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The challenge of hospitals in health sector reform: the case of Zambia.
Nordic Council of Ministers, Nordic School of Public Health NHV. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), The World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland.
2001 (English)In: Health Policy and Planning, ISSN 0268-1080, E-ISSN 1460-2237, Vol. 16 Suppl 2, 29-43 p.Article in journal (Refereed) Published
Abstract [en]

Zambia underwent a period of health sector reform from 1993 to 1998. The reform attracted substantial support from the World Bank and bilateral donors. While significant achievements were made with respect to decentralization, increased accountability and donor collaboration, the reform stalled in 1998 without having achieved its objectives, largely because of the handling of hospital reform and the civil servants in the health sector. This study was an attempt to analyze this experience with the hospital issue. Service and infrastructure information was collected from all 88 hospitals in the country. Further, information was collected about the social, economic, and political context of the reform. The results show that an historical legacy from the colonial and post-colonial eras has left the country with an expensive and skewed hospital structure that is rapidly deteriorating and very difficult to reform. The referral system is not functioning: higher-level hospitals provide a higher level of care to their immediate catchment populations than is available to the population in general. The reality is thus far from the vision of equity of access to cost-effective quality care. Zambian doctors have either left the country or are concentrated at the highest referral levels in two provinces, leaving the lower levels and most of the country in the hands of expatriate doctors. There are no resources in the government or the private systems to maintain the current hospital infrastructure and things will likely deteriorate unless radical decisions are taken and implemented. The study further shows that the question of hospital reform is a political high-risk zone. If the problems are to be dealt with, the Zambian planners must, together with the politicians, work to create a broad national consensus for understanding the situation, its urgency, and the limited options for forward action.

Place, publisher, year, edition, pages
2001. Vol. 16 Suppl 2, 29-43 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:norden:org:diva-3791PubMedID: 11772988OAI: oai:DiVA.org:norden-3791DiVA: diva2:787364
Available from: 2015-02-10 Created: 2015-02-10 Last updated: 2017-12-04Bibliographically approved
In thesis
1. 1990 - 2000: A Decade of Health Sector Reformin Developing Countries: Why, and What Did We Learn?
Open this publication in new window or tab >>1990 - 2000: A Decade of Health Sector Reformin Developing Countries: Why, and What Did We Learn?
2005 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objective: The overall aim of the work is to contribute to a better understanding of the dynamics between health sector reform policies and practices as well as the factors that determine and shape the thinking about global public health; and to try out a framework for understanding the inter-linkages and interactions between the determinants for and the elements of health sector reforms and their implementation.

Methods: The object of study was a contemporary phenomenon, consisting of a diverse array of interventions in many different directions and fields within a complex political, social and economic environment. It is difficult to attribute the effects of the reforms to any single intervention or to establish exact boundaries between the phenomenon and the context. Therefore, a multi-stage case study research strategy, based on the work of R.K.Yin, was chosen. The study involved two major sub-units of analysis, i.e., the macro and the micro level. Each of these involved several sub-units of analysis. The analysis of the micro level further comprised a cross-case analysis of 10 individual case studies conducted in six developing countries.

Results: Clear linkages were found between the greater societal processes and the shape and results of reforms during the decade. The reforms had not been completed in any of the countries studied, but appeared to be stuck with undesired effects, lacking energy to move forward. Contributing to this was the diminishing role of the state, which bordered abdication from public health in most of the countries, leaving the drive to the market and individual demands and interests. The net effect could well be a reversal of some of the public health achievements of the past - however, it was also found that reverting to dedicated disease control programmes would not be the answer, as these were found unsustainable and undermining the health systems.

Conclusion: There is a divide between libertarian and utilitarian values on the one side and communitarian and egalitarian values on the other. Thus, it is not just about public health practitioners not being good enough to implement, it is more so about what we want to achieve and what it acceptable respectively not acceptable and reaching compromises. This place the societal processes at centre-stage for public health. However, it is also about implementation, it is about how public health policy-makers and reformers can effectively dialogue and facilitate achieving consensus and translate the societal 'wants' and 'want nots' into managerial bites. Implementation becomes a process of constant adjustment and readjustment oscillating between political and technocratic levels

Publisher
110 p.
Series
NHV Reports and Doctor of Public Health-Theses, ISSN 0283-1961 ; NHV Report 2005:2
Keyword
Health sector reform, values, implementation, developing countries, international public health
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:norden:org:diva-3794 (URN)91-7997-111-3 (ISBN)
Public defence
2015-06-01, Nordic School of Public Health NHV, Göteborg, Sweden, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-02-10 Created: 2015-02-10 Last updated: 2015-02-10Bibliographically approved

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