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Comprehensive Analytical Profile: Zambia

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This analytical profile provides a health situation analysis of the Zambia and, coupled with the Factsheet, it is the most significant output of the African Health Observatory. The profile is structured in such a way to be as comprehensive as possible. It is systematically arranged under eight major headings:
1. Introduction to Country Context
2. Health Status and Trends
3. Progress on the Health-Related MDGs
4. The Health System
5. Specific Programmes and Services
6. Key Determinants
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Statistical profile
Introduction to Country Context
Health Status and Trends
Progress
Progress on SDGs
The Health System
Health system outcomes

The health status of the Zambian people has been improving over the past 18 years.

Since the commencement of major health sector reforms in 1991, Zambia’s efforts have been directed towards improving the standards of living, particularly health, of the population throughout the country. This is being done through a combination of strategies and approaches, which include health specific strategies and those intended to influence the performance of other determinants of health, including education, poverty reduction, and access to good sanitation and safe water.

These efforts have manifested through the implementation of the Millennium Development Goals and the development and implementation of the vision 2030, the national development plan, national health strategic plans (see the latest National Health Strategic Plan 2006-2010) and other relevant sector strategies.

Leadership and governance

Descriptive summary

Since the end of the socialist era in 1991, the Government of Zambia has developed complex mechanisms of leadership and governance. The National Health Policies and Strategies published the same year set the starting point for the development of far reaching health reforms in the following years, including the decentralization policy, the introduction of the Basic Health Care Package (please check the NATIONAL HEALTH STRATEGIC PLAN 2006-2010 for more information), and the early steps of Sector Wide Approaches in coordination with Cooperating Partners.

Community ownership and participation

In the Zambian health sector context, community ownership and participation in the governance and delivery of health services is considered as an important pillar of the health systems. In this respect, the Ministry of Health (MOH) has established popular structures for facilitating broad-based community ownership and participation. Within this framework, community ownership and participation could be analysed at three levels: participation as individuals, user and provider interactions; local community mobilization; and civil society involvement.

Partnerships for health development
Health information, research, evidence and knowledge
Health financing system

The Zambian Health Sector is donor reliant. By 2006, 42% of the health sector expenditures coming from donors, 27% from households, 24% from government, 5% from employers and 1% from others. This is partly due to the SWAp arrangement and an upsurge in the number of parallel projects and vertical programmes which represents the bulk of external aid.

On the other hand the country is yet to develop a holistic and explicit policy on Health Care Financing and this has to some extent lead to fragmented financing of the health care services and inadequate Knowledge on the projected health care resource envelope.

In 2006 the country abolished user fees in health centres and districts hospitals of rural and peri – urban areas in an attempt to increase equity of access to health care services. A programme of social health insurance is also under study and is aimed at complimenting the existing resources for the health sector. Furthermore the government is also in the process of implementing Performance Based Financing Schemes (PBFS) in order to optimize the use of scarce resources.

Service delivery

Service delivery is largely dominated by the public sector that controls 90% of health facilities, either directly, or through agreements with Churches Health Association of Zambia (CHAZ). Yet the private sector is getting increasingly developed particularly in urban areas. The packages of health services are defined along a combination of paradigms: the need to identify limited priority cost-effective services through the definition of the Basic Health Care Package, population-based approach, through decentralisation of health care delivery to the districts and communities, disease-centred services, and life-cycle approach to health service delivery.

Health workforce

The World Health Report 2006 - Working Together for Health identifies Zambia as one of fifty-seven countries worldwide suffering from a critical shortage of health care workers.

The crisis has arisen from a long period of under-funding to the health sector. The crisis manifests through a depleted workforce, inequitable distribution of the existing workforce, poor pay and poor work environment leading to high workloads and a de-motivated workforce. The Government of Zambia has recognized this crisis. It turned into the development of a Human Resources for Health Strategic Plan 2006-2010 which has since led to a number of measures to address and reverse the crisis.

Medical products, vaccines, infrastructures and equipment

Support services are probably remaining one of the weak chain of the Zambian health sector. Efforts have been consented these last years on restructuring and streamlining the organization of pharmaceuticals, but some problems remain. Some areas, particularly rural and peri-urban areas in poor provinces, suffer from insufficient equipment and infrastructure, and poor maintenance.

General country health policies

Over the past years, the Government of Zambia has taken a number of actions and strategies in various sectors, aimed at reducing inequities and improving health and living conditions. The concept of "equity of access to assure quality, cost-effective and affordable health services, as close to the family as possible" is at the heart of the 1992 National Health Policies and Strategies which is guiding policy reforms since it enactment.

Universal coverage

Access by the population to quality social and health services has been an area of concern for successful Zambian Governance since ninepence in 1964. Public health infrastructures have been progressively brought closer to the population, while decentralization policies were aimed at giving them ownership on their health services. Different health financing systems have been tested, resulting today in an increasing tendency towards the provision of free or highly subsidized health services.

Specific Programmes and Services
HIV/AIDS

Zambia is among the countries that are most affected by the HIV and AIDS epidemic in Sub-Saharan Africa. The epidemic is generalized and cuts across gender, age, geographical, and socio-economic status of the population. In view of the foregoing, HIV and AIDS form part of the national health priorities.

Over the past 10 years, the country has intensified the fight against HIV and AIDS, through introduction and scaling of high impact interventions in prevention, treatment and care. The main objective is to halt and begin to reduce the spread of HIV/AIDS and STIs, by increasing access to quality interventions. Both the objective and targets are aligned to the MDGs.

Further, in line with the UNAIDS/WHO “Universal Access” goal, Zambia is on track towards reducing new HIV infections in children by 50% by the end of 2010. The country has also adopted the goal of “ virtual elimination of paediatric HIV transmission by 2010”. In this respect, MOH and its Partners intend to achieve this by reducing the rate of transmission via Mother to Child Transmission (MTCT) to less than 5%, through further scaling up of Prevention of Mother to Child Transmission (PMTCT).

Tuberculosis

TB continues to be among the major public health problems in the country. Although there has been a gradual reduction in the number of notifications (see Figure xxx below). A total of 50,415 TB cases were recorded in 2007, compared to 47,333 in 2008, representing a decrease in notification rates from 419/100,000 in 2007 to 408/100,000 in 2008.

Zambia TB cases 1980 - 2009

There is universal facility coverage with TB-DOTS services in all the provinces in the country and microscopy services have been expanding progressively since 2006. Innovations approaches have also been introduced, including the involvement of DOTS supporters and sputum referral systems where laboratory services are not available. Zambia has a policy of ensuring the availability of quality first line anti TB drugs at all times in all the public Health facilities.

Malaria

Malaria is a major public health problem in Zambia and has for a long time remained the leading cause of morbidity and mortality in the country. A total of 3.2 million cases (confirmed and unconfirmed) were reported in 2009, leading to approximately 4,000 deaths . Notwithstanding this situation, Zambia has made considerable progress in the fight against malaria, implementing effective malaria prevention, treatment and care interventions across the country.

Strong partnerships have also been established, with appropriate coordination mechanisms. As a result of all these efforts, over the past 5 years, malaria incidence decreased, from 412 cases per 1,000 in 2006 to 246 cases per 1,000 population in 2009. The figure presents the trends in the incidence of malaria in Zambia, from 2000 to 2009.

Immunization and vaccines development

Zambia has adopted the WHO guidelines for vaccinating children through the Expanded Programme on Immunization (EPI). Children are considered fully immunized if they receive a vaccination against TB, (BCG), and three doses of each of the following: diphtheria; pertussis; tetanus/hepatitis B/Haemophilis influenza type b (DPT-HepB-Hib). Additionally, they must be vaccinated against Polio and a Measles, within the first twelve months from birth. According to the ZDHS 2007, in 2007:

  • 68% of children aged 12-23 months were fully immunized;
  • 92% of children received the BCG vaccination;
  • 85% were vaccinated against measles;
  • The coverage of the first dose of DPT or DPT-HepB-Hib vaccine and polio was at 92% and 94%, respectively;
  • 80% of children received the third dose of DPT or DPT-HepB-Hib vaccine; and
  • 77% received the third dose of polio vaccine.
Child and adolescent health

The country’s objectives for child and adolescent health are aligned to the MDGs and other relevant global strategies and targets. The main child health interventions being implemented in Zambia are the Expanded Programme on Immunisation (EPI); and the Integrated Management of Child Illnesses (IMCI) programme. Both programmes have recorded significant achievements. However, the national response to adolescent health is not well coordinated and harmonized.

The EPI programme is strong and has scored tremendous success, with significant support from the partners. All the districts are implementing IMCI strategies, but reaching optimal saturation levels (80% health workers managing sick children trained in IMCI) has been a challenge due to resource constraints. Other major factors include: the supportive supervision monitoring tools used at provincial and district levels do not adequately address IMCI; staff shortages; and weak health systems.

Maternal and newborn health

The health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her baby. In Zambia, maternal and newborn health is among the national health priorities. The objectives in this area are aligned to the Millennium Development Goals and other global objectives and strategies relevant to maternal and newborn health.

Zambia is among the countries with the highest maternal and neonatal mortality rates in the world. However, over the past 10 years, the country has intensified its efforts towards strengthening of maternal and newborn health by scaling up high impact interventions.

As a result of these efforts, significant progress has been reported, leading to reductions in maternal, infant and under five mortality rates. According to the ZDHS 2007, maternal mortality ratio has reduced from 729 per 100000 live births in 2002 to 591 in 2007, infant mortality rate has decreased from 95 deaths per 1000 live births to 70 and under-five mortality from 168 per 1000 live births to 119, respectively.

Gender and women's health

Understanding of linkages between gender equity and the goals of the health sector is essential. Gender mainstreaming is therefore being strengthened in the design and implementation of all health programmes. In order to address basic human rights which deal with poverty and gender, the Ministry if Health has been striving to tackle the social determinants of health through:

  • fair financing and social protection,
  • health equity in all policies,
  • engendering health programmes,
  • promotion of universal health care, including maternal, newborn and early child development,
  • alleviating the human resources crisis,
  • infrastructure development,
  • promotion of healthy places.

Some health policies on Reproductive Health, Food and Nutrition, and Child Health have incorporated gender mainstreaming issues. Gender Focal Point Persons were also appointed at all provincial and district levels and provided with short-term training in gender mainstreaming in 2006.

Epidemic and pandemic-prone diseases

The majority of epidemics that occur in Zambia are due to environmental factors. According to the Zambia Demographic and Health Survey (ZDHS) 2007, the country has challenges with respect to its preparedness and control of emerging and known epidemics, such as Cholera, Typhoid, HINI (Influenza A virus subtype H1N1), Avian Influenza and Measles. To a large extent, these diseases are driven by lack of equitable access to improved water sources and safe sanitation. For instance, it is estimated that only 41% of the households have access to improved source of water and 25% of households in Zambia have no toilet facilities (ZDHS 2007).

For diseases such as cholera, the situation is compounded by waek multi-sectoral emergency preparedness and control coordination, communication strategy, and definition of the role of key stakeholders. As the control of human epidemics is enshrined in the Public Health Act, the perception is that only the MOH is responsible for health and should undertake such an activities. This undermines multi-sector response and participation of all stakeholders, particularly the communities and local authorities.

Neglected tropical diseases

Neglected tropical diseases place an unacceptable burden on the health of the poorest people in Zambia. The main Neglected Tropical Diseases that are common in the country include schistosomiasis, lymphatic filariasis, human African trypanosomiasis, soil transmitted helminthes and trachoma.

Schistosomiasis (Bilharzia) is prevalent in rural districts especially those close to the Lakes and rivers, with close to 2 million people infected in Zambia. Infections with soil transmitted helminths (hookworm, Ascaris and whip worm) are also common throughout the country.

Other endemic NTDs include Lymphatic Filariasis (elephantiasis) with prevalence rates ranging between 1% and 25% of the circulating Filarial antigen, Trypanosomiasis (sleeping sickness) in Mpika, Chama, Chipata and Katete, and Trachoma in the southern and western provinces of Zambia. For the lallet, five districts were surveyed and the prevalence rates ranged between 14.3% of TF in Sinazongwe to 32.7 in Kaoma (MoH trachoma survey report 2007).

Non-communicable diseases and conditions

Zambia is currently experiencing a major increase in the burden of non-communicable diseases (NCDs). The common NCDs include cardiovascular diseases, diabetes mellitus (Type II), cancers, chronic respiratory diseases, epilepsy, mental illnesses, oral health, eye diseases, injuries (mostly due to road traffic accidents and burns) and sickle anaemia.

Most of these health conditions are associated with lifestyles, such as unhealthy diets, physical inactivity, alcohol abuse and tobacco use, while some are also associated with biological risk factors, which run in families.

Key Determinants
Risk factors for health
The physical environment

Poor environmental sanitation is a major source of public health problems and epidemics in Zambia. It is estimated that over 80% of health conditions presented at health institutions are diseases related to poor environmental sanitation, including water and food borne diseases, such as cholera, dysentery and typhoid. These environmental health problems are caused by traditional and modern environmental factors.

Food safety and nutrition

Food safety and nutrition are important determinants of health in Zambia. Issues of food safety are addressed through environmental health services, whose objective is to promote, improve health through adhering to food safety standards, and maintaining conditions necessary for the prevention of disease. In order to strengthen this area, the country has formulated a draft National Environmental Health Policy. Further, the legislation relating to food and drugs (The Food and Drugs Regulations 2001), has been reviewed and updated to take into account challenges brought globalization and its effect on food safety, and other associated risks.

Access to good nutrition is a major and cross-cutting determinant of health. In Zambia, malnutrition underlies up to 52% of all under-five deaths. The stunting rate in under-five children currently stands at 45%, with 5% being acutely malnourished (wasted) and 15% underweight. The rates of micronutrient deficiencies are also high, with 53% Vitamin A deficiency and 46% Iron deficiency anaemia (NFNC, 2003), while 4% of school aged children were at risk of mild to severe iodine disorders deficiency (NFNC, 2002).

Social determinants

The social and economic environment is a major determinant of health. It includes factors such as the demographic situation and trends, income and socio-economic status, education and literacy, employment and working conditions.

Demographic situation and trends
The population of Zambia has rapidly grown from about 3 million people in 1964, to 13.2 Million in 2010 . The average life expectancy at birth has also increased from 40.5 years in 1998 to 51.3 years in 2010. This rapid population growth, places an increasing burden on the national economy, particularly the country’s capacity to keep pace with the health needs of a rapidly increasing population and its dynamics.

Education and Literacy
Education is the gateway to better employment and improved household income, while literacy is an important tool for accessing health information and education. Zambia has recorded major improvements in education and literacy.



References