Legislature committees and the current national health strategic plan report increasing incidence of teenage pregnancies, persistence of customary child marriages, low secondary education completion rates amongst girls and infrequent use of contraceptives, in addition to a relatively high rate of HIV prevalence in the Zambian population. Rates of HIV prevalence are higher in urban areas compared to rural areas, and there is a high rate of TB/HIV co-infection.
Zambia faces severe sexual and reproductive health and HIV-related health challenges with variable access to healthcare. For example, the proportion of births attended by skilled birth attendants varies widely according to the interconnected variables of household wealth and environment. Although there is provision for free basic health care, user fees are applied in secondary and tertiary level public health care, where services are also more expensive. Improvement through wide-scale expansion of infrastructure and services in many rural areas is not seen as feasible in the short and medium term.
Service delivery is largely dominated by the public sector which controls the overwhelming majority of health facilities, either directly, or through agreements with the Churches Health Association of Zambia. Since 2006, Zambia has fallen short of meeting their Abuja Declaration commitment to spend a minimum of 15% of their national budget on health, with a funding allocation to the health budget of 11.3% in 2014 (Zambia met their Abuja Declaration commitment 2003-2005, though data varies somewhat between sources).
Sources : World Databank (2015) Health expenditure, public (% of government expenditure) https://data.worldbank.org/indicator/SH.XPD.PUBL.GX.ZS Accessed 23.02.2018
There exists a two year service gap between the minimum legal age for sexual consent (16, though customary law permits marriage earlier, after puberty) and to access sexual health services without parental consent – which currently stands at 18 years of age. Within a broader context of gender inequality, this may contribute to high rates of induced abortion, low prevalence of contraception, relatively high rates of HIV, and low rates of secondary school completion amongst teenage girls. Successive Zambian governments have been aware of the issues and have taken some measures to address them such as a commitment to introduce comprehensive sex education in schools.
Public hospitals reported a dramatic increase in the number of cases of complications from unsanctioned, unsafe abortions: from 5,600 cases in 2003 to over 10,000 in 2008 with a total of 52,791 cases in those six years. This is in contrast to just 616 safe and legal abortions carried out between 2003 and 2008. According to hospital-based records, unsafe abortions are estimated to be the cause of approximately 30% of maternal deaths. Additional research suggests up to 80% of all women in Zambia who seek treatment for complications from unsafe abortions are under the age of 19 years. Abortion is legally permitted on grounds in common with many African countries – namely if the mental or physical health or life of the mother is threatened or if the fetus shows physical or mental abnormalities. Additionally an usual basis is provided for abortion to be permitted where “continuance of the pregnancy would have involved risk of injury to the physical or mental health of the existing child(ren) of the family” (Termination of Pregnancy Act, Cap 304). However, stigma, cultural attitudes, women’s lack of agency, bureaucratic barriers, and limited awareness about the availability of safe abortion contributes to high rates of illegal, unsafe abortion. In May 2009, the Ministry of Health published a series of standards & guidelines for administering comprehensive care around abortion, to address the trend.
Guttmacher Institute, 2009, Unsafe Abortion in Zambia, Brief No.3
SADC (2014) Gender Protocol Barometer, ch.6
Zambia’s health system encompasses a set of human rights-oriented policies, which have clearly been influenced by the principles of decentralization, community participation, patient centeredness and equity. Health reforms are ongoing and there are still gaps between the principles of bringing health services as close to the family as possible and implementation. Zambia’s Constitution places customary law beyond the realm of state legislation, limiting the scope for leverage and legal challenge to some practices sanctioned by customary law, such as child marriage.
Termination of Pregnancy Act of 1972 allow abortions in cases where there is threat to the health of the mother, to that of her existing children, and the foetus but procedures to obtain legally sanctioned abortions are arduous
Reproductive Health Policy of 2005 that guarantees free contraceptives in public health facilities
Zambia Family Planning National Guidelines and protocols of 2006 offer guidance for health-care workers on how to provide quality FP services
The Anti Gender-Based Violence Act specifically addresses Gender-Based Violence
National guidelines for the multi-disciplinary Management of survivors of Gender Based Violence in Zambia 2011 and amendments to the Penal Code has created a stronger foundation to deal with the high incidence of rape and improve social protection of women and girls although marital rape is not explicitly covered by any legislation
Zambia Integrated Family Planning Scale Up Plan for 2013–20 forms the strategy for widening access to family planning services, particularly modern contraception
Zambia National Health Strategic Plan 2017 – 2021 includes stated aims to “increase the availability and utilization of high-impact sexual and reproductive health services” with a focus on adolescent sexual and reproductive health and rights such as a 2021 target to have 90% of adolescents accessing integrated SRH services and including clear policies and guidelines on age of consent to key SRH and HIV services
HIV&AIDS programmes, including the National HIV/AIDS/STI/TB Council (NAC); the National Malaria Control programme; National TB and Leprosy Control Programme; the Child Health and Nutrition Programme; and the Maternal Health Programme form Zambia’s main priority health programmes
African Charter on Human and Peoples’ Rights (also known as the Banjul Charter)
United Nations Convention on the Rights of the Child (UNCRC)
Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)
Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa
African Charter on Democracy, Elections and Governance