RESULTS UK recently led a delegation to Zambia with four parliamentarians from the UK’s three largest parties to examine how the country is addressing the global health challenges of Tuberculosis (TB) and child survival. Zambia is an interesting case study in health: it is a Lower Middle Income country, which has had a growth rate of between 6% and 10% for the last decade, but its population of 15 million is dispersed over a wide geographic area the size of France and Spain put together and many people continue to live in poverty. It has made some progress in meeting health indicators but has lagged behind in others, which in turn has held back its social and economic development. For example, Zambia has met the MDG target to reduce child deaths by two-thirds with child mortality falling from 193 deaths per 1000 live births in 1990 to 21 in 2013; yet, 51,000 children under 5 continue to die each year. Similarly, the TB incidence rate has gone from 793 people per 100,000 population in 1995 to 410 in 2013, but 60,000 people still develop TB annually and 12,000 die as a result. Two-thirds of those with TB are also living with HIV. TB-HIV co-infection is a major problem, with TB being the biggest killer of people living with HIV around the world. Of course behind these statistics are individuals and the purpose of our delegation was to meet with patients and the health workers who assist them to better understand how progress has been made and how the remaining gaps can be closed. Together with RESULTS UK, Stuart Andrew MP, Lisa Cameron MP, Oliver Colvile MP and Kate Osamor MP visited national and community-based health programmes in Zambia’s capital city, Lusaka, and in more rural settings around Chongwe District. We witnessed a lot of good practice: local communities in Lusaka benefiting from the TB and HIV expertise of staff at the nearby ZEHRP HIV vaccine laboratory, including couples counselling; integrated TB and HIV services at St Luke’s Mission Hospital near Chongwe, and procedures in place to prevent mother-to-child HIV transmission; and Unicef staff working to ensure that children in hard-to-reach locations – including in the rural communities around Kanakantapa in Chongwe District – receive the vaccinations and treatment they require. Towards the end of our delegation, we met with Zambia’s Health Minister, Joseph Kasonde, who outlined his ambitious Elimination Agenda to end infectious diseases and avoidable deaths in Zambia; and, in the shorter term, his aim that healthcare be ‘clean, caring and competent’. Notwithstanding the excellent work that we saw, it is clear that there are pressures on the delivery of healthcare in Zambia that will only become more apparent as efforts are scaled up. Each health centre had long queues of patients waiting hours to be seen; we were informed at one clinic that one doctor was responsible for 1,200 there. Zambia faces an acute human resources challenge, especially in rural locations, with many of its facilities relying on the efforts of volunteers to deliver services at clinics and in the community. We heard some really inspiring accounts from people who had attended clinics to receive treatment for TB and HIV, but who had now become volunteers helping to break through the stigma in their local communities. It can be incredibly difficult to access healthcare in remote communities, despite the substantial investment that there has been in infrastructure. We heard of one father who had carried his sick son for two days, only for him to die as he approached the entrance of St Luke’s Mission Hospital near Chongwe. In a bid to tackle the problems presented by staffing and geography, the Government has commissioned the creation of 650 health posts throughout the country. Each post is staffed by a Community Health Assistant who provides local residents with advice on disease prevention, diagnosis and treatment of common illnesses like diarrhoea in children, and refers more serious cases to health centres. DFID has financed the recruitment, training and deployment of Community Health Assistants and they are expected to be on the Zambian Government’s payroll by next month. At Kanyongola, we met 24-year old Elias Lungu, Community Health Assistant at the local health post. As with most other Community Health Assistants, Elias lived in the community before he completed his year of training, which means that he has local knowledge and the people know and trust him. As well as diagnosing and treating patients who contact him, Elias goes out into the community two days a week to conduct home visits where he informs families how to improve their living conditions and prevent ill-health. We visited a family with him who had made improvements to their latrine and cooking area after a previous visit. Such improvements can also help reduce the risk factors for more serious conditions like TB, which is exacerbated by overcrowding, poor ventilation and sanitation. DFID’s investment in Community Health Assistants is a clear example of UK Aid being used to help meet Zambia’s health challenges. In addition, UK funding helps the other projects that we visited through DFID’s substantial contributions to the Global Fund and GAVI. As Zambia’s economy continues to develop, however, the sustainability of services will become more precarious. Its status as a Lower Middle Income Country will negatively impact the medium and long-term financing of health from multilateral donors, such as GAVI and the Global Fund. Meanwhile, in 2001 the African Union agreed that national governments should spend 15% GDP on healthcare, but the Zambian Government does not currently meet this target. Last month RESULTS UK published its report Who Pays for Progress, a case study of Kenya’s transition from Low Income to Lower Middle Income status and the impact of this on financing for healthcare. Zambia is a different country from Kenya with a different set of challenges, but the issue of financing healthcare in a Lower Middle Income Country is common to both. In line with that report’s findings, it appears there will have to be greater Domestic Resource Mobilization in Zambia if the country is to build on its progress in tackling diseases like TB and improving child health, alongside continued support from donors. It is very clear that even with dramatic scale-up in domestic resources, donors have a vital role to play given the scale of the challenges in ensuring healthcare reaches everyone. But the commitment of volunteers and staff like Elias is helping ensure that healthcare in Zambia is ‘clean, caring and competent’, and it was heartening to see such passion to ensure that everyone has access and to close the gaps.