Exploring for-profit healthcare providers' perceptions of inclusion in the Zambia National Health Insurance Scheme: A qualitative content analysis.

BACKGROUND: In 2019, Zambia introduced the national health insurance (NHI) as a healthcare financing strategy to increase universal access to health care services. The private health sector can complement public sector providers as service providers under the NHI. As such, the NHI Management Authority seeks to accredit for-profit private healthcare facilities in the NHI. Ascertaining factors that influence private-for-profit health providers to participate in the NHI is essential, but the evidence is lacking. In this study, we aimed to explore and characterize perceptions and experiences of for-profit private hospitals, dental clinics, eye clinics, diagnostic centres, and pharmacies regarding their inclusion in the NHI. METHODS: We conducted in-depth interviews with owners or management officers of purposively sampled private health care providers in Lusaka, Zambia (n = 22) between May and June 2020. Qualitative content analysis was used to analyse data. RESULTS: The findings highlight low awareness of the NHI among providers and a need to understand the NHI. Providers revealed their positions and views on the accreditation process and payment arrangements and stated that their participation would complement the NHI. They also cited conditions to participate in the NHI, highlighted opportunities and challenges of engaging in the NHI, and expressed a need for sustainable ways of governing the scheme. CONCLUSION: The assessment of health providers' inclusion in the NHI scheme is multifaceted. The results of this study surfaced factors such as raising awareness on the NHI among providers and how their concerns on aspects such as payments can be considered as inputs to enlighten consensual agreements between the NHI authority and health providers in leveraging the private health sector. Private providers' concerns must be further understood and considered as the NHI strives to include this group as health care providers in the scheme.

The potential health and revenue effects of a tax on sugar sweetened beverages in Zambia.

The global burden of non-communicable diseases (NCDs) has been rising. A key risk factor for NCDs is obesity, which has been partly linked to consumption of sugar sweetened beverages (SSBs). A tax on SSBs is an attractive control measure to curb the rising trend in NCDs, as it has the potential to reduce consumption of SSBs. However, studies on the potential effects of SSB taxes have been concentrated in high-income countries with limited studies in low-income and middle-income countries. Using data from the 2015 Zambia Living Conditions Monitoring Survey (LCMS) data, the 2017 Zambia NCD STEPS Survey, and key parameters from the literature, we simulated the effect of a 25% SSB tax in Zambia on energy intake and the corresponding change in body mass index (BMI), obesity prevalence, deaths averted, life years gained and revenues generated using a mathematical model developed using Microsoft Excel. We conducted Monte Carlo simulations to construct 95% confidence bands and sensitivity analyses to account for uncertainties in key parameters. We found that a 25% SSB would avert 2526 deaths, though these results were not statistically significant overall. However, when broken down by gender, the tax was found to significantly avert 1133 deaths in women (95% CI 353 to 1970). The tax was found to potentially generate an additional US$5.46 million (95% CI 4.66 to 6.14) in revenue annually. We conclude that an SSB tax in Zambia has the potential to significantly decrease the amount of disability-adjusted life years lost to lifestyle-related diseases in women, highlighting important health equity outcomes. Women have higher baseline BMI and therefore are at higher risk for NCDs. In addition, an SSB tax will provide government with additional revenue which if earmarked for health could contribute to healthcare financing in Zambia.

Looking at the bigger picture: effect of performance-based contracting of district health services on equity of access to maternal health services in Zambia.

Zambia has been using output-based approaches for over two decades to finance whole or part of the public health system. Between 1996 and 2006, performance-based contracting (PBC) was implemented countrywide with the Central Board of Health (CBoH) as the provider of health services. This study reviews the association between PBC and equity of access to maternal health services in Zambia between 1996 and 2006. A comprehensive document review was undertaken to evaluate the implementation process, followed by a trend analysis of health expenditure at district level, and a segmented regression analysis of data on antenatal care (ANC) and deliveries at health facilities that was obtained from five demographic and health survey datasets (1992, 1996, 2002, 2007 and 2014). The results show that PBC was anchored by high-level political support, an overarching policy and legal framework, and collective planning and implementation with all key stakeholders. Decentralization of health service provision was also an enabling factor. ANC coverage increased in both the lower and upper wealth quintiles during the PBC era, followed by a declining trend after the PBC era in both quintiles. Further, the percentage of women delivering at health facilities increased during the PBC era, particularly in rural areas and among the poor. The positive trend continued after the PBC era with similar patterns in both lower and upper wealth quintiles. Despite these gains, per capita health expenditure at district level declined during the PBC era, with the situation worsening after the PBC era. The study concludes that a nationwide PBC approach can contribute to improved equity of access to maternal health services and that PBC is a cost-efficient and sustainable policy reform. The study calls for policymakers to comprehensively evaluate the impact of health system reforms before terminating them.

Crunch Time: The Transformational Universal Health Coverage Agenda for Zambia.

There is a realization worldwide that health expenditure can be catastrophic, exacerbate inequalities between poor and rich households, and drive people into poverty. As such, a number of countries seek to provide universal health coverage (UHC) to all of their citizens in order for everyone to access quality health care without financial adversity. However, attaining UHC is difficult. It has also been recognized that there is no universal formula for attaining UHC and that each country must create its own. This article describes Zambia's trajectory to achieving UHC from the 1990s to date. The article highlights some of the past institutional and financing reforms, achievements made, and gaps and challenges that the government is determined to address through an explicit transformational agenda that was launched in 2011. This agenda is being pursued with renewed vigor given that Zambia's economy and population are growing rapidly, the time to transition from external support is fast approaching, and the disease profile is changing.

Adherence support workers: a way to address human resource constraints in antiretroviral treatment programs in the public health setting in Zambia.

BACKGROUND: In order to address staff shortages and improve adherence counseling for people on antiretroviral therapy (ART), the Zambia Prevention, Care and Treatment Partnership (ZPCT) developed an innovative strategy of training community volunteers to provide adherence support at the health facility and community levels. The objective of this study was to assess the effectiveness of these 'adherence support workers' (ASWs) in adherence counseling, treatment retention and addressing inadequate human resources at health facilities. METHODOLOGY/PRINCIPAL FINDINGS: The study used quantitative and qualitative research techniques at five selected ART sites in four provinces in Zambia. Five hundred patients on ART were interviewed using a structured questionnaire to compare the quality of adherence counseling before and after the ASW scheme was introduced at the selected sites and between ASWs and HCWs after the introduction of ASWs. In addition, 3,903 and 4,972 electronic records of all new patients accessing antiretroviral therapy for the time period of 12 months before and 12 months after the introduction of ASWs respectively, were analyzed to assess loss to follow-up rates. Two focus group discussions with ASWs and health care workers (HCWs) were conducted in each clinic. Key informant interviews in the ART clinics were also conducted. There was a marked shift of workload from HCWs to ASWs without any compromise in the quality of counseling. Quality of adherence counseling by ASWs was comparable to HCWs after their introduction. The findings suggest that the deployment of ASWs helped reduce waiting times for adherence counseling. Loss to follow-up rates of new clients declined from 15% to 0% after the deployment of ASWs. CONCLUSION: Adherence counseling tasks can be shifted to lay cadres like ASWs without compromising the quality of counseling. Follow-up of clients by ASWs within the community is necessary to improve retention of clients on ART.