In pursuit of Universal Health Coverage (UHC), Zambia has been implementing decentralization reforms alongside strategic health purchasing reforms, including the establishment of the National Health Insurance Scheme (NHIS) in 2019. While these reforms mark important progress, decentralization continues to face challenges. This policy brief is based on a qualitative study that utilized the Strategic Health Purchasing Progress Tracking Framework to assess strategic health purchasing progress and gaps in Zambia’s decentralized health system. Findings reveal persistent barriers, including limited resources, fragmented governance, weak coordination, outdated benefit packages, passive provider payment, and fragmented data systems. To strengthen strategic health purchasing within decentralization, this brief outlines key policy opportunities, including stronger governance arrangements, improved data management, the use of Health Technology Assessment (HTA) in benefit design, and capacity building at the district level.