Enhancing SRH service coverage for UHC in Zambia

Summary article
The article discusses Zambia’s efforts to enhance Sexual Reproductive Health (SRH) service coverage for vulnerable populations, aligning with Universal Health Care (UHC) goals. It highlights challenges in SRH indicators, especially among adolescents, and addresses barriers faced by those with disabilities. The Make Way program, implemented in Zambia, creates safe spaces to break down access barriers. An analysis of health budget allocations reveals positive trends but falls short of Abuja Declaration targets. Successful engagement with parliamentarians leads to acknowledgment of gaps and support for key recommendations, including increased budget allocation and improved health worker recruitment strategies.

The Government of Zambia, aligning with national targets and UHC goals, prioritizes sexual reproductive health and rights (SRHR) in its key strategy areas. Recent efforts focus on legislative, policy, and program reforms to inclusively address SRHR for marginalized groups.

Background and government prioritization
A comprehensive overview of the government’s budgetary plans, spending assessment, and recommendations aimed at enhancing the 2024 Health budget allocation and to ensure the effective implementation of strategies outlined in key documents such as the 8th National Development Plan, Medium Term Budget Plan 2023-226, National Health Strategy 2022-2026, Adolescent Health Strategy 2022-2026, and international commitments for instance the Abuja Declaration, most recently the African Leader Meeting and Revised Maputo plan of action.

Challenges and inequalities in SRH indicators
Although much progress has been made to improve SRH indicators in Zambia as evidenced from the Zambia Demographic and Health Survey (2018 ZDHS), challenges and inequalities are still visible. Data from the 2018 ZDHS illustrates that about 32% of adolescents aged 15-17 and 60% of those aged 18-19 are sexually active in Zambia, and therefore are at high risk from HIV and other sexually transmitted infections (STIs), especially as only 40% of them report regular condom use. As a result, 5.6% of female youth (15 – 25 years) and 1.8% of male youth are living with HIV. While teenage pregnancy declined over time, the 2018 ZDHS shows that over 29% of girls under 20 in Zambia experienced a teenage pregnancy. Southern province has with 42.5% the highest percentage of teenage pregnancy in Zambia (2018 ZDHS). Eastern province has a teenage pregnancy rate of 39.5%, Muchinga 29.3% and Luapula 29%. The percentage of teenagers who have begun childbearing is higher in rural areas (37%) than in urban areas (19%). (ZDHS, 2018).

Barriers faced by adolescents and young people with disabilities
Evidence suggests that adolescents and young people (especially minoritized girls) living in poverty with a disability – face high barriers to accessing the services they need and want. Interrelated and systemic barriers keep marginalized youth from realizing their SRHR. Negative societal views including gender and social norms cause stigma, discrimination, and exclusion. SRH services are often not accessible or of low quality. As such, young people in Zambia are faced with a range of problems related to their sexual and reproductive health rights. The unavailability of professional health workers as well the Health workers attitude of being judgmental as well as poor quality of service provision affects the acceptability of SRH services provided in health facilities. The inadequate of health financing, long distances to points of supply of SRH services that prevents young people with in accessing services. It also notably that barriers to teaching contraceptive was barrier to girls because of cultural and social norms that led to young people to have limited decision-making power regarding health especially reproductive health which require parental consent. As a result, parents who are expected to give consent do not understand the reproductive health needs of the girls and feel that such information was not appropriate for the young girls.

Introduction to the Make Way programme

The ‘Make Way programme’ is a five-year programme (2021-2025) aiming to break down barriers to Sexual and Reproductive Health Rights (SRHR) by promoting a new way of considering discrimination through an intersectional lens. The Make Way programme is implemented in Ethiopia, Kenya, Rwanda, Uganda, and Zambia. In Zambia, the Make-Way is a consortium led programme which consists of Akina Mama wa Afrika, The Circle of Concerned African Women Theologians, Forum for African Women Educationalists in Zambia and Cheshire Home society of Zambia.

Make Way programme implementation in Zambia

Cheshire Homes Society of Zambia with its cooperating partners (Zambia Federation of disability Organization, Group Focused Consultations and Advocacy on Human Development) embarked on establishing both inclusive and exclusive safe spaces to break barriers to access Sexual reproductive Health services in Lusaka Ndola, Mufulira, Mansa.

Safe spaces for breaking barriers

Under the Make Way programme the definition, “safe space” refers to a physical or digital context where people can express their views, needs and opinions and non-judgmentally and respectfully enter into dialogue with each other and duty bearers. Safe spaces are spaces where adolescents and young people can trust they will not be exposed to discrimination, harassment, or any other emotional, psychological or physical harm.

It is through the Make Way programme that young people with compounded vulnerabilities have been able to be part of these safe spaces and learn about sexual reproductive and health rights as well as being advocates of intersectional sexual reproductive health services.

Government budgetary plans and spending assessment

Through these spaces young people with consortium members conducted a comprehensive overview of the government’s budgetary plans, spending assessment, and recommendations aimed at enhancing the 2024 health budget allocation. Its main objective is to ensure the effective implementation of strategies outlined in key documents such as the 8th National Development Plan, Medium Term Budget Plan 2023-226, National Health Strategy 2022-2026, Adolescent Health Strategy 2022-2026, and international commitments for instance the Abuja Declaration, most recently the African Leader Meeting and Revised Maputo plan of action.

Analysis of health budget allocations

Through an examination of the government’s budgetary plans, the brief assesses the progress made in aligning financial resources with the outlined strategies, this assessment helps identify gaps and areas that require improvement to ensure the achievement of desired developmental outcomes in the health sector, particularly in relation to sexual reproductive health services for young people with compounded vulnerabilities

Furthermore, the health budget’s share of the total expenditure has experienced a slight increase, climbing from 7.72% in 2021 to 9.6% in 2023. Despite this positive trend, it is important to note that this allocation falls short of the target set in the Abuja Declaration. In the Abuja Declaration, Zambia committed to allocating at least 15% of its annual budget to enhance the health sector. Unfortunately, Zambia has not met this target in any of the past three years. The current 2023 health allocation needs to be increase by 56.1 % to attain the Abuja Declaration.

According to the Alma-Ata Declaration, maternal and child healthcare, including family planning, reproductive, maternal neonatal, child, and adolescent health and nutrition (RMNCAH-N), are among the essential components of Primary Health Care.

Therefore, assessing the trend in primary healthcare allocation provides an indication of the trend in allocations towards sexual and reproductive health and rights (SRHR).
Within the allocation for Primary Health Care, where most sexual and reproductive health (SRH) services fall, there has been an increase in personal emoluments. The average allocation for personal emoluments rose from ZMW 1.5 billion between 2021 and 2022 to ZMW 2.4 billion in 2023.

On the other hand, the allocation for the use of goods has experienced a marginal increase, indicating a slight upward trend in the allocation for goods and services. However, it is crucial to note that the effects of inflation may diminish the increase in the allocation for the use of goods and services in the delivery of primary healthcare in 2023.

The 2023 Budget Speech and the 2023-2026 Medium Term Budget Plan show that government aims to attain human and social development in the medium term through improved health provision, supported by integrated systems, improved access to quality health services, including specialized services. Over the medium term, Government will focus on providing equitable access to preventive, curative and quality health care at all levels of service delivery. It will address the high disease burden, through recruitment of 10,000 medical personnel (3000 recruited in 2023), enhance the provision of drugs, medical supplies and medical equipment, increase health financing and complete and construct health infrastructure. At the local level, it is also envisaged that health projects will be prioritized under the Constituency Development Fund (CDF).

Successes and acknowledgment from parliamentarians

The Zambia Make Way consortium members held a one-day advocacy meeting with Parliamentarians and relevant Parliamentary Committees members on Health, SRHR caucus and Budget. The objective of the meeting was in order to present the finding on the gaps in the 2023 national budget particularly health budget in attainting the universal health coverage by 2030 as well as recommendation for the 2024 budget in order to attain the desired outcome in health of not leaving anyone behind.

It was a success meeting that saw parliamentarians acknowledging and admitting to the finding that were presented on the budget analysis for 2023 in form of a health policy brief.

The buy in of the recommendation by parliamentarians committee members presents was a plus to achieving the goal of the meeting e.g Honorable members agreed that the matrix needs to be conducted before the recruitment of health workers in the 2023 should be considered that will mirror the needs of the Ministry of health not the way it was previously done in 2022 in Lundazi where five mortuary attendants were posted instead of Nurses and Doctors to provide primary health care services in order to attain of universal health coverage.

The parliamentarians stated that they have little to do with the budget in its currently state of reforms so parliamentarians are advocating for sector budgeting, so that they have greater influence. They are need to have robust fundraising to meet the Abuja commitment and stated that the its declaration has outlived and countries have challenges to attain it and there is need to review the Abuja declaration. They pledged to increase domestic resources to finance health as it is donor driven. They implored young people to involved to take a step in all development agenda in the country. Parliamentarians as well pledged to continue to be the agent of change and to ensure that awareness is raised on constituencies development funds (CDF) their respective constituencies and for Community Based Organizations, non-governmental organizations to take advantage of CDF for adolescents programming.

Lessons learned and recommendations for future actions

• To fulfill its pledge to allocate 15% of the national budget to the health sector in 2024.
• To ensure an equitable distribution of health workers across the country, it is important for Ministry of Health to develop a location and desired skills matrix for the recruitment of the remaining 7000 health work in 2024 and 2025.
• In the construction and rehabilitation of district hospitals, it is essential for the government in construction plans to prioritize the inclusion of youth-friendly spaces that are accessible and equipped with the necessary resources outlined in the Adolescent Health Strategy of 2022-2026.
• It is crucial for the Ministry of Health (MoH) to evaluate the effectiveness of existing mentorship programs and establish to more comprehensive capacity-building strategy to enhance the attitudes of healthcare personnel specifically when providing SRH service to marginalized young people.
• To ensure no one is left behind in-service delivery, there is need to introduce disability training course as compulsory course for medical personnel.