Perspective Chapter: Health Inequalities in Zambia – A Comprehensive Exploration

Abstract

Zambia like any other developing country is faced with a lot of health inequalities that includes disease burden, poor housing and infrastructure, poor sanitation, water supply challenges, poverty and nutrition deficiencies. In 2019, the Ministry of Health Zambia reported to have made significant steps towards improving the health of the population based on the principle of Universal Health Coverage using an integrated people-centred approach. Through these steps, the National Health Insurance Scheme was introduced which is still in effect and its positive outcome has been noted by the population even though it had its negative sides such as not providing some essential services especially those related to accidents.

1. Introduction

According to the 2022–2026 National Health Strategic Plan issued by the Ministry of Health, Zambia faces a number of diseases such as maternal, child and adolescent health problems; communicable diseases (Malaria, HIV/AIDS, Sexually Transmitted Infections (STIs), Tuberculosis (TB), Covid-19, among others, and a growing burden of non-communicable diseases (NCDs). Even though there has been progress in selected health indicators, particularly for maternal and child health, this progress has been inadequate and below the targets [1].

As the world faces the cascading and interlinked global crises and conflicts, the aspirations set out in the 2030 Agenda for Sustainable Development are in jeopardy. The Ukraine-Russia war has also contributed to the health inequalities in Zambia through food crisis, fertiliser and oil price increments [2]. These factors have heavily affected the country and this is evidenced by the increase of essential commodities, borrowing by the government to cushion the national treasury, inadequate availability of medicines and essential medical supplies as well as failing to manage the agriculture and mining industry.

2. The health inequalities in Zambia

2.1 The health system

Zambia is a signatory to many conventions or treaties and on health, it is a signatory to the abuja declaration on HIV and AIDS, T.B and other Infectious Diseases which set a target for all member states to allocate at least 15% of its national budget to health to ensure proper management of the health sector. In the 2022–2023 National Budget, Zambia was below the target and only managed to allocate 10.4% out of the target required to meet the target. Even though there was a slight increment of 2.4% from the 2022 national budget which the government allocated 8% from the total National Budget. This is the reason why there is inadequate essential medicine and other medical supply [3].

Health is wealth. The country which struggles with its health system has no guarantee of being a wealthy nation. According to the 2023 national budget address presented to parliament by finance minister Hon. Minister Situmbeko Musokotwane, the budget indicated that the government had committed towards improving the health of the Zambian population by recruiting health personnel, infrastructure development and provision of drugs and medical supply [4].

In 2023, the government managed to recruit more than 11,000 health personnel and placed them in different health facilities across the country. While this progress was made, the health sector experienced shortages of medicines in health facilities across the country and many patients were issued with prescriptions to go and buy and only those under National Health Insurance Scheme (NHIMA) had the privilege of certain types of medication and services [5].

According to the report of the Committee on Health, Community Development and Social Services for the First Session of the 13th National Assembly of Zambia, the committee confirmed the shortages of medicines in most public health facilities. The report also outlined some of the contributing factors to the shortage of pharmaceutical products such as the dependency on importation of products and delayed payments by government which resulted in the government accumulating debt owed to players in the pharmaceutical sector for the provision of various goods and services [6, 7].

The committee was saddened to learn that the government was importing intravenous fluids (IVF/Drips) despite having a fully-fledged local manufacturing company producing these fluids. This later impacted the patients who bore the cost of medicines and medical supplies from private Pharmacies. There was a need for the government to prioritise the local manufacturers and speed up the payment procedures so as to encourage local manufacturers to produce more and since the same money government pays is used to acquire raw materials for the manufacture of goods needed in the health sector. Government will also need to reduce the tax of all the products that the private local manufacturers may need for the production of essential goods such as medicines and medical supplies. In that way, the local producers will be encouraged to produce more and this will lead to more employment as more manpower will be required to meet the demand.

3. Transport system

In Zambia, to travel from one town or district, you either use the bus or your own private vehicle and only few people use local aircraft to travel from one province to the other. Road transport is the only reliable and faster way of travelling. With the increase in the prices of fuel, that means transportation has become a challenge. Transport challenges is a negative signal indicating that commodities like food will be difficult to be transported from one place to the other and in 2023, Zambia observed the increase of mealie meal prices which most Zambians depend on a daily basis.

4. Cost of leaving

The cost of living has been observed to have been rising year in year out. This has been observed through the increase in prices of essential commodities like fuel and maize meal. According to the Jesuit Centre for Theological Reflection 2023 May, the cost of living for a family of five as measured by the Jesuit centre for Theological Reflection (JCTR) Basic Needs and Nutrition Basket (BNNB) for the month of July stood at K9301.18 compared to June which stood at K9239.45 which shows an increase of K61.73. This has a huge impact on the livelihood of the people across the country. Most people with families do not earn even K9000 or more; the majority of the people earn less, meaning they resort to getting loans to ensure that they reach the amount of money needed to provide the necessary home essential goods or reduce the amount of meals per day which later on affects people’s health [8].

When people do not have enough meals or are burdened with financial challenges, they lose focus at work. Imagine a theatre nurse without proper meals, not enough concentration will be given to the patient. Imagine a Pharmacist who cannot take care of the family because of financial issues when he actually is tempted to sell medical supplies to support the family, he/she will resort to stealing to cover the financial gap. These same challenges that people go through are the ones that facilitate wrong acts. If enough money is given to employees that meet their needs, the temptation of stealing may neither be here nor there but because of the circumstance, the opportunity of stealing becomes a relief to some people and when they are caught is another tragedy to talk about.

The increase on the prices of mealie meal has led some families to reduce on the normal 3 meals by adjusting to either one or 2 meals per day just to sustain the little mealie meal available in the house.

This is contrary to the United Nations (UN) sustainable development goals (SDGs) No. 3 ‘Health and Well-being’ which demands from governments to ensure their people have healthy lives and promote well-being. It is clear that when people do not have enough available food, poverty kicks in and later on affects their mental health and well-being. The increase of essential commodities has raised anxiety among the Zambian people though the current government has blamed it on the previous regime to have made reckless decisions that has contributed to the suffering of the people [2].

According to the 2022 report by World Food Program (WFP) in February last year 2022, prices of staple food commodities such as maize grain and maize meal rose sharply, especially in the Northern province as the lean season peaked. While national maize stocks were well above-average, commodity prices remained high and above-average levels. The cost of living measured by the Basic Needs and Nutrition Basket (BNNB) continued on an upward trend for a third consecutive month, with significant increases being noted in the prices of meat and animal protein foods or products. Although cumulative rainfall received countrywide was in the normal range, temporal distribution was a major concern; most of the rains were witnessed around January, resulting in the worst flash floods in the last decade, which destroyed livelihoods especially in Southern province [9].

According to the Jesuit Centre for Theological Reflection (JCTR), the Basic Needs and Nutrition Basket (BNNB) for a family of five living in Lusaka stood at K9305.38 in February, marking a K256.13 (nearly 3%) increase compared to the January basket that stood at K9049.25. This upward trend has been observed since November 2021, implying reduced household purchasing power. Increases in the cost of the basket were mostly on account of increases in prices of animal and plant protein foods or their products. Macroeconomic conditions in February, the annual rate of inflation continued its downward trend for the seventh month in a row, falling to 14.2% from 15.1% in January. Non-food inflation fell from 12.7% in January to 11.8% in February. The annual food inflation, on the other hand, increased slightly, rising to 16.9% from 16.0% the previous month. Price changes in plant and animal protein foods were largely attributed to this trend. In the same month, the local currency, the Zambian Kwacha, depreciated slightly against the US dollar, with the exchange rate increasing by 4% [8].

5. Political will

The decisions made by the politicians in power have the higher chances of affecting the health and well-being of the people. The equal distribution of resources especially on developmental agenda such as construction of health care facilities, provision of medicines and provision of safe water and sanitation all depend on the present political will. When these are not fairly distributed, it causes a number of the population to lack the necessary requirements for the health of the community and the nation. A normal family is supposed to have 3 meals in a day but currently it seems impossible as the increase in the cost of living has been attributed to the increase of commodities which a number of people cannot afford.

6. Sanitation water quality and supply

Sanitation and water supply are very important to every country. It is one of the symbols of a well managing governance system. These important services are as important as food and if overlooked, may bring catastrophic events. Zambia historically has been facing challenges with Sanitation and water quality supply in almost many parts of the country including its capital city Lusaka [10].

On October 6, 2017, a cholera outbreak was declared in Zambia after laboratory confirmation of vibrio cholerae O1 from stool specimens from two patients who suffered from acute water diarrhoea. The Ministry of Health worked with different organisations including World Health Organization (WHO), CDC, UNICEF, OXFAM and many other international and local organisations including the defence forces to ensure the outbreak was contained but it later spread to all 10 provinces of the country [11].

On 15th March 2019, it was reported that a 9 year old girl was brought to Rural Health Centre presenting with acute watery diarrhoea and vomiting in Nsumbu district, Northern province. More cases were recorded and this was attributed to the contamination of drinking water [11]. It is satisfying to see to it that the government of the republic of Zambia working with cooperating partners plan to continue the rehabilitation of old and dilapidated water supply and sanitation infrastructure as well as embark on new projects in both rural and urban areas [12].

Now looking at the experience the country has had over the years concerning cholera. Do these events need to continue even when all the factors leading to these outbreaks are known? Definitely not. There is a need to be more proactive than ever before especially before the rainy season to ensure that all the sanitation facilities are well built.

According to the European Centre for Disease Prevention and Control, since 21 June 2023 and as of 20 August 2023, 99,463 new cholera cases were recorded worldwide clearly indicating that globally the cholera challenge still exists. The countries identified to have more cases include Bangladesh, Afghanistan, DR Congo, Haiti and Ethiopia. Even though Zambia is not mentioned in this report, it still has chances of recording higher cases in the future provided that the preventive measures are relaxed [13].

Many people who live in rural areas have difficulties accessing good quality water and sanitation services. Most programs and decisions are made from the capital city Lusaka including approval of budgets which makes it even difficult and delay certain interventions to improve these services. More better facilities like water treatment plants are found in the capital city while in rural areas people draw water either from the wells or streams, rivers or lakes Most of the people living in islands in Zambia have difficulties in managing their human waste and mostly others they resort to dumping in the water though natural purification may occur but contamination do happen.

Other contamination has been observed like the Nsumbu cases which occurred after floods during the rainy season where runoffs were contributing factors after the pitlands were submerged with water thereby carrying all the human waste around into the water sources and contaminating the water. There is still hope for improvement on water and sanitation as the government keeps on track the good budget score on international best practices in its allocation of resources towards the water and sanitation and social protection sectors [3].

Another important factor that contributes to these hygiene related diseases are the distances from where the water sources are and the households. In some areas, some water sources can even be a kilometre and so people may only visit the water source once and young people even at the age of 12 may be forced to start carrying loads of containers of water thereby affecting their health. According to World Vision Zambia, access to clean water is unequal.

In Zambia, 90% of households in urban areas have access to safe water compared to only 53% of households in rural areas. Urban areas have about 70% access to sanitation compared to those in rural areas who have only 25% access. These poor water supply and sanitation services especially in rural areas are the main contributing factors to a high burden of water-borne diseases that Zambia experiences almost every year (Figure 1) [14].

Figure 1.

Water supply and sanitation challenges. Photo by WorldVisionZambia.

To prevent children and mothers from lifting heavy loads of water containers, there was a need for more investments to ensure that equal water and sanitation programs are done so as to ensure every household is provided with clean water and sanitation services closer to their homes. In that way many diseases including health effects on the musculo-skeletal system will be reduced especially in young girls and boys [14].

In 2022, the government committed to construct 1350 boreholes and 8 solar powered small water schemes in all 10 provinces which are ongoing. Further government also committed to construct and rehabilitate more boreholes in different parts of the country especially in rural areas such as western province where Sanitation and Hygiene (WASH) Project in refugee settlements and host communities in Nchelenge, Kaoma and Lusaka districts with support from the German Government, through the United Nations International Children’s Emergency Fund (UNICEF). This involves the construction of over 300 boreholes and sixteen solar powered medium piped water schemes, which are expected to benefit around 75,000 people and 16,000 people, respectively. Once these projects are done, they will have a huge impact and benefit the community with clean water provision services [15].

7. Mental health

Mental health worldwide is accompanied by stigma and discrimination. Most of the people experiencing mental health issues either struggle to solve the issues by themselves or commit suicide. The first time I saw someone who committed suicide was in 2000 were my mother’s young brother committed suicide in the uncompleted house where we were supposed to shift to, a house that belonged to my grandparents but unfortunately no one occupied it after the suicide. Since then, pictures of him hanging by the rooftop comes in the moment I hear of suicide. Well, by then I was only 7 years and I am 30 years now and still traumatised about my uncle’s death. Now imagine those reports that are received where women are abused by their husbands and step children being abused by step-mothers, how do you expect them to cope with their daily lives. More harm is done on their mental health than to their body.

According to the Gender-Based violence assessment in Zambia 2022, despite the progressive provisions on gender and GBV in international, regional and national legislation, gender inequalities continue to be significant in Zambia. The 2021 data showed that 4115 cases were reported of GBV against girls, including 2238 of cases of child development and in 2023, the Zambia police reported 10,797 cases of GBV country-wide [16].

Imagine how those girls are abused or defiled, how traumatised they become, how much those women who are beaten and mistreated in their homes. Most women in these toxic homes live in fear and they have no freedom and cannot make any decisions for themselves. It is almost the same as modern day slavery. GBV should have been made a criminal offence to prevent those who intend to infringe other people’s rights to freedom. This is the reason why most of the women have resorted to drinking alcohol especially after divorce to prevent them from thinking about the abuse they went through in their previous marriages.

The most renowned and famous place where people with mental health issues are treated is at Chainama hospital. This is the largest and referral facility where all the individuals who have mental health issues end up whenever families fail to manage them though almost every 10 provinces, there individuals in the streets with mental health issues who move around picking food in dumping areas or refuse pits. According to the Borgen project, mental health practices and research are very limited. However, there have been more government and NGO efforts that aim at making awareness programs for mental health care [17]. The most prevalent disorders include schizophrenia, brain infections, alcoholism and psychotic episodes. Imagine a developing country with so many mental health issues only having one facility in Lusaka to address all the mental health issues with only 3 local psychiatrists for a population of 12 million.

8. Disease burden

Since the time Zambia recorded cases of Covid-19 in 2020, the country faced a lot of financial challenges as more money was allocated to the health sector to fight the disease. Even though International communities like the World Health organisation (WHO), The United Nations International Children’s Emergency Fund (UNICEF), United Agency for International Development (USAID), United kingdom Agency for International Development and many more local companies like Lafarge now Chilanga Cement, Trade Kings and many more also contributed to the fight against the fight of Covid-19.

Every country faces a disease burden and Zambia is not an exception. The common diseases in Zambia include Covid-19, Tuberculosis, HIV/AIDS, Malaria, diabetes, cancer, heart conditions and other infectious diseases [1]. The major disease that crippled the economy was Covid-19 since 2020 when the first cases were reported in March. Since then, the government through the ministry of health struggled to fight against the disease which claimed many lives and affected all the provinces in the area [18]. The same Covid-19 disease exposed a lot of gaps that the ministry of health needed to address to improve the health system. As the world struggled to fight against Covid-19, many parts of the world went into shutdown which led to suspension of transportation of some essential commodities that the country needed and this disadvantaged Zambia since most of the medicines and essential medical supplies are imported.

Luckily developed countries came to aid and essential commodities like vaccines were donated together with funds to use during the pandemic. According to the World Bank Group, policy Research paper 9571, a research on Covid-19, Poverty and Social Safety Net response in Zambia, the impacts of Covid-19 such as lockdowns and travel restrictions resulted in unprecedented health and economic crisis. This came at a time when the country was facing serious macroeconomic crisis because of rising inflation, a high fiscal deficit, a depreciating kwacha and pressing external debt which the country even defaulted to pay and luckily, there has been some relief through the new government through his excellency Mr. Hakainde Hichilema who managed to restructure the debt with the lenders which gives the country more time to plan on how to pay the external debt [18].

Most companies in the country were closed as employees were getting infected on a daily basis and other lost jobs thereby affecting their normal lively wood. This clearly shows that during this period unemployment increased. Many employees from private institutions complained of having difficulties buying essential commodities like food in their homes because they were not paid when their companies were closed due to the pandemic. This affected their mental health as they got worried on how they could feed their families.

One of the good part that was observed during the pandemic was that even though the ministry of health had no capacity to manage the pandemic on its own, other ministries and cooperating partners came on board and the pandemic was managed in a multi-sectoral approach and this made it easy as resources came from different sources. Patients used to receive donations such as food and beddings from different cooperating partners and on some occasions, staff in isolation centres were given food and some presents as appreciation for the sacrifice shown during the pandemic.

In 2023, the minister of health Hon. Sylvia Masebo when attending 76 World Health assembly called on world leaders in health through the world health organisation to give attention to the public health issues of concern like cholera, which continues to affect countries like Zambia and the Southern African region [19]. These diseases claim lives every year and when neglected, they lead to catastrophic events such as outbreaks which are observed almost every year in some parts of Zambia.

Since the time Covid-19 unmasked the gaps that the ministry was facing, a lot of improvements has been observed where government has invested more in construction of more medical facilities since 2020 and medical supply facilities like in 2023 groundbreaking for the construction of an Oxygen Generation Plant in Kitwe Teaching Hospital. With the new administration in the ministry of health, people’s expectation is to see more improvement in the health sector, especially quality health care.

Therefore, there was a need to have more projects to be done locally including manufacture of medicines, vaccines and other essential products so as to reduce on external dependency and funding. When such industrial activities are available in most parts of the country, it leads to more employment thereby reducing the unemployment as well as making youths more productive. Many youths are involved in drug abuse and excessive alcohol abuse making them problematic and unproductive in the community. Others resort to stealing so as to sponsor their drinking activities. And when more jobs are available, even for the uneducated, theft is reduced, and the community is safe and productive.

9. Unemployment of the youth

I am more concentrated on the employment of the youth because I am a youth and what affects youths affects me. The majority among the Zambian population are the youth and many of them are unemployed. On the 18th August 2023, a Zambian youth by the name Moses Sichione attempted to commit suicide after he was left on the army recruitment [20]. Moses climbed a network tower and threatened to throw himself down but he was later convinced and he came down from the tower. This is shown by the photo by Figure 2.

Figure 2.

Suicide attempt due to unemployment.

This was a clear mental health issues that many youths in the country who are committing suicide are going through. Many youths have graduated from Colleges and University but there are no available jobs available for everyone to grab on. At least in 2023 government recruited more than 11,000 health workers and additional 3000 health workers to be recruited, others recruited included people in defence, police, teachers as well as other government institutions and parastatals [5]. Even though those efforts were made, there is still unemployment that needs to be addressed. Some health personnel who graduated cannot even intern or find direct jobs because they have to undergo an additional licence exam which disadvantages them an opportunity to join the workforce only until they undergo the exam while other professions grab it easily [21]. There was a need to look into the licence exam issues to ensure they are either integrated with the final normal exam so that when people graduate immediately they have opportunities to work but in this case, graduates have to wait. On 20th September, the Health Professions Council of Zambia (HPCZ) nullified the licensure exams due to malpractice and also suspending 9 of its staff members [22]. These decisions and events will not only disadvantage the youth who after completing school needs jobs but also affect their mental health as their hope of finding employment is delayed. This is the reason why government needs to find a way to change this system of competence assessment to either allow the HPCZ and other health examination board to make on comprehensive exams that will include all the inputs from difference stakeholders such as HPCZ and other University or to create an examination board that prepares examination papers that satisfies the HPCZ standards. In that way, it will allow students to be ready for employment upon graduation. As things stand, that method of assessment is a clear way of stealing employment opportunities for the youth especially those in the health sector. Remember, students are ready to work after graduation, not after writing licensure exams.

10. Conclusion

It is a fact that many parts of the world face a lot of challenges in ensuring equal opportunities are given to people regardless of social status, race, age and health status. Even in most developing countries, health inequalities do exist. Therefore, it is a huge task given to governing bodies to ensure distribution of resources among the population and prioritise the weakest, most vulnerable and those at higher risk. The government of the republic of Zambia has a huge task to ensure that at least invest more in the health sector so as to improve health and prolong life. When the nation is healthy, it is wealthy. This may not come easy but with strong leadership and political will, the sky’s the limit. Hippocrates once said, “Healing is a matter of time, but it is sometimes also a matter of opportunity.” When the opportunities are not given equally, those who do not have the chance for health opportunities suffer the most. I hope for the future where we all share resources equally with discrimination and that future is coming.

Acknowledgments

I would like to thank IntechOpen Publishers for the assistance and guidance during the process of making this chapter. Many thanks to my wife Abigail for the support.