Challenges

Financial limitations

Although Zambia allocates its health spending very efficiently, its resources are limited, and the country’s health budget is relatively small.

The country’s economy depends on a single industry—copper—so price instability in that industry has an unusually large ripple effect.

The country’s economy also relies on foreign loans and investments, leaving it at the mercy of its lenders—a situation that worsened in the aftermath of the COVID-19 pandemic and the subsequent default. Although the country is currently trying to restructure its loans, observers note that in 2021, debt repayments comprised nearly 40% of the national budget, compared to 20% in 2018.¹ Funding for health and other sectors declined accordingly¹ and in 2020, the $1.7 billion Zambia spent on external debt payments was four times more than the $400 million that the government spends on public health care.²

The health system in particular is unusually dependent on donor funds and development assistance for health (DAH), which means that disbursements at the district level can fluctuate despite strong planning and coordination structures and a national commitment to PHC.

Low and unpredictable levels of financing have hampered the scale-up and sustainability of successful reforms, most notably results-based financing (RBF) and the community health assistant (CHA) program. RBF was discontinued when World Bank funding ended in 2018, and the same can happen to the CHAs, whose donor support terminated in 2021.

Available data on health financing and system performance are, in theory, used to produce more accurate budget forecasts and to advocate for increased domestic funding for PHC to the districts, with the goal of decreasing Zambia’s reliance on donor spending. In 2019, government spending accounted for roughly 40% of Zambia’s health spending, whereas DAH accounted for 46%.

Despite the 2006 reform to make services associated with PHC priorities legally exempt from user fees everywhere in Zambia, service readiness remains a challenge due to the low availability of supplies. Despite this, Zambia has been testing new approaches in recent years to make services more affordable. For example, the National health Insurance Scheme have been testing mixed payment mechanism meant to improve reimbursements, though people within each level of the health system note that even this increased funding is not adequate to close the gap in providing high-quality services.³

Staff shortages and retention

Despite the substantial increase in clinical staff this report documents, retention in rural areas is still a critical challenge for the Zambian health system, mostly because of widening income inequality and uneven development in rural areas.

• Zambia still falls well short of the WHO minimum recommended threshold of 22.8 doctors, nurses, and midwives per 10,000 persons. In 2017, Zambia’s value was 11.2 per 10,000 persons.⁴ Consequently, finding ways to support health workers and increase their number remains at the core of Zambia’s PHC strategy.⁵

Because of nursing staff shortages in rural health centers, CHAs spend a large proportion of their time in facilities rather than doing outreach in the community, often providing services they might not be adequately trained for. In response, one strategy the Ministry of Health is considering to make up for the shortfall in funding for the CHA program and to mitigate human resource scarcity in rural areas is to offer CHAs additional training to become nurses.

• Many CHAs are working without pay or the equipment they were promised.

District financial autonomy

In Zambia, though decentralized units such as districts and health facilities have some managerial autonomy—for example, districts can adjust planning and financing decisions based on local needs, many service delivery units have limited financial autonomy because they no longer have substantive revenue-raising capabilities since user fees were abolished. Consequently, district and facility budgets no longer include substantial discretionary components. Discretionary budgets are limited to 10%–19% of districts’ total cash disbursements, and can be used to cover limited administrative and operational costs such as maintenance, fuel costs, supplementary staff allowances, and additional drugs or supplies in cases of shortfall or delay. District discretionary budgets also have required percentage allocations by cost type (5% for supplementary drugs, for instance).⁶

The results-based financing trial, which enabled facilities to make spending decisions on the RBF portions of their budgets, found that some financial autonomy at the facility level improved productivity and staff morale: discretionary spending enabled some flexibility to conduct unplanned activities such as obtaining local drugs in the event of stock out or hiring support staff for shortages or emergent needs. However, it might not have been sustained when RBF was discontinued.

The impact of COVID-19

The prevailing narrative is that much of sub-Saharan Africa—including Zambia—and the Global South as a whole might have avoided the worst of the COVID-19 pandemic. For example, through April 1, 2023, there were only 4,063 cumulative reported deaths (22.3 per 100,000) in Zambia, versus 1,134,674 reported deaths (346.3 per 100,000) in the United States.⁷

However, this might be an inaccurate picture of COVID-19 in Zambia. The estimate by the Institute for Health Metrics and Evaluation (IHME) of “total” COVID-19 deaths, which includes excess mortality—a term WHO defines as “the difference between the total number of deaths estimated for a specific place and given time period and the number that would have been expected in the absence of a crisis” ⁸—shows that through April 1, 2023, a total of 75,497 people (414.0 per 100,000) died in Zambia, versus 1,447,082 (441.1 per 100,000) in the United States.

Put another way, the total per capita impact of COVID-19 in Zambia might have been nearly as severe as it was in countries with higher reported COVID-19 mortality numbers.

And although the pandemic’s secondary and tertiary effects, such as the impact of COVID-19 on the burden of other diseases and injuries, have yet to be fully assessed, initial studies have demonstrated an association between COVID-19 and depression in health care workers,⁹ a pandemic-driven decline in tuberculosis testing and treatment,¹⁰ and an additional degree of vaccine hesitancy among health care workers in Lusaka.¹¹

The COVID-19 pandemic delivered a major shock to Zambia’s relatively fragile health system. Additional work is needed to thoroughly assess the full impact of COVID-19 on the health of Zambians, and specifically on the country’s PHC efforts and outcomes.