ZAMBIA NATIONAL HEALTH

STRATEGIC PLAN 2017 – 2021

Contents
.

Acronyms ................................................................................................. vii

1. Executive Summary ........................................................................... 1
1.1 Introduction ................................................................................................... 1
1.2 Health Sector Performance ........................................................................ 1
1.2.1 Health Service Delivery................................................................. 1
1.2.2 Human Resources for Heath ....................................................... 1
1.2.3 Infrastructure Development......................................................... 2
1.2.4 Drugs and Medical Supplies .......................................................... 2
1.2.5 Health Care Financing ................................................................... 2
1.2.6 Health Information ......................................................................... 2
1.3 Strategic Direction ....................................................................................... 2
1.4 Strategic Framework .................................................................................... 3
1.5 Implementation Framework ....................................................................... 3
1.6 Monitoring and Evaluation (M&E).............................................................. 3
1.7 Required Financial Resources .................................................................... 4
2. Introduction ........................................................................................ 5
2.1 Country Background .................................................................................... 5
2.2 Achievements and Challenges of the Health Sector Strategic
Plan .................................................................................................................. 5
2.3 Disease Burden ............................................................................................. 7
2.4 Health Sector Strategic Programmed Approach.................................... 8
2.5 Socio-economic Determinants of Health ................................................ 9
2.6 The National Health System .................................................................... 10
3. Vision, Mission, Overall Goal, Principles and Priorities ............... 13
4. Health Service Delivery System ..................................................... 15
4.1 Primary Health Care and Community Health ...................................... 15
4.2 Reproductive, Maternal, Child, and Adolescent Health and
Nutrition ....................................................................................................... 19
4.2.1 Reproductive and Maternal Health ........................................... 19
4.2.2 Child Health ................................................................................... 22
4.2.3 Nutrition ........................................................................................ 24
4.2.4 Adolescent Health ........................................................................ 27
4.3 Communicable Diseases ........................................................................... 28
4.3.1 General Introduction ................................................................... 28
4.3.2 Malaria ............................................................................................. 28
4.3.3 HIV/AIDS ........................................................................................ 31
4.3.4 Sexually Transmitted Infections ................................................. 33
4.3.5 TB..................................................................................................... 34
4.3.6 Viral Hepatitis ................................................................................ 36
4.3.7 Neglected Tropical Diseases...................................................... 36
4.4 Public Health Surveillance and Disease Intelligence ............................ 38
4.5 Epidemic Preparedness and Response, and Emerging Issues ............. 40
4.6 Non-Communicable Diseases .................................................................. 42
4.7 Hospital Services ......................................................................................... 44

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 4.7.1 Surgical, Obstetric, and Anesthesia Services .......................... 46
4.7.2 Eye Health Services ...................................................................... 47
4.7.3 Paediatric Services ........................................................................ 48
4.7.4 Renal Health Services .................................................................. 49
4.8 Emergency and Mobile Health Services ................................................. 50
4.9 Diagnostic Services ..................................................................................... 51
4.10 Imaging Services .......................................................................................... 54
4.11 Blood Transfusion Services....................................................................... 56
4.12 Ear, Nose, and Throat (ENT) Services .................................................. 58
4.13 Nursing and Midwifery Services .............................................................. 59
4.14 Pharmaceuticals and Medical Supplies .................................................... 61
5. Integrated Health Service Support Systems................................. 65
5.1 Leadership and Governance ..................................................................... 65
5.2 HRH............................................................................................................... 71
5.3 Health Care Financing................................................................................ 75
5.4 Health Information Technology and Research ..................................... 79
5.5 Infrastructure, Equipment and Transport .............................................. 80
5.6 Implementation, Monitoring and Evaluation.......................................... 82
5.6.1 Legal, Policy and Regulatory Framework................................. 82
5.6.2 Institutional Framework .............................................................. 83
5.6.3 Key Sector Partners ..................................................................... 84
5.6.4 Planning, budgeting, and capacity building ............................... 85
6. Costing of the NHSP........................................................................ 87
6.1 Overview ...................................................................................................... 87
6.2 Total NHPS Costs by Major Health Systems Input
Components ................................................................................................ 90
7. Key Performance Indicators ........................................................... 93
7.1 Reproductive, Maternal, Neo-natal, Child Health, Nutrition,
and Adolescent Health .............................................................................. 93
7.2 Malaria ........................................................................................................... 97
7.3 HIV/AIDS ...................................................................................................... 98
7.4 Tuberculosis............................................................................................... 100
7.5 Neglected Tropical Diseases .................................................................. 101
7.6 Public Health Surveillance ....................................................................... 102
7.7 Epidemic Preparedness and Response and Emerging Issues ............ 103
7.8 Non-Communicable Diseases ................................................................ 104
7.9 Hospital Services ....................................................................................... 106
7.10 Eye Health .................................................................................................. 107
7.11 Emergency and Mobile Health Services ............................................... 107
7.12 Imaging Services ........................................................................................ 108
7.13 Blood Transfusion Services..................................................................... 108
7.14 Laboratory Services.................................................................................. 109
7.15 Environmental Health, Food Safety, and Occupational Health ....... 111
7.16 Human Resources..................................................................................... 112
7.17 Health Care Financing Strategy.............................................................. 112
7.18 Health Information Technology and Research ................................... 113
7.19 Health Infrastructure ............................................................................... 113

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Foreword
Despite progress made in reducing maternal and child mortality rates, Zambia
remains a country with a high disease burden which is under significant
pressure to improve the health status of the people. This plan identifies
strategies to significantly reduce the disease burden and accelerate the
attainment of the Sustainable Development Goals. The plan is a major
departure from the past strategic plans. While the plan recognizes that all
health care interventions are important and should continue to receive
support; it also recognizes that interventions must be prioritized due to the constraints on
available resources and capabilities. The plan therefore focuses on Primary Health Care as the
main vehicle of service delivery; resolving the human resource crisis; addressing public health
problems and ensuring that priority systems and services receive the necessary support.
This National Health Strategic Plan (NHSP) supports the National Vision 2030 which expresses
the Zambian people’s aspiration “to become a prosperous middle-income nation by 2030.” This
plan envisions a prosperous country where all Zambians have access to quality health services. As
a government, we are committed to sustaining the gains made in the past five years, and to
expanding the coverage and improving the quality of health services provided to our people.
This plan identifies strategies and programs which will ensure that people of Zambia are healthy
and able to contribute to economic development as articulated in the National Vision 2030 and
the Seventh National Development Plan which prioritize health as a key economic investment
that will drive our socio-economic development agenda.
The National Health Strategic Plan 2017-2021 has a transformative agenda which focuses on
building robust and resilient health systems. The plan focuses on delivering quality health services
across the continuum of care which includes promotive, preventive, curative, rehabilitative and
palliative care. provided as close to the family settings as possible. The attainment of the
universal health coverage will be made possible through primary health care with a focus on
community health.
Through the integrated community and primary health care approach, the country will achieve
reduction in maternal and child mortality rates, malaria elimination and reduction in the incidence
of HIV among other key health outcomes. We acknowledge that good health is a function of not
only health care services, but also other socioeconomic factors which include education,
agriculture, housing, water and sanitation. Therefore this document emphasizes strong multi-
sectoral collaboration to address all the social determinants of health.
It is my considered view that – with appropriate levels of commitment and support from the
Government, Cooperating Partners, health workers and other key stakeholders – this plan will
significantly improve the health status of Zambians and significantly contribute to national
development. I therefore, urge all the people involved in the implementation of this plan to fully
dedicate themselves to this important national assignment. My Ministry is committed to ensuring
the successful implementation of this plan.

Honorable Dr. Chitalu Chilufya, MP

MINISTER OF HEALTH

iii
Acknowledgments

I would like to acknowledge the all-inclusive and widespread consultative processes that have
facilitated the development of this National Health Strategic Plan 2017–2021. The consultative
process entailed engaging with varied stakeholders at the various levels of the health and support
system in order to ensure that the outcome reflected the wishes and aspirations of all. The
stakeholders committed material, financial, and technical expertise to the process, which is highly
commended.
First and foremost, I wish to express my sincere gratitude to the late Mr. John Moyo, Permanent
Secretary-Administration, who until his untimely death had dedicated himself to the completion
of this document; May His Soul Rest in Peace.
My gratitude also goes to our various partners and colleagues who encouraged and supported
the development of this Strategic Plan through their various forms of support. Special thanks go
to the United States Agency for International Development through the Systems for Better
Health Project, and the European Commission for supporting us with consultants, and the
Government of Sweden for supporting us with the consultative process. Special thanks also go
to other Cooperating Partners, international non-governmental organizations, and academic
institutions namely Japan International Cooperation Agency, World Health Organisation, United
Nations Children’s Fund, United Nations Population Fund, Department For International
Development, World Bank, Clinton Health Access Initiative, Churches Health Association of
Zambia, and the University of Zambia, Department of Economics. They were highly critical and
committed to bring in their experience from programmes, projects, and pilots.
I wish to pay special tribute to the core planning team at the MOH headquarters for their
leadership and steady commitment in the process of formulating this Strategic Plan. The Core
team included: the Director Health Policy and Health Services Planning, Dr. Maximillian Bweupe;
the Deputy Director, Mr. Henry Kansembe; the Chief Planner, Planning and Budgeting, Mr.
Patrick Banda; the Coordinators – Mr. Amadeus Mukobe, Chief Planner, Development
Cooperation; Ms. Maudy Kaoma, Principal Planner, Planning and Budgeting; Mr. Terence
Siansalama, Principal Planner, Bilateral and Multilateral Cooperation; Mr. Wesley Mwambazi,
Principal Planner – Health Systems; Mr. Melvin Sikazwe, Senior Planner, Planning and Budgeting;
Mr. Mannix Ngabwe, Senior Planner, Planning and Budgeting; Mr. Alex Kaba, Senior Planner,
Sector-wide Approach. We would like to thank Mr. Davies Makasa Chimfwembe, the former
Director, Policy and Planning, and Mr. Mubita Luwabelwa, the former Deputy Director, Planning
and Budgeting, who initially mooted the process for the development of this strategic plan.
Finally, but not least, I thank the consultants Dr. Victor Mukonka and Dr. Jolly Kamwanga, and
Ms. Emily Moonze, Senior Manager Health System Strengthening (SBH) for their tireless and hard
work in putting the document together.
It is my hope that this Strategic Plan will fulfil the people’s expectations with regard to primary
health care as the focus of the plan. It is anticipated that other stakeholders will buy into the plan
and support the Ministry in order to achieve all its objectives in line with our agreed upon
principle of one plan, one budget, and one monitoring framework.

Dr. Jabbin Mulwanda

Permanent Secretary – Health Services
MINISTRY OF HEALTH

v
Acronyms

ABC Activity-Based Costing

ADH Adolescent Health
AfSBT Africa Society for Blood Transfusion
AIDS Acquired Immune Deficiency Syndrome
AMR Anti-Microbial Resistance
ANC Antenatal Care
ART Antiretroviral Therapy
ARV Antiretroviral Drugs
BSIS Blood Safety Information System
CBOH Central Board of Health
CDH Cancer Disease Hospital
CHAs Community Health Assistants
CHAZ Churches Health Association of Zambia
CHW Community Health Workers
CPs Cooperating Partners
CSO Central Statistical Office
CT Computed Tomography
CVDs Cardiovascular Diseases
DHIS2 District Health Information System
DHO District Health Office
DHS Demographic and Health Survey
EH Environmental Health
EID Early Infant Diagnosis
EmONC Emergency Obstetric and Newborn Care
EMTCT Elimination of Mother-to-Child Transmission
ENC Essential Newborn Care
ENT Ear, Nose, and Throat
EPI Expanded Programme on Immunization
ETAT Emergency Triage Assessment and Treatment
FANC Focused Antenatal Care
FFP Fresh Frozen Plasma
FP Family Planning
GDP Gross Domestic Product

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GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria
GHE Government Health Expenditure
GMP Growth Monitoring Programme
GNC General Nursing Council
GRZ Government of the Republic of Zambia
HFCA Health Facility Catchment Area
HiAP Health in All Policies
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HPCZ Health Professional Council of Zambia
HPV Human Papiloma Virus
HRH Human Resources for Health
HRIS Human Resource Information System
iCCM Integrated Community Case Management
ICT Information Communication Technology
ICU Intensive Care Unit
IDSR Integrated Disease Surveillance and Response
IEC Information Education and Communication
IFMIS Integrated Financial Management Information System
IHP+ International Health Partnerships
IHR International Health Regulation
IMAM Integrated Management of Acute Malnutrition
IMCI Integrated Management of Childhood Illnesses
IMR Infant Mortality Rate
IPTp Intermittent Preventive Treatment during Pregnancy
IRS Indoor Residual Spraying
ITN Insecticide Treated Net
JAR Joint Annual Review
LARC Long-Acting Reversible Contraceptives
LCMS Living Conditions and Monitoring Survey
LLITN Long-Lasting Insecticide-Treated Net
LMIS Logistics Management Information System
M&E Monitoring & Evaluation
MC Male Circumcision
MDA Mass Drug Administration
MDG Millennium Development Goal
MDR-TB Multi-Drug Resistant Tuberculosis

viii
MDSR Maternal Death Surveillance Review
MMR Maternal Mortality Ratio
MNCH Maternal, Newborn and Child Health
MOF Ministry of Finance
MOGE Ministry of General Education
MOH Ministry of Health
MSL Medical Stores Limited
MTEF Medium Term Expenditure Framework
MTR Mid-Term Review
NAC National AIDS Council
NCDs Non-Communicable Diseases
NDQCL National Drug Quality Control Laboratory
NFNC National Food and Nutrition Commission
NGOs Non-Governmental Organizations
NHA National Health Accounts
NHC Neighborhood Health Committee
NHCP National Health Care Package
NHSP National Health Strategic Plan
NTDs Neglected Tropical Diseases
NTOP National Training Operating Plan
NTP National Tuberculosis Programme
PHC Primary Health Care
PHO Provincial Health Office
PLHIV People Living with HIV
PMDT Programmatic Management of Drug-Resistant Tuberculosis
PPP Public Private Partnership
QA Quality Assurance
QC Quality Control
QI Quality Improvement
RAF Resource Allocation Formula
RCC Regional Collaborating Centre
RED/C Reach Every District and Every Child
RH Reproductive Health
RHC Rural Health Centre
7NDP Seventh National Development Plan
SBCC Social and Behavior Change Communication
SDG Sustainable Development Goal

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SGBV Sexual Gender Based Violence
SHI Social Health Insurance
SMAG Safe Motherhood Action Group
SOP Standard Operating Procedure
SRH Sexual and Reproductive Health
STI Sexually Transmitted Infection
SWAp Sector Wide Approach
TB Tuberculosis
TDRC Tropical Disease Research Centre
THE Total Health Expenditure
TWG Technical Working Group
UNAIDS United Nations AIDS
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
UTH University Teaching Hospital
VMMC Voluntary Medical Male Circumcision
WHO World Health Organisation
ZAMPHIA Zambia Population HIV Impact Assessment
ZDHS Zambia Demographic and Health Survey
ZFDS Zambia Flying Doctors Services
ZNBTS Zambia National Blood Transfusion Service
ZNPHI Zambia National Public Health Institute

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1. Executive Summary

1.1 Introduction
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. The
2017-2021 National Health Sector Strategic Plan (NHSP) covering five-years provides guidance
on all health interventions in the health sector. The plan details the direction the health sector
will take, the achievements and outcomes that will be attained, and the interventions that will be
undertaken to make sure these targets are met. It also specifies the roles and responsibilities that
all actors involved in the health sector will have to perform, the implementation challenges that
have to be overcome, the monitoring and evaluation required, and the financial resources needed
to enable the plan to be successfully implemented.

1.2 Health Sector Performance

1.2.1 Health Service Delivery
Zambia still experiences a high disease burden despite making tremendous progress in some
selected indicators. According to the recent Zambia Demographic Health Survey (ZDHS) 2013-
14 report, the maternal mortality ratio (MMR) and infant mortality rate (IMR) have declined from
591 per 100,000 live births to 398 per 100,000 live births and from 70 per 1,000 live births to 45
per 1,000 live births. Furthermore, under-five mortality also declined from 119 per 1,000 live
births to 75 per 1,000 live births. According to the Health Management Information System
(HMIS), hospital malaria fatalities decreased from 24.6 per 1,000 admissions in 2014 to 19 per
1,000 admissions in 2016.
Human immunodeficiency virus (HIV) prevalence in Zambia continued to decline. The recent
Zambia Population HIV Impact Assessment (ZAMPHIA) survey shows a reduction of about 1.7
percentage points from 13.3% in 2014 to 11.6% in 2016. The health sector has also recorded
remarkable progress on antiretroviral treatment (ART) coverage, which stands at 72% of the
eligible people against the United Nations AIDS (UNAIDS) global target of 90%. The country’s
national tuberculosis (TB) notification rate also declined from 321 cases per 100,000 population
in 2012 to 314 cases per 100,000 population.
In addressing the management of cervical cancer, the Ministry opened 11 clinics in general and
central hospitals and completed the construction of the Regional Cancer Disease Hospital, which
has been upgraded to become an oncology regional state-of-the-art centre for cancers.

1.2.2 Human Resources for Heath

With regard to Human Resources for Health (HRH), the Ministry as of December 2016 had an
approved establishment of 63,057 positions, but only 42,515 were filled, representing 67% of the
approved establishment. Worth to note is that during 2016, the Ministry recruited a total of
2,071 health workers against the targeted 2,500 health workers.

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1.2.3 Infrastructure Development
Positive strides were also made in infrastructure upgrade and construction. As of December
2016, 275 out of 650 health posts were built and are now operational. Furthermore, 36 district
hospitals were under construction, while Matero and Chilenje Health Facilities have been
upgraded. The University Teaching Hospital (UTH) and provincial hospitals were undergoing
modernization with the installation of computerized tomography (CT) scans, mammography
equipment. Intensive care units (ICU) in some selected general hospitals had also been installed.
The construction of the National Health Training Institute with a 3,000 student capacity is
nearing completion, with 70% of construction work done. Construction of 240 in-patient bed
capacity at the Cancer Disease Hospital (CDH) was completed and is now operational.

1.2.4 Drugs and Medical Supplies

To ensure commodity (drugs and medical supplies) security in the country, significant investment
has been made to upgrade Medical Stores Limited (MSL) infrastructure and to establish regional
hubs such as Mongu, Choma, Chipata, and Ndola, which are now all operational.

1.2.5 Health Care Financing

In order to improve health care financing, a Health Care Financing Strategy to address issues of
resource mobilization, allocation, reimbursement mechanisms, resource tracking, and fund holder
management is nearing completion and will be implemented going forward. The Social Health
Insurance (SHI) scheme, which is a strategy under health care financing, is regarded by the
Ministry as a major priority. It is envisaged that the SHI will increase the resource envelope for
health and enhance Universal Health Coverage.

1.2.6 Health Information

Efforts have also been made to enhance information to guide planning and decision making at
district and hospital levels countrywide. This has also been extended to the community level
through the introduction of community health information systems.

1.3 Strategic Direction

The strategic plan’s vision is having ‘A Nation of Healthy and Productive People’, while the
mission is ‘To provide equitable access to cost effective, quality health services as close to the
family as possible’. In pursuance of the overall goal, which is ‘To improve the health status of
people in Zambia in order to contribute to increased productivity and socio-economic
development’, this strategic plan was developed in line with the National Transformative Agenda,
which recognizes the importance of the health sector in improving national productivity.
The health service model embedded within this strategic plan will therefore be re-engineered
with emphasis in this particular order: health promotion, disease prevention, and curative and
rehabilitative services in close-to-client settings. The first rung on the ladder of the health
services will be community-based prevention health services rather than curative services.
Additional direction for this strategic plan was further provided through key international and
national policies and goals, which include the Sustainable Development Goals (SDGs), Abuja
Declaration, Zambia Vision 2030, Seventh National Development Plan (7NDP), and National
Health Policy. The outcomes and targets in this plan are consistent with the targets and goals in
these policies. In particular, the NHSP specifically includes strategies and high impact
interventions that aim to speed up the achievement of the health-related SDGs.

2
The implementation of this strategic plan has guided prioritization of strategic interventions
aimed at attaining the specific objectives within various programmes under the Health Service
Delivery System and the Integrated Health Service Support Systems.

1.4 Strategic Framework

The critical factors for the success of this strategic plan have been identified as: strong political
leadership and commitment from the central government and MOH; better planning,
management, and monitoring and evaluation at all levels of the health sector; sustainable and
equitable financing mechanisms; improved geographical access for the entire population; the
availability of sufficient numbers of quality human resources; the availability and rational use of
drugs and medical supplies; community participation in health activities; continued and enhanced
partnerships between Government and CP; timely provision of adequate funds; strengthening of
referral systems and specialised services; development of strong research capabilities; and
ensuring good quality of service and delivery at all levels of care.
The NHSP 2017-2021 builds on the success of the NHSP 2011-2016 with greater prominence
placed on selected areas as well as other new initiatives being introduced based on emerging
needs in the health sector. In this plan, primary health care has been given greater emphasis and
more funds will be directed to these programmes to ensure that outlined targets are met. More
attention will be paid to preventing and treating non-communicable diseases, health promotion,
social determinants of health, disease surveillance, and enhancing good governance. New
initiatives will be introduced to mobilise additional resources to implement this plan, such as
Social Insurance Schemes. Increased community health interventions to bring services closer to
the people through revitalisation of Neighbourhood Health Committees (NHCs) will be
encouraged.

1.5 Implementation Framework

The implementation of this plan will require harmonized and integrated actions by the MOH and
other line ministries, local government, provinces, districts, Cooperating Partners (CPs), and local
communities. The MOH will provide leadership in implementing the plan, but will do so based on
the principles of partnership and collaboration embodied in the Sector Wide Approach (SWAp).
The 2017-2021 NHSP will be implemented through national annual work plans developed jointly
by the MOH and all CPs within the structure of the Medium Term Expenditure Framework
(MTEF). At the decentralised level, District Health Offices (DHOs) under the Councils will
produce annual, costed, action plans in collaboration with the MOH.
The major risks to successful implementation have been identified as: the health sector’s
dependence on donor financing; the Government not increasing the percentage of the general
budget spent on health; and CPs not committing funds in line with global declarations. However,
continuous efforts will be made throughout the lifetime of the NHSP to ensure these potential
challenges are overcome.

1.6 Monitoring and Evaluation (M&E)

The NHSP 2017-2021 interventions, which are aimed at reaching desired outcomes and targets,
will be measured using a set of annual and periodic indicators that have been developed through
consultations with all stakeholders. These indicators, which are important for measuring the
sector’s performance, are consistent with 7NDP indicators and have been informed by the
country’s long-term vision and strategic direction (Vision 2030 and SDGs). These indicators will
also form the basis of M&E of the NHSP 2017-2021.
Joint Health Sector Annual Review (JAR) will be undertaken to look at annual and periodic
performance indicators as well as process indicators. Furthermore, the 2017-2021 NHSP will be

3
evaluated at mid-term (in 2019) and adjusted accordingly. A final assessment of the NHSP will be
conducted in 2021 in order to inform the development of the 2022-2026 strategic plan.

1.7 Required Financial Resources

The NHSP 2017-2021 has been costed using an Activity-Based Costing Approach (ABC). The
total cost of this strategic plan for all five years is estimated at US$14.3 billion (ZMK 139.8
billion). The major cost drivers are HRH at an estimated US$3.2 billion (22.6% of the total). Next
is infrastructure at an estimated US$2.4 billion (17.1% of the total). Pharmaceuticals and supply
chain management--composed of essential drugs, commodities, and supplies—comes in third at
an estimated US$2.2 (15.8% of the total). HIV/acquired immune deficiency syndrome (AIDS) at an
estimated US$ 1.0 billion (7% of the total) comes in fourth, and malaria is fifth with an estimated
US$0.9 billion (6.5% of the total).

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2. Introduction

2.1 Country Background

Zambia is a landlocked country in Southern Africa and covers a total area of 752,612 square
kilometres. As a lower middle-income country with a population of about 13.1 million1 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 20302.
Economy: Zambia’s economy is primarily driven by the mining, agriculture, construction,
transport, and communications sectors. The country has undertaken policy reforms aimed at
creating an enabling economic environment, which enhances private-sector participation and
ultimately achieves economic growth. Against the backdrop of these policy reforms, the country
has achieved consistent positive gross domestic product (GDP) growth over the past decade.
The GDP was estimated to have grown by 7.2% in 2005 and 10.3% in 2010 before declining to 5%
in 2013 and 2014 and declining further to 2.9% in 2015.
Poverty: The 2015 Living Conditions and Monitoring Survey (LCMS) results show that the majority
of the population is affected by poverty. In 1996, the headcount ratio of the population living
below the poverty line was 69 per cent, declining to 61 per cent in 2010 and 54.4 in 2015.
Poverty is a predominantly rural phenomenon, with the ratio of the population living below the
poverty line in rural areas estimated at 76.6 percent, compared with 23.4% in urban regions.
Further, the survey showed that 40.8% of the population were extremely poor (60.8% in rural
areas and 12.8% in urban areas).
Unemployment: The current unemployment rate3 is estimated at 7.8% (Central Statistical Office
[CSO], 2012), and this is higher than the global average of 6% (International Labour Organisation,
2013). The problem of unemployment is more prevalent in urban areas and among youth,
women, and people with disabilities.

2.2 Achievements and Challenges of the Health Sector

Strategic Plan
The health sector has been implementing reforms aimed at improving service delivery. At the
core of the reforms was decentralization, under which health delivery was devolved to the
district level. In part owing to the reforms that were implemented and cooperation from the
international community, the health sector made some remarkable achievements. This was
amply demonstrated by the performance of health related Millennium Development Goals
(MDGs) indicators. The ZDHS data shows that HIV prevalence declined from 14% in 2007 to
13.3% in 2014. Maternal mortality, which was estimated at 649 per 100,000 live births in 1996,
declined to 591 deaths per 100,000 live births in 2007. The 2013-14 ZDHS indicates a further
decline to 398 deaths per 100,000 live births. The IMR per 1,000 live births was 109, 95, 70 and
45 in 1996, 2001-02, 2007, and 2013-14 ZDHSs, respectively. Child mortality has declined by 61%
since 1996. The mortality rate of children under five dropped from 197 deaths per 1,000 live

1
Central Statistical Office. Census. Lusaka, Zambia: 2010
2
Central Statistical Office. National Accounts Statistics. Lusaka, Zambia: 2010.
3
This is defined as the ratio of the unemployed population to the labour force in a given period of time (CSO,
2013).

5
births in 1996 to 75 per 1,000 live births in 2013-14. The 2013-14 figure is the baseline for the
NHSP 2017-2021 indicator.
The concerted efforts to implement effective programmes by the Government and with support
from the CPs accounted for the noted improvements in the health indicators. For instance, the
reduction in child mortality was facilitated by the rise in immunization coverage, exclusive breast-
feeding, vitamin and mineral supplementation, and malaria prevention and treatment. The decline
in maternal mortality is benefited from interventions such as improved use of contraception for
birth spacing, prevention of early marriages, improved referral systems, provision of and access to
emergency obstetric care, and the improved use of more trained midwives and birth attendants.
International cooperation in the fight against HIV and AIDS, for instance, has been hailed for the
corresponding decline in prevalence and incidence; elimination of mother-to-child transmission,
male circumcision, voluntary HIV counselling and testing, and treatment have proved to be
effective interventions.
Table 2.1: Zambia: NHSP 2017-2021 Key Performance Indicators

Targets
NHSP Data
Indicator Baseline
Targets Sources
2017 2018 2019 2020 2021
Under 5 Per 1000 75 35/1000 ZDHS 67 35
Mortality live birth
Rate
IMR Per 1000 45 15 ZDHS 30 15
live birth
MMR Per 398 100 ZDHS 350 250 200 150 100
100,000
live birth
Adult Per 1000 24 12 ZDHS 21 18 16 14 12
Mortality popu-
Rate lation
HIV % 13.3% 5% ZDHS 8% 5%
Prevalence
in adults
aged 15-49
years
TB Cure % 85 87 HMIS 85.5 86 86.5 86.8 87
rate
Malaria Per 1000 394 0 HMIS 168 101 15 0
Incidence popu-
Rate lation

The positive outcomes of the NHSP 2011-2016 notwithstanding, the health sector still faces
challenges. During the Plan period, financial irregularities were unveiled in the sector, which
highlighted the governance and accountability constraints. Regional inequities in the health
services also persisted. Moving forward, there will be need to revisit national level indicators so
that indicators are disaggregated to the level where these inequities are shown. The 2017-2012
Plan will build on the success of the predecessor Plan through enhanced interventions on:
1. Building on the success of improving human resources for health, additional efforts are
required to enhance service delivery
2. In the light of the decentralisation policy, interventions for enhancing district level
decision-making capacities will be enhanced so as to improved local-level decision making

6
 3. While acknowledging the contribution of CPS in the health sector, financing challenges
are still pervasive. To this end, the 2017-2021 Strategic Plan will expedite the
implementation of the SHI scheme
4. Enhance the achievement made in infant mortality reduction by ensuring that more
children are put on ART; ART uptake could be improved through close monitoring of
mothers enrolled in the Prevention of Mother-to-Child Transmission (PMTCT)
programme
5. Delivering further reductions in maternal mortality will entail addressing the deep-rooted
gender inequalities that manifest in early marriages, adolescent pregnancy, and inadequate
access to sexual and reproductive health services

2.3 Disease Burden

The 2015 Mid-Term Review report showed that Zambia’s epidemiological profile was
characterized by the high prevalence and impact of preventable and treatable communicable
diseases, particularly malaria, HIV and AIDs, sexually transmitted infections (STIs) and TB.
Further, there was a growing burden of non-communicable disease (NCD), including mental
health problems, cancer diseases, trauma, sickle cell anemia, diabetes mellitus, hypertension, and
cardiovascular diseases (CVDs), chronic respiratory disorders, blindness and eye refractive
defects, oral health problems, and maternal and child health problems.
Analysis of disease trends from 2011 to 2015 indicates that malaria remained the leading cause of
morbidity and mortality in the country. With an HIV prevalence estimated at 13.3%, Zambia is
one of the most affected countries in the world (CSO, ZDHS 2013-14). Different diseases have
varying disease burdens: some diseases cause premature death, while chronic conditions may
cause long-time disability and impose a great emotional and monetary toll for patients, family
members, and society. Tables 2.2 and 2.3 below show the top ten causes of morbidity and
mortality in health facilities.
Table 2.2 Show Top Ten Causes of Mortality in Health Institutions Over a Period of
Five Years for All Ages (Source: HMIS)

Disease Name 2011 2012 2013 2014 2015 Average

Malaria 4593 4029 3564 3225 2360 3554.2
ARI/Pneumonia 2999 2520 2239 2012 1890 2332
Trauma 911 1012 682 859 969 886.6
Diarrhoea (Non-Bloody) 1770 1954 1428 1467 1281 1580
Anaemia 2760 2152 1805 1754 1493 1992.8
Non-infectious digestive system 634 595 509 604 640 596.4
Hypertension 632 680 811 692 739 710.8
TB 2175 1992 1646 1677 1576 1813.2
Cardiovascular 1012 1195 1217 1296 1268 1197.6
Severe malnutrition new case 1763 1314 996 886 792 1150.2

Table 2.3: Top ten causes of morbidity (Incidence per 100 pop - All Ages)

2011 2012 2013 2014 2015

Respiratory Respiratory
Infection: Infection:
Malaria 344 Malaria 339 382 Malaria 394 388
non- non-
pneumonia pneumonia

7
2011 2012 2013 2014 2015

Respiratory Respirator Respiratory

Infection- y Infection- Infection:
309 310 Malaria 370 376 Malaria 316
non non non-
Pneumonia Pneumonia pneumonia

Diarrhoea Diarrhoea Diarrhoea

Diarrhoea Diarrhoea
86 85 (non- 96 (non- 97 (non- 97
non-bloody non-bloody
bloody) bloody) bloody)

Muscular Muscular Muscular Muscular Muscular

Skeletal & Skeletal & skeletal and skeletal and skeletal and
Connective 54 Connective 62 connective 66 connective 67 connective 67
Tissue non Tissue non tissue (not tissue (not tissue (not
Trauma Trauma trauma) trauma) trauma)

Trauma Trauma Digestive Digestive

Digestive
other other system: system:
38 39 45 system: (not 46 46
Injuries Injuries (not (not
infectious)
wounds wounds infectious) infectious)

Digestive Digestive Trauma: Trauma: Trauma:

system system Other Other Other
37 39 39 40 38
non- non- Injuries, Injuries, Injuries,
infectious infectious wounds wounds wounds

Respiratory Respirator Respiratory Respiratory Respiratory

infection- 36 y infection- 33 Infection: 36 Infection: 32 Infection: 30
Pneumonia Pneumonia pneumonia pneumonia pneumonia

Skin Skin
Eye disease Eye disease Diseases Diseases Sickle Cell
27 26 26 26 30
Infectious Infectious (not (not Anaemia
infectious) infectious)

Skin Skin
Eye
diseases diseases Eye diseases Dental
23 25 diseases 26 25 24
non- non- (infectious) Carries
(infectious)
infectious infectious

Skin
Dental Dental Dental Dental Diseases
22 24 25 25 24
Carries Carries Carries Carries (not
infectious)

2.4 Health Sector Strategic Programmed Approach

The GRZ has prioritized health as a key economic investment to spur the country to become a
prosperous middle-income country by 2030. The NHSP (2017-2021) is anchored on a National
Transformation Agenda, which recognizes the importance of the health sector in improving

8
national productivity. Investments in the health sector will be treated as inputs toward raising
overall productivity and hence contributing to economic growth. The focus for the NHSP shall be
on attaining Universal Health Coverage using the primary health care approach. Underpinning the
approach is health system strengthening across the continuum of care and spanning promotive,
preventive, curative, rehabilitative, and palliative health services. The investment in the health
sector shall be informed by key pillars of a functional health care system, namely service delivery,
human resource for health, health management information and research, medical products,
vaccines, supplies, health infrastructure, equipment, transport, financing, leadership, and
governance.
The NHSP uses a model that incorporates underlying socio-economic factors impacting health
behaviours. The socio-economic determinants model postulates that poor social and economic
factors impact health throughout an individual’s life; these factors could be isolated at the
personal, societal, and physical environment levels.

2.5 Socio-economic Determinants of Health

Personal Health Practices
Personal character and commitment to health seeking behaviours, including prevention of disease,
promotion of healthy practices and early seeking of appropriate treatment and care, are
important for enhancing health status. In Zambia, there are attempts to promote these practices
and skills through strengthening of health promotion and education. However, this area of health
is not adequately developed and requires significant strengthening to meet the required levels of
health awareness and education.

Societal Level Factors

Demographic Profile: The absolute size, rate of growth, spatial distribution of the population,
and age structure are important determinants of health. The population of Zambia has more
than doubled from 5.7 million in 1980 to about 13.1 million in 20104. The population is likely to
grow to about 17.9 million by 2020 and reach 26.9 million by 20355. This rapid population
growth places an increasing burden on the national economy, particularly the country’s health
delivery capacity.
Income and Economic Status: The country currently has a high level of unemployment,
meaning many people are not in gainful employment, making them vulnerable to illness and
thereby imposing a heavy burden on the health delivery system. The level of formal sector
employment is even lower, resulting in a narrow tax base. The low level of formal sector
employment has implications for effectiveness of the proposed SHI scheme.
Nutrition Status: Undernutrition is endemic in many parts of the country. It is responsible for
52% of all deaths occurring in children below the age of five (United Nations Children’s Fund
[UNICEF] 2008; Department for International Development 2011). Micronutrient deficiency
remains high and is a major contributor to childhood morbidity and mortality. It is estimated that
54% of children under the age of five and 13% of women of child bearing age are vitamin A
deficient (National Food and Nutrition Commission [NFNC], 2003), and about 38% of the
population is at risk of low zinc intake (IZiNCG, 2004).
Education and Literacy: Citizens with low literacy levels are more likely to be unemployed and
experience poor health status. According to the 2015 LCMS, school attendance rates for the
primary school-age population (7-13 years) was 83.1%, while that of the secondary school-age
population (14-18 years) was 75.7 percent. According to UNICEF, 64% of Zambia’s young people

4
Zambia in Figures 1964 - 2014
5
Zambia Census Projection 2011 - 2035

9
(aged between 15 and 24 years old) are literate, with 47% of children dropping out of school
before completing primary education.
Socio-cultural Attributes: Zambia is a multi-cultural society, characterized by different racial
and ethnic groups and religious and traditional groupings. The country is also characterized by a
high level of urbanization and increasing access to the internet and other sources of information.
These have significant potential for promoting good health. However, there are some social,
cultural, and religious beliefs and practices that negatively affect health. These include practices
such as sexual cleansing of surviving spouses, unsafe traditional male circumcision procedures,
early marriages for the girl child, and negative patriarchal traits that perpetuate the low status of
women.
The Family and Community: Families and communities have an important role in shaping the
character and behaviours of people. Social pressure could produce both negative and positive
outcomes. For instance, peer pressure among the youth has been associated with increased risky
sex behaviour that exposes young people to HIV and other STIs, trauma, teenage pregnancies,
and mental illnesses. On the positive side, social pressure could also be used to mobilize
communities to support health programmes.
Gender Attributes: Gender considerations are important for both health service delivery and
also for assessing the health sector outcomes. Some of the pernicious manifestations of gender
inequality in Zambia include the disproportionately high ratio of educated men to women and
low representation of women in politics and formal employment. In addressing issues of gender
and health, the NHSP in the next five years will stress the inclusion of gender mainstreaming in
planning, design, and M&E of health programmes and policies.

Physical Environment
Water and Sanitation: The 2015 LCMS indicates that about 67.7% of households had access to
safe water sources. Furthermore, 51.6% of households in rural areas had access to safe water
while 89.2% of households in urban areas had access to safe water. Limited access to safe water
and sanitation facilities accompanied by poor hygiene is associated with skin diseases, acute
respiratory infections, and diarrheal disease, which is the leading preventable disease (ZDHS]
2013-14).
Climate Change: Climate change is a global threat to health and is becoming a major problem
for Zambia. The 2005 Zambia National Policy on Environment recognizes the need to harmonize
the different sectoral development strategic plans through a National Climate Change Response
Strategy.
Housing: Traditional housing is the most common type of dwelling in Zambia. Slightly more than
half (52.9%) of households in rural areas live in traditional huts. Further, about 30% live in
improved traditional huts, and 14.2% live in detached houses. It should be noted that affordable,
stable housing in well-designed communities helps families have better access to health and other
supportive services.

2.6 The National Health System

Sector Coordination and Organization
The NHSP outlined strategic programmes for service delivery and support systems. The strategic
plan provides a framework to guide collaboration in the implementation of health programmes.
The strategic plans are accompanied by a memorandum of understanding signed by all
collaboration partners. The GRZ has expressly indicated the basket approach as the preferable
mode for support to the sector. However, there is still a considerable amount of external funds
that are channelled to discrete projects. The health sector in Zambia requires that all partners

10
buy into the One Plan, One Budget, One Report system and one monitoring and evaluation
framework. The sector will institutionalise the compact during the 2017–2021 NHSP. This will
entail mobilising all partners to support the sector through a pooled rather than project-funding
approach.

Health Care Delivery System

Zambia is divided into 10 administrative provinces and 105 districts. Health management is done
through provincial health offices (PHOs) (10), DHOs (105), and statutory bodies. The country
has eight third-level hospitals, 34 second-level hospitals, 99 first-level hospitals, 1,839 health
centres, and 953 health posts. All third-level hospitals are Government owned. Of the second-
level hospitals, 26 are Government-owned, and eight are owned by the Churches Health
Associations of Zambia (CHAZ).
The health services in Zambia are provided by four main players, namely the Government, faith-
based (not-for-profit) providers, the mines, and private (for-profit) providers. The public sector is
the biggest health provider; 90% of patients seek care in facilities owned and run by the
Government (Masiye et al., 2010). The national level is responsible for overall coordination and
management, policy formulation, strategic planning, and resource mobilisation.
The health service delivery system mirrors the political administrative structure. The PHO is the
link between the national and district level and is charged with backstopping provincial and
district health services. The provincial is also tasked with the provision of second-level referral
services (through general hospitals).
The district is responsible for implementation of health promotion, preventive, curative, and
rehabilitative services. Administratively, the district health office is responsible for coordinating
service delivery at that level. Each district has a district hospital, which provides first-level referral
services.
Below the district there are health centres, which provide both static and outreach activities.
These are staffed by a clinical officer, midwife, nurse, and environmental officer. The main
activities at health centre level are predominantly health promotion and disease prevention.
There are some limited curative services provided, too, with complicated cases being referred to
first-level district hospitals. Each health centre is responsible for running key health programmes,
which include maternal, newborn and child health, communicable and non-communicable
diseases, environmental, water and sanitation, school health and nutrition, and epidemic
preparedness (NHSP, 2012).
The NHSP is operationalized through the processes and systems of the Government’s MTEF and
the annual budgets and plans. These action plans are jointly developed and implemented by the
MOH and its CPs. All the structures from the central level, provinces, hospitals, statutory bodies,
districts, and training schools have annual action plans, which are independently implemented.
The MOH and its CPs increasingly use health sector indicators for performance M&E. This M&E
of sector performance takes place at different levels. The sector uses the SWAp model, which is
operationalised through technical working groups (TWGs), policy meetings, sector advisory
group meetings and, annual consultative meetings. The review of sector performance takes place
on an annual basis through the JARs. Further assessments are undertaken through mid-term
reviews and final evaluations.
Zambia’s health system has been decentralized to district and hospital levels. The Provincial
Medical Office, second- and third-level hospitals and central hospitals, DHOs, and training schools
receive funds directly from Ministry of Finance (MOF). The GRZ has in its new constitution
added decentralisation as one of the ways to develop the local levels. Decentralisation will be by
devolution where local government authorities will be responsible for delivering public services in
local health, primary education, agriculture extension and livestock, water supply, and local road
maintenance.

11
The MOH will retain such functions as policy formulation and guidance; monitoring and
evaluation; and donor coordination. At the district level, the MOH will provide technical guidance
on quality of care, planning, health facility management, good governance, human resources, and
rational use of drugs. The central level will also play the role of provision of standards in
construction and renovation of health infrastructure and in-service training of health workers.
The districts are responsible for administrative supervision of health facilities and data
compilation, which will be shared with the MOH.

12
3. Vision, Mission, Overall Goal, Principles
and Priorities

Vision
A Nation of Healthy and Productive People

Mission Statement
To provide equitable access to cost effective, quality health services as close to the family as
possible

Overall goal
To improve the health status of people in Zambia in order to contribute to increased
productivity and socio-economic development

Key Principles
PHC
Equity of access
Affordability
Cost-effectiveness
Accountability
Partnerships
Decentralization and leadership
Health systems strengthening
Table 3.1 National Health Priority Areas
Public Health Priorities Health System Priorities
 Primary health care  HRH
 Maternal, neonatal and child health,  Essential drugs and medical supplies
youth and adolescent health  Infrastructure and equipment
 Communicable diseases, especially  Health information
malaria, HIV and AIDS, STIs and TB
 Health care financing
 NCDs
 Leadership and governance
 Disease outbreaks and epidemic
control, public health surveillance
 Environmental health and food safety
 Health service referral systems
 Health promotion and education
 Community health
 Social determinants of health

13
4. Health Service Delivery System

4.1 Primary Health Care and Community Health

Situation Analysis
PHC refers to ‘essential health care’ that is based on scientifically sound and socially acceptable
methods and technologies that make universal health care accessible to all individuals and families
in a community. This is achieved through full community participation at a cost that both the
community and the country at large can afford in the spirit of self-reliance and self-determination.
It is an approach to health beyond the traditional health care system, which focusses on equitable
distribution of health services to achieve improved health outcomes. A continuing effort is
required to secure meaningful community participation in the planning, design, and
implementation, as well as monitoring and evaluation, of health service delivery. This is anchored
on the principle of inter-sectoral coordination facilitating the interest of communities from all
related sectors and factors that impact on health and well-being. Key to this approach is the use
of appropriate technology that is acceptable and within the reach of communities.
Community health extends the principles of PHC down to the household level within
communities through proactive promotion of good health, disease prevention and control,
curative services, rehabilitation, and palliative care. Further, community health concerns itself
with the health of specific groups of people, including the actions and conditions that promote,
protect, and preserve their health. It draws from other disciplines and includes social
determinants of health, which enables the isolation of physical environment, socio-economic
status, and cultural factors that have a bearing on health outcomes.
Mobilizing community resources is an important aspect of community health. Communities are
therefore vital resources and form part of a network of relationships and support on which
people rely when seeking health services. Community health increases the utilization and
coverage of health services provided at the household level through expanded access to basic
health services, and thus supports the eight essential components of PHC. Community health
complements PHC by incorporating the element of strengthened referrals between health
services and community health services.
Health promotion is one of the major components of primary health care and community health.
Health promotion enables individuals, families, households, and communities to realize the
highest level of health and development irrespective of age, race, income, geographical location,
or education level. Health promotion also calls for integration of activities across sectors and
encourages multi-sectoral collaboration.
Most chronic health conditions are caused by social and environmental determinants of health,
which are outside the control of the health sector. In order to meaningfully address these
external factors in the planning process, the health system should be re-oriented so that it is
more responsive to community needs, especially the poor and vulnerable groups. Health
promotion interventions seek to promote healthy behaviours and empower individuals, families,
households, and communities to take necessary actions aimed at improving their health status.
In Zambia, primary health care services are provided through outreach posts, health posts, health
centres, and district hospitals. These are linked to the communities through health centres and
NHCs.
The Government has embarked on a massive health infrastructure development project aimed at
improving the equitable distribution of primary health care. This has, however, been limited by

15
the non-availability of a community health strategy, which has since been developed alongside this
NHSP. Further, the HRH challenges and the high drop-out rate of community-based volunteers
have compounded the problem. Interventions for improving the availability of community health
workers include the introduction of an incentives scheme and development of two training
schools targeting community health workers. However, by 2016, only 1,577 community health
assistants graduated against the targeted 5,000.
A weak referral system has adversely affected service delivery at the community level. Further,
the Neighbourhood Health and Health Centre Committees do not have a supportive legal or
regulatory framework. While the NHCs exist in 84% of the health zones, their functionality
varies within and across districts. The weak inter-sectoral collaboration at the district level has
also limited the effectiveness of community health interventions.

Strategic Interventions
This NHSP aims to promote and ensure harmonized and strengthened inter-sectoral action on
health using a Whole Government and Whole Society approach within the Health in All Policies
framework. This shall be achieved through organizational structures and coordination
mechanisms that support regular interaction for comprehensive community health. This is in line
with the Ouagadougou Declaration (2008), the key values of which are equity, solidarity, social
justice, principles of multi-sectoral action, community participation, and unconditional enjoyment
of health as a human right by all. It also fosters the adoption of healthier lifestyles.
The Plan emphasizes facilitation and creation of an environment that enables individuals and
families to maintain and improve their own health. It aims at the development of Community
Health, which includes supportive mechanisms for community participation in organization,
coordination, and financing. In order to ensure effective implementation of community health, the
recruitment of CHAs and volunteers shall be enhanced. Further, community nurses, nutritionists,
and health promotion and surveillance officers will be deployed in the communities. The
community-based health services will be linked to strengthened clinical services. Supported by
community-based workers, health facilities shall cooperate in their outreach work. These will be
supported by strengthened NHCs.

Goal: To have empowered communities taking responsibility for improving their own health
status through community health interventions in line with the principles of PHC by 2021

Objectives Strategies

To formalise community Facilitate the inclusion of community health structures in existing

health structures in line with and emerging regulatory frameworks such as the Public Health
the decentralization policy Act and National Health Services Act

Develop and implement community health strategy

implementation framework

Establish national, district, and community support structures

Facilitate technical skills development of community health

workers

Strengthen multi-sectoral collaboration, community linkages, and

coordination in line with the decentralization policy to address
Social Determinants of Health and within the Health in All
Policies framework

16
Goal: To have empowered communities taking responsibility for improving their own health
status through community health interventions in line with the principles of PHC by 2021

Objectives Strategies

Revive the use of NHC/HCC guidelines in community health

Design and implement standardized management including

incentive schemes for community based volunteers

Strengthen community participation in planning, coordination,

implementation, monitoring, and evaluation at the facility and
community levels

Create an enabling environment for the participation of

traditional, civic, political, and faith-based organisations, media,
and academia in executing an all-inclusive gender-sensitive
community health system

To strengthen health Strengthen the integration of health promotion and disease

promotion and education at prevention, control, and surveillance in all community-level
the community level programmes

Strengthen comprehensive e-learning institutions, school health

and nutrition, and comprehensive sexual health education
programmes

Promote inter-sectoral collaboration (including private-public

collaboration) at the community level

Enhance demand creation for gender-sensitive community health

services

Scale up the recruitment and retention of community-based

volunteers

Scale up standardized capacity building for health promotion and

education at district, facility, and community levels

To improve the capacity of Revise the PHC package to focus on health promotion, disease
districts, hospitals, and prevention, basic health care, and multi-sector collaboration for
health centres to deliver community health
health services at the
community level Develop a framework for the delineation of the roles and
functions as well as standard operating procedures to support
community health and technical skills at each level

Revitalize the referral and feedback systems between health

facilities and communities

Strengthen PHC facilities with appropriate staff, equipment and

supplies, and essential medicines and commodities

17
Goal: To have empowered communities taking responsibility for improving their own health
status through community health interventions in line with the principles of PHC by 2021

Objectives Strategies

To mobilize adequate Ensure equitable resource allocation considering

financial and other demographics/geography, disease burden, and gender
resources to strengthen
community health Develop mechanisms for ensuring that 10% of DHO is reserved
for community health activities

Introduce community financing schemes

Strengthen community-based HMIS, and link to all the levels of

the health delivery system

Develop/enhance skills for utilizing community-based HMIS data

for decision making

To provide and maintain Develop an infrastructure development plan to support

quality and appropriate community health
essential infrastructure to
support community health Strengthen maintenance and rehabilitation of infrastructure and
services equipment

To enhance resilience and Develop guidelines for community health adaptation in public
empowerment of the health emergency situation including climate change and related
community in health disasters
emergencies, public health
effects, and consequences of Establish and sustain health-related emergency and disaster
disasters and climate change management and response systems at the community level
impacts

To establish a community- Develop a framework of innovations for enhancing gender-

friendly platform for sensitive community health systems and service delivery models
innovations
Roll out community health system innovations throughout the
country

To strengthen healthy public Create a platform for multi-sectoral collaboration

policies
Build capacity for the MOH to assume leadership for Health in
All Policies (HiAP)

Collaborate with key stakeholders to implement (HiAP)

To strengthen community Engage community, civic, civil society organizations, and public
action and personal skills and private care providers in promoting health
development for health
Create health literacy in the population

Build capacities for health promotion and community health

18
 Goal: To have empowered communities taking responsibility for improving their own health
status through community health interventions in line with the principles of PHC by 2021

Objectives Strategies

Advocate for health-promoting work environments

Enhance health-promoting schools

Advocate for policies that promote health

Advocate for healthy city and community concept

To create a health system Reorient the current health service delivery model towards
responsive to health health promotion and disease prevention
promotion, disease
prevention, and Advocate for holistic health services
rehabilitation
Enhance curriculum of all health cadres by promoting health
promotion, diseases prevention, and rehabilitative services

4.2 Reproductive, Maternal, Child, and Adolescent

Health and Nutrition
4.2.1 Reproductive and Maternal Health
Situation Analysis
Remarkable improvements have been achieved in reducing the MMR from 591 deaths per
100,000 live births in 2007 to 398 deaths per 100,000 live births in 2014.6 Despite the decrease,
maternal mortality is still high in absolute terms, and Zambia was not able to achieve the MDG
target of 162 deaths per 100,000 live births at the end of 2015.
There has been significant progress in the provision of family planning services, with the
contraceptive prevalence rate for modern family planning methods having been estimated to have
increased from 33% to 45% and unmet need reducing from 27% to 21% in 2007 and 2013,
respectively. Despite the nearly universal knowledge of family planning, the total fertility rate is
still high (5.3), with rural areas reporting a higher rate of 6.6 than urban areas at 3.7. The ZDHS
2013-14 statistics show that although 96% of pregnant women attend ante-natal care (ANC)
services at least once during pregnancy, only 24% initiated ANC in the first trimester and 25%
made a minimum of four visits during their pregnancy.
According to the 2013-14 ZDHS, the proportion of deliveries in health facilities stood at 67%,
with skilled birth attendance at 64%. A National Emergency Obstetric and Newborn Care
(EmONC) Assessment conducted in 2013-14 revealed that only 18% of the designated EmONC
facilities were fully functional. This contributed to the unmet need for EmONC services; the
caesarean section rate, which was estimated at 3.6%, is below the globally acceptable standard of
5.5%.

6
DHIS

19
According to ZDHS 2013-14, the uptake of postnatal services within 48 hours stood at 63%, and
uptake within six days was estimated at 65.7%; both of which fall below the World Health
Organisation (WHO) acceptable levels.
The country has made significant progress in institutionalizing maternal death surveillance reviews
(MDSRs) using the WHO Guidelines, with all provinces having started to conduct maternal death
reviews and perinatal death surveillance. However, there are weaknesses in surveillance and
response mechanisms to address the identified challenges. The 2014 MDSR report indicates that
84% of maternal deaths occur in health facilities; most of the deaths occur at first-level and
tertiary-level hospitals. The report also revealed that maternal death was less likely if referral was
made from lower- to higher-level facilities, as opposed to referral to a facility of the same level
(MOH, United Nations Population Fund [UNFPA], 2014 MDSR Report).
One of the major reproductive health challenges facing the MOH is the issue of obstetric fistula.
The MOH has conducted close to 2,000 fistulae surgical repairs in the past 10 years. A recent
tracking report for 638 women treated for fistula revealed that 64.9% were completely healed at
the time of the study (MOH, UNFPA, 2015). Most of the surgical operations are done through
‘fistula repair camps’ because there is limited institutional capacity in all provinces; there are
limited fistula surgeons and support staff. In addition, there is limited data on the magnitude of
obstetric fistula cases in Zambia, making it difficult to design management interventions.
One of the contributing factors to maternal morbidity and mortality is sexual and gender-based
violence (SGBV). The 2013–14 ZDHS shows that 47% of all married women aged 15–49
reported ever having experienced physical, sexual, and/or emotional violence from their current
or most recent husband or partner. Further, the survey revealed domestic violence as one of the
reasons for poor health, insecurity, and inadequate social mobilization among women; this
negatively affects the uptake of reproductive and maternal health services. In an effort to address
this problem, the GRZ has developed an SGBV policy. The MOH is part of a multi-sectoral
response and mechanism established to address SGBV cases.
Cancer has rapidly become a major factor in the local and global burden of disease, especially
among women. As of 2010, Zambia reported having 3.21 million females aged 15 years and older
(CSO 2010) who were at risk of developing cancer of the cervix. Cervical cancer is the most
frequent cancer among females in Zambia, and it is the second most frequent cancer among
females between 15 and 44 years of age, followed by cancer of the breast. Cervical cancer is
highly preventable and treatable, but requires knowledge and practice of prevention, early
detection, and treatment.
Key challenges with regard to reproductive and maternal health remain and include the following:
 Inequities in the distribution of services between urban and rural areas
 Low ratio of skilled providers to the population
 Inadequate infrastructure for delivery of services
 Inadequate equipment, transport, and communication facilities
 Weaknesses in RMNCAH commodities and supply chain systems
 Inadequate community involvement for RMNCAH
 Weak quality assurance systems for RMNCAH
 Inadequate health sector response for SGBV

20
Strategic Interventions
Goal: To reduce MMR from 398/100,000 live births in 2014 to 162/100,000 live births by 2021
Objectives Strategies
To create demand for sexual and Support the development and implementation of social
reproductive health services (women and behaviour change communications (SBCC)
of reproductive age, men, elderly interventions for women of reproductive age, men,
people, and marginalized populations) elderly people, and marginalized populations
Support the development and implementation of a
comprehensive SBCC strategy for sexual and
reproductive health services
To increase the availability and Enhance community mobilization for improved uptake of
utilization of high-impact sexual and reproductive health services.
reproductive health services (youth-
Improve micronutrient supplementation in pre-
friendly, family planning, SGBV, and
pregnancy by integrating with family planning and other
cancer screening services)
sexual and reproductive health (SRH) services
Scale up family planning services with a focus on
community-based distribution, long-acting reversible
contraceptives (LARC), and post-partum family planning;
and with particular focus on underserved areas
Scale up cervical cancer screening (using visual inspection
with acetic acid [VIA]), management, and vaccination for
human papiloma virus (HPV)
Scale up integrated management of SGBV survivors in
the health sector
Strengthen male involvement in sexual and reproductive
health services
To increase the availability and Strengthen community (church, Safe Motherhood Action
utilization of quality focused antenatal Groups [SMAGs], traditional counsellors, Community-
care (FANC) services Based Distributors [CBDs], and ward councillors)
engagement that focusses on improving ANC attendance
in the first trimester
Strengthen the service package for FANC
Enhance capacities of health workers in the delivery of
FANC services
Realign the structures of the SMAGs
Enhance service delivery capacity through
implementation of health cooperatives
To increase access to skilled Strengthen the referral system, including scaling up of
attendance at birth including EmONC maternity waiting shelters
Scale up EmONC coverage according to national
standards
Strengthen health care provider skills (pre and in-
service) for delivery of quality EmONC services with a
focus on mentorship systems
Strengthen monitoring of the EmONC programme at all
levels
Strengthen respectful maternity care

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 Goal: To reduce MMR from 398/100,000 live births in 2014 to 162/100,000 live births by 2021
Objectives Strategies
Enhance the MDSR process by strengthening systems for
accountabilities of health workers and the health system
in response to maternal deaths
To improve access to postnatal Strengthen postnatal services (six hours, 48 hours, six
services days, and six weeks) including domiciliary visits by
midwives and community health workers (CHWs)
Strengthen institutional capacity for fistula management
To strengthen the enabling Strengthen multi-sectoral collaboration for improved
environment for RMNCAH RMNCAH services including SGBV and menopausal
services
Strengthen knowledge management for RMNCAH
(policies, guidelines, research)
Introduce health worker cooperatives
Institutionalize approaches for equity analysis for
monitoring RMNCAHN service coverage at district level
as a tool to guide programme delivery planning
Enhance comprehensive infrastructure for quality service
delivery (delivery facilities, Outreach Posts)
Implement Quality Management System at all levels of
RMNCAH services (quality assurance [QA]/quality
improvement [QI])
Strengthen supply chain systems for RMNCAH
commodities and equipment
To improve Enhance capacity building in oversight functions
maternal/neonatal/perinatal death
Strengthen the HMIS component that deals with MDSR
surveillance and response
(data collection, data management and data use, and
improving oversight) in the utilization of data in informed
decision making

4.2.2 Child Health

Situation Analysis
Steady progress has been made in child health in Zambia; this is exemplified by the reductions in
the morbidity and mortality. Mortality under age five and infant mortality reduced from 168 to 75
per 1,000 live births and from 95 to 45 per 1,000, respectively, between 2002 and 2014. The
neonatal mortality rate was estimated at 24 per 1,000 live births in 2014, constituting
approximately half the number of all infant deaths. Although the Neonatal Mortality Rate has
declined from 34 per 1,000 live births in 2007 to 24 per 1,000 live births in 2014, it remains
unacceptably high. This is unsurprising when seen in the light of the high maternal mortality ratio
of 398 per 100,000 live births currently prevailing in Zambia. While children are surviving fairly
well in Zambia, there are no effective interventions that could foster child development beyond
survival. Children need to survive and thrive. Seen in the context of the high rates of chronic
malnutrition, limited skills in play, and communication, interventions that support thriving become
imperative.
The progress made in improved child survival is premised on the proven interventions. These
include the introduction of three new vaccines (rota, pneumococcal conjugate vaccine, and

22
measles second dose including switch from trivalent oral polio vaccine to bivalent oral polio
vaccine) and vaccine cold chain expansion; sustained polio-free status; and newborn care
interventions and strengthened Expanded Programme on Immunization (EPI), integrated
management of childhood illnesses (IMCI), and newborn care in pre-service nursing curricula. The
impressive immunisation coverage, averaging 80% for the past 10 years, has also contributed to
this positive picture. Other interventions include vitamin A supplementation, infant and young
child feeding, sustained coverage of traditional and new vaccine immunizations, and improved
management of common childhood illnesses, including IMCI and integrated community case
management (iCCM).
While noting the positive strides made in improved child health, there are persistent constraints
that need to be addressed. These include:
 Ineffective coordination of partners under the child health programme
 Inequities in the distribution of staff, which disadvantage rural areas; scarcities of staff to
provide newborn care and child health interventions
 Inadequate transport and infrastructure to conduct outreach services
 Lack of a system and skills to forecast and timely procure child health programme
supplies, commodities, and equipment
 Lack of ownership of child health services at the community level
 Weak programming around community participation and engagement to increase demand
for and utilisation of newborn care and child health services
 Weak systems to collect, collate, analyse, and use community- and facility-level data for
programme management especially at the point of data collection
 Low coverage and lack of quality newborn care and child health services
 Skewed emphasis on child survival and limited attention to thrive interventions such as
early child development and rehabilitation programmes
These and many other factors have continued to constrain improvements in child health services.
In this plan, emphasis will continue to be placed on implementing/scaling up: the EPI; care for the
sick child and emergency triage assessment and treatment (ETAT); IMCI; iCCM; and care for
early child development, essential newborn care (ENC), RED/C, and nutrition interventions.
Further efforts will be made to empower communities to improve community newborn care and
child health care practices, support the continuum of care and emphasize the importance of
immunizations.

Strategic Interventions
Goal: To reduce the under-five mortality rate from 75 (ZDHS, 2013-14) to 56 deaths per 1,000 live
births by 2021
Objectives Strategies
To scale up high-impact child Increase immunization coverage through routine, child health days
survival interventions and outreach services; care for the sick child; and emergency triage
assessment and treatment.
Expand, strengthen, and enforce the use of all components of IMCI
strategy
Scale up integrated community case management, IMCI, iCCM,
Care for Early Child Development, ETAT, ENC, and RED/C
interventions

23
 Goal: To reduce the under-five mortality rate from 75 (ZDHS, 2013-14) to 56 deaths per 1,000 live
births by 2021
Objectives Strategies
Empower communities to improve community newborn and child
health care practices and support continuum of care, and engage
them on benefits of immunizations to create demand

Strengthen community involvement in maternal newborn and child

health (MNCH) and nutrition services

Strengthen referral services at all levels particularly from

community to facility level
Increase availability, access, and utilization of quality newborn and
perinatal health care at all levels
Strengthen promotion of breastfeeding (early initiation and
exclusive breastfeeding)
Strengthen the School Health and Nutrition Programme
Scale up infant and young child feeding services, including
promotion of breastfeeding and complementary feeding after six
months up to two years.
To improve coordination and Strengthen inter-sectoral coordination in the provision of child
health systems to support health services at all levels
delivery of child health
Improve supply chain management practices for child health
services
programmes
Integrate and strengthen outreach services particularly for hard-to-
reach areas
Increase the availability of essential drugs, vaccines, and
immunization supplies including cold chain equipment
Strengthen data quality management with particular emphasis at
lower levels
Support research and development of innovations and technologies
for newborn, child health, and nutrition interventions

4.2.3 Nutrition
Situation Analysis
Poor nutrition affects the entire population. However, women and children are especially
vulnerable because of their unique physiologic and socio-economic characteristics. Adequate
nutrition is critical to children’s growth and development. The period from birth to age two is
especially important for optimal physical and cognitive growth and development. A woman’s
nutritional status has important implications for her health as well as for the health of her
children. Malnutrition results in reduced productivity, increased susceptibility to infections,
slowed recovery from illness, and a heightened risk of adverse pregnancy outcomes. A woman
who is underweight, with short stature, anemia, or other micronutrient deficiencies has a greater
risk of intrauterine growth restriction, intrauterine foetal death, and obstructed labour. Other
risks include, low birthweight babies, death from postpartum haemorrhage and increased
morbidity for herself and her baby.

24
According to the 2013–14 ZDHS, 40% of children under age five were stunted (chronic
malnutrition); 15% were underweight, and 6% were wasted. Some 10% of women aged 15–49
were underweight (BMI cutoff of 18.5). The percentage of women who were overweight or
obese increased steadily over the last decade from 19% to 23%.
In the area of clinical nutrition and dietetics, nutrition care is essential in the clinical management
of patients. It enhances patient outcomes, improves response to treatment, reduces length of
hospitalisation, and contributes to reduced morbidity and mortality. To support nutrition clinical
management of patients requires availability of skilled manpower, appropriate equipment,
protocols, and nutrition commodities. Clinical nutrition and dietetics is essential in tackling
current and emerging health conditions.
Currently, there is inadequate clinical nutrition capacity in the health sector to effectively
contribute towards acceptable nutrition therapy and practice. Specialized clinical nutrition care
services are limited in the management of different health conditions at the health facility level.
This is compounded by the limited numbers of qualified dieticians/clinical nutritionists to provide
comprehensive nutrition therapy. Furthermore, there is limited available equipment, guidelines
and protocols, supplies, and commodities to provide specialized nutrition services.
While acknowledging the challenges, the sector has made some positive strides, such as
reduction in stunting levels among children aged less than five years and achieving an almost
three-quarters (73 percent) level of exclusive breastfeeding. Further, the sector has implemented
high-impact nutrition-specific interventions and strengthened linkages with other sectors
implementing nutrition-sensitive interventions. The acute malnutrition database was
operationalised, and provincial and frontline staff were trained in nutritional packages.
The programme has, however, faced the following constraints:
 Limited positions for nutrition and dieticians staff in the establishment
 Inadequate nutrition supplies, commodities, materials, and equipment
 Poor M&E data collection, analysis, and utilisation of nutritional data
 Inadequate incorporation of nutrition activities in community programmes
 Inadequate coordination of various nutrition stakeholders
 Limited space for managing and implementing nutrition interventions in health facilities
 Inadequate financial and HR allocation to address all forms of malnutrition effectively
In this NHSP, focus will be placed on improving nutrition in the lifecycle. The main thrust will be
on scaling up high-impact nutrition-specific interventions to cover at least 80% of the target
population. Key interventions will focus on promotion of appropriate nutrition practices; creation
of awareness and empowering communities to adopt and sustain recommended nutrition
practices; strengthening multi-sectoral collaboration; and mainstreaming and integrating nutrition
programmes into other health programmes. Other focus areas are strengthening the capacity of
the nutrition workforce at all levels; improving nutrition supply chain management, and
strengthening the legal framework for nutrition interventions.

25
Strategic Interventions
Goal: To reduce under and over nutrition and improve clinical nutrition by 2021
Objectives Strategies
To increase access and Strengthen provision of an updated package of high-impact
utilisation of high-impact nutrition-direct interventions, such as maternal, infant
nutrition-specific interventions adolescent, and young child nutrition; integrated management of
acute malnutrition (IMAM); Growth Monitoring Programme
(GMP); micronutrient deficiency control; nutrition in HIV; and
clinical nutrition and dietetics
Strengthen integration of nutrition in other key health sector
interventions, such as maternal and adolescent health, HIV care,
TB, IMCI, and NCDs
Strengthen community partnerships
Strengthen SBCC for effective adoption and practice of good
nutrition
Provide appropriate shelters to facilitate delivery of a minimum
package of high-impact nutrition interventions at facility and
community zones
To improve coordination and Strengthen mechanisms for multi-sectoral collaboration and
systems that support delivery coordination at all levels including national, district, and sub-
of nutrition services district levels
Increase and strengthen capacity for nutrition workforce for
effective service delivery
Improve nutrition supply chain management

To promote generation and Support research and development of innovations and

use of evidence for improved technologies that enhance implementation of child health and
nutrition programming nutrition interventions
Strengthen M&E of nutrition interventions for decision making
Strengthen nutrition operational research, data management
analysis, and utilization
To strengthen the legal, Integrate in the Nutrition Act to support clinical nutrition and
regulatory, and policy dietetics in health facilities
framework for nutrition
Increase funding for nutrition care services in health facilities
programmes
Incorporate clinical nutrition and dietetics in the food and
nutrition policy
To strengthen capacity for Establish positions for clinical nutritionists and dieticians for
clinical nutrition care services provision of nutrition care services in health facilities
at the health facility level
Develop protocols for nutrition care services for health facilities
Improve nutrition supply chain management and availability of
supplies and commodities
Support research and development of innovations in nutrition
therapy
Support professional development opportunities for clinical
nutritionists and dieticians

26
4.2.4 Adolescent Health
Situation Analysis
Zambia has the fifth-highest adolescent birth rate in Sub-Saharan Africa, which in turn has the
highest rate in the world. About 29% of adolescent girls become pregnant by the age of 19 years
(ZDHS 2013-14). Teenage pregnancies reported among girls in grades 1–12 increased five times
(from 3,663 in 2002 to 15,125 in 2015) according to the Ministry of General Education (MOGE
Statistical Bulletin, 2015). However, ZDHS statistics show that the adolescent fertility rate has
slowly been declining, from 146 births in 2007 to 141 births per 1,000 adolescent girls in 2014,
with teenage pregnancies in rural areas standing at 36% and urban areas at 20% of all pregnancies
(ZDHS, 2013-14). About 32% of adolescents aged 15–17 and 60% of those aged 18–19 are
sexually active in Zambia, and therefore face risks to HIV and other STIs, especially as only 40%
of them report regular condom use. A related fact is that 42% of women aged 20–24 in Zambia
report having been married by age 18.
Contraceptive prevalence rate for modern family planning methods among adolescent girls aged
15–19 was 10.2%, despite the rate having been estimated to have increased from 33% to 45% in
the general population (ZDHS 2013-14).
Adolescents also experience other health problems that include mental health, trauma, physical
and sexual violence, non-communicable diseases, and alcohol and substance abuse.
Key challenges are the following:
 Inadequate implementation of ADH strategies at lower levels
 Inadequate knowledge among adolescents of the existing health services
 Inadequate knowledge among health care workers of key adolescent health issues
 Inadequate HIV/SRH outreach services for adolescents
 Lack of ADH-specific indicators in the current HMIS

Strategic Interventions
Goal: To improve the health status of adolescents by 2021
Objectives Strategies
To provide a minimum Health Service Delivery Strengthening
adolescent health service
Prioritize the delivery of comprehensive and integrated
platform in all districts of
adolescent-responsive health services at all levels of service
Zambia by 2021
delivery (prioritize allocation of physical space/room and
commodities)
Scale up pre-service and in-service adolescent health training of
health workers
Scale up training of peer educators and their deployment to
adolescent-friendly spaces at health facilities and communities
Strengthen and scale up school health programmes
To increase adolescents’ Health Promotion and Demand Creation
awareness of the available health
Design and implement targeted innovative SBCC campaigns
services from 13.5% (average) to
with adolescents to promote the use of preventative health
60% to promote healthy living
services
Achieve cultural and value shifts through changes in social
norms and behaviours, such as SGBV, child marriage, alcohol
and substance abuse, etc.
Increase demand and utilization of relevant health services

27
 Goal: To improve the health status of adolescents by 2021
Objectives Strategies
through peer education and outreach

To strengthen the leadership Leadership and Governance

and governance of an
Strengthen the policy and regulatory framework for provision
adolescent-responsive health
and access of adolescent health services, including clear policies
system in 60% of the districts by
and guidelines on age of consent to key SRH and HIV services
2021
Roll out an adaptive leadership approach targeting key
stakeholders, and strengthen organization and multi-sectoral
coordination for an efficient and effective harmonized response
to delivering adolescent-responsive health services
Strengthen management of key commodities, health
infrastructure, equipment, and transport logistics
Roll out and implement the collection and analysis of age and
gender disaggregated HMIS data
Strengthen management, supervision, organization, and
coordination of the ADH activities at all levels

4.3 Communicable Diseases

4.3.1 General Introduction
A communicable disease is defined as an illness that arises from transmission of an infectious
agent or its toxic product from an infected person, animal, or reservoir to a susceptible host,
either directly or indirectly through an intermediate plant or animal host, vector, or environment.
Communicable diseases have remained a major cause of morbidity and mortality in Zambia.
There are three main infectious diseases of public health interest in Zambia: malaria, HIV/AIDS,
and TB. The MOH has put in place a disease surveillance system in order to promptly, effectively,
and efficiently prevent unnecessary disabilities or deaths. In this regard, the NHSP 2017–2021 will
continue to reduce recurrences in communicable diseases through a strengthened surveillance
system and programme. The MOH will implement health promotion interventions aimed at
empowering members of the public to develop personal skills and knowledge for increased
control over predisposing factors to communicable diseases.

4.3.2 Malaria
Situation Analysis
Malaria is a major public health concern in Zambia. Eliminating malaria is a national priority that
requires an evidence-based focused, comprehensive, and sustained strategic approach. The entire
population of Zambia is at risk of malaria, although the prevalence varies widely across and within
districts. Children under the age of five years, pregnant women, the chronically ill, and immuno-
compromised persons, such as those living with HIV and AIDS, are considered to be among the
highest risk groups for malaria infection in Zambia (World Malaria Report 2016, WHO).

28
Malaria transmission is prevented through two main primary vector control methods; namely, (1)
the use of long-lasting insecticide-treated nets (LLITNs) and (2) indoor residual spraying (IRS)
complemented by larval source management. Where cases occur, these should be diagnosed or
confirmed promptly within 24 hours of symptom onset and treated with safe and efficacious
medicines. These efforts to control malaria are complemented by specific interventions for
pregnant women—namely, the provision of intermittent preventive treatment (IPTp) with
sulfadoxine-pyrimethamine during pregnancy. In addition, each of the malaria interventions
requires supportive facilities, including procurement, supply, distribution, and logistics
management of commodities; HRH at all levels; communication for social behaviour change
among communities and health care providers, quality assurance, surveillance, monitoring,
evaluation, and operational research.
Much progress has been made to increase the coverage of primary malaria interventions in
Zambia in the past decade. Ownership of at least one insecticide-treated net (ITN) per
household has increased from 68% in 2012 to 77% in 2015. Likewise, in the same period,
households with insecticide-treated bed nets or that had their dwellings sprayed increased from
73% to 81%, while the proportion of women receiving IPTp during pregnancy increased from 72%
to 78%. Access to malaria diagnosis and treatment also increased, particularly at the community
level, with 25% of the population accessing the services through CHWs (HMIS 2015). These
interventions have led to reductions in malaria morbidity and mortality. As a result, the malaria
epidemiological classification has noted marked transmission zones, ranging from low
transmission with incidence of about 30 cases per 1,000 to incidence above 400 (HMIS 2016).
While noting the progress made in combating malaria, there is need to continue scaling up
interventions aimed at eliminating the disease. The key challenges facing a malaria elimination
programme include:
 Inadequate surveillance and weak information systems to provide real-time disaggregated
malaria data from the points of its generation including the community level
 Unpredictable and inadequate funds, which negatively affect timely procurement, logistic
and stock management, and storage of malaria commodities
 Low community involvement in the malaria elimination agenda, compounded by negative
community practices and misconceptions that perpetuate the transmission of malaria
 Low community uptake of preventive and curative malaria interventions or services
 Weak quality assurance or control systems for malaria interventions (such as IRS),
commodities (such as diagnostic tools), and services (such as treatment practices and
data management)

Strategic Interventions
The NHSP 2017–2021 will give priority to achieving universal access to malaria prevention and
treatment services with core interventions (LLITNs, IRS, diagnosis and treatment at all levels).
Further, the Plan will use additional approaches such as mass drug administration and larval
source management where appropriate; enhance community ownership of malaria interventions;
ensure quality of malaria interventions; and enhance cross-border collaboration. The surveillance,
research, and M&E systems will be strengthened in order to ensure timely availability of quality,
consistent, and relevant data to guide policy and decision making. Implementation of interventions
will be informed by the malaria transmission intensity or epidemiological patterns/levels, in order
to ensure appropriate interventions and impact. The following principles will guide the malaria
elimination agenda:
 The unit of elimination and of intervention implementation will be the health facility
catchment area

29
  Malaria incidence thresholds will guide the intervention package toward the goal of
malaria elimination
 Epidemiologic and entomological information (clarified using data reviews and verification
procedures) will be critical in directing action and tracking progress
The malaria elimination intervention packages for different regions will depend on transmission
intensity levels as explained below:
Level 0: Zero cases and no local transmission:
 High-quality surveillance and vigilance
 Core vector control and case management
 Case investigation capacity maintained
 Chemoprophylaxis
Level 1: Very low malaria transmission (1–49 cases per 1,000 populations/yr; range <1% parasite
prevalence)
 High-quality surveillance
 Vector control (possibly enhanced)
 Community- and facility-based case management
 Case and foci investigation
 Mass drug administration (under certain circumstances)
Level 2: Low malaria transmission (50–199 case per 1,000 populations/yr; range 0.5% to <5%
parasite prevalence)
 Build high-quality surveillance
 Vector control (possibly enhanced)
 Community- and facility-based case management
 Establish case and foci investigation capacity
 Mass drug administration
Level 3: Moderate malaria transmission (200–499 cases per 1,000 populations/yr; range 5% to
<15% parasite prevalence)
 Improve quality of surveillance
 Vector control (possibly enhanced)
 Facility-based case management, build community case management and outreach
 Establish case and foci instigation capacity
 Mass drug administration (may be considered for specific areas with case investigation
capacity)
 Enhanced vector control, if relevant
Level 4: High malaria transmission (>500 cases per 1,000 populations/yr; range >15% parasite
prevalence)
 Build quality surveillance
 Vector control at high coverage (100% coverage of IRS and sustained high coverage of
ITNs)

30
  Facility-based case management begins to build community case management and
outreach
 Prepare for case and foci and investigation
 Prepare for mass drug administration (MDA) and conduct where logistics and feasibility
considerations are met, especially at lower Level 4 thresholds
 Enhanced vector control, if relevant
Goal: To eliminate local malaria infection and disease in Zambia by 2021
Objectives Strategies
To increase the malaria-free Prevent the re-emergence of malaria transmission due to
health facility catchment areas importation in HFCAs where it had been eliminated
(HFCAs) from 0.5% in 2015 to
Enhance surveillance, monitoring, and evaluation systems
100% in 2021
To reduce malaria incidence Enhance IRS
from 336 cases per 1,000
Enhance the distribution of ITNs
populations per year in 2015 to
less than 5 cases per 1,000 Enhance larval source management
populations by 2021
Expand use of emerging tools and strategies, such as spatial
repellents and baited traps
To reduce malaria deaths from Undertake MDA
15.2 deaths per 100,000
Reactive case investigation
population per year in 2015 to
less than 5 deaths per 100,000 Enhance focal drug administration
populations by 2021
Strengthen diagnosis, treatment, integrated community case
management

4.3.3 HIV/AIDS
Situation Analysis
Zambia has an estimated adult (15–49 years) HIV prevalence of 12.3% (ZAMPHIA 2016) and 1.3%
among children (0–14 years). HIV prevalence is higher in the urban areas at 18.2% compared with
rural areas at 9.1% (DHS 2013–14). HIV incidence is estimated at 0.7% among adults (ZAMPHIA
2016). HIV prevalence is lowest among those aged 15–19 and peaks among those aged 40–44 for
both males and females (ZDHS 2013–14). Adolescents comprise 23% of the total Zambian
population, with 4.8% of females and 4.1% of males currently living with HIV. Based on recent
estimates and projections from Spectrum, Zambia had 1.2 million people living with HIV in 2015,
and this number is expected to increase to 1.3 million people in 2020.
The country has made progress in scaling up high-impact HIV preventive interventions. There has
been a marked improvement in male circumcision (MC) rates among men in the group aged 15–
49 from 13% in 2007 to 22% in 2014 (ZDHS 2013-14). Close to 1.2 million men have been
circumcised from programme inception to December 2015, with up to 17,000 new infections
averted (Voluntary Medical Male Circumcision [VMMC] Impact Evaluation Report 2016). The
uptake for HIV testing services has risen from 14% in 2001 to 37% in 2013 among men aged 15–
49, and from 9% in 2001 to 46% in 2013 among women aged 15–49. The number of people living
with HIV accessing ART has also increased from 3% in 2004 to 62% (758,646) in 2015. The
survival and retention of people on ART at 12 months increased from 65% in 2010 to 81% in
2013. The mortality attributable to AIDS has reduced from an estimated 65,000 in 2000 to
20,000 in 2015 among adults.

31
According to the 2015 Zambia Spectrum projections, the estimated number of children living
with HIV has dropped from 92,000 in 2000 to 89,000 in 2015. New HIV infections among
children dropped from 23,000 in 2000 to 8,900 in 2015. The estimated number of children living
with HIV and receiving ART increased from 5,400 in 2005 to 51,903 (59%) at the end of
December 2015. The estimated number of deaths among children attributed to AIDS dropped
from 12,000 in 2000 to 4,300 in 2015.
The proportion of pregnant women living with HIV who accessed antiretroviral drugs (ARVs) for
prophylaxis to prevent HIV transmission to infants increased from 20% in 2004 to 86% in 2015.
The need for elimination of mother-to-child transmission (EMTCT) has been increasing steadily,
from an estimated 59,000 in 2005 to 72,000 in 2014. The EMTCT rate at six weeks in 2005 was
estimated at 15% and rapidly declined to 5% in 2015.
The key service delivery challenges for EMTCT include the following:
 Low rates of retesting, quality of testing of clients and partners, and delayed return of
results (e.g., DNA-PCR, CD4, viral load)
 Suboptimal time frame from time of positive HIV test result to initiation of ART
 Suboptimal ARV adherence/retention and mother-infant pair follow-up (cohort
monitoring) and effective transition to chronic services
 Suboptimal compliance for ART and enhanced infant prophylaxis
 Poor infant outcomes and suboptimal HIV prevention services and care of pregnant
adolescents

Strategic Interventions
The goal of the HIV programme over the next five years is to reduce new HIV infections and
AIDS-related mortality by 75% and reduce HIV-related stigma and discrimination to zero within
the context of ensuring healthy lives and promoting well-being across all ages.
In order to accelerate progress towards ending the epidemic, bold and ambitious targets have
been set. These targets aim to transform the vision of zero new HIV infections, zero
discrimination, and zero AIDS-related deaths into concrete milestones and end-points. These aim
at ensuring 90% of people living with HIV know their HIV status, 90% of people who know their
status receive life treatment, and 90% of people on HIV treatment having a suppressed viral load
so that their immune system remains strong, and to increase to 95% for each target by 2030
(UNAIDS 2016).
Goal: To reduce the incidence and prevalence of HIV
Objectives Strategies
To reduce the number of Eliminate vertical transmission of HIV
new HIV infections
Optimise timely initiation, repeat testing in ANC and post-natal
care, compliance with infant prophylaxis
Open up new spaces to roll out comprehensive sexuality education
Targeted behaviour change communication including
comprehensive condom programming
Scale up MC services including neonatal circumcision
Early diagnosis and treatment of STIs
Enhance provision of post-exposure prophylaxis and pre-exposure
prophylaxis for priority populations

32
 Goal: To reduce the incidence and prevalence of HIV
Objectives Strategies
To ensure that 90% of the Encourage and promote universal HIV testing and counselling
population know their status
Targeted provider-initiated HIV testing and counselling across
services such as EPI, ANC, VMMC, family planning (FP), in-patient,
out-patient, TB, STI
Improve logistics and supply chain management for HIV testing
reagents and other laboratory consumables and supplies
To ensure that 90% of 100% of identified HIV positive people are linked to care and
people living with HIV treatment services
receive lifelong ART
Implementation and scaling up of test and start
90% of people living with HIV on ART are retained in care 12
months after initiation
Early diagnosis and treatment of opportunistic infections
Intensify identification and ART initiation for HIV positive children
Enhance implementation of the three Is and TB/HIV collaborative
services
To ensure that 90% of Improve supply chain management for laboratory consumables
people living with HIV on
Use of point of care machines
ART have suppressed viral
loads Enhanced follow-up and adherence counselling

4.3.4 Sexually Transmitted Infections

Situation Analysis
As in many other Sub-Saharan African countries, curable STIs continue to represent a large
burden of disease in Zambia, accounting for about 10% of out-patient department attendances.
The actual incidence must be much higher considering that many STI clients seek care with
private clinics and traditional healers where they feel more assured of privacy and confidentiality.
In addition, asymptomatic infections remain high in the population and among high-risk groups.
Studies by Corridors of Hope (2006) estimated the rapid plasma reagin positive rate in the 15–49
age group to be 7% for women and 8% for men (ZDHS 2001–2002), while prevalence rates of
gonorrhoea, chlamydia, trichomoniasis, and syphilis among female sex workers were 10.4%, 6.8%,
38.8%, and 23.3%, respectively.
The synergy between STIs and HIV is underscored by a significantly higher HIV prevalence
among STI clients (36%) (UTH 2007–2008) compared with a national prevalence rate of 14.3%
(ZDHS 2007). Controlling STIs is therefore a high priority for the country and is one of the main
strategies for HIV control advocated by the MOH.
The key service delivery challenges for STIs include:
 Inadequate strategies to reach the vulnerable and most-at-risk populations
 Mismatch between increased burden of STIs and the allocated financial and human
resources
 Inadequate levels of appropriate training, limited quality assurance, supervision, and
feedback among STI service providers
 Inadequate surveillance, monitoring, and evaluation system, which has limited
programming for STIs

33
  Inadequate coordination and collaboration with other programmes and weak regulation
of the private sector involved in STI management

Strategic Interventions
Goal: To halt and begin to reverse the spread of HIV/AIDS and STIs by increasing access to quality
HIV/AIDS and STI interventions
Objectives Strategies
To reduce the incidence Ensure treatment algorithms remain reliable and valid
of STIs
Ensure an uninterrupted supply of STI drugs and commodities
Improve STI management at the community level
Improve capacity for laboratory diagnosis of STIs at the provincial and
district hospital levels to complement syndromic management
Achieve greater integration of STI services in other health delivery
services
Improve STI services for special and most at risk populations
Improve standards of STI care and reporting in private practice by
entrenching syndromic management
Strengthen STI surveillance at all levels
Integrate STI into cervical cancer and MC

4.3.5 TB
Situation Analysis
According to the WHO, Zambia is one of the 30 countries in the world with high TB and TB-HIV
burden. Since 2000, Zambia has successfully implemented three national TB strategic plans. The
2014–2016 NSP, which was modelled on the Global Stop TB Strategy, focused on scaling up
intensified TB case finding, TB-HIV collaborative services, and building the structure for
implementing Programmatic Management of Drug-Resistant Tuberculosis (PMDT). Within this
period, Zambia successfully conducted the first ever national Tuberculosis Prevalence Survey. It is
now known that the country has a higher and unevenly distributed TB burden than previously
estimated. The prevalence of bacteriologically confirmed TB is 638 (502–774) cases per 100,000
populations. The TB prevalence for all ages and all forms of TB is 455 cases per 100,000
populations (Zambia TB Prevalence Survey 2014).
Based on the Global End TB Strategy and the NHSP, the MOH has started the process of
developing its post-2015 End TB National Tuberculosis Strategic Plan. The plan will mark the
beginning of efforts towards ending the TB epidemic by 2035.
The key challenges for the TB programme include:
 Decreasing TB notifications in both adults and children
 Inadequate human resources and weak capacity especially on multi-drug resistant TB
 Weak M&E and TB data management system
 Limited involvement of private providers such as pharmacies and private hospitals in TB
programmes
 Inadequate cross-border strategies to address issues of increased rates of lost-to-follow
TB cases
 Inadequate diagnostic capacity especially at the implementation level

34
  Inadequate skills and diagnostic tools for childhood TB
 Slow roll-out of PMDT activities

Strategic Interventions
Goal: To reduce the number of TB deaths in the population by 40% in 2021 compared with 2015
Objectives Strategies
To increase the number of Improve case detection though expanding case finding to all clinical
notified cases of new TB settings and using data from the National TB Prevalence Survey
episodes from 36,700 in
Involve all care providers practicing outside the National
2015 to at least 59,000 in
Tuberculosis Programme (NTP) network in TB case detection and
2021
management
Strengthen TB services for high-risk groups and vulnerable
populations
Improve the technical platform for TB diagnostic procedures
To increase the treatment Improve and reinforce TB services in high TB burden spot areas
success rate for TB from
Strengthen TB diagnostic capacity through expanding and enhancing
87% to at least 90% from
the laboratory network
2018 onwards
Ensure appropriate TB treatment for all detected patients
Implement early TB case detection, treatment of latent TB infection,
and treatment among key affected populations (persons living with
HIV, children, prisoners, miners, diabetics)
Introduce and implement sensitive TB diagnostic algorithm and roll-
out of rapid TB diagnostic tools (Xpert MTB/RIF; loop-mediated
isothermal amplification [TB-LAMP])
To increase the treatment Scale up clinical and diagnostic capacity to detect MDR TB
success rate for multi-drug
Improve active contact investigation of MDR TB patients
resistant (MDR) TB patients
to 80% by the year 2021 Expand and strengthen the capacity for treatment of MDR
Improve Social Welfare for MDR TB patients
Improve and strengthen M&E for MDR TB including operational
research
Scale up MDR TB management to all the provinces and districts, and
introduce MDR-TB shorter regimen
To achieve 100% HIV Strengthen TB/HIV collaboration at all levels
testing of notified TB
Intensify HIV screening in presumptive and confirmed TB patients
patients by 2018
and offer quality patient-centred HIV care for HIV-infected TB
patients
To achieve ARV therapy for Reduce the burden of TB in people living with HIV (PLHIV) and
100% of TB/HIV patients by people at high risk of HIV infection
2018
Strengthen TB infection control in health services dealing with PLHIV
To improve and strengthen Develop and reinforce the technical and managerial capacities at
the managerial and technical central and sub-national levels
capacities of the national
Strengthen coordination between the NTP and collaborating
TB/leprosy control
partners
programme
Ensure resource mobilization
Ensure quality services through technical support and supervision

35
 Goal: To reduce the number of TB deaths in the population by 40% in 2021 compared with 2015
Objectives Strategies
Improve the TB monitoring and evaluation system

4.3.6 Viral Hepatitis

Situation Analysis
Viral hepatitis infection is widely spread, affecting more than 10 times the number of people
infected with HIV. Globally, about 1.4 million people die each year from hepatitis. It is estimated
that only 5% of people with chronic hepatitis know of their infection, and less than 1% have
access to treatment.
Hepatitis is fully preventable and treatable: there are effective vaccines and treatments for
hepatitis B and more than 90% of people with hepatitis C can be cured with treatment. The
vision of eliminating hepatitis as a public health threat by 2030 can be achieved, if people have
access to adequate prevention and treatment services.

Strategic Interventions
Goal: To reduce the impact of viral hepatitis on people, society and the economy
Objectives Strategies
To raise awareness of viral Increase knowledge in the general population and protect key
hepatitis populations at risk of viral hepatitis
Increase awareness of health care providers in screening high-
risk populations
Reduce stigma and discrimination associated with hepatitis
To monitor the health sector Estimate the national burden of viral hepatitis
response to viral hepatitis
Monitor trends of viral hepatitis
To reduce new viral hepatitis Stop mother-to-child transmission of hepatitis B
infections
Prevent health care-related transmission of hepatitis B and C
Reduce the number of people susceptible to hepatitis infection
Decrease hepatitis C virus (HCV) incidence among injection
drug users
To reduce deaths due to viral Increase the proportion of people diagnosed with viral hepatitis
hepatitis
Ensure adequate follow-up of and management of people
diagnosed with viral hepatitis

4.3.7 Neglected Tropical Diseases

Situation Analysis
Neglected Tropical Diseases (NTDs) are a group of infectious diseases that affect poor people in
the tropics. They are disabling and cause severe morbidity and suffering in the poorest
communities in the country. They present one of the largest economic and health burdens on the
population; because of their debilitating nature, they perpetuate poverty. The endemic NTDs
include lymphatic filariasis (elephantiasis), schistosomiasis (bilharziasis), soil-transmitted
helminthiasis, trachoma, trypanosomiasis, leprosy, and taeniasis.

36
In line with the WHO resolution on NTDs as agreed during the World Health Assembly in 2012,
Zambia is committed to control and eliminate these diseases. This will be achieved through the
implementation of both community- and school-based interventions.
Zambia has commenced an NTD control and elimination programme in an effort to achieve the
targets set out by the WHO for the African region by the year 2020. Successful MDA campaigns
commenced for the NTDs amenable to preventative chemotherapy. These include lymphatic
filariasis (lf), schistosomiasis, soil-transmitted helminthiasis (STH), and trachoma. The MDA
campaigns were rapidly scaled up in 2016 with the view of achieving 100% coverage by the year
2017.
The NTD control programme challenges include:
 Inadequate coordination in management of the NTD programme starting at the national
level
 Inadequate trained focal point persons at the district level
 Inadequate set targets and indicators of NTDs in NHSP 2011–2015
 Inadequate data on prevalence and incidence of NTDs
 Inadequate funds for advocacy and partnership
 Limited capacity for distribution of drugs
The strategic interventions to be scaled up include adequate management of cases of NTDs
including parasitic diseases and improving the ability to detect and respond to epidemics and
emergencies.

Strategic Interventions
Goal: To have a Zambia free of NTDs
Objectives Strategies
To eliminate NTDs in Scale up MDA campaigns for preventive chemotherapy for amenable
Zambia by 2020 NTDs
Enhance surveillance of NTDs and improve management so that all
cases are promptly treated
Formulate health (sanitation and hygiene) promotion programmes that
are aimed at preventing and reducing NTDs
Sustain the elimination status of leprosy in Zambia through enhanced
surveillance
Implement treatment guidelines and protocols for all CM NTDs in line
with WHO
Strengthen coordination between stakeholders involved in NTD
control and elimination
Integrate the NTD control activities into the primary health care
services
Strengthen advocacy for resource mobilization for NTD control
programmes
Produce data capturing tools for NTDs to be incorporated in the
existing HMIS
Include the control of NTDs in the curricula for health care
professionals

37
4.4 Public Health Surveillance and Disease Intelligence
Situation Analysis
Public health surveillance is the continuous, systematic collection, analysis, and interpretation of
health-related data needed for the planning, implementation, and evaluation of public health
practice. Such surveillance serves as an early warning system for impending public health
emergencies; documents the impact of an intervention; tracks progress toward specified goals;
and monitors and clarifies the epidemiology of health problems to allow priorities to be set and
to inform public health policy and strategies. (WHO Public Health Surveillance). Public Health
Surveillance is an essential need more now than ever before as there are now more challenges of
a public health nature that require timely monitoring and evaluation to ensure public health
security. Issues of climate change, bioterrorism, and technological advances in industry and
agriculture have created a paradigm shift in public health surveillance (WHO).
Zambia’s public health system functions through the activity of different ministerial directorates
and external partners. This creates gaps in its national capacity to carry out essential public health
functions, establish informed public health policies, inform its citizenry and health fraternity, and
protect the health of its population. Structures for public health surveillance exist, but not fairly
supported with technical competences, system, and supportive public health informatics
technologies. As such, collection and collation of surveillance data from the various sources have
had challenges of completeness, timeliness, and validity and oftentimes are disjointed.
A strengthened public health system would enable the MOH to better collect, analyse, and use
routine disease surveillance data to systematically inform public health decisions. Further, Zambia
lacks a public health laboratory system. Currently, Public Health Laboratory functions are
conducted within clinical laboratories.
Zambia adopted the WHO-recommended Integrated Disease Surveillance and Response (IDSR)
as a strategy for early detection and efficacious response to priority communicable and notifiable
diseases. The IDSR Technical Guidelines were adapted in 2002 and were revised in August 2011.
Since 2007, training of health workers using the IDSR Training Guidelines has been conducted at
national, provincial, and district levels. The programme, though commanding a national
representation, falls far short of the required national representation. This is on account that
training in IDSR has concentrated at the national, provincial, and district levels, leaving out the
implementation levels (health facilities and the community).
It is against the above mentioned and unmentioned challenges that Zambia took a policy decision
to establish the National Public Health Institute, the function of which is to provide a defined
coordination mechanism that will turn around the many challenges currently faced into
opportunities for a successful public health surveillance system. The Zambia National Public
Health Institute (ZNPHI) serves as a specialized institution, the main mandate of which is to
support districts in improving the health of the people through prevention of infection;
surveillance and response to emergencies including outbreaks, man-made and natural disasters,
and public health events; and capacity building in reducing disease burden in the country.
The main mandate for the Institute is to serve as a credible authority for the development of
well-informed public health priorities, guidelines, policies, and programmes by effectively
translating public health data into action; coordinate priority public health functions and speak as
one voice for Zambia’s public health system; actively protect the health and safety of the nation;
and build capacities in the country to detect and respond quickly and effectively to disease threats
and outbreaks based on science, policy, and data-driven interventions and programmes.
Zambia has also been designated as the Southern Africa Development Community Regional
Collaborating Centre (RCC) to coordinate the southern region of Africa under the Africa Centre
for Disease Control established by the Heads of State and Government during the 24th Ordinary

38
General Assembly held in Addis Ababa, Ethiopia, in January 2015. As RCC, the main function will
be providing technical support to member states in the southern region to ensure that the core
capacities in surveillance, laboratory systems and networks, information systems, emergency
preparedness and response, and public health research are implemented and strengthened.

Strategic Interventions
Goal: To strengthen routine, community-based, and facility-based surveillance systems for improved
public health decision making and action by 2021
Objectives Strategies
To strengthen and scale up Assess health cluster performance every six months against the
national disease protocols of the United Nations Inter-Agency Standing Committee’s
surveillance systems transformative agenda, using the cluster performance monitoring
(district and community) too, and take remedial measures where necessary
Ensure adequate reporting on implementation of the International
Health Regulations (2005)
To strengthen and equip Build capacity at all levels, and monitor and supervise surveillance
the national surveillance sites
system to generate timely,
Support development of the epidemiology and surveillance
high-quality data on all
workforce at the district and provincial levels through a field
national notifiable and
epidemiology training programme
priority diseases,
conditions, and events to Carry out surveillance data quality assessments
inform policy and
programmes Support analysis of existing data and biobank
Prepare and provide policy briefs to MOH, and disseminate data for
usage through a regular epidemiological bulletin
Enhance communication at all levels
To establish a National Develop a national public health laboratory system and network
Public Health Laboratory
Establish a National Public Health Laboratory
and strengthen the existing
laboratory network at the Conduct assessments and mapping of lab capacity in the country to
provincial and district carry out public health functions
levels to carry out basic
public health laboratory Build regional capacity to carry out public health lab functions and
functions strengthen the lab quality management system
Conduct a national anti-microbial resistance (AMR) situation analysis
and develop a national action plan for AMR
To strengthen public health Provide technical input on the national public health research agenda
research
Conduct high-quality public health research and programme
evaluations
Build capacity nationwide by providing mentorship and training and
sponsoring research projects
Establish a national repository for public health research

39
 Goal: To strengthen routine, community-based, and facility-based surveillance systems for improved
public health decision making and action by 2021
Objectives Strategies
To strengthen the Develop an electronic IDSR component on the District Health
information system Information System (DHIS2) platform that will ensure timely and
accurate generation of health information for surveillance systems
Strengthen the Health Press–Zambia capacity to inform policy
makers, public health practitioners, and the general public on health
matters to include surveillance data, outbreak investigation reports,
medical reviews, policy briefs, and morbidity and mortality data
Strengthen the platform for health promotion, and develop a
communication strategy and tools for timely and accurate
dissemination of information

4.5 Epidemic Preparedness and Response, and Emerging

Issues
Situation Analysis
Zambia like other countries is challenged by recurrent disease outbreaks and other health
emergencies. Although most of these outbreaks and health emergencies are preventable, they
result in unacceptably high morbidity, mortality, disability, and socio-economic disruptions. The
high frequency of these outbreaks reflects weak health systems.
The WHO has guided member states to use of the ‘all-hazards approach’, defined as ‘an
integrated hazard management strategy that incorporates planning for and consideration of all
potential natural and technological hazards’. In Zambia, there are established structures for
disease outbreak investigation and response at the national, province, and district levels. Epidemic
preparedness and response committees exist at the national, province, and district levels. These
bodies coordinate the responses at the various levels. In addition, response capacity is being built
for emerging and re-emerging diseases causing epidemics, such as Ebola and Zika. The presence
of antimicrobial resistance in the country threatens the effective prevention and treatment of an
increasing range of infections caused by bacteria, parasites, viruses, and fungi.
The country has adopted mechanisms for dealing with epidemics and other disease outbreaks.
For the country to enhance its preparedness, the following challenges need to be addressed:
 Currently, the responses are limited to disease outbreaks and are not extended to other
sudden disturbances
 Public threats such as floods, droughts, and environmental pollution are not included in
the programme
 The level of preparedness at all levels (including human resources, health products, and
technology) is currently limited
 There is limited involvement of communities in preparedness programmes
The NHSP 2017–2021 will aim at reducing morbidity, mortality, disability, and socioeconomic
disruptions due to outbreaks and other health emergencies. In a bid to address these challenges,
Zambia through the ZNPHI will build capacities to detect and respond quickly and effectively to
disease threats and outbreaks based on science, policy, and data-driven interventions and
programmes.

40
Strategic Interventions
Goal: To strengthen capacities to effectively and efficiently implement preparedness and response to
emergencies
Objectives Strategies
To strengthen and sustain the Formulate national legislation and policies to prioritize disaster
capacity to prepare for and risk management, health security, and international health
prevent health emergencies regulation (IHR)
Develop mechanisms for monitoring AMR
Develop systems for ensuring access to quality essential
antibiotics, and regulating and promoting the rational use of
antibiotics in humans and animals
Develop and implement operational frameworks for zoonotic
diseases, emerging and reemerging infectious diseases, and
environmental risk factors using the ‘One Health approach’.
To strengthen the capacity to Establish and sustain the human resources to implement IHR
promptly detect, report, and core capacity and domestic resource mobilization strategy
confirm outbreaks requirements; formulate a public health workforce strategy
In collaboration with the EPI and other relevant stakeholders,
establish regional vaccine stockpiles
Improve vaccine delivery and implementation systems to
facilitate preventive and reactive vaccination against epidemic-
prone diseases
Increase investments in preparedness through joint external
evaluations of the IHR core capacities, risk analysis, and mapping
Develop and implement a multi-hazard and multi-sectoral
national public health emergency preparedness and response
plan
Develop a national multi-hazard emergency risk communication
plan
Establish and test communication coordination with all partners,
and ensure continuous wide-coverage communication
Engage in proactive media outreach guided by risk
communication best practices
To establish a functioning Create a public health emergency operations centre with
public health emergency standard operating procedures and trained staff
preparedness and response
Develop an incident management systems and maintain multi-
programme and strengthen and
sectoral response and recovery capacity
sustain the capacity to
promptly respond to and Develop an information system for tracking and assessing
recover from the negative outbreaks and emergencies
effects of outbreaks and health
emergencies Conduct incident management system training for public health
emergency operations centre staff
Conduct public health emergency operations table top
exercises
Strengthen partnerships with both public and private actors in
health emergencies

41
4.6 Non-Communicable Diseases
Situation Analysis
Most premature deaths from NCDs are mostly preventable by enabling health systems to
respond more effectively and equitably to the health care needs of people with NCDs, and by
influencing policies in sectors outside health that address risk factors such as tobacco use,
unhealthy diet, physical inactivity, and harmful use of alcohol. The Government has committed
itself to establish and strengthen multi-sectoral plans and policies and plans for the prevention
and control of NCDs.
The burden of NCDs in Zambia is increasing, with significant consequences on morbidity and
mortality levels. The most common NCDs in the country include chronic respiratory diseases,
CVDs, diabetes mellitus (Type II), cancers, epilepsy, mental illnesses, oral diseases, eye diseases,
trauma (mostly due to road traffic accidents and burns), and sickle cell anaemia. In 2016, it was
estimated that NCDs caused 23% of all deaths in the country, with nearly one in five people dying
prematurely from these conditions. It was further reviewed that 24% of men smoke and more
than a third of men had hypertension. Road crashes are the third leading cause of death after
malaria and HIV/AIDS, accounting for 2,000 deaths per year, with many thousands being injured
each year. Most of these NCDs are associated with lifestyles, such as unhealthy diets, physical
inactivity, alcohol and substance abuse, and tobacco use.
Prevention and control of the major communicable diseases in Zambia has received more
attention over the past decades compared with NCDs. There has been a lot of focus on
treatment and care of communicable diseases with little attention to community sensitisation and
health promotion in order to reduce risk factors. Careful identification of the priority
interventions is required in order to promote good health and to prevent, control, and manage
non-communicable diseases. This would also facilitate the allocation of the required resources for
effective interventions. There is need for risk factor stratification at the community level so that
it forms the basis of incidence and prevalence data, which are currently inadequate. Diagnosis and
case management of non-communicable diseases is an important aspect of health service delivery
for the country to successfully reduce the associated disease burden. Further, hospital
information systems need to be revised to allow for collection of data to show morbidity data
that is segregated into uncomplicated and complicated NCDs.
In the light of the increasing NCDs, the health sector will put up measures to forestall this trend.
There will be need to undertake routine assessment of prevalence and incidence of NCDs;
develop policies to guide interventions for NCDs; enhance community education and awareness,
prevention, early diagnosis, and treatment; and revise protocols to aid health care workers in
prevention, diagnosis, treatment, equipment, drugs, and case management of NCDs. Community-
based volunteers should be trained to offer basic advice and care on NCDs and refer people to
health facilities, where necessary. Across all levels of the health delivery system, special focus
should be placed on preventing the rapid rise in NCDs, as this will help reduce future treatment
costs to the health sector.
A key shift in strategy will be to ensure that nutrition interventions are embedded in the overall
plan that addresses diet-related NCDs. Nutrition interventions are a cost-effective way of
promoting good health. Maintaining optimal nutritional status at any age is important and can
contribute to preventing some chronic diseases, reducing frequent episodes of illness, shortening
hospital stays, reducing complications, and ensuring higher survival rates. Dietary adjustments
influence present health and may determine whether or not an individual will develop NCDs
much later in life.
The Government has continued its commitment to increase specialized human resources for
NCD control in line with the Human Resource Development Strategic Plan. Nevertheless, the
human resources required to support the country’s NCD needs are inadequate at all levels. Skills

42
and knowledge for the prevention, screening, and treatment of NCDs need to be strengthened
and scaled up through a multi-sectoral approach.
The MOH has made tremendous progress in ensuring the availability of medicines and medical
supplies for the management and control of NCDs by including NCD medicines and supplies on
the essential medicine list for Zambia. However, the essential medicine list does not exhaustively
provide for all NCDs and conditions. In order to provide guidance to the fight against NCDs, the
Government developed the NCD Strategic Plan 2011–2016, the National Cancer Control
Strategic Plan 2016–2021, oral health standards of practice, and NCDs standard treatment
guidelines. Notable achievements include establishment and expansion of the Cancer Diseases
Hospital; establishment of a national cervical cancer screening programme; finalisation of the
mental health and tobacco products control bill; initiation of the HPV vaccination programme for
prevention of cervical cancer and accompanying scale-up plan; the commissioning of the cardiac
catheterisation laboratory; and implementation of the Rheumatic Heart Disease study.
Furthermore, national NCD risk factor surveys will be conducted in 2017 to establish baseline
data.
Despite these achievements, key challenges remain and include:
 Policy and legal frameworks not clearly supporting reductions in NCDs
 Uncoordinated multidisciplinary approach in control of NCD
 Inadequate human, financial, and material resources for NCD prevention and control
 Low level of public awareness of NCDs
 Lack of a communication strategy on NCDs
 Inadequate NCD diagnostic capacity at various levels of health care
 Erratic supply of NCD medicines and medical supplies

Strategic Interventions
Goal: To reduce the morbidity and mortality due to non-communicable diseases by 2021
Objectives Strategies
To improve the policy/legal Strengthen legislation/regulation that supports prevention and
framework for NCDs control of NCDs
Strengthen policies/legislation targeted at mental health, alcohol,
tobacco use, and healthy diets
To reduce the incidence and Scale up health promotion and education on the risk factors and
prevalence of NCDs through prevention of NCDs, at all levels, using a multi-sectoral approach
enhanced health promotion Scale up health promotion on healthy diets among the population,
including exclusive breastfeeding
Scale up promotion and support of physical activity among the
population, including in schools, workplaces, and communities
To strengthen and orient health Introduce vaccines that are effective in preventing NCDs
systems to address the prevention Strengthen and promote active screening for NCDs at all levels,
and control of NCDs and the including within health facilities, schools, and communities, so as to
underlying social determinants generate demand for such services
through people-centred primary Implement the STEPwise approach to surveillance (STEPS) survey
health care and Universal Health to better understand the current situation and allow for
Coverage prioritization of interventions, including innovative screening and
surveillance protocols
Introduce new screening techniques and surveillance for NCDs
To strengthen and scale up the Scale up early diagnosis of NCDs at primary, secondary, and
treatment, rehabilitation, care, and tertiary levels
support for people suffering from Strengthen case management of NCDs
NCDs, in order to reduce Strengthen gender-responsive rehabilitation, care, and support

43
 Goal: To reduce the morbidity and mortality due to non-communicable diseases by 2021
Objectives Strategies
morbidity and mortality and systems and services for people suffering from NCDs at all levels of
improve quality of life care, including community and household levels
Scale up the production of appropriately skilled health workers, by
prioritising NCDs in the curricula for training of all health workers,
in health training institutions, at different levels
Strengthen skills and capacities of health workers in the prevention,
management, and care for NCDs, both at the health facility and
community levels
Strengthen NCD services, by integration and prioritization of
NCDs in the existing health services including outreach
To ensure availability of essential Strengthen quantification and increased procurement of essential
infrastructure, medical supplies, drugs and diagnostic supplies for NCDs
equipment, and technologies Strengthen the infrastructure, medical equipment, and technologies
for the prevention and management of NCDs in health facilities and
communities
Encourage public-private partnerships and other stakeholders in
improving access to and affordability of medicines for NCDs
Strengthen the infrastructure, medical equipment and technologies
for the prevention and management of NCDs in health facilities and
communities
Enhance leadership and Establish a national NCD coordinating committee (or equivalent)
governance for the social with membership by all ministries
determinants and risk factors for Develop a national multi-sectoral NCD Action Plan, with full
NCDs participation of non-health ministries and non-state actors
Strengthen leadership for enforcing existing legislation and
regulations
To scale up promotion strategies Develop and distribute information education and communication
for cancer awareness (IEC) materials for the various cancers
Strengthen the cancer awareness strategies in the national
communication strategy
Commemorate cancer-related national events
To reduce the number of cancer Promote healthy living strategies
cases Implement an HPV vaccination programme
Implement and scale up cervical cancer screening services
Strengthen diagnostic capacities at all levels of care
Provide training and mentorship in cancer management
Decentralize chemo-radiotherapy Implement phase three expansion programme
centres Upgrade CDH with advanced diagnostic and treatment equipment
To improve palliative care services Develop national palliative care policy
at all levels of care

4.7 Hospital Services

Situation Analysis
A fair distribution of hospital services is essential in order to ensure an effectively functioning
health delivery system. Currently, there is an uneven distribution of hospital facilities, with urban
areas being disproportionately favoured compared with rural areas. The hospitals were either set
up by missionaries wherever they settled or constructed by mining companies in the case of the
Copperbelt.
Challenges for hospital services include:

44
• Inadequate funding to the hospitals
• Inadequate competencies, infrastructure, and equipment
• Breakdown of referral system, which imposes pressure on hospitals
• Erratic supply of medicines and medical supplies
• Weak health information management systems for the hospitals
• Limited availability of guidelines and protocols
In the NHSP 2017–2021, the focus will be placed on ensuring that hospitals have all the necessary
competencies to ensure that they operate according to their level. In addition, investment in
health systems strengthening is required.

Strategic Interventions
Goal: Achieving Universal Health Coverage through safe, affordable, accessible, and timely hospital
services by 2021
Objectives Strategies
To strengthen and expand Reorganize the clinical units, (surgery, medicine, paediatrics, obstetrics
clinical disciplines at all and gynaecology) to respond to 80% of first-level health needs of a
levels of hospital care district
Extend outreach services to district- or council-operated health
centres
Have specialists in all four major disciplines at Level 2 hospitals
Promote mentorship and outreach programmes between Level 2 and
Level 1 hospitals
Create one internship site per province
Upgrade one general hospital to a central hospital per province
To enhance the efficiency Creation of e-patient record management systems (EMS)
of patient care at all levels
Strengthen referral system and feedback mechanism by formulating
guidelines and policies
Develop and roll out treatment protocols and treatment guidelines
To build the capacity of Enhance professional skills through mentorship, continuous
service providers in order professional development, and long-term training
to improve service delivery
Extend implementation of tele-consultation services
Create a National Clinical Centre Of Excellence (NCCE)
To increase access for Train super specialists for all cadres in Level 3 hospitals
patients in need of
Create centres of excellence for HIV and AIDS and other infectious
advanced medical care
diseases, renal and eye services, cancer, orthopaedic and rehabilitative
services, cardiac, dietetics and clinical nutrition, and any other areas of
need
Streamline the referral system
Improve quality of clinical Implement standard treatment protocols
services in hospitals
Implement infection prevention activities
Conduct regular clinical audits and QA/QI interventions

45
4.7.1 Surgical, Obstetric, and Anesthesia Services
Situation Analysis
Surgery and anaesthesia have traditionally been neglected sectors of health care in low- and
middle-income countries. In order to redress the situation, there have been concerted efforts to
improve the provision of surgical, obstetric, and anaesthesia services in Zambia. Surgery,
obstetrics, and anaesthesia are all integral parts of health care and contribute significantly to the
reduction of maternal and trauma mortality, prevention of HIV, and screening and treatment of
cervical cancer.
It is estimated that 74% of Zambians do not have access to safe, affordable, and timely surgical,
obstetric, and anaesthesia care. Only 26% of Zambians are able to access hospitals that can
perform a caesarean delivery, laparotomy, and stabilization of open fracture. The National
Surgical, Obstetric, and Anaesthesia Strategic Plan 2017–2021 was therefore developed to fulfil
this unmet need.
In the 2011–2016 NHSP, very little was achieved in surgical service delivery, as this was not
prioritised. For the NHSP 2017–2021 Plan, focus shall be on several key priorities to ensure
equitable access of surgical, obstetric, and anaesthesia services. The Plan will focus on increasing
the surgical capacity to meet at least 80% of the surgical needs, from the current 26%.
Additionally, the Plan will target to increase the number of surgical, obstetric, and anaesthesia
providers to at least three per 100,000 populations, as compared with the current situation of 1.1
per 100,000 populations. The aim is also to increase the safety of surgery and decrease all
preventable deaths.
The NHSP 2017–2021 aims to address the many surgical, obstetric, and anaesthesia challenges,
which are caused mainly by trauma, cancer, and complications of pregnancy. The Plan will address
these challenges through a strategic framework that seeks to strengthen service provision with a
focus at the district level through skill upgrading and infrastructure expansion. Efforts will also be
expended in building high-quality surgical, obstetric, and anaesthesia systems through
strengthening health management information systems and research capabilities.
At Level 1 hospitals, the following interventions will be implemented:
 Establish and strengthen the provision of quality essential and emergency surgical services
 Strengthen the provision of quality essential and emergency obstetric and gynaecologic
services
 Establish and strengthen the provision of quality essential and emergency anaesthesia
services
 Strengthen mentorship in surgery, obstetrics, and anaesthesia
At Level 2 and Level 3 hospitals, the interventions to be implemented include:
 Establishing and strengthening the provision of quality, comprehensive, highly specialized,
and complex surgical care
 Establishing and strengthening the provision of quality, comprehensive, highly specialized,
and complex obstetric and gynaecologic care
 Establishing and strengthening the provision of quality, comprehensive, highly specialized,
and complex anaesthesia care

46
Strategic Interventions
Goal: Achieving Universal Health Coverage through safe, affordable, and timely surgery, obstetrics, and
anaesthesia by 2021
Objectives Strategies
To provide all Zambians with safe, Strengthen provision of essential and emergency care at the
equitable, and timely surgical, district level
obstetric, and anaesthesia services
Strengthen provision of comprehensive care at the
secondary level
Strengthen provision of highly specialized and complex care
at the third and fourth levels
To provide adequate, appropriate, Ensure all levels of facilities have standard and functional
and well-maintained functional equipment to provide safe and timely essential and surgical,
surgical, obstetric, and anaesthesia obstetric, and anaesthesia services
equipment in accordance with the set
Strengthen equipment maintenance services at all levels of
standards at each level
facilities by conducting preventive maintenance of equipment
for surgical, obstetric, and anaesthesia services
To provide quality, safe, and Ensure that all levels of facilities have adequate stocks of
affordable essential supplies to essential medical and surgical supplies (commodity security)
improve palliative care services at all in order to provide safe and essential surgical, obstetric,
levels of care anaesthesia and palliative care services

4.7.2 Eye Health Services

Situation Analysis
Eye health services are available mainly at provincial and tertiary centres. The existing eye health
outreach programmes are inadequate and confined to selected parts of the country. The current
state of University Teaching Hospital–Eye Hospital infrastructure is not adequate, hence there is
critical need for construction and modernization to enhance service delivery and coordination of
eye health services across the country.
MSL in Lusaka does not stock most medicines and surgical consumables required in eye units.
Although much has been done in procuring and distributing ophthalmic equipment, there are still
gaps around the equipment provision, and the newly established eye hospital needs to be
equipped. The shortage of human resources for eye health has seriously affected the efforts
towards the prevention of avoidable blindness.
Cataract accounts for 55% of the causes of avoidable blindness. Other causes include glaucoma,
refractive errors, trauma, corneal opacities, trachoma, and diabetes mellitus. The cataract surgical
rate (CSR), which is a measure of the availability of cataract services, is 732 cataract operations
per year per million populations.

Strategic Interventions
Goal: To eliminate causes of preventable or avoidable blindness by 2021
Objective Strategies
To construct a modern state- Mobilise required funds for the construction of a modern
of-the-art eye hospital at UTH state-of-the-art eye hospital at UTH
to become a national eye care
referral hospital

47
 Goal: To eliminate causes of preventable or avoidable blindness by 2021
Objective Strategies
To establish and construct eye Mobilise and increase required funds for the establishment and
hospitals in five provincial equipping of eye care hospitals in Luapula, Eastern, Muchinga,
hospitals Southern, North Western, and Northern provinces
To promote good eye health Orientation of school teachers and community leaders on how
and prevention of eye diseases to identify students and community members who have eye
by 100% ailments and to refer them to relevant health facilities
To increase the cataract Provide comprehensive static and outreach cataract surgical
surgical rate by 100% services in all 105 districts
Introduce phacoemulsification surgery to address cataract
surgery backlog at the UTH-Eye Hospital
To establish vitreous and Train specialists in management of DR and related retina
retina services at the UTH-Eye diseases
Hospital

4.7.3 Paediatric Services

Situation Analysis
The Zambian population is predominantly young, with about 53% being below 18 years of age,
50% aged 0–14 years, and 18% below the age of 5 years. The country has a fast-growing
population, estimated at 13.5 million in 2010 and projected to increase to 16 million in 2016.
Further, a very large proportion of Zambia’s population is children, including adolescents; as such,
the scope of care is wide and varied, from newborns to adolescents. This poses a challenge as the
different age groups that encompass the field of paediatrics have their own unique needs.
The overall staffing challenges in the health sector have not spared paediatrics programmes, and
there is need for scaled training that is tailored towards addressing the gap. This is especially
essential in view of the established sub-specialties at the University Teaching Hospitals–
Children’s Hospital: cardiology, haematology, endocrinology, rheumatology, infectious disease,
neurology, neonatology, clinical nutrition, emergency care, and nephrology. Funds will be made
available for staff training in these specializations in order to build capacity and formally create the
required departments.
The key planning issues for paediatric services are:
 Develop adequately equipped health facilities to facilitate improved paediatric service
delivery
 Improving the locally driven operational research for common paediatric conditions
 Dysfunctional referral systems for paediatric cases
 Ineffective information flow among the different levels of health care to allow for
informed decision making
 Inadequate human resources at all levels of service delivery
 Limited quaternary-level services for children countrywide

48
Strategic Interventions
Goal: To improve the health status of children in Zambia in order to contribute to socio-economic
development

Objectives Strategies

To develop adequately equipped Design a basic health care package for equipment appropriate
health facilities to enable health for different levels of care
care workers to make objective
decisions in paediatric and child Procure basic equipment and required skills that could be used
care in evaluation, treatment, or transfer of patients in health facilities

Implement preventive maintenance of medical and surgical

equipment

Regularly monitor and evaluate the appropriate use of the

equipment

To develop adequate locally Enhance capacity to engage with ethics committees in

driven operational research for institutional research in Level 2 and 3 facilities
paediatric conditions
Strengthen capacity building on research methodologies amongst
staff in these institutions

Identify local and international sources of funding to assist in

developing and strengthening research methodologies in these
institutions

To develop adequate and well- Procure child-friendly transportation equipment and services for
equipped transportation of timely patient movement
paediatric patients within the
health referral system through Provide life support package training during patient care
different levels of care

To develop adequate information Operationalize the e-Governance system for in-patient

generation from Level 1 to Level management and data capture
3 to capture data at all levels in
the continuum of care Actualize the medical record registers to assist in quantifying
disease burden in terms of morbidity and mortality

To operate an effective, Institute performance assessment tailored for paediatrics and

nationwide quality assurance child health
system for improving the
standard of care of children Rationalize the referral system from Level 1 to Level 3

4.7.4 Renal Health Services

Situation Analysis
The country has fully functional national renal services, which are currently being decentralized to
the provinces. There are currently five renal units countrywide, which are based at the University
Teaching Hospital, Kitwe Central Hospital, Ndola Teaching Hospital, Livingstone Central
Hospital, and Maina Soko Military Hospital.

49
The demand for renal services has been increasing over the years and poses a challenge to
service provision, which has been compounded by the high cost of providing the services.
Currently, the unit cost per treatment is estimated between K900 and K1000. Each chronic
kidney disease patient needs three treatments per week for life or until they receive a kidney
transplant.
The UTH currently has 21 machines; it treats 40 new patients per month and has 66 patients that
need permanent dialysis. Ndola Central Hospital has on average eight new patients per month
and 15 patients on permanent dialysis. Kitwe Hospital has eight to 12 new patients per month
and has 20 patients on permanent dialysis. Livingstone has four new patients per month and has
16 patients on permanent dialysis. These numbers are underestimates, as most kidney disease
patients die before they are referred to the renal units. In addition to the financial barriers,
people may also not access on account of the limited number of renal units and distance.
The burden of kidney disease is further illustrated in the HIV population, with an estimated 8%
prevalence of kidney disease among patients receiving combination ART for one year. This is a
very high number when the number of patients on combination ART in the country (748,000 at
the end of 2016) is taken into account.

Strategic Interventions
Goal: To establish renal centres and ensure availability of adequate supplies of renal consumables and
medical supplies to all renal patients in Zambia

Objectives Strategies

To expand availability of adequate renal Increase number of supplies and equipment for renal
consumables, infrastructure, services
equipment, and commodities
Create or build more infrastructure for renal services

To establish a renal transplant unit Create a renal transplant unit at UTH–Adult Hospital

To build capacity of renal staff Enhance the skills of renal staff

Develop renal protocols for the assessment and

management of renal diseases

Strengthen monitoring and evaluation Develop performance indicators for all renal services
of renal services
Develop reporting tools for renal services

4.8 Emergency and Mobile Health Services

Situation Analysis
Mobile health services are a complementary service delivery mode to people in hard-to-reach
and remote parts of Zambia, with the exception of Lusaka, Central, and Copperbelt provinces.
Mobile health services provide second-level hospital services and accord an opportunity for
mentorship of health local staff. From the inception of the programme in 2011, a total of 642,056
clients were attended to and 31,196 operations were conducted through December 2016. There
is demand for increased primary health care and strengthening of existing services such as
cervical, breast, and prostate cancer screening as well as health promotion activities.

50
Emergency health services include ambulance, critical care, accident and emergency (A&E), and
aero medical services. The current emergency health services are not very effective. In order to
build capacity among health professionals, more than 1,000 health professionals were trained in
basic life and support/trauma management. Further, 16 paramedics were trained abroad.
Construction of the first A&E Centre in Zambia was completed at Kabwe General Hospital. All
provincial hospitals have functional ICUs.
Despite these achievements, the key constraints and challenges include:
 Inadequate infrastructure and skilled personnel for emergency health services
 Constant breakdown of equipment in the mobile health units, particularly laboratory and
x-ray equipment
 Poor emergency communication system
 Inadequate resources for local air evacuations


Strategic Interventions
Goal: To provide adequate emergency and mobile health service in a timely manner
Objectives Strategies
To provide mobile health Conduct mobile outreach services
services as a complementary
Provide mentorship to local health staff
service delivery mode to people
in hard-to-reach rural and Conduct specialist outreach in all provincial hospitals and
remote parts of Zambia general hospitals
Strengthen cervical cancer screening and introduce HPV
screening
Introduce mobile clinics for PHC outreach services
To coordinate and evaluate Construct emergency centres
emergency health services in
Procure equipment for emergency health services
Zambia
Formulate the Ambulance Services Act
Incorporate a framework on emergency services into the
National Health Service Bill
Construct and operationalize the national emergency
communication centre

4.9 Diagnostic Services

Situation Analysis
Laboratory, medical imaging, and blood transfusion services are important determinants of health
service delivery. They play a critical role in supporting decision making in diagnosis and patient
management, disease prevention, disease surveillance, outbreak investigation, research, and
quality assurance. They enhance cost-effective health interventions. These services will assume an
even more important role with the scaling up of core interventions such as EmOC, TB, malaria,
and HIV services in interventions.
Zambia has a five-tier laboratory services system: starting at the health post and health centre
through level 1, 2, and 3 hospitals. In addition, there are also mobile health services provided for
distance locations. For each level, minimum standard requirements for test profiles, equipment,
reagents, and consumables have been defined. Ideally, investigations that cannot be effectively

51
carried at one level are supposed to be referred to higher levels. However, challenges with the
referral system have militated against this.
The provision of laboratory services is marred by numerous challenges: unclear management
systems at the provincial and district levels; limited human resource capacities; unclear
management systems at the district level; and lack of coordination among participants in
Laboratory services. Further, the current laboratory organizational structure is outdated and
needs to be revised.
Zambia adopted the 2008 Maputo Declaration on standardization of laboratory equipment based
on the level of care. To this end, haematology, chemistry, CD4, viral load, and early infant
diagnosis have been standardized by level of care. While there has been an increase in equipment
availability in the last five years, not all 395 laboratories are fully equipped. The laboratory
capacities have further been adversely impacted by the lack of timely preventive maintenance,
which has led to frequent breakdowns and long equipment downtimes. To date, the country has
not procured any maintenance systems for laboratory equipment. This plan therefore seeks to
provide equipment to all laboratories and put in place sustainable maintenance mechanisms.
While there has been an increase in laboratory services, here has been no corresponding
increase of space. To date, Zambia has only four laboratories that are able to provide pathology
services, due to limitations in both infrastructure and specialists required in the area. This plan
therefore seeks to address these limitations.
Quality laboratory results are critical to informed decision making and effective patient
management. The development of a laboratory quality assurance policy is long overdue and needs
to be completed. In a quest to improve quality, Zambia enrolled 17 laboratories into the WHO/
African Society for Laboratory Management quality improvement process; two were assessed and
granted a two-star rating. To achieve international accreditation, Zambia needs to develop and
implement a national laboratory quality assurance programme, with a dedicated secretariat.
The key planning issues in this sub-theme include:
 Weak supply chain management of laboratory logistics and commodities, resulting in
shortages and expiries of reagents and consumables
 Weak monitoring and evaluation of laboratory services
 Inadequate equipment and equipment breakdowns
 Critical shortage of human resources including biomedical specialist positions
 Weak systems for implementing quality management systems and regulation of laboratory
equipment and commodities
 Poor infrastructure for expanded testing and weak systems for sample referral
 Lack of a national laboratory quality assurance system
 Ineffective coordination and supervision of laboratory services at all levels

Strategic Interventions
Goal: To contribute to the improvement of the health status of the people of Zambia by providing
safe, efficient, and sustainable diagnostic services able to meet the needs of the health care system
Objectives Strategies
To improve institutional and Revise the organization structure in order to enhance
management framework for the laboratory services
provision of laboratory services in
Strengthen internal and external coordination and
Zambia
collaboration in order to harmonize service provision in the
health sector

52
Goal: To contribute to the improvement of the health status of the people of Zambia by providing
safe, efficient, and sustainable diagnostic services able to meet the needs of the health care system
Objectives Strategies
Strengthen lab management capacity in order to increase
institutional effectiveness
Develop and review relevant policy and legal framework in
order to guide the provision of laboratory services in Zambia
To strengthen the provision of Provide appropriate equipment
laboratory services appropriate
Ensure that all laboratories are well staffed and managed by
for each level of care to support
qualified laboratory personnel
the National Health Care Package
(NHCP) implementation Provide test profiles at each level of care to support the Basic
Health Care Package
Strengthen laboratories to provide referral services
Provide appropriate transportation packaging materials
Establish a courier system for specimen referrals
To establish a sustainable Conduct a needs assessment and develop a consolidated plan
laboratory supplies system as part for laboratory infrastructure and equipment to allow for the
of the essential medicines and necessary testing at each level
supplies management, that will
Develop mechanisms for procurement of standard equipment
ensure steady availability of
laboratory equipment, reagents, Build capacity for laboratory reagents and consumables
and supplies at all levels quantification, procurement, and management at all levels
Establish a Laboratory Management Information System, both
electronic and paper based
To consolidate and strengthen Develop and implement a national quality assurance
the National Laboratory Quality programme for all levels of service
Assurance system and establish
Develop external quality assurance schemes for all tests
laboratory linkages so as to
ensure an effective, sustainable Complete Chainama to house the National Laboratory
laboratory referral system Quality Assurance programme with dedicated staff
Strengthen and support laboratories to acquire international
accreditation
To promote research and Develop a research and development programme relevant to
development in laboratory laboratory sciences
sciences in order to improve the
Monitor and evaluate implementation of the National
quality of health in the
Laboratory Strategic Plan
communities
To improve laboratory Develop and implement an investment plan for laboratory
infrastructure and safety in order infrastructure
to contribute to quality service
Promote health and ensure safety standards in laboratories
provision
whilst protecting the community and environment
Support implementation of the Laboratory Diagnostics
Regulatory Authority

53
4.10 Imaging Services
Situation Analysis
Medical imaging is essential not only for initial diagnosis, but for monitoring disease response to
treatment and deciding when to stop or adjust a treatment plan. The demand for medical imaging
services has increased as a result of changes in the disease profile, with communicable diseases
such as HIV/AIDS and TB and non-communicable diseases such as cancer, diabetes, and cardiac
conditions becoming more prominent. To this effect, the MOH has prioritized strengthening of
medical imaging services.
The prioritization of imaging services has, however, not been accompanied by the requisite
expansion of human resource capacities. According to 2016 updated imaging staff information,
there were approximately 400 imaging staff unevenly distributed among more than 100 Imaging
facilities. Critical positions for radiographers, radiologists, sonographers, and medical physicists
do not exist in 80% of imaging facilities, while about 30 newly constructed hospitals will need a
minimum of four positions each. This plan will ensure that all first-level hospitals are headed by a
radiographer, second-level hospitals by a senior radiographer, and third-level hospitals by a chief
radiographer. Radiologists and medical physicist positions shall be a priority at all second and
third levels of care.
There is need to strengthen the coordination of imaging services at the provincial and district
levels. The medical imaging organizational structure from central to district level needs to be
revised, while the positions need to be established and filled, leadership and management skills
enhanced, and proper management systems established.
Medical imaging services such as film x-ray, contrast-aided imaging and ultrasound, magnetic
resonance imaging, CT, nuclear medicine, and interventional imaging are currently available at all
hospital levels. This is complemented by mobile facilities that offer x-ray and ultrasound.
Portable and battery-operated ultrasound for monitoring and management of emergencies in
pregnant mothers who develop complications in areas far from hospitals is one of the gaps that
has been identified.
There are 99 first-level, 34 second-level, and eight third-level hospitals offering Imaging services
and equipped with various imaging equipment. There are currently health facility construction and
modernization projects that require corresponding diagnostic capacities.
It is expected that all second- and third-level facilities be equipped with CT scanning services.
Currently, six out of eight third-level hospitals and two out of 34 second-level hospitals provide
CT scans.
Although the country has made efforts to strengthen imaging services, the provision of services at
the facility level has not been improved. Some 60% of the equipment is old and obsolete.
Additionally, lack of routine servicing has compounded the situation. Further, the supply chain
management system for imaging consumables is weak, leading to occasional inappropriate
procurements and frequent stock outages of specialized imaging supplies. The lack of an
electronic system for managing data has compounded the problem. This plan will endeavour to
address the problems of imaging equipment servicing, data management, and supply chain
management.
Comprehensive QA/quality control (QC) in medical imaging and radiotherapy is cardinal. QA/QC
ensures that the diagnostic and radiotherapy services offered are of high quality and safe to
clients undergoing radiological exposures. Currently, QA/QC is being implemented without a
framework that guarantees systematic implementation across the country. It is therefore critical
that the framework is put in place in order for the QA/QC to be fully implemented.
The following gaps have been identified:

54
  Inadequate imaging equipment to cover all third- and second-level hospitals
 Lack of portable ultrasound to address maternal health
 Shortages of specialized imaging supplies
 Critical shortage of radiologists, radiographers, and medical physicists
 Non-existent structure at provincial and district levels for management and coordination
of imaging services
 Lack of digital imaging equipment to full implementation of tele-radiology
 Lack of national medical imaging quality assurance system
 Training of end users in health facilities
 Maintenance of imaging equipment
In view of the above, it is critical that the modern equipment is procured and the proper
structures are put in place.

Strategic Interventions
Goal: To contribute to the improvement of the health status of the people of Zambia by providing
safe, efficient, and sustainable medical imaging diagnostic services able to meet the needs of the
health care system
Objectives Strategies
To improve institutional and Revise the organization structure in order to enhance
management frameworks for Imaging services
the provision of services in
Zambia Strengthen management capacity in order to increase
institutional effectiveness
Develop and review relevant policy and legal frameworks in
order to guide the provision of imaging services in Zambia
To strengthen the provision of Provide appropriate equipment
Imaging services appropriate for
Ensure that all departments are well staffed and managed by
each level of care to support
qualified imaging personnel
the NHCP implementation
Train and build capacity in all medical imaging categories
To significantly improve on the Conduct a needs assessment and develop a consolidated plan
availability and condition of for imaging infrastructure and equipment at each level
medical imaging and
Develop mechanisms for procurement of standard equipment
radiotherapy equipment to
ensure efficient and effective Strengthen capacity for management and maintenance of
service delivery at all levels medical imaging and radiotherapy equipment
To provide adequate imaging Build capacity for imaging supplies quantification,
and radiotherapy supplies procurement, and management at all levels
through an efficient and effective
Establish Radiology Information System
logistics management system
To consolidate and strengthen Develop and implement a national medical imaging quality
the national quality assurance assurance programme for all levels of service
scheme
Establish a national QA committee
Strengthen coordination of QA activities (clinical and
equipment) among end users, biomedical engineers, and
medical physicists
Train staff in QA

55
 Goal: To contribute to the improvement of the health status of the people of Zambia by providing
safe, efficient, and sustainable medical imaging diagnostic services able to meet the needs of the
health care system
Objectives Strategies
To improve the availability and Increase the number of skilled workforce in imaging and
distribution of qualified medical radiotherapy by category and levels of practice/care
imaging and radiotherapy staff in
Facilitate for the expansion of imaging and radiotherapy
identified categories and levels
of practice in the facilities Revise the organisation structure in order to enhance imaging
throughout country and radiotherapy services
To facilitate consultation among Establish a framework for coordination of tele-radiology and
medical imaging and tele-oncology services
radiotherapy professionals
Set up tele-radiology and tele-oncology infrastructure
through tele-radiology and tele-
oncology Train practitioners (medical imaging and radiotherapy) in the
application of tele-radiology and tele-oncology
Sensitise health facilities on tele-radiology and tele-oncology
To promote research and Establish mechanisms to coordinate research activities
development in imaging in order conducted in imaging and radiotherapy
to improve the quality of health
Build capacity in imaging and radiotherapy research
in the communities
methodologies and bioethics

4.11 Blood Transfusion Services

Situation Analysis
The National Blood Transfusion Service is fully operational with efficient central coordination, but
sufficiently decentralized to render services to all regions of the country. Each regional blood
transfusion centre has the capability and capacity to test all donated blood for transfusion
transmissible infections including HIV, hepatitis B, hepatitis C and syphilis.
There is no upward trend in the number of blood units collected per annum from 2011 to 2015.
On average, there about 107,000 blood units collected per annum, with a crude discard rate of
around 10% (3.0% attributable to HIV, 5.4% to HBV, 0.9% to HCV, and 0.6% to syphilis). In 2015,
some 100,110 units were collected against the national requirement of 150,000 units; the unmet
need for blood and blood products is well over 30%.
A key strategy to reduce the discard rate is to expand the pool of repeat donors, where the
discard rate is significantly lower compared with first-time donors. The proportion of repeat
donors has declined from 56% in 2012 to 47% in 2015. Strengthening donor retention can
reverse this negative trend and lead to a significant reduction of the discard rate.
Failure to meet the national targets is attributable to many factors. Firstly, the operational budget
for donor refreshments, fuel, and allowances has not been adequate to support scaling up donor
recruitments and retention. In addition, the Blood Transfusion Service does not have adequate
transport and human resources required for optimal operations; every regional blood transfusion
centre needs a minimum of three operational vehicles, but most provinces have just one vehicle.
There is also need to strengthen the donor sensitisation programme, as well as social
mobilisation and marketing. Strengthening the counselling programme has potential to increase
the number of HIV-negative donors coming back to donate, while at the same time facilitating the
referral of HIV-positive donors for continued care and treatment.

56
As the country adopts newer medical procedures such as open heart surgery, cancer treatments
and tissue transplants, demand for blood, blood products and plasma-derived medicinal products
is likely to grow. Currently, demand for fresh frozen plasma (FFP) at UTH stands at 30% of the
total requests; currently, only 5% of the demand is met. If the country introduces more modern
technologies, such as individual donation nucleic acid amplification testing (ID-NAT), then
procedures such as apheresis, the harvest of blood components and production of plasma
products will significantly improve. Currently, only five regional centres have the capacity (in
terms of equipment) to do blood component production.
The key planning issues for blood transfusion services are:
 Donor sensitisation, social mobilisation, and marketing
 Donor retention, which can help in reducing the discard rate
 Lack of apheresis procedures
 Lack of ID-NAT testing procedures
 Inadequate transport and inadequate equipment for transportation of blood
 Inadequate equipment for storage of blood and blood products
 Inadequate number of lab technologists
 Donor counselling and referral system
 Lack of cost recovery or reimbursement system
During the life of this plan, the Zambia National Blood Transfusion Service (ZNBTS) shall operate
as a nationally coordinated institution with sufficient capacity to meet the blood transfusion needs
of the country. The National Blood Transfusion Policy shall be enacted within the framework of
the Health Sector Policy and supported by appropriate legislation. With the national
requirements expected to rise to 180,000 units per annum by 2015, there will be need to ensure
availability of the critical inputs, including human resources, equipment, and supplies.

Strategic Interventions
Goal: To ensure availability of adequate supplies of safe blood and blood products to all patients in
Zambia

Objectives Strategies

To increase the annual blood Create donor retention schemes to expand the pool of repeat
collection to meet the national donors
blood and blood products
requirements Increase social mobilisation and marketing activities

Strengthen capacity for blood collection through expansion of

staffing and procurement of blood collection vehicles

Increase outreach counselling programmes to reach all donors

in the communities

Expand capacity for blood products production in all provinces

To develop the National Apheresis, Set up the National Apheresis, Tissue Transplantation, and
Tissue Transplantation, and Human Human Genetics Centre at the Lusaka Provincial Blood Centre
Genetics Centre
Build management and technical skills related to the Tissue
Transplantation and Human Genetics Centre

57
Goal: To ensure availability of adequate supplies of safe blood and blood products to all patients in
Zambia

Objectives Strategies

To develop and implement ICT Roll out the Blood Safety Information System (BSIS)
solutions to improve the
management of the blood Roll out the ICT stock management system
transfusion processes
Develop reliable and secure ICT systems to enhance data
security

To improve the clinical interphase Create and operationalise hospital transfusion committees
in the blood transfusion chain
Review guidelines on rational use of blood and blood
components

To operate an effective, nationwide Review and re-align the current ZNBTS quality systems with
quality assurance programme that reference to Africa Society For Blood Transfusion (AfSBT)
ensures security of the entire blood standards
transfusion process
Prepare ZNBTS and apply for step-wise AfSBT accreditation

To strengthen monitoring and Develop performance indicators for ZNBTS provincial centres
evaluation function of ZNBTS
Develop reporting tools for transfusion outlets

Formalise registration of transfusion outlets

To provide adequate blood Ensure uninterrupted supply of critical reagents and

transfusion infrastructure, consumables
equipment, and commodities
Ensure buildings at the provincial blood transfusion centres are
GMP compliant

To strengthen the institutional and Complete the ZNBTS restructuring process

regulatory capacity of ZNBTS
Finalise the blood transfusion bill

4.12 Ear, Nose, and Throat (ENT) Services

Situation Analysis
The burden of ENT diseases continues to be high. Every third patient seeking medical treatment
at any health facility presents with an ENT health-related condition. The prevalence of disabling
hearing impairment is estimated at 4-6%. Half of this could be prevented if dealt with sufficiently
at the primary health care level. Although many of the patients are attended to at first-level
facilities, most of them cannot access higher-level services and/or are not managed appropriately.
This is due to the limited number of trained ENT personnel at all levels. This is further
complicated by the challenges in the referral system. Due to limited ENT health services, there is
late diagnosis and treatment of ENT conditions such as chronic suppurative otitis media and
head and neck neoplasms, which have increased morbidity and mortality among ENT patients.
Furthermore, the inadequacy of ENT health service awareness in the community limits services
accessibility. As a result, people in the communities are unable to receive treatment and
rehabilitation for ENT diseases. People with hearing impairment face stigma and considerable
challenges in finding ways to sustain themselves and their families, limiting their potential to
contribute to the development of the nation.

58
Strategic Interventions
Goal: To provide comprehensive ENT services in an equitable manner
Objective Strategies
To increase infrastructure and Identify first-, second-, third-, and fourth-level hospitals in the
equipment for ENT services at country where ENT units will be developed
first-, second-, third-, and
Equip these identified centres with ENT diagnostic sets and
fourth-level hospitals
ENT equipment
Ensure the establishment of a sustainable procurement
system (maintenance costs, consumables)
To train ENT health personnel Source scholarships for ENT MMed, audiology, and speech
and strengthen existing health therapist postgraduate training
personnel to provide excellent
Establish an advanced ENT diploma training programme for
ENT care at all levels
clinical officers
Conduct refresher courses for different cadres working in
the field of ENT
Establish ENT and audiology MMed programme
To sensitise the public on ENT Promote ENT health by running promotional campaigns in
conditions communities
Participate in international events such as the International
Ear and Hearing Care Day
To strengthen the ENT Establish baseline statistics of ENT diseases in Zambia
information system in Zambia
Participate in ENT-related tele-health and e-learning
programmes
To create an ENT society Engage stakeholders and seek guidance from relevant
regulatory bodies

4.13 Nursing and Midwifery Services

Situation Analysis
Nurses and midwives are the largest workforce in the health sector in Zambia. They provide a
24-hour critical continuum of care, which includes health promotion, prevention, curative,
rehabilitative, and palliative services, in line with what is contained in the Nurses and Midwives
Act No. 31 of 1997. The developments in nursing and midwifery are changing rapidly, with
increasing client or patient expectations and service needs. Over time, nursing and midwifery
services have been hampered by a number of challenges. These include rapid population growth,
increased disease burden from communicable diseases and NCDs, and shortage of nurses,
midwives, and lecturers, leading to increased workload in both the clinical and training areas. This
is exacerbated by inadequate equipment and supplies needed to provide quality care. In order to
tackle this ever-increasing demand and dynamism of nursing and midwifery, there is need for
pragmatic shift towards innovation, productivity, and improved efficiency.
The strategic interventions for nursing and midwifery services in the next five years will focus in
the following areas: nursing and specialized services; midwifery; nursing and midwifery education;
strong and effective partnership; nursing research and development; nursing and midwifery
workforce; policy and legal framework; and finance and logistics management.

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Strategic Interventions
Goal: To improve the quality of nursing and midwifery education and practice standards at all levels
of care
Objectives Strategies
To provide safe, acceptable, Strengthen respectful nursing care to all clients
equitable, and timely nursing
Enhance professionalism in nursing services
services to clients at all levels of
care in order to improve health Improve documentation of nursing care
outcomes
Improve adherence to nursing procedures
Strengthen and expand availability of medical, surgical, and
other specialised nursing services at all levels of health
service delivery
Strengthen provision of public health nursing services
Review nursing protocols every two years to contribute to
improvement of nursing services
Strengthen clinical nursing and audits
Encourage nurses to participate in inter-professional and
nursing clinical rounds to improve their knowledge
Strengthen mentorship for qualified nurses
To provide integrated quality Strengthen respectful midwifery care to all clients
reproductive, maternal, neonatal,
Enhance professionalism in midwifery services
child, and adolescent services in
order to contribute to the Improve documentation of midwifery care
reduction in maternal, neonatal,
and child morbidity and mortality Strengthen provision of quality maternal, neonatal, child,
and adolescent health services at all levels of health care
Strengthen provision of quality reproductive and maternal
health services
Strengthen provision of essential and emergency obstetrics
and gynaecology services
Strengthen e-MTCT services to all women of reproductive
age in order to eliminate MTCT
Strengthen neonatal and child health nursing services at all
levels of care
Strengthen adolescent health services at all levels of care
To produce an educated, Develop and review existing curricula in order to respond
competent, and motivated nursing to current and emerging health needs
and midwifery workforce able to
Strengthen the programme for the provision of learning and
meet the health needs of the public
training materials and library services
Strengthen students’ clinical experience
Strengthen management of computer laboratory services in
the training institutions
Strengthen the functionality of skills laboratories
Develop new a National Training Operational Plan in order
to give clear direction to the development of nursing and
midwifery education in Zambia by 2021

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 Goal: To improve the quality of nursing and midwifery education and practice standards at all levels
of care
Objectives Strategies
To strengthen partnerships and Strengthen stakeholder engagement at all levels of care
collaboration with stakeholders in
Enhancing mobilisation of technical and financial support for
the health sector in order to foster
nursing and midwifery services
linkages and synergies in the
delivery of nursing and midwifery Advocate for resources for nursing and midwifery services
services
Implement a strategy that ensures smooth coordination of
partners and ensures continued support to nursing and
midwifery services
To promote research in nursing Build capacity for nurses and midwives in research and
and midwifery in order to generate proposal writing
evidence for informed education,
Establish database for nursing and midwifery research
practice, policy, and decision
making
To effectively manage and develop Review the organograms and establishment in public, faith-
the nursing and midwifery based, and private sectors for nurses and midwives to
workforce in order to enhance increase the numbers and provide streamlined career
individual and organizational progression and specialisation
performance
Strengthen human resource policies and systems for nursing
and midwifery
Strengthen preceptorship and mentorship for students,
nurses, and midwives
Strengthen intra- and inter-professional collaboration
among public and private health facilities and training
institutions
Advocate to training institutions to offer courses in
leadership and management for nurses and midwives
To formulate and review policies Hold two validation meetings on the Nurses and Midwives
and legislation in order to provide Repeal Bill
appropriate policy and legal
Hold provincial dissemination meetings on the Nurses and
framework for the delivery of
Midwives Act
quality nursing and midwifery
services Hold a five-day workshop to draft regulations to
operationalise the Nurses and Midwives Act
To effectively manage financial, Advocate for dedicated and improved funding for nursing
administrative, and logistical and midwifery services at all levels
support services for nurses and
Equip nurses and midwives with skills in financial
midwives in order to improve
management
operations and promote
accountability in utilization of Advocate for the provision of adequate and appropriate
public resources infrastructure and equipment
Strengthen corporate governance and management systems
for nurses and midwives

4.14 Pharmaceuticals and Medical Supplies

Situation Analysis
The Medicines and Allied Substances Act (3) 2013, the National Medicines Policy, and the Public
Health Act Zambia provide the policy and regulatory framework for the pharmaceutical sub-

61
sector; traditional and herbal medicines are not effectively covered. The framework allows
coordinated selection, forecasting and quantification, procurement, storage and distribution,
rational use, quality control, and regulation of medicines and medical supplies.
The current challenges include irregular post-marketing surveillance on all medicines and weak
enforcement of standards of practice, which leads to irrational use of medicines in both private
and public facilities. In addition, there is inadequacy of specialized equipment and capacities at the
National Drug Quality Control Laboratory (NDQCL). The NDQCL is not yet WHO
prequalified; the Zambia Medicines Regulatory Authority (ZAMRA) is working on getting it
prequalified.
The human resource challenges also impact the sub-sector; there are inadequate pharmaceutical
personnel at service delivery points, resulting in pharmaceutical, Logistics Management
Information System (LMIS), and supply chain functions being performed by nursing or clinical staff.
This necessitates the development of a human resource workforce plan for supply chain
specialists, clinical pharmacists, and pharmaceutical public pharmacists.
Over the past five years, Government and CPs have increased the drug budget support by more
than 100%, leading to about 78% availability of essential medicines and medical supplies in the
public sector (MTR 2014 Main Report). Zambia has identified essential medicines that have been
designated as tracer drugs and are used as the basis for determining the availability of medicines
in health facilities. To ensure national commodity security of essential medicines, the national
supply chain coordination committee should be strengthened; collaboration structures in
procurement planning, selection, and quantification should be enhanced.
The MOH has continued to review and update the essential medicines list that guides product
selection and availability. In order to improve the effectiveness of procurement services, the
Government has initiated the transfer of the procurement functions from the MOH to MSL.
Zambia has inadequate local pharmaceuticals manufacturing capacities, leading to overreliance on
imports, which often have lengthy delivery times. Zambia’s continued membership in World
Trade Organisation Trade-Related Intellectual Property Rights (WTO TRIPS), which protects
inventions (including medicines), contributed toward improved local production of drugs.
The Government of Zambia is implementing the National Supply Chain strategy in order to
strengthen forecasting and quantification, procurement, coordination, and distribution of
medicines and medical supplies. The level of procurement coordination mechanisms and
procedures between the national authorities and CPs still requires strengthening in order to
optimize the implementation of the supply chain management and procurement plans.
The management of the supply chains for vaccines and for nutrition products are parallel systems
to the central-level supply plan under the Child Health and Nutrition units, respectively. There is
need to integrate the Child Health and Nutrition supply chain systems into a national logistics
management system.
MSL’s mandates on supply chain include distribution of health commodities to all hospitals and
health centres down to the last mile; procurement of essential medicines and medical supplies,
and the coordination of commodity quantification activities. With increased volumes of orders,
distribution of drugs and medical supplies is being implemented through establishment of regional
hub strategy in the provinces. So far, four regional hubs have been established in four provinces.
MSL challenges include an inadequate fleet of vehicles to service all routes and inadequate storage
space (only 7,200 m2 instead of the ideal 22,000 m2). The inadequate storage space is a threat to
a well-functioning supply chain at both MSL and health facilities. In order to increase the storage
space at the central and provincial levels, MSL has developed an infrastructure improvement
master plan. Further, there is need to invest in storage capacity at the district level through the
concept of storage in a box (SIB).

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The ICT infrastructure supporting the collection of data for health supplies needs to be
strengthened further to ensure effective and efficient collection and sharing of information. While
noting the achievements made in the medicines and medical supplies sub-sector, further
interventions are required in order to achieve timely availability of safe and efficacious medicines
and supplies at all the points.
The key planning issues for the pharmaceutical and medical supplies sub-sector are:
 Weak coordination mechanisms and accountability in supply chain management
 Inadequate quality management system for data in the supply chain
 Insufficient integration of the logistics information system (e.g., ART, VMMC, nutrition,
vaccines)
 Limited scale of implementation of electronic LMIS
 Limited specialized human resource capacity in supply chain management and regulation
 Limited storage and distribution capacity at central, provincial, district, and health facility
levels
 Limited supervision and mentorship of staff in the supply chain
 Ineffective Medicines and Therapeutic Committees (MTCs) at all levels
 Insufficient capacity of local pharmaceutical manufacturing industry

Strategic Interventions
Goal: To ensure availability of safe, adequate, quality, efficacious, and affordable essential medicines
and medical supplies at all levels of service delivery, through efficient and effective procurement and
logistics management systems
Objectives Strategies
To provide a policy and legal Strengthen mechanisms for enforcing regulations to ensure
regulatory framework to facilitate compliance to the set standards for manufacture,
efficient and effective provision of exportation and importation, distribution, sale, and use of
oversight on all medicines to ensure medicines and allied substances
their conformity to set standards
Establish and strengthen technical capacity of NDQCL and
coordinate the key quality assurance activities among
partners.
To ensure constant availability and Mobilise resources with the MOF and from health partners
accessibility of essential medicines for increased budgetary allocation to the drug supply
and medical and nutrition supplies budget line and timely disbursement of funds
required for the provision of priority
Develop coordinated procurement planning based on
core interventions at each level of
accurate information from nationally agreed upon
the health system through a
methodologies of forecasting and quantification
comprehensive, integrated, and
harmonized procurement, financing,
and logistics systems
To strengthen national LMIS Improve storage capacity for service delivery points and
(including storage and distribution) MSL central warehouse within the period of the NHSP
to improve efficiency, data accuracy,
Scale up implementation of electronic LMIS to all service
and visibility
delivery points
Review the health centre kit (biannually) to reflect the
current needs for reproductive, maternal, child health, and
nutrition units
Support private sector and non-governmental organizations
(NGOs) service delivery initiatives through effective supply

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Goal: To ensure availability of safe, adequate, quality, efficacious, and affordable essential medicines
and medical supplies at all levels of service delivery, through efficient and effective procurement and
logistics management systems
Objectives Strategies
chain systems
Institute use of analytics to harness pipeline, warehouse
management system, and service delivery point LMIS to
monitor and predict key supply chain events and risks
Foster use of business intelligence systems to improve
supply chain data use for strategic decision making
Establish fully functional regional medical stores in the
Copperbelt to cover for the northern half of the country
and the construction of provincial hubs in Chipata, Choma,
Mongu, Mansa, and Mpika and of mini-hubs in Livingstone
and Kabompo
Third-party delivery of essential medicines to achieve last
mile distribution and increase private sector participation
Review of the National Essential Medicines List to respond
to priorities of modernization and NHCP
To improve pharmaceutical care at Strengthen pharmacovigilance activities and promote
all levels of care and promote use of rational medicine use
safe, quality, and efficacious
Strengthen Medicines and Therapeutic Committees (MTCs)
medicines using approved standard
in all districts and hospitals
treatment guidelines as well as
standards of pharmacy practice
To establish monitoring and Develop and implement M&E tools for supply chain
evaluation management
To ensure the availability of well- Restructure and scale up the deployment of supply chain
trained and adequate pharmaceutical specialists personnel and clinical and public health
personnel pharmacists, aligning them with the needs assessment plans
for public health, the essential health care package, and
supply chain strategy at all levels

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5. Integrated Health Service Support
Systems

5.1 Leadership and Governance

Health systems leadership and governance deals with the interrelationships, roles, and activities
of the various agencies in the production, distribution, and consumption of health services. The
organizational structures governing these processes are also considered in dealing with leadership
and governance issues. IHP+ provides a framework for analysing governance of the health sector
by focusing on: strategic vision; participation and consensus orientation; rule of law; transparency;
responsiveness of institutions; equity, effectiveness, and efficiency; accountability; intelligence and
information; and ethics.

The National Health Policy

The National Health Policy sets out the guidelines for directing the implementation of national
health strategies. The Health Policy is anchored in the devolution of functions to the lower,
District level. The overall National Decentralization Policy provides the framework with which
the sector policy operates; it specifies devolution of functions and authorities with matching
resources to local authority levels. Under the devolved governance system, the central level is
expected to provide policy, strategic guidelines, overall coordination, and M&E. The local
devolved units are in turn expected to concentrate on programme implementation.
The health policy, which was revised in 2012, provides overall guidance to the sector. The policy
emphasizes the importance of decentralization, which is expected to ensure effective
participation of communities and hence assure relevance of interventions. The district forms the
basic point of reference for the articulation of peoples' power in health care. Through district
health management teams, popular representation and technical/professional interests will
provide an opportunity to give Zambia a health care system that is responsive to local and
national interests and needs. While recognizing the importance of bottom-up planning in the
sector, the policy also recognizes the importance of provincial and central level actors in
providing technical guidance to the district and other local levels of service delivery.
Further, service delivery has been defined to follow a PHC approach. The definition of PHC in
Zambia is action-oriented, focused on promotive, preventive, curative, rehabilitative, and
palliative care efforts within and outside the health sector. In a Zambian context, PHC would not
merely mean ‘accessibility to health services’ but also peoples' participation in improving their
quality of life and gaining power to master their affairs for health improvements. The PHC
approach is, therefore, expected to address the main health problems in the community. In doing
so, particular attention will be given to people in rural and peri-urban areas, the underserved,
high-risk, and vulnerable groups, such as women, children, and the youth.

Participation and Consensus Orientation

The health sector has diverse partners who provide financial, material, and technical support. The
coordination challenges arising from such partnerships necessitate coordination mechanisms.
From the inception of health reforms, the MOH adopted the SWAp through which CPs were
expected to provide support to the sector. The CPs were expected to align their interventions
with the MOH priorities as specified in the NHSP and in line with international obligations such
as the IHP+ Principles and Paris and Busan Declarations.

65
The overall framework for coordination in the sector is in line with the broader framework as
detailed in the Joint Assistance Strategy for Zambia and in harmony with the overall national
planning framework.
The coordination arrangements in Zambia were generally deemed to have been successful and
were used as a model for other countries. Despite most of the CPs buying into the SWAp
model, a few still remain outside these arrangements, among them the Global Health Initiatives
and the President’s Emergency Plan for AIDS Relief, which preferred parallel structures and
financing mechanisms. In an effort to address this and to further pursue the agenda on
harmonization and alignment from the Paris Declaration, an addendum to the memorandum of
understanding (MOU) was drafted in collaboration between partners and within the framework
of IHP+.
All the efforts to consolidate the coordination of the CPs have been done through signing of an
MOU with partners, which provides a modus operandi between MOH and health partners. In
2009, an attempt was made to sign an IHP+ compact as an addendum to the existing MOU as
way of strengthening the SWAp coordination mechanism. Moving forward, it is important that
trust between the Government and CPs is sustained and that the structures are further
developed to be truly sector wide, including more partners in both planning and implementation
of programmes. It would be advisable to improve accountability by broadening the membership
of GRZ/CP consultative meetings by inviting other players, such as the civil society and private
sector actors. Other opportunities that could be exploited to improve accountability include:
a) The IHP+ process could provide active support and expertise for partners to resolve
issues and review mechanisms for the Zambia health SWAp
b) The initiation by the U.S. Government of greater harmonization involving the
development of a five-year horizon for a cooperation framework on HIV and AIDS. It is expected
that the framework would be fully supportive and aligned with the National Strategic
Frameworks and would use existing coordination mechanisms such as the Global Fund to Fight
AIDS, Tuberculosis, and Malaria (GFATM) or IHP+ structures.
c) The imminent strategy of using the national planning frameworks for disbursement of the
GFATM.

Regulatory Functions
The sector is currently operating without a legislative framework, and it is expected that a bill to
replace the 2005 Health Services Act will be presented during the 2017 Parliamentary session. In
addition, there are other on-going legislative activities, such as the Mental Health Bill, Public
Health Act, Tropical Diseases Research Act, Flying Doctor Services’ Act, Food Safety and Quality
Bill, Human Tissue Act, Traditional Health Practitioners’ Bill, Zambia Medical Association Bill,
Tobacco Control Bill, and SHI Bill. The passing of these bills will improve the legislative
environment in the sector.
The MOH has delegated regulatory functions to public statutory bodies, such as the Health
Professional Council of Zambia (HPCZ), General Nursing Council (GNC), National Radiation
Protection Authority, and NFNC. Other statutory bodies include: ZNBTS, Zambia Flying
Doctors Services (ZFDS), National AIDS Council (NAC), MSL, and the Tropical Disease
Research Centre (TDRC).
The HPCZ is a statutory regulatory body established under the Health Professions Act No. 24 of
2009 of the Laws of Zambia. HPCZ is mandated to register and regulate all health facilities in
Zambia, both public and private, and training institutions teaching health sciences. The GNC is a
statutory body established in 1970 under the Nurses and Midwives Act No. 55 of 1970, which
was repealed and replaced by the Nurses and Midwives Act No. 31 of 1997. The GNC is
responsible for ensuring that members of the public receive the best possible care. The GNC
sets, monitors, and evaluates performance standards for nursing and midwifery education, clinical

66
practice, management, and research. The NFNC is a statutory body that was established in 1967
by an act of Parliament, Chapter 308, No. 41. The NFNC serves under the MOH as an advisory
body to the Government on matters concerning food and nutrition. It is mandated to promote
and oversee nutrition activities in the country, primarily focusing on vulnerable groups such as
children and women. The Zambia Medicines Regulatory Authority, formerly the Pharmaceutical
Regulatory Authority, is the statutory national medicines regulatory body for Zambia established
under an act of Parliament, the Medicines and Allied Substances Act No. 3 of 2013 of the Laws of
Zambia. The act empowers the authority to regulate and control the manufacture, importation,
storage distribution, supply, sale, and use of medicines and allied substances.

Transparency
At the national level, plans and budgets are prepared and discussed in consultative processes.
Budget and planning follow a bottom-up approach. Lower levels make proposals, which are taken
to the provincial and national levels for consolidation and presentation to the Treasury for
allocation. The annual budgets fall within the MTEF.
The Auditor General’s office performs audits of expenditures of all MOH agencies once every
year and submits such reports to Parliament.
In addition, the MOH has in place an Internal Audit unit, which is aimed at enhancing
accountability at all levels of service delivery in the MOH. The roles of Internal Audit, as
established under section 11 of the Public Finance Act of 2004, are:
I. To ascertain that the risk management and internal control systems are in place and
continually being improved and optimized in response to an ever changing environment
II. To provide reasonable assurance to the Controlling Officer, Sub-Warrant Holders, and
the Secretary to the Treasury that internal controls exist and are being complied with as required
by the law and other regulations
III. To ascertain, evaluate, and improve on the governance processes put in place by
management

Accountability
At the local level, the recently completed JAR indicates that village health committees are
operational and do play a significant role in supporting the local health services, also from a
governance perspective. District Health Advisory Committees were not functioning in a number
of districts. More information is required on how to make them functional and how they can
support management at district level. It is hoped that the decentralization implementation plan
will also include this important aspect of health management. Other governance structures
available at the district level include procurement committees, financial committees, and audit
committees.
At the national level, the Mutual Accountability Framework guided the relationship between the
Ministry and its CPs. The Governance Capacity Strengthening plan has been established to
enhance accountability systems, namely: procurement, audit, financial management, planning, and
budgeting systems. Under this framework, the MOH has put in place a set of indicators for
monitoring the capacity strengthening of accountability systems.

Responsiveness of Institutions
The health services are delivered through Government institutions, NGOs, and the private
sector. Services provided by the public sector are free or provided at a nominal charge in urban
areas. Apart from provision of some drugs and other commodities free of charge, private health
providers are not subsidized. The NGO health providers are dominated by churches, which are
concentrated in rural areas, where access to services is difficult for the residents.

67
At the local level, village health and health facility committees provide an opportunity to capture
views and sentiments from the community. However, any mechanisms to capture perceived or
actual demand of services are not institutionalized. There are no effective tools for management
to capture the views and experiences of communities. There is obvious need for improvement in
this regard. A system for capturing this information and using it for management purposes is
required.
There have been improvements in the supply of drugs and medical supplies to health facilities.
The Government and CPs have increased the drug budget support by more than 100%, leading to
about 78% (MTR 2014 main report) availability of essential medicines and medical supplies in the
public sector. Zambia has identified essential medicines, which have been designated as tracer
drugs and are used as the basis for determining the availability of medicines in health facilities.
Further improvements in the availability of essential medicines will require strengthening of the
national supply chain management and improved coordination.
The pharmaceutical sub-sector has further been affected by human resource challenges. There
are inadequate pharmaceutical personnel at service delivery points, resulting in pharmaceutical,
LMIS, and supply chain functions being performed by nursing or clinical staff. This necessitates the
development of an HRH workforce plan for supply chain specialists, clinical pharmacists, and
public pharmacists.

Equity
The country has made some commendable achievements in terms of service delivery for all
population groups. However, some avoidable gender and socio-economic disparities have
persisted. For instance, attended deliveries are more than three times as usual among the highest
level of income quintile and among women in urban areas compared with poor women in rural
settings. Contraceptive use is generally at a low level in Zambia, and the differences between
poor and rich and urban and rural are similar to those for attended deliveries. In terms of
malaria, IRS benefits the richer households significantly more than poor households. Further, in
terms of HIV testing, people in the richest quintile are two-thirds more likely to be tested than
people in the poorest quintile. From a gender perspective, disease prevalence is higher among
men, while treatment use is higher among women.
The question of targeting is important for equity-focused interventions. A significant weakness is
the poor or insignificant targeting of poor or underprivileged households. Apart from possible
targeting of these groups in the performance targets within the health sector, there are some
promising initiatives ongoing, such as: (i) the participatory reflection and action methods tested in
four districts, and (ii) the Social Cash Transfer Scheme and Public Welfare Assistance Scheme.
Particularly the latter more technical approach might be interesting to study in relation to
financing of health care.
In trying to address these and other disparities in service delivery, the government has
implemented mechanisms aiming at distributing health resources more equitably:
 The resources allocation criteria for district health grants. The criteria are based
on a material deprivation index. The per capita allocation is varied based on a score
derived from a set of deprivation indicators; districts are ranked from the poorest to the
richest, with the poorer districts having a higher weight and attracting more resources.
The district grant formula only applies to less than 50% of the health ministry budget.
There is need to revise the formula.

68
  The retention scheme for health workers. Health workers are given incentives to
settle and work in underserved areas. The value of the package varies depending on the
deprivation index in the district where staff are posted. Although this has helped bridge
the gap in staffing levels between rural and urban areas, it has not completely addressed
the staffing deficits of the worst-off districts.
 CHWs. As with other low-income countries, Zambia has implemented different kinds of
CHW schemes. However, the absence of a corresponding policy in this area has limited
the effectiveness of this intervention.
It is clear that Zambia does not have a comprehensive and balanced approach toward equity. The
above only presents a number of approaches currently implemented. Other strategies should be
considered in order to enhance and entrench equity in health service delivery.

Effectiveness and Efficiency

The health sector has been implementing wide-ranging policies and strategies aimed at enhancing
effectiveness and efficiency. The health reforms of 1992 saw the separation of service provision
and supervision functions between the Central Board of Health (CBOH) and MOH. Service
provision became the mandate of boards under the CBOH while resource mobilization, policy
guidance, regulation, and monitoring remained the mandate of MOH.
In 2004, however, a decision was made to dissolve the CBOH and integrate it into the MOH.
This was followed with the repeal of the 2005 Health Service Act under which the CBOH had
been established. This is yet to be replaced by a new policy, which is scheduled to be passed
during the lifespan of the current NHSP.
In continuing efforts at restructuring the health sector, in 2012 all level one services from the
district hospital up to the health post were moved to the Ministry of Community Development,
Mother, and Child Health. This decision was reversed in 2015 with the department of Mother
and Child Health moving back to MOH. Many officers have been newly recruited into positions at
different levels of the systems, which means that a huge exercise is required to build management
teams at all levels, and to disseminate the vision, purpose and strategic direction to officers in the
health sector.

Intelligence and Information

Information is gathered through the information systems, but also through the following
processes:
 Performance Assessments. According to structured questionnaires, performance
assessments are made in all health facilities twice a year. The assessments, which follow a
Total Quality Management approach, are then followed up by support supervision visits
at the sites to address the weaknesses found in the performance assessments. The
programme has been operating for some time and is well established.
 JAR. The reviews aim at assessing the progress from the previous year in implementing
the strategic plan through the operational plans. The JAR is an exercise limited to the
national level with national level stakeholders. Although field visits are conducted to the
national level, these visits are more to inform the national team than to involve local level
stakeholders in the review process.
 The midterm review and final evaluation of the implementation of the
strategic and operational plans. According to the MOU for the health SWAp,
progress in implementing the national strategic plan is to be assessed through a midterm
review and a final evaluation. The review and plan evaluation are intended to feed into
both plan implementation and the design of the new plan. In practice, however, the
sector has regularly done midterm reviews but no final evaluation has ever been done.

69
  The annual planning process. The annual planning process encompasses all levels and
requires districts and institutions to develop a three-year rolling plan with a substantial
situation analysis every year. The plans from the districts form the basis for the sector
submission into the midterm economic framework. The planning framework is thus well
established. However, the process could be simplified as the process is very time-
consuming and the planning documents developed extremely bulky.

Strategic Interventions
Goal: To develop an accountable, transparent, and equitable health sector that will
respond to the needs of the Zambian people by the year 2021.
Objective Key Strategies
To strengthen partner Develop a formal agreement that binds partners to IHP+
coordination in the health sector principles
Uphold and strengthen the SWAp structure mechanisms
Enhance transparency and allocation of funding modalities
Develop an engagement plan with private sector through their
associations
Develop a coordination plan for engagement with civil society
To implement an efficient and Build capacity of local authorities in planning and budgeting for
effective decentralized system by PHC services and infrastructure
devolution of governance by 2021
Operationalize the devolution plan for all PHC services at
in all districts
district level to the local authorities
Develop and implement decentralization communication
strategy for local authorities
Develop capacity in leadership and governance in the councils
to implement PHC services
Strengthen HMIS for decision-making at district level
To strengthen and implement Review, update, and implement sector collaboration
transparent and accountable mechanisms, including governance community participatory
governance systems at all levels of structures in the health sector
health service delivery in the
Review, update, and implement leadership, management, and
public health sector by 2021
governance structures
Develop and implement community governance and
accountability structures
Strengthen transparency, accountability, and access to
information at all levels, especially the community level
Train non-financial managers at the provincial and district level
in financial management

Develop and implement harmonized guidelines for the use of

locally generated funds from training schools and all health
facilities, i.e., school fees and user fees respectively
Roll out a computer-based, integrated financial management
system (IFMIS) and automated accounting systems to the
provinces, districts, hospitals, and health facilities

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 Goal: To develop an accountable, transparent, and equitable health sector that will
respond to the needs of the Zambian people by the year 2021.
Objective Key Strategies
To strengthen the health Formulate and enact appropriate health-related bills into law,
legislative and regulatory e.g., National Health Services Act, Social Protection Bill, Public
framework to improve service Health Bill, Tobacco Bill, Food Safety Bill, Mental Health Bill
delivery
Revise and update the overall legal and policy framework for
health
Ensure that statutory instruments are in place to implement
the approved laws
To strengthen the enforcement of Develop and implement a communication strategy for
regulation in the provision of regulation of health services
health service delivery at all levels
Disseminate all policy documents and laws to all levels of
of health care for both the public
health care system
and the private sector
Review and update practicing licensing procedure (for
practitioners)

Alignment of health care services in the private sector to the

NHSP
Establish a patient charter on the rights and responsibilities of
the patient and health providers

To promote private investments Update specific areas of private sector investment and possible
in the health sector partners
Collaborate with other line ministries, e.g., commerce, foreign
affairs, and tourism, to develop a prospectus for potential
investors

5.2 HRH
Situation Analysis
HRH are an essential input into the delivery of health services. An appropriately trained, skilled,
and well-motivated workforce is cardinal for the efficient delivery of health services. The MOH
will, therefore, continue to prioritize HRH and ensure that there is an adequate number of well-
trained workers equitably distributed in health facilities across the country.
A review of the human resource performance showed that significant achievements were made
during the period 2011-2016, although human resource deficits remained high as indicated in
Table 5.1. The GRZ has demonstrated strong commitment to addressing the country’s HRH
crisis through development and implementation of the 2013-2016 National Training Operational
Plan (NTOP) and the National Human Resources for Health Strategic Plan 2011 – 2015.
In scaling-up the production of health workers, new training institutions (public and private) were
opened. This subsequently contributed to the increase in the number of health workers, although
the numbers are still too low to meet the required demand. In efforts to augment the number of
health workers, new training programmes have been introduced for community health assistants,
combined registered nurse midwifery, bachelor of dental surgery, direct entry midwifery, clinical
instructor, HIV nurse practitioner, critical care, paediatrics, and master of medicine, bachelor of
clinical sciences, and e-learning training of nurses.

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 The Government has expanded the staff establishment by approving new structures and
providing for net recruitments on an annual basis. However, the net recruitment budget
allocation is not adequate to absorb all health workers in a given fiscal year.
As a result of improved conditions of service, there has been a significant reduction in attrition
among health workers. Information systems have provided the data for improved planning and
management of human resources. The MOH has rolled out performance management systems to
the provincial level on a ‘training of trainers’ basis, and the training of staff has been conducted in
most facilities. Implementation of individual performance management plans needs to be
strengthened for it to yield desired results.
Although there has been a substantial increase in numbers of staff deployed at health centres and
hospitals over the past years, these are still inadequate for the effective delivery of the minimum
health care package. This is further compounded by the unequal distribution and inappropriate
skills-mix. Rural areas continue to face relatively more severe human resource shortages due to
challenges in retention. The low population densities of Zambia pose a serious challenge to the
optimal distribution and utilization of health workers for efficient delivery of health services.
Table 5.1: Staffing Levels from 2011 and 2016

2011 2016

ESTABLISHMENT ANALYSIS ESTABLISHMENT ANALYSIS

CATEGOR Approve
Y Approved Actual d Actual
Gap % Gap %
Sector Est Staff Sector Staff
Est
ADMIN 6,115 1,683 4,432 72.5 22,353 19,254 3,099 14
CLINICAL
OFFICER 4,813 1,509 3,304 68.6 4,883 1,814 3,069 63
DENTAL 865 278 587 67.9 908 312 596 66
DOCTOR 2,939 1,076 1,863 63.4 3,119 1,514 1,605 51
ENVIRON-
MENTAL 2,063 1,367 696 33.7 2,319 1,796 523 23
LAB 2,023 713 1,310 64.8 2,110 921 1,189 56
MIDWIFE 6,106 2,753 3,353 54.9 6,322 3,141 3,181 50
NURSES 17,497 7,996 9,501 54.3 18,484 11,666 6,818 37
NUTRI-
TION 330 170 160 48.5 350 202 148 42
PHAR-
MACY 1,108 777 331 29.9 1,219 1,159 60 5
PHYSIO-
THERAPY 421 297 124 29.5 448 432 16 4
RADIO-
GRAPHY 483 276 207 42.9 542 419 123 23
TOTALS 44,763 18,895 25,868 58 63,057 42,630 20,427 32

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The current number of health workers in the health sector is estimated at 42,630 (against the
required establishment of 63,057). The sector faces a deficit of about a third (20,427) of the
establishment. As shown in Table 5.1 above, only 68% of the positions provided on the approved
establishment are filled, resulting in a continued shortage of health staff. The shortage cuts across
all cadres, especially the professional health cadres: clinicians, nurses, pharmacy technologists,
laboratory technologists, radiographers, physiotherapists, and environmental health technologists.
A disaggregation of health workers shows that the distribution is skewed toward urban areas.
Public facilities in rural and remote areas have the lowest number of health workers compared
with urban areas. The situation is so severe that some facilities in the rural areas have insignificant
numbers of staff and in the worst scenario are managed by unqualified staff.

Retention of Health Workers

The Ministry was implementing a health workers retention scheme that was monetary-based in
order to attract and retain staff in rural areas. However, the approach was unsustainable, arising
from limited budgetary allocation. As a result, the Ministry abolished the scheme effective
September 1, 2013.
In order to improve retention and geographical distribution of health personnel across the
country, a non-monetary retention strategy and deployment policy should be developed.
Incentive packages for health professionals should be scaled-up and adapted as needed, in
particular to increase the number of medical doctors and midwives in remote areas.

Training and Development

Despite improvements in the capacity of public training institutions and the involvement of the
private sector in the training of health workers, there are still challenges in meeting human
resource needs in the health sector. The establishments for the training institutions are not
adequate to meet the demand. There is limited fiscal space in most training institutions to employ
teaching and other support staff to allow for increased enrolments. Further, the infrastructure,
equipment, and other training requisites need to continue to be expanded in order to improve
the quality of training. There is also need to strengthen the monitoring of the training of health
workers by the regulatory bodies in order to enhance the quality of training.

Recruitment
The health sector has made strides in addressing the HRH deficits. Fiscal constraints impose
restrictions on the extent of the number of health workers employed annually.
The planning and management capacity for human resources should be improved at all levels
based on an effective and a comprehensive human resource information system (HRIS). Incentive
structures for health workers will be implemented to improve performance and motivation of
health workers. A performance-based management system, making use of ‘pay for performance,’
will enhance the retention of staff. This will entail effective collaboration with the Public Service
Management Department, MOF, and the Ministry of General Education (MOGE).

Strategic Interventions
Goal: To increase availability of trained and motivated staff that are equitably distributed to
contribute to the effective delivery of the NHCP.
Objectives Strategies
To improve the availability Scale up recruitment of health workers to reach optimum levels in
and distribution of qualified accordance with the approved staff establishment
health workers in the
Introduction of relevant health cadres to support the implementation of
country
PHC
Increase numbers of specialist doctors and other health workers to

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Goal: To increase availability of trained and motivated staff that are equitably distributed to
contribute to the effective delivery of the NHCP.
Objectives Strategies
provide specialized services in order to strengthen the referral system
Develop and implement appropriate mechanisms for more equitable
distribution of health workers, including improved targeting and
regulation of staff posting
Carry out a skills gap analysis and based on its findings develop a
comprehensive human resources plan
Review and strengthen a system for needs- and priority-based staff
posting of health workers
Review the existing establishment to respond to the required health
needs
Develop a mechanism to influence an increase in the allocation of net
recruitment budget allocation (e.g., buy-in, concept notes, involvement,
MOGE)
To strengthen human Enhance the implementation of performance management package and
resource management in the performance appraisal system.
order to improve efficiency
Transform the HRIS into a reliable HR information system to enhance
and effectiveness in
HR planning and sound decision-making (updated, web-based, HRIS)
utilization of existing staff
Strengthen multi-sectoral collaboration with Government line ministries,
faith-based institutions, the private sector, and CPs
Implement the HR reforms/decentralization and efficiently manage HR
cases (enhance employee motivation by ensuring quick responses in HR
cases/appointments and promotions committees)
To significantly increase the Develop and implement an appropriate plan for production of health
annual outputs of the health workers based on projected HRH needs (at all levels), both in numbers
training institutions to and skills-mix in line with the HRH Strategic Plan 2017-2021
mitigate the critical
Develop and implement an appropriate in-service training plan to
shortages of qualified health
improve skills levels for existing staff.
workers
Expand capacities at health training facilities and increase training
outputs in line with the NTOP 2017-2021.
Collaborate with the MOGE and other stakeholders toward increasing
the intakes for health workers in public and private institutions
Strengthen the management of internship programmes for health
workers
Scale up the recruitment and retention of teaching staff at health training
institutions
Develop a clear career pathway for CHAs and strengthen the
curriculum to scale up health promotion interventions at community
level
Initiate the introduction of programmes for various cadres to respond
to needs and emerging issues
Introduction of new training programmes to support the
implementation of primary health care

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 Goal: To increase availability of trained and motivated staff that are equitably distributed to
contribute to the effective delivery of the NHCP.
Objectives Strategies
To promote quality in Strengthen continued professional development for various cadres
training and health service
Mentorship and supportive supervision
delivery.
Review/ develop and enforcement of standard operations procedures
(SOPs)
Enhance provision of teaching aids/job aids, transport, equipment, and
learning materials
Promote operational research
Strengthen the management of internship programmes for health
workers
Initiate the introduction of programmes for various cadres to respond
to needs and emerging issues
Develop and implement a national policy that addresses recruitment,
placement, retention, and progression of specific cadres

5.3 Health Care Financing

Situation Analysis
Health financing is an important component of the health system as it impacts the production,
delivery, and consumption of health services. Further it impacts the coverage of the poor against
financial risks and the magnitude of impact on health outcomes and equity. Financing the NHCP
for this strategic plan necessitates identification of financing mechanisms that are able to bring
forth significant and sustainable amounts of funds in the medium to long term while upholding
equity principles.
The GRZ has shown commitment to health as demonstrated through a growing health budget in
absolute terms and in per capita terms. 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.
The results of the national health accounts show that total health expenditure (THE) per capita
increased to US$73.6 in 2012 from US$51.8 in 2010. The THE per capita has been increasing
since 2010. The government contribution within the THE reduced from 50.1% in 2010 to 39.9%
in 2011 and 38.1% in 2012 while the donor contribution increased from 39.3% in 2010 to 46.6%
in 2011 to 48.0 % in 2012. As a percentage of GDP, THE reduced from 4.2% in 2010 to 3.9% in
2011 and 4.0% in 2012. Government health expenditure (GHE) as a percentage of GDP reduced
from 2.1% in 2010 to 1.5% in 2012. Both GHE and THE increased at lower rates than the GDP
growth rate.
The increase in the financial resources to the health sector is largely due to additional donor
support. A stable number of CPs are committing funds and technical assistance to the health
sector. However most of the assistance is still used for vertical programmes (i.e., disease-specific
programmes such as malaria and HIV/AIDS) instead of targeting the entire health system, which
would in the long run produce a greater impact on mortality and morbidity reduction. In addition,
significant amounts of funding provided by NGOs and some CPSs are often not accounted for in
the budget. While donor support (estimated at 56% of THE in 2012) augments domestic
resources, lower than expected nominal public expenditure levels create sustainability issues. It is

75
important to note that donor support has little flexibility, making it impossible to fund priorities
defined in strategic plans.
Figure 5.2: Government Budget for Health as a Share of Total Government Budget
25% 25%
24%

20% 20%

15%
15% 13% 13% 15%
12% 12%
12%
10% 11.3% 10%
9.3% 9.9% 9.6%
8.6%
6% 5%
5% 5%

0% 0%
2011 2012 2013 2014 2015
Expenditure Budget

GRZ Health Budget as share Total GRZ Budget Abuja Target (15%)

NHSP 2011-16 Target, 13% Average (Scenario 3) Addi onal alloca on for Health from addi onal GRZ resources

Although the health sector has made important strides in establishing a SWAp to enhance
coordination and efficiency and reduce duplication, most of donor funding is still off budget. In
2013 all major CPs signed the MOU. Following the resolution of the fall-out from the 2009 Office
of the Auditor General’s Audit report, which resulted in some CPs reverting to the project
mode, a number of CPs resumed government-to-government funding to support health systems
strengthening and core health programmes, especially maternal and child health. Different CPs
have adopted different provinces to support in strengthening the Reproductive Maternal
Newborn and Child Health programme. An important innovation has been the adoption of
results-based financing, which is being in piloted five of the 10 provinces with support from the
World Bank.
Despite significant improvements in resource availability for health services, inadequate financing
remains the primary constraint inhibiting the development of the health sector in Zambia.
Funding a basic package of services in developing countries has been estimated at US$30–$40 per
capita, excluding ARVs and the pentavalent vaccine.
Several notable achievements were reached during the NHSP 2011–2016 period. These
achievements will enable greater progress to be made under the NHSP 2017–2021. Government
with CPs have continued efforts to strengthen the SWAp governance and accountability
mechanisms. Although the implementation of the SHI has been delayed, progress has been made,
including development of the draft bill, which has since been submitted to Cabinet. In addition,
the resource allocation formula for hospitals has been developed and the process to
institutionalize the national health accounts is underway. In the area of financial management,
achievements include implementation of IFMIS at MOH headquarters and some provinces, leading
to a reduction in audit queries; and strengthened internal controls leading to a reduction in audit
queries and strengthening the tracking system for Sector Advisory Group reports and
simplification of the presentation format for easy understanding. While noting these
achievements, we must acknowledge that some key challenges have persisted:
a. Low and erratic funding to the health sector in relation to allocations and needs,
especially in the districts
b. Fragmented and earmarked donor funding to the health sector mainly through project
mode funding and channelling of support through NGOs

76
 c. Lack of a health care financing strategy
d. Low level of private participation in healthcare financing
e. Delayed implementation of the SHI scheme
f. Outdated resource allocation formulas for districts, training institutions, and statutory
boards
g. Delay in institutionalization of the National Health Accounts (NHA)
h. Non-implementation of IFMIS in some provinces and districts
i. Weak linkage between health financing and performance
To achieve universal health coverage, Zambia is committed to improving the efficiency and
effectiveness of health resources in the sector. The MOH will continue to strengthen resource
mobilization, allocation, and tracking. Every effort will be made to increase the amount of non-
earmarked financial resources available to the health sector by increasing the share of GRZ
expenditures on health to 15% of the total national budget, by piloting an SHI programme, and by
convincing more CPs to support the SWAp.
Caution will be exercised to ensure that donor project funding and global funding initiatives do
not displace GRZ budget money for crucial services and do not suppress overarching objectives
of the sector. The different health financing options for the sector and their potential to raise
funds for health services will be elaborated on in a comprehensive Health Sector Financing
Strategy to be developed by 2017 followed by concerted efforts to implement it.
Allocation of resources in the health sector shall continue to be guided by the principles of
efficiency and equity. Currently, the grant to districts is determined by taking into consideration
the size of the population, poverty levels, health status of the district, special health needs, and
access to other funding sources. It will be important to maintain this needs-based approach. In
improving allocative efficiency, it is clear that the sector needs to increase the consumption of
services to reach more people and concentrate resources on cost effective activities that tackle
the greatest burden of disease. This translates into increasing the proportion of resources
allocated to the district health services where the majority of the population lives.
The health sector has decentralized decision-making in respect to budget allocation, with the
district political and technical leadership taking more responsibility for apportioning centrally
allocated funds. The increased autonomy of districts resulting from this policy change demands
stronger and more proactive buy-in by the district authorities to the nationally defined health
sector priorities. Money should follow priorities and evidence and therefore the health sector
budget will allocate more resources to PHC (including healthy lifestyles and prevention of
disease); FP; MNCH; reproductive health (RH); nutrition; and community health. These very
cost-effective interventions will have the highest impact on key health indicators. The Ministry
will take all necessary steps to sensitize local governments and the district health teams in
particular on the process of implementation to ensure that district plans are fully consistent with
national priorities for the sector and in line with the principles of the national development plan.
Central support for strengthening the capacity of district health management teams to prioritize
and negotiate for resources based on sound evidence will receive greater attention during the life
of this plan.
Efforts will be expended to ensure that the gap between approved estimates and actual
expenditures is minimized and that there is timely flow of funds, which is essential in the
continuity of delivery of health services leading to better budget performance. Financial
management and accounting at the provincial and district levels will need further strengthening
during this plan by implementation of accounting packages such as Navision and IFMIS.

77
Strategic Interventions
Goal: To raise sufficient financial resources to fund the plan while ensuring equity and
efficiency in resource mobilization, allocation, and utilization during the plan period.
Objectives Strategies
To reduce the budget Finalize and implement the Health Sector Financing Strategy for the health
gap in the health sector sector
by mobilizing adequate
Establishment of the SHI scheme
and sustainable financial
resources Promotion of private sector participation, public-private partnerships (PPPs)
And introduction of other innovative financing mechanisms, i.e., fuel
subsidies
Increase external funding through direct sector budget support and
strengthen partnerships with CPs and civil society
Develop and implement a new MOU with CPs and CSOs.
Implementation of the IHP+ principles in the MOU as the basis for mutual
accountability and predictability of financing to the Government rather than
other channels
Oversight over decentralization of PHC funding modalities
Comprehensive revision and costing of the NHCP with clear priority-
setting criteria properly documented
Develop financial projection of human resource costs with different
scenarios to guide resource allocation
To ensure Update and refine evidence-based resource allocation formula (RAF) at
effectiveness, efficiency, district level to take into account epidemiological, geographic, demographic,
and equity in resource socioeconomic, and intra-district factors
allocation and
Update and implement evidence-based RAFs for second- and third-level
utilization
facilities and training institution.
Develop and implement evidence-based RAF for statutory boards
Evaluate and explore the results-based financing initiatives, including
assessing financial sustainability
Strengthen systems and processes for evidence-based planning and budget
execution, including profiling
Strengthen the system that incorporates CP budgets into the overall sector
budget at various levels
To ensure Institutionalize the system for NHAs at all levels
transparency and
Strengthen the system that links budget, disbursement, and expenditure to
accountability in
performance in order to inform planning
resource utilization
Strengthen the system that incorporates CP budgets into the overall sector
budget at various levels
Strengthen fiduciary responsibility and ensure timely financial reporting and
audits

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5.4 Health Information Technology and Research
Situation Analysis
The health delivery process is hinged on health information, technology, and research, which
support evidence-based decision-making. A well-defined health delivery process ensures
availability of accurate, timely, and accessible health data according to SOPs. In an age of big data
(intelligent data for decision-making), which is the new gold, and informatics, health information
around cost per unit of conducting service delivery impacts research and can strengthen linkages
of integrated and interoperable health systems to support planning in the whole sector.
The currently available systems collecting data may not yet meet the demand for consolidated
decision-making. This has affected the health sector. One example is the many systems in logistics
and commodity management, which in 2016 had multiple disjointed electronic systems. This
produced information silos and hampered health workers’ ability to collect and analyse accurate
data for decision-making.
A feedback mechanism from health research conducted in the sector is required at all levels to
help improve service delivery. The mechanism should be in a national repository, overseen by
Government, stakeholders, donors, CPs, or the private sector. This will ensure no publication of
data or information that is not cleared by the Ministry.
During the period under review, significant achievements were made. The community module for
Smart Care was developed, and registration of births and deaths using Smart Care was piloted in
Livingstone. Ten provincial cancer registries were established as well a population-based cancer
registry for Lusaka district with more than 75% coverage. A web-based HRIS for the HPCZ and
GNC was developed, and integration into the national human resource system is in progress. The
eHealth strategy was developed and disseminated, and the DHIS2 was upgraded to a web-based
platform. Hospital HMIS was developed and rolled out, and Smart Care electronic health records
were deployed to six hospital outpatient and inpatient departments. In health research, a health
research registry was developed and updated, and research ethics guidelines were developed and
disseminated. Lastly, a health research priority-setting framework was developed.
There has been limited coverage and under-utilisation of the HMIS in respect to timeliness,
completeness of reports, data usage, and accessibility. The scope of the HMIS therefore has to be
broadened to facilitate better data visualization to improve decision-making. There is need for
only one incorporated and standardized M&E framework across all levels of the health care
delivery system and a further need for use of data at all levels of decision-making to facilitate
research. There has been a perception of poor data quality from HMIS due to inconsistent
primary sources of data.
The inadequately documented health delivery processes and SOPs to meet technological
requirements have greatly impacted the implementation of change management in service areas.
The inadequate document produces undefined business processes, resulting in a single worker
with multiple systems in the same service area and causing a gap in quality data collection.
Furthermore, it has been noted that uncoordinated financing of e-health systems by CPs and
various stakeholders has contributed to the mushrooming of parallel and duplicative systems,
causing information silos and thus weakening governance and accurate decision-making.
In addition, it has been noted that there are low levels of computer literacy at facility level as
there is inadequate incorporation of basic computer skills in the training curricula. The key
planning issues are:
 Lack of research positions in the MOH establishment at all levels
 Lack of an electronic health information exchange platform (interoperability layer)
 Inadequate local area networks infrastructure and connectivity

79
  Limited number of private health facilities reporting into the HMIS
 Health information systems in use that do not conform to MOH health delivery
processes
 Limited funding for health research priority areas
 Low compliance with health research ethics and standards by stakeholders
 Inadequate health research infrastructure
 Limited health research capacity in the health sector
 Weak coordination of health research activities

Strategic Interventions

5.5 Infrastructure, Equipment and Transport

Situation Analysis
Most of the public hospitals are in a state of disrepair owing to long periods of underinvestment.
In order to improve the situation, a hospital upgrading programme had been embarked upon. The
upgrading programme is expected to improve the delivery of specialist tertiary care. By enhancing
the functional capacities of hospitals, it is expected that the referral systems will be improved.
Hospitals are important as they provide practising bases for medical training institutions. It is
further envisaged that upgrading of hospitals will lead to a reduction in the number of patients
referred for specialised care abroad. Specific interventions include the division of the UTH into
five hospitals and modernization of second- and third-level hospitals through improvement of
emergency and specialized units, renal, cardiac, catheterization lab, ICU, and radiotherapy.
The MOH has embarked on health infrastructure development; 35 district hospitals have been
built and will require medical equipment. The Government is also upgrading health facilities from
one level to another, which requires appropriate equipment. Owing to obsolete equipment in the
most of the health facilities, the MOH was one of the beneficiaries of 2016 Euro bond, which was
used to procure medical equipment for central hospitals.
Maintaining an effective transport system is essential for ensuring a functioning and integrated
health delivery system. The Ministry continues experiencing transport constraints, which
adversely impact operations. For instance, only half of the 105 districts have road-worthy utility
vehicles. Basic life support ambulances are unevenly distributed across the provinces. Transport
constraints are especially severe for rural-based health facilities; 30% of the health centres use
motor bikes for service delivery; and some remote health centres use bicycles.

Strategic Interventions for Health Infrastructure

Goal: To increase access to health services through construction and rehabilitation of
health facilities in order to facilitate equity of access to quality health services.
Objectives Strategies
To increase access to health services through Modernisation of tertiary hospitals (second
construction/ rehabilitation of health facilities in and third-level, and specialist hospitals)
order to facilitate equity of access to quality health
Creation of new facilities in all districts
services
Upgrading some of the facilities to higher
levels (zonal health centres and district
hospitals)
Review, update the Capital Investment Plan

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 Goal: To increase access to health services through construction and rehabilitation of
health facilities in order to facilitate equity of access to quality health services.
Objectives Strategies
Strengthen management and maintenance of
medical equipment
To establish management systems for infrastructure Create an electronic medical equipment
and medical equipment at all levels database
Integration of human resource, equipment,
and infrastructure planning
Review, update, and implement the equipment
investment plan integrating health facilities and
training schools to ensure access to
appropriate technology
Study and revise the designs of health facilities,
at different levels, to address current
To provide optimal availability, appropriateness, and concerns, e.g. appropriateness of basic
distribution of essential medical and non-medical services at each level of care.
equipment in order to facilitate equity of access to
Promote private sector participation and
quality health services
PPPs.
Maintain an updated database for
infrastructure equipment and transport
Strengthen maintenance and rehabilitation of
infrastructure, equipment, and transport at all
levels

Strategic Interventions for Medical Equipment

Goal: To manage and implement the acquisition, usage, maintenance, and management
of medical health care technology in health institutions for the provision of quality health
care
Objectives Strategies
To provide 85% of health facilities in Zambia Procurement of medical equipment using the GRZ
with medical equipment for treatment and funds
diagnosis by 2021
Provisional of medical equipment to facilities by
getting donated medical equipment from CPs
To have 90% of medical equipment well Procurement of service contract for the high-end
maintained and managed by 2021 equipment
Implement an effective planned preventive
maintenance plan for equipment at all levels
Implementation of equipment replacement plan for
high end hi-tech equipment
Provisional of technical training for maintenance
engineers and technologists to have well-trained
in-house personnel
Provide user with proper use and care of the
equipment for continuity in health care service
delivery.
Procurement and provision of test equipment for
medical equipment

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 Goal: To manage and implement the acquisition, usage, maintenance, and management
of medical health care technology in health institutions for the provision of quality health
care
Objectives Strategies
To provide 95% of hospitals with linen to all
Procurement of hospital linen for all levels of care.
facilities

Strategic Interventions for Transport

Goal: To have a well-maintained fleet to ensure mobility for service delivery.
Objectives Strategies
To facilitate provision of transport Divide zoning districts into four sections for easier use of the
in the sector for ease of mobility available ambulances and utility vehicles
Increase the grants to vehicle service centres for
procurement of spares
Train riders of both motorcycles and bicycle ambulances in
basic maintenance so that the service can be done at Health
centre level
Procure more ambulances and utility vehicles for districts
Procure more motorcycles and bicycle ambulances for the
rural health centres (RHCs) for expecting mothers.
Procure boats with smaller engines to ease the problem of
higher consumption of fuel as the is the case with the current
boats
Procure spare parts for the mini-ambulances to enhance
mobility of patients within vast hospitals

5.6 Implementation, Monitoring and Evaluation

5.6.1 Legal, Policy and Regulatory Framework
This NHSP is anchored in the Vision 2030, National Health Policy (NHP 2012), and the SDGs. It
is also reflected in the 7NDP. Vision 2030 is Zambia's first-ever written long-term plan. It
expresses Zambia’s aspirations to become a prosperous middle-income nation by 2030. The
Vision articulates possible long-term alternative development policy scenarios, which would
contribute to the attainment of the desirable socio-economic targets by the year 2030.
Within the sector, the broader vision is to ‘ensure equitable access to quality health care by all by
2030’. Zambia envisions a healthy and productive citizenry that can contribute positively to ‘a
prosperous middle-income nation by 2030’. The Vision 2030 identifies health as one of the
priority sectors which is expected to contribute to a healthy and productive citizenry. This is
expected to be attained through strategies to ensure realization of the following health service
targets:
1. Reduce the under-five mortality rate from the current 168 to 50 per 1,000 live births by
2030
2. Reduce the MMR from the current 398 to 100 per 100,000 live births by 2030

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 3. Increase the proportion of rural households living within 5km of the nearest health
facility from the current 50% to 80% by 2030
4. Reduce the population/doctor ratio from the current 17,589 to 5,000 by 2030
5. Reduce the population/nurse ratio from the current 1,864 to 700 by 2030
This strategic plan is closely linked to the Zambian Constitution, which is the supreme law of the
land. The Constitution guarantees the right to life and right to health. It also guarantees other
fundamental human, social, and economic rights to the population, which have direct and/or
indirect impacts on health. The strategic plan will be backed by the new National Health Services
Act to be enacted by Parliament; the new act will replace the National Health Services Act of
2005. In addition, there are various health-related pieces of legislation for addressing specific
aspects of health which are expected to be enacted by Parliament. These include: mental health;
public health; tropical diseases research; Flying Doctor Services; food safety and quality; human
tissue; traditional health practitioners; Zambia Medical Association; tobacco control; and the SHI
Act/Bill. The Government will continuously review the needs and gaps for specific health-related
legislation and develop appropriate legislation necessary for the enforcement of particular aspects
of health.
This NHSP is consistent with the Country’s National Planning and Budgeting Policy of 2014. The
policy seeks to promote coordination of national planning and budgeting functions and outlines
processes and procedures for development planning. It also provides an effective institutional
arrangement for the development, implementation, and M&E of development plans and budgets.
This NHSP has taken into account the National Decentralization Policy of 2014, which provides
for the strengthening of local government to facilitate more effective citizen participation in the
delivery of public services. Under the National Decentralization Policy of 2013, the MOH will
devolve responsibility for PHC functions, from the District Medical Office and Health Centre to
the lowest level of health service delivery, to the Councils.
The MOH has delegated regulatory functions to public statutory bodies, such as the HPCZ,
GNC, National Radiation Protection Authority, and NFNC. Other statutory bodies include:
ZNBT, ZFDS, NAC, MSL, and the TDRC.
The HPCZ is a statutory regulatory body established under the Health Professions Act No. 24 of
2009 of the Laws of Zambia. The Council is mandated to register and regulate all private and
public health facilities and health training institutions in the country. The GNC is a statutory body
established in 1970 under the Nurses and Midwives Act No.55 of 1970. The Act was repealed
and replaced by the Nurses and Midwives Act No. 31 of 1997. The GNC is responsible for
ensuring that members of the public receive the best possible care. The GNC sets, monitors, and
evaluates performance standards for nursing and midwifery education, clinical practice,
management, and research. The NFNC is a statutory body that was established in 1967 by an Act
of Parliament. It serves as an advisory body to the Government on matters to do with food and
nutrition. It is mandated to promote and oversee nutrition activities, primarily focusing on
vulnerable groups such as children and women. The Zambia Medicines Regulatory Authority was
established under the Medicines and Allied Substances Act No. 3 of 2013 to regulate and control
the manufacture, importation, storage distribution, supply, sale, and use of medicines and allied
substances.
The service delivery statutory boards responsible for providing specialised support services to
core health service delivery facilities include the ZNBTS, ZFDS, NAC, MSL, and TDRC.

5.6.2 Institutional Framework

The implementation of the health sector strategic plan is complex and includes several public and
private institutions, CPs, and NGOs that operate at central, provincial, and district levels. The
MOH has a role to make sure that there is a coordinated governance system. This requires
sharing of information at various levels for evidence-based management decisions. The strategic

83
plan is implemented and coordinated through the existing health sector organisational and
management structures, which are explained below.
 MOH head office and sector coordination: The MOH headquarters is responsible
for the overall leadership of the health sector. The Ministry is responsible for policy
development, strategic planning, resource mobilization, and M&E. The Ministry further
provides technical guidance to service providers and monitors the quality of health
services. Technical guidance is provided by the various directorates, which are based at
headquarters.
The SWAp provides a framework of collaboration among the stakeholders, Government
ministries, civil society, the private sector, and CPs. It coordinates financing, planning, and
monitoring mechanisms. The aim is to achieve maximum results and in the process
reduce transaction costs. The participants under SWAp are bound by a Code of
Conduct, which is aimed at increasing transparency and improving predictability for
allocation of resources. The SWAp is administered through TWGs, policy meetings,
sector advisory group meetings, and the annual consultative meetings. There is also one
annual planning meeting and one JAR. Half way in the implementation of the Strategic
Plan, a midterm review is conducted in which all stakeholders are involved.
 PHOs serve as intermediaries for the implementation of health plans within their
provinces. They represent the ministry’s functional link to the lower level structures,
training institutions, and civil society. PHOs will continue to be responsible for
coordinating and supervising the implementation of the NHSP and providing technical
support to all health service institutions within their provinces.
 DHOs and hospitals will be responsible for implementing the district and hospital
plans. Harmonization of district and hospital plans to match the aspirations of the NHSP
2017-2021 will, therefore, be crucial for successful implementation of the NHSP. In the
light of the decentralisation policy, all the PHC functions will be devolved to the local
authorities except for first-level hospital services, which will remain with the MOH.
 Health service delivery facilities: Health posts, health centres and hospitals. Health
centres and health posts are the points of service delivery. In the devolved system, all the
facilities below the first-level of care will be under the councils.
 Statutory boards: There are two types of statutory boards under the MOH structures:
regulatory and service statutory boards. The role of the regulatory statutory boards will
be to ensure that the relevant laws and regulations are developed and enforced in order
to ensure high standards of safety, ethics, and professionalism in the health sector. On
the other hand, the role of the service statutory boards will be to provide services to
support the core health services.
 Health training institutions will be responsible for the production of appropriately
qualified health workers for implementation of the plan.

5.6.3 Key Sector Partners

All the key sector partners will play their respective roles in the implementation of this plan. In
order to ensure efficient and effective coordination of the partnerships, the MOH will strengthen
inter-sector collaboration and coordination mechanisms at all levels. The following are the key
partners:
 Government line ministries and departments: Several government ministries and
departments impact the performance of the health sector. Some actively participate in
health service delivery. Others impact the determinants of health. Still others provide
support to the health sector. Strong inter-sector coordination mechanisms will be

84
 maintained. The newly introduced cluster approach in the 7NDP will guide the Ministry’s
coordination work under the human development pillar.
 The faith-based health sector/CHAZ: CHAZ represents a large number of faith-
based organisations and is the largest partner to the Government in the health sector.
CHAZ is also currently the second largest provider of health services to the general
public. CHAZ health facilities are fully funded by the Government. CHAZ plays an
important role in the implementation of the plan through their network of health
facilities, which include hospitals, health centres, and health posts distributed throughout
the country. An important aspect to note is the fact that CHAZ has good coverage of
rural areas. The MOU with CHAZ will be reviewed, updated, and implemented.
 Private sector: In Zambia, private health facilities include for-and not-for- profit
facilities owned by private business entities and civil society organisations. Deliberate
efforts shall be directed at promoting private sector participation, including PPPs,
collaboration in research and development, and strengthening of coordination,
harmonisation, and referrals.
 Civil society: The civil society, both local and international, will play an important role
in the implementation of the plan. Some civil society organisations are involved in health
promotion, provision of health services, and training and capacity building, while others
are involved in advocacy for health. The MOH will work toward promoting stronger
coordination and participation of the civil society in the health sector through the SWAp.
 Communities: Much of the progress made in improving the health status of individuals
depends on the existence of healthy environments and lifestyles. The government will
work toward strengthening health promotion among communities and strengthening
community involvement and participation in the planning, management, implementation,
and M&E of health services to achieve greater impact. This will be achieved by
strengthening the community participation structures and transparency and accountability
in the management of health services at community level.
 CPs: The CPs are expected to play an important role in the implementation of the plan
through provision of financial and technical support to the sector and specific
programmes. The Government will work toward strengthening partnerships with the
CPs and harmonisation of their support efforts for high impact. This will be structured
and agreed upon in the MOU that will be signed between the MOH, CPs, and civil
society groups.
 Traditional and alternative health services: Traditional health practitioners are
organized under the Traditional Health Practitioners of Zambia (THOPAZ). Traditional
health practitioners provide herbal and spiritual healing services within the communities.
Through implementation of this NHSP 2017-2021, the MOH will strengthen regulation,
supervision, research, and coordination of this sector to ensure that they provide safe
and evidence-based health services to the communities.

5.6.4 Planning, budgeting, and capacity building

The NHSP 2017-2021 will be implemented through the development and implementation of
appropriate plans at sector and sub-sector levels. Currently, the planning framework depends on
a bottom-up planning process. MOH will work towards advocating for increased funding to the
health sector in line with the Abuja declaration target of 15% of the national budget. Further,
GRZ/MOH will ensure that all plans, budgets, and expenditures are in line with national policy
and the requirements of the National Development Plan, NHSP, and MTEF.
The CPs will be requested to support the health sector by aligning and – to the extent possible –
synchronising their interventions with the MOH priorities and timelines as specified in the NHSP.

85
To support this process, MOH will work toward agreeing with the CPs to implement the IHP+ in
Zambia.
For successful programme implementation, MOH in consultation with the sector partners will be
developing annual capacity building plans aimed at ensuring adequate capacity building linked to
performance. Programmes supported by CPs will work through the structures designated by the
MOH in order to build capacity, improve sustainability, and ensure maximum integration with
MOH policies and programmes.

86
 6. Costing of the NHSP

6.1 Overview
The NHSP costing aims to support strategic planning and evidence-based decision-making by
estimating the cost of scaling up priority areas/programmes in the health sector. In addition,
estimating total resource needs of the NHSP supports domestic and donor resource mobilization
and transparent and accountable operationalization of the plan.
While many costing tools for costing strategic plans exist, the bottom line or what is behind any
models is the identification of activities (unbundling of strategies or interventions) and finding unit
cost (prices) of inputs required to carry them out. In other words, cost is simply summing up the
product of quantity and price of each input used in undertaking the activity.
The costing exercise involved estimating the resource requirements for all 33 priority areas,
which included: 1) drugs, medical supplies, and commodities, 2) programmatic support activities,
e.g., in-service training sessions/workshops, supervision visits, mentoring, coordination meetings,
transport, consultancies, supervision, and 3) systems costs, e.g., human resources for health,
health financing, infrastructure, and equipment needed to achieve the goals and strategic
objectives using the activity-based costing approach. The ingredient approach was used to
identify the specific inputs needed to carry out each intervention and the targets sets in
consultation with the programme focal point persons.
Costs for drugs, medical supplies, and commodities (including essential drugs and medical
supplies, ARV therapy, malaria commodities, RH commodities, and vaccines) were based on
MOH pharmaceutical- and supply chain management unit-led quantification exercises, which
utilized the ingredient approach and the latest consumption, epidemiological, and pricing data
available.
The total cost of the NHSP for all five years is estimated at US$14.3 billion (ZMK 139.8 billion).
The priority areas that are major cost drivers are HRH US$3.2 billion (22.6% of the estimated
total); infrastructure US$2.4 billion (17.1% of the estimated total); pharmaceuticals and supply
chain management (essential drugs, commodities, and supplies) US$2.2 (15.8% of the estimated
total); HIV/AIDS US$ 1.0 billion (7% of the estimated total); and malaria US$0.9 billion (6.5% of
the estimated total). Table 6.1 below shows the distribution of the estimated costs by Priority
Area of the NHSP 2017-2021.
Table 6.1: Total NHSP Costs by Priority Area per Year

2017 2018 2019 2020 2021 Total USD %

TOTAL 2,545,396,089 2,727,022,224 3,011,244,374 3,010,253,352 2,972,743,913 14,266,358,741

PRIORITY 1:
PHC and
community
health 1,065,567 1,463,144 1,808,396 1,708,130 708,394 6,753,633 0.0%
PRIORITY 2:
Health
Promotion 1,906,339 6,772,260 9,191,691 3,213,831 1,397,895 22,482,016 0.2%
PRIORITY 3:
Reproductive
and Maternal
Health 51,250,600 78,655,736 79,712,546 78,323,996 78,238,918 366,181,796 2.6%

87
 2017 2018 2019 2020 2021 Total USD %

PRIORITY 4:
Child Health 23,363,366 19,361,907 56,464,747 8,437,909 10,449,286 118,077,215 0.8%
PRIORITY 5:
Nutrition 49,249,228 52,191,352 52,225,329 51,963,725 51,689,255 257,318,889 1.8%
PRIORITY 6:
Malaria 178,793,023 127,393,139 338,733,586 158,005,991 127,373,586 930,299,326 6.5%

PRIORITY 7:
HIV/AIDS 169,367,800 186,245,400 200,998,600 215,412,300 229,815,200 1,001,839,300 7.0%

PRIORITY 8:
TB 86,123,085 58,919,541 49,402,319 50,290,517 57,800,424 302,535,886 2.1%
PRIORITY 9:
Viral
Hepatitis 456,003 123,677 124,327 123,677 124,327 953,522 0.0%

PRIORITY
10: NTDs 20,060,713 36,106,081 18,791,755 26,681,586 18,123,158 119,479,069 0.8%
PRIRIORITY
11: Public
Health
Surveillance 291,486 223,600 1,507,798 156,792 156,792 2,336,468 0.0%
PRIORITY
12: Epidemic
Preparedness
and
Response,
and Emerging
Issues 941,878 5,644,699 6,361,490 5,361,490 5,361,490 23,671,048 0.2%

PRIORITY
13: NCDs 145,071 77,278 77,278 77,278 77,278 454,184 0.0%
PRIORITY
14: Cancer 1,157,609 16,740,937 1,213,684 1,299,986 1,009,111 21,421,326 0.2%
PRIORITY
15: Palliative
Care 86,757 105,003 86,757 105,003 86,757 470,276 0.0%
PRIORITY
16: Hospital
Services 42,926 12,813 12,813 12,813 12,813 94,176 0.0%
PRIORITY:
Padaetrics 520,882 294,815 273,115 273,115 273,115 1,635,043 0.0%
PRIORITY:
Eye Health
Services 601,250 536,337 508,980 508,980 508,980 2,664,526 0.0%
PRIORITY
17: Surgical,
Obstetric
and
Anaesthesia
Services 1,617,321 434,629 434,629 378,789 179,701 3,045,069 0.0%
PRIORITY
18:
Rehabilitative
Services 790,976 677,068 645,854 614,640 614,640 3,343,178 0.0%

PRIORITY
19: ENT 6,939,372 6,900,127 6,923,738 6,855,727 6,855,727 34,474,692 0.2%

88
 2017 2018 2019 2020 2021 Total USD %

PRIORITY
20: Nursing
and
Midwifery
Services 92,125,765 80,655,487 19,868,278 19,801,041 19,764,244 232,214,815 1.6%
PRIORITY
22: Imaging
Services 135,509 1,481,219 1,971,759 916,219 841,759 5,346,465 0.0%
PRIORITY
23. Blood
Transfusion
Services 2,735,452 4,663,037 4,333,882 4,454,599 4,333,882 20,520,851 0.1%
PRIORITY
24: Medical &
Non-Medical
Equipment 74,655,359 81,952,859 89,980,109 98,810,084 108,523,056 453,921,467 3.2%
PRIORITY
25:
Laboratory 9,183,400 9,309,296 9,315,826 9,275,277 9,315,826 46,399,624 0.3%

PRIORITY
26: QA/QI 4,425,357 4,375,624 4,344,927 4,344,927 4,344,927 21,835,761 0.2%
PRIORITY
27:
Environment
al Health,
Food Safety
and
Occupational
Health 1,304,910 1,633,984 1,190,101 1,473,973 947,258 6,550,227 0.0%
PRIORITY
28:
Integrated
Health
Support
Systems 2,310,142 3,221,474 546,258 496,863 496,863 7,071,598 0.0%

PRIORITY
29: HRH 485,442,286 549,988,894 628,166,931 722,194,066 834,894,170 3,220,667,847 22.6%
PRIORITY
30: Health
Care
Financing 847,131 3,736,172 1,234,137 1,352,374 1,123,476 8,293,289 0.1%

PRIORITY
31: Health
Information
Technology
and Research 13,784,242 12,104,218 13,424,216 8,199,208 5,563,016 53,074,899 0.4%
PRIORITY
32:
Infrastruc-
ture 475,716,802 475,680,272 475,680,272 538,605,442 475,680,272 2,441,363,060 17.1%
PRIORITY
33:
Transport 5,243,711.55 10,372,361.55 5,973,711.55 10,372,361.55 5,973,711.55 37,935,857.76 0.3%
PRIORITY
34:
Pharmaceu-
ticals and
Supply Chain
Management 391,181,800 446,505,853 465,072,521 490,274,865 455,258,918 2,248,293,957 15.8%

89
 2017 2018 2019 2020 2021 Total USD %

of Drugs and
Medical
Supplies,
ARV
Therapy, TB
Drugs,
Vaccines, RH
commodities,
Malaria
Com-
modities,
NTDs
MDAs, Viral
Hepatitis
vaccines, and
Cancer
supplies and
Drugs 390,885,998 441,682,938 464,017,836 489,286,595 454,270,648 2,240,144,016 15.7%

When the total costs are presented by three major health systems input categories, health
systems costs (comprising HRH, health financing, equipment, laboratory, M&E, information
communication technology (ICT), research, and governance) are the major cost drivers at an
estimated US$6.2 billion (43.7% of the total costs). Programme management costs (which consist
of in-service training sessions/workshops, supervision visits, mentoring, coordination meetings,
transport, and consultancies, etc.) come in second at an estimated US$5.8 billion (40.6% of the
total costs) in five years. Drugs, commodities, and medical supplies come in third at an estimated
US$2.2 billion (22.6% of the total costs) in five years.
Figure 6.1: Total NHSP Costs Per Year (US$ Millions)

$3,100
$3,000
$2,900
US$ MILLIONS

$2,800
$2,700
$2,600
$2,500
$2,400
$2,300
2017 2018 2019 2020 2021
Total NHSP Cost Per Year $2,545 $2,727 $3,011 $3,010 $2,972
YEAR

6.2 Total NHPS Costs by Major Health Systems Input

Components
The distribution of costs can be viewed through three major system input components: 1) drugs,
commodities, and medical supplies; 2) programme management costs comprising in-
service/workshops, supervision/mentoring etc.; and 3) systems costs composed of HRH, health

90
financing, infrastructure, equipment, M&E, and governance. Systems costs are the major cost
drivers at an estimated US$6.2 billion representing 43.7% of the total costs of the NHSP
implementation period (See Table 6.2 below). Programme management costs are estimated at
US$5.8 billion or 40.6% of the total costs. Drugs, commodities, and medical supplies come in
third at an estimated US$2.2 billion representing 15.7% of the total costs. (See Table 6.2 below).
Table 6.2: Total NHSP Cost per Year by Major System Input Components

2017 2018 2019 2020 2021 Total %

Component 2,545,396,089 2,727,022,224 3,011,244,374 3,010,253,352 2,972,743,913 14,266,659,953 100.0%
Drugs and
Medical
supplies costs 390,885,998 441,682,938 464,017,836 489,286,595 454,270,648 2,240,144,016 15.7%
Programme
Management
Costs 1,092,570,731 1,149,346,102 1,328,878,789 1,142,033,444 1,082,876,586 5,795,705,652 40.6%
Systems costs
composed of: 1,061,939,360 1,135,993,184 1,218,347,749 1,378,933,313 1,435,596,678 6,230,810,285 43.7%
HRH 485,442,286 549,988,894 628,166,931 722,194,066 834,894,170 3,220,686,347 22.6%
Health
Financing 847,131 3,736,172 1,234,137 1,352,374 1,123,476 8,293,289 0.1%
M&E,
Research,
and ICT 13,784,242 12,104,218 13,424,216 8,199,208 5,563,016 53,074,899 0.4%
Equipment 74,655,359 81,952,859 89,980,109 98,810,084 108,523,056 453,921,467 3.2%
Governance 2,310,142 3,221,474 546,258 496,863 496,863 7,071,598 0.0%
Infrastructure 475,716,802 475,680,272 475,680,272 538,605,442 475,680,272 2,441,363,060 17.1%
Laboratory 9,183,400 9,309,296 9,315,826 9,275,277 9,315,826 46,399,624 0.3%

91
7. Key Performance Indicators

7.1 Reproductive, Maternal, Neo-natal, Child Health,

Nutrition, and Adolescent Health
Objective 1: To create demand for sexual and reproductive health services (adolescents and
youths, women of reproductive age, men, elderly people and the marginalized populations).
Objective 2: To scale up high-impact child survival interventions
Objective 3: To increase access to and utilization of high impact nutrition-specific interventions.

Baseline Target
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

Outcome
MMR (per
100,000 live 398 289 100 ZDHS
births)
Under-five
67/100
mortality 75/1000 35/1000 ZDHS
0
rate
30/100
IMR 45/1000 15/1000 ZDHS
0
Neonatal
15/100
mortality 24/1000 5/1000 ZDHS
0
rate
Adolescent
birth rate 141/100 131/10 121/100
ZDHS
(per 1,000 0 00 0
live births)
Exclusive
breastfeeding
rates up to 73% 76% 80% ZDHS
six months of
age
% of children
aged under
40% 20% 14% ZDHS
five years
with stunting
% of women
of
MIS/
reproductive 47% 35% 22% 20% 18% 16%
ZDHS
age with
anaemia

93
 Baseline Target
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

% of
newborns
with weight
9% 9% 8% 7% 6% 5% ZDHS
below 2.5kg
(low birth
weight)
% of children
aged under
five years 15% 10% 2% ZDHS
who are
underweight
% of children
aged under
five years 9% 7% 4% ZDHS
who are
overweight
% of children
aged under HMIS/
6% 5% 4% 3% 2% 1%
five years ZDHS
with wasting
% of children
aged 6-23
months who
are fed with 11% 43% 90% ZDHS
minimum
acceptable
diet
Proportion
ZDHS
of household
National
consuming 53% 60% 68% 75% 83% 90%
IDD
adequately
Survey
iodized salt
Adolescent
141/100
birth rate
0 live 136 131 125 122 121 ZDHS
(15-19 year
births
old girls)
% of
adolescents
accessing TBA 60% 70% 80% 85% 90% ZDHS
integrated
SRH services
% of
adolescents
accessing TBA 60% 70% 80% 85% 90% ZDHS
integrated
HIV services
% of
adolescents
accessing
TBA 60% 70% 80% 85% 90% ZDHS
integrated
post-GBV
services

94
 Baseline Target
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

% of
survivors
(M&F) of
sexual
violence
(10-19, 20+
years) who
43% 37% 34% 31% 28% 25% ZDHS
received
post-
exposure
prophylaxis
within 72 hrs
of sexual
assault
% of the
population
age 15-19 F=50% F=70%
F=60%, F=80%,
with F=39%, , , F=90%,
M=60 M=80 ZDHS
comprehen- M=42% M=50 M=70 M=90%
% %
sive correct % %
knowledge of
HIV/AIDS
Prevalence of
teenage 29% 27% 25% 21% 19% 18% ZDHS
pregnancy
% of women
age 15-49
years who
ZDHS/
received
63% 68% 70% 73% 75% 80% MOH
postnatal
Reports
check-up in
first two days
after birth
% of births
with a
postnatal ZDHS/
check in first 63% 68% 70% 73% 75% 80% MOH
two days Report
after giving
birth
% of children
under five
with fever
for whom
advice or MOH
72% 78% 84% 90% 96% 100%
treatment Reports
was sought
from a health
facility or
provider
Output
% of
deliveries
assisted by 54% 64% 70% 75% 80% 85% HMIS
skilled
personnel

95
 Baseline Target
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

% of women
attending
ANC within
24% 30% 36% 42% 48% 50% HMIS
the first
three months
of pregnancy
Contracep-
tive
prevalence
45% 50% 55% 57% 59% 60% HMIS
rate for
modern
methods
% of fully
immunized
85% 86% 87% 88% 90% 96% HMIS
children
under one
% of
functional
18.4% 36% 54% 72% 90% 100% HMIS
EmONC
facilities
% of health
facilities that
RHC
offer LARC 40% 55% 65% 75% 80% 85%
Survey
Services
output
% of health
centres
offering at
least five RHCS
56% 62% 68% 74% 78% 80%
modern Survey
types of
contracep-
tives output
% of districts
with at least
one fully
functional
MOH
one-stop 24% 30% 36% 42% 48% 50%
Reports
centre for
care of GBV
survivors
output
% of
institutional
67% 69% 71% 73% 74% 75% HMIS
deliveries
output
% of
antenatal
visits in first 24.4% 30% 36% 42% 48% 50% HMIS
trimester
output

96
 Baseline Target
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

% of women
accessing
postnatal 63% 68% 73% 78% 83% 85% HMIS
care within
six days
Nutritio
% of OTP
15% 20% 25% 27% 29% 30% n IMAM
sites
database
% of facilities
achieving
90%
coverage of
Nutritio
vitamin A 80% 82% 84% 86% 88% 90%
n IMAM
supplementat
ion children
aged 6 to 59
months
% of districts
with
functional MOH-
adolescent/ 24% 31% 39% 46% 53% 60% ADH
youth- Reports
friendly
health spaces

7.2 Malaria
Objective 1: To eliminate local malaria infection and diseases in Zambia by 2021
Baseline Targets
Indicators Data
2016 2017 2018 2019 2020 2021
Source
Outcome
Malaria 336 - 168 101 15 0 HMIS
incidence (50%) (70%) (85%) (100%)
rate
(confirmed
and clinical
cases) per
1,000
persons per
year
In-patient 15.5 - 13.3 11.2 4.7 0 HMIS
malaria (14%) (28%) (70%) (100%)
deaths (all
ages) per
100,000
persons per
year

97
 Baseline Targets
Indicators Data
2016 2017 2018 2019 2020 2021
Source
Malaria TBA - 75 1,000 2,000 0 HMIS
eliminated in (3.1%) (42%) (83%) (100%)
HFCA
Resurgence TBA - 100% 100% 100% 2,400 HMIS
of malaria is (100%)
prevented in
HFCAs
where
malaria has
been
eliminated.

7.3 HIV/AIDS
Objective 1: To reduce the incidence and prevalence of HIV
Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source
Outcome
% of new ZAMPHIA/
0.7% 0.7% 0.6% 0.5% 0.5% 0.4%
infections Spectrum
% of
women and
men aged
15-49 years
who
55% 67% 70% 75% 85% 90% HMIS
received an
HIV and
test and
know their
results
% of PLHIV
women and
men aged
15-49 years
who know
70.6% 72.6% 74.7% 76.8% 78.9% 81% HMIS
their status
and are
currently
receiving
ART
% of HIV
positive
children 0-
14 years 73.8% 69.1% 72.1% 75% 78% 80% HMIS
currently
receiving
ART

98
 Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source
% of PLHIV
women and
men who
are virally 52% 60% 65% 70% 80% 90% HMIS
suppressed,
aged 15-49
years
% of virally
suppressed,
52% 60% 65% 70% 80% 90% HMIS
aged 0-14
years
% VMMC
coverage
among HIV
42% 47% 58% 69% 90% 90% HMIS
negative
men, aged
15-29 years
% of males
and females
who
reported an 15% 12% 9% 7% 5% 2% HMIS
STI in the
past 12
months
% of HIV-
positive
pregnant
women
who receive
ART to
89% 89.5% 91% 95.4% 99.4% 100% HMIS
reduce the
risk of
mother-to-
child
transmissio
n
% of
children
born with
HIV from 5% 3% 2% 2% 1% 1% HMIS
mothers
living with
HIV
% of men
and women
aged 15-49
years
reporting
more than
F=36.5, F=45, F=55,M F=68M F=78M F=90,
one sexual HMIS
M=42.5 M=50 =60 =70 =80 M=90
partner in
last 12
months,
reporting
condom use
at last sex

99
 Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source
Output
50%
VMMC (10 – 49 60% 70% 80% 90% 90% HMIS
years)
Early infant
medical 50%
male (0-60 55% 60% 70% 80% 90% HMIS
circumcisio days)
n
% of HIV
positive
61% 65% 70% 75% 80% 90% HMIS
children on
ART
% of adults
and children
with HIV
known to
be on
75% 76% 78% 80% 82% 85% HMIS
treatment
12 months
after
initiation of
ART

7.4 Tuberculosis
Objective 1: To reduce the number of TB deaths in the population by 40% in 2021 compared to
2015
Baseline Target
Indicator Data
2015 2017 2018 2019 2020 2021
Source
Outcome
TB incidence
HMIS/TB
rate compared TBA 2.8 % 4.3% 5.3% 6.9% 8%
Survey
to 2015 %
TB cure rate 84% 85.5% 86% 86.5% 86.8% 87% HMIS
% of TB
directory
observed
therapy 85% >87% >90% >90% >90% >90% HMIS
short-course
treatment
success rate

100
 Baseline Target
Indicator Data
2015 2017 2018 2019 2020 2021
Source
% of multi-drug
resistance TB
cases 30% 50% 65% 75% 80% 90% HMIS
successfully
treated
Output
TB/HIV on ART 76% 76.5% 77% 77.5% 77.8% 80% HMIS

7.5 Neglected Tropical Diseases

Objective 1: To eliminate the NTDs in Zambia by 2021.
Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source

Outcome

SDG, SAFE
Number of
Strategy,
trachoma
Implementation
endemic
24 (TF) 20 15 9 5 0 Framework
districts with
Toward the
TF<5% and
Elimination of
TT<0.1%
NTDs

Number of Zambia’s
districts Master Plan
endemic to 85 75 55 35 15 0 toward the
lymphatic elimination of
filariasis NTDs

Number of
districts
105 100 87 55 13 0 MOH reports
endemic to
schistosomiasis

Number of
districts
endemic to soil 105 98 71 37 17 0 MOH reports
transmitted
helminths

Output

Number of
people receiving
prophylactic
1,842,517 1,934,643 2,031,375 2,132,944 2,239,590 2,351,570 NTD reports
treatment
against
trachoma

101
 Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source

Number of
people receiving
prophylactic
4,611,776 2,819,688 1,5584,58 2,766,977 1,781,057 2,597,203 NTD reports
treatment
against
schistosomiasis

7.6 Public Health Surveillance

Objective 1: To improve national disease surveillance systems to address the burden of
morbidity and mortality due to non- and communicable.
Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source

Output

Proportion of IHR Core

districts meeting Capacities
and sustaining Monitoring
International Tool
35% 80% 85% 90% 95% 100%
Health Routine
Regulations surveillance
(IHR [2005]) and outbreak
core capacities reports

Cluster IHR Core

Performance Capacities
0 100% 100% 100% 100% 100%
Monitoring Tool Monitoring
applied annually Tool

Results
analysed,
IHR Core
documented
Capacities
and remedial 0 100% 100% 100% 100% 100%
Monitoring
actions agreed
Tool
with MOH and
partners

Input

Percentage of
districts with
equipment for
50% 60% 70% 80% 90% 100% MOH Reports
epidemiological
data
management

102
 Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source

Laboratory
capacity to P3 :
Number of
laboratory staff
trained on 30 35 45 70 100 150 MOH Reports
diagnosis and
identification of
disease in a P3
laboratory

7.7 Epidemic Preparedness and Response and Emerging

Issues
Objective 1: To strengthen capacities to effectively and efficiently implement preparedness and
response in emergencies in Zambia
Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source

Outcome

% of children
who have
received all basic
89% 90% 91% 92% 93% 94% MIS/ZDHS
immunizations by
age 12 months
(fully immunized)

Proportion of
laboratories with
capacity to
30/150 35 45 75 100 150/150 MIS/ZDHS
effectively
investigate public
health threats

Emergency
9% 27% 45% 64% 73% 100%
operation centre MOH report
(1/11) (3/11) (5/11) (7/11) (8/11) (11/11)
in place

IHR core
IHR minimum
capacities
core capacities 50% 60% 70% 80% 90% 100%
monitoring
demonstrated
tool

103
 Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source

Percentage of
districts that
demonstrated an
adequate
response to an
IHR core
emergency from
capacities
any hazard with a 72/105 70/105 80/105 90/105 100/105 105/105
monitoring
coordinated
tool
initial assessment
and a health
sector response
plan within five
days of onset

Early warning
systems,
including event
based
surveillance, IHR core
preparedness, capacities
27/105 54/105 81/105 90/105 100/105 105/105
response, risk monitoring
management, tool
logistics support,
health cluster
coordination in
place

Emergency
Operation
IHR core
Centres and
capacities
their related 1/11 3/11 5/11 7/11 8/11 11/11
monitoring
functions
tool
established/
strengthened

Number of staff MOH training

420 420 500 600 700 800
trained in IDSR report

7.8 Non-Communicable Diseases

Objective 1: To reduce the morbidity and mortality due to non-communicable diseases
Baselin
Target
e
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

Outcome

Reduction of
STEPS Survey,
premature
23% 22% 21% 20% 17% 15% ZNCR, HMIS,
mortality from
DHIS2
NCDs

104
 Baselin
Target
e
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

Cancer incidence,
by type per 58/ 56.3/ 55/ 54/ 53/ 52.3/
HMIS
100,000 100,000 100,000 100,000 100,000 100,000 100,000
population

Prevalence of
childhood 23% 22% 20% 19% 18% 17% ZDHS/HMIS
obesity:

Knowledge level
in population ZDHS/MOH
10% 10% 15% 20% 25% 30%
regarding healthy Survey
lifestyle:

Output

IEC materials
developed for the 10% 20% 40% 60% 80% 95% HMIS
top 10 cancers

% of girls
received HPV 72% 74% 76% 77% 80% 80% HMIS
vaccine

% of regional
hospitals with
chemo- 10% 10% 10% 20% 30% 40% HMIS
radiotherapy
centres.

% upgraded
diagnostic and
treatment 60% 65% 65% 70% 75% 75% HMIS
equipment at
CDH

% districts
conducting
40% 54% 65% 72% 78% 80% HMIS
cervical cancer
screening

% facilities trained
and mentored in
14% 18% 25% 30% 45% 52% HMIS
cancer
management

105
7.9 Hospital Services
Objective 1: To ensure that all hospitals meet standards set per level of care as stated in the
NHCP by 2021
Baselin
Target
e
Indicator
Data
2016 2017 2018 2019 2020 2021
Source

Outcome

Reduced rate of
post-operative 5-10% <1% 0% MOH Survey
wound infection

Output

% of facilities at
all levels offering
surgical, obstetric 25% 30% 50% 88% 90% 100% HMIS
and anaesthesia
care

Number of
procedures
performed in an
1,000 1,000 2,000 2,500 4,000 6,145 MOH Reports
operating room /
100,000
population

% of facilities
using Lifebox,
30% 30% 40% 60% 80% 100% HMIS
SafeObs, and
SafePeds reports

% of hospitals
meeting required 40% 40% 60% 70% 80% 100% PA, HMIS
standards

% of facilities that
have equipment
20% 30% 40% 50% 60% 80% HMIS/HFC
maintenance
plans

% of facilities with
standard and
40% 40% 50% 60% 70% 80% HMIS
functional
equipment

% of hospitals
using e-patient
40% 40% 60% 80% 90% 100% HMIS
record
management

Number of
comprehensive
emergency care 2 6 10 14 18 24 HMIS
units/trauma
centres

106
7.10 Eye Health
Objective 1: To eliminate causes of avoidable or preventable blindness
Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source
Output
Number of Report from
operational eye 1 1 1 1 1 1 MOH/UTH
hospitals Eye Hospital
Percentage of Report from
eye health MOH/UTH
20% 20% 40% 60% 80% 100%
promotion Eye Hospital
programmes
Annual facility
reports/
Cataract surgical
732 732 800 1,000 1,200 1,500 report from
rate
MOH/UTH
Eye Hospital
Number of Report from
active vitreous MOH/UTH
0 0 1 1 2 3
and retina Eye Hospital
surgeons

7.11 Emergency and Mobile Health Services

Objective 1: To provide mobile health services as a complimentary service delivery mode to
people in hard to reach rural and remote parts of Zambia
Objective 2: To coordinate and evaluate emergency health services in Zambia
Baseline Target
Indicator Data
2016 2017 2018 2019 2020 2021
Source
Output
% mobile
outreaches
66% 70% 76% 82% 84% 90% MOH Reports
conducted out
put
% specialist
outreaches
40% 47% 55% 62% 69% 75% MOH Reports
conducted
output
Number of
comprehensive
emergency care 1 2 3 4 5 6 MOH Reports
units/trauma
centres

107
7.12 Imaging Services
Objective 1: To strengthen the provision of imaging services appropriate for each level of car
Baselin
Target
e
Indicator
202 Data
2016 2017 2018 2019 2021
0 Source
Output
% of imaging
departments
providing 66% 76% 84% 86% 88% 90% MOH Reports
accurate
diagnostic results
Number of level
2 and level 3
hospitals with
9 31 MOH Reports
radiologist and
medical
physicists input
% of districts and
provinces with
imaging 40% 50% 60% 65% 70% 75% MOH Reports
coordinators
input
% of imaging
departments
implementing
QI/QA activities
1 2 3 4 4 4 MOH Reports
towards
international
accreditation.
input

7.13 Blood Transfusion Services

Objective 1: To increase the annual blood collection to meet the national blood and blood
products requirements
Baselin
Target
e
Indicator
202 Data
2016 2017 2018 2019 2021
0 Source
Output
% of discards due
to transfusion ZNBTS
10% 9% 5% 4% 3% 1%
transmissible records
infections
Output
Number of units
ZNBTS
collected per 150,000 155,000 160,000 170,000 175,000 180 000
records
year
% of repeat
voluntary blood ZNBTS
40% 45% 60% 70% 75% 80%
donors out of records
total donors bled

108
 Baselin
Target
e
Indicator
202 Data
2016 2017 2018 2019 2021
0 Source
Number of
plasma units
ZNBTS
produced under 0 10,000 20,000 30,000 40,000 50 000
records
plasmapheresis
programme
% of units
processed into
blood
30% 35% 40% 45% 47% 50% MOH Reports
components out
of total units
collected
Number of
provincial blood
1 2 6 8 9 10 MOH Reports
centres using
BSIS

7.14 Laboratory Services

Objective 1: To strengthen the provision of laboratory services that are appropriate for each
level of care to support the national health care package implementation
Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source

Output
Number of
facilities with
functional
389 400 450 470 480 500 NLSP
laboratories
according to
levels
Number of
laboratories
13 20 25 27 30 33 MOH Records
providing
molecular testing
Process
% of laboratories
implementing
quality
17% 20% 30% 40% 45% 50 MOH Reports
management
systems (QMS)
activities
% of
laboratories
with planned
equipment
0 40% 60% 80% 90% 100% MOH Reports
preventive
maintenance
contracts
process

109
 Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source

National
laboratory QA
programme
established at 0 0 0 0 1 1 MOH Reports
Chainama with
adequate staff
process
Output
Number of level
2 and level 3
hospitals with 0 0 5 10 15 20 MOH Reports
biomedical
specialists
% laboratories
with standard
42% 52% 62% 65% 68% 70% MOH Reports
appropriate
infrastructure
% of provinces
and districts with
0 40% 60% 80% 90% 100% MOH Reports
laboratory
coordinators
% of
laboratories
equipped with
automated
analyser
(chemistry, 42% 40% 60% 80% 90% 100% MOH Reports
haematology and
CD4) with
preventive
maintenance
systems
Number of
laboratory
commodities 278 300 350 400 450 500 MOH Reports
available at full
supply input

110
7.15 Environmental Health, Food Safety, and Occupational
Health
Objective 1: To strengthen delivery of sustainable environmental health services.
Objective 2: To promote the health of the consumer by ensuring high standards in the
production, collection, preparation, processing, storage, sale and consumption of food staff
Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source
Outcome

Reduction in
districts
HMIS,
reporting
epidemic
environmental 27 22 17 13 12 15
investigation
related
reports
epidemics
outcome

Output

# of food
establishments
implementing
HMIS reports,
Hazard analysis None 5% 10% 15% 20% 30%
food register
and Critical
Control Point
plan output

Inputs

# of points of
entry with
8/14 8/14 10/14 11/14 12/14 14/14 Reports
established port
health services

Proportion of
staff recruited in
Performance
an established
0/14 0/14 5/14 10/14 12/14 14/14 Assessment
structure for
reports
port health
points of entry

Number of
health facilities
Environmental
with appropriate
50% 52% 60% 65% 75% ≥90% Health (EH)
health care waste
reports
management
system.

Number of
districts with
POTALABS and
27 35 40 45 48 50 EH reports
conducting water
quality
monitoring

111
7.16 Human Resources
Objective 1: To improve the availability of and distribution of qualified health workers in the
country
Objective 2: To strengthen human resource management, in order to improve efficiency and
effectiveness in utilisation of existing staff
Objective 3: To significantly increase the annual outputs of the health training institutions, to
mitigate the critical shortages of qualified health workers
Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source
Output

Number of health
workers Training
graduating from reports
4,000 6,000 7,000 8,000 9,000 10,000
training
institutions Index registers
annually

Inputs

% of rural health
facilities with at
88% 88% 90% 94% 96% 100% Staff returns
least one qualified
health worker

% of health
facilities with at 95
73% 73% 80% 85% 100% Staff returns
least 80% filled %
establishment

7.17 Health Care Financing Strategy

Objective 1: To reduce the budget gap in the health sector by mobilizing adequate and
sustainable financial resources.
Baseline Targets
Indicator
2016 2017 2018 2019 2020 2021 Data Source

Input

GHE/Total 9% 10% 12% 13% 15%

government 8.3% NHA
expenditure

HHE/THE 30% 26% 24% 22% 20% 18% NHA

112
7.18 Health Information Technology and Research
Objective 1: To ensure availability of relevant, accurate, timely and accessible health data, to
support the planning, coordination, research, and M&E of the health sector to inform evidence-
based decision-making
Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source

Output

% of facilities with
E-Health
functional
2% 4% 20% 30% 40% 60% Strategy 2017-
electronic records
2021
process

Output

Number of
research
institutions/sites Research
0 0 0 0 1 2
designated as registry
National Bio
Banks

7.19 Health Infrastructure

Objective 1: To increase access to health services through construction/ rehabilitation of health
facilities in order to facilitate equity of access to quality health services
Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source

Output

Number of first- Infrastructure

level hospitals 36 6 - 10 10 (10)36 Operation
completed Plan reports

Number of health Infrastructure

posts / centres 272 300 100 100 100 600 Operation
constructed Plan reports

Number of Infrastructure
facilities 250 50 50 50 50 (50) 250 Operation
modernized Plan reports

Number of
ongoing
Infrastructure
construction
TBA 200 100 100 500 Operation
health posts
Plan reports
works
commissioned

113
 Baseline Target
Indicator
2016 2017 2018 2019 2020 2021 Data Source

Number of
ongoing Infrastructure
construction TBA 6 10 10 10 36 Operation
district hospitals Plan reports
commissioned

Number planned Infrastructure

health centres TBA 56 56 25 25 162 Operation
commissioned Plan reports

Number planned Infrastructure

general hospitals TBA 4 2 2 8 Operation
commissioned Plan reports

Number planned
Infrastructure
health specialists
TBA 1 3 2 6 Operation
hospitals
Plan reports
commissioned

Proportion of
Infrastructure
population living
78.6% 80% 85% 90% 95% 100% Operation
within 5 km of
Plan reports
health facility

Number of new Infrastructure

first-level hospitals 36 3 10 10 7 30 Operation
commenced Plan reports

114
 5

LIST OF CONTRIBUTORS
Directors/ Senior Management at the MOH
1. Dr. Maximillian Bweupe Director, Health Policy & Health Systems Planning
2. Prof. Sekelani Banda Director, Human Resource Development
3. Dr. Kennedy Malama Director, Public Health
4. Dr. Francis Bwalya Director, Health Promotion, Environmental Health &
Determinants of Health
5. Dr. Mzaza Nthele Director, Clinical Care & Diagnostics Services
6. Dr. Elizabeth Chizema Director, National Malaria Elimination Centre
7. Dr. Wezi Kaonga Deputy Director, Health Promotion, Environmental
Health & Determinants of Health
8. Mr. Mulonda Mate Deputy Director, Environmental Health
9. Dr. Daniel Makawa Deputy Director, Clinical Care & Diagnostics Services
10. Mr. Henry Kansembe Deputy Director, Planning & Budgeting
11. Mr. Chipalo Kaliki Deputy Director, Monitoring & Evaluation
12. Dr. Mpuma Kamanga Deputy Director, Health Policy
Provincial Health Directors/Provincial Staff
1. Dr. Abel Kabalo Provincial Health Director, Eastern Province
2. Dr. Consity Mwale Provincial Health Director, Copperbelt Province
3. Dr. Andrew Silumesi Provincial Health Director, North-Western Province
4. Dr. Rose Mwanza Provincial Health Director, Central Province
5. Dr. Jelita Chinyonga Provincial Health Director, Southern Province
6. Dr. Manase Zulu Provincial Medical Officer (Former), Muchinga Province
7. Dr. Asphalt Choonga Provincial Medical Officer (Former), North-Western
Province
8. Dr. Francis Bwalya Provincial Medical Officer (Former), Northern Province
9. Dr. Kennedy Malama Provincial Medical Officer (Former), Lusaka Province
10. Dr. Ng’ambi Mathews Provincial Medical Officer (Former), Luapula Province
11. Dr. Wajilovia Chilambo Clinical Care Specialist, Lusaka Province
12. Dr. Charles Msiska District Health Director, Chongwe District

Core Team
1. Dr. Maximillian Bweupe Director, Health Policy & Health Systems Planning
2. Mr. Henry Kansembe Deputy Director, Planning & Budgeting
3. Mr. Patrick Banda Chief Planner, Planning and Budgeting
4. Mr. Amadeus Mukobe Chief Planner, Development Cooperation
5. Mr. Roy Chihinga Chief Human Development Officer
6. Mr. Terence Siansalama Principal Planner, Bilateral & Multilateral Cooperation
7. Mr. Wesley Mwambazi Principal Planner, Health Systems
8. Ms. Maudy Kaoma Principal Planner, Planning & Budgeting
9. Mr. Alex Kaba Senior Planners, SWAp
10. Ms. Yolanda Lumpuma Senior Planner, Development Cooperation
11. Ms. Namwiinga Choobe Senior Planner, Planning & Budgeting
12. Mr. Melvin Sikazwe Senior Planner, Planning & Budgeting
13. Mr. Mannix Ngambwe Senior Planner, Planning & Budgeting
14. Ms. Rita Mweeka Banda Planner, Planning & Budgeting
15. Ms. Judith Shonga Planner, Planning & Budgeting

115
 16. Ms. Fridah Ng’uni Planner, SWAp
17. Mr. Francis Chipasha Planner, SWAp
18. Ms. Doreen Bwalya Planner, Planning & Budgeting
Editors
1. Mr. Amadeus Mukobe Chief Planner, Development Cooperation
2. Mr. Patrick Banda Chief Planner, Planning and Budgeting
3. Mr. Terence Siansalama Principal Planner, Bilateral & Multilateral Cooperation
4. Ms. Maudy Kaoma Principal Planner, Planning and Budgeting
5. Mr. Wesley Mwambazi Principal Planner, Health Systems
6. Mr. Alex Kaba Senior Planner, SWAp
7. Ms. Yolanda Lumpuma Senior Planner, Development Cooperation
8. Ms. Namwiinga Choobe Senior Planner, Planning & Budgeting
9. Ms. Rita Mweeka Banda Planner, Planning & Budgeting
10. Ms. Judith Shonga Planner, Planning & Budgeting
11. Mr. Francis Chipasha Planner, SWAp
12. Ms. Doreen Bwalya Planner, Planning & Budgeting
13. Abt Associates Inc. USAID Systems for Better Health Project
Consultants
1. Dr. Victor M. Munkoka
2. Dr. Jolly Kamwanga
3. Dr. Ute Schumann
4. Mr. Takondwa Mwase

116