Challenges

Remaining equity challenges

Efforts to improve community access have increased DTP3 coverage (all three doses of the diphtheria, tetanus, and pertussis vaccine) for both urban and rural populations, with access improving more rapidly among urban populations (see Figure 16). Although substantial variation has remained over the past two decades, the spread of vaccine coverage across districts has narrowed in recent years.

Although Zambia has made significant progress in improving DTP3 coverage, the rates of under-one children with zero doses (DTP0), defined as children under the age of one who have not received their first DTP dose, have shown slower progress over time (see Figure 17).¹

Since 2010, DTP0 rates in Zambia have experienced slight increases, particularly in rural areas, where wide variations have persisted over the past decade. Despite narrowing DTP0 variation among urban communities since 2000, progress has mostly stalled in recent years. The slower progress in DTP0 compared with DTP3 suggests that reaching unreached communities remains a challenge, potentially requiring targeted efforts to maintain high overall vaccine coverage.

Inequities by sociodemographic factors, such as wealth and maternal education, have grown over the years, as seen in Figure 18. Infants born to mothers with no education are more than 10% less likely to get all three doses of the DTP vaccine compared with those whose mothers have attended school.

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% in 2011 to 37% in 2016.²

Despite this improvement, human resources for health remains a challenge in Zambia, especially in rural facilities. For example, community health assistants are mandated to spend 20% of their time in the health facility and 80% in the communities. Due to continued shortages of health workers, however, community health assistants often spend more time in the facilities and almost one-quarter have taken on a similar role to the nurse in charge.³

According to Zambia’s National Health Strategic Plan,⁴ 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.⁵

Attrition among community-based volunteers (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. These challenges are not unusual; in several other countries, CBVs expected stipends for their involvement in Reaching Every District activities, and lack thereof resulted in attrition, just as it has in Zambia.⁶

Context-specific strategies to retain CBVs may include improved coordination of activities between health facility catchment areas, consideration of CBVs’ work schedules in planning, and provision of timely feedback on performance.

Financial challenges

Zambia is highly reliant on external financial support for immunization, but domestic resources remain essential to service delivery. Although 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 2018, a Full Country Evaluations brief by Gavi highlighted that the Zambian government might need to increase domestic funding for immunization in the coming years to sustain the country’s high immunization coverage levels and to account for potential rising costs associated with upkeep.⁶ In addition, challenges remain in disbursing funds and tracking immunization financing to lower levels.² More details on financing can be found in the Context section.