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Abstract Background Many low-and middle-income countries have adopted social health insurance schemes. However, the collection of contributions from the large informal sector of these economies poses a significant challenge. Employing an integrated system of contribution collection from all relevant institutions may be cost-effective. We used the integrative framework for collaborative governance, to explore and explain factors that may shape the governance of an integrated system for collecting contributions for social health insurance, pension, and taxes from the informal sector in Zambia. Methods We undertook a qualitative case study involving 25 key informants drawn from government ministries and institutions, cooperating partners, non-governmental organizations, and association representatives in the informal sector. Data were analyzed thematically using Emerson’s integrative framework for collaborative governance. Results The main drivers of collaboration included a need for comprehensive policies and legislation to oversee the integrated system for contribution collection, prevent redundancy, reduce costs, and enhance organizational effectiveness. However, challenges such as leadership issues and coordination complexities were noted. Factors affecting principled engagement within the collaborative regime consisted of communication gaps, organizational structure disparities, and the adoption of appropriate strategies to engage the informal sector. Additionally, factors influencing shared motivation involved concerns about power dynamics, self-interests, trust issues, corruption, and a lack of common understanding of the informal sector. Conclusion This study sheds light on a multitude of factors that may shape collaborative governance of an integrated system for contribution collection for social health insurance, pension, and taxes from the informal sector, providing valuable insights for policymakers and implementers alike. Expanding social health insurance coverage to the large but often excluded informal sector will require leveraging factors identified in this study to enhance collaboration with pension and tax subsystems.

Abstract Background Despite several global interventions, tuberculosis (TB) remains a leading cause of death affecting millions of people globally. Many TB patients either have no access to quality care or go undetected by national health systems. Several multilevel factors account for under-detection of persons with TB. This study sought to explore patient-related software, community and health systems software and hardware factors influencing time to notification of TB in Lusaka District, Zambia. Methods This was an exploratory qualitative case study that adopted a software and hardware lens of conceptualizing health systems. Data were collected from across three sites – urban and peri-urban areas: Chongwe, Kafue, and Lusaka – within Lusaka Province, Zambia. Sixteen key informants - TB corner nurses, community TB treatment supporters, and TB program managers - were interviewed. Six focus groups were held with TB patients. Data were analyzed using thematic analysis. Results The study identified factors influencing timely TB notification, categorized into software and hardware elements. Patient-related software elements, including TB knowledge and awareness, and health-seeking behavior, are crucial for prompt notification among TB patients. In the community health system, software elements like social stigma and undesirable community attitudes towards contact tracing, and hardware elements such as unbalanced schedules, excessive workload and limited capacity of community TB treatment supporters contribute to delayed TB notification. In the formal health system, software elements like negative attitudes of health providers towards TB patients and demotivation of TB staff, and hardware elements such as high diagnostics and transportation costs, outdated diagnostics in primary care facilities, and slow referral mechanisms, can also delay TB notification. Conclusion Delays in time to TB notification are influenced by a combination of software (attitudinal and behavioral) and hardware (resource-related) elements across TB patients, community health systems, community TB treatment supporters, health providers, and TB staff. Addressing these factors, particularly social stigma, negative attitudes, and resource constraints, is crucial to improving timely TB detection and treatment.

Abstract Background Hypertension affects over one billion people globally and is one of the leading causes of premature death. Low- and middle-income countries, especially the sub-Saharan Africa region, bear a disproportionately higher share of hypertension globally. Recent evidence shows a steady shift in the burden of hypertension from more affluent and urban populations towards poorer and rural communities. Our study examined inequalities in self-rated health (SRH) among people with hypertension and whether there is a rural‒urban gap in the health of these patients. We then quantified factors driving the health gap. We also examined how much HIV accounts for differences in self-rated health among hypertension patients due to the relationship between HIV, hypertension and health in sub-Saharan Africa. Methods We utilized the Zambia Household Health Expenditure and Utilization Survey for data on SRH and other demographic and socioeconomic controls. District HIV prevalence information was from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) survey. We applied the Linear Probability Model to assess the association between self-rated health and independent variables as a preliminary step. We then used the Blinder-Oaxaca decomposition to identify self-rated health inequality between urban and rural patients and determine determinants of the health gap between the two groups. Results Advanced age, lower education and low district HIV prevalence were significantly associated with poor health rating among hypertension patients. The decomposition analysis indicated that 45.5% of urban patients and 36.9% of rural patients reported good self-rated health, representing a statistically significant health gap of 8.6%. Most of the identified health gap can be attributed to endowment effects, with education (73.6%), district HIV prevalence (30.8%) and household expenditure (4.8%) being the most important determinants that explain the health gap. Conclusions Urban hypertension patients have better SRH than rural patients in Zambia. Education, district HIV prevalence and household expenditure were the most important determinants of the health gap between rural and urban hypertension patients. Policies aimed at promoting educational interventions, improving access to financial resources and strengthening hypertension health services, especially in rural areas, can significantly improve the health of rural patients, and potentially reduce health inequalities between the two regions.

Abstract Background Traumatic injuries are rising globally, disproportionately affecting low- and middle-income countries, constituting 88% of the burden of surgically treatable conditions. While contributing to the highest burden, LMICs also have the least availability of resources to address this growing burden effectively. Studies on the cost-of-service provision in these settings have concentrated on the most common traumatic injuries, leaving an evidence gap on other traumatic injuries. This study aimed to address the gap in understanding the cost of orthopaedic services in low-income settings by conducting a comprehensive costing analysis in two tertiary-level hospitals in Malawi. Methods We used a mixed costing methodology, utilising both Top-Down and Time-Driven Activity-Based Costing approaches. Data on resource utilisation, personnel costs, medicines, supplies, capital costs, laboratory costs, radiology service costs, and overhead costs were collected for one year, from July 2021 to June 2022. We conducted a retrospective review of all the available patient files for the period under review. Assumptions on the intensity of service use were based on utilisation patterns observed in patient records. All costs were expressed in 2021 United States Dollars. Results We conducted a review of 2,372 patient files, 72% of which were male. The median length of stay for all patients was 9.5 days (8–11). The mean weighted cost of treatment across the entire pathway varied, ranging from $195 ($136—$235) for Supracondylar Fractures to $711 ($389—$931) for Proximal Ulna Fractures. The main cost components were personnel (30%) and medicines and supplies (23%). Within diagnosis-specific costs, the length of stay was the most significant cost driver, contributing to the substantial disparity in treatment costs between the two hospitals. Conclusion This study underscores the critical role of orthopaedic care in LMICs and the need for context-specific cost data. It highlights the variation in cost drivers and resource utilisation patterns between hospitals, emphasising the importance of tailored healthcare planning and resource allocation approaches. Understanding the costs of surgical interventions in LMICs can inform policy decisions and improve access to essential orthopaedic services, potentially reducing the disease burden associated with trauma-related injuries. We recommend that future studies focus on evaluating the cost-effectiveness of orthopaedic interventions, particularly those that have not been analysed within the existing literature.

Taxes on sugar sweetened beverages (SSBs) have been widely implemented and heralded as a panacea in reversing the growing burden of non-communicable diseases (NCDs). Using a qualitative research methodology, Forde et al explored how sugary drink companies respond to changes in taxation positing that relative effectiveness of sugar taxes will not only depend on how prices are affected, and how consumers respond, but also how producers respond by reformulating their products or engaging in counteractive marketing strategies. They argue that these responses may undermine the public health goal. We discuss some of the key issues that arise in their paper and conclude that company responses may not be sufficient in undermining the public health goal, and that consumption of sugary drinks fall after imposition of taxes, though demand is inelastic. We argue that inelasticity of demand for SSB may require a combination of interventions to sufficiently reduce excess consumption of sugar drinks.

According to the Demographic and Health Surveys (DHSs), Zambia has shown an increasing trend in the percentage of married women using contraceptives in the last three decades. As of 2018, this percentage increased from 34.2% in 2001 to 40.8% in 2007 and from 45% in 2013 to 48% in 2018. Despite the increasing trend in contraceptive use, the unmet needs remain relatively high. The low percentage of contraception use translates into 20% of women of reproductive age who are either married/partnered and want to stop or delay childbearing but are not using contraception. This study analyzed factors other than availability that influence women’s ability to make or influence the decision to use contraception using logistic regression using data from the Zambia 2013/2014 and 2018 DHSs. Furthermore, adjusted odds ratios and predicted probabilities were estimated using the fitted logistic regression. Data on 8,335 women were analyzed, and 13.7% (n = 1,145) had their husband as the sole decision maker for contraception use, while 86.3% (n = 7,189) made the decisions or participated in making the decision. Contrary to most literature, those with primary or secondary school education were less likely to decide than those without education. The data also associate women who contribute to daily household decisions to having a say in deciding to use contraception. Lastly, women using reversible contraception methods, other methods, hormonal methods, and fertility awareness were associated with less likelihood to decide on using contraceptives than those using barrier methods. Women with lower household decision-making powers are less likely to make or influence decisions to use contraception. Consequently, there is a need to prioritize such women in interventions aimed at increasing contraception use decision-making. Furthermore, more studies are required to investigate why uneducated women in Zambia are more likely to choose contraception. Also, the vast odds ratio difference between all other methods compared to barrier methods (condoms) indicates underlying factors that play a role, which warrants further studies.

Abstract Background The HIV/AIDS pandemic has had a very devastating impact at a global level, with the Eastern and Southern African region being the hardest hit. The considerable geographical variation in the pandemic means varying impact of the disease in different settings, requiring differentiated interventions. While information on the prevalence of HIV at regional and national levels is readily available, the burden of the disease at smaller area levels, where health services are organized and delivered, is not well documented. This affects the targeting of HIV resources. There is need, therefore, for studies to estimate HIV prevalence at appropriate levels to improve HIV-related planning and resource allocation. Methods We estimated the district-level prevalence of HIV using Small-Area Estimation (SAE) technique by utilizing the 2016 Zambia Population-Based HIV Impact Assessment Survey (ZAMPHIA) data and auxiliary data from the 2010 Zambian Census of Population and Housing and the HIV sentinel surveillance data from selected antenatal care clinics (ANC). SAE models were fitted in R Programming to ascertain the best HIV predicting model. We then used the Fay–Herriot (FH) model to obtain weighted, more precise and reliable HIV prevalence for all the districts. Results The results revealed variations in the district HIV prevalence in Zambia, with the prevalence ranging from as low as 4.2% to as high as 23.5%. Approximately 32% of the districts (n = 24) had HIV prevalence above the national average, with one district having almost twice as much prevalence as the national level. Some rural districts have very high HIV prevalence rates. Conclusions HIV prevalence in Zambian is highest in districts located near international borders, along the main transit routes and adjacent to other districts with very high prevalence. The variations in the burden of HIV across districts in Zambia point to the need for a differentiated approach in HIV programming within the country. HIV resources need to be prioritized toward districts with high population mobility.

Rural areas have the greatest health needs and yet they face the largest shortage of human resources for health which negatively impacts health systems capacity to deliver quality care as they struggle to motivate and retain healthcare workers in such settings. This study explored factors that shape motivation and retention of primary healthcare workers in rural health facilities in Chipata and Chadiza Districts of Zambia using a phenomenological research design. The data consisted 28 in-depth interviews with rural primary healthcare workers and were analysed using thematic analysis. Three main themes of factors shaping motivation and retention of rural primary healthcare workers were identified. Firstly, professional development with emergent themes of career advancement and opportunities for attending capacity-building workshops. Secondly, the work environment with emergent themes of challenging and stimulating tasks, availability of opportunities for promotion and co-workers’ recognition and supportive relationships. Thirdly, rural community dynamics with emergent themes of reduced cost of living, community recognition and support, and easy access to farmland for economic and consumption purposes. Interventions that are contextually relavant, which can streamline career progression pathways, enhance rural working environments, offer suitable incentives, and rally community support for rural primary healthcare workers are required.

Several low and lower- middle income countries have been using Performance-Based Financing (PBF) to motivate health workers to increase the quantity and quality of health services. Studies have demonstrated that PBF can contribute to improved health service delivery and health outcomes, but there is limited evidence on the mechanisms through which PBF can necessitate changes in the health system. Using difference-in-difference and synthetic control analytical approaches, we investigated the effect of PBF on autonomy and accountability at service delivery level using data from a 3-arm cluster randomised trial in Zambia. The arms consisted of PBF where financing is linked to outputs in terms of quality and quantity (intervention 1), input financing where funding is fully provided to finance all required inputs regardless of performance (intervention 2), and the current standard of care where there is input financing but with possible challenges in funding (pure control). The results show an increase in autonomy at PBF sites compared to sites in the pure control arm and an increase in accountability at PBF sites compared to sites in both the input-financing and pure control arms. On the other hand, there were no effects on autonomy and accountability in the input-financing sites compared to the pure control sites. The study concludes that PBF can improve financial and managerial autonomy and accountability, which are important for improving health service delivery. However, within the PBF districts, the magnitude of change was different, implying that management and leadership styles matter. Future research could examine whether personal attributes, managerial capacities of the facility managers, and the operating environment have an effect on autonomy and accountability.

Abstract Background Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. Methods A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices. Results Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6–52 and USD 8–73, but cesarean section costs between USD 56–377 and USD 80–562, respectively. Patient and health system costs of abortion range between USD 11–66 and USD 40–298, while post-abortion care costs between USD 21–158 and USD 46–151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52–231 and USD 123–186, while for maternal hemorrhage they range between USD 65–196 and USD 30–127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38–489 while the health system cost was estimated to be USD 514. Conclusion This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.

Abstract The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

Abstract Background The youths in Zambia have limited access to information concerning Sexual Reproductive Health (SRH) and this puts them at risk of unwanted pregnancies. Talking about other methods of preventing pregnancy or sexually transmitted infections than abstinence is regarded as culturally unacceptable. The Research Initiative to Support the Empowerment of Girls (RISE) is a cluster randomised controlled trial testing the effectiveness of different support packages on teenage pregnancies, early marriages and school drop-out rates. One of the support packages included youth clubs focusing on Comprehensive Sexual and Reproductive Health Education (CSRHE). Although similar interventions have been implemented in other settings, their integration process has been complex and comprehensive assessments of factors shaping acceptability of CSRHE are lacking. This article qualitatively aimed at identifying factors that shaped the acceptability of CSRHE youth clubs in rural schools in Central Province. Method A qualitative case study was conducted after the youth clubs had been running for a year. Data were gathered through eight focus group discussions with grade eight pupils and eight individual interviews with teachers. Data were analysed using thematic analysis. Results The perceived advantage and simplicity of the clubs related to the use of participatory learning methods, films and role plays to communicate sensitive reproductive health information made the learners like the youth clubs. Further, the perceived compatibility of the content of the sessions with the science curriculum increased the learners’ interest in the youth clubs as the meetings also helped them to prepare for the school examinations. However, cultural and religious beliefs among teachers and parents regarding the use of contraceptives complicated the delivery of reproductive health messages and the acceptability of youth clubs’ information among the learners. Conclusion The study indicated that CSRHE youth clubs may be acceptable in rural schools if participatory learning methods are used and head-teachers, teachers as well as parents appreciate and support the clubs.

Abstract Background A recurring discussion in the literature relates to the possible contradictions among the Sustainable Development Goals (SDGs). The focus has been on economic goals, such as economic growth and goals related to climate change. We explore the possible contradictions that may arise between economic goals and health goals, specifically, the goal on Non-Communicable Diseases (NCDs) — SDG3.4. As a way to achieve SDG3.4, countries have been urged to introduce sin taxes, such as those on sugar. Yet others have argued that such taxes may affect employment (SDG 8.5), economic growth (SDG 8.1), and increase poverty (SDG1). However, there is limited or no reliable evidence, using actual experience, on the effect of sugar tax on health and economic outcomes. This makes it hard to assess the possible contradictions in SDGs that sugar taxes may generate. Main body Using a conceptual framework on SDGs that views relationships among SDGs as either contradictory, reinforcing, or neutral, we carefully consider whether there are contradictions between SDG 3.4 on one hand and SDG 1, SDG 8.1, and SDG 8.5 on the other hand. We illustrate this using Zambia which recently introduced an equivalent 3% tax on non-alcoholic beverages, implicitly targeted at sugar-sweetened beverages (SSBs), given the stated goal of reducing NCDs. Concerns are that such a tax would be detrimental to the Zambia sugar value chain which contributes about 6% to GDP, in which case the achievement of SDG 3.4 (health) would be at odds with, or contradict, SDG 1, SDG 8.1, and SDG 8.5 (poverty eradication, economic growth, and creation of employment). We discuss that the existence of contradictions depend on a number of contextual factors, which allows us to make two conclusions about sugar taxation in Zambia. First, the current tax rate of 3% is likely neutral (no contradictions or reinforcing relationships) because it is too low to have any health or employment effects. However, the revenue raised can be reinvested to improve livelihoods. Secondly, the tax rate should be increased but care has to be exercised to ensure that the rate is not too high to generate contradictions. There will be need to carefully assess important parameters such as elasticities and explore alternative economic livelihoods. Conclusion Without paying due consideration to important contextual factors, Zambia and many LMIC risk experiencing contradictions among SDGs.

Abstract Background Malaria is among the top causes of mortality and morbidity in Zambia. Efforts to control, prevent, and eliminate it have been intensified in the past two decades which has contributed to reductions in malaria prevalence and under-five mortality. However, there was a 21% upsurge in malaria prevalence between 2010 and 2015. Zambia is one of the only 13 countries to record an increase in malaria among 91 countries monitored by the World Health Organization in 2015. This study investigated the upsurge by decomposition of drivers of malaria. Methods The study used secondary data from three waves of nationally representative cross-sectional surveys on key malaria indicators conducted in 2010, 2012 and 2015. Using multivariable logistic regression, determinants of malaria prevalence were identified and then marginal effects of each determinant were derived. The marginal effects were then combined with changes in coverage rates of determinants between 2010 and 2015 to obtain the magnitude of how much each variable contributed to the change in the malaria prevalence. Results The odds ratio of malaria for those who slept under an insecticide-treated net (ITN) was 0.90 (95% CI 0.77–0.97), indoor residual spraying (IRS) was 0.66 (95% CI 0.49–0.89), urban residence was 0.23 (95% CI 0.15–0.37), standard house was 0.40 (95% CI 0.35–0.71) and age group 12–59 Months against those below 12 months was 4.04 (95% CI 2.80–5.81). Decomposition of prevalence changes by determinants showed that IRS reduced malaria prevalence by − 0.3% and ITNs by − 0.2% however, these reductions were overridden by increases in prevalence due to increases in the proportion of more at-risk children aged 12–59 months by + 2.3% and rural residents by + 2.2%. Conclusion The increases in interventions, such as ITNs and IRS, were shown to have contributed to malaria reduction in 2015; however, changes in demographics such as increases in the proportion of more at risk groups among under-five children and rural residents may have overridden the impact of these interventions and resulted in an overall increase. The upsurge in malaria in 2015 compared to 2010 may not have been due to weaknesses in programme interventions but due to increases in more at-risk children and rural residents compared to 2010. The apparent increase in rural residents in the sample population may not have been a true reflection of the population structure but due to oversampling in rural areas which was not fully adjusted for. The increase in malaria prevalence may therefore have been overestimated.

IntroductionActive-case finding (ACF) programs have an important role in addressing case detection gaps and halting tuberculosis (TB) transmission. Evidence is limited on the cost-effectiveness of ACF interventions, particularly on how their value is impacted by different operational, epidemiological and patient care-seeking patterns.MethodsWe evaluated the costs and cost-effectiveness of a combined facility and community-based ACF intervention in Zambia that utilized mobile chest X-ray with computer-aided reading/interpretation software and laboratory-based Xpert MTB/RIF testing. Programmatic costs (in 2018 US dollars) were assessed from the health system perspective using prospectively collected cost and operational data. Cost-effectiveness of the ACF intervention was assessed as the incremental cost per TB death averted over a five-year time horizon using a multi-stage Markov state-transition model reflecting patient symptom-associated care-seeking and TB care under ACF compared to passive care.ResultsOver 18 months of field operations, the ACF intervention costed $435 to diagnose and initiate treatment for one person with TB. After accounting for patient symptom-associated care-seeking patterns in Zambia, we estimate that this one-time ACF intervention would incrementally diagnose 407 (7,207 versus 6,800) TB patients and avert 502 (611 versus 1,113) TB-associated deaths compared to the status quo (passive case finding), at an incremental cost of $2,284 per death averted over the next five-year period. HIV/TB mortality rate, patient symptom-associated care-seeking probabilities in the absence of ACF, and the costs of ACF patient screening were key drivers of cost-effectiveness.ConclusionsA one-time comprehensive ACF intervention simultaneously operating in public health clinics and corresponding catchment communities can have important medium-term impact on case-finding and be cost-effective in Zambia. The value of such interventions increases if targeted to populations with high HIV/TB mortality, substantial barriers (both behavioral and physical) to care-seeking exist, and when ACF interventions can optimize screening by achieving operational efficiency.

Globally, life expectancy increased while infant mortality reduced substantially between the 19th and late 20th century. Although there is relatively mature literature on the drivers behind these gains in life expectancy and reductions in infant mortality, there is a dearth of studies that focus on the drivers of health in sub-Saharan African (SSA) countries. The few studies that do exist do not account for a broader array of determinants such as the quality of access to health services and institutional quality which may have important implications for health policy. We contribute in filling this gap by estimating the effect of a rich set of socio-economic, environmental, health system and lifestyle factors on life expectancy and infant mortality using a panel of 30 sub-Saharan African countries. We employ a dynamic Generalized Method of Moments (GMM) estimator and focus on the period between 1995—2014.Our findings show that increases in health expenditure, educational attainment, and health care access quality are associated with increases in life expectancy and reductions in infant mortality. Higher HIV prevalence rates are associated with reductions in life expectancy whereas urbanization, per capita income growth and access to clean water are positively associated with life expectancy.We conclude that increases in life expectancy and reductions in infant mortality can be accelerated by paying particular attention to interventions linked to these drivers, including, health care access quality.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project.

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.

Substantial efforts have seen the reduction in malaria prevalence from 33% in 2006 to 19.4% in 2015 in Zambia. Many studies have used effect measures, such as odds ratios, of malaria interventions without combining this information with coverage levels of the interventions to assess how malaria prevalence would change if these interventions were scaled up. We contribute to filling this gap by combining intervention coverage information with marginal predictions to model the extent to which key interventions can bring down malaria in Zambia. We used logistic regression models and derived marginal effects using repeated cross-sectional survey data from the Malaria Indicator Survey (MIS) datasets for Zambia collected in 2010, 2012 and 2015. Average monthly temperature and rainfall data were obtained from climate explorer a satellite-generated database. We then conducted a counterfactual analysis using the estimated marginal effects and various hypothetical levels of intervention coverage to assess how different levels of coverage would affect malaria prevalence. Increasing IRS and ITNs from the 2015 levels of coverage of 28.9% and 58.9% respectively to at least 80% and rising standard housing to 20% from the 13.4% in 2015 may bring malaria prevalence down to below 15%. If the percentage of modern houses were increased further to 90%, malaria prevalence might decrease to 10%. Other than ITN and IRS, streamlining and increasing of the percentage of standard houses in malaria fight would augment and bring malaria down to the levels needed for focal malaria elimination. The effects of ITNs, IRS and Standard housing were pronounced in high than low epidemiological areas.

BACKGROUND:Child health interventions were drastically scaled up in the period leading up to 2015 as countries aimed at meeting the 2015 target of the Millennium Development Goals (MDGs). MDGs were defined in terms of achieving improvements in average health. Significant improvements in average child health are documented, but evidence also points to rising inequality. It is important to investigate factors that drive the increasing disparities in order to inform the post-2015 development agenda of reducing inequality, as captured in the Sustainable Development Goals (SDGs). We investigated changes in socioeconomic inequality in stunting and fever in Zambia in 2007 and 2014. Unlike the huge literature that seeks to quantify the contribution of different determinants on the observed inequality at any given time, we quantify determinants of changes in inequality. METHODS:Data from the 2007 and 2014 waves of the Zambia Demographic and Health Survey (DHS) were utilized. Our sample consisted of children aged 0-5 years (n = 5,616 in 2007 and n = 12,714 in 2014). We employed multilevel models to assess the determinants of stunting and fever, which are two important child health indicators. The concentration index (CI) was used to measure the magnitude of inequality. Changes in inequality of stunting and fever were investigated using Oaxaca-type decomposition of the CI. In this approach, the change in the CI for stunting/fever is decomposed into changes in CI for each determinant and changes in the effect-measured as an elasticity-of each determinant on stunting/fever. RESULTS:While average rates of stunting reduced in 2014 socioeconomic inequality in stunting increased significantly. Inequality in fever incidence also increased significantly, but average rates of fever did not reduce. The increase in the inequality (CI) of determinants accounted for the largest part (42.5%) of the increase in inequality of stunting, while the increase in the effect of determinants explained 35% of the increase. The determinants with the greatest total contribution (change in CI plus change in effect) to the increase in inequality of stunting were mother's height and weight, wealth, birth order, facility delivery, duration of breastfeeding, and maternal education. For fever, almost all (86%) the increase in inequality was accounted for by the increase in the effect of determinants of fever, while the distribution of determinants mattered less. The determinants with the greatest total contribution to the increase in inequality of fever were wealth, maternal education, birth order and breastfeeding duration. In the multilevel model, we found that the likelihood of a child being stunted or experiencing fever depends on the community in which they live. CONCLUSIONS:To curb the increase in inequality of stunting and fever, policy may focus on improving levels of, and reducing inequality in, access to facility deliveries, maternal nutrition (which may be related to maternal weight and height), complementary feeding (for breastfed children), wealth, maternal education, and child care (related to birth order effects). Improving overall levels of these determinants contribute to the persistence of inequality if these determinants are unequally concentrated on the well off to begin with.