Provider Purchasing and Contracting for Health Services_The Case

The Hospital Management Boards are responsible for managing the second- and third-level
hospitals within the referral flow system, while the District Health Boards and District Health
Management Teams are responsible for managing the first-level facilities in delivering
primary (preventive and curative) interventions. The first level is where the bulk of health
service delivery takes place in Zambia. The facilities are categorized as follows:
Health posts are intended to cater to populations of 500 households (3,500 people) in rural
areas and 1,000 households (7,000 people) in the urban areas, or to be established within a
five-kilometer radius in sparsely populated areas.
Health centers include Urban Health Centers, which are intended to serve a population of
30,000 to 50,000 people, and Rural Health Centers, serving a catchment area within a 29-
kilometer radius or population of 10,000.
First-level referral hospitals are found in most of the 72 districts of Zambia and are intended
to serve a population of between 80,000 and 200,000 with medical, surgical, obstetric, and
diagnostic services, including all clinical services to support health center referrals. The
country had 74 first-level referral hospitals in 2007.
General hospitals are second-level hospitals at the provincial level and are intended to cater
to a catchment area of 200,000 to 800,000 people, with services in internal medicine, general
surgery, pediatrics, obstetrics and gynecology, dental, psychiatry, and intensive care. These
hospitals are also intended to act as referral centers for the first-level institutions, including
the provision of technical backup and training functions. In 2007, there were 19 second-level
hospitals concentrated along the railway in the Southern and Copperbelt Provinces, which
have 5 and 3 second-level hospitals, respectively. There is a need to rationalize the
distribution of these facilities through right-sizing.
Central hospitals are for catchment populations of 800,000 and above, and have subspecializations
in internal medicine, surgery, pediatrics, obstetrics, gynecology, intensive
care, psychiatry, training, and research. These hospitals also act as referral centers for secondlevel
hospitals. There are five such facilities in Zambia, three of which are in the Copperbelt
Province. There is need to rationalize the distribution of these facilities.
The design of the layers of the system forms the basis of the referral system that provides for
contracting-in and -out at various levels of the health care system. The services provided at
each level of care are defined by the Basic Health Care Package.
Composition and distribution of health care facilities
According to a study by the Ministry of Health (MoH 2008), government and private not-forprofit
institutions provide the largest proportion of health services in Zambia. The private
sector is relatively small, although it has grown significantly since the beginning of the
reforms in 1992 (see table 5).
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