Decentralisation and Health Service Governance in Zambia

Abstract Decentralisation is a tool that’s advocated for to govern health services by academic literature and development agencies. Its popularity stems from the notion that decentralisation increases local capacity by delivering efficient administrative and decision-making systems. Advocates of decentralisation further postulate that decentralisation allows for government to be closer to the people and is, therefore, a more responsive tool in improving delivery of social services and addressing poverty at local levels. Despite its popularity, critics of decentralisation often suggest that its success is dependent on the type of decentralisation that is implemented in specific contexts and how the implementation strategies relate to in-country institutional arrangements and capacities. In spite of its critics, decentralisation has over the years continued to dominate the development agenda in both developing and developed countries, especially in the health sector. In Zambia, since 1992 governments have implemented health sector decentralisation with varying degrees of success. Therefore, this thesis seeks to examine why and how health sector decentralisation has been implemented in Zambia since 1992. Drawing on conceptual literature and historical understandings of decentralisation processes, the research uses the health policy triangle framework (HPTF) developed by Walt and Gilson (1994); to understand the content, context, processes and actors involved in Zambian national decentralisation processes between 1992 and 2018. The thesis uses two specific examples of decentralisation processes – the health reforms of 1992 to 2006; and the devolution agenda that started in 2002 to date. Based on textual analysis of policy documents and on qualitative field research conducted in Zambia between February 2018 and August 2018 – forty-three (43) interviews conducted in total - the thesis makes contributions through a number of original insights and conclusions related to the practice of decentralisation for health service governance in Zambia. First, it shows how policy ideas come to the forefront of policy agenda and how and why these ideas come to be widely accepted in local policy practice in Zambia. Second, it locates the ensemble of actors and how they come to interpret policy ideas. Third, it demonstrates how actors’ interactions shape policy interpretation and implementation. Lastly, it shows how international policy agenda engulfs local policy practice in Zambia and how the conglomerate of international ideas, ideologies and actors plays out within the Zambian context

Preference for Human Papillomavirus–Based Cervical Cancer Screening: Results of a Choice-Based Conjoint Study in Zambia

The objective of this study was to assess the conditions under which Zambia women with a history of cervical cancer screening by visual inspection with acetic acid might switch to HPV-based testing in the future

"The problem is ours, it is not CRAIDS' ". Evaluating sustainability of Community Based Organisations for HIV/AIDS in a rural district in Zambia.

BACKGROUND: While sustainability of health programmes has been the subject of empirical studies, there is little evidence specifically on the sustainability of Community Based Organisations (CBOs) for HIV/AIDS. Debates around optimal approaches in community health have centred on utilitarian versus empowerment approaches. This paper, using the World Bank Multi-Country AIDS Program (MAP) in Zambia as a case study, seeks to evaluate whether or not this global programme contributed to the sustainability of CBOs working in the area of HIV/AIDS in Zambia. Lessons for optimising sustainability of CBOs in lower income countries are drawn. METHODS: In-depth interviews with representatives of all CBOs that received CRAIDS funding (n = 18) and district stakeholders (n= 10) in Mumbwa rural district in Zambia, in 2010; and national stakeholders (n=6) in 2011. RESULTS: FUNDING: All eighteen CBOs in Mumbwa that received MAP funding between 2003 and 2008 had existed prior to receiving MAP grants, some from as early as 1992. This was contrary to national level perceptions that CBOs were established to access funds rather than from the needs of communities. FUNDING opportunities for CBOs in Mumbwa in 2010 were scarce.Health services: While all CBOs were functioning in 2010, most reported reductions in service provision. Home visits had reduced due to a shortage of food to bring to people living with HIV/AIDS and scarcity of funding for transport, which reduced antiretroviral treatment adherence support and transport of patients to clinics.Organisational capacity and viability: Sustainability had been promoted during MAP through funding Income Generating Activities. However, there was a lack of infrastructure and training to make these sustainable. Links between health facilities and communities improved over time, however volunteers' skills levels had reduced. CONCLUSIONS: Whilst the World Bank espoused the idea of sustainability in their plans, it remained on the periphery of their Zambia strategy. Assessments of need on the ground and accurate costings for sustainable service delivery, building on existing community strengths, are needed before projects commence. This study highlights the importance of enabling and building the capacity of existing CBOs and community structures, rather than creating new mechanisms

‘Worse than HIV’ or ‘not as serious as other diseases’? Conceptualization of cervical cancer among newly screened women in Zambia

Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based “see and treat” cervical cancer prevention program. In this study, conducted between September, 2009-July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer

Motivations and experiences of women who accessed “see and treat” cervical cancer prevention services in Zambia

BACKGROUND: In Zambia, a country with a generalized HIV epidemic, age-adjusted cervical cancer incidence is among the highest worldwide. In 2006, the UAB-Center for Infectious Disease Research in Zambia and the Zambian Ministry of Health launched a visual inspection with acetic acid (VIA)-based “see and treat” cervical cancer prevention program in Lusaka. All services were integrated within existing government-operated primary health care facilities. OBJECTIVE: Study aims were to: 1) identify women's motivations for cervical screening; 2) document women's experiences with screening; and 3) describe the potentially reciprocal influences between women undergoing cervical screening and their social networks. DESIGN & METHODS: Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with women who accepted screening and with care providers. Low-level content analysis was performed to identify themes evoked by participants. Between September, 2009 and July, 2010, 60 women and 21 care providers participated in 8 FGD and 10 IDI. RESULTS: Women presented for screening with varying needs and expectations. A majority discussed their screening decisions and experiences with members of their social networks. Key reinforcing factors and obstacles to VIA screening were identified. CONCLUSIONS: Interventions are needed to gain support for the screening process from influential family members and peers