Institutional pluralism, two publics theory and performance reporting practices in Zambia’s health sector

Purpose: The purpose of this paper is to investigate accounting and performance reporting practices embraced in the midst of a pluralistic institutional environment of an emerging economy (EE), Zambia. The research is necessitated due to the increased presence and influence of donor institutions whose information needs may not conform to the needs of local citizens in many EEs. Design/methodology/approach: The study draws on institutional pluralism and Ekeh’s post-colonial theory of “two publics” to depict pluralistic environments that are typical of EEs. Primary data were collected through semi-structured interviews with 33 respondents drawn from the main stakeholder groups involved in health service delivery including legislators, policy makers, regulators, healthcare professionals and health service managers. Data analysis took the form of thematic analysis which involved identifying, analysing and constructing patterns and themes implicit within the data that were deemed to address the study’s research questions. Findings: Findings indicate that Zambia’s institutional environment within the health sector is highly fragmented and pluralistic as reflected by the multiplicity of both internal and external stakeholders. These stakeholder groups equally require different reporting mechanisms to fulfil their information expectations. Social implications: The multiple reporting practices evident within the health sector entail that the effectiveness of health programmes may be compromised due to the fragmentation in goals between government and international donor institutions. Rather than pooling resources and skills for maximum impact, these practices have the effect of dispersing performance efforts with the consequence of compromising their impact. Fragmented reporting equally complicates the work of policy makers in terms of monitoring the progress and impact of such programmes. Originality/value: Beyond Goddard et al. (2016), the study depicts the usefulness of Ekeh’s theory in understanding how organisations and institutions operating in pluralistic institutional environments may be better managed. In view of contradictory expectations of accounting and performance reporting requirements between the civic and primordial publics, the study indicates that different practices, mechanisms and structures have to be embraced in order to maintain institutional harmony and relevance to different communities within the health sector

Stratified ontology, institutional pluralism and performance monitoring in Zambia’s health sector

Purpose: This paper aims to investigate funding and performance monitoring practices in Zambia’s health sector from an institutional and stratified ontology perspective. Such an approach was deemed appropriate in view of pluralistic institutional environments characterising most African economies that are also considered to be highly stratified. Design/methodology/approach: Blended with insights from stratified ontology, the paper draws on institutional pluralism as a theoretical lens to understand the institutional structures, mechanisms, events and experiences encountered by actors operating at different levels of Zambia’s health sector. The study adopted an interpretive approach that helped to investigate the multifaceted and subjective nature of social phenomena and practices being studied. Data were collected from both archival sources and interviews with key stakeholders operating within Zambia’s health sector. Findings: The study’s findings indicate the high levels of stratification within Zambia’s health sector as evidenced by the three sector levels that possessed different characteristics in terms of actor responses to donor influence. This study equally demonstrates the capacity of agents operating under highly fragmented institutional environments to engage in enabling and constraining responses depending on the understanding of their empirical world. Originality/value: Through blending insights from stratified ontology with institutional pluralism, the study contributes to the literature by demonstrating the enabling and constraining reflexive capacity of agents to exercise choices under highly fragmented institutional environments while responding to multiple demands and expectations to sustain the co-existence of diverse stakeholders. Accordingly, the study advances thinking on the application of institutional theory to critical accounting research in line with recent ontological and epistemological shifts in institutional theory

GRID3 Zambia Operational Health Facility Layer, Version 01 (Beta)

The data set provides health facility point locations and their names to spatially locate, identify, and visualize health facility locations in Zambia. This work has been undertaken as part of the Geo-referenced Infrastructure and Demographic Data for Development (GRID3) initiative. GRID3 works with countries to generate, validate and use geospatial data on population, settlements, infrastructure, and subnational boundaries. For more information, see https://grid3.org/ Keywords: health facilitie

Task sharing in Zambia: HIV service scale-up compounds the human resource crisis

BACKGROUND: Considerable attention has been given by policy makers and researchers to the human resources for health crisis in Africa. However, little attention has been paid to quantifying health facility-level trends in health worker numbers, distribution and workload, despite growing demands on health workers due to the availability of new funds for HIV/AIDS control scale-up. This study analyses and reports trends in HIV and non-HIV ambulatory service workloads on clinical staff in urban and rural district level facilities. METHODS: Structured surveys of health facility managers, and health services covering 2005-07 were conducted in three districts of Zambia in 2008 (two urban and one rural), to fill this evidence gap. Intra-facility analyses were conducted, comparing trends in HIV and non-HIV service utilisation with staff trends. RESULTS: Clinical staff (doctors, nurses and nurse-midwives, and clinical officers) numbers and staff population densities fell slightly, with lower ratios of staff to population in the rural district. The ratios of antenatal care and family planning registrants to nurses/nurse-midwives were highest at baseline and increased further at the rural facilities over the three years, while daily outpatient department (OPD) workload in urban facilities fell below that in rural facilities. HIV workload, as measured by numbers of clients receiving antiretroviral treatment (ART) and prevention of mother to child transmission (PMTCT) per facility staff member, was highest in the capital city, but increased rapidly in all three districts. The analysis suggests evidence of task sharing, in that staff designated by managers as ART and PMTCT workers made up a higher proportion of frontline service providers by 2007. CONCLUSIONS: This analysis of workforce patterns across 30 facilities in three districts of Zambia illustrates that the remarkable achievements in scaling-up HIV/AIDS service delivery has been on the back of sustained non-HIV workload levels, increasing HIV workload and stagnant health worker numbers. The findings are based on an analysis of routine data that are available to district and national managers. Mixed methods research is needed, combining quantitative analyses of routine health information with follow-up qualitative interviews, to explore and explain workload changes, and to identify and measure where problems are most acute, so that decision makers can respond appropriately. This study provides quantitative evidence of a human resource crisis in health facilities in Zambia, which may be more acute in rural areas

Increasing the uptake of prevention of mother-to-child transmission of HIV services in a resource-limited setting

<p>Abstract</p> <p>Background</p> <p>As in other resource limited settings, the Ministry of Health in Zambia is challenged to make affordable and acceptable PMTCT interventions accessible and available. With a 14.3% HIV prevalence, the MOH estimates over one million people are HIV positive in Zambia. Approximately 500,000 children are born annually in Zambia and 40,000 acquire the infection vertically each year if no intervention is offered. This study sought to review uptake of prevention of mother-to-child (PMTCT) services in a resource-limited setting following the introduction of context-specific interventions.</p> <p>Methods</p> <p>Interventions to improve PMTCT uptake were introduced into 38 sites providing PMTCT services in Zambia in July 2005. Baseline and follow up service data were collected on a monthly basis through September 2008. Data was checked for internal and external consistency using logic built into databases used for data management. Data audits were conducted to determine accuracy and reliability. Trends were analyzed pre- and post- intervention.</p> <p>Results</p> <p>Uptake among pregnant women increased across the 13 quarters (39 months) of observation, particularly in the case of acceptance of counseling and HIV testing from 45% to 90% (p value = 0.00) in the first year and 99% by year 3 (p value = 0.00). Receipt of complete course of antiretroviral (ARV) prophylaxis increased from 29% to 66% (p = 0.00) in the first year and 97% by year 3 (p value = 0.00). There was also significant improvement in the percentage of HIV positive pregnant women referred for clinical care.</p> <p>Conclusions</p> <p>Uptake of PMTCT services in resource-limited settings can be improved by utilizing innovative alternatives to mitigate the effects of human resource shortage such as by providing technical assistance and mentorship beyond regular training courses, integrating PMTCT services into existing maternal and child health structures, addressing information gaps, mobilizing traditional and opinion leaders and building strong relationships with the government. These health system based approaches provide a sustainable improvement in the capacity and uptake of services.</p

Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes

<p>Abstract</p> <p>Background</p> <p>There is increasing attention, globally and in countries, to monitoring and addressing the health systems and human resources inputs, processes and outputs that impede or facilitate progress towards achieving the Millennium Development Goals for maternal and child health. We reviewed the situation of human resources for health (HRH) in 68 low- and middle-income countries that together account for over 95% of all maternal and child deaths.</p> <p>Methods</p> <p>We collected and analysed cross-nationally comparable data on HRH availability, distribution, roles and functions from new and existing sources, and information from country reviews of HRH interventions that are associated with positive impacts on health services delivery and population health outcomes.</p> <p>Results</p> <p>Findings from 68 countries demonstrate availability of doctors, nurses and midwives is positively correlated with coverage of skilled birth attendance. Most (78%) of the target countries face acute shortages of highly skilled health personnel, and large variations persist within and across countries in workforce distribution, skills mix and skills utilization. Too few countries appropriately plan for, authorize and support nurses, midwives and community health workers to deliver essential maternal, newborn and child health-care interventions that could save lives.</p> <p>Conclusions</p> <p>Despite certain limitations of the data and findings, we identify some key areas where governments, international partners and other stakeholders can target efforts to ensure a sufficient, equitably distributed and efficiently utilized health workforce to achieve MDGs 4 and 5.</p

Meeting human resources for health staffing goals by 2018: a quantitative analysis of policy options in Zambia

<p>Abstract</p> <p>Background</p> <p>The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear.</p> <p>Methods</p> <p>We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018.</p> <p>Results</p> <p>With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.</p> <p>Conclusions</p> <p>Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels.</p

Social and economic barriers to adherence among patients at Livingstone General Hospital in Zambia

Zambia is one of the countries hardest hit by the human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) pandemic with a national HIV prevalence estimated at 14% among those aged 15–49 years in 2012. Antiretroviral therapy (ART) has been available in public health facilities in Zambia since 2003. By early 2016, 65% of the 1.2 million Zambians living with HIV were accessing ART. While access to ART has improved the lives of people living with HIV globally, the lack of adherence to ART is a major challenge to treatment success globally.This article reports on social and economic barriers to ART adherence among HIV patients being attended to at Livingstone General Hospital in Zambia

The reach and impact of social marketing and reproductive health communication campaigns in Zambia

Background: Like many sub-Saharan African countries, Zambia is dealing with major health issues, including HIV/AIDS, family planning, and reproductive health. To address reproductive health problems and the HIV/AIDS epidemic in Zambia, several social marketing and health communication programs focusing on reproductive and HIV/AIDS prevention programs are being implemented. This paper describes the reach of these programs and assesses their impact on condom use. Methods: This paper assesses the reach of selected radio and television programs about family planning and HIV/AIDS and of communications about the socially marketed Maximum condoms in Zambia, as well as their impact on condom use, using data from the 2001-2002 Zambia Demographic and Health Survey. To control for self-selection and endogeneity, we use a two-stage regression model to estimate the effect of program exposure on the behavioural outcomes. Results: Those who were exposed to radio and television programs about family planning and HIV/AIDS were more likely to have ever used a condom (OR = 1.16 for men and 1.06 for women). Men highly exposed to Maximum condoms social marketing communication were more likely than those with low exposure to the program to have ever used a condom (OR = 1.48), and to have used a condom at their last sexual intercourse (OR = 1.23). Conclusion: Findings suggest that the reproductive health and social marketing campaigns in Zambia reached a large portion of the population and had a significant impact on condom use. The results suggest that future reproductive health communication campaigns that invest in radio programming may be more effective than those investing in television programming, and that future campaigns should seek to increase their impact among women, perhaps by focusing on the specific constrains that prevent females from using condoms