By Prof Wilbroad Mutale, MD, MPhil, PhD
The past few weeks have caused tremendous confusion and uncertainty globally, in this
article our interest is what this means for Zambia.
Having worked in the health sector for over 20 years and at the center of service
delivery, research, training and policy advocacy, it seems right to share my thoughts and
my understanding of what has happened and what the implications are based on
experience and literature.
While Zambia has faced many health emergencies, most of them are disease specific crisis, for example the cholera epidemic and covid epidemic. There are also natural disasters like drought that we have experienced affecting food security and electricity.
However, what we are experiencing now following the aid freeze by the US government
support especially to the health sector, is a “system-wide emergency” that we are not
used to. The closest situation relatable to this crisis is when structural adjustment
programs were introduced in the late 1980s by the World Bank, whose consequences
have left our health system permanently weakened.
In fact, Kaunda and his team started their free fall from grace following that “system emergency” and we were not ready for that. Consequently, our health system faltered and only started picking up
much later, especially when the US government introduced programmes such as
PEPFAR ( HIV program) and the Global fund came into the picture.
While it has been argued that subsequent governments have tried to invest in the
health system, the sector depends on donor support with the US contributing a
significant amount, especially to HIV treatment and care, supporting procurement of
HIV drugs.
Quoting former minister of health Masebo in 2023,
“I would like to state that the performance of the Ministry, which I am about to highlight, has been largely facilitated by domestic resources and contributions from partners. In 2023, the total budget for Ministry of Health was K16.1 billion, representing a percentage increment of 30%, out of which K14.7 billion was from GRZ and K1.3 billion from Cooperating Partners.
The Personal Emolument was allocated K7.7 billion while the Non-Personal Emolument had a total budget of K8.4 billion which is inclusive of K1.3 billion from Cooperating Partners through their direct budget support. It is important to note that several donors provide off-budget support which also made significant contributions to the success of the Ministry this year”
The statement “budget support” is an important one and makes it almost impossible
to estimate how much donors have contributed directly and indirectly, but it should suffice to say that our health system is heavily donor reliant. Another large contributor to the health sector is the Global fund, which itself depends largely on funds from donors like the US, which is the largest donor.
The US is also the largest contributor to the WHO from which it has pulled out. Another thing to note from the former minister’s statement is that government contribution is mainly to human resource and salaries.
So put in a sentence, we are in a system crisis of a generation that cannot compare to
what we have seen before in the health sector. This requires a completely different
approach, calling for innovation and long-term plans.
A little bit about the health system can help us imagine what crisis we are in, just in case
you are among those “burying” their heads in the sand. The health system has six (6)
building blocks; these are human resources, leadership, health information, medical
supplies, finance and service delivery.
These are related and if you could imagine how square roots multiply the effect with a short-change, that’s how complicated it can become if you imagine that each building block impacts the other and that if one
malfunctions then the whole thing is in reverse gear and self-destruction. Let me add two more points about the health system, then I will return to the issue at hand.
The health system is resistant to change and often there are delays in “cause” and “effect”.Meaning that in the current crisis, those entrusted with the management of the health system, might refuse to listen and continue business as usual when they need to change course!
The delays between cause and effect means that if we delay to act and fail to plan,
“hasty/emergency interventions” won’t help, as the system will need time to change.
Finally, on the health system, there is what is known as “unintended consequences”. This simply means that you might do a very good action you hope will affect the health system, but it might carry “contaminants”! Things you don’t even expect, for example closing ART clinics and integrating them into routine care given the USAID aid freeze, might look reasonable, but doing so might kill even the little services that are being offered!
Back to the crisis, responding to crisis or disaster, we can be guided by literature and
experience from other sectors. While government has put out statements to calm
people down and assure patients on HIV treatment, this falls short of the scale required
to get ready to avert the crisis at least from what I can see and hear. Let’s imagine some of the consequences of this aid freeze by building blocks:
Human resources: about 16,000 highly skilled health workers are directly impacted by
the USAID freeze. These offer services and support families and communities. These
are on the streets and cannot offer their skills and this directly impacts service delivery.
The second building block I want to highlight is the medical supplies: this is a complex
one. It requires forecasting and excellent logistics especially for ARVs and related labs.
Delays in procurement can easily cost 1.2 million lives which is the number of people
depending on these medications in Zambia.
Those providing assurance, must be seen to act to finding alternative resources and systems for service delivery. Like I mentioned above, delays can cause disruption permanently, such that even when drugs arrive later, drug resistance has occurred and some people would have died and babies would
have been infected, these cannot be reversed.
What can we do about this?
My suggestion is summarized in a Bemba proverb: “I chakukonka ulubilo, naiwe,
uchikonke ulubilo” (If something comes rushing at you, you must reciprocate!)
The aid freeze is very sudden and immediate, this should be replicated by our sense of
urgency and crisis preparedness. We cannot act in a business as usual manner, in fact I
dare say the system we have in place, might be insufficient to respond to this in time
and so, we must look outside the box.
It must be noted that even if US Government funding resumes, the system is
permanently changed by the disruption. To tackle the sudden, current US induced crisis in HIV/AIDS management, we propose an approach borrowed from the field of disaster preparedness and emergency
response, with the aim of implementing an eBective, structured response to mitigate
damage by leveraging Incident Command Centers (ICCs) and developing resource
allocation strategies to rapidly respond for immediate harm reduction and to build a
sustainable approach moving forward.
The ICC can guide a strategic and integrated approach to five key emergency response
areas most relevant to this scenario: 1) human resources, 2) data, 3) commodities, and
4) information sharing and coordination. For each area, in the immediate term, it will
assess what is working, what is needed, resource options, and a framework for rational
resource allocation.
It will also craft clear messaging for community, institutional, and
regional audiences to limit the harmful misinformation that often thrives in an
emergency. In the long term, it will support transition to sustainable systems. Following
emergency response good practices, the ICC can be a formal coordination mechanism
with defined members and roles.
It can seek representation from critical constituencies
but will remain agile to facilitate the rapid decision making required in an emergency. It
can be led by the Zambian National AIDS Commission or the Zambia National Public
Health Institute in collaboration with other partners. The ICC will limit immediate harm
and support transitions to a sustainable future.
We propose the following specific objectives of the ICC:
1. Develop and implement an Incident Command Center framework to
coordinate Zambian national and regional HIV response efforts.
2. Assess and optimize critical response streams, including human resources for
health, data management, commodity distribution, and information sharing.
3. Strengthen resource identification, management, and allocation
mechanisms to mitigate immediate negative impacts of funding loss through
alternative financial strategies and resource coordination.
4. Enhance communication and advocacy to counteract misinformation, engage
policymakers in sustainable funding discussions, and involve communities,
including HIV advocates, NGOs, neighborhood health communities, faith
organizations, and others, to guide decision-making and foster trust required for
successful action.
5. Facilitate the transition from emergency response to long-term HIV service
sustainability by integrating response measures into existing healthcare
structures.
NB: This approach can be replicated to other sectors affected by the USAID aid freeze,
but here we focused on the impact and mitigations for HIV response.
Conclusion:
The future is in our hands, this aid freeze crisis can be an opportunity which we should
be prepared to leverage. We have the brains and experience to steer the ship safely to
the harbor, but this requires “all hands’ on deck. The government should facilitate
setting up of such a crisis center or similar structure and should be willing to work with
people outside the government payroll. We have work to do before it is too late, lets
avert the disaster but also let’s learn from this. No one can be trusted to look after your
health, we need to do it ourselves.
