Purchasing for high-quality care using national health insurance: evidence from Zambia

Improving the quality of care is essential for progress toward universal health coverage. Health financing arrangements offer opportunities for governments to incentivize and reward improvements in the quality of care provided. This study examines the extent to which the purchasing arrangements established within Zambia's new National Health Insurance can improve equitable access to high-quality care. We adopt the Strategic Purchasing Progress and the Lancet Commission for High-Quality Health Systems frameworks to critically examine the broader health system and the purchasing dimensions of this insurance scheme and its implications for quality care. We reviewed policy documents and conducted 31 key-informant interviews with stakeholders at national, sub-national, and health facility levels. We find that the new health insurance could boost financial resources in higher-levels of care, improve access to high-cost interventions and improve care experiences for its beneficiaries as well as integrate the public and private sectors. Our findings also suggest that the health insurance will likely improve some aspects of structural quality but may not be able to influence process and outcome measures of quality. It is also not clear if health insurance will improve efficiency in service delivery, and whether benefits realized will be distributed in an equitable manner. These potential limitations are attributable to the existing governance and financial challenges, low investments in primary care, and shortcomings in the design and implementation of the purchasing arrangements of health insurance. Although Zambia has made progress in a short span, there is a need to improve its provider payment mechanisms, and monitoring and accounting for higher quality of care.