Context

Geographic and economic context

The Republic of Zambia is a landlocked country in southern Africa, and classified as a lower-middle-income country.¹ Zambia is administratively divided into 10 provinces and 118 districts. As of 2022, it had a population of a little over 20 million; 43.0% were under age 15 and 54.3% lived in rural areas.¹ From 2004 to 2014, Zambia had one of the fastest-growing economies, until growth slowed due to falling copper prices, decreased power generation, and inflation. This downturn decreased the resources available for health.^2,3

Zambia’s community health service and vaccine delivery structure

Community health services in Zambia are delivered through two primary streams: the formal public health system and alternative channels (see Figure 6). Alternative health channels include private providers, nongovernmental organizations, faith-based providers, and traditional healers. Church-affiliated facilities are common in Zambia and work closely with the government to improve health services. For example, the Churches Health Association of Zambia is a faith-based nongovernmental organization that oversees about 60% of the country’s rural health facilities in hard-to-reach areas. See the What did Zambia do? section for more information on the Churches Health Association of Zambia (CHAZ).

Government-run health facilities are the backbone of Zambia’s health system and provides the majority of the health care in the country. In the formal public health system, the Ministry of Health (MOH) manages overall policy and the provision of health care services at national and provincial levels and the Ministry of Community Development Mother and Child Health, oversees public health facilities.⁴ The provincial health offices provide supervisory services to the districts, and district health offices are responsible for curative and preventive services, including vaccination activities at district-level hospitals, health centers, and health posts. Health centers and health posts provide facility-based immunizations, with the former in primarily urban and central areas and the latter in primarily rural areas. See Figure 6 for more information.

Nurses in charge manage health centers and health posts, supported by community health assistants and community-based volunteers.⁴ Community health assistants and community-based volunteers provide community-level services and often conduct immunization outreach sessions in community spaces such as schools and homes. Most of the health workforce is employed and salaried through the MOH.⁵ In this report, we use the term “health facility” to encompass district-level hospitals, rural health centers, and health posts.

Decentralization of the health sector

In 1991, the MOH was restructured, concurrent with the arrival of the first democratic government in Zambia. Responsibility for policymaking, sector regulation, and monitoring and evaluation remained at the national level, whereas supportive supervision was transferred to the provincial level and service provision shifted to the district level.

From 1992 to 1997, district staff underwent training for their new responsibilities in health planning, management, and service delivery in collaboration with local communities. In 1995, the National Health Services Act was enacted, which brought new reforms, such as the introduction of universal health coverage, with user fees at all levels of health facilities.

Evaluations showed that these reforms improved service delivery, facility maintenance, and health worker morale at the community level. As stewardship of health promotion shifted to the community level, neighborhood health committees (NHCs) were created to mobilize communities to engage in health activities and report community priorities to the district level.⁶ Between 2006 and 2012, user fees were abolished at all primary health care facilities in rural, peri-urban, and urban areas.

History of the immunization program

The Expanded Programme on Immunization (EPI) in Zambia was launched in 1975, shortly after the World Health Organization (WHO) launched EPI. Zambia’s Universal Child Immunization program followed in 1987. It introduced strategies such as immunization on demand at all health institutions, intensification of outreach activities, national immunization weeks, and social mobilization to reduce dropout rates.⁶ Funding for immunization in Zambia comes primarily from the national government and international development assistance for health (see Figure 7). Notably, financing from the government has typically remained steady over the years, whereas international development assistance started increasing in 2002 and has fluctuated over the years.

Since the creation of Gavi in 2000, Zambia has received funding and technical support for health systems strengthening, cold chain equipment optimization, and new vaccine introductions. Gavi has also funded the purchase and introduction of new and underutilized vaccines, enabling the implementation of vaccines against hepatitis B, Haemophilus influenzae type B, human papillomavirus, pneumococcus, poliovirus (inactivated vaccine), rotavirus, and rubella, as well as of a second dose of measles-containing vaccine.⁷

Zambia follows the routine immunization schedule recommended in the WHO vaccine position papers.⁸ Figure 8 outlines the schedule for children up to 14 years of age, which has evolved since the start of the immunization program in 1975. Notably, in 2019, the government of Zambia introduced the human papillomavirus vaccine into the national and routine immunization program for individuals 14 years of age.⁹ Routine immunization for children under the age of one includes bacille Calmette-Guérin given as soon as possible after birth; pentavalent vaccine (for diphtheria, tetanus, pertussis, Haemophilus influenzae type B, and hepatitis B) at 6, 10, and 14 weeks of age; inactivated polio vaccine at 14 weeks; oral polio vaccine at 6, 10, and 14 weeks; measles and rubella vaccine at 9 months; rotavirus vaccine at 6 and 10 weeks; and pneumococcal conjugate vaccine at 6, 10, and 14 weeks.⁸

Zambia established its national Inter-agency Coordinating Committee (ICC) in 1999 to plan, implement, and monitor vaccine programming.^5,10 A unique attribute of Zambia’s ICC was that it expanded its scope to include other health sectors, such as maternal health, child health, and nutrition, which allowed for greater horizontal coordination. In 2016, the Zambia Immunization Technical Advisory Group (ZITAG) was established as an independent advisory group to facilitate national decision making. The ZITAG serves as the principal group overseeing and monitoring immunization policy and programming, and it provides technical and scientific expertise. Both the ICC and ZITAG work together, whereby the ZITAG presents technical recommendations and the ICC considers them for national-level decision making.

Initiated in 2001, Zambia’s National Health Strategic Plan (NHSP) was enacted as part of a broader national effort to address pertinent health challenges occurring in Zambia. The plan was subsequently updated in 2006, 2011, 2017, and most recently in 2022. In Zambia’s NHSP for 2022 to 2026, one of the objectives is to increase fully immunized coverage of children under the age of one to 95% by 2026.¹¹

Zambia’s Vision 2030, which was launched by the government in 2006 to create a sustainable and prosperous middle-income nation, provides a guiding principle for each NHSP.¹² One of the objectives in Vision 2030 is to achieve equitable access to health care for all by 2030; thus, this policy has driven implementation decisions to improve health care in Zamba.¹²

Figure 9 presents a summary of significant milestones related to immunization coverage in Zambia since 2000. The aforementioned policies and their timelines can be seen alongside immunization coverage over time.

Financial planning

The national government determines health resource planning and allocation, and the subnational levels plan the budget to implement activities. Health sector planning and budgeting are done every three years with annual updates.¹³ The entire health sector uses the Financial and Administrative Management System, a public system developed by the Central Board of Health in the 1990s to track budgeting and expenditures across primary health care services, including immunization.

Financial planning and economic management of Zambia’s health sector is overseen by the minister of health, as stipulated in the Public Finance Act of 2004.¹⁴ The minister also presents annual estimates of revenue and expenditure to the cabinet for approval, and then to the National Assembly.¹⁵ The sustainability of immunization funding may depend on mobilizing additional resources from internal and external sources and ensuring increased reliability and efficiency of resource flows.¹⁶

The national government also oversees plans for building new health facilities, although the districts inform the location of new facilities based on population and distance. Districts’ requests for any additional items, such as vehicles (e.g., motorbikes), are prioritized at the national level, with the requested items then distributed when available, likely funded by donors.¹⁴

Financing for health activities is planned from the bottom up, using action plans specific to district, health facility, and community levels; this bottom-up approach to financing is unique to Zambia’s health sector.¹⁷ Districts can determine the budget needed to meet performance indicators, such as 95% coverage of fully immunized children by their first birthday, which was recently set in the NHSP 2022–2026.

Health facilities budget for specific outcomes, such as vaccination coverage rates, on a multiyear basis. Health facilities submit their budgets to the district level, which then submits them to the provincial and national levels. This creates strict budgetary line-item control, in which funds may be allocated only for budgeted items that were previously approved by the legislature. The intention is to increase the integrity of financial management, but inefficiencies arise when facilities do not have the financial autonomy to adapt to priorities such as a disease outbreak. Additionally, the budget formulation is not adequately informed by up-to-date equity criteria, such as population density and poverty rates, or adjusted for inequities within the districts.¹⁸