Context

Health systems—and a country’s ability to effectively deliver primary health care services—are inherently complex and multifaceted, and their success (or failure) can depend on a range of non-health factors, from a country’s geographic characteristics to the availability of funding for health care services and workers.

Geography and culture

Zambia is a large, landlocked country in sub-Saharan Africa bordered by Angola, Botswana, the Democratic Republic of the Congo, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe.

Zambia’s population is young: in 2022, 43% of Zambians were younger than 15.¹ It is also rural: in that same year, 54% of the population lived in remote or hard-to-reach areas.² In 2022, Zambia’s population was an estimated 20.1 million.³

The country has roughly 70 ethnic groups and seven official languages (Bemba, Kaonde, Lozi, Lunda, Luvale, Nyanja, and Tonga); English is the official language of Zambia’s government.⁴ Zambian society is therefore community-driven, multicultural, and multilingual, and its ethnic groups have their own leaders; the country has more than 286 “chief-related positions” across provinces and districts of Zambia.⁵

Politics

From the end of the 19th century until 1964, the land that is now Zambia was under British control. (From 1911, it was a protectorate known as Northern Rhodesia.) After a sustained campaign of civil disobedience, the British government granted Northern Rhodesia’s independence in 1964.⁶

In 1972, the embattled United National Independence Party banned all other political parties, turning Zambia into a one-party state until 1991.⁷ Since then, Zambia has been a multiparty democracy, despite protracted periods of economic turmoil.

Economy

At the time it was formed, Zambia was one of the richest countries in Africa.⁷ The Central African Copperbelt spans the border between the Democratic Republic of Congo and Zambia⁸ and has been the site of large-scale industrialized copper mining since the early 20th century. In the 1960s, the region produced one-fifth of the world’s copper.⁹ Copper exports are still critically important to the country’s economy and fiscal health.¹⁰

In 1969, the Zambian government nationalized its copper mines to pay for its development plans and to improve economic opportunities for Zambians themselves.¹¹ However, the oil crises of the 1970s caused copper prices to collapse and production to plummet.^12,13 The economic depression that followed pushed the government to take on crippling amounts of foreign debt and to agree to the political and economic “structural adjustment” conditions and concessions that came with it.¹⁴ This made Zambia one of the poorest countries in the world.

In 1987, Zambia introduced a “New Economic Recovery Program” that reversed many of the free-market structural adjustment policies it had agreed to; as a result, many donors and lenders suspended their payments to the country.^7,15 In 1996, as part of its efforts to requalify for debt relief from the International Monetary Fund and the World Bank, the country began the process of privatizing its copper mines again.¹⁶

During the COVID-19 pandemic, Zambia defaulted on its international debts; payments have subsequently been restructured.¹⁷ In 2023, the country’s finance minister told reporters that 90% of the taxes Zambia collects go toward public servants’ salaries and servicing its debt.¹⁸

Since 2011, the World Bank has classified Zambia as a lower-middle-income country.

Organization of Zambia’s health system

Zambia’s public health system is highly decentralized and consists of three levels: hospitals; health centers; and health posts. The focus of the health service provision has traditionally been the community. PHC is provided primarily through a network of government clinics, urban and rural health centers and posts, where outreach services to the communities within the catchment areas aim to reach people to deliver services. The role of the private sector in PHC provision is limited, particularly in rural areas.¹⁹ In 2019, Zambia introduced the national health insurance (NHI) as a healthcare financing strategy to increase access to universal health care. However, the scheme is still in its nascency and evaluations have not yet been conducted at scale.

Health spending

Zambia finances its health system through multiple sources of funds. This includes government health spending, development (or donor) assistance for health (DAH), individuals’ payroll contributions and out-of-pocket spending (OOP), and prepaid private health spending from non-public programs – such as private health insurance and services provided for free by NGOs – that are funded prior to obtaining healthcare.

Much of Zambia’s health spending comes in the form of DAH. (See Figure 14) Between 2000 and 2019, DAH comprised almost 50% of Zambia’s total spending on health. And in 2019, the most recent year for which total spending estimates are available,²⁰ 46% ($520 million) of Zambia’s health spending came from DAH, whereas 38% ($429 million) was government spending, 10% ($113 million) was out-of-pocket spending, and less than 6% ($66 million) was prepaid private spending.²¹

Although government health spending in Zambia has increased since 2000—going from 23% of total spending on health in 2000 to 38% in 2019—the country remains reliant on DAH, even when compared to its peers.

For example, in 2019 per capita DAH in Zambia was $30.19. In that year, its neighbors spent less per capita:

• Zimbabwe: 37.1% of 2019 total health expenditure / per capita DAH of $19.66
• Mozambique: 49.1% / $23.05
• Malawi: 57.2% / $28.87
• Tanzania: 33.5% / $17.11
• Democratic Republic of the Congo: 45.6% / $7.30
• Angola: 4.8% / $3.87
• Namibia: 5.5% / $45.17
• Botswana: 6.4% / $36.19

Much of the development assistance for health Zambia receives has been for HIV/AIDS prevention and treatment. In 2019, 48.5% of Zambia’s DAH—$259 million, out of a total of $534 million—was for HIV/AIDS. This is an estimated 23% of Zambia’s total expenditure on health for the same year.

PHC performance has benefited over the years from Zambia’s efforts to coordinate health expenditure across various funding sources – including both government and donors - via SWAp implementation for government-donor coordination in the planning, financing, and oversight of health sector programming.