Decentralization, Health System and Gender Issues in Zambia

The Decentralisation Policy: In 2003, the Government launched the National Decentralisation Policy, which aims at devolving specified functions and authority, with matching resources, to local authorities at a district level. Under this environment, the role of the center would be to provide policy, strategic guidelines, overall coordination, monitoring, and evaluation while implementation and supervision of the programmes would be through the local authorities. The Decentralisation Implementation Plan was approved by the Cabinet in late 2009, and the country is heading towards a full-scale devolution.

Functions:- The new decentralized structure of governance that will be established by the law, through which services will be delivered. The new structure will comprise four levels namely National, provincial, District and sub-district.

Decentralisation will riot necessarily imply that all authority will be transferred to local authorities. The Central Government (including line ministries) will retain a core of functions over essential national matters and ultimately have the authority to redesign the system of government and to discipline or suspend decentralized units that are not performing effectively. Specifically, the Central Government will retain the overall responsibility of:

  1. general and legislative Policy formulation, monitoring and evaluation and provision of advice to Councils on their operations;
  2. setting national performance standards;
  3. controlling arms, ammunition and explosives;
  4. national defense and security;
  5. regulating banks and financial institutions, promissory notes, currency, and exchange;
  6. citizenship, immigration emigration. refugees, deportation, extradition, and designing of passports and national identities;
  7. copyrights, patents, trademarks and all forms of intellectual property, incorporation and regulation of business organizations;
  8. control of state land and minerals;
  9. declaration of public holidays, working and shopping hours;
  10. preservation of national monuments, antiquities, archives and public records;
  11. foreign relations and trade, regulation of trade and commerce;
  12. national and local government elections;
  13. guidelines on national census and statistics;
  14. control of publications of national surveys and mapping;
  15. control and management epidemics, pandemics and disasters;
  16. airports, aerodromes, and airstrips;
  17. national development projects and programmes;
  18. correctional policy and maximum security prisons;
  19. trunk roads and highways;
  20. prosecutorial functions;
  21. high school and tertiary education; and
  22. Any other functions delegated by Parliament.

Functions at the Provincial level, functions to be performed include:

  1. coordinating and consolidating district plans into provincial development plans for submission to the center;
  2. monitoring the utilization of resources and implementation of development programmes in the province;
  3. coordinating and auditing of local institutions; (d) preparing provincial progress reports for the central
  4. The government on the implementation of development programmes and projects;
  5. ensuring implementation of Central Government policies and regulations;
  6. implementation of National development projects and programmes which cut across sectors;
  7. ensuring proper utilization and maintenance of Government buildings, equipment, plant and other infrastructure; and
  8. any other functions delegated from the center.

The Government shall decentralize with matching resources, some of its function & to the district, which shall perform these functions through democratically elected councils. The Councils will raise part of their own revenue and receive grants from central treasury and line ministries to perform the devolved functions such as’.

  1. coordination of decentralized structures, including Health and Education Boards;
  2. disaster management;
  3. community development;
  4. primary health care;
  5. primary and basic education;
  6. water and sanitation;
  7. rehabilitation, maintenance, and construction of feeder roads;
  8. infrastructure development and maintenance;
  9. planning and implementation of development projects and programmes;
  10. mobilization of local resources;
  11. preparation of progress reports for the province;
  12. management, conservation of natural and wildlife resources;
  13. environmental services;
  14. provision and maintenance of public amenities; land
  15. allocation and utilization;
  16. trade and business licensing;
  17. agriculture extension services;
  18. bye-laws;
  19. community Police Service;
  20. community Prisons Service;
  21. youth and juvenile delinquency; and
  22. any other functions as delegated from the center.

Zambia’s Health System

Zambia’s health policy, created in 1992 and becoming operational with the Health Services Act 1995, is intended to ‘provide people of Zambia with equity of access to cost-effective, quality healthcare as close to the family as possible…’(MOH 2005:1). The aim of the policy was to provide a service that was responsive to local needs by decentralization of decision making to districts and promote peoples’ power through encouraging local representation on health management boards. The Ministry of Health (MOH) was given responsibility for policy, financing, and regulation, and a new organization, the Central Board of Health (CBOH), was tasked with service implementation (ACCA, 2013).

However, following 10 years of implementation, the health policy had become outdated and the Health Services Act was repealed in 2006 leading to the abolition of CBOH structures and creation of a unified four-tier health system under the MOH. The four levels as indicated on National Health Strategic Plan 2011-2015 document include:

  • The MOH Head Office at the Centre, responsible for policy guidance and oversight, regulation and defining standards;
  • The Provincial Health Offices (PHOs), responsible for coordination, monitoring, technical supportive supervision, and quality assurance and performance management at provincial level;
  • The District Health Offices (DHOs) at a district level, as the focal point for services delivery, providing supervision, coordination, planning and management support to Health Posts, Health Centres, and 1st level hospitals; and
  • The health service delivery facilities, which are the backbone of the system, providing “treatment and care services” to the general population at the community level.

In addition, national units were established to oversee specific health programmes, including the National Malaria Control Center, Reproductive Health Unit, Tuberculosis and Leprosy Unit, and National Aids Council.

Health Care is provided by a multitude of providers, including the MOH, church organizations, the private sector (both nonprofit and for-profit) and alternative providers. The vast majority of health facilities (1489) are owned and operated by the public sector. These are supplemented by 122 mission health facilities and 271 private health facilities (ACCA, 2013).

The health services delivery system in Zambia is focused on providing health services as close to the family as possible using a Primary Health Care approach. Zambia operates a pyramid classification structure of health care provision (National Health Policy, 2012):

  • tertiary or specialist care is provided in Level 3 hospitals
  • provincial-level care is provided in Level 2 hospitals
  • district-level care is provided in Level 1 hospitals
  • community-level care is provided through community services, health posts, and health centers.

The structuring of the health system suggests that a managed hierarchical referral system is in operation, but owing to undeveloped communication systems and limited availability of ambulances, referral systems between the different levels of care are often poor.

The Zambian health policy stipulates that every Zambian with an income should contribute to the cost of his/her health. However exemptions exist based on age (children under 5 and adults over 65), diseases (TB, HIV/AIDS, Cholera and dysentery; safe motherhood and family planning services; immunization; and treatment of chronic hypertension and diabetes) and other factors. This is aimed at enhancing equitable and appropriate delivery of health services to all Zambians, but in practice is not implemented due to lack of resources (1).

There is inequitable access to basic health services in Zambia between provinces and between urban and rural areas. In urban areas, 99 percent of households are within 5 kilometers of a health facility compared to 50 percent in rural areas. In Zambia, household expenditures on health vary according to location. Poor households spend the highest proportion of their income on health, which can be up to 10% of total expenditure when in-kind costs are included (2).

Many of the key determinants of health are outside the direct scope of the health sector. There is often poor access to safe water and sanitation, malnutrition accounts nearly half (42%) of all deaths in under five children; lack of education, particularly among females; gender discrimination; Climate variability and change. Other key factors include poor road networks (particularly in rainy seasons), an insufficient number of vehicles for transportation, and limited access to electricity (ACCA, 2013).

Organization and management structures;

Since 2005, the health sector has been undergoing a major restructuring process. Through this process, the sector has established a comprehensive organization and management structures at national, provincial, district and community levels, intended to facilitate efficient and effective management of health services. However, the organization and management structures have very weak linkages with the community that existed before the repeal of the NHSA in 2006, over the past two decades decentralization in the health sector has an increasingly familiar theme, commonly linked to a wider public sector and governance reforms. The intent was to bring decision making, responsibility, and accountability, closer to where health care services are provided, in order to realize increased efficiency (National Health Policy, 2012).

Gender situation in Zambia

Zambian Government Policies and Laws on Gender

  • At the policy level, there have been some improvements towards gender equality. In 2012, the Ministry of Gender became an independent ministry and the National Gender Policy was formulated in 2014. This policy lists the strategy and actions to be implemented by government ministries and agencies in 15 different fields to achieve gender equality, although there are no formal commitments in terms of indicators and annual budgets. The Ministry of Gender is in the process of drafting a monitoring report for this policy and there is no clear picture concerning the progress of this policy (JICA, 2016).
  • In 2005, the Penal Code was revised making the punishments for (sexual) violence against women and children stricter, and the Anti-Gender Based Violence Act was enacted in 2011. However, the actual enforcement of these laws and policies has been slow and acceleration of their enforcement is sought.
  • At present, deliberations on the Gender Equity and Equality Rights Bill are in progress along with those to revise the Constitution. The intended revision of the Constitution includes (i) revision of the text in line with the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) and other human rights-related documents, and (ii) rectification of the dual structure of statutory law and customary law to realize gender equality. The bill in question aims at (i) incorporating the spirit of the human rights-related documents in national laws and policies, and (ii) establishing the Gender Equity and Equality Commission as an organization to supervise the implementation of gender equality

Population (UNDP, 2016)

  • The total population of Zambia is 16.2 million
  • Females account for 50.7% of the total population and males accounting for 49.3 percent.
  • 77.5 percent of households were headed by males while 22.5 percent were headed by females

Gender inequality index (UNDP GII, HDR 2016) 

  • The UNDP Gender Inequality Index (GII) reflects gender-based inequalities in three dimensions namely reproductive health, empowerment and economic activity. Zambia has a GII value of 0.526 ranking 139 out of 188 countries in the 2016 index assessment. This high level of gender inequalities arises because only 12.7 percent of parliamentary seats are held by women. However, the number of women who have reached at least a secondary level education account for 52.3 percent of adult Zambian women compared to 48.9 percent of Zambian men, this is the area where Zambia showed significant improvement in the last five years.  For every 100,000 live births, 224 women die from pregnancy-related causes; and the adolescent birth rate is 90.4 births per 1000 live births. Female participation in the labor market is 69.8 percent compared to 80.9 percent for men (1).


Statistics show that employment in Zambia is dominated by the informal sector with females being the majority. There has been an increase in the percentage of persons in formal employment from 11.0 percent in 2008 to 15.4 percent in 2012 (1).

  • The percentage of females in the formal sector increased from 6.0 percent in 2008 to 8.7 percent in 2012 while that of males increased from 15.0 percent to 22.3 percent.
  • There are more females (52 percent) than males (48 percent) employed in the Agriculture, forestry & fisheries industry (2).

In the Republic of Zambia, there exists a deep-rooted concept of an unequal gender relationship in which men are considered to be superior to women. This biased view regarding gender equality originates from not only traditional cultural and social norms but also from the dual structure of statutory law and customary law. Rights, which are supposed to be protected under statutory law, are not necessarily observed and women endure unfair treatment in terms of child marriage, unequal distribution of property, etc. Meanwhile, there have been some positive developments at the policy level, including the establishment of an independent Ministry of Gender, the introduction of specific gender policies and revision of certain provisions of the Constitution, which epitomize gender inequality (currently being deliberated) (Jica, 2016).  

According to a report published in 2015, Zambia ranks as low as 11th of 15 countries surveyed among Southern African Development Community (SADC) members in the areas of women’s participation in politics. In terms of political empowerment as a global gender gap indicator, Zambia ranks 102nd of 145 countries.  

While the net enrollment rate for girls in primary education is similar to that for boys, the dropout ratio for girls increases as they advance to higher grades (especially 7th grade and thereafter), mainly due to pregnancy (JICA, 2016)  

As 78% of women are engaged in agriculture, women constitute an important labor force for agriculture. However, their role is often to assist men in family farming or production for home consumption due to (i) their little access to production equipment and land compared to men and (ii) their prominent role in household work and child-rearing. Outside the agricultural sector, many women are employed in the informal sector (JICA, 2016)

Marriage at a young age, teenage pregnancy, and violence against women are quite common and the prevalence of HIV/AIDS is higher for women than for men. Because of women’s limited decision-making power, women are negatively affected regarding their sexuality and health.  The Zambia Demographic and Health Survey (ZDHS) for 2013-14 reported that 43% of women in the age bracket of 15 to 49 have experienced violence at the age of 15 or older (JICA, 2016)

Gender Index

In Zambia, marriage, child custody, property rights, and inheritance are governed by a dual legal system statutory and customary laws. The marriage act provides the minimum age of marriage at 16 for both men and women, with parental consent needed under the age of 21. These rules, however, apply to statutory and not customary marriages; under customary law, it is legal to marry a girl child who has attained puberty.

Regarding parental authority, there are no legal restrictions on women becoming heads of households and equally the new draft constitution grants women equality in marriage.

According to  ZDHS 2013-14,  

  • One in three currently married women who earn cash for their work makes independent decisions about how to spend their earnings.
  • Fifty-nine percent of currently married women whose husband receives cash earnings say that they decide jointly with their husband about the use of his earnings.
  • Seventy-four percent of women participate in decisions regarding their own health, as compared with 89 percent of men.
  • One in two (53%) women participate in four specified decisions pertaining to their own health, major household purchases, purchases for daily household needs, and visits to their family or relatives.
  • Empowerment is strongest among women who participate in all four specified decisions, who agree that wife beating is not justified for any reason, and who agree that a woman can refuse sexual intercourse with her husband for any reason.
  • Contraceptive use is positively associated with all three empowerment indices measured in the 2013-14 ZDHS.

Women Empowerment

  • According to the ZDHS 2013-14, 8.4 percent of women aged 15-49 years compared to 3.7 percent of men of the same age group had never attended any level of formal Education.
  • More males compared to females were literate, 82.7 percent and 67.5 percent, respectively.
  • 48.8 percent of the total number of women aged 15-49 years were currently employed compared to 72 percent of men in the same age category.
  • 34.7 percent of married women with Cash earnings decided how their earnings were used, 49 percent decided jointly with their husbands, 16 percent said that their husbands decided how their earnings were used.
  • The men (22.5 percent) were more likely than women (9.4 percent) to have sole ownership a house. 30.4 percent of women-owned assets jointly. 58.0 percent of men and 53.8 percent of women did not own a house (ZDHS, 2013-14).



ACCA. (2013, April). Key Health Challenges for Zambia. Retrieved from

The Republic of Zambia. (2012, August). National Health Policy

The Republic of Zambia. Ministry of Health. National Health Strategic Plan 2011-2015. Retrieved from

Zambia Health System. Retrieved from.

Zambia Demographic and Health Survey. 2013-14. Retrieved from

Zambia 2002. The National Decentralization Policy ‘’Towards Empowering People’’ Retrieved from

Zambia Central statistics office. Gender Status Report 2012-14. Retrieved from

JICA. JDS. 2016. Country Gender Profile: Zambia Final Report. Retrieved from