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Background: In 2014, Zambia adopted the Comprehensive Sexuality Education (CSE) framework to promote sexual reproductive health and rights (SRHR) in schools. Effective CSE implementation requires multisectoral collaboration with diverse government sectors (education, health, etc.), the community, traditional, and religious leaders. However, research on CSE with a focus on collaboration remains scarce, especially in Sub-Saharan Africa. The overall aim of this thesis was to explore the delivery of the CSE framework in Zambia, with a particular focus on collaborative governance.

Methods: This study employed both a systematic review and a qualitative case study design. Firstly, the systematic review used the thematic analysis to identify factors influencing the integration of CSE into the education system in low- and middle-income countries (Sub-study I). Secondly, the qualitative case study aimed to understand how national policy frameworks (Sub-study II), provincial multisectoral collaboration (Sub-study III), and community system dynamics (Sub-study IV) interact to shape the delivery of CSE in Zambia. We collected data using qualitative interviews with diverse stakeholders representing government, NGOs, religious, and traditional leadership. Qualitative content analysis and reflexive thematic analysis were used as analytical approaches.

Findings: Key factors influencing the integration of CSE into education systems included the nature of the problem, actors’ perceptions, attributes of the intervention, adopting systems, and broader system characteristics. While Zambia’s policy environment supports CSE, contradictions—such as restrictions on contraceptive delivery in schools and social norms that promote child marriage—undermine effective implementation. In addition, the perceived inclusion of abortion and LGBTQ+ related topics increases stakeholders’ resistance towards the implementation of CSE. Furthermore, factors influencing multisectoral collaboration in implementing CSE at the provincial level included a supportive provincial structure that facilitated stakeholder engagement. Nevertheless, this structure was weakened by the exclusion of key groups, limited transparency, and the bypassing of institutional mandates. The study also highlights factors that influence collaborative community health system (CHS) pathways and the barriers to implementing CSE in rural Zambia. Stakeholders from the school, community, health and police sectors participated in facilitating collective delivery of CSE across settings. However, social norms contributed to community resistance in addressing SRHR-related challenges, including child abuse, early marriages, and unintended pregnancies. 

Conclusion: Effective delivery of the CSE framework in Zambia requires a comprehensive multisectoral collaborative governance across all levels. However, this requires strengthening institutional mandates, improved coordination, and collective action in promoting SRHR services, including abolishing some harmful local by-laws that hinder promoting SRHR efforts. 

Mbiri ya ntchito: Mu 2014, Zambia idavomereza ndondomeko ya Maphunziro okhudza Zogonana (Comprehensive Sexuality Education: CSE) kuti ithandize kukweza thanzi la chibadwidwe ndi ufulu wa ana ndi achinyamata (SRHR) m’sukulu. Kuti CSE igwire bwino ntchito, zimafuna mgwirizano wa magawo osiyanasiyana a boma (monga zamaphunziro, zaumoyo, ndi ena), anthu a m’mudzi, atsogoleri achikhalidwe, komanso atsogoleri azipembedzo. Komabe, kafukufuku wokhudza CSE wokhudzana ndi mgwirizano ukusakabe, makamaka ku Sub‑Saharan Africa. Cholinga chachikulu cha thesis iyi chinali kufufuza momwe CSE ikuchitidwira ku Zambia, makamaka potanthauzira ulamuliro wogwirizana (collaborative governance).

Njira za kafukufuku: Kafukufukuyu adagwiritsa ntchito systematic review (kuwunika mwadongosolo) ndi kafukufuku wa qualitative case study design. Choyamba, kuwunika mwadongosolo kunagwiritsa ntchito thematic analysis (kusanthula mitu) kuti apeze zinthu zomwe zimakhudza kuphatikizidwa kwa CSE mu dongosolo la maphunziro m'maiko otsika ndi apakati pa chitukuko (Sub‑study I). Kenako, qualitative case study inali yolingalira kumvetsa momwe malamulo a boma (Sub‑study II), mgwirizano wa magawo osiyanasiyana pa mlingo wa chigawo (Sub‑study III), komanso machitidwe a m’madera a m’mudzi (Sub‑study IV) zimagwirizanirana popanga CSE ku Zambia. Deta idasonkhanitsidwa pogwiritsa ntchito kuyankhulana kwa mtundu wa qualitative (qualitative interviews) ndi omwe amayimira boma, NGOs, atsogoleri azipembedzo, komanso atsogoleri achikhalidwe. Kusanthula kwa zolemba (qualitative content analysis) limodzi ndi reflexive thematic analysis zidagwiritsidwa ntchito pakupanga kusanthula.

Zotsatira: Zinthu zazikulu zomwe zinapezeka kuti zimakhudza kuphatikizidwa kwa CSE mu dongosolo la maphunziro zinkaphatikizapo: momwe vutoli limvelekere, mmene omwe akhudzidwa amaonera pulogalamuyi, khalidwe la pulogalamu ya CSE, momwe machitidwe a boma amalandirira ndondomeko, komanso mikhalidwe ya dongosolo lonse la maphunziro. Ngakhale Zambia ili ndi malamulo othandiza CSE, kusiyana kwa malamulo—kuphatikizapo zoletsa monga kusapereka mankhwala oletsa mimba m'masukulu komanso miyambo yolimbikitsa ukwati wa ana—zimalepheretsa kuchitidwa bwino kwa CSE. Komanso, malingaliro oti CSE ili ndi mitu yokhudza kuchotsa mimba (abortion) kapena LGBTQ+ zimayambitsa kukana kuchokera kwa omwe akhudzidwa. Kuphatikizapo, zinthu zomwe zimakhudza mgwirizano wa magawo osiyanasiyana pa mlingo wa chigawo zinkaphatikizapo dongosolo labwino lomwe limathandiza kutenga nawo mbali kwa omwe akhudzidwa. Komabe, dongosololi limafooka chifukwa chosaphatikiza magulu ena ofunika, kusowa kwa kuwonekera kwa ntchito, komanso kuphwanya maudindo a mabungwe a boma. Kafukufukuyu awonetsanso zinthu zomwe zimakhudza njira za mgwirizano wa okhudzidwa a m’mudzi komanso zopinga pakukhazikitsa CSE kumudzi. Anthu ochokera m’sukulu, m’magulu a m’mudzi, zaumoyo, komanso apolisi anali kutenga nawo mbali polimbikitsa ntchito za CSE. Komabe, miyambo ya m’mudzi inali imodzi mwa zinthu zomwe zimayambitsa kukana kuthana ndi mavuto a SRHR monga nkhanza za ana, ukwati wa msanga, ndi mimba zosafunika.

Pomaliza: Kuti CSE igwire bwino ntchito ku Zambia, zikufunika mgwirizano wamphamvu pakati pa magawo onse kuyambira pa mlingo wa boma mpaka kumudzi. Zikufunikanso kulimbitsa maudindo a mabungwe, kusintha mgwirizano, ndi kulimbikitsa ntchito za limodzi pothandiza SRHR—kuphatikizapo kuchotsa malamulo ndi miyambo yowononga yomwe imalepheretsa kukwezedwa kwa SRHR.

Introduction: Globally, adolescent pregnancy and marriage contribute to high school dropout rates. Girls who drop out of school early tend to have poorer health indicators than those who continue their education. In 1997, the government of Zambia, through the Ministry of Education, introduced the Re-entry Policy to facilitate adolescent girls who had dropped out of school to continue their education. However, since this policy enactment, there has not been any formal study to explore the facilitators and challenges of its implementation. This study explored factors influencing the re-engagement of school dropout girls into the education system following the enactment of the Re-entry Policy in Zambia.

Methods: This was a qualitative study conducted in three priority districts in Zambia between September and October 2022. We conducted 26 key informant interviews with officials from the district government department, implementing partners, community members, and parent-teacher association representatives, 14 in-depth interviews, and 5 focus-group discussions with girls who re-engaged into the education system and those who had not returned to school. Data were collected on the reasons why girls had dropped out, facilitators of their re-engagement, and challenges experienced during and/or after the re-engagement process. Data analysis was conducted using a reflexive thematic analysis approach, following a structured coding process.

Results: Factors influencing girls to drop out of school included socioeconomic constraints, gender roles and inequality, long distances to schools, and inadequate and unsafe boarding facilities. Conversely, factors facilitating girls’ return to school included the recognition of the value of education as a means for achieving personal development, a supportive policy environment, educational sponsorships, the engagement of community and traditional leadership in ending child marriages. However, the challenges for re-engaging girls back to school included limited comprehensive sponsorship and funding opportunities, limited implementing partners funding opportunities for girls to stay in school, and inadequate community awareness of the Re-entry Policy. Suggested strategies to address the challenges that girls face in re-engaging them back to school included an expansion of existing limited school infrastructure and increased implementation of Comprehensive Sexuality Education (CSE) in schools.

Conclusion: Socioeconomic, cultural, and structural factors rank among the major challenges that limit girls’ re-entry and retention in the school system. Therefore, increasing resources and opportunities for scholarships, expanding school infrastructure, and engaging stakeholders to improve access to and delivery of quality education are essential measures to enable girls to attain their educational potential.

Policy Implications: The findings highlight the need for strengthening existing policies to address socioeconomic constraints, gender inequality, and unsafe boarding to reduce dropout rates. Additionally, increasing educational sponsorship, community awareness of the Re-entry Policy, community leadership, and parents’ involvement in preventing child pregnancies and marriages is essential. Finally, the government should expand the school infrastructure, strengthen the implementation of CSE to facilitate overcoming the current challenges, and support girls’ return to school for social development.

Background: In recent years, the international health discourse has increasingly focused on achieving universal health coverage (UHC) through the provision of health insurance. Low- and middle-income countries (LMICs), such as Zambia, have adopted national health insurance schemes to improve health service delivery among their citizens. This study explored the role of Zambia’s National Health Insurance Scheme (NHIS) in strengthening the delivery of health services to the elderly at the district level in Zambia.

Methods: The study employed a qualitative case approach, and purposive sampling was used to select 22 participants for in-depth and key informant interviews. These included 14 elderly NHIS members, 6 staff members from health insurance facilities, and 2 NHIMA provincial office managers. The data was analysed using a thematic analysis approach. This was achieved by identifying patterns in service delivery and user experiences in accessing health services.

Results: The study findings revealed that the National Health Insurance Scheme (NHIS) has improved healthcare access for the elderly by offering affordable and increasing utilisation of services through accrediting facilities and reducing financial risks. Outreach efforts have helped register elderly members directly from their homes. However, challenges remain, including medication shortages, inadequate healthcare providers, long-distance travel, and system inefficiencies. The strategies to address the challenges include the government increasing medical subsidies, improving monitoring of the NHIS fund, policy reform to enhance equitable elderly care, and health infrastructure expansion.

Conclusion: While NHIS might have enhanced health service access among the elderly, service-related gaps still hinder its optimal effect. The challenges include limited health facility accreditation, shortages of medicines, and weak governance. Overcoming the barriers requires ethical NHIS reforms that promote better accreditation of healthcare, increased funding for improved infrastructure, and universal availability of medical services.

Background: Global concerns regarding effective response strategies to the COVID-19 pandemic arose amid the swift spread of the virus to low- and middle-income country (LMIC) settings. Although LMICs instituted several measures to mitigate spread of the virus in low resource settings, including task shifting certain demand and supply functions to community actors such as community health workers (CHWs), there remains a lack of synthesized evidence on these experiences and lessons. This scoping review sought to synthesize evidence regarding the roles and challenges faced by CHWs during the fight against COVID-19, along with strategies to address these challenges.

Methodology: We systematically searched several major electronic databases including PubMed, HINARI, Cochrane Library (Reviews and Trials), Science Direct and Google Scholar for relevant literature. The search strategy was designed to capture literature published in LMICs on CHWs roles during COVID-19 period spanning 2019–2023. Two researchers were responsible for retrieving these studies, and critically reviewed them in accordance with Arksey and O’Malley scoping review approach. In total, 22 articles were included and analysed using Clarke and Braun thematic analysis in NVivo 12 Pro Software.

Results: Community health workers (CHWs) played a vital role during the COVID-19 pandemic. They engaged in health promotion and education, conducted surveillance and contact tracing, supported quarantine efforts, and maintained essential primary health services. They also facilitated referrals, advocated for clients and communities, and contributed to vaccination planning and coordination, including tracking and follow-up. However, CHWs faced significant challenges, including a lack of supplies, inadequate infection prevention and control measures, and stigma from community members. Additionally, they encountered limited supportive policies, insufficient remuneration and incentives. To enhance CHWs’ performance, regular training on preventive measures is essential. Utilizing digital technology, such as mobile health, can be beneficial. Establishing collaborative groups through messaging platforms and prioritizing access to COVID-19 vaccines are important steps. Additionally, delivering wellness programs and providing quality protective equipment for CHWs are crucial for their effectiveness.

Conclusion: The study found that CHWs are vital actors within the health system during global pandemics like COVID-19. This entails the need for increased support and investment to better integrate CHWs into health systems during such crises, which could ultimately contribute to sustaining the credibility of CHWs programs and foster more inclusive community health systems (CHSs).

Background: In 2014, the Zambian government introduced the Comprehensive Sexuality Education (CSE) framework, decentralising its implementation from the national to the provincial administration. The provincial structures of the Ministries of Health and Education play an important role in providing technical, policy direction and coordination support. However, little research has focused on the role of CSE collaboration at the provincial level.

Objectives: This study sought to explore multisectoral collaboration dynamics influencing the implementation of the CSE framework at the provincial level in Zambia. Methods: This qualitative study involved 29 interviews with diverse stakeholders at the provincial level such as government departments (health, education, etc.), private sector, religious and traditional leaders involved in CSE implementation. We used reflexive thematic analysis, guided by an integrative collaborative governance framework.

Results: The findings were grouped under collaboration dynamics domains: principled engagement, shared motivation, and capacity for joint action. Barriers to principled engagement included provincial structures and their mandate, exclusion or sidelining of certain actors, inadequate financial transparency, and weak formal relations. Shared motivation included collective understanding of the purpose, a supportive policy environment and consensus in adapting the CSE framework. Capacity for joint action efforts included collaborative training of teachers, joint monitoring, and collaborative to address SRHR challenges.

Conclusion: This study highlights challenges limiting meaningful engagement, exclusion of some actors, financial constraints, and weak coordination, which hinder collaboration. There is need for enhancing provincial leadership capacity to effectively coordinate stakeholders through enforcement of transparent resource management, collective planning, implementation and monitoring for effective CSE delivery.

Introduction: Child, early and forced marriage (CEFM) remains a problem in many low- and middle-income countries. This study aimed to investigate contextual social norms on CEFM and explore barriers to implementation of policies designed to address these norms in Mozambique, Uganda, and Ethiopia.

Methods: Qualitative data was collected from a total of 90 respondents. Forty-two (n=42) interviews were conducted with adolescents, parents, traditional leaders, government officials and civil society organizations. Four (n=4) focus group discussions (FGDs) were held with parents, adolescents, community members and community leaders, comprising a total of 48 participants. Data were analyzed using thematic analysis.

Results: The main social norms which contributed to CEFM in the three countries included the high social value attached to the motherhood status; the commodification of marriage; marriage as a rite of passage into adulthood, social construction of sexuality and the collective moral judgment about responsible parenthood. The norms were sustained by allowing those who abide by them to accumulate social and economic benefits such as stronger social ties within the community and improved social status. Although several policies and laws have been enacted to address these social norms, their impact has been limited. The main policy implementation barriers were the inadequate consideration of social norms that promote CEFM within the policy and legal framework, limited collaboration among key stakeholders, lack of comprehensive monitoring processes, and difficulties among community members to understand the policies due to low literacy levels and poor policy monitoring.

Conclusion: Enhancing the policy response to social norms that perpetuate CEFM will require strengthening collaboration between non-governmental organizations, government departments and community leaders in implementation and monitoring of the policies.

Introduction: The Zambian government decentralised tuberculosis control programs by transferring responsibility for the care and treatment of multidrug-resistant tuberculosis (MDR-TB) patients from a two-national hospital model to provincial hospitals and other lower-level healthcare structures. Limited evidence exists on the effects of decentralisation on the quality of TB care provided through public sector decentralisation. In this paper, we explored the impact of decentralising MDR-TB on patient and service outcomes.

Methods: This study used a mixed-methods approach. Quantitative data were collected through a survey of 244 MDR-TB patients, while qualitative data was collected through interviews with TB coordinators, healthcare providers, patients, and caregivers. Participants were drawn from health facilities and the Ministry of Health. Quantitative data was analysed in STATA version 16.0, while thematic analysis was used for the qualitative data.

Results: Decentralisation has improved patient care and management by increasing access to essential commodities such as medication and diagnostic testing. It has led to more equitable distribution of MDR-TB healthcare services and resources across different population groups, regardless of social, economic, or demographic factors. Furthermore, the quality of life for MDR-TB patients has improved, with better adherence to medication resulting from increased family support. Due to decentralisation, tailored community and patient-centred services have been integrated resulting in reduced congestion at facilities. The study also identified challenges, including heavy workload for healthcare staff, fragmented coordination of supervisory responsibilities, and confusion over roles in patient management, which negatively impacted the decentralisation process.

Conclusion: The decentralisation of MDR TB services offers significant benefits but is not a guaranteed solution, as poor planning or implementation can lead to challenges in service delivery.

Background: Early childhood development (ECD) programmes play a crucial role in child development through the promotion of health, nutrition, early education, and playful parenting interventions. Community-based volunteers (CBVs) also play an essential role in facilitating the integration of ECD into rural community systems for health to promote interactive playful parenting for early childhood development. However, little is known about the role of CBVs integrating interactive playful parenting interventions for early childhood development and health in Zambia’s community systems for health. This study explores the role of community-based volunteers in integrating interactive playful parenting interventions for early childhood development in rural community systems for health in Zambia.

Methods: This was a qualitative study conducted in Katete and Petauke districts in Eastern Province, Zambia. We conducted 38 qualitative interviews including 12 focus group discussions (FGDs) with parents/caregivers and CBVs, 18 key informant interviews (KIIs) with district government and NGO stakeholders involved in the implementation, and 8 in-depth interviews (IDIs) with representatives from the Neighbourhood Health Committee (NHC). Data was analysed using thematic analysis guided by five domains of Atun’s conceptual framework on the integration of innovations into health systems: nature of the problem, attributes of the intervention, adoption system, broad system characteristics, and broad context.

Findings: For the nature of the problem, the stakeholders recognized ECD as a cross-cutting issue and highlighted the need for the delivery of ECD interventions that foster playful parenting while emphasizing the need for trained manpower to deliver these interventions. The attributes of the ECD interventions included the design of an ECD training package, provision of capacity-building training and the distribution of training materials and resources to support implementation. The degree of adoption of ECD interventions into community systems for health depended on actors’ perspectives, including community leadership, parents, and teachers on ECD activities. The broader system characteristics shaping ECD integration included district-based multisectoral collaboration in delivery of ECD, community-based collaboration, education and linkages on ECDs. Additionally, the availability of community structures played a significant role in shaping the delivery of ECD activities, while school administration was instrumental in coordinating ECD programmes. Healthcare workers played a key role in providing supportive supervision for delivery of ECD interventions. The broader context influencing the integration of ECD interventions was shaped by the policy and legal environment, political commitment to deliver ECD interventions, challenges related to inadequate allocation of human, financial, and material resources. Furthermore, the lack of infrastructure development posed a barrier to collaborative efforts in delivering ECD services effectively.

Conclusion: The integration of playful and interactive parenting highlights both barriers and facilitators, particularly regarding resources, personnel, and infrastructure. Addressing these challenges requires collaborative and coordinated efforts among the health, education, and social sectors to enhance the integration of ECD interventions. Strengthening ECD service delivery further necessitates increased resource allocation, expanded capacity building initiatives, and infrastructure development to support holistic child development and health.

Background: Multi-drug-resistant tuberculosis (MDR-TB) infections are a public health concern. Since 2017, the Ministry of Health (MoH) in Zambia, in collaboration with its partners, has been implementing decentralised MDR-TB services to address the limited community access to treatment. This study sought to explore the role of collaboration in the implementation of decentralised multi drug-resistant tuberculosis services in Zambia.

Methods: A qualitative case study design was conducted in selected provinces in Zambia using in-depth and key informant interviews as data collection methods. We conducted a total of 112 interviews involving 18 healthcare workers, 17 community health workers, 32 patients and 21 caregivers in healthcare facilities located in 10 selected districts. Additionally, 24 key informant interviews were conducted with healthcare workers managers at facility, district, provincial, and national-levels. Thematic analysis was employed guided by the Integrative Framework for Collaborative Governance.

Findings: The principled engagement was shaped by the global health agenda/summit meeting influence on the decentralisation of TB, engagement of stakeholders to initiate decentralisation, a supportive policy environment for the decentralisation process and guidelines and quarterly clinical expert committee meetings. The factors that influenced the shared motivation for the introduction of MDR-TB decentralisation included actors having a common understanding, limited access to health facilities and emergency transport services, a shared understanding of challenges in providing optimal patient monitoring and review and their appreciation of the value of evidence-based decision-making in the implementation of MDR- TB decentralisation. The capacity for joint action strategies included MoH initiating strategic partnerships in enhancing MDR-TB decentralisation, the role of leadership in organising training of healthcare workers and of multidisciplinary teams, inadequate coordination, supervision and monitoring of laboratory services and joint action in health infrastructural rehabilitation.

Conclusions: Principled engagement facilitated the involvement of various stakeholders, the dissemination of relevant policies and guidelines and regular quarterly meetings of clinical expert committees to ensure ongoing support and guidance. A shared motivation among actors was underpinned by a common understanding of the barriers faced while implementing decentralisation efforts. The capacity for joint action was demonstrated through several key strategies, however, challenges such as inadequate coordination, supervision and monitoring of laboratory services, as well as the need for collaborative efforts in health infrastructural rehabilitation were observed. Overall, collaboration has facilitated the creation of a more responsive and comprehensive TB care system, addressing the critical needs of patients and improving health outcomes.

Introduction: Adolescents and young women in low-middle-income countries face obstacles to accessing HIV, Sexual and Reproductive Health (SRH), and related Gender-Based Violence (GBV) services. This paper presents facilitators, opportunities, and barriers to enhance uptake of HIV, GBV, and SRH services among Adolescent Girls and Young Women (AGYW) in selected districts in Zambia.

Methods: This study was conducted in Chongwe, Mazabuka, and Mongu Districts among adolescent girls and young women in Zambia. Key informants (n = 29) and in and out-of-school adolescents and young people (n = 25) were interviewed. Purposive sampling was used to select and recruit the study participants. Interviews were transcribed verbatim, and a content analysis approach was used for analysis.

Results: The facilitators that were used to enhance the uptake of services included having access to health education information on comprehensive adolescent HIV and gender-based violence services. Non-governmental organisations (NGOs) were the main source of this information. The opportunities bordered on the availability of integrated approaches to service delivery and strengthened community and health center linkages with referrals for specialised services. However, the researchers noted some barriers at individual, community, and health system levels. Refusal or delay to seek the services, fear of side effects associated with contraceptives, and long distance to the health facility affected the uptake of services. Social stigma and cultural beliefs also influenced the understanding and use of the available services in the community. Health systems barriers were; inadequate infrastructure, low staffing levels, limited capacity of staff to provide all the services, age and gender of providers, and lack of commodities and specialised services.

Conclusion: The researchers acknowledge facilitators and opportunities that enhance the uptake of HIV, GBV, and SRH services. However, failure to address barriers at the individual and health systems level always negatively impacts the uptake of known and effective interventions. They propose that programme managers exploit the identified opportunities to enhance uptake of these services for the young population.