Africa Lower-middle-income countries

Financing options for universal health coverage in Zambia

Bona Chitah and Dick Jonsson, of the Department of Economics at the University of Zambia, have written an assessment of Zambia’s progress towards universal health coverage for GNHE.

You can read the full assessment here.

The authors’ main conclusions are:

  • Zambia is making continuous progress in all the key areas of its health system. However, there are gaps which need to be resolved for the country to be able to realise the goal of universal coverage, including universal financial protection and access to care.
  • A more equitable distribution of resources between urban and rural areas is required. Currently there is an urban bias in resource distribution. This is evidenced not only in the allocation of public health sector resources, but also in expenditures by the wealthy on private health care.
  • Resources need to be allocated to promote access to, and utilisation of, health care by the poorer socio-economic groups. The higher consumption of public inpatient health care services by wealthier groups is a striking example of inequitable utilisation, as is the relatively greater levels of government subsidy received by wealthier groups, even for primary health care.
  • The impoverishing effect of out-of-pocket payments exposes poorer households to financial risk, driving households into poverty or further into poverty. This requires reconsideration of public hospital user fees, both in terms of the level of fees and the application of bypass fees (which are charged when patients bypass primary health care facilities, including because of the severity of their conditions and their proximity to higher-level health facilities).
  • Finally, Zambia’s ambition to introduce social health insurance as a mechanism for improving the pooling and purchasing of services needs to be scrutinised for its possible impacts on equity. The proposed social health insurance scheme would require co-payments and perhaps other contributions, which would increase the financial burden on households. This means that the proposed scheme could effectively run counter to the ambition of attaining universal health coverage.
  • There should be a critical evaluation of the alternative option of simply continuing – and strengthening – the current tax-based financing system.

Chitah B, Jonsson D. 2015. Universal health coverage assessment: Zambia. Global Network for Health Equity (GNHE). Available at:


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