Published on January 20, 2008
Implementation of Equity Policies at the Grassroots level – A policy Process Analysis of Planning and Budgeting for Equity in Primary Health Care provision in Zambia : Implementation of Equity Policies at the Grassroots level – A policy Process Analysis of Planning and Budgeting for Equity in Primary Health Care provision in Zambia T. J. Ngulube, L. Q. Mdhluli, K. Gondwe, C. A. Njobvu The Centre for Health, Science & Social Research (CHESSORE) P. O. Box 320168, Woodlands Lusaka, Zambia Email: firstname.lastname@example.org Budgeting for Primary Health care in Zambia: Budgeting for Primary Health care in Zambia Background: - Good economy + Independence Top-down budget policy (Free care + more facilities) Economic down turn Deteriorated health system, shortages (staff, supplies, funds, run down facilities) Health Reforms - 1980’s Attempts at reforms with community participation priority setting at grassroots “the bottom-up” priority setting approach Expected results maximum benefits - from rational use of meagre resources, consensus on local health priorities and budget allocations “Equity of access to cost-effective quality health care as close to the family as possible for ALL Zambians”. Presentation Angle of Focus: Presentation Angle of Focus Budgeting in Zambia is assumed to allow a bottom-up involvement in priority setting. In reality the extent and nature of the involvement of implementing actors and communities is limited by restrictive budget guidelines and conflicting understanding of the purpose of budgeting Sample Sizes and Level of Actors Interviewed in the study: Sample Sizes and Level of Actors Interviewed in the study Methodology - 1: Methodology - 1 Tools used Interview schedule Review of available documents Sampling DHMT (MPD + District Director) Health Centre in-charge + Other staff Community level HCC Chairperson Key Informants Other HCC members Community Health Worker Influential community members (Business) Community leaders (Chiefs, chairpersons, etc) Application of tools Methodology - 2: Methodology - 2 Application of tools Started at Community level Then Health Centre level Then District level This helped to take issues for clarification to next (higher) level Analytical Framework used Policy process analysis using The Walt-Gilson Triangle ANALYTICAL FRAMEWORK- “The WALT-GILSON Triangle”________________________________________________________________: ANALYTICAL FRAMEWORK - “The WALT-GILSON Triangle” ________________________________________________________________ Actors invited and involved in the budgeting process : Actors invited and involved in the budgeting process DISTRICT LEVEL District Health office District Hospital Health Centre In-charges (+) HCC Chairpersons Others (NGO, Donors, FBOs, CBOs, etc) HEALTH CENTRE LEVEL Health Centre in-charges + Other health staff HCC Members CHWs + NHC members CBOs, NGOs, FBOs, Influential community members, etc COMMUNITY LEVEL HCC members “The People” RESULTSKey Actors and Knowledge of Policy Content: RESULTS Key Actors and Knowledge of Policy Content Key Actors and Context Factors: Key Actors and Context Factors The purpose of a District Budgeting Workshop Meeting: The purpose of a District Budgeting Workshop Meeting “We were told not to prepare big budgets for our 2004 Action Plans. They also advised us not to budget for what was ideal but for what was practical, realistic or attainable. They also introduced us to some co-operating partners such as CARE, JICA, CDC, AED, and others that I cannot remember because we were many of us in attendance.” – Recollection by a Nurse who attended a recent priority setting meeting Contributing to a District Priority Setting Workshop : Contributing to a District Priority Setting Workshop “We had no choice but to follow what the DHMT told us. We just want to go by their word so that when things fail we will also point a finger at them. If we do otherwise and things fail they will blame us and find excuses as to why we didn’t receive our budgeted for funds.” – Health Centre-in-Charge Other Contextual factors in budgeting for PHC: Other Contextual factors in budgeting for PHC Actors and Procedures - 1: Actors and Procedures - 1 Actors and Self-interest: Actors and Self-interest Power Play in Budgeting at a Health Centre : Power Play in Budgeting at a Health Centre “We sat down with community representatives from all the 10 zones We told them not to have a ‘wish budget’ that was ideal but instead one that was ‘real’ and practical just as the DHMT had advised. The communities also had brought with them long lists of items, but we had to priorities them by considering the common ones. Since the community representatives are ‘our eyes’ we have no problems in agreeing on issues of common interest” – Health Worker Actors & Budget “Dislocation”: Actors & Budget “Dislocation” On HCC Participation in Budgeting: On HCC Participation in Budgeting “We were told that some of the problems shall be excluded on account of lack of adequate funds to cover them up. Besides, we were not clearly told how inadequate the allocated funds were. Some of the excluded community prioritized health problems involved construction of fee-paying toilets in the neighborhoods to be run and controlled by the community and the acquisition of a hammer mill” – HCC Chairman Community Confidence & Trust in HCCs on Budgeting : Community Confidence & Trust in HCCs on Budgeting “Some of our people have shed off some trust in us as their legislative body on account that every year we ask them to prioritize the same community health problems which are not being implemented. This is quite frustrating on our part as leaders; They tell us that we are ineffective and weak as leaders or that health workers have bought us off. They no longer entertain issues of lack of funds or inadequacy of it; They tell us, “Why do you budget every year if they (Health Centre and/or DHMT) claim to have no money. You cannot invite people to share a meal with you when you do not have food.” – HCC Member Community solidarity on health: Community solidarity on health “We know that we are the ones who are directly affected so what we do is to mobilize our communities and try to collect garbage on our own; But some members of the community as usual do not co-operate. They do not want to work for nothing. They always want to be paid even if it is they themselves whose health is at stake.” – HCC & NHC Member Conclusion: Conclusion The introduction of a bottom-up approach in priority setting for primary health care in Zambia was thought to be a more beneficial approach for a resource constrained health system; But in reality, the process has been characterized by varied interests and used for different purposes, making it difficult to achieve the intended health equity goals.