International Development CommitteeWritten evidence submitted by Marie Stopes International
1. Introduction
1.1 Zambia is changing. A population growth rate of almost 3% per year is leading to rapidly growing urban slums and increasing numbers living in remote rural areas. In addition to greater focus on reproductive health, Zambia’s health system needs to adapt and modernise to meet this challenge. This must involve new models of service delivery that can function effectively in areas lacking basic infrastructure, and integrating the service providers with experience in these systems into government plans for public healthcare. This submission identifies four key ways in which DFID can have a transformative impact upon both reproductive health and the health system as a whole in Zambia.
2. MSI Zambia
2.1 MSI Zambia (MSIZ) is a relatively young member of the MSI partnership having opened its first clinic in 2008. Nevertheless, it is already a major agency in the delivery of sexual and reproductive health services in Zambia, including HIV/AIDS and family planning. In 2011 MSIZ delivered reproductive health services to over 38,000 clients including more than 21,000 young people.
2.2 Geography presents a major obstacle to accessing services across much of Zambia. Rural communities are typically situated long distances from public health infrastructure with poor road networks. Urban slums grow at a rapid rate with large areas without power or fresh water supply. MSIZ therefore plans to launch a network of mini-clinics situated within the communities that are underserved. These mini-clinics will provide essential SRHR services and provide a point for referral to larger clinics. Nevertheless, the clinics would be able to achieve an even greater impact if various government restrictions on non-state health service providers were removed. Examples of these restrictions with recommendations for UK action are given below.
3. DFID in Zambia
3.1 DFID’s strategic commitment to improving the lives of women and girls is in strong evidence in Zambia. Key interventions by DFID in this field include partnership with Population Council for support to adolescent girls; with Abt Associates for family planning service delivery; and with MSIZ for reproductive health services including family planning.
3.2 DFID is also making strategic interventions to strengthen the overall health system. Notably, DFID is helping to address the chronic shortage of health workers in Zambia with support for training and recruitment of nurses and community health assistants.
3.3 MSI applauds DFID’s investments for both the empowerment of women and girls and for health system strengthening. We urge DFID to build upon this strong platform by leveraging its influence as a health sector partner to the Government of Zambia to support policy reform for stronger health systems. A stronger policy environment within the Zambian health system would enable DFID’s investments to achieve even greater impact. We outline three key ways in which political support from DFID can have a catalytic affect on improving health services for women and girls. We also identify two key strategic interventions where additional DFID resources would have maximum impact upon access to RH services in Zambia.
4. Recommendations
4.1 Support for task-sharing long-acting and permanent methods of family planning (LAPM)
The shortage of doctors in Zambia is particularly acute yet many LAPM, such as contraceptive implants, are restricted by national health policy to provision by doctors only. This is exceptionally restrictive in rural areas because the vast majority of Zambia’s few doctors are based in urban centres. Relaxing these restrictions so that mid-level providers, such as non-physician clinicians, nurses and midwives can be trained to provide LAPM in line with health care research—as many countries in the region have safely done—would remove a key bottleneck constraint on improving access to family planning. DFID should use the political capital obtained through its support for the health workforce to persuade the Ministry of Health to “task-share” LAPM with doctors and nurses and midwives.
4.2 Fostering more constructive engagement between government and non-state health providers
The Zambian medical authorities continue to rely upon a number of outdated and unnecessary restrictions on health service delivery. These include restrictions on the ability of clinics to publish basic information to the public about the availability of the services they offer. Importantly, minimum standards for clinics around staffing and infrastructure have not yet been adapted for small, local clinics (such as the MSIZ mini-clinic), leading to a number of obstacles and impracticalities for any provider attempting to serve hard-to-reach populations. We urge DFID to be pro-active in encouraging government to evolve its understanding of the health system to be more inclusive of the non-state providers at their disposal. This should include utilisation of ‘convening power’ to facilitate dialogue between government and non-state providers with regards to a more enabling policy environment.
4.3 Constitutional support for women’s empowerment
We urge DFID to encourage the Government of Zambia to ensure that Zambian constitutional reform, currently in process, is used to advance women’s rights and leads to no erosion of rights already established.
4.4 New targeted interventions
Government investment in RH remains substantially below what is required for Zambia to achieve its MDG5 targets. Under investment in services is particularly acute for both the large rural population and for services accessible to Zambia’s large youth cohort. We urge DFID to focus upon the following areas for additional strategic investment in order to maximise their impact upon RH in Zambia:
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April 2012