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«2015 Bilateral debt Multilateral 8000 7000 poverty 6000 goals 5000 sustainability 4000 3000 macroeconomic millennium 2000 1000 0 1995 1996 1997 1998 ...»

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In relation to goal number 1 (halving extreme poverty by 2015) two UNDP progress reports (2003 and 2005) make very different observations. In 2003, it was determined that the goal was ‘unlikely’ to be achieved, but later (in 2005) the goal was reflected as ‘likely’ to be achieved. The debate on the likelihood of achieving goal number 1 of the MDGs is still on-going. Overall however, with such high historic poverty levels, it is not surprising that Zambia is ranked number 165 out of 177 countries according to the UNDP human development index (HDI) and that some observers remain fairly sceptical about the country’s resource capacity to adequately redress its poverty challenge.

6 Zambia has experienced a positive growth trend since 1999, but the PRSP was only implemented in 2002; thus, though no direct, quantifiable contribution is being attributed to the PRSP here, it is reasonable to presume that the PRSP had at least some positive growth benefits.

7 Measured by taking a lower poverty line that reflects the minimum requirements of food spending only (excluding the other items included in the overall poverty line)

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50 40 30 20 1991 1993 1996 1998 2004 Observers have argued that one reason why poverty has not significantly reduced in spite of the improved economic performance since 1999 is the weak growth-poverty relationship associated with the recent growth. The positive growth outturns have been concentrated in the mining, wholesale and retail trade and construction sectors which are all mainly capital intensive urban-based economic activities. This type of growth fails to generate sufficient employment due to weak linkages with the rest of the economy.

Since the growth path does not include utilization of the main economic asset of the poor – their labour – it does not foster enough poverty alleviation, particularly in the rural areas where about 70 percent of the poor reside.

The FNDP (MOFNP, 2006b) estimates that if the country continues with this growth path, overall (head count) poverty will only marginally decline to 62.3 percent by 2010 (from 68 percent) in 2004. This will clearly be insufficient for making progress towards halving the 1990 poverty of 70 percent10 level by 2015. Similarly, as evidenced later on, Zambia’s projected growth path will not result in the reduction of the extreme poverty level of 58 percent in 1990 to 29 percent by 2015. Income poverty therefore remains a significant concern for Zambia.

8 Op. cit 9 Data from the LCMS III (of 2002/03) were not included due to incomparability with the other datasets reflected in Fig 1.1 (i.e., PS I & II and LCMS I, II & IV). This arose from significant differences in sampling and data collection methods and definitions used in LCMS III compared with the approaches in the other datasets.

10 The 1991 figure given in the Priority Survey I is the closest estimate

5 Zambia: Debt Strategies to Meet the Millennium Development Goals

1.3 Additional Dimension of Poverty and Inequalities In terms of other (non-income) social dimensions of human development of importance to household welfare, limited progress has been made in redressing some of the social

dimensions of poverty; but much more can be done still. The country has seen improvements in some education and health indicators (see Table 1.1 and 1.2):

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Source: CSO (2003b) & MOE (2004) A significant concern in education is with the increase in the repetition rate because this has negative implications on prospects for achieving the third MDG Goal of ensuring that by 2015, children everywhere, boys and girls alike, will complete a full course of primary schooling. The obvious fact is that completion of primary school by everyone requires not only ensuring high enrolment into the primary schooling system, but also reducing repetition and drop out rates (these later aspects ensure efficient progression through the system). Another concern is that the gender parity index (GPI) – which measures sex-related differences in school attendance rates as the gross attendance ratio for females divided by the gross attendance ratio for males – is still fairly low at

0.87. There will be slower progress in achieving universal primary education for girl children.

The role of civil society and donors in fostering positive social outcomes is clearly demonstrated in the education sector, where significant time, effort and m oney have been invested to sensitize stakeholders and lobby more resources. Indeed, the recent positive outturn of indicators in the sector attests to this (see Annex 3: Table A3).

In health, a mixed picture is painted by the indicators selected in Table 1.2. Given the improvements in infant and child mortality indicators, it is not surprising that the 2005 MDGs progress report observes that there is potential for meeting goal number 5.

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Source: CSO (2003a) On the other hand, deteriorations are observed in both indicators on maternal mortality.

This is also consistent with the views of the MDGs progress report, where the likelihood of reducing maternal mortality by three-quarters by 2015 is reflected as ‘unlikely’.

Moreover, the burden of disease is very high, with the Central Statistical Office (CSO) reporting that about 13 percent of persons in Zambia reported an illness in the two weeks period prior to the LCMS III survey. This implies a total of approximately 1.4 million persons reporting an illness nationwide in the two weeks period of the survey.

The disease burden is dominated by malaria (36.9 percent) and respiratory infections non-pneumonia (21.1 percent), which jointly makes up about 58 percent of all cases of illness seen at public health facilities in Zambia. The two diseases are also the leading causes of death.

Another significant socio-economic and health stress factor is the country’s continued vulnerability to HIV/AIDS, with the country currently experiencing the health, economic and social impacts of a mature epidemic. In this regard, since the mid 1980s, Zambia’s growth and poverty problems have been severely compounded by one of the world’s most devastating HIV/AIDS epidemics. The national HIV prevalence rate is estimated at about 15.6 percent. The statistics below11,12 emphasize the significance and

some of the inequalities of the HIV/AIDS burden in Zambia:

• Out of a population of about 10.9 million, 1.1 million people (over 10% of the total population) were living with HIV in 2005;

• Adult HIV/AIDS prevalence remains twice as high in urban areas as in rural areas;

• Women are 40% more likely to be infected than men;

• About 7.7% of young people aged 15-24 years were HIV positive in 2003;

• Almost 40% of infants born to HIV positive parents are infected;

• More than 89,000 people died of AIDS in 2003;

11 op. cit CSO 2003a 12 MOH and CBOH (2006)

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• With the impact of HIV/AIDS mortality, life expectancy at birth in 2004 was about 14% lower than it would have been without AIDS deaths13;

• Out of about 1.1 million orphans under 18 years of age, over 630,000 children (57% of the total) are AIDS orphans;

1 • About 200,000 of the 1.1 million HIV positive people required ARVs in 2004;

• As of end-2005, only 51,764 persons (or 26%) of those in immediate need of antiretroviral therapy (ART) were on ARVs.

Zambia’s national response to HIV/AIDS was formalized through the creation of the National HIV/AIDS/STD/TB Council (NAC) in March 2000; although the NAC did not become operational until December 2002 when Parliament passed a national AIDS bill that made the NAC a legally-established body able to apply for funding. At the passing of this bill, the NAC became the single, high-level institution responsible for coordinating the actions of all segments of government and society in the fight against HIV/AIDS.

In October 2000, the NAC published a National Strategic Intervention Plan (2002and in May 2006, finalized a successor Zambia HIV and AIDS Strategic Framework (ZASF) 2006-2010. These documents: provided a comprehensive overview of the HIV epidemic in Zambia and outlined guiding principles for the national response in terms of prevention programs, universal access to treatment, socio-economic impact management and mitigation, and policy and institutional responses. A landmark decision was made in August 2005 in the area of HIV/AIDS treatment when the government took the policy decision to provide ARVs and a wide range of related ART services free of charge to Zambian citizens. To a limited extent, this decision was perhaps possible to take because of the sizable debt relief that the country benefited from. To a larger extent, however, it was the establishment of HIV/AIDS specific funds such as the Global Fund, the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) and the World Bank Multi-country AIDS Program (MAP) and the resulting partnerships between these funds and the Zambian government that encouraged the government to take the bold decision on free ART.

As would be expected, the funding resources required for an effective response to the HIV/AIDS epidemic are substantial and somewhat overwhelming. The ZASF 2006broadly estimates the resources required to mount an effective response as US$1.22 billion (approximately K4.88 trillion) during 2006-2010. Clearly, for a poor, resourceconstrained country like Zambia, prospects for achieving goal number 6 of the MDGs are (and will continue to be) heavily dependant on external donor financing to sustain the current and future HIV/AIDS effort. The ZASF notes that although the resources 13 Other source estimate there is a 38-66% difference between current life expectancy (with AIDS deaths) and the life expectancy that would have been observed without AIDS.

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required to implement the HIV/AIDS intervention seem daunting, it is clear that there are many partners prepared to provide significant support to Zambia to ensure success in meeting the goals and objectives of the strategic framework. It is perhaps partly from this point of view that the 2005 MDGs progress report determined that halting by 2015 1 and beginning to reverse the spread of HIV/AIDS is ‘likely’ to be achieved. The view of the MDGs report is also probably partly due to observations of the natural trajectory of the disease in Zambia, though not enough empirical attention has been paid to this aspect to provide insights that would enable this paper to make a stronger assertion about the natural trajectory of HIV/AIDS.

Reducing the incidence of malaria is also understood as an important health target of the MDGs, like HIV/AIDS and others. Malaria remains a major public health problem in Zambia, accounting for almost half (46-47 percent) of the country’s total disease burden (defined here as total visitations to public health facilities; see Table 1.3 below)14.

The Health Management Information Systems (HMIS) shows that in 2005/2006 an annual average of about 3.5 million cases of malaria, both confirmed and unconfirmed, were notified (MOH, 2006).

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14 Visitations account for only a small proportion of the total incidence of disease in general. However, the proportions of specific diseases within the overall morbidity profile are consistent between data in the HMIS and survey data such as from the Zambia Demographic and Health Survey (ZDHS) or the LCMS. Thus, we do not augment the HMIS data present above with any data from the surveys.

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Despite malaria accounting for significantly the largest proportion of morbidity, there have been some successes in combating the disease. During the 2005/2006 malaria transmission season there were marginal improvements in malaria-based mortality and morbidity, as evidenced in the reported reduction in mortality and morbidity indicators public health facilities (MOH, 2006). For instance, the national incidence of malaria dropped by 2 percent from 383 cases per 1,000 population in 2004 to 373 cases per 1,000 population in 2005.

Partly, the marginal gains in addressing malaria are the result of the scaling up of case management and preventive interventions. Recent interventions in Zambia include prevention through indoor residual spraying (IRS), insecticide treated nets (ITNs), and to a lesser extent prophylactic drug prescriptions as well as treatment through the use of drugs and case management for those infected. The overall malaria program also supports an Integrated Vector Management (IVM) component, information, education and communication (IEC), behaviour change from communication (BCC), monitoring, surveillance and operations research and so on.

Among the many challenges to the malaria program, some are general problems facing the health sector. For instance, human resource shortages due to attrition (health worker deaths and departures for better prospects abroad and in the private sector) have adverse effects on malaria control. Furthermore, limited capacities at all levels for procurement, supply logistics management of malaria commodities and late disbursement of funds negatively affect speedy implementation of anti-malaria programs.

On the other hand, as specific challenges to the malaria program, the high costs of malaria commodities are a barrier to expanding services to the home management of fever. This is particularly problematic in view of the high level of poverty in the country, resulting in low community participation in malaria programs.

As with HIV/AIDS, many global partners such as the World Bank (Malaria Booster Program), the United Nations (through the Global Fund) and more recently, the US Government (through PEPFAR) recognize malaria as a significant health stress.

Through various models and mechanisms, the global partners have therefore pledged sizable support to malaria efforts in Zambia. While these pledges and extra resources have been generally welcome, some observers worry that at the same time that they address the problems associated with specific diseases, they distort the health system.

This is partly through drawing attention, human resources and financial resources away

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