Zambia’s national health insurance cuts costs for older people, but funding gaps limit its potential

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As people age, they are more likely to experience chronic illnesses such as hypertension (high blood pressure), diabetes and heart disease that require regular medical attention. Yet many older adults can't afford healthcare.

This is particularly true in low- and middle-income countries. In 2019 Zambia introduced a National Health Insurance Scheme (NHIS) to help more people access healthcare and move the country closer to universal health coverage. The United Nations defines universal health coverage as “all people having access to the full range of quality health services they need, when and where they need them, without financial hardship”.

The scheme is managed by the National Health Insurance Management Authority. Zambian citizens and established residents have to be members. Adults aged 18 to 64 years must register as contributing members. Children are enrolled as dependants under a principal member. The elderly, people with disabilities, and those classified as poor or vulnerable are exempt from contributions.

But there are gaps in coverage: the poor and informal sector workers still remain eligible for any additional costs of care. Formal sector workers contribute through payroll deductions. Informal workers make direct contributions. Once registered, members can access a package of health at accredited public, private and mission healthcare facilities across the country.

As public health researchers, my colleagues and I wanted to explore how the scheme has strengthened healthcare delivery for older people in Zambia's north-central district of Kitwe.

Kitwe is the second-largest city in Zambia. It was historically a major mining centre, but the decline in mining activities since the 1990s has contributed to high unemployment and reduced economic activity. Kitwe serves as a regional centre for health services, attracting people from surrounding rural areas. This made it the ideal setting for our study. Its well-established administrative structures enabled us to interview local residents and people from rural communities, as well as district managers.

We undertook a qualitative study, speaking with elderly patients, healthcare workers and health insurance administrators about their experience of the health system since the introduction of the National Health Insurance Scheme.

Our research, undertaken with our colleague Lucky Sakala, found that the scheme plays an important role in improving healthcare access for older people by reducing financial barriers, expanding service availabiliy and promoting enrolment. However, challenges related to medicines shortages, infrastructure, staffing and administrative efficiency limit its full potential.

Our findings

We made three key findings about improvements to:

affordability
access
awareness.

Firstly, through member contributions and government support, the scheme helps to cover healthcare costs that patients would otherwise have to pay directly.

People in the formal sector contribute 1% of their basic pay as members of the scheme. People in the informal sector who are younger than 65, and are not on the social cash transfer scheme, undergo an income assessment. Typically, they pay between K30 and K50 (US$1.50-2.60) monthly.

We spoke with 14 elderly members. Many said the scheme had reduced their out-of-pocket healthcare expenses. Those who were 65 years and above said they didn't make any contributions. Most of those aged 55 to 64 said they paid the minimum amount of K30 monthly.

This financial protection is particularly important for older adults who may no longer have a stable income. For example, several participants said they could now undergo costly procedures, such as cataract surgery or orthopaedic operations, with little to no direct payment to the hospital. For many households, this protection can prevent financial hardship and reduce the risk of delayed treatment due to cost concerns.

The second major finding was in relation to access.

Scheme members have equal access to the health services provided in the benefit package. They can access services at all accredited facilities, public or private, without any restrictions. This gives older people more options.

The third positive outcome was that investment in awareness campaigns and registration drives had paid off. Outreach teams conducted door-to-door registration activities and visited communities to enrol older people who might otherwise struggle to register. These efforts have helped bring services closer to vulnerable populations and increase participation in the scheme.

The gaps

Despite these successes, several barriers continue to affect older people's access to healthcare.

One of the most frequently mentioned challenges was the shortage of medicines at some facilities. Participants reported that they sometimes travelled long distances to clinics or hospitals only to find that medicines were unavailable. In some cases, they were required to buy medicines using their own money.

Distance was another major barrier. Some elderly participants living in rural and peri-urban areas said they had to travel considerable distances to reach accredited facilities. Transport costs can be burdensome for older people. Long journeys may also be difficult for individuals with mobility challenges or chronic health conditions.

Participants described difficulties caused by system failures and administrative delays. Some services require pre-authorisation. Delays in approvals, coupled with technical system interruptions, sometimes affected timely access to care.

We spoke with six healthcare workers and two administrators who also acknowledged that there were shortages of healthcare personnel, pressure on infrastructure, and rapidly growing demand for services. As more people join the insurance scheme, ensuring sufficient resources and maintaining service quality becomes increasingly important.

There's been little increase in the national health budget since the scheme was introduced.

What needs to happen next

The study identified several strategies that could help improve healthcare access for older people.

The first is increased government support for elderly members who still struggle to pay contributions.

Participants also emphasised the importance of building and accrediting additional healthcare facilities, particularly in underserved areas. Expanding the provider network could reduce travel distances and ease congestion at busy facilities.

This was an overall concern about poor service delivery, delays in reimbursement, and how scheme funds were managed. As a result, participants highlighted the need for stronger monitoring and accountability in the management of scheme resources.

Addressing these challenges will require coordinated efforts from the government, healthcare providers and health insurance administrators. Continued investment in health infrastructure, medicine availability, workforce development and service quality will be essential to accommodate an increase in scheme membership and the healthcare services it covers.

Lucky Sakala, a researcher at the University of Zambia, contributed to this article and led the research it is based on.

The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.

By Malizgani Paul Chavula, Lecturer and Researcher in the Department of Community and Family Medicine, University of Zambia And

Cosmas Zyambo, Lecturer & Researcher in Public Healths, University of Zambia