Why is Zambia an Exemplar?

Since 1991, when Zambia held its first multiparty elections, officials have been implementing reforms to its health system aimed at delivering more care to more people nationwide. Typically, these reforms have prioritized the delivery of PHC services, and in many cases they have accomplished their goals. Moreover, they have done so without much increased public spending on health. Instead, Zambia has changed the way it allocates the limited health funding it has—spending better, not substantially more.

Spending better: Zambia’s dual commitment to efficiency and equity

In a health system context, efficiency means getting the most care out of limited resources by ensuring those limited resources are directed to the right things.¹ Equity means minimizing differences in health access and outcomes among different population groups and ensuring everyone has access to the care they need.^1,2,3 In Zambia, though resources for health care are limited, policymakers have given due importance and attention to both efficiency and equity objectives. The interventions they have implemented aim to achieve both.

Improving health system efficiency in Zambia

Charting a country’s performance on the universal health coverage (UHC) effective coverage index against the amount it spends on health care (measured by total health expenditure) over time is one way to measure health system efficiency. The effective coverage index is a composite measure of primary health system performance reflecting service coverage across a range of health services—including prevention, promotion, treatment, rehabilitation, and palliative care—and across the life course; it also reflects the need for health services, the use of health services, and the quality of health services.^15,16 Its formal definition, a 2014 PLOS Medicine paper explains, is “the fraction of potential health gain that is actually delivered to the population through the health system, given its capacity.”¹⁵

We selected Exemplar countries by benchmarking country performance against an optimal possible output—the “frontier”—which is the modeled, maximum effective coverage a country could attain at a given level of spending, in addition to other factors. This method of econometric analysis demonstrates how close a country is getting to the maximum possible output it could be achieving with its money, charting its health system’s improvement over time. This optimal production framing implies an underlying assumption about the relationship between investment and output – there is only so much health a country can achieve at a given level of spend. Once a country has hit the frontier, it must invest more resources if it seeks to achieve greater gains in health system performance.

Zambia shows a unique profile of this performance: the country's given level of spending did not grow significantly in real terms, but its effective coverage index improved over time. In 2000, Zambia’s effective coverage index measure was 26.7; in 2018, it grew to 51.2. At the same time, the country’s total health expenditure (THE) per capita grew from $147.13 to $169.60. In other words, although Zambia’s spending has also remained fairly steady over time—between 2000 and 2018, total health expenditure per capita in Zambia increased by only 15%—effective coverage of health services in Zambia increased by 88% during this period. This shows that improving health performance does not always require more money.

The nearly vertical trajectory in Figure 1 shows Zambia’s health system squeezing better outputs out of its modestly increased spending over time.

At the same time, though its overall health spending is relatively low,¹⁷ many of the health system reforms Zambia has implemented in recent decades were specifically designed to maximize the efficiency of its spending by prioritizing primary health care (PHC). On average, Institute for Health Metrics and Evaluation data show that since 2000, Zambia has allocated 40%–45% of its total health expenditure to PHC—nearly 75% more than other LMICs. (WHO data show an even more substantial allocation to PHC: 78% of Zambia‘s total health spending in 2021). Concurrent improvements to Zambia’s effective coverage index have included a wide range of indicators associated with PHC, including childhood immunization, skilled birth attendance, and family planning services. Between 2000 and 2019, DTP3 coverage increased from 77% to 91%, skilled birth attendance coverage increased from 44% to 80%, and the prevalence rate for modern methods of contraception (mCPR) increased from 15% to 33%. (See Figure 2.)

Health outcomes in Zambia have improved as well. As Figure 4 shows, DALYs reflecting the burden of disease impacted by PHC interventions—such as maternal disorders, tuberculosis, and diarrheal diseases—declined significantly over the past three decades. Zambia’s focus on PHC and improved coverage for indicators like childhood immunization, skilled birth attendance, and family planning services have contributed to improved disease outcomes. For example, in 1990 maternal disorders accounted for 807 disability-adjusted life years¹⁸ (DALYs) per 100,000, whereas in 2019 they accounted for 316 DALYs per 100,000, a decline of 61%. And diarrheal diseases, which caused 11,653 DALYs per 100,000 and 12,253 total deaths in 1990, accounted for 2,782 DALYs per 100,000 (-76%) and 7,224 (-41%) total deaths, respectively, in 2019. Similarly, under-five mortality was 142 deaths per 1,000 live births in 2000 but 62 deaths per 1,000 live births in 2017, reflecting a decline of 56%. Neonatal mortality was 35 deaths per 1,000 live births in 2000 but 25 deaths per 1,000 live births in 2017 (reflecting a 26% reduction). Maternal mortality was 222 per 100,000 live births in 2000 but 137 in 2017 (reflecting a 39% reduction).

Like many of its neighbors, Zambia’s health sector receives substantial external aid, much of which is spent on antiretroviral therapy and other HIV interventions, and HIV outcomes in Zambia have improved. In 2000, HIV/AIDS led to 609 deaths per 100,000 (60,302 total deaths), whereas in 2019 it led to 124 deaths per 100,000 (22,540 deaths), an almost 80% decline.

Improving health system equity in Zambia

“Equitable health care for all” has been the centerpiece of health policy in Zambia since the country’s independence in 1964.²² Policymakers’ emphasis on reaching communities has shaped subsequent interventions designed to improve geographic and financial access to health services—especially PHC.

Zambia’s interventions thus worked through different pathways to improve equitable access to PHC services.

Data from the Zambia Demographic and Health Surveys (DHS) show that these efforts to improve PHC service coverage have markedly reduced the gap in coverage between the most and least wealthy quintiles of the population. For instance, between 2001 and 2018, coverage disparities shrank by 33% for antenatal care with skilled providers, 53% for DTP3, and 56% for skilled birth attendance. At the same time, women in the lowest wealth quintile were more likely than women in the highest quintile to be using modern contraceptives if they wanted to be.

Zambia DHS surveys show that PHC coverage was done equitably, improving access across populations with different education attainment (See Figure 6). Surveys additionally show that efforts have been successful to narrow the gap in coverage of PHC core indicators between women with secondary or tertiary education and women without any formal schooling. The greatest improvement in PHC coverage has been recorded in women without formal schooling.

Zambia’s commitment to increasing health equity also included measures aimed at removing financial barriers to access, and the proportion of total health spending that is considered out-of-pocket in Zambia decreased from 27% in 2000 to 9% in 2019.