Key Points 

  • While equity has improved between urban and rural districts, inequities by wealth and maternal education have persisted.
  • Human resources for health remain a challenge, especially in rural facilities.
  • Domestic funding for immunization is not consistently available at the facility level, due to insufficient resources and inefficient flow of funds.
  • COVID-19 is placing an unprecedented strain on Zambia’s health system.

Remaining Equity Challenges

Efforts to improve community access have increased immunization coverage for both urban and rural populations, with access improving more rapidly among urban populations. Overall, district-to-district differences in coverage are more marked than urban versus rural disparities.

Patterns in district-level DTP3 coverage

Source: Institute for Health Metrics and Evaluation (IHME)

Inequities by wealth and maternal education have persisted. DTP3 coverage among the wealthiest 40 percent of the population remains more than 7 percent higher than for less wealthy populations. Infants born to mothers with no education are more than 10 percent less likely to get all three doses of DTP3 compared with those whose mothers have attended school.

DTP3 Coverage

Data Source: ICF, 2015. The DHS program STATcompiler. DTP3 coverage. Funded by USAID., Maryland. Accessed March 18 2021

Addressing Human Resource Needs

Findings from the interviews and focus groups indicate that the number of both paid and volunteer health workers has increased dramatically during the past two decades, which has greatly improved vaccine delivery. Vacancy rates among nurses have declined from 54.3 percent in 2011 to 37 percent in 2016.1

Despite this improvement, human resources for health remains a challenge in Zambia, especially in rural facilities. For example, CHAs are mandated to spend 20 percent of their time in the health facility and 80 percent in the communities. However, due to continued shortages of health workers, CHAs often spend more time in the facilities, and almost one-quarter have taken on a similar role to the nurse in charge.2

According to Zambia’s National Health Strategic Plan, addressing the human resources challenge will require training more staff, in combination with measures to mitigate attrition and improve productivity. Death is the single greatest cause for attrition among clinical officers and nurses. Due in part to HIV, the average age at death for health professionals in Zambia is 37.7 years. Other causes of attrition among health personnel include resignation, dismissal, retirement, and end of contract.3

Attrition among CBVs is high due to inconsistent management, low or nonexistent remuneration, and inadequate supplies. A worker strike in 2009 led to better compensation for health workers, but community-level volunteers reported struggling to obtain basic items to perform their jobs, such as T-shirts, rain boots, and flashlights.

Context-specific strategies to retain CBVs may include improved coordination of activities between health facility catchment areas, consideration of CBV’s work schedules in planning, and provision of timely feedback on performance. These challenges are not unusual; in several other countries, CBVs expected stipends for their involvement in RED activities, and lack thereof resulted in attrition, just as it has in Zambia.4

Financial Challenges

Zambia is highly reliant on external financial support for immunization, but domestic resources remain essential to service delivery. While sufficient resources are generally allocated in national health budgets for the immunization program, in some years economic difficulties have led to limited funds being released for routine immunization services. In addition, challenges remain in the disbursement of funds and tracking immunization financing to lower levels.1


As of May 2021, COVID-19 cases and deaths in Africa have plateaued, but most countries in the region—including Zambia—are still experiencing community transmission. Less than 1 percent of Zambians have received their first dose of COVID-19 vaccine as of May 2021. In addition, the massive surge of cases in India is delaying access to vaccines produced there for lower-income countries. COVID-19 has also exacerbated Zambia’s economic challenges, and the country is now in a deep recession and grappling with unsustainable levels of public debt.

The ongoing pandemic, future surges of disease, mitigation measures, and vaccination campaigns will place unprecedented burdens on Zambia’s health system and human and financial resources.

  1. 1
    Republic of Zambia Ministry of Health. Zambia National Health Strategic Plan 2017-2021. Lusaka, Zambia: Republic of Zambia Ministry of Health. Accessed July 9, 2021.
  2. 2
    Republic of Zambia Ministry of Health. National Community Health Strategy 2019-2021. Lusaka, Zambia: Republic of Zambia Ministry of Health; 2019. Accessed July 9, 2021.
  3. 3
    Ferrinho P, Siziya S, Goma F, Dussault G. The human resource for health situation in Zambia: deficit and maldistribution. Hum Resour Health. 2011;9:30. DOI: 10.1186/1478-4491-9-30
  4. 4
    Ryman T, Macauley R, Nshimirimana D, Taylor P, Shimp L, Wilkins K. Reaching every district (RED) approach to strengthen routine immunization services: evaluation in the African region, 2005. Journal of Public Health. 2010;32(1):18-25. DOI: