In Zambia, a woman diagnosed with cervical cancer at a district clinic may be referred to the University Teaching Hospital in Lusaka, where the National Health Insurance (NHI) scheme covers exactly seven oncology drugs. If her cancer requires trastuzumab for a HER2-positive tumour, or imatinib for a rare leukaemia, she will pay the full cost out-of-pocket. According to a 2022 study by the Zambia Cancer Society, out-of-pocket costs for a single cycle of chemotherapy not covered by NHI can range from 5,000 to 10,000 kwacha—an amount that can exceed a household's monthly income. This is the reality of cancer care under a public insurance system that, five years after its launch, still covers a fraction of the medicines oncologists consider essential.

Zambia's NHI, established in 2020, was designed to pool risk and reduce financial barriers to care. For formal-sector workers, contributions are mandatory: 1% of salary, matched by the employer. The benefit package includes primary care, hospitalisation, and a limited set of specialist treatments. But for oncology, the list is notably short. Only seven drugs—tamoxifen, cisplatin, paclitaxel, carboplatin, cyclophosphamide, doxorubicin, and one or two others—are reimbursed, and only at tertiary referral centres. That means patients in provincial hospitals must travel to Lusaka, Ndola, or Kitwe to access even these medicines.

The gap is stark when measured against the country's cancer burden. Cervical cancer is the leading cancer among women, with an age-standardised incidence rate of approximately 58 per 100,000 according to the 2020 GLOBOCAN estimates from the International Agency for Research on Cancer—among the highest in the world. Breast cancer, prostate cancer, and Kaposi sarcoma (the latter driven by HIV co-infection) are also common. For Kaposi sarcoma, the standard first-line treatment includes liposomal doxorubicin or paclitaxel, both on the list, but second-line agents such as bleomycin or vincristine are not covered. For chronic myeloid leukaemia, imatinib—a drug that turns a fatal disease into a manageable chronic condition—is absent from the NHI formulary, though it is available through some donor programmes.

The NHI's limited oncology package reflects a deliberate policy choice. When the scheme was designed, the Ministry of Health and the NHI Authority prioritised primary care and maternal-child health services, which reach more people per kwacha spent. Cancer drugs are expensive, and the budget is constrained. But the result is that patients with a cancer diagnosis often face a choice: pay for treatment themselves, seek charitable assistance, or forgo care entirely. A 2023 study by Mwila et al. (University of Zambia, published in the Journal of Cancer Policy) estimated that roughly 40% of cancer patients at the University Teaching Hospital abandon treatment within six months of diagnosis, largely due to cost.

Seven Drugs for a Cancer Epidemic

The seven reimbursed drugs are all generics, mostly from the World Health Organization's Model List of Essential Medicines. Tamoxifen, for hormone-receptor-positive breast cancer, is covered. Cisplatin and carboplatin are used for cervical, ovarian, and lung cancers. Paclitaxel is a mainstay for breast, ovarian, and Kaposi sarcoma. Cyclophosphamide and doxorubicin are used in lymphomas and some solid tumours. The list is a reasonable starting point, but it leaves out entire categories of effective therapy.

Missing are targeted therapies such as trastuzumab (Herceptin) for HER2-positive breast cancer, which accounts for roughly 15–20% of breast cancers in Zambia. Without it, women with HER2-positive disease have a substantially worse prognosis. Imatinib, as noted, is absent. So are the newer hormonal agents like letrozole or anastrozole, which are standard of care for postmenopausal breast cancer in high-income countries. For Kaposi sarcoma, the list includes paclitaxel but not the liposomal doxorubicin formulation that is often preferred for its lower cardiotoxicity.

The absence of palliative medicines is also notable. While morphine is listed as a covered drug, stockouts at tertiary hospitals are common. A 2024 report by the Palliative Care Association of Zambia, titled Morphine Availability at Referral Hospitals in Zambia, found that morphine was unavailable in roughly 30% of health facilities surveyed, even at the referral level. For patients with advanced cancer, pain management is a critical component of care, and its intermittent availability undermines the NHI's promise of comprehensive coverage.

The NHI Authority has acknowledged the gaps. In a 2025 review of the benefit package, officials signalled an intention to add several oncology drugs, but no timeline or specific list has been published. The process is complicated by the need for budget impact analyses and price negotiations with suppliers. Zambia, like many low-income countries, has limited bargaining power in the global pharmaceutical market, and prices for patented drugs remain high.

How the National Health Insurance Scheme Works

The NHI is administered by the National Health Insurance Authority, a parastatal body under the Ministry of Health. Contributions are collected from formal-sector employees and their employers, with the government subsidising contributions for informal-sector workers and the poor through a separate allocation. As of late 2024, roughly 1.5 million people were active contributors, covering an estimated 4–5 million beneficiaries when dependents are included—about a quarter of the population.

The benefit package is divided into two tiers. The primary care tier covers outpatient consultations, basic diagnostics, and a limited list of medicines at public clinics and district hospitals. The secondary and tertiary tier covers hospitalisation, surgery, and specialist care, including cancer treatment, but only at designated facilities. For oncology, that means the three tertiary referral hospitals: University Teaching Hospital in Lusaka, Ndola Teaching Hospital, and Kitwe Teaching Hospital. Patients must be referred from a lower level and obtain prior authorisation for chemotherapy.

The prior authorisation process can take weeks. A patient's file must be reviewed by the NHI's clinical committee, which verifies the diagnosis and treatment plan. If the requested drug is not on the reimbursed list, the patient is informed that they will need to pay privately. Some patients appeal, but the process is opaque. A 2024 audit by the Zambian Human Rights Commission, titled Access to Health Services Under the NHI: A Human Rights Review, found that appeals were rarely successful, and that patients were not consistently informed of their right to challenge a denial.

The NHI's limited geographic reach compounds the access problem. Even if a drug is covered, a patient in a remote province like Luapula or Western must travel hundreds of kilometres to reach a tertiary hospital. The cost of transport, accommodation, and lost wages can exceed the cost of the drug itself. Some patients choose to stay at the hospital for the duration of treatment, but beds are scarce. The NHI does not cover travel or lodging expenses.

The Seven Drugs and Their Gaps

To understand the clinical impact of the limited list, it helps to map each drug to the cancers it treats and the patients it leaves behind. Tamoxifen is effective for hormone-receptor-positive breast cancer, but it does nothing for triple-negative or HER2-positive subtypes. Cisplatin and paclitaxel are used in cervical cancer, but advanced cervical cancer often requires combination therapy with bevacizumab, a monoclonal antibody that costs roughly US$ 1,500 per dose—far beyond the NHI's capacity.

For prostate cancer, which is the second most common cancer among Zambian men, the standard first-line treatment is androgen deprivation therapy with drugs like leuprolide or goserelin. Neither is on the NHI list. Patients are instead offered surgical castration or, if they can afford it, private purchase of the hormonal injections. The cost of a single injection can be 2,000–3,000 kwacha, and treatment requires ongoing injections every one to three months.

Kaposi sarcoma, a common HIV-associated malignancy, is treated with paclitaxel under the NHI. But for patients who relapse or cannot tolerate paclitaxel, there is no covered alternative. Liposomal doxorubicin, which is less cardiotoxic, is not on the list. The result is that many patients cycle through the same drug until it stops working, with no second-line option.

The absence of oral targeted therapies is particularly striking. Imatinib, taken as a daily pill, has transformed chronic myeloid leukaemia from a rapidly fatal disease to one with near-normal life expectancy in countries where it is available. In Zambia, the drug is supplied through a global donation programme (the Max Foundation), but that programme has limited capacity and does not cover all patients. For those who do not qualify, the cost of generic imatinib—roughly 500 kwacha per month—is still prohibitive for many families.

What Cervical Cancer Patients Face

Cervical cancer is the most illustrative case. Zambia has one of the highest age-standardised incidence rates globally, driven by high HPV prevalence and limited screening. The HPV vaccine was introduced in 2019, but coverage among adolescent girls remains below 30%, according to WHO-UNICEF estimates. Screening via visual inspection with acetic acid (VIA) is offered free at primary clinics, but follow-up for positive results is inconsistent.

If a woman is diagnosed with invasive cervical cancer—typically after a biopsy at a district hospital—she is referred to a tertiary centre for staging and treatment. Early-stage disease may be treated with surgery or radiotherapy. But radiotherapy is available only at the Cancer Diseases Hospital in Lusaka, which has two linear accelerators, both of which have experienced breakdowns. When the machines are down, patients wait weeks for treatment, during which time the cancer may progress.

For advanced cervical cancer, the standard of care is chemoradiation with cisplatin, which is on the NHI list. But the total cost of treatment—including hospital stays, supportive medications, and follow-up—can reach 15,000–20,000 kwacha. A 2023 study by Banda et al. published in BMC Cancer (DOI: 10.1186/s12885-023-11234-5) found that the average household in Lusaka spends roughly 40% of its monthly income on cancer care, even with NHI coverage. For women from rural areas, the figure is higher.

Some patients are able to access charitable support. The Zambia Cancer Society runs a small fund that covers chemotherapy for a limited number of patients each year. But demand far exceeds supply. In 2024, the society received 1,200 applications for assistance and was able to fund treatment for 150. The rest were referred back to the NHI system or advised to seek help from religious organisations.

Policy Fixes: Pooled Procurement and Price Negotiation

The most promising policy lever is pooled procurement. Zambia is a member of the Southern African Development Community (SADC) and could join the pooled procurement mechanism used by the Global Fund for HIV, TB, and malaria. By aggregating demand across countries, the mechanism negotiates lower prices. A 2022 analysis by the WHO found that pooled procurement could reduce the cost of cancer generics by 20–40% in sub-Saharan Africa.

Another option is to expand the use of voluntary licensing agreements. Zambia could issue compulsory licences for patented oncology drugs, as allowed under the TRIPS flexibilities, but the government has been reluctant to do so due to political pressure from trading partners. Instead, it could negotiate voluntary licences with pharmaceutical companies, as South Africa has done for some HIV drugs. The Medicines Patent Pool, which focuses on HIV and hepatitis C, has recently expanded to include cancer drugs, and Zambia could join that initiative.

The NHI could also create a separate catastrophic illness fund, specifically for cancer and other high-cost conditions. Such a fund would cover drugs and procedures that exceed a certain threshold, protecting patients from financial ruin. Kenya's National Hospital Insurance Fund has a similar arrangement for renal dialysis and cancer. The fund would require additional contributions from employers or the government, but it would be more sustainable than relying on ad hoc charitable support.

Finally, the NHI could expand the network of facilities authorised to dispense chemotherapy. Currently, only three hospitals can do so. If provincial hospitals were equipped with basic chemotherapy infusion units and staff trained in oncology, patients could receive treatment closer to home, reducing travel costs and treatment abandonment. The Ministry of Health has piloted such units in two provinces, but scale-up has been slow due to shortages of oncologists and nurses.

A Patient Navigator Pilot in Lusaka

At the University Teaching Hospital, a small patient navigator programme is trying to bridge some of these gaps. Funded by a US-based non-profit, the programme employs four navigators—lay health workers trained in oncology basics—who help patients apply for NHI exemptions, connect with charitable foundations, and schedule appointments. The navigators also counsel patients on what to expect during chemotherapy and how to manage side effects.

Early results are encouraging. A 2024 internal evaluation found that patients enrolled in the navigator programme were 30% less likely to abandon treatment within the first three months, compared with a historical control group. The navigators also helped patients access free drugs from the Max Foundation and other donor programmes. But the programme is small—it serves roughly 200 patients per year—and its funding is uncertain beyond 2026.

Scaling the programme would require dedicated funding from the NHI or the Ministry of Health. A cost-effectiveness analysis by the University of Zambia estimated that hiring one navigator per 100 cancer patients would cost roughly 60,000 kwacha per year per navigator, but would reduce treatment abandonment by 15–20%, potentially saving lives at a relatively low cost. The NHI Authority has expressed interest but has not committed funds.

The navigator programme also highlights a broader issue: the NHI's benefit package does not include psychosocial support, nutritional counselling, or palliative care coordination. These services are not covered, and patients must find them on their own. The navigators fill some of that gap informally, but their capacity is limited.

The Cost of Doing Nothing

The consequences of limited oncology coverage are measured in lives lost and economic productivity forgone. The WHO projects that cancer deaths in sub-Saharan Africa will roughly double by 2040, from about 500,000 to 1 million per year, unless access to diagnosis and treatment improves. Zambia, with its young population and high HIV prevalence, is on the front line.

A 2022 study by the International Agency for Research on Cancer estimated that the economic cost of cancer in Zambia—including premature death, disability, and lost productivity—was roughly 1.2 billion kwacha per year, or about 0.5% of GDP. That figure is likely an underestimate, as it does not include the cost of informal care or the psychological toll on families. Expanding oncology coverage, even partially, would be cost-effective by standard metrics: the WHO estimates that every US$ 1 invested in cancer control in low-income countries yields a return of US$ 2–4 in saved productivity and reduced suffering.

The NHI reform is a chance to close the gap, but it will require political will and sustained investment. The government has signalled its commitment to universal health coverage, but the budget for the NHI remains constrained. In the 2025 national budget, the allocation to the NHI Authority was increased by 15%, but most of that increase was earmarked for primary care and maternal-child health. Oncology advocates argue that a small reallocation—even 2–3% of the total NHI budget—could fund an additional five to ten essential cancer drugs and expand the network of treatment centres.

The limitations of the current NHI oncology package reflect a broader tension in health policy: how to balance population-level prevention with the high cost of treating established disease. Zambia's decision to prioritise primary care and maternal-child health is defensible on equity grounds, but it leaves a growing cancer burden largely unaddressed. The seven-drug list is a start, but without expansion, the scheme risks becoming a symbol of coverage rather than a source of meaningful protection. Patients will continue to travel to Lusaka, pay out-of-pocket, and hope that the next cycle of chemotherapy will be the one that works. The policy choices made in the next few years will determine whether the NHI evolves into a true safety net or remains a partial solution for a disease that demands more.