Swimming against the tide – health reform in South Africa and Zambia

The transition periods of the 1990s provided South Africa and Zambia with windows of opportunity to implement much-needed health financing reform. But is the end result of these reforms what was first envisaged? Researchers examined the political factors that have influenced the outcome of policy implementation in these two southern African countries.

The research carried out by the University of Witwatersrand, the London School of Hygiene and Tropical Medicine, the University of Cape Town and the University of Zambia investigated the process of health policy-making in South Africa and Zambia. The research asks why the implementation of health sector reform policies often produces unexpected results. The researchers conducted a policy analysis of health financing reform in South Africa and Zambia because – despite differences – both countries offered interesting cases of health reform after radical political change in the 1990s. 

Health policy reform was implemented in both countries during the 1990s. In Zambia and South Africa the results of the reforms were mixed. Both health systems experienced successes and failures. The research found that:

• Rapid implementation of policy reform followed the political momentum of change. Administrative and political structures in the country changed almost as rapidly. The result was that many policies were rushed through without full planning and anticipation of the full range of their potential outcomes.
• The enormous influence of individuals in the shape and nature of policies had a detrimental effect on the outcome of the introduction of those policies. In both countries, individuals (i.e. health ministers) had undue influence on health policy development.
• In both South Africa and Zambia, government and non-governmental technical analysts designed health financing reform but had little real political power to implement their ideas.
• These analysts designed policies that were politically difficult to implement as they created unequal, segmented and privatised health systems.
• Policy-makers failed to anticipate some of the most important effects of the policies once implemented. The removal of user fees in South Africa resulted in the increased utilisation of health services but their perceived quality deteriorated. In Zambia, the introduction of fees undermined, at least initially, utilisation levels and increased inequalities.

So what are the lessons for strengthening future implementation of health reform? The report suggests that:

• It is important to strengthen the links between government and non-governmental analysts so that existing knowledge can be better used.
• The political awareness of analysts must be raised by ensuring they work with political decision-makers at the highest level.
• The smooth implementation of policy can be achieved if analysts work with middle managers and front line health workers.
• Political leaders must balance the political and technical considerations of policy reform.
• Political leaders must create the adequate conditions for analysts to develop solutions that tackle the priority problems in the health system.
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Source(s):
'The SAZA study: implementing health financing reform in South Africa and Zambia', Health Policy and Planning 18(1): 31-46, by L. Gilson et al, 2003

id21 Research Highlight: 19 May 2003

Further Information:
Lucy Gilson
Associate Professor
Centre for Health Policy
PO Box 1038
Johannesburg 2000
South Africa

Contact the contributor: lucyg@mail.saimr.wits.ac.za

University of the Witwatersrand, South Africa

London School of Hygiene and Tropical Medicine, UK

Health Economics Unit, University of Cape Town, South Africa

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