Zambia’s Path to Universal Health Coverage: A Mixed Journey of Progress and Challenges

Zambia has made significant progress in improving access to healthcare, but achieving Universal Health Coverage (UHC) remains a work in progress. A new report, Health Financing Progress Matrix Assessment, Zambia 2024, highlights the challenges Zambia faces, including reliance on external funding and the need to strengthen the National Health Insurance Scheme. Recommendations include increasing domestic funding for health and improving financial management to ensure equitable healthcare access.

Zambia has made notable strides towards achieving Universal Health Coverage (UHC), but the journey has been anything but straightforward. According to the latest Health Financing Progress Matrix Assessment, Zambia 2024, conducted by the Ministry of Health in collaboration with the World Health Organization (WHO), the nation is moving closer to ensuring that all its citizens have access to essential health services. However, several critical challenges still stand in the way of achieving this goal. This report offers an in-depth analysis of Zambia’s health financing landscape, highlights the progress made, and identifies the key areas that need attention for sustained improvements.

Progress on UHC: A Steady Climb but Not There Yet

Since 2000, Zambia’s UHC Service Coverage Index has grown steadily, moving from a low of 27 percent to 56 percent by 2021. While this is a significant improvement, Zambia still trails behind the average for lower-middle-income countries. The increase is attributed to improved service coverage for essential health services, including maternal and child health, communicable diseases, and access to medicines.

Central to this progress is Zambia’s Health Financing Strategy 2017–2027, which outlines the government's long-term goals for achieving UHC. The strategy has seen fluctuating government health allocations, ranging from 5.5 percent to 9.4 percent of the national budget between 2009 and 2021. Despite the fluctuations, per capita government health spending has risen from USD 19 in 2009 to USD 32 in 2021.

However, these improvements still leave Zambia short of reaching its UHC goals. More public funding is needed to ensure that health services are available and affordable to all citizens, particularly in underserved areas. The report calls for maintaining or even increasing the prioritization of public health funding, especially given the economic challenges posed by external debt and the impacts of the COVID-19 pandemic.

Financing the Health Sector: Balancing Domestic and External Funding

One of the most significant findings of the report is the country’s reliance on external financing, which accounted for 49 percent of Zambia’s health expenditure in 2021. Domestic public health spending, meanwhile, represented 43 percent, with the remaining 7 percent coming from out-of-pocket payments by individuals—a considerable reduction from the 45 percent recorded in 2000.

The reduction in out-of-pocket costs is a notable achievement, as it reflects the government's efforts to reduce the financial burden on individuals seeking healthcare. Still, the heavy reliance on external funding raises concerns about the sustainability of the health system. If international donors reduce their contributions, Zambia may struggle to maintain current levels of healthcare access, let alone expand them.

To address this, the report recommends that Zambia should reduce its dependence on external aid by increasing domestic funding sources. Improved tax revenue collection and better financial management systems could help Zambia bridge the gap and ensure a more self-reliant healthcare system. More importantly, it calls for greater alignment between donor funds and Zambia’s national health priorities, reducing duplication of services and fostering a more coordinated approach to healthcare financing.

National Health Insurance: A Work in Progress

Another key initiative aimed at boosting Zambia’s health system is the National Health Insurance Scheme (NHIS), established in 2018. The NHIS is designed to pool funds from both formal and informal sectors to provide health coverage for all citizens. However, as of 2022, the scheme still faces significant challenges in terms of enrollment and funding.

The NHIS was intended to cover 35 percent of Zambia’s population by early 2022, but actual enrollment has lagged, with only a fraction of eligible beneficiaries registered. Furthermore, the scheme struggles to enroll informal sector workers, who make up a significant portion of Zambia’s labor force. The report emphasizes the need for policy reforms to expand the NHIS’s reach, including the introduction of subsidies for vulnerable populations and improved enrollment systems for informal workers.

Additionally, the NHIS has been criticized for its passive purchasing mechanisms, which do not provide sufficient incentives for improving the quality of care. Healthcare providers are currently reimbursed based on services rendered, without adequate oversight to ensure that the quality of care meets national standards. The report suggests shifting toward a more strategic purchasing model, with clear quality-related requirements for healthcare providers.

Key Recommendations: Pathways to Better Health Financing

While Zambia has made progress in reducing financial barriers to healthcare, much work remains to be done to create a sustainable, equitable health system. The Health Financing Progress Matrix Assessment, Zambia 2024 offers several recommendations to guide the country’s efforts toward UHC:

Increase domestic health spending: The government should work to protect and increase the proportion of public spending allocated to healthcare, especially in light of fiscal challenges such as debt repayment obligations.

Improve financial management at the local level: Ensuring that frontline health workers and facilities have more flexibility and control over financial resources could lead to more efficient service delivery.

Enhance coordination of external and domestic funds: By aligning donor-funded programs with national health priorities, Zambia can reduce service duplication and fragmentation in the health sector.

Strengthen the NHIS: Expanding enrollment in the NHIS and ensuring that it becomes a more effective tool for reducing health inequalities should be a top priority. Reforming provider payment mechanisms to focus on quality improvements is also essential.

Zambia has made notable progress on the path toward UHC, achieving full coverage will require sustained effort, increased domestic investment, and smarter management of resources. The Health Financing Progress Matrix Assessment, Zambia 2024 provides a comprehensive roadmap for tackling these challenges and moving closer to the goal of universal healthcare for all Zambians.