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Making free health care work for all Zambians: will this election deliver?

Vote Health for All logoWhile in the midst of parliamentary and presidential elections here in Zambia, I want to use this post to bring broader international attention to our joint NGO ‘Vote Health For All’ campaign and some of the issues we raise in our new policy brief – Making free health care work for all Zambians: Will this election deliver?

A recent evaluation suggests that five years of free health care has done little to improve access to services for rural Zambians.[1] While use of facilities increased by an impressive 55% when fees were first removed, this increase has not been sustained over time. Some commentators will undoubtedly use the evaluation to claim that Zambia’s ‘free health care experiment’ has been a resounding failure and should be abandoned. But with one of the highest maternal mortality rates in the world, rising inequality and urban poverty, and continuing barriers to access such as long distances to health facilities, abandoning free care in Zambia is just not an option. A closer look at the evaluation also raises some serious questions as to whether free care itself is the problem or rather how it was implemented.

Firstly, it’s difficult to conclude that free care had no impact on numbers seeking care when in many facilities, although fees were reduced (by an average of 51% in hospitals and 31% in health centres)[2] they were not actually removed. Even after the policy was introduced up to a third of people in rural areas continued to pay out of pocket when they received treatment.[3] In a country where half the population cannot meet basic needs even modest fees represent a major barrier for the very poor. To suggest that fee removal has not worked when in practice people are still paying for treatment would therefore be misleading.

Secondly, few of the now well understood necessary steps for successful fee removal have been taken.[i] When the Zambian President announced the policy change in January 2006, he committed to abolish user fees in all government and mission-run facilities in rural districts from April 2006. This allowed just three months for planning and communication. When the policy came into effect, lack of resources including drugs, staff and additional funding seriously compromised the ability of facilities to meet the needs of patients. Additional health workers were not deployed to rural areas and steps were not taken to mitigate the impact on staff.[ii] Measures were not taken to reduce the risk of drug stock-outs and in the first year 60% of essential drugs were unavailable.[4] To make matters worse, many health facilities experienced a loss of income. While the loss of user fee revenue was due to be compensated – through a UK DFID replacement grant – in practice problems with disbursement meant that many districts had still not received the grant several months after the policy change. But user fee removal wasn’t the only reason for a drop in resources – between 2004 and 2006 there was a large reduction in district non-wage and district drug expenditure (down by 13% and 34% respectively). Overall, quality of health care suffered and patients faced longer waiting times, fewer drugs, and overworked staff.

Should the free health care policy be abandoned? I would argue that while the obstacles to successful implementation are formidable they can and must be overcome. The issues identified in the evaluation should be urgently addressed by the Government of Zambia with aligned support from development partners.  Free health care must be made to work – continuing user fees puts lifesaving treatment out of reach for the poorest and most vulnerable people. If the right steps are taken free health care for all is both possible and affordable in Zambia. With the 2011 general election literally round the corner, the time is ripe for political leaders to step up to the challenge and make free health care work for all Zambians.


Felix Mwanza is the National Coordinator of Treatment, Advocacy and Literacy Campaign (TALC), a membership organisation which lobbies for equitable and sustainable access to affordable, quality HIV treatment, support and care in Zambia.

‘Vote Health for All’  is a coalition campaign whose members include: Civil Society Health Forum, Fair Play for Africa, Women in Law Southern Africa, 2410, Media Life, and Oxfam.

[i] For example, in the original terms of reference for the User Fee Removal Committee, budget proposals were to be prepared to meet the costs of an anticipated increase in demand for free services, including the procurement of additional drugs and recruitment and deployment of more health workers to rural areas. However, these proposals were never finalised. For a fuller discussion of the necessary steps for successful fee removal see Save the Children UK (2008) ‘Freeing Up Health Care: A guide to removing user fees’
[ii] Staff bonuses (typically 10% of fees raised) were scrapped and health workers faced an increased workload as demand rose. This led to high levels of dissatisfaction among health workers.

[1] Carasso, B et al. (2010) ‘Evaluating the impact of abolishing user fees in Zambia – summary of findings’  LSHTM, UZAM, UCT, MoH Zambia
[2] Lagarde, M (2010) ‘ Analysis of the impact of user fee removal on health seeking behaviours using a difference-in-differences approach’ LSHTM, UZAM, UCT, MoH Zambia
[3] Ibid.
[4] Zambia Ministry of Health (2007) Health Sector Joint Annual Review Report 2006. Lusaka, GRZ 


3 Responses to “Making free health care work for all Zambians: will this election deliver?”

  1. Peter Cross says:

    With all due respect, Felix should read “Dead Aid” written by a fellow Zambian, Dambisa Moyo. As demonstrated implicitly in the data cited by Felix, the problem of access lies as much in the quality of the services as in the price. Once you have reasonable quality, access and, more importantly, utilization will follow. Then, governments can target their resources on those that cannot afford the cost. Since the wealthy always have more influence in a political system, universal free services always benefit the wealthy more than the poor. In the case of foreign aid studied by Dambisa, the money remains disproportionately near the top of the pyramid.

    Felix says: The reality is that for quite a long time to come, although Zambia’s economy is improving, we are going to be dependent on aid.

    Access, quality and assurance of health services in Zambia is a problem. We have people who don’t have access to health facilities – according to the WHO, health clinics should be within a radius of 10km, and a person should be attended to within an hour of arriving at the clinic or health facility. This a dream for the average Zambian, not reality, because they often have to travel a distance of 20km. In worse cases people in more rural areas have to travel between 80 to 100 kms to access services.

    So what we need to be doing at the moment is to utilise the little available resources that are coming from cooperating partners and donors and make sure that these resources are properly used and are transparently accounted for. Then we should also endeavour to allocate more resources to the health budget so that we are in a position to improve the quality of health service delivery by ensuring that we build more health facilities near the people, we have more qualified health personnel, and we have enough medicines.

    Any comments that do not offer new solutions about how Zambia as a nation should tackle these issues are not helping. I have read Dambisa’s book. Of course it is interesting but I am sorry to say that she does not offer much in the way of solutions about how Zambia can be self-sustaining in addressing its problems regarding health, sanitation, education and poverty.

    • Anna Marriott says:

      Thanks Peter. Here’s a link to some others who, like Felix, wouldn’t be so quick to agree with Moyo. Thanks to Oxfam’s Head of Research Duncan Green for doing the work for us already on this.

      And on universal free services always benefiting the better off, there are plenty who agree with you and plenty who don’t. To date the most convincing and comprehensive piece of work on this issue I’ve come across is a massive study done a few years ago by EQUITAP .

      Just to give you a flavour: In their empirical assessment of health care equity across 16 Asian countries Equitap found that ‘the ability of countries to reach and protect the poor varies considerably not by level of economic development, or even levels of public spending, but by type of health system…

      In most [Asian] countries, the poorest quintile benefits from less than 20% of total government spending. However, there are three exceptions: in Sri Lanka, Malaysia and Hong Kong, the poor do benefit more from government spending than the rich. What is particularly remarkable about this is that these three countries, ranging from low-income Sri Lanka to high-income Hong Kong, are the three countries in Asia which rely on tax-funding for their public sector, do not levy significant user charges in their public hospitals, and make no effort to explicitly target government services….

      the countries where the poor are most effectively reached by services, are the countries where national policies stress universalism (Sri Lanka, Thailand post-2000, Malaysia). Although universalism is often not in favour in development circles, because it is considered unfeasible in resource-constrained settings, the reality is that the only poor countries where the poor are effectively reached are those where policies do not explicitly target the poor, either through user fee exemptions or specially-targeted programmes.’

  2. Rob Yates says:

    You analysis is spot-on Felix. Your problems in Zambia stem from the fact that appropriate supply side reforms didn’t take place as fees were removed. Experience is showing that the most important ares to strengthen concern recurrent inputs – in particular paying health workers and sustaining drug supplies. Were your Govt and donors to put more resources into these areas and strengthen management systems I am sure you free health care policy would be more successful.


    Rob Yates

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