Governance, participatory mechanisms and structures in Zambia’s health system: An assessment of the impact of Health Centre Committees (HCCs) on equity in health and health care Centre for Health, Science & Social Research (CHESSORE) P. O. Box 320168, Woodlands Lusaka, Zambia T J Ngulube, Laxonie Mdhluli, Khuzwayo Gondwe, C. A. Njobvu Regional Network for Equity in Health in Southern Africa (EQUINET) EQUINET DISCUSSION PAPER NUMBER 21 December 2004 This paper has been produced with the support of IDRC (Canada) Table of Contents Terms and abbreviations used .................................................................4 1. Introduction...........................................................................................6 1.1 Background.............................................................................................. 7 1.2 Literature review ...................................................................................... 7 1.3 Previous work done ................................................................................. 8 1.4 Research questions ................................................................................. 9 2. Statement of the problem and objectives .............................................9 2.1 The major objective................................................................................ 10 2.2 Specific objectives ................................................................................. 10 3. Methodology.......................................................................................10 3.1 Tools and techniques............................................................................. 10 3.2 Sampling/sample sizes .......................................................................... 11 3.3 Data entry and analysis ......................................................................... 12 3.4 Quality control ........................................................................................ 12 3.5 Biases and limitations ............................................................................ 13 4. Findings..............................................................................................13 4a Socio-demographic characteristics......................................................... 13 4a.1 Socio-economic characteristics of the areas studied and respondents ................................................................................................................... 14 4a1.1 Community ....................................................................................................... 14 4a1.2 The age and gender distribution and distances to health facilities of respondents................................................................................................................ 14 4a1.3 Age and gender distribution of respondents..................................................... 15 4a1.4 Educational status of respondents ................................................................... 16 4a1.5 Socio-economic status ranking of respondents................................................ 16 4a1.6 Social groups in the community ....................................................................... 17 4a.2 Health, health-seeking behaviour and health status in the study areas................. 18 4b Structure and position of HCCs for good governance in health.............. 19 4b.1 Representative legitimacy of the HCCs.................................................................. 22 4b.2 The performance of the HCCs as governance structures in the Zambian health services since their inception ......................................................................................... 23 4b.3 Accountability ......................................................................................................... 24 4b.4 Competence and appropriateness ......................................................................... 25 4c Performance rating of HCCs in bringing about equity in health .............. 27 4c.1 Some equity gains from the current performance of governance structures in health ............................................................................................................................. 27 4c.2 Performance rating of HCCs in Zambia.................................................................. 28 4c2.1 Effectiveness (key outcome factors)................................................................. 28 4c2.2 Accessibility (structural and functional access) ................................................ 30 4c2.3 Acceptability (structural and proximal).............................................................. 35 4c2.4 Responsiveness (structural and proximal) ....................................................... 39 4d Findings from outcome mapping and stakeholder consultant session ... 40 4d.1 Desired features in the performance of governance structures in the Zambian health system ................................................................................................................. 40 4d.2 HCC activities that one can expect to see in Zambia............................................. 44 4d.3 Activities one would like to see more often ............................................................ 45 4d.4 Activities that stakeholders would love to see more often...................................... 46 4e Desired help to overcome the above barriers (stakeholder views and current performance ratings)........................................................................ 47 4e.1 Potential for sustaining positive initiatives undertaken by governance structures in Zambia’s health system............................................................................. 47 4e.2 Comparison on outcomes from governance variables between high performing and low performing HCCs .............................................................................................. 48 4e.3 Comparison between current performance rating of high and low performing HCCs.............................................................................................................................. 49 4f Community participation and access to health services by the poor/ vulnerable in communities ........................................................................... 56 4f.1 Poverty, disability, vulnerability and health problems experienced ......................... 58 4f.2 Actions taken by HCCs and others to redress their plight....................................... 60 4f.3 Action taken to try solving the health problems of the poor and vulnerable............ 60 4f.4 Health outcomes in last 12 months ......................................................................... 61 5. Discussion ..........................................................................................61 6. Conclusions........................................................................................63 6.1 Comparison of sustaining gains in previous study as reflected by findings in this study..................................................................................... 64 7. Recommendations..............................................................................68 8. References .........................................................................................69 Annexes .................................................................................................71 Annex 1: Prescribed functions and roles of HCCs in the Zambian public health services ............................................................................................. 71 Annex 2: Desired ‘ideal’ definitions of community participation and actions for community participation in Zambia............................................. 72 Terms and abbreviations used Terms used Autonomy That in a partnership arrangement the relationships developed should not undermine each partner’s autonomy. Chingola: A copper-mining town in Zambia Clinician: A health worker trained to diagnose and manage disease conditions Dresser: An untrained health worker authorised to provide clinical care to patients Due process: This notion refers to the arrangements through which partnerships (stakeholder groups) are governed. It incorporates the notion that transparency of decision-making to the public is essential, as well as measures to remove conflicts of interest such that information is not controlled or censored. Equity: The notion that benefits should be distributed to those most in need (especially the poor and vulnerable). High performing: An assessment of the performance of the HCC based on capacity for financial management or capacity to positively influence access to health services by the poor and vulnerable in communities. Low performing: An assessment of the performance of the HCC based on the perceptions of health managers, and/or in relation to the performance of others in a sampled district. Lusaka: The capital city of Zambia Ndola: A copper-mining town (the third biggest town in Zambia) Quintile: Asset scores for 20% of households grouped in ascending order, where quintile 1 represents the lowest 20% of asset scores (the poorest households), quintile 2 the next 20% (the very poor), quintile 3 the next 20% (the middle poor), quintile 4 the next 20% (the less poor) and quintile 5 represents the asset scores for the top 20% of households (the least poor) – this being socially correct terminology for a poor country like Zambia. Abbreviations