Provider Purchasing and Contracting for Health Services_The Case

appears to be minimal evidence that meaningful progress has been made toward achieving
these two initial goals.
As a matter of fact, the dissolution of the boards, which led to the reversal of decentralization
in the health system, appears to have worked against the initial objectives. For instance, the
Ministry of Health currently functions as both a principal and agent by virtue of being a fund
holder and service provider. This lack of legal separation between the Ministry of Health and
District Health Management Teams and Hospital Management Teams dilutes the validity of
the contractual arrangements and the accountability of the institutions. To this effect, some
respondents observed that contracts are in some cases not signed, and the Ministry of Health
does not conduct performance audits, partly undermining the essence of contracting.
Although the private for-profit health sector has been emphasized since 1991, very little has
been done to formally integrate it into the health system. In areas with a large private sector
presence, there is a lack of master planning to include all stakeholders. According to
interviews with Ministry of Health officials, there is not yet a clear policy on how the
government should work with the private sector in Zambia. This is contrary to the declaration
that one of the target areas for action to achieve the Millennium Development Goals is the
use of the private sector to expand access to health care. Governments must provide
stewardship in overseeing their health systems by providing a clear vision and direction for
health policy as well as regulation (Francisco A and S. Martin 2006)
Moreover, the accreditation procedure for private facilities to enter the referral system is not
clear. This calls for the Ministry of Health to provide appropriate standards and guidelines to
the private sector on acceptable levels of practice. Moreover, the Ministry of Health provides
no incentives aimed at attracting the private sector to participate in the implementation of the
Basic Health Care Package through the public health care delivery system. The reasons
usually cited for this state of affairs include inadequate knowledge about the private sector by
Ministry of Health policymakers; limited dialogue between the public and private
stakeholders; and the lack of institutionalized policy instruments from the Ministry of Health
for interacting with the private sector, especially in financing, regulation, and dissemination
of information. Given this background, contracting with the private sector in Zambia has
been limited to nonclinical services and laboratory services.
Although private and public providers treat each other with suspicion, they are willing to
work together. On the subject of contracting, the District Health Management Teams
observed that it would be more effective if they were given more autonomy and resources to
enable them to purchase services from the private sector. Inadequate funding of public
providers is perceived to be the major constraint to contracting-out. The private sector, on the
other hand, recommended a voucher system that covers clients who are unable to pay through
an insurance system.
The Ministry of Health, on the other hand, reached an advanced stage in developing a social
health insurance scheme as a health financing mechanism. The scheme is expected to be
extended to the private sector covering all citizens. Furthermore, the Ministry of Health is
promoting investment in a wide range of potential contracting areas with the private for-profit
providers in both clinical and nonclinical functions, including specialized medicine, training
of human resources, and repair of medical equipment, among other functions.
Conclusions
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