Project Finance Syndication: An Evaluation of the Challenges Faced by Parastatals in Accessing Project Finance in Developing Countries, a Case of Zambia
The presence of good infrastructure and social amenities not only provides opportunities for employment and a physical beautiful environment but most importantly attracts direct foreign investments which may open a lot of doors for developing countries. It is for this reason that African countries particularly parastatals in Zambia have felt the need to participate actively to build and provide good roads, state of art hospitals, housing, telecommunications infrastructure, schools and shopping malls. However, these parastatals face a myriad of challenges in accessing project finance. Therefore, this study evaluated the challenges faced by parastatals in procuring project finance. Qualitative approach was used in collecting, collating, analyzing and integrating data. The population comprised parastatal’s, financial regulators and utility companies and ministry of finance. The sample of Thirty (30) was drawn from boards of directors, officials in charge of finance, investments and regulations using purposive sampling. The samples were drawn using purposive sampling.
## I. INTRODUCTION
Project finance serves as a financing mechanism specifically designed to support projects with substantial capital requirements. Its distinctive advantages encompass enhanced access to capital, heightened flexibility, a more economical cost of capital, diminished risk exposure, improved decision-making processes, heightened operational efficiency, and potential tax benefits. The involvement of multiple investors in project finance contributes to risk mitigation, alleviating the financial burden on the project sponsor.
By actively engaging all stakeholders in the project and its progression, project finance fosters improved decision-making and operational efficiency. Furthermore, it often brings tax advantages to investors, as project-related costs are typically eligible for tax deductions.
However, despite the potential of parastatals to propel economic growth, they encounter impediments in accessing project finance. These challenges stem from factors such as limited access to capital markets, a dearth of financing alternatives, elevated investment risk, and a restricted understanding of the intricacies of project finance.
This research aims to scrutinize the hurdles confronting parastatals in securing project finance in Zambia and propose viable solutions to facilitate their access to funding. The study will delineate the current project finance landscape in Zambia, evaluating both opportunities and risks inherent in the investment climate. Ultimately, the research endeavors to furnish the Zambian government with recommendations aimed at refining the project finance environment, thereby streamlining access to funding for parastatals in the country.
## II. LITERATURE REVIEW
The critical need for infrastructural investment in Africa is underscored by staggering statistics, with estimates reaching US $93 billion annually. However, the current investment levels on the continent are only half of this requirement, creating a substantial infrastructure gap (Dentons, 2013). A more recent report by the African Finance Corporation and Boston Consulting Group indicates an even higher annual infrastructure gap for Sub-Saharan Africa, reaching US$ 100 billion (African Finance Corporation & Boston Consulting Group, 2017). Alarming figures reveal that up to two-thirds of the continent's population lacks access to power, and only a third of the land is accessible by road (African Finance Corporation & Boston Consulting Group, 2017). This stark reality, coupled with an annual cost of $2.1\%$ of Sub-Saharan Africa's GDP attributed to the infrastructural gap, positions the region as the world's least developed in terms of infrastructure performance (African Finance Corporation & Boston Consulting Group, 2017; World Bank, 2017).
While the World Bank's 'Africa Pulse' notes improvements in telecommunication and water/ sanitation sectors, there are persistent disparities in access to safe water between rural and urban areas (World Bank, 2017). Public investment in infrastructure, as a percentage of GDP, has declined from around $5.8\%$ in 2014 (World Bank, 2017). Several studies highlight the general challenges of accessing project finance in developing countries, citing limited access to capital markets, lack of transparency, political risk, and insufficient knowledge of the project finance process as major hurdles (Olomola, 2018; Okorie & Onu, 2017; Sharma & Pandey, 2020; Bhatt & Sharma, 2019).
Zooming in on Zambia, studies point out challenges such as limited access to capital markets, financing options, and a lack of understanding of the project finance process (Lungu, 2015). Addressing the inadequacy of infrastructure is crucial for economic growth, and private capital emerges as a potential solution (Bhattacharya et al., 2012; Helm, 2009). Successful projects in Sub-Saharan Africa are seen as offering higher returns, attracting private capital. However, obstacles such as political will, policy uncertainty, and poor regulatory frameworks hinder private investment (African Finance Corporation & Boston Consulting Group, 2017). Governments must enact legislation, develop policies, and invest in capacity building to create a conducive environment for private investment and foreign direct investment (FDI) (African Finance Corporation & Boston Consulting Group, 2017).
Public-Private Partnerships (PPPs) could bridge the infrastructural funding gap in Sub-Saharan countries, but their prevalence remains limited (World Bank, 2017). The literature emphasizes the importance of private capital in financing infrastructure, citing the need for policies that address shortcomings such as currency risk, long payback periods, and the lack of specific sources of private finance (Rajé, 2017).
To attract private investment and FDI, deliberate policies should include tax incentives, risk guarantees, and project financing. Capacity building is crucial to develop technical skills for successful infrastructure projects. Initiatives like finance investment programs, regulatory reforms, and promoting projects with risk-sharing structures can incentivize local market borrowing. Collaboration between governments and private investors, sharing best practices, and financial innovations like local currency infrastructure finance bonds can further enhance infrastructure development (African Finance Corporation & Boston Consulting Group, 2017).
The shift away from multilateral development banks is attributed to the emergence of private capital markets and increased availability of development finance from other sources. The reduced prominence of multilateral development banks is due to their conservative lending and slower response compared to other sources. The growing reliance on private finance and a decrease in the share provided by multilateral development banks highlight the changing landscape of infrastructure financing.
## III. METHODS
### a) Ethics Statement
Prior to commencing the study, the researchers diligently obtained informed consent from all participants. Each respondent was requested to provide a signed consent form, signifying their willingness to partake in the research. Before the interviews were conducted, interviewees received comprehensive information that the study exclusively served academic purposes. Furthermore, the research team meticulously safeguarded the anonymity and confidentiality of all records. To uphold privacy, respondents were not required to disclose their names; instead, a unique respondent code was assigned to each questionnaire. Importantly, the study adhered to ethical standards by obtaining approval from the University of Zambia's School of Humanities and Social Sciences Research Ethics Clearance Committee (HSSREC) before its commencement.
### b) Study Design
This research used the qualitative approach in collecting, collating, analyzing and integrating data. By using the qualitative methods, the research gained in understanding and validating the data collected and research findings, while eliminating some limitation intrinsic to using this approach. In parallel, secondary data sources, including scholarly journals, government policy documents, and online resources, were harnessed to augment and contextualize the study's findings. The study was conducted in Zambia. The Country is an ideal study location for this research as it is an emerging market and is classified as a lower-middle income country by the World Bank. This makes it an ideal location to study the challenges faced by parastatals in accessing project finance in developing countries. In this study, the population comprised parastatal's, financial regulators and utility companies and ministry of finance. The sample of Thirty (30) was drawn from boards of directors, officials in charge of finance, investments and regulations using purposive sampling.
## IV. RESULTS
### a) Infrastructure Profile of Selected Parastatals
## i. Zambia Electricity Supply Corporation (ZESCO)
Zambia Electricity Supply Corporation (ZESCO) is the main power generation and distribution utility in Zambia. The majority of the power distributed by ZESCO is generated at hydro power stations, with the most notable being Kariba, Victoria Falls, and Kafue Gorge. Kariba is notable for being the site of one of the largest man-made lakes in Africa, while Victoria Falls is located to the south of the country. The Kafue Gorge power station is the largest in Zambia and provides a large portion of the country's energyneeds. In addition to hydroelectricity, ZESCO also operates numerous solar, wind, and thermal power plants. These plants provide an additional source of renewable energy to Zambia, helping to reduce the country's reliance on fossil fuels.
### Eurobond Financed Projects
The Government of the Republic of Zambia was able to successfully issue a USD750 million Eurobond, and allocated USD69 million of that to ZESCO for the purpose of rehabilitating and expanding the national power grid. This financing gave ZESCO the resources to construct new substations, expand and modernize existing ones, as well as replace any outdated transmission equipment. This enabled ZESCO to improve the infrastructure of the power grid, providing a more reliable and efficient system. Furthermore, this investment helped to create jobs and boost the local economy, as well as improve the quality of life for citizens by providing a reliable energy source.
## ii. National Road Fund Agency
The National Road Fund Agency is responsible for managing the financing of the road sector. It administers the country's road fund and allocates resources for the construction, rehabilitation, and maintenance of roads. The funds given by the National Road Fund are based on the work plan submitted by the Road Development Agency. The road sector was one of the primary recipients of funds from the Government of the Republic of Zambia's issuance of
Infrastructure Eurobonds. This allowed for an increase in investment into the road sector, providing resources for the construction, rehabilitation, and maintenance of roads. This, in turn, helped to improve the quality of the roads, providing safer and more efficient transportation for citizens. Additionally, this investment helped to create jobs and stimulate the local economy.
## iii. Lusaka Water and Sewerage Company
The Lusaka Water and Sewerage Company provides water and sanitation services to Lusaka Province. It is the country's biggest water utility. The construction of new water supply systems in the province, the installation of modern water meters, the expansion of pumping stations and water reservoirs, the installation of new sewerage systems, and the rehabilitation of existing drinking water and sanitation systems. The company also operates a laboratory for water quality testing, as well as a customer service center to provide information and support for customers. In addition, the company hasimplemented a number of initiatives to improve water efficiency, such as the installation of rainwater harvesting systems and the promotion of water conservation measures among the population. The Lusaka Water and Sewerage Company is committed to providing safe and reliable water and sanitation services to the people of Lusaka Province.
Infrastructural projects carried out by the Lusaka Water and Sewerage Company include.
### Kafue Bulk Water Supply Project
This project, worth USD150 million, has a scope of works which includes a 150,000m3/day intake structure, a 50,000m3/day water treatment plant complete with a high lift station as well as a booster station in Chilanga, which lies 20km south of Lusaka.
#### Lusaka Sanitation Program
This project has earmarked the construction of 520km of sewer lines in 26 previously unreached locations. In addition, treatment facilities are slated to be constructed in seven high density neighborhoods. The project also includes the rehabilitation of existing sewerage systems, the installation of pumping stations and water reservoirs, the installation of modern water meters, the upgrading of wastewater treatment plants, and the construction of new water supply systems. In order to further improve the quality of water and sanitation services, the project also plans to implement a number of initiatives such as the promotion of water conservation measures and the installation of rainwater harvesting systems. Furthermore, the project has ensured that the people of LusakaProvince will have access to reliable and safe water and sanitation services by providing training to local staff and technicians on the best maintenance practices.
## iv. Public Service Pensions Fund
Public Service Pensions Fund (PSPF) is a body corporate that was established under the Public Service
Pensions (PSP) Act Number 35 of 1996. The PSPF has a current membership base of 146,000 (one hundred and forty-six thousand) of which 93,300 are active and contributing members while the remainder are retired and on monthly pension payroll. The Fund presently has an investment portfolio of around K2.3 (Two billion and three hundred million kwacha). This amount is equivalent to about US$191,000,000.00 (One hundred and ninety-one million United States of America dollars using the current average exchange rate. This investment portfolio is expected to continue growing into the foreseeable future.
### - Commercial Projects
In its quest to continue growing the investments portfolio, the PSPF carefully identifies commercially viable infrastructure projects. Once the projects have been scrutinized, the fund management obtains Board approval before resources can be allocated to such projects in order to actualize the funds' objectives.
The Public Service Pension Fund (PSPF) is committed to enhancing the financial health and sustainability of the fund. To this end, PSPF has actively sought to diversify its investment portfolio with a focus on increasing the Commercial Property and Real Estate portfolio. Additionally, PSPF has strived to achieve a strong and consistent financial and investment performance, while providing appropriate returns on the members' contributions. All these initiatives are aimed at providing the PSPF members with a secure and stable retirement income. However, due to the need to maintain a balance between the funds needed to be reinvested by PSPF's Investments arm and those needed to pay pension benefits, other sources of financing have been necessary to fund infrastructure projects. This has led to PSPF taking a semi-business approach of raising capital on the open market.
The Public Service Pension Fund (PSPF) has had to resort to capital markets in order to finance infrastructure projects. This has necessitated the implementation of a semi- business approach to raise capital. However, the conditions of the open market for borrowing can be stringent, as demonstrated by the fund's past attempts to develop properties. Furthermore, local banks may impose high lending rates, making viable projects expensive to finance in a developing country.
The Public Service Pension Fund has had to look abroad for project finances due to the unfavorable local lending rates. However, this presents its own challenges such as requiring a sovereign guarantee issued by a Minister of Finance, taking up expensive insurance, and having to adhere to arbitration jurisdictions dictated by the financier. In addition, a country's negative rating by rating agencies can have a detrimental effect on the borrowing entity. Moreover, the schedule of Conditions Precedent can be daunting to fulfil, potentially discouraging the borrowing entity.
Furthermore, the foreign financiers will typically assess the risk of the project by looking at the country's sovereign debt, which can be a challenge for the PSPF. They will also evaluate the bankability of the project by analyzing its positive NPV/IRR and other financial metrics. In addition to the sovereign guarantee, the financers usually require the borrowing entity to take out insurance from their own insurance houses. This can be costly depending on the amount of money being borrowed. Once a financing agreement is in place, the financers will also dictate the arbitration jurisdictions, which can be a challenge for the PSPF. All of these factors must be taken into account when the PSPF is seeking project finance from outside Zambia.
## v. Food Reserve Agency
The function of the Food Reserve Agency is to ensure the nation's food security by stockpiling food reserves and providing a market for small farmers in far flung areas whom might not otherwise have the capacity to market their crops to large scale millers and other food processors in the value chain. This failure is caused by their individualinability to meet certain minimum quotas. The Food Reserve Agency aggregates the yield purchased from farmers and keeps this in storage for most of the year, before being sold on to millers and other manufacturers up the food value chain. In addition to acting as an aggregate supplier to the food industry, the Food Reserve Agency keeps stores of food in various parts of the country as emergency stock in the event of drought or other reasons for crop failure. In this event, the stored cereal crops are made available where need arises.
The main infrastructural projects carried out by the Food Reserve Agency revolve around building adequate storage facilities throughout the country. In order to successfully carry out its mandate, the Food Reserve Agency seeks to increase its storage capacity in all ten provinces of the country.
### b) Challenges Faced by Parastatals in Procuring Project Finance
In a quest to establish challenges faced by parastatals in procuring project finance by ZESCO, the study found that despite Zambia's huge potential to harness its major water resources and develop hydro power generating stations, progress has been slow due to the poor company statement of financial position, high debt equity ratio, challenges of the treasury in terms of lacking adequate space under the Loans and Guarantees regulations resulting into a capping on the debt ceiling of the treasury, delays in obtaining Sovereign Guarantees to support the borrowing on the international financial market, delays in obtaining consents from Attorney Generals, abandoned projects due to failure to acquire financing, and the government's inability to convince multilateral development agencies to support and/or extend financial facilities for key and bankable infrastructure projects.
In the same vain, NRFA revealed that the Agency faced various challenges. These included the need for a guaranteed source of project financing, as well as the need for upskilling in project formulation and implementation. To achieve this, an Act of parliament was passed which authorized the Agency to construct road tolling facilities as an alternative model for raising finances. However, even with this new strategy, the Agency still faced difficulties in persuading financial institutions to provide funding, as it was evident that the funds would have no real impact unless a deliberate funding mechanism was set in place to jumpstart the process. This challenge with regards to secure sources of financing is largely due to the fact that a lot of the project financing comes from government and is not always guaranteed or disbursed on time due to budgetary constraints.
In revealing the challenges faced by Lusaka Water and Sewerage Company in procuring project finance, the study found that the water utility company in Lusaka is facing a major challenge of erratic release of project funding, especially when the funding comes from government budgetary allocation. It also takes a long time to secure project financing, resulting in the restructuring and rescheduling of priority projects, and continual revision of the master plan. With the population of Lusaka continuing to grow, the water utility company is in need of expanding its water treatment and supplying facilities but is hindered by the difficulty of accessing affordable financing. To ensure that the water utility company can fulfill its mandate, it is essential that adequate funding is provided, and the government can play a key role in this by providing sovereign guarantees and other forms of support to help the company acquire the financing it needs.
In postulating its challenges, the Food Reserve Agency (FRA), expressed a need for more appropriate levels of funding from the government. They would prefer the government to obtain infrastructure financing on their behalf, as they lack the financial capacity to put up adequate grain storage facilities to prevent food wastage. The Agency has a very weak balance sheet, making it difficult to seek infrastructure funding without the support of the treasury. Even though the Agency exports some of its excess crop, such as nongenetically modified maize, to the sub-region where it can command a good selling price, all the gains are lost due to overdraft facilities, leaving the Agency financially strained. This means that for the FRA to develop its storage capacity, it must rely on the treasury for funding, although this can be very erratic and unreliable. Therefore, the government must take measures to ensure that adequate and reliable funding is provided to the FRA in order to allow it to develop the necessary storage capacity and prevent food wastage.
Adding to the lamentations, the Public Service Pensions Fund bemoaned a high cost of borrowing on the local financial markets, stringent conditions precedent by multilateral financing institutions and inadequate technical capacity to manage large scale projects. It was recommended that the government ensures economic stability through appropriate economic policies and effective adherence to monetary policy. The spiraling sovereign debt by the Zambian Government has also presented its own problems to the Public Service pensions fund in that the financier of its flagship infrastructure project which is being co-financed by the Industrial and Commercial Bank of China has faced challenges when drawdowns are triggered. The author of this dissertation who happens to the Manager responsible for projects has had this firsthand experience. This has resulted in delayed payments of more than 5 months thereby forcing the project completion time to be extended at great cost to the developer.
The Development Bank of Zambia summarized the challenges faced parastatals and private entities in procuring project finance included; limited financing and a need for improved skills in project finance proposal formulation. Under limited financing, it was discovered that despite the well-intended purpose for setting this local development financing institution, the Treasury did not have adequate financial resources to channel to this financial institution for on-lending to the local market parastatals included. Furthermore, even in instances where this local financial institution borrowed on the international market with the same intention of on-lending onto the domestic market, the volatility of the local currency rendered such initiatives ineffective as the borrowers more often than not would still be required to purchase forex currency to service the loan as well as subsequent redemption of the principal debt thereby rendering the whole initiativeunattractive and expensive.
To add to the complication, the Development Bank of Zambia makes financing available to private entities. This entails a high level of competition for financing if parastatal bodies are to acquire it on commercial terms. The above scenario further entails that the likelihood of default at repayment is high as sometimes the failure to repay the debt is triggered by the further devaluation of the local functional currency the Zambian kwacha. Furthermore, the Bank revealed that in recent times, it experienced severe cash flow problems mainly due to its failure to recover debt despite it having deployed adequate mechanisms to recover loans. This has arisen from the fact that the principal lenders have also faced challenges to recover funds which the institution itself borrowed. This has resulted into the bank finding itself into a debt trap thus leaving it with no choice but to also raise the interest rates whenever an opportunity arises to lend money to parastatals as well as private bodies thereby further making it impossible for parastatals to access affordable project finances.
## V. DISCUSSION
### a) Theme 1. Infrastructure Profile of Selected Parastatals
## i. Zambia Electricity Supply Corporation (ZESCO)
ZESCO, as Zambia's primary power generation and distribution utility, relies heavily on hydroelectric power stations, including notable ones like Kariba, Victoria Falls, and Kafue Gorge. The Kafue Gorge power station, the largest in Zambia, plays a pivotal role in meeting the country's energy needs. Complementing hydroelectricity, ZESCO operates solar, wind, and thermal power plants, contributing to Zambia's renewable energy goals.
The government's issuance of a USD750 million Eurobond, with USD69 million allocated to ZESCO, fueled infrastructure improvements. This financial injection facilitated the construction of new substations, modernization of existing ones, and the replacement of outdated transmission equipment. The resulting enhanced power grid not only bolstered reliability and efficiency but also spurred economic growth by creating jobs and improving the quality of life for citizens.
## ii. National Road Fund Agency
Tasked with managing road sector financing, the National Road Fund Agency allocates resources based on the Road Development Agency's work plan. Infrastructural Eurobonds further boosted investments in the road sector, leading to significant improvements in road quality. This influx of funds facilitated the construction, rehabilitation, and maintenance of roads, ultimately ensuring safer and more efficient transportation for citizens. Additionally, the investment stimulated job creation and contributed to the local economy.
## iii. Lusaka Water and Sewerage Company
As Zambia's largest water utility, the Lusaka Water and Sewerage Company undertakes various projects to provide water and sanitation services to Lusaka Province. Notable infrastructural projects, like the Kafue Bulk Water Supply Project and the Lusaka Sanitation Program, involve constructing water treatment plants, sewer lines, and wastewater treatment facilities. These initiatives aim to enhance water quality, expand access to safe water, and improve sanitation services. The company's commitment extends to water efficiency measures, such as rainwater harvesting systems and water conservation initiatives, ensuring reliable services for Lusaka Province residents.
## iv. Public Service Pensions Fund (PSPF)
Established under the Public Service Pensions (PSP) Act, PSPF actively manages an investment portfolio to secure stable retirement income for its members. Identifying commercially viable infrastructure projects, PSPF diversifies its portfolio, with a focus on commercial property and real estate. While seeking to grow its investments, PSPF has resorted to raising capital through a semi-business approach in the open market. The fund balances the need for reinvestment with pension benefits, necessitating strategic financial decisions.
## v. Food Reserve Agency
The Food Reserve Agency plays a crucial role in ensuring national food security by stockpiling reserves and providing a market for small farmers. The agency's primary infrastructural focus lies in building adequate storage facilities throughout Zambia. By increasing storage capacity in all ten provinces, the Food Reserve Agency efficiently aggregates and stores crops, acting as a reliable supplier to the food industry. The stored reserves also serve as emergency stock in times of crop failure, contributing to the nation's resilience against factors like drought.
Each of these companies showcases Zambia's commitment to addressing critical infrastructure needs, spanning power generation, road development, water and sanitation services, pension fund investments, and food security. These initiatives not only enhance the quality of life for citizens but also contribute to economic growth and sustainability.
### b) Theme 2. Challenges Faced by Parastatals in Procuring Project Finance
In an exploration of the impediments faced by parastatals, particularly ZESCO, in securing project finance, the investigation unearthed a myriad of challenges. Despite Zambia's abundant water resources and potential for hydro power projects, ZESCO has been hindered by factors such as a weakened financial position, a high debt equity ratio, limitations within the Loans and Guarantees regulations, resulting in a capped debt ceiling for the treasury. Delays in obtaining Sovereign Guarantees, consents from Attorney Generals, abandoned projects due to funding shortfalls, and struggles to persuade multilateral development agencies for crucial infrastructure projects have compounded the hurdles.
Similarly, a study by Mwelwa (2018) reiterated the challenges faced by parastatals in Zambia, mirroring the issues of financial instability, high debt equity ratios, and obstacles in obtaining guarantees and consents. NRFA faced its own set of challenges, emphasizing the necessity for a reliable source of project financing and the imperative need for enhanced capabilities in project formulation and execution. Despite legislative authorizations for constructing road tolling facilities, challenges persisted in convincing financial institutions due to the absence of a deliberate funding mechanism.
Kapungwe (2020) echoed the persistent challenges faced by parastatals, stressing the recurring need for assured project financing and advancements in project formulation and implementation. Lusaka Water and Sewerage Company confronted difficulties, notably the erratic release of project funding, prolonged procurement periods, and the challenge of accessing affordable financing for essential expansions. The Food Reserve Agency sought more government funding to address storage capacity needs and prevent food wastage, emphasizing their reliance on the treasury due to financial limitations.
Public Service Pensions Fund highlighted the high cost of borrowing locally, stringent conditions from multilateral financing institutions, and insufficient technical capacity for managing large-scale projects. Economic stability through appropriate policies and adherence to monetary policies was recommended, particularly in light of the Zambian government's escalating sovereign debt, causing delays and financial strain. The Development Bank of Zambia shed light on challenges shared by both parastatals and private entities, including limited financing and competition for commercial terms.
Currency volatility and cash flow problems further complicated matters, leading to increased interest rates and rendering project finances for parastatals less accessible and affordable.
## VI. CONCLUSION
This study evaluated the challenges confronted by Zambian parastatals when seeking project finance. These hurdles eminent from a compromised company financial position, elevated debt equity ratios, limitations under the Loans and Guarantees regulations leading to a capped debt ceiling, delays in securing Sovereign Guarantees, consents from Attorney Generals, as well as instances of project abandonment due to insufficient financing.
These shared challenges underscore the crucial need for a guaranteed source of project financing, enhanced skills in project formulation and execution, and the imperative for the government to secure infrastructure financing on their behalf. To ensure the sustained and reliable funding required by these parastatals, it is incumbent upon the government totake proactive measures in providing essential support, including sovereign guarantees and other forms of assistance, to facilitate the acquisition of the necessary financing.
## VII. RECOMMENDATIONS
The research has identified inherent challenges in procuring project finance in Zambia. Arising from these inadequacies, the following are the recommendations to make it easier for parastatals to procure project finance;
1. Create a streamlined process for parastatals to access project finance. This should include developing a clear set of criteria and requirements for project funding that is easy to understand and implement.
2. Establish a credit enhancement programme to help parastatals access project finance. This could involve government guarantees or other forms of credit enhancement.
3. Encourage the development of local capital markets and the growth of specialised financial institutions that can provide project finance.
4. Provide technical assistance to parastatals to help them develop sound business plans and project proposals that are attractive to investors.
5. Establish a centralised fund to provide grants or low-interest loans to parastatals for investment in projects.
6. Facilitate the development of public-private partnerships to provide more efficient and effective access to project finance.
Authors Contribution
Francis Nyirenda played a pivotal role in the inception and conceptualization of the research study, lending his expertise to shape the study's overarching framework and research objectives. Furthermore, he made substantial contributions throughout the research process, actively participating in data collection, meticulously analyzing the gathered data, and making significant contributions to the drafting and refinement of the article.
Hanson Chishimba, on the other hand, brought valuable expertise to the project by taking the lead in the development of data collection instruments, demonstrating a keen eye for methodological rigor. In addition to this instrumental role, he played a central part in the meticulous analysis of the acquired data, employing advanced analytical techniques to derive meaningful insights. Moreover, his skillful structuring of the article, coupled with his dedication to the clarity and coherence of the narrative, significantly contributed to the overall quality and readability of the research output. Together, the collaborative efforts of Francis Nyirenda and Hanson Chishimba synergized to produce a well-rounded and rigorously conducted study.
### Disclosure of Interest
The authors declare that there are no conflicts of interest pertaining to the research, authorship, or publication of this article. We affirm that the research conducted and the findings presented in this manuscript are devoid of any financial, personal, or professional relationships or affiliations that could potentially bias or influence our objectivity in the research process, data analysis, or the presentation of results.
#### Declaration of Funding
The authors wish to declare that no external funding, grants, or financial support were received for the design, execution, or analysis of the study presented in this article. The research was solely conducted with internal resources, and the authors have not received any financial contributions or incentives from any external entities that could potentially influence the research process or outcomes.
#### Data Availability Statement
The data supporting the findings of this study is publicly available and can be accessed at the University of Zambia library. Additionally, datasets pertaining to the institutions that were investigated in this research are also accessible through the respective institutions' data repositories or archives. Researchers interested in accessing and utilizing this data for further analysis or validation are encouraged to refer to the University of Zambia library's data repository or contact the relevant institutions directly.
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Bárbara Terçariolli,Janaína Rosa,Guilherme Vieira,Renato Cardoso,Paula Lage (2015). RESUMO Introdução: Os transtornos mentais são definidos como sendo síndromes caracterizadas por uma perturbação clinicamente expressiva na cognição, na regulação emocional ou no comportamento de um indivíduo, que refletem uma disfunção nos processos psicológicos, biológicos ou de desenvolvimento subjacentes ao funcionamento mental. Estes estão frequentemente associados ao sofrimento ou às incapacidades. Sabe-se que uma das características marcantes de determinados transtornos está relacionada à cronicidade dos mesmos, o que reduz a possiblidade de cura e levanta a discussão a respeito do controle dos sintomas destes para a manutenção da qualidade de vida dos indivíduos que deles sofrem. Uma intervenção pouco associada, mas relevante, se for analisado o estado dos usuários crônicos em saúde mental, são os cuidados paliativos e suas ações paliativas que não buscam por cura, mas por oferecer o máximo de conforto possível ao usuário desde o diagnóstico até o seu último dia de vida. Objetivo: Reunir e analisar informações a respeito da psiquiatria paliativa e seus benefícios aos pacientes com transtornos mentais. Metodologia: Foram avaliados artigos publicados em revistas indexadas nas bases de dados Scientific Electronic Library Online (SCIELO), National Library of Medicine/NLM (MEDLINE) e National Library of Medicine/NLM (PUBMED), além de sites oficiais como o Ministério da Saúde do Brasil e a Organização Mundial da Saúde, no período de 2014 a 2024. Resultados e discussão: Após busca foram encontrados 33 artigos relacionados ao tema proposto. Foi observado que a psiquiatria paliativa abrange uma ampla gama de questões, incluindo condições de saúde mental amplamente conhecidas, como ansiedade ou depressão, doenças mentais graves refratárias ao tratamento, cuidados neuropaliativos e carga de sintomas em vários níveis. Além disso, aborda problemas éticos e psicossociais, sofrimento psicológico, personalidade, desejo e vontade de morrer, dignidade, solidão, isolamento social, bem como psicofarmacologia. E que esses cuidados seriam vantajosos e de fundamental importância aos pacientes com doenças mentais graves. Conclusão: Diante das novas perspectivas para o cuidado em saúde mental de uma maneira cada vez mais humanizada, os artigos evidenciaram os benefícios da psiquiatria paliativa e sua importância na melhora da qualidade de vida dos pacientes com transtornos mentais graves. Entretanto, foi observado ainda que muitas barreiras precisam ser vencidas para garantir o atendimento de qualidade para o grupo em questão. Palavras chave: Cuidados Paliativos, Psiquiatria Paliativa, Benefícios ABSTRACT Introduction: Mental disorders are defined as syndromes characterized by a clinically significant disturbance in an individual's cognition, emotional regulation or behavior, which reflect a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These are often associated with suffering or disabilities. It is known that one of the striking characteristics of certain disorders is related to their chronicity, which reduces the possibility of a cure and raises the discussion about controlling their symptoms to maintain the quality of life of individuals who suffer from them. A little associated but relevant intervention, if the state of chronic users in mental health is analyzed, is palliative care and its palliative actions that do not seek a cure, but to offer the maximum possible comfort to the user from diagnosis until their last day of life. Objective: Gather and analyze information regarding palliative psychiatry and its benefits for patients with mental disorders. Methodology: Articles published in indexed journals in the Scientific Electronic Library Online (SCIELO), National Library of Medicine/NLM (MEDLINE), and National Library of Medicine/NLM (PUBMED) databases were evaluated, in addition to official sites such as the Ministry of Health of Brazil and the World Health Organization, covering the period from 2014 to 2024. Results and Discussion: After completing the data collection phase, 33 relevant articles were identified for analysis of the proposed theme. It has been noted that palliative psychiatry encompasses a wide range of issues, including widely known mental health conditions such as anxiety or depression, severe mental illnesses refractory to treatment, neuropalliative care, and symptom burden at various levels. Furthermore, it addresses ethical and psychosocial problems, psychological suffering, personality, desire and desire to die, dignity, loneliness, social isolation, as well as psychopharmacology. And that this care would be advantageous and of fundamental importance to patients with serious mental illnesses. Conclusion: Given the new perspectives for mental health care in an increasingly humanized way, the articles highlighted the benefits of palliative psychiatry and its importance in improving the quality of life of patients with serious mental disorders. However, it was also observed that many barriers need to be overcome to guarantee quality care for the group in question. Keywords: Palliative care, Palliative Psychiatry, Benefits 1. INTRODUÇÃO De acordo com a Organização Mundial de Saúde os Cuidados Paliativos (CP) são uma abordagem que melhora a qualidade de vida dos pacientes, adultos ou crianças, e de seus familiares que enfrentam problemas associados a doenças que ameaçam a vida. Eles previnem e aliviam o sofrimento por meio da investigação precoce, da avaliação correta e do tratamento da dor e de outros problemas como físicos, psicossociais ou espirituais [1]. Sendo considerados relevantes, mais frequentemente, quando as tentativas curativas cessam ou perto do fim da vida. Entretanto, este foco prejudica seriamente seu potencial para abordar questões de qualidade de vida, diante da variedade de doenças crônicas e no início das patologias. Atualmente, esses são vistos como um direito do ser humano, com o foco na melhoria da qualidade de vida dos pacientes e familiares, e não apenas na gestão dos sintomas de final de vida. Além disso, os cuidados paliativos e as intervenções curativas não são mutuamente exclusivos, os princípios de ambos podem e devem coexistir quando relevantes e apropriados para uma gama diversificada de doenças que limitam a vida [2]. O campo da Psiquiatria e Cuidados Paliativos compartilham um terreno comum, pois ambas as disciplinas evoluíram historicamente da medicina interna, são fundamentadas no modelo biopsicossocial e geralmente operam dentro de equipes multiprofissionais [3]. Aproximadamente 4,5% da população vive com doença mental grave [4]. Essas estão em risco de mortalidade prematura em relação às pessoas sem doenças mentais graves e as enfermidades crônicas contribuem significativamente para a mortalidade entre esses indivíduos. O padrão de atendimento para indivíduos com problemas médicos graves inclui cuidados paliativos. No entanto, o acesso universal a esses e aos cuidados de fim de vida para pacientes que sofrem de doenças mentais graves continua a ser um objetivo não alcançado [5]. A psiquiatria paliativa abrange uma ampla gama de problemas, incluindo condições de saúde mental amplamente conhecidas, como ansiedade ou depressão, doenças mentais graves refratárias ao tratamento, cuidados neuropaliativos e carga de sintomas em vários níveis. Além disso, aborda problemas éticos e psicossociais, sofrimento psicológico, personalidade, desejo e vontade de morrer, dignidade, solidão, isolamento social, bem como psicofarmacologia. Além disso, os “3 Ds” da psiquiatria paliativa incluem depressão, demência e delirium [6]. E vale ressaltar que as comorbidades psiquiátricas são comuns em pacientes que recebem cuidados paliativos [7]. No geral, a colaboração entre os campos da psiquiatria e dos CP cresceu significativamente na maioria dos países desenvolvidos nas últimas duas décadas [3]. E a prestação de cuidados psiquiátricos, psicoterapêuticos ou psicossociais é considerada um indicador de CP de alta qualidade em casos de doença médica avançada [8]. Pessoas com doenças mentais graves e comorbidades de saúde física que limitam a vida são uma população vulnerável que está sub-representada nas pesquisas sobre disparidades em saúde [9]. Isso ocorre devido esses pacientes serem afetados pelo estigma associado a doenças mentais [10]. E ainda existe na área da saúde mental um desafio que é identificar e tratar eficazmente pacientes com doenças mentais graves e condições concomitantes limitantes de vida em diversos ambientes de cuidados, para que esta população tenha resultados de saúde física e qualidade de vida pelo menos equivalentes aos pacientes sem doenças mentais graves [11]. Estudos têm mostrado maior mortalidade entre pacientes com doença mental grave e persistentes, que morrem 10 a 20 anos antes, em média, do que pessoas na população em geral [12, 13, 14, 15]. Estudo de Olfson e colaboradores em 2015 [14] demonstrou que esse grupo de pacientes apresentam taxas de mortalidade padronizadas de 3,6% para doenças cardiovasculares, 2,4% para câncer e 9,9% para doença pulmonar obstrutiva crônica. Com valores persistentes mesmo quando se controlam fatores como situação socioeconômica e comorbidades [16]. Estudos tem descrito ainda a relevância no tratamento de certas doenças mentais graves e persistentes, como na depressão refratária, na esquizofrenia e na anorexia nervosa [3, 17]. Dessa maneira, a psiquiatria paliativa poderia ser particularmente útil fazendo uma interfase entre as doenças psíquicas e físicas, como exemplo: garantindo que os regimes de medicamentos psiquiátricos sejam mantidos e atualizados de acordo com tratamentos médicos, visando a diminuição dos efeitos adversos. Os psiquiatras paliativos também podem fornecer avaliações contínuas de comorbidades e riscos psiquiátricos, uma vez que o fator biopsicossocial das doenças crônicas graves pode colocar os pacientes em risco de crises de sintomas psiquiátricos, agitação e/ou suicídio. Ao garantir a continuidade cuidados psiquiátricos, esses podem dar aos pacientes a melhor oportunidade possível de participar plenamente do tratamento e, ao mesmo tempo, ampliar as opções disponíveis [5,17]. Um outro ponto relevante é que a maioria dos pacientes com doença mental grave e persistente são capaz de tomar decisões em relação ao seu tratamento e esses devem ser engajados em um modelo de tomada de decisão compartilhada, no qual as partes interessadas: pacientes, médicos e famílias tomem as decisões conjuntamente. É importante salientar que mesmo entre os pacientes sem diagnóstico de doença mental, há evidências de uma na maioria das vezes essa parceria na tomada de decisão não ocorre. E assim, pacientes e familiares podem ter um papel de tomada de decisão menor do que o desejado [18]. É importante salientar que a utilização de cuidados paliativos em psiquiatria, como em outras áreas da saúde, não exclui outras abordagens de tratamento. As características das abordagens do cuidado, como a aliança contínua com os pacientes e seus familiares, o manejo dos sintomas e a busca por conforto do paciente e da família de maneira integral, por exemplo, são compatíveis e consistentes com os princípios do modelo de recuperação. Neste sentido, as abordagens desses podem oferecer aos psiquiatras ferramentas adicionais no cuidado do paciente com doença mental grave e persistente, particularmente quando as necessidades e objetivos do paciente não podem ser atendidos pelas intervenções psiquiátricas atuais [19]. Nesse contexto, considerando o número de pacientes com doenças mentais graves e persistentes, sua concomitância com doenças físicas, e sabendo da necessidade de um acompanhamento mais integral, que os cuidados paliativos pode trazer por meio do alívio de sintomas e do acompanhamento global do paciente e de seus familiares, trazendo inúmeros benefícios e a necessidade do aumento da oferta desse tipo de cuidados no grupo em questão, esta revisão integrativa teve como objetivo reunir e analisar informações sobre a abordagem da psiquiatria paliativa e seus benefícios. 2. METODOLOGIA Este artigo foi elaborado a partir de uma revisão integrativa da literatura. Para isso, foram identificados artigos publicados em revistas indexadas nas seguintes bases de dados: Scientific Electronic Library Online (SCIELO), Google Acadêmico, National Library of Medicine/NLM (MEDLINE) e National Library of Medicine/NLM (PUBMED). Também foram utilizados dados de fontes oficiais como Organização Mundial de Saúde e o Ministério da Saúde do Brasil. O estudo foi dividido em dois momentos, sendo que no primeiro, foram buscados os seguintes descritores em artigos nacionais e internacionais nos idiomas português e inglês: psiquiatria paliativa, cuidados paliativos, doenças mentais graves, benefícios, desafios, palliative psychiatry, palliative care, serious mental illnesses, benefits and challenges. No segundo momento, foram avaliados os títulos e resumos dos artigos encontrados para definir sua inclusão ou exclusão com base nos critérios descritos a seguir, inclusão: estudos realizados por meio de revisões, meta-análises e ensaios clínicos controlados publicados entre 2014 e 2024, que abordavam o tema em questão e que fossem de livre acesso, foram encontrados 315 artigos. E para exclusão do artigo, foram utilizados os seguintes critérios: estudos anteriores há 10 anos de publicação e artigos com baixo rigor metodológico. Para garantir a relevância e qualidade dos estudos selecionados neste artigo valeu-se destes critérios de forma que a revisão de literatura tivesse maior grau de validade e confiabilidade em seus resultados. Após a inclusão dos artigos baseados nos critérios supracitados e que havia relação ao tema proposto, os textos foram integralmente lidos, interpretados e tiveram suas principais informações sintetizadas, finalizando com 33 artigos. 3. RESULTADOS E DISCUSSÃO Como resultado da metodologia após a seleção dos artigos esses foram usados para síntese. Sendo assim, elaborada a Tabela 1 com as principais informações. Tabela 1. Síntese dos trabalhos encontrados relacionando psiquiatria paliativa e seus benéficos para os paceinets com transtornos mentais Título Palliative Psychiatry for Patients With Severe and Persistent Mental Illness: A Survey on the Attitudes of Psychiatrists in India Compared to Psychiatrists in Switzerland [20] Autor/ ano Stoll, J.et al., 2022. Principais achados Enquanto a psiquiatria curativa se concentra no transtorno mental com o objetivo de remissão (parcial) dos sintomas, a psiquiatria paliativa visa melhorar a qualidade de vida por outros meios, além da remissão de sintomas. Em resumo, este estudo demonstrou o potencial da psiquiatria paliativa como uma abordagem biopsicossocial-existencial genuína que integra sistematicamente fatores biológicos, psicológicos, sociais e existenciais do cuidado. Título Atuação da medicina paliativa em pacientes psiquiátricos [21] Autor/ ano Sampaio; Ribeiro; 2024. Principais achados Foram identificados 182 artigos, sendo que 176 documentos foram excluídos após aplicação dos critérios de exclusão e inclusão. A amostra final resultou em 6 estudos, na qual três foram publicados em 2019, um em 2020, um em 2021 e um em 2022. Concluiu-se, então, que é comum existir atraso nos diagnósticos de fim de vida, falta de suporte para os sintomas, presunção de incapacidade na tomada de decisões, e barreiras que as condições psiquiátricas graves podem trazer ao cuidado. Título On the Margins of Death: A Scoping Review on Palliative Care and Schizophrenia [22] Autor/ ano Relyea et al., 2019. Principais achados Foi realizada uma revisão de literatura com o objetivo de melhorar a compreensão dos cuidados paliativos em pacientes com esquizofrenia. Foram identificados os seguintes temas: Estigma que afeta a qualidade do cuidado e o acesso ao cuidado; questões relacionadas com o consentimento e capacidade para tomar decisões sobre cuidados de fim de vida do paciente e nomear decisores substitutos; melhores práticas para intervenções psicossociais, farmacologia, colaboração familiar e de cuidados de saúde, objetivos de cuidados, ambiente e tabagismo; e barreiras aos cuidados, incluindo ambiente, comunicação, educação do prestador e acesso aos cuidados. A revisão sugeriu a importância de práticas de formação interdisciplinares obrigatórias e de normas políticas que definam a comunicação cooperativa entre os prestadores de cuidados de saúde. Destaca lacunas na investigação baseada em evidências sobre intervenções psicossociais e quadros colaborativos para permitir a prestação de cuidados de qualidade no fim da vida a indivíduos com esquizofrenia. Título End of life care for people with severe mental illness: Mixed methods systematic review and thematic synthesis (the MENLOC study) [23] Autor/ ano Edwards et al., 2021. Principais achados O objetivo desse artigo foi sintetizar políticas e orientações internacionais, relativas à organização, prestação e recepção de cuidados de fim de vida para pessoas com doenças mentais graves. Foram avaliadas a estrutura do sistema; questões profissionais; contextos de cuidado; e viver com doença mental grave. As implicações para os serviços e a prática refletiram evidências nas quais existe um elevado grau de confiança. Sugerem que devem ser desenvolvidas parcerias em todos os sistemas de saúde mental e de fim de vida, e é necessário que sejam encontradas formas de ajudar as pessoas a morrer de forma digna. Os profissionais que cuidam de pessoas com doenças mentais graves em fim de vida necessitam de educação, apoio e supervisão. Os cuidados de fim de vida para pessoas com doenças mentais graves requerem uma abordagem multidisciplinar, incluindo a advogacia. E por fim, são necessários cuidados proativos de saúde física para pessoas com doenças mentais graves para resolver problemas como o diagnóstico tardio. Título A palliative care approach in psychiatry: clinical implications [24] Autor/ ano Strand et al., 2023. Principais achados Este artigo contribui para a crescente literatura sobre uma abordagem paliativa em psiquiatria e baseia-se no pressuposto de que uma mudança de perspectiva de uma abordagem curativa para uma abordagem paliativa poderia ajudar a promover a centralização no paciente e aumentar a qualidade de vida de pacientes gravemente enfermos também em psiquiatria. Foram avaliados três cenários clínicos diferentes: anorexia nervosa grave e duradoura, esquizofrenia refratária ao tratamento, automutilação persistente no transtorno de personalidade borderline e suicídio. O trabalho demonstrou que muitas intervenções típicas para transtornos psiquiátricos refratários ao tratamento podem, de fato, ser de natureza paliativa. Além disso, a introdução de características tradicionais de cuidados paliativos, por exemplo os chamados objetivos das conversas sobre cuidados, poderiam ajudar ainda mais a garantir que cuidadores, pacientes e famílias concordem sobre quais objetivos de tratamento devem ser priorizados, a fim de otimizar a qualidade de vida, apesar do transtorno mental grave e persistente. Título Severe mental illness and palliative care: patient semistructured interviews [25] Autor/ ano Knippenberg et al., 2021. Principais achados O objetivo desse artigo foi explorar percepções, experiências e expectativas em relação aos cuidados paliativos de pacientes com doença mental grave (SMI) e uma doença crônica incurável e limitante da vida. A análise dos dados revelou oito categorias: percepções sobre saúde e problemas de saúde, enfrentamento de doenças e sintomas, experiências e desejos de cuidados de saúde atuais, contato com familiares e residentes, experiências com o fim da vida de familiares e residentes, disposição para discutir a respeito do fim da vida, vida e morte, desejos e expectativas em relação ao próprio fim da vida e aspectos práticos relativos a assuntos após a morte. Essas categorias foram agrupadas em dois temas distintos: situação atual e antecipação do fim da vida. Os entrevistados pareciam não estar habituados a comunicar sobre questões de fim de vida, morte e morrer devido a doenças potencialmente fatais. Eles tendiam a discutir apenas sua situação atual e, após maior exploração do pesquisador, a fase terminal da vida. Eles pareciam não estar envolvidos no planejamento futuro de cuidados paliativos. Os resultados deste estudo destacam inadequações no planejamento antecipado de cuidados para pacientes com doenças mentais graves. Os resultados sugerem a utilização de valores, desejos atuais e próximos e necessidades como ponto de partida para estabelecer uma discussão gradual sobre objetivos e preferências para futuros tratamentos e cuidados médicos e mentais. Título Adapting the collaborative care model to palliative care: Establishing mental health–serious illness care integration [26] Autor/ ano Wozniak et al., 2023. Principais achados Os modelos de integração entre cuidados paliativos e cuidados especializados em doenças graves permitiram que um maior número de pessoas usufruísse dos benefícios dos cuidados paliativos. A integração da saúde mental é a próxima fronteira na prestação de cuidados holísticos a indivíduos que vivem com doenças graves. Modelos da integração saúde mental-médica, como o modelo de cuidado colaborativo, são meios atraentes para alcançar a integração da saúde mental porque têm sido utilizados de forma eficaz para melhorar a prestação de serviços de saúde mental nos cuidados primários e noutros contextos médicos; também foram adaptados à integração dos cuidados paliativos com a oncologia e outras áreas médicas. A integração entre os cuidados médicos especializados, cuidados paliativos e saúde mental poderia promover um alívio do sofrimento e a melhoria da qualidade de vida. Título Por uma Psiquiatria paliativa: Aplicação de cuidados paliativos a usuários da Rede de Atenção Psicossocial (RAPS) [27] Autor/ ano Konig Luiz R.C., 2024. Principais achados O objetivo geral desse artigo foi investigar, nas perspectivas médica e bioética, a viabilidade de portadores de sofrimento psíquico, transtornos mentais e abuso ou dependência de substâncias serem submetidos a cuidados paliativos na RAPS, em função desses agravos e não como condição secundária a doenças de base orgânica. Foram objetivos específicos: identificar os fundamentos bioéticos da ideia de cuidado; examinar o papel da clínica ampliada e do Projeto Terapêutico Singular (PTS) no contexto da atenção psicossocial; e vislumbrar o eventual caráter paliativo das intervenções em saúde mental. O estudo propôs ainda uma análise de dados obtidos a partir de levantamento não-sistemático da literatura. Do ponto de vista bioético, medidas paliativas justificam-se na perspectiva integradora de uma ética do cuidado. Verificou-se também que termos como “cura” e “cuidado” comportam uma imprecisão – e, portanto, uma plasticidade conceitual – que possibilita estender a ideia de paliatividade às práticas dentro da RAPS, de maneira alinhada aos princípios do movimento hospice e da Reforma Psiquiátrica brasileira. Para tanto, o ponto de partida deve ser a elaboração do PTS, no âmbito da clínica ampliada. Por fim, ao incluir medidas suportivas, isoladamente ou em conjunto com ações terapêuticas, o modelo de intervenção atual parece admitir a possibilidade de inclusão de práticas paliativas. Ressalva-se ainda a necessidade das equipes multidisciplinares que atuam em saúde mental devem receber treinamento específico quanto a técnicas em cuidados paliativos, com vistas ao aperfeiçoamento da assistência prestada. Título Transtornos mentais crônicos e cuidados paliativos: a prática de terapeutas ocupacionais [28] Autor/ ano Silva et al., 2024. Principais achados O objetivo desse estudo foi investigar a prática de terapeutas ocupacionais, bem como suas abordagens e recursos utilizados na saúde mental, a partir da perspectiva dos cuidados paliativos. Participaram quatro terapeutas ocupacionais atuantes em um hospital de referência em emergência psiquiátrica. Emergiram quatro categorias: 1) Relação entre a abordagem dos cuidados paliativos e saúde mental; 2) Prática do terapeuta ocupacional atuante em saúde mental utilizando a abordagem dos cuidados paliativos; 3) Recursos utilizados por terapeutas ocupacionais em suas práticas no contexto da saúde mental; 4) Desafios encontrados pelo terapeuta ocupacional ao trabalhar com a abordagem dos cuidados paliativos na saúde mental. Os profissionais entrevistados já utilizavam em suas práticas no campo da Saúde Mental a abordagem dos cuidados paliativos, e observaram um aumento da qualidade de vida dos pacientes atendidos. Embora a maioria dos sistemas de saúde separe a saúde mental dos serviços de saúde física, criando barreiras sistémicas aos cuidados paliativos integrados para pacientes com doenças mentais graves, algumas áreas médicas, como a psiquiatria clínica, estão a prestar cuidados no sentido inverso num quadro de cuidados paliativos. Na verdade, a psiquiatria paliativa é um campo em evolução que se concentra em doenças mentais graves, refratárias e muitas vezes que não respondem aos tratamentos psiquiátricos e psicossociais convencionais [7]. Com base nesta definição ampla, algumas intervenções psiquiátricas podem ser consideradas paliativas, pois visam principalmente melhorar a qualidade de vida por meio do controle adequado dos sintomas e concentrando-se na incapacidade e não na cura da doença [3]. Em indivíduos com esquizofrenia estudos apontaram que menos da metade tinham a probabilidade de receber cuidados paliativos especializados. Eles também tinham cerca de 30% menos probabilidades de receber analgesia prescrita, possivelmente refletindo subtratamento ou subnotificação de dor; essa discrepância foi ainda mais pronunciada entre indivíduos com câncer. Enquanto doentes terminais, os indivíduos com esquizofrenia também tinham significativamente menos acesso aos seus psiquiatras e foram mais propensos a passar os últimos meses em uma enfermagem lar [5]. Dados a nível populacional de outros sistemas de saúde incluindo a Austrália e a Nova Zelândia demonstraram que os indivíduos com doenças mentais graves têm entre 2 e 4 vezes menos probabilidade do que indivíduos sem doença mental de acessar serviços de cuidados paliativos nos últimos meses de vida [30, 31]. Em um inquérito aos psiquiatras na Suíça, quase todos os inquiridos acreditavam que o pacientes com doença mental crônica podem apresentar doenças terminais, entretanto eles apresentam uma prioridade menor de cuidados, como a redução do sofrimento e o funcionamento na vida quotidiana. A mortalidade prematura é um aspecto negligenciado nos cuidados de saúde mental [32]. Outros estudos citam três diferentes cenários de condições psiquiátricas relacionadas a sofrimento intenso: anorexia nervosa grave e prolongada; esquizofrenia resistente ao tratamento; e tendência crônica ao suicídio e automutilação persistente no transtorno de personalidade borderline. Em relação à anorexia nervosa, cerca de 25% dos pacientes não alcançam remissão a longo prazo, com artigos mostrando a ineficácia dos tratamentos médicos, levando à morte por desnutrição extrema ou por complicações de tratamentos agressivos. O estudo também destaca a frustração e tratamentos indesejados causados por múltiplos ciclos de alta e retorno aos cuidados devido à falta de motivação dos pacientes. Propõe-se que o foco no aumento da qualidade de vida pode ser uma solução para este problema, destacando programas que visam a reintegração dos pacientes na sociedade e a prevenção de complicações, em vez de apenas restaurar o peso corporal, permitindo uma transição suave entre cuidados paliativos e curativos [24]. As abordagens em cuidados paliativos, no entanto, são aplicáveis em conjunto com outras terapias destinadas a prolongar a vida. Um próximo passo poderia ser envolver os usuários do serviço e desenvolver um consenso sobre o que os cuidados paliativos e seus benefícios para os pacientes com transtorne mental. Uma estrutura para identificar quais pacientes podem se beneficiar de cuidados paliativos deve ser explorada para o desenvolvimento futuro de cuidados para os pacientes [16]. O padrão de cuidados para doenças graves inclui cuidados especializados e cuidados paliativos integrados longitudinalmente; os benefícios dos cuidados paliativos para pacientes com doenças graves estão bem descritos e incluem melhoria da qualidade de vida, diminuição da carga de sintomas, aumento dos cuidados concordantes com os objetivos e apoio do cuidador [33]. Entretanto, o cuidado de pacientes psiquiátricos em fim de vida é um desafio complexo e delicado. Muitas vezes, esses pacientes são vistos como incapazes de tomar decisões sobre seu tratamento, mesmo que possam ter capacidade para isso. Ademais, a falta de diretivas antecipadas pode levar a decisões sendo tomadas por tutores ou curadores, muitas vezes contra os desejos do paciente. Por fim, ressalta que o tratamento de pacientes psiquiátricos em fim de vida deve ser adequado e humanizado, respeitando suas necessidades e autonomia (COFFEY, Michael et al. End-of-life care for people with severe mental illness: mixed methods systematic review and thematic synthesis of published case studies (the MENLOC study) [21]. 4. CONCLUSÕES Dessa maneira a psiquiatria paliativa mostra-se de fundamental importância no acompanhamento dos pacientes e de seus familiares, auxiliando na melhora significativa da qualidade de vida. Entretanto, ainda existem muitas barreiras no cuidado dos pacientes com transtornos mentais. Ressaltamos ainda que a uma necessidade de mais estudos a respeito do tema. REFERÊNCIAS 1- World Heath Organization. Palliative care key facts. Disponível em: https://www.who.int/europe/news-room/fact-sheets/item/palliative-care. Acesso em ago de 2024. 2- Fond G, Salas S, Pauly V, et al. End-of-life care among patients with schizophrenia and cancer: a population-based cohort study from the French national hospital database. Lancet Public Health 2019; 4: e583–91. DOI: 10.1016/S2468-2667(19)30187-2. 3- Trachsel, M., Irwin, S. 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How to Cite This Article
Dr. Hanson Chishimba. 2026. \u201cProject Finance Syndication: An Evaluation of the Challenges Faced by Parastatals in Accessing Project Finance in Developing Countries, a Case of Zambia\u201d. Global Journal of Management and Business Research - C: Finance GJMBR-C Volume 24 (GJMBR Volume 24 Issue C1).
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Project Finance Syndication: An Evaluation of the Challenges Faced by Parastatals in Accessing Project Finance in Developing Countries, a Case of Zambia