Prioritizing health service provision as a pathway to achieving middle income status by 2030
Zambia is a landlocked country in Southern Africa and covers a total area of 752,612 square kilometers. As a lower middle-income country with a population of about 17 million people and a population growth rate of about 3% per annum, the country has been implementing the Vision 2030 Long-Term Plan since 2006. This is aimed at transforming Zambia into a prosperous middle-income nation by 2030.
The successful attainment of Zambia’s goal of being a prosperous, middle-income country by 2030 as stipulated in its Vision 2030 begins with transforming the country into a nation of healthy and productive people. Therefore, the Government of the Republic of Zambia (GRZ) through the Ministry of Health (MOH) has continued to prioritize health service provision as a pathway to achieving this. The MOH’s focus is the provision of a continuum of care with particular emphasis placed on strengthening health systems and services using the primary health care (PHC) approach.
Public and private sector team up to boost health
Health services in Zambia are provided by four main players: the Government, faith based (not-for-profit) providers, the mines, and private (for-profit) providers.
The public sector is the biggest health provider with 90% of patients seeking care in facilities owned and run by the Government. The Lusaka-based University Teaching Hospital, with a 1655-bed capacity is the largest public tertiary hospital in the country. It functions as a referral center for serious health conditions and is particularly specialized in general surgery, pediatrics and gynecology.
Other major third-level hospitals include the 826-bed Levy Mwanawasa University Teaching Hospital and the 630-bed capacity Kitwe Central Hospital. In total, Zambia has eight third-level hospitals, 34 second-level hospitals, 99 first-level hospitals, 1,839 health centers and 953 health posts. All third-level hospitals are Government owned.
The private sector also has a significant contribution to Zambia’s health care with its wide network of hospitals and clinics. Some of the notable health facilities include the CFB Medical Centre, a private non-profit health provider with over 35-years of operation in Zambia, the Progress Medical Centre, and the Mary Begg Community Clinic, which has grown into a Class A private hospital offering specialized services in general surgery, urology, dermatology, pediatrics, gynecology and dentistry. A new entrant into Zambia’s private sector is Medland Hospital, which offers a range of specialized care to the country’s growing, increasingly urbanized population.
Specialized private hospitals such as Dr. Agarwal’s Eye Hospital and Vision Care Appasamy Eye Hospital also exist to boost access to specialized care.
Faith-based organizations have also invested in healthcare to boost access to proper healthcare services especially serving communities in rural and hard-to-reach areas. Notable facilities include the Coptic Hospital, which provides specialized treatment in neurology, nephrology, cardiology, gynecology, dentistry and general surgery, the Lusaka eye Hospital and the Chitokoloki Hospital in the Zambezi region.
Even with support from private and faith-based organizations, the national government is responsible for overall coordination and management, policy formulation, strategic planning and resource mobilization. Several agencies under the Ministry of Health exist to regulate and coordinate activities in the health sector.
The Health Professionals Council of Zambia has the mandate to register and regulate all Health facilities in Zambia both public and private training institutions. Meanwhile, the Zambia Medicine Regulatory Authority (ZAMRA) is tasked with the role of ensuring that all medicines and allied substances being made available to the public consistently meet the set standards of quality, safety and efficacy. The National Health Research Authority (NHRA) is mandated to provide a regulatory framework for the development, regulation, financing, coordination of Health research to ensure the standards and guidelines for ethically sound health research in Zambia.
Health Care Financing
Zambia’s health expenditure is mainly dominated by external funding (42%), followed by general taxes (39%) and out-of-pocket payments (13%). The Government allocation to the health sector in nominal terms has been increasing even though the share of the health sector budget to national budget has been decreasing over the past five years.
The proportion of the MOH budget to the national budget was 9.9% in 2014, 9.6% in 2015 and 8.3% in 2016. Declining budgetary allocation keeps Zambia from meeting the target set by the Abuja Declaration of having 15% of government annual expenditure allocated to the health sector.
Although budgetary contribution to health has been low, Zambia has made strides in health insurance to enhance access to care. In 2019, it implemented the National Health Insurance Scheme (NHIS) to ensuring sustainable, predictable, and dedicated financing for the health sector and financial risk cover for Zambians. The NHIS is based on the solidarity model, where the risk is redistributed from healthy individuals to sick ones, from the rich to the poor, from the young to the elderly, and from small families to large families.
The introduction of the mandatory NHIS poses a threat to the existence of private health insurance (PHI) which was struggling even before the NHIS was introduce. For instance, in 2018, 3% of men were insured while only 2% of women had health insurance coverage. This represents a sharp decline in coverage, from 8 and 9% among women and men, respectively reported in the 2007 Zambia Demographic and Health Survey (ZDHS).
Low rates of health insurance coverage imply that most Zambian citizens have to make direct out-of-pocket payments when they seek healthcare services or be catered for under government taxes. This makes them vulnerable to catastrophic health treatment costs and hampers any progress towards the achievement of Universal Health Care.
Team efforts helps drive down Zambia disease burden
Zambia has a high disease burden, particularly in terms of communicable diseases with a high prevalence of HIV/AIDS, tuberculosis, and sexually transmitted infections. The country is experiencing a widespread HIV/AIDS epidemic, with an estimated national prevalence of about 11.1 percent among adults (15-59 years) and 14.6 percent among children. Infection rates are highest in urban areas, and women are more likely than men to be infected.
A recent study on district-level prevalence of HIV using Small-Area Estimation (SAE) concluded that highest HIV prevalence is found in districts near international borders, along major transit routes, and adjacent to other districts with high prevalence.
HIV management has taken a team approach with a number of development partners chipping in to assist the government in taming the disease. The Global Fund to Fight AIDS, The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the Center for Disease Control (CDC) have been some of the star players in this field. Because of the synergistic efforts by multisectoral players in fight against HIV/AIDS, the country managed to achieve the UNAIDS 90:90:90 targets in 2019.
Annual HIV infections (for all ages) in Zambia have decreased from 60,000 in 2010 to 51,000 in 2019 while new infections among children aged 0-14 years have decreased from an estimated 10,000 in 2010 to 6,000 in 2019. AIDS-related deaths have also decreased significantly, from 24,000 in 2010 to 19,000 in 2019, a 30% decrease.
Zambia is now focusing on the 95:95:95 targets for 2030. Annual HIV infections (for all ages) in Zambia have decreased from 60,000 in 2010 to 51,000 in 2019. The number of new infections among children aged 0-14 years has decreased from an estimated 10,000 in 2010 to 6,000 in 2019. Annual AIDS-related deaths have also decreased significantly, from 24,000 in 2010 to 19,000 in 2019, a 30% decrease.
Annual HIV infections (for all
ages) in Zambia have decreased from 60,000 in 2010 to 51,000 in 2019.
Tuberculosis (TB) remains a public health concern. The increased incidence of TB can be attributed to the high HIV prevalence. Zambia is ranked 21st among the 30 high TB burden countries, with an estimated burden of 333 TB cases per 100,000 people (approximately 0.33%) in 2019. As a result, TB is one of the top five causes of morbidity and mortality, particularly among young and economically productive adults aged 15-49 years. The CDC is an active player in management of the disease and is assisting the MOH in improving TB testing platforms and increasing access to TB Preventive Therapy (TPT) for people living with HIV.
Zambia also suffers from seasonal epidemics such as cholera, which are caused by unequal access to improved water sources, and poor solid waste management, among other factors. Outbreaks are most common during the rainy season. Between January 1977 and December 2018, Zambia experienced 29 cholera outbreaks ranging in size from 14 to 13,500 cases, with case fatality rates (CFR) ranging between 0.5 and 9.3 percent. The majority of cases occur in peri-urban areas of the densely populated Lusaka and Copperbelt provinces, as well as in rural fishing camps.
Zambia has taken the bold and ambitious step of eliminating cholera in Zambia by 2025, well ahead of the global 2030 target. As a result, Zambia has developed its first country Multisectoral Cholera Elimination Plan (MCEP) 2019-2025, which aims to reduce cholera morbidity and mortality and, eventually eliminate cholera from the country.
Malaria is also endemic in Zambia and has a year-round transmission pattern and remains the leading cause of outpatient attendance. The disease’s burden has a seasonal pattern that is determined by environmental factors such as rainfall, vegetation, and temperature, among others. Although the incidence of malaria has decreased dramatically, there is significant intra-country variation with the northern parts of Zambia posting the highest prevalence rates followed by central and southern parts respectively.
Zambia has also seen an increase in noncommunicable disease (NCD) cases over the years, particularly those related to hypertension, cardio-vascular disease, diabetes, and cancer. According to the 2018 WHO NCD country profiles, NCDs account for 29% of all deaths in Zambia. This is unacceptably high, given that the majority of these diseases can be reduced by changing four major behavioral risk factors for NCDs: tobacco use, harmful alcohol use, unhealthy diets, and physical inactivity.
Using incentives to attract private sector involvement
Since 1992 the Government of Zambia has been implementing health reforms whose vision is to create environments that are conducive to health. The government for instance, made health sector is among the key sectors being targeted for private investment under the Strategic Action Initiative for Economic Development termed as Triangle of Hope (TOH).
In 2007, Zambia identified medical services, manufacture of pharmaceutical products, medical laboratory services, diagnostic services, repair and maintenance of medical equipment, provision of laundry service to medical institutions, ambulance services and education & training (human resource for health development) as priority sectors for investment by the private sector.
Additionally, Zambia has identified telemedicine, establishment of hi-tech hospitals for treatment of specialized cases, diagnostic centers, drugs logistics supply chain and storage, hospital fleet management and repair, laundry services, repair of medical equipment and training of health personnel (medical school and nursing school) as some of the areas ripe for Public Private sector partnerships.
When it comes to pharmaceuticals, Zambia only has 7 manufacturing companies and approximately 50 trading companies. Most of these are engaged in the manufacturing of basic pharmaceutical medicines. The majority of drugs required under the essential drugs list are still being imported.
In its quest to provide affordable good quality, safe and efficacious drugs the Zambian Government has extended its investment friendly incentives to the pharmaceutical manufacturing sector. There exists a 5-year tax holiday for existing and future manufacturers to help them establish and cement their presence in the country. Zambia has also waived import duties and taxes on all raw materials, printing and packaging material for the pharmaceutical manufacturing Industry. Import duties and taxes on capital expenditure for the pharmaceutical manufacturing and printing industry have also been waived in an effort to attract both foreign and local investment in drug manufacturing.
Digital to drive Zambia future health space
The ongoing COVID-19 pandemic shed a light on the importance of integrating digital technology in healthcare in order to provide effective interventions to patients for a sustainable tomorrow.
The unveiling of e-health platform Dawa Health, has for instance shown the potential of digital health in accelerating Zambia’s journey to universal healthcare. The platform empowers mothers to receive remote maternal health while guiding them throughout the perinatal period via web, mobile, SMS and the platform’s audio/text chatbot.
The launch of Venous, an integrated digital health management system is also heralding a new era for medical records management, where automation and operational efficiencies reign supreme. DelphiCare was also launched at the height of the pandemic to assist in delivery of care. The android app enables health workers to provide longitudinal, expert-level patient management through monitoring, screening for illness, recommending tests, interpreting results, advising on drugs and dosages, and suggesting follow-up.
In total, Zambia’s health system is estimated to have 64 digital health tools, which combined, enhance access to healthcare and simultaneously strengthen the country’s health system. The space is also lucrative for investors.
Opportunities exist amidst immense challenges
Amidst the immense challenges of poverty, low uptake of health insurance schemes, and declining share of the health sector budget to national budget, the country still presents opportunities for investment in healthcare.
The country’s population, which is estimated at about 17.9 million is growing rapidly at 3% per year, resulting in the population doubling close every 25 years. This trend is expected to continue as the large youth population enters reproductive age creating demand for health care services that outstrips current demand.
Private sector players thus have an opportunity to invest in health care facilities to tap into this demand. Setting up will equally not be cumbersome as the government has identified health as a priority sector and relaxed policies to incentivize private sector players. The opportunities in digital health can also not be overstated – the sector is simply too attractive to be ignored by any serious investor. Affordability will continue to be a challenge as most of the citizens are poor, but the national health insurance scheme also provides a great opportunity to provide capitation for hospitals and other health facilities providing services to citizens under the scheme.
This feature appeared in the June 2022 issue of Healthcare Middle East & Africa. You can read this and the entire magazine HERE
