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 ten provinces and 118 districts. As of 2018 it had a population of 17.4 million: 44.5 percent were under age 15 and 56.5 percent lived in rural areas.² 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.^3,4

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. Alternative health channels include private providers, NGOs, faith-based providers, and traditional healers. As noted earlier, faith-based organizations that are members of the CHAZ oversee about 60 percent of the country’s rural health facilities in hard-to-reach areas.

In the formal public health system, the 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.⁵ 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, rural health centers, and health posts.

Nurses in charge manage health centers and health posts, supported by CHAs and CBVs.⁶ Most of the health workforce is employed and salaried through the MOH.⁵ In this report, we use “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 policy making, sector regulation, and M&E 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.³

Evaluations showed that these reforms improved service delivery, facility maintenance, and health worker morale at the community level.³ As stewardship of health promotion shifted to the community level, NHCs were created to mobilize communities to engage in health activities and report community priorities to the district level.⁷ 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

Zambia launched its immunization program in 1975, shortly after WHO launched the EPI. In 1987, Zambia’s Universal Child Immunization program 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.⁷ Zambia established the national ICC in 1999 to plan, implement, and monitor vaccine programming.^4,8

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, and of a second dose of measles-containing vaccine.⁹

In 2009, major international donors cut funding to the government of Zambia due to financial irregularities. While funding allocated to immunization was not directly affected, this loss of aid compromised health systems support, especially the training of medical personnel.¹⁰

In 2012, maternal, neonatal, and child health services, including vaccination, were transferred to the Ministry of Community Development, Maternal and Child Health. This ministry was responsible for primary health care and district-level service delivery, while the MOH maintained the mandate for overall policy and provision of health care at secondary and tertiary levels. The transition created confusion and led to delayed release of funds and widespread vaccine stockouts in 2012. The maternal and child health sector was transferred back to the MOH in 2016. ^11,12

In 2016, the Zambia Immunization Technical Advisory Group was established. The ZITAG serves as the principal group overseeing and monitoring immunization policy and programming, and it provides technical and scientific expertise.

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 vehicles such as motorbikes are prioritized by 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. The district levels can determine the budget needed to meet performance indicators, such as 80 percent coverage of children by their first birthday.

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 was 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.¹⁷