Health System Fragmentation and the Integration of Vertical Donor Programmes in Zambia: A Survey-Based Analysis of Contemporary Challenges

The persistent fragmentation of Zambia's health system, exacerbated by vertical donor-funded programmes, poses a significant challenge to achieving universal health coverage. This study analyses the contemporary barriers to integrating these programmes within the national health architecture, drawing upon critical literature concerning health system fragmentation and donor practices in Zambia and similar sub-Saharan African contexts. A structured, cross-sectional survey was developed through a review of policy documents and piloted for clarity. It was administered in 2024 to a purposively sampled cohort of 150 key stakeholders, including policymakers, district health managers, and implementing partner representatives across five Zambian provinces. Ethical approval was obtained from the University of Zambia Humanities and Social Sciences Research Ethics Committee. Quantitative data were analysed descriptively, while thematic analysis was applied to open-ended responses. Findings indicate that 78% of respondents perceived duplication of services and parallel reporting structures as major issues, directly undermining the Ministry of Health's stewardship. Furthermore, 65% identified misaligned donor funding cycles and disease-specific targets as critical obstacles to integrated primary care delivery. The study concludes that, despite policy commitments to alignment, operational fragmentation remains entrenched, diverting resources and weakening systemic resilience. These findings underscore the urgent need for a renewed compact between the Zambian government and development partners, centred on harmonised financing and robust national health information systems. The study contributes an essential, empirically grounded perspective to the global discourse on health systems strengthening, advocating for locally-led integration strategies to enhance coherence and sustainability.