Joseph M. Zulu
1,2* 
, Maligzani P. Chavula
1,2 , Adam Silumbwe
2 , Margarate N. Munakampe
2 , Chama Mulubwa
1,2 , Wanga Zulu
3,4, Charles Michelo
4 , Helen Schneider
5,6 , Uta Lehmann
5,6 1 Department of Health Promotion and Education, School of Public Health, The University of Zambia, Lusaka, Zambia.
2 Department of Health Policy and Management, School of Public Health, The University of Zambia, Lusaka, Zambia.
3 The Ministry of Health, Lusaka, Zambia.
4 Department of Epidemiology and Biostatistics, School of Public Health, The University of Zambia, Lusaka, Zambia.
5 School of Public Health, University of the Western Cape, Cape Town, South Africa.
6 South African Medical Research Council Health Services to Systems Unit, University of the Western Cape, Cape Town, South Africa.
Abstract
There have been increased calls for low- and middle-income countries to develop community health systems (CHS) policies or strategies. However, emerging global guidance brackets the inherent complexity and contestation of policy development at the country level. This is explored through the case of Zambia’s 5-year Community Health Strategy (CH Strategy), formulated in 2017 and then summarily withdrawn and reissued two years later, with largely similar content. This paper examines the events, actors, and contexts behind this abrupt change in the Strategy, through an analysis of documentary sources and interviews with 21 stakeholders involved in the policy process. We describe an environment of contestation, characterised by numerous international partners weighing in on the CH Strategy, interfacing with shifting loci of responsibility for the CHS in the Ministry of Health (MoH). Despite the rhetoric of participation, providers and communities played no part in the policy process. These dynamics created the conditions for the abrupt change in strategy, illustrating the inherently fraught and political nature of policy development on the CHS in many countries. Going forward, we conclude that paying attention to processes of CHS policy development, and in particular the interaction between events, actors, and contexts, is as important as ensuring meaningful policy content.