A new study reveals that while Zambia has made great progress against malaria over the past decade or so it was losing ground on many other health needs like basic child immunizations and maternal health care.
The findings, though limited to evaluating select health trends in one African country, may well become fodder in the long-running – but, lately, increasingly intense – debate over whether the global health community should continue favoring targeted or disease-specific interventions or shift its emphasis to more fundamental “health systems” improvements.
“Zambia has been recognized worldwide for its successes in improving childhood survival and tackling many deadly diseases, including malaria and HIV/AIDS,” said one of the lead authors, Emmanuela Gakidou, a researcher at the University of Washington’s Institute for Health Metrics and Evaluation. The study is published today in BMC Medicine.
But Gakidou and her colleagues, including researchers at the University of Zambia, found evidence that these disease-specific programs (which represent the lion’s share of most international health funding) may have undermined other forms of routine care.
“At the national and district level, Zambia achieved greater successes in newer, rapidly scaled-up interventions while gains in routine services delivery either stalled or declined,” the study authors report. Put simply, Zambia’s much-celebrated success against malaria may have come at the expense of de-emphasizing some aspects of basic primary care.
An illustration of ‘composite coverage’ for 10 key health services in Zambia shows an overall increase due to in malaria control (ITN, IPTp2) and other measures. But a deeper look reveals stagnation or decline in antenatal care and polio immunizations. BMC Medicine, IHME
The researchers did not set out intending to demonstrate the existence of contradictory health trends in Zambia. The primary goal for the study was to demonstrate the value of assessing health at the sub-national or district levels within a country as opposed to measuring progress only on overall national statistics.
“The main message is that Zambia, as a nation, has seen substantial gains in coverage for a number of health interventions,” said Nancy Fullman, one of Gakidou’s colleagues at the Seattle research institute and a co-author on the paper. The other message, Fullman said, is that you need to look beyond the national statistics to determine if these gains represent systemic improvements or are serving to mask areas of decline.
Insecticide-treated net ownership or indoor residual spraying to combat malaria, 2000-2010. (Red is low numbers; greener is higher). IHME
Polio immunizations stagnated or, in some cases, declined between 1990-2010
“This shows that Zambia’s health service landscape is tremendously heterogeneous,” Fullman said.
Yes, but why?
Did targeting malaria or other specific diseases contribute to neglect of other basic health services in Zambia? Many in the ‘health systems’ camp – those who argue for funding basic care and infrastructure rather than targeting specific problems – make that case. Or are these contradictory trends operating independent of each other?
Fullman said the research in Zambia was only designed to say what was happening, not why.
“These questions are important to answer but are outside the scope of what this paper covers,” she said.
Yet the very first sentence of the BMC Medicine report opens by saying “Achieving universal health coverage is a primary goal for an increasing number of health systems worldwide.” As Humanosphere has noted before, making universal health coverage – or ‘health system strengthening’ – a primary goal within the global health community is not necessarily shared by all.
Part of the reluctance has been the lack of a clear, agreed-upon definition of universal health coverage or what is meant by ‘health system.’
In addition to evaluating select health indicators in Zambia to assess regional variations within the country, Gakidou and her team also sought to test out metrics aimed at measuring health system performance.
“Our knowledge of how well health programs or policies are working can only be as deep as our level of analysis,” Gakidou told BMC Medicine, in an accompanying article for the journal’s blog Biome. The level of inequality, or variation, in terms of access to services is one measure of system performance, she said.
Fullman said they couldn’t measure every indicator (in some cases because the data was just not available) but decided that tracking the delivery of other basic services such as child immunization coverage, pregnancy care and skilled birth attendance would provide a good barometer of Zambia’s overall health system. They selected 10 health interventions to measure as an estimate of ‘composite coverage.’
“Measuring health system performance is far from easy,” Fullman noted.
In the United States, health indicators track well with socioeconomic status – in the sense that poor people suffer more illnesses and die sooner than do wealthier people. That’s a ‘good’ indicator of an unequal health system. In Zambia, the researchers did not find this trend despite the variations across indicators.
“In some ways, this weak correlation between socioeconomic and intervention coverage may reflect the country’s success in providing a subset of health services to the people who need them the most,” Gakidou told BMC Medicine.
So does this study show that Zambia is, as it is sometimes hailed to be, a global health success story or a country with isolated areas of progress masking a health care system that is weak at its very foundation?
More study is needed to answer that question, say the scientists (as they almost always say). Meanwhile, Zambia is expected to begin rolling out a new national health insurance program aimed at moving toward universal health coverage.
