is impossible if you dream," he says. (END/PANOS/PL/DDS/97)

970519
PS970502

Copyright © 1997 - Panos Institute. All rights reserved. Reproduced with permission. Reproduction of this article (other than one copy for personal reference) must be cleared through the Panos Institute, Permissions Desk, 9 White Lion St., London N1 9PD, UK TEL: (+44) 171 278 1111 FAX: (+44) 171 278 0345  http://www.oneworld.org/panos/
Email:panos@panoslondon.org.uk